Central giant cell granuloma of the jaws-long-term clinical and radiological outcomes of surgical and pharmacological management.

OBJECTIVES: To compare long-term results of different treatment modalities in central giant cell granuloma of the maxillofacial-skeleton. Primary resection may result in major defects. Alternative treatments include pharmacological agents. As yet there has been no consensus on the use of the variety of treatment options, and few studies have reported clarifying long-term results. MATERIALS AND METHODS: This retrospective study on 22 patients with 25 lesions evaluated clinical, radiological and histological features, treatment preformed and lesion recurrence. Success was defined as regression/calcification and failure as recurrence, progression or un-responsiveness. RESULTS: Of the presenting patients, 77% were under age 40. Lesion prevalence was higher in the anterior mandible and left posterior maxilla. Most cases exhibited pain, tooth-mobility or mucosal-expansion. The appearance was predominantly unilocular in the maxilla and multilocular in the mandible, which also exhibited higher prevalence of cortical perforation. Up to 80% of lesions were classified as aggressive. Intralesional steroids/calcitonin were used in 7 cases. Mean follow-up was 39.8 months. Two cases showed recurrence. In 71% of the cases treated pharmacologically, calcification/regression were observed. CONCLUSIONS: Our analysis indicates better outcomes using a combined approach, including both pharmacological and surgical treatments in large aggressive lesions. Pharmacological treatment resulted in decreased size or well-defined lesions, thus reducing the need for extensive bone resection. Dual treatment with corticosteroids and calcitonin showed no superior outcomes, but a larger cohort should be assessed. CLINICAL RELEVANCE: There are several protocols for treatment of central-giant-cell-granuloma lesions, but most are not fully established. It is important to report results that contribute to the establishment of proven protocols. This report attempts to establish the relevance of the combined approach: pharmacological treatment followed by surgical resection.

Real-time Reconstruction of Comminuted Mandibular Fractures Using 3D Printing.

Background: Comminuted fractures of the jaws are complex injuries requiring special attention. In the past, treatment included closed reduction using maxillomandibular fixation. With advancements in technology and fixation systems, open reduction became a prevalent option. These fractures are difficult to reconstruct during the primary treatment phase, thus resulting in higher complication rates. The introduction of three-dimensional (3D) planning and printing brought about superior outcomes, yet these focus on secondary reconstruction due to the need for outsourcing planning and titanium printing. Methods: In this report, we describe real-time in-house 3D planning and printing using computer-assisted design software and a 3D-fused deposition printer for virtual reduction of the comminuted fractures and printing of the reconstructed mandible. Results: Following virtual 3D reduction, the newly created mandibles were 3D printed. The model was then used to preband a reconstruction plate, which in turn was used as a template during surgery for reducing the segments. The process of virtual reduction and printing should take a couple of hours at most. The results of five cases showed good alignment and proper function. Conclusion: Three-dimensional technology can be applied in the everyday primary care treatment protocol of comminuted fractures as an in-house tool which greatly improves both functional and aesthetic outcomes.

Comparison of patient specific implant reconstruction vs conventional titanium mesh reconstruction of orbital fractures using a novel method.

To compare the reconstruction of orbital fractures using patient-specific implants (PSI) and conventional pre-formed titanium mesh; to develop a method of three-dimensional (3D) superimposition and analysis of the reconstructed orbits; and to present the pitfalls in 3D planning of orbital PSI and how to avoid them. This was a retrospective study of patients with orbital fractures who were treated in our institution between the years 2022 and 2023 using PSI or conservative prefabricated titanium mesh. Three different methods for virtual reconstruction of orbital fractures were used and are detailed with advantages, disadvantages and indications. Data acquired included age, gender, method of reconstruction, functional outcomes and aesthetic outcomes. 3D analysis for accuracy of reconstruction was performed. A total of 23 patients were included; 12 were treated using PSI and 11 using prefabricated titanium meshes. There were 8 male and 4 female patients in the PSI group comparted to 5 and 6 in the prefabricated group. All three virtual methods for reconstruction were used successfully, each with the proper indications. When comparing PSI reconstruction to conventional mesh, a significant difference in accuracy was observed; PSI cases showed an inaccuracy of 0.58 mm compared to 1.54 mm with the conventional method. Complications are presented, and tips for avoiding them are detailed. Three different methods for virtual reconstruction were used successfully; automated computerized reconstruction is used for small defects, repositioning is the superior method for non-comminuted cases while mirroring is the method of choice in comminuted fractures. 3D analysis can be performed using a novel method detailed in this report. PSI reconstruction showed superior results, indicating it should be the method of choice when possible. Pitfalls are presented and approaches to prevent them are discussed. Orbital reconstruction is a very important entity in maxillofacial surgery with crucial functional and esthetical implications, and one should use virtual planning and PSI implants, as they significantly improve outcomes.

Surgical Dilemmas in Multiple Facial Fractures - Coronal Flap Versus Minimally Invasive: Case Report and Literature Review.

THE RATIONALE: Pan-facial fracture is a complex trauma that involves the upper, middle, and lower third of the facial bones. The surgical management of such complex cases is either by the posterior approach (coronal flap) or anterior approach through local incisions. PATIENT CONCERNS: This report describes the case of severe pan-facial trauma in a 52-year-old male who sustained a severe pan-facial trauma. DIAGNOSIS: He suffered from multiple facial fractures that included: Frontal bone, skull base, Naso-orbitoethmoid (NOE), zygomatic and sub-condylar fractures. TREATMENT: He was managed by minimally local periorbital and lynch incisions. OUTCOMES: Fractures were properly reduced with resultant symmetrical facial dimensions. No postoperative complications were demonstrated including facial nerve function. TAKE-AWAY LESSONS: We should consider minimally invasive local incisions in pan-facial fractures when there is no need to restore the frontal sinus and the anterior-posterior dimensions of the zygomatic arch.

Solitary Extraosseous Neurofibroma in a 5-Year-Old Child - A Case Report.

Rationale: Neurofibroma (NF) is the most common benign peripheral nerve sheath tumour that most often occurs as a solitary tumour. A clinical and imaging diagnosis may be challenging since no distinctive features are unique for this lesion. Solitary NFs are treated by complete resection that may sometimes require a nerve sacrifice, ending with a neurological deficit. Patient Concerns: A 5-year-old girl with mild asymptomatic slow-growing swelling in the vestibulum of her right mandible. Diagnosis: A solitary variant of extraosseous NF involving the right mental branch of the inferior alveolar nerve. Treatment: Surgical removal of the lesion while fully preserving the mental branch. Outcomes: No sensory deficit was identified during a 3-month follow-up. Take-Away Lessons: Ultrasonography is a valuable tool for evaluating soft-tissue masses of the oral cavity. A solitary extraosseous NF involving the mental branch can be surgically removed without nerve deficit.

A life-threatening floor of the mouth hematoma secondary to explantation attempt in the anterior mandible.

Implant dentistry is considered to be a safe and routine surgical procedure. However, cases of life-threatening hematoma of the floor of the mouth resulting in airway obstruction were previously reported as a complication of implant placement in the anterior mandible. Massive bleeding in this anatomical site may be caused by perforating the lingual cortex and/or damaging the lingual perimandibular vessels. In the long term, dental implants can fail, mainly due to peri-implantitis, and must be removed. Explantation procedure may occasionally become a complex challenge, with a risk for various complications.
Case report: This report presents the first case of life-threatening hematoma of the floor of the mouth, as a complication secondary to a failed attempt of dental implant removal at the anterior mandible. The proximity of the implant to the lingual vascular canal might have served as a cause for vascular damage during explantation.
Conclusions: Implant removal complications are scarcely described in the literature. Nonetheless, damaging blood vessels during explantation should not be underestimated. Computed tomography (CT) may be of value not only in preoperative implant planning but also before implant removal in jeopardized anatomical zones such as the anterior mandible. Lingual vascular canals should be looked for on computed tomography scans.

Do neck kinematics correlate with pain intensity, neck disability or with fear of motion?

PURPOSE: This study aimed to investigate the relationship between cervical kinematics and subjective measures, including pain intensity, disability, and fear of motion. METHODS: Twenty-five patients (19 females, 6 males; mean age 39 ± 12.7 years) with chronic neck pain participated in this cross-sectional study. A customized virtual reality system was employed to evaluate cervical range of motion (ROM) and kinematics, using an interactive game controlled by cervical motion via electromagnetic tracking. Self-reported outcome measures included pain intensity (visual analogue scale); disability (Neck Disability Index); and fear of motion (TAMPA scale of kinesiophobia). Kinematic measures included cervical ROM, mean and peak velocity, and number of velocity peaks (NVP) reflecting smoothness of motion. RESULTS: Results showed significant correlations of approximately 0.4-0.6 between ROM and fear of motion, pain intensity, and disability. All 12 kinematic measures were correlated with fear of motion, but only a few were correlated with pain intensity, and with disability. CONCLUSIONS: The results emphasise fear of motion as a subjective measure primarily correlated with neck kinematics, including range, velocity, and smoothness of cervical motion. The level of neck disability was found to be partly related to ROM or to other kinematic impairments. However, ROM by itself remains a valid measure related to pain intensity and to fear of motion in patients with chronic neck pain. All correlations demonstrated were moderate, indicating that these measures involve other factors in need of further research.

Evaluation of clinical methods for peroneal muscle testing.

BACKGROUND: Manual muscle testing of the peroneal muscles is well accepted as a testing method in musculoskeletal physiotherapy for the assessment of the foot and ankle. The peroneus longus and brevis are primary evertors and secondary plantar flexors of the ankle joint. However, some international textbooks describe them as dorsi flexors, when instructing peroneal muscle testing. The identified variability raised a question whether these educational texts are reflected in the clinical field. PURPOSE: The purposes of this study were to investigate what are the methods commonly used in the clinical field for peroneal muscle testing and to evaluate their compatibility with functional anatomy. METHODS: A cross-sectional study was conducted, using an electronic questionnaire sent to 143 Israeli physiotherapists in the musculoskeletal field. The survey questioned on the anatomical location of manual resistance and the combination of motions resisted. RESULTS: Ninety-seven responses were received. The majority (69%) of respondents related correctly to the peronei as evertors, but asserted that resistance should be located over the dorsal aspect of the fifth metatarsus, thereby disregarding the peroneus longus. Moreover, 38% of the respondents described the peronei as dorsi flexors, rather than plantar flexors. Only 2% selected the correct method of resisting plantarflexion and eversion at the base of the first metatarsus. We consider this technique to be the most compatible with the anatomy of the peroneus longus and brevis. The Fisher-Freeman-Halton test indicated that there was a significant relationship between responses on the questions (P = 0.0253, 95% CI 0.0249-0.0257), thus justifying further correspondence analysis. The correspondence analysis found no clustering of the answers that were compatible with anatomical evidence and were applied in the correct technique, but did demonstrate a common error, resisting dorsiflexion rather than plantarflexion, which was in agreement with the described frequencies. CONCLUSION: Inconsistencies were identified between the instruction method commonly provided for peroneal muscle testing in textbook and the functional anatomy of these muscles. Results reflect the lack of accuracy in applying functional anatomy to peroneal testing. This may be due to limited use of peroneal muscle testing or to inadequate investigation of the existing evaluation methods and their validity. Accordingly, teaching materials and clinical methods used for this test should be re-evaluated. Further research should investigate the value of peroneal muscle testing in clinical ankle evaluation.