Trismus Due to Hyperplastic Coronoid Process: Series of Five Cases and Review of Literature.

ABSTRACT: Hyperplasia of the coronoid process is a rare condition, potentially leading to a mechanical mouth opening restriction. Diagnostic workup and treatment will be discussed based on 5 cases. This article presents 5 cases of true coronoid process hyperplasia. In addition, we reviewed accessible literature on the topic with special attention to pathophysiologic theories, surgical approach, and postoperative physiotherapy. The improvement in the maximal intercuspidal opening ranged from 4 and 31 mm. Greater maximal intercuspidal opening improvement was connected to compliant patients, while poor outcome occurred in the case of a patient that neither followed the recommendations for physical therapy nor showed up for his follow up appointments. The success of the therapy is defined by a long-lasting and stable improvement of the mouth opening compared to the preoperative situation. In the presented cases, the outcome was strongly dependent on the patients' postoperative compliance. Based on the cases described, we conclude that a good outcome is accomplishable for patients using the methods presented, as long as patients cooperate well after surgery.Diagnostic workup in patients with trismus should be thorough to correctly diagnose rare entities such as coronoid hyperplasia. If treated correctly this condition has a good outcome, as long as the compliance of the patient is adequate.

Mapping the microbiological diversity of odontogenic abscess: are we using the right drugs?

OBJECTIVES: The aim of this study was categorizing the microbial flora and susceptibility to antibiotics and to clarify to which degree the empiric administered antibiotics are suitable for therapy. MATERIALS AND METHODS: A 3.5-year retrospective study evaluated hospital records of 206 patients who suffered from head and neck infections of odontogenic origin. All patients underwent surgical incision and drainage and received intravenous antibiotics and inpatient treatment. The specimens were obtained by performing a swab. RESULTS: Two hundred six patients were included with 251 strains isolated (1.22 per patient). One hundred eight strains showed antibiotic resistance. Eighty-seven patients showed at least one bacterial strain that showed antibiotic resistance (42.2%). The most frequent isolated bacteria were Streptococcus spp. (n = 116), with a high rate of antibiotic resistance (50.8%). We investigated 205 cases of antibiotic resistance in 87 subjects. Nine bacterial strains showed no susceptibility to unacid (4.3%) and 36 strains to clindamycin (17.5%). CONCLUSION: Antibiotic resistance against clindamycin was rather high. The distribution of the afflicted spaces and isolated bacteria was alike recent findings. It is mandatory to understand that immediate surgical treatment in terms of incision and drainage is the basis in abscess treatment. Antibiotic treatment is adjunct therapy. CLINICAL RELEVANCE: Streptococcus species were the most frequently identified bacteria presenting antibiotic resistance in more than 50%. Increased resistant rates for clindamycin require reconsiderations regarding an empiric antibiotic treatment.

Predictability of pharyngeal airway space dimension changes after orthognathic surgery in class II patients: A mathematical approach.

INTRODUCTION: Angle Class II malocclusion due to mandibular retrognathia is a common dentofacial deformity. It is well known that mandibular advancement increases pharyngeal airway dimensions. The aim of this study was to evolve a mathematical method for predicting posterior pharyngeal airway space (PAS) changes based on 2D lateral cephalographic radiographs (LCRs) and expected extent of mandibular advancement prior to BSSO. MATERIALS AND METHODS: Linear regression analyses were performed in order to investigate the relation between the posterior airway space and mandibular advancement. LCRs where carried out to assess skeletal landmarks and pharyngeal airway space pre- (T0) and postoperatively (T1). To detect changes postoperatively, the posterior airway space was divided into three units: nasopharyngeal airway space (superior airway space - SPAS), oropharyngeal airway space (mid airway space - MAS) and hypopharyngeal airway space (inferior airway space - IAS). The differences between the distances of distinct measurement points (DIFF) were measured pre- and postoperatively. DOA referred to the distance of mandibular advancement and DP to the distance between the measurement points preoperatively. The parameters a, b1 and b2 were the regression coefficients that were determined separately for each unit (SPAS, MAS, and IAS). RESULTS: 49 patients (16 male and 33 female) with a mean age of 27.2 years (SD: 10.09), ranging from 18 to 51 years, who underwent mandibular advancement surgery (BSSO) were enrolled in this study. The mean distance of mandibular advancement was 5.05 mm (SD: 1.63). Regarding SPAS and IAS, mandibular advancement did not affect dimensions significantly: SPAS DIFF, 0.33 mm ± 1.13 mm (b1, p = 0.0881; b2, p = 0.087); IAS DIFF, 0.66 mm ± 2.45 mm (b1, p = 0.342; b2, p = 0.765). DOA and DP did not influence DIFF significantly in both sections. Regarding MAS, the mean effect of mandibular advancement was an expansion of 2.47 mm ± 2.24. The linear regression model showed a statistically significant (b1, p = 0.0064; b2, p = 0.0240) influence of DOA and DP on DIFF in posterior airway dimensions pre- and postoperatively. DISCUSSION: Based on preoperative LCR imaging data, a linear regression model was developed as a mathematical approach to allow prediction of PAS development in patients with Angle Class II malocclusions of different degrees. Increasing mandibular advancement was shown to be linked to increasing PAS, while a greater distance between the measuring points preoperatively led to smaller predicted PAS increases postoperatively. CONCLUSION: Predicting pharyngeal airway space (PAS) development after mandibular advancement by analysing lateral cephalometric radiographs (LCR) may be useful in the screening and treatment of obstructive sleep apnea syndrome (OSAS) patients. Our mathematical approach is a simple and sustainable prediction tool based on LTR data for patients with Class II malocclusions.

The role of immediate versus secondary removal of the odontogenic focus in treatment of deep head and neck space infections. A retrospective analysis of 248 patients.

OBJECTIVES: Aim of this study was to investigate conditions and predisposing factors for head and neck infection progress regarding the length of stay (LOS) in hospital, with special emphasis on the time of removal of the odontogenic infection focus. MATERIAL AND METHODS: A 3-year retrospective study reviewed hospital records of 248 subjects who were treated under inpatient conditions with severe odontogenic infections who received surgical incisions, drainage, and intravenous (IV) antibiotics. Outcomes measured included age, gender, involved fascial spaces, LOS, number of infected spaces, antibiotics administered, and comorbidities. We precisely recorded the time between abscess incision and focus extraction. RESULTS: Removal of infection focus (tooth) in the same stay (1 stay, n = 106; group 1; mean 6.5 days ± 3) showed significantly higher (p = 0.042) LOS than extraction in a second stay (2 stays, n = 46; group 2; 5.3 ± 3.1). Group 3 patients showed infection after removal of teeth in outpatient management (1 stay ex-op, n = 96) and presented significantly lower LOS (5.6 ± 2.5) compared to group 1 (p = 0.0216). LOS of group 3 to group 2 patients showed no significance (p = 0.668). Infection expansion and diabetes showed a significant increase of LOS. CONCLUSION: Simultaneous removal of infection focus and abscess incision leads to the lowest LOS. If tooth extraction is performed after incision, subsequent focus extraction performed in a second stay shows lower overall-LOS than extraction at the same stay at later stage. CLINICAL RELEVANCE: Multiple factors tend to increase the LOS of patients with severe head and neck infections of odontogenic origin. Our data reveals the role of removal of odontogenic focus and additionally ranks further parameters that influence the LOS. Based on our findings, decisions regarding the surgical treatment can be recommended.

A mathematical approach improves the predictability of length of hospitalization due to acute odontogenic infection: A retrospective investigation of 303 patients.

PURPOSE: Increasing rates of hospitalization of patients diagnosed with acute odontogenic infection have become a burden for public health care, with significant economic concerns. The aim of this study was to investigate factors that tend to prolong hospital length of stay (LOS) in the treatment of severe infections. We present a statistical model that enables the prediction of LOS by exposing the feasibility of the essential statistical determinants. MATERIALS AND METHODS: A 5-year retrospective study investigated records of 303 in-hospital patients with abscess of odontogenic origin. Time-to-event models were used to analyse data where the outcome variable is the time to the occurrence of a specific event. Here, the focus is on a statistical model for the prediction of LOS of patients. RESULTS: The group of all patients (n = 303) was analysed by considering seven characteristics of the patients (age, gender, spreading of infection, localization of infection focus, type of administered antibiotics, diagnosed diabetes mellitus, and existence of a remaining infection focus). Age (p = 0.049; rc = -0.007) and spreading of infection (p < 0.001; rc = -0.965) showed a significant impact on the LOS. Subjects were divided into two groups. Group A (n = 185) consisted of patients who presented with a severe odontogenic infection and not yet removed infection focus; group B were patients having undergone outpatient operative tooth removal (n = 118). To group A patients' data, two new risk factors ("days between abscess incision and removal of infection focus" = dbir and "removal of infection focus during the same stay as abscess incision" = riss) replaced the risk factors "remaining infection focus." A significant impact on the LOS was detected for dbir (p < 0.001; rc = -0.15) and riss (p < 0.001; rc = -1.76). Our statistical model explicitly describes how the probability for discharge depends on the time and how specific characteristics affect the LOS. We observed a significantly higher LOS in older patients and subjects with infection spreading. In group A patients, dbir and riss had a highly significant impact on the LOS. CONCLUSION: Predicting the LOS may promote transparency to costs and management of patients under inpatient treatment. Our statistical model describes the probability of a discharge at time t compared to a discharge later than t (a LOS longer than t). Furthermore, the model enables a prediction of the LOS of each patient for practitioners in an easy way.

The role of C-reactive protein and white blood cell count in the prediction of length of stay in hospital and severity of odontogenic abscess.

INTRODUCTION: Odontogenic infections and subsequent developing abscess remain to be a potentially life-threatening event, due to septicemia, airway compression and spreading into sensitive anatomic tissues. C-reactive proten (CRP) and white blood cell (WBC) count are routinely blood-measured indicators for inflammation. Are CRP-levels and WBC-count predictive factors of the developement of odontogenic abscess? METHODS: A 4-year retrospective study evaluated hospital records of 218 patients, diagnosed and inpatiently treated for acute odontogenic abscess. They received surgical incision, drainage and intravenous antibiotics. CRP-levels and WBC-counts were measured preoperativly. RESULTS: 218 subjects were enrolled in this study. Patients hospitalized 10 days or more showed significantly higher CRP-levels (p = < 0.001) and WBC-counts (p = 0.006) on admission day than patients with lower LOS. CRP-levels of patients with LOS from 7-9 days were significantly lower (p = 0.47) than in people hospitalized 10 days or more. Abscess focus in the mandible shows significantly higher WBC-counts (p = 0.014). Multiple space infections present a significantly higher CRP (p = 0.003) and WBC (p < 0.001) on admission day. DISCUSSION: According to the presented data, CRP-levels and WBC-count can be regarded as predictive factors for LOS (length of stay in hospital) in patients with long term hospitalization (CRP:7-9 days and > 10 days; WBC: > 10 days). Further WBC and CRP are suitable to predict multiple space infections and localisation of the abscess (WBC) in certain limits. CONCLUSION: In predicting the developement of odontogenic abscess, CRP is more capable in providing exact statements regarding the LOS. However, WBC-counts are more suitable in predicting multiple space infections and localization of infection.

Bite force and electromyography evaluation after cranioplasty in patients with craniosynostosis.

OBJECTIVE: This long-term follow-up investigation aimed to assess masticatory muscle function in 15 patients with craniosynostosis with detachment of the temporal muscle during fronto-orbital advancement 6 years after cranioplasty compared with a non-operative stomatognathic healthy cohort in the same age group (n = 25). STUDY DESIGN: The follow-up assessment for the operated children occurred on average 5.2 ± 1.7 years after surgery at the age of 7 ± 1.6 years. The maximum bite force was assessed, in addition to the bilateral function of both temporal and masseter muscles, which were analyzed using superficial electromyography. RESULTS: The maximum bite force was 257 ± 89 N 255 ± 88 N (right/left), respectively, in the group of operated children and 212 ± 61 N and 203 ± 57 N (right/left), respectively, in the control group, without clinical relevant difference between groups. The surface electromyography signal of the temporal muscle correlated positively with the bite force and showed a slightly lower average resting tone activity in the control group, whereas muscle fatigue occurred slightly faster in the operated children in both muscles without statistically significant difference between the 2 groups. CONCLUSIONS: There was no measurable dysfunction in the temporal muscle after the operative correction of craniosynostosis compared with a healthy population of children.

Microbiology and antibiotic sensitivity of head and neck space infections of odontogenic origin. Differences in inpatient and outpatient management.

INTRODUCTION: The microbial flora of infections of the orofacial region of odontogenic origin is typically polymicrobial. Shortly after mass production of the first antibiotics, antibiotic resistant microorganisms were observed. METHODS: A 28-months retrospective study evaluated hospital records of 107 patients that were treated for head and neck infections of odontogenic origin. All patients underwent surgical incision and drainage. RESULTS: There were 65 male (61%) and 42 female (39%) patients ranging in age from 5 to 91 years, with a mean age of 48 years (SD = 21). 52 patients underwent outpatient management and 55 patients inpatient management. A total of 92 bacterial strains were isolated from 107 patients, accounting for 0.86 isolates per patient. Overall 46 bacterial strains were isolated from patients that underwent outpatient and 34 bacterial strains that underwent inpatient treatment. 32.6% of the strains, isolated from outpatient treated individuals showed resistances against one or more of the tested antibiotics. Isolated strains of inpatient treated individuals showed resistances in 52.9%. DISCUSSION: According to this study's data, penicillin continues to be a highly effective antibiotic to be used against viridans streptococci, group C Streptococci and prevotella, whereas clindamycin was not shown to be effective as an empirical drug of choice for most odontogenic infections. CONCLUSION: Microorganisms that show low susceptibility to one or more of the standard antibiotic therapy regimes have a significantly higher chance of causing serious health problems, a tendency of spreading and are more likely to require an inpatient management with admission of IV antibiotics. Penicillin continues to be a highly effective antibiotic to be used against viridans streptococci, group C Streptococci and prevotella, whereas clindamycin could not be shown to be effective as an empirical drug of choice for a high number of odontogenic infections.