A retrospective study of patients with mandibular fractures treated at a Swedish University Hospital 1999-2008.

BACKGROUND: Fracture of the mandible is one of the most common fractures of the maxillofacial skeleton. However, the etiology, gender, and age distribution vary between different regions and countries, and the purpose of this study was to evaluate the current trend of patients with mandibular fractures at the Department of Oral and Maxillofacial Surgery, in Uppsala, Sweden. AIM: The aim of this retrospective study was to analyze patients with mandibular fractures treated in the University Hospital of Uppsala (the county capital of Uppland) Sweden during a 10-year period (1999-2008). MATERIALS AND METHODS: This study was designed as a retrospective study of patients admitted to the Department of Oral and Maxillofacial Surgery at Uppsala University Hospital, Sweden. The location of fractures was evaluated clinically by the surgeon and on the X-rays. We classified the data according to gender, age, etiology, day of the week, month of the year, fracture site, and method of treatment of the fractures. RESULTS: Records were collected from patient charts from 266 patients. One hundred eighty-seven patients (70%) with mandibular fractures were of male gender, and 132 patients (50%) were aged 16-30 years. Interpersonal violence constituted the most common etiological factor for mandibular fractures (24%), followed by falls (23%). Forty-nine percentages of the patients were treated surgically, and 51% were treated conservatively. There was an increase of the annual incidence of fractures toward the end of the period, even though not statistically significant. CONCLUSIONS: Mandibular fractures occurred primarily among younger men between 16- and 30-year-old. Condyle fractures were the most common fracture site and 50% of the patients required surgery. Summer months and weekends were the most common time of mandibular fractures.

Treatment of sleep apnoea using a mandibular advancement splint--an open prospective study.

Obstructive sleep apnoea (OSA) may cause considerable disturbances, including the development of health problems. This study was performed in order to evaluate the results of treating OAS with a mandibular advancement splint (MAS), and to evaluate the effects of this treatment. This was a prospective open longitudinal study. Ninety patients were randomly selected and included in the study. All 90 patients received an MAS. Forty-eight patients concluded the study, whereas 27 dropped-out and 15 were excluded. The sleep pattern was monitored at home with portable equipment. There was a clear tendency towards a reduction in the apnoea/hypopnea index (AHI) and the oxygen desaturation index (ODI) between the two investigations. Furthermore, there was a tendency towards reduced sleep apnoea; ratings on the Epworth sleepiness scale were lower, indicating a reduction in daytime sleepiness. Treatment with MAS in our study reduced sleep apnoea and snoring, and lowered the values of the Epworth sleepiness scale, indicating a reduction in daytime sleepiness in the majority of the patients. Lifestyle factors are not believed to have affected the results.

Oral cancer in Swedish snuff dippers.

Over recent decades there has been debate over whether or not Swedish snuff is carcinogenic in humans. Animal studies and molecular biological and experimental studies have shown the carcinogenic potential of Swedish snuff, but this has not been proved in prospective randomized studies. We present a case series of patients with oral squamous cell carcinomas diagnosed at the sites where the patients had used Swedish snuff for several years. Sixteen male patients were referred to and treated at Oral and Maxillofacial Surgery Departments and Ear, Nose and Throat clinics at seven different hospitals in Sweden. The mean age of the patients at the time of diagnosis was 72.9 years and the mean time of snuff use prior to cancer diagnosis was 42.9 years. This case series shows that Swedish snuff may not be a harmless alternative to smoking.

Local tolerance of a sublingual nicotine tablet, an open single-centre study.

Nicotine replacement therapy (NRT) is now widely used in various forms of administration to aid cessation of tobacco use. In this smoking cessation programme, a new tablet formulation has been compared to and found bioequivalent to the existing one. The present trial was performed in order to investigate the local tolerance of the new sublingual tablet. The study was performed as a prospective follow-up study of 16 weeks' duration on smokers using the new tablet, Nicorette® Microtab, over a period of 12 weeks. Fifty smokers were included in the study and the oral mucosa was inspected and photographed at each visit. At 12 weeks, participants were asked for their consent to take a biopsy from the site of application. Compliance with tablet use was high, with participants using an average of 12 tablets/day throughout the 12 week treatment period. Adverse events related to treatment were mild and tolerable. The changes observed were classified as being induced by frictional stimuli, with no changes to the deeper layers of the epithelium, and no thickening of the basal layers of the epithelium. The new tablet was considered well tolerated during the course of this study, with a benign local effect on the mucous membrane that was consistent with lesions that are reversible in nature.

Imaging, virtual planning, design, and production of patient-specific implants and clinical validation in craniomaxillofacial surgery.

The purpose of this article was to describe the workflow from imaging, via virtual design, to manufacturing of patient-specific titanium reconstruction plates, cutting guide and mesh, and its utility in connection with surgical treatment of acquired bone defects in the mandible using additive manufacturing by electron beam melting (EBM). Based on computed tomography scans, polygon skulls were created. Following that virtual treatment plans entailing free microvascular transfer of fibula flaps using patient-specific reconstruction plates, mesh, and cutting guides were designed. The design was based on the specification of a Compact UniLOCK 2.4 Large (Synthes(®), Switzerland). The obtained polygon plates were bent virtually round the reconstructed mandibles. Next, the resections of the mandibles were planned virtually. A cutting guide was outlined to facilitate resection, as well as plates and titanium mesh for insertion of bone or bone substitutes. Polygon plates and meshes were converted to stereolithography format and used in the software Magics for preparation of input files for the successive step, additive manufacturing. EBM was used to manufacture the customized implants in a biocompatible titanium grade, Ti6Al4V ELI. The implants and the cutting guide were cleaned and sterilized, then transferred to the operating theater, and applied during surgery. Commercially available software programs are sufficient in order to virtually plan for production of patient-specific implants. Furthermore, EBM-produced implants are fully usable under clinical conditions in reconstruction of acquired defects in the mandible. A good compliance between the treatment plan and the fit was demonstrated during operation. Within the constraints of this article, the authors describe a workflow for production of patient-specific implants, using EBM manufacturing. Titanium cutting guides, reconstruction plates for fixation of microvascular transfer of osteomyocutaneous bone grafts, and mesh to replace resected bone that can function as a carrier for bone or bone substitutes were designed and tested during reconstructive maxillofacial surgery. A clinically fit, well within the requirements for what is needed and obtained using traditional free hand bending of commercially available devices, or even higher precision, was demonstrated in ablative surgery in four patients.

Differential expression of apoptosis, cell cycle regulation and intermediate filament genes in oral squamous cell carcinomas associated with toombak use in Sudan.

Previously we used microarray genomic hybridization technology to explore genome-wide profiles of chromosomal aberrations in samples of oral squamous cell carcinomas (OSCCs) and paired normal controls. Based on these findings, 9 genes related to apoptosis, cell cycle regulation and intermediate filament proteins were selected and their differential expression status was examined by real-time quantitative RT-PCR in 26 samples of Sudanese OSCCs and their matched normal controls. The findings were correlated with the habit of toombak use. The mRNA levels of Bcl2, keratin 1, keratin 13 and p53 were significantly lower and the level of survivin was significantly higher in the OSCC samples of the toombak users compared to their paired control samples. A significant down-regulation in keratin 1 and keratin 13 expression levels was found in the OSCC samples of the nontoombak users compared to their normal control samples. The differential expression of genes related to apoptosis, cell cycle regulation and types I and II keratin could be useful diagnostic markers and provide valuable information for the understanding of oral malignancy in relation to toombak use.

A cessation program for snuff-dippers with long-term, extensive exposure to Swedish moist snuff: A 1-year follow-up study.

OBJECTIVE: Smokeless tobacco (Swedish moist 'snus') users are often strongly addicted to nicotine. Compared to the large number of smoking-cessation studies, there have been few evaluated clinical cessation programs in conjunction with nicotine replacement therapy (NRT). The aim of this study was to evaluate a cessation program for snus users with a weekly use of >2 cans/week for >10 years. MATERIAL AND METHODS: A prospective, open, non-randomized intervention trial was undertaken including baseline oral examination and soft tissue biopsy, minor physical examination, brief cessation advice, NRT recommendations and five prospective follow-up visits within 12 months. Individual cessation counseling was given, together with oral examination in the dental office. Fifty snus users with a minimum consumption of 100 g/week who were actively seeking cessation treatment were recruited through advertising. Self-reported abstaining, including random-sample biochemical verification, and NRT use were evaluated at 6 weeks and 3, 6 and 12 months. RESULTS: At the 3-, 6- and 12-month visits, 58%, 46% and 30% of subjects, respectively were tobacco-abstinent. All nicotine abstinence was randomly controlled during the study except at 12 months, where all subjects claiming abstinence were confirmed biochemically and clinically. CONCLUSION: Smokeless tobacco cessation achieved together with suitable NRT seems a promising way to improve a persistent tobacco-free condition.

Presence of human papilloma virus, herpes simplex virus and Epstein-Barr virus DNA in oral biopsies from Sudanese patients with regard to toombak use.

Using PCR/DNA sequencing, we investigated the prevalence of human papillomavirus (HPV), herpes simplex virus (HSV) and Epstein-Barr virus (EBV) DNA in brush biopsies obtained from 150 users of Sudanese snuff (toombak) and 25 non-users of toombak in formalin-fixed paraffin-embedded tissue samples obtained from 31 patients with oral dysplasias (25 toombak users and 6 non-users), and from 217 patients with oral cancers (145 toombak users and 72 non-users). In the brush tissue samples from toombak users, HPV was detected in 60 (40%), HSV in 44 (29%) and EBV in 97 (65%) of the samples. The corresponding figures for the 25 samples from non-users were 17 (68%) positive for HPV, 6 (24%) positive for HSV and 21 (84%) for EBV. The formalin-fixed samples with oral dysplasias were all negative for HPV. In the 145 oral cancer samples from toombak users, HPV was detected in 39 (27%), HSV in 15 (10%) and EBV in 53 (37%) of the samples. The corresponding figures for the samples from non-users were 15 (21%) positive for HPV, 5 (7%) for HSV and 16 (22%) for EBV. These findings illustrate that prevalence of HSV, HPV and EBV infections are common and may influence oral health and cancer development. It is not obvious that cancer risk is increased in infected toombak users. These observations warrant further studies involving toombak-associated oral lesions, to uncover the possible mechanisms of these viral infections in the development of oral cancer, and the influence of toombak on these viruses.

Gene expression analysis by cDNA microarray in oral cancers from two Western populations.

BACKGROUND: In this work, gene expression profile was examined in 19 cases of oral cancer (OC) obtained from patients from Sweden (n=8) and UK (n=11) and the findings were tested for correlation to patient's clinicopathological data. MATERIALS AND METHODS: Following total RNA extraction, cDNA synthesis, labeling with fluorescent dyes and hybridization to the 21 k human oligonucleotide microarrays, slides were scanned and images were subjected to Genepix and J-Express analysis. Results for selected genes were validated by quantitative reverse transcriptase polymerase chain reaction (Q-RT-PCR). RESULTS: 42 genes were identified as being differentially expressed. These included 39 genes of known functions (such as fatty acid synthase (FASN), 5' nucleotidase, ecto (NT5E), high mobility group AT-hook (HMGA1), and v-fos FBJ murine osteosarcoma viral oncogene homolog (FOS)) and 3 novel genes; 26 (67%) of the 39 genes with known functions were previously reported in oral/head and neck tumors examined from other populations. Hierarchical clustering of the samples using the 42 genes demonstrated that samples mainly clustered in the same population. CONCLUSION: These results illustrate that microarrays can be used to identify distinct patterns of gene expression in different populations, but with no direct association to clinicopathological parameters. The fact that 67% of the 39 genes with known functions found in this work were previously reported in oral/head and neck tumors from other populations provides clear evidence that development of these tumors follows the same biological pathways irrespective of the source of the samples used.

Prevalence of viral (HPV, EBV, HSV) infections in oral submucous fibrosis and oral cancer from India.

CONCLUSION: There is a high prevalence of human papilloma viruses (HPV) in oral submucous fibrosis (OSMF) and the etiologic implication of this finding warrants further studies. OBJECTIVE: The prevalence of oral squamous cell carcinoma (OSCC) and OSMF is high in India, and the diseases are partly attributed to high consumption of betel quid containing areca nut and tobacco. This study investigated the prevalence of HPV, herpes simplex virus (HSV), and Epstein­Barr virus (EBV) DNA in two groups of patients using betel quid with tobacco, those with OSMF (n = 12) and those with OSCC (n = 62). METHODS: DNA was extracted from all the samples and viral genome was examined by PCR/DNA sequencing. HPV-positive samples were analyzed separately for the high-risk types HPV 16 and 18. RESULTS: HPV DNA, HSV DNA, and EBV DNA were detected in 11 (91%), 1 (8%), and 3 (25%) of the 12 samples from patients with OSMF compared with 15 (24%), 3 (5%), and 18 (29%), respectively, from 62 patients with OSCC. HPV 16 and 18 DNA was detected in 8/12 (67%) in the OSMF group and 10/62 (16%) in the OSCC group. The difference between presence of HPV DNA in OSMF and OSCC groups was statistically significant, while the difference between HSV and EBV DNA content in OSMF and OSCC groups was insignificant.

Malignant tumors of the maxilla: virtual planning and real-time rehabilitation with custom-made R-zygoma fixtures and carbon-graphite fiber-reinforced polymer prosthesis.

BACKGROUND: Oral cancer is a mutilating disease. Because of the expanding application of computer technology in medicine, new methods are constantly evolving. This project leads into a new technology in maxillofacial reconstructive therapy using a redesigned zygoma fixture. PURPOSE: Previous development experiences showed that the procedure was time-consuming and painful for the patients. Frequent episodes of sedation or general anesthetics were required and the rehabilitation is costly. The aim of our new treatment goal was to allow the patients to wake up after tumor surgery with a functional rehabilitation in place. MATERIALS AND METHODS: Stereolithographic models were introduced to produce a model from the three-dimensional computed tomography (CT). A guide with the proposed resection was fabricated, and the real-time maxillectomy was performed. From the postoperative CT, a second stereolithographic model was manufactured and in addition, a stent for the optimal position of the implants. Customized zygoma implants were installed (R-zygoma, Integration AB, Göteborg, Sweden). A fixed construction was fabricated by using a new material based on poly(methylacrylate) reinforced with carbon/graphite fibers and attached to the implants. On the same master cast, a separate obturator was fabricated in permanent soft silicon. RESULTS: The result of this project showed that it was possible to create a virtual plan preoperatively to apply during surgery in order for the patient to wake up functionally rehabilitated. CONCLUSION: From a quality-of-life perspective, it is an advantage to be rehabilitated fast. By using new computer technology, pain and discomfort are less and the total rehabilitation is faster, which in turn reduces days in hospital and thereby total costs.