Update on Antimicrobial Therapy in Management of Acute Odontogenic Infection in Oral and Maxillofacial Surgery.

This article focuses on the antimicrobial therapy of head and neck infections from odontogenic origin. Odontogenic infections are among the most common infections of the oral cavity. They are sourced primarily from dental caries and periodontal disease (gingivitis and periodontitis). Many odontogenic infections are self-limiting and may drain spontaneously. However, these infections may drain into the anatomic spaces adjacent to the oral cavity and spread along the contiguous facial planes, leading to more serious infections. Antibiotics are an important aspect of care of the patient with an acute odontogenic infection. Antibiotics are not a substitute for definitive surgical management.

Immediate Implants.

Immediate implants have become a popular option for replacing teeth. This article describes the surgical and restorative considerations involved in the planning and placement of an immediate implant. Immediate implants require appropriate hard and soft tissue assessment. Virtual planning can help assist in planning of immediate implants. Radiographic and computed tomographic guidance can help in establishing the relationship between the planned implant to the hard tissue and anatomic structures. This article discusses a technique in fabrication of the immediate provisional and final restoration.

Soft-Tissue Grafting Solutions.

Many soft-tissue grafting solutions are available for reconstruction and restoration of volume and esthetics of keratinized attached mucosa at compromised periodontal and peri-implant interfaces. Presence of healthy soft tissues is crucial for functional and esthetic implant success as well as longevity of natural dentition. The options available each provide unique characteristics with different indications. This article is intended to provide an efficient and comprehensive overview of this topic, covering the essentials of periodontal anatomy and physiology, indications for soft-tissue grafting, and keys in recipient and donor-site preparation, and exploring the available procedural arsenal in soft-tissue grafting.

Interproximal invasion as the basis of a Dental Risk Classification: a pilot study.

An important mission statement for modern dentistry is to maintain patients' implants and teeth for a lifetime. As a corollary, a standardized dental caries risk classification should provide the basis for evidence-based specific therapies. This paper proposes that interproximal caries lesions, also termed "restorative invasion," which destroys natural anatomical tooth structure with periodontal and occlusal sequelae, is a key factor in the cascade of destruction of the dentition and periodontitis. Thus it can serve as the basis for caries risk assessment. The standardized Dental Risk Classification system proposed here can provide a basis for therapeutic modalities as well as for public health assessment and insurance reimbursement.

Theoretical Basis for Virtual Skull Orientation According to Three-Dimensional Frankfort Horizontal Plane for Computer-Aided Surgical Simulation.

PURPOSE: Computer-aided surgical simulation (CASS) is an evolving technology which has significantly affected surgical correction of dentofacial deformities, a key step of which is orientation of the virtual skull model to allow for analysis and treatment planning. Explored in this study is the coplanarity of a 3-dimensional Frankfort horizontal plane (3D FHP). MATERIALS AND METHODS: The 122 17.0 cm field-of-view cone-beam computed-tomogram (CBCT) scans were oriented to a 3D FHP using right porion, right orbitale, and left orbitale. The distance between the 3D FHP and left porion was then measured. The 18 CBCT scans were found to have external fiducial markers which were used for orientation into natural head position (NHP). The distance between left porion and a true horizontal plan coincidental with the right porion was measured. Concordance reliability measures were calculated to compare NHP to 3D FHP. RESULTS: The average distance of left porion to 3D FHP was found to be -0.107 mm (SD = 1.148), and the average distance from the coincidental left porion in NHP was found to be 0.846 mm (SD = 2.611). Concordance reliability calculations shows little consistency between the 2 methods of orientation (P = 0.838). CONCLUSIONS: The data shows coincidence between left porion and 3D FHP. Orientation of the virtual skull model according to 3D FHP offers a quick and easy method for this important step in CASS. Further study is needed for evaluation of this method in vivo.

Bifid Mandibular Canal: A Case Review and Retrospective Review of CBCTs.

PURPOSE: This case presentation and retrospective review of cone-beam computed tomograms is to evaluate prevalence, classification, and demographics of bifid mandibular canals (BMC) to inform practitioners on this variation and avoid untoward complications due to failure to diagnose. MATERIALS AND METHODS: Two thousand one hundred thirty scans were evaluated by 2 oral and maxillofacial radiologists. BMCs were noted and classified according to Naitoh. Demographic data were also collected and analyzed. RESULTS: Twenty-eight patients were noted to have bifid mandibular canal, with an average age of 39 years (± 19.5), with no strong sex predilection. Patients (1.31%) were noted to have bifid canals. A greater percentage of patients were shown to have bilateral bifid canals (42.9%) versus either unilateral side (25% left, 32.1% right), but is statistically insignificant. Prevalence was greatest in types 1 and 3 (35.9% and 51.3%, respectively, P = 0.000011). Types 2 and 4 were much less common. CONCLUSION: BMCs are an important anatomic variation that has implications on any mandibular surgery, including implant surgery. Just more than 1% of patients have this variation, but failure to recognize this in a patient can result in poor outcome, as illustrated in the case presented.

Mandibular Osteomyelitis Associated with Candida Albicans in Marijuana and Heroin Abusers.

Osteomyelitis of the mandible is most commonly caused by bacterial infections and is rarely linked to fungal infections. In 2003, Friedman et al. studied the relationship of multiple drugs including marijuana, opioids, nicotine, and alcohol and its effect on the immune system. It is important to consider potential risks and complications of patients who are immunocompromised and present a history of substance abuse. These complications include infections and osteomyelitis which can be associated with multiple microorganisms; some of the most common microorganisms isolated in mandibular osteomyelitis include Streptococcus, Eikenella, and Candida. Candida albicans is commonly found in the skin and mucosa of healthy individuals; however, it has been proven to cause disease in individuals who are immunocompromised. Two cases of mandibular osteomyelitis after routine dental extractions and a history of drug abuse, including heroin and marijuana, are presented in this case series. These specific infections were resistant to multiple antibiotic therapy and grew C. albicans species in cultures collected. These cases were treated with irrigation and debridement or mandibular resection in combination with antimicrobial treatment and fluconazole with complete resolution. Although osteomyelitis is most commonly caused by bacterial infections, special attention must be given to patients with medical histories of immunosuppression and intravenous drug use. Patients who do not respond to broad-spectrum antibiotics might benefit from bacterial and fungal cultures and sensitivity. Antifungal treatment with an antifungal agent, such as oral fluconazole, is indicated if fungal organisms are yielded in the culture.

Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective 10-Year Multicenter Review.

PURPOSE: The purpose of this study was to analyze maxillofacial trauma sustained by patients at least 75 years old. With the injury patterns identified, treatment recommendations for the contemporary oral and maxillofacial surgeon are made. PATIENTS AND METHODS: This study was a retrospective case series using data from 2 level 1 trauma centers. The variables of interest included age at traumatic event, gender, mechanism of trauma, concomitant injuries, radiographic studies performed, management of maxillofacial injuries, and disposition. Numerical analysis was completed with statistical software. RESULTS: One hundred seventy-six patients at least 75 years old who sustained facial trauma were identified. Ground-level falls caused most cases of maxillofacial trauma in the geriatric population. The median age at the time of trauma was 83 and 85 years for men and women, respectively. The most common injuries were midface fractures. Intracranial hemorrhage was the most common concomitant injury, and all but 1 patient underwent computed tomography of at least the head after their traumatic event. Most maxillofacial injuries were treated without operative repair. CONCLUSIONS: The information gained from this study suggests that oral and maxillofacial surgeons should counsel geriatric patients on the risk of falls and encourage the prevention of potential hazards for falls in their homes.

Opioid Use Disorder in Dental Patients: The Latest on How to Identify, Treat, Refer and Apply Laws and Regulations in Your Practice.

Opioid use disorder is a persistent problem in the United States and has become an important issue to medical and dental professionals. Americans are the largest users of opioids by a large margin. The importance of knowing how to identify, handle, refer, and treat patients with opioid use disorder cannot be understated. This article attempts to educate dental professionals on the current epidemiology of opioid use, explain the physiology of addiction, teach practitioners how to identify chronic opioid users, gives options for treating dental pain, establishes criteria for referring to an addiction specialist, and describes the laws, regulations, and resources available to practitioners. With this article, practitioners should have a greater understanding of the current problem of opioid use disorder and be able to develop a protocol for treating these patients.

Hypotensive anesthesia: Comparing the effects of different drug combinations on mean arterial pressure, estimated blood loss, and surgery time in orthognathic surgery.

UNLABELLED: Sevoflurane, an inhalational hypotensive anesthetic agent with a vasodilatory property, has been commonly used as a single agent to induce hypotension and effectively decrease blood loss in orthognathic surgery. However, it is common for patients to receive other hypotensive anesthetic agents in combination with sevoflurane. The purpose of our retrospective cohort study is to investigate whether administering an additional hypotensive agent has greater effect at reducing mean arterial pressure (MAP), estimated blood loss (EBL) and surgery time during orthognathic surgery. MATERIAL AND METHODS: 57 subjects, aged 0-89 of both genders, who underwent orthognathic surgery were investigated in this study. Each patient's anesthesia records were reviewed to record the following variables of interest: EBL, duration of surgery, and MAP reduction in %. 41 subjects were placed in Group I and they received sevoflurane alone. 16 subjects were placed in Group II and they received sevoflurane plus a "supportive" agent. These "supportive" agents were esmolol, labetalol, metoprolol, nicardipine, and dexmedetomidine. The significant differences between two groups were assessed by using ANCOVA and p < 0.05 was regarded as significant. Wilcoxon signed-rank test was used to look for differences in surgery time. RESULTS: Subjects in Group II experienced a greater reduction in MAP during surgery than subjects in Group I, 27.30% and 20.44%, respectively (p = 0.027). There was no significant difference for sex (p = 0.417) or age group (p = 0.113) in estimated blood loss, however. The mean surgery time in Group I was 1.93, 2.77, and 4.54 h with respect to LeFort, BSSO/IVRO, and double jaw surgery. Patients in Group II had a mean surgery time of 1.73, 2.07, and 5.64 h with respect to LeFort, BSSO/IVRO, and double jaw surgery. No statistically significant difference was demonstrated in surgery time between Group I vs. Group II (p > 0.05). Subjects in Group II experienced, on average, more blood loss than subjects in Group I, 355.50 ml and 238.90 ml, respectively. CONCLUSION: The use of multi-drug combination may offer significant advantage of reducing patients' mean arterial pressure. However, this has no significant effect on reducing blood loss or surgery time in comparison to sevoflurane alone.

Pediatric Maxillofacial Trauma: A Review of 156 Patients.

PURPOSE: To review the epidemiology and management of facial fractures in a pediatric population. MATERIALS AND METHODS: This study was a retrospective review of patients younger than 18 years who presented to a pediatric emergency department during a 5-year period in an urban, academic, level 1 designated trauma center. RESULTS: Of the 156 patients identified, most were boys (87%) and the mean age was 13.5 years (standard deviation, 4.9 yr; interquartile range, 12 to 17 yr). The most common mechanism of injury was assault (48.1%). Mandibular fractures (40.7%) were most common. Multiple fractures occurred in 26.9% of patients. Concomitant injuries occurred in 73.7% of patients, most commonly concussions (39.1%). Intracranial hemorrhages were associated with panfacial (P = .005), frontal (P = .001), and orbital (P = .04) fractures. Most patients (91.7%) were admitted, and nonoperative repair was undertaken in 57.1%. There was an independent association of surgical intervention with age older than 14 years and with mandibular fractures (P < .01). CONCLUSIONS: Assault was the most common mechanism of injury and mandibular fracture was the most commonly encountered. Concomitant nonfacial injuries occurred in most patients. Patients sustaining panfacial, frontal, and orbital fractures should provoke an evaluation for other intracranial injuries. Children older than 14 years and those with mandibular fractures should prompt mobilization of resources for operative repair.

Dental treatment of the pregnant patient: literature review and guidelines for the practicing clinician.

The purpose of this review article is to assist the practicing clinician by categorizing and packaging useful clinical information into a format that will assist with the treatment of pregnant patients. Our goal is to offer the scientific foundations that lead to current practice guidelines, specifically those that are of particular relevance to today's dental professional.

Use of temporary anchorage devices in regaining lost interocclusal space. Case series.

The absence of interocclusal space, a common consequence of trauma, maxillofacial pathology or carious process, causes loss of function, compromised aesthetics for the patient, and represents a major challenge for the restorative dentist. Such cases were treated historically with dental procedures and orthodontic appliances, which, in turn, caused associated unwanted sequelae. The introduction of mini-implants for skeletal anchorage presents a change in treatment paradigm and provides a safe and successful management of the absent space without undesirable side effects. We present three cases of a successful adjustment of vertical correction with temporary skeletal anchorage from mini-implants.

Tonsilloliths appearing as multiple opacities on panoramic imaging: case report.

Tonsilloliths are dystrophic calcifications that can form in tonsillar crypts. They can be asymptomatic or a component of tonsillitis. This article presents a case of tonsilloliths that appeared on a panoramic image as multiple opacities.

Analysis of skeletal mandibular abnormalities associated with cervicofacial lymphatic malformations.

OBJECTIVES/HYPOTHESIS: Many children with cervicofacial lymphatic malformations have facial skeletal abnormalities. This study qualitatively and quantitatively evaluated these bony mandibular abnormalities. STUDY DESIGN: Retrospective chart review. METHODS: Patients with craniofacial lymphatic malformations presenting to a vascular anomalies center during a 2-year period were included. An age-matched control population was found on the Picture Archiving and Communication System database. Three-dimensional reconstructions were created from computed tomography and magnetic resonance imaging. Qualitative observations and quantitative measurements were taken of the gonial angle, mandibular anterior dentoalveolar height, and anterior condylar displacement. RESULTS: There were 23 controls. A total of 21 patients with "beard" distribution malformations were studied; 10 had unilateral and 11 had bilateral disease.Qualitatively, a few patterns emerged: outward ramal flaring, anterior displacement of the mandible, relative ipsilateral facial "hypertrophy," and anterior positioning of the maxilla and orbit. The open-bite deformity was a common finding leading to malocclusion and oral incompetence. Quantitatively, in 67 nondiseased sides, the average gonial angle was 131 degrees (standard deviation [SD] = 6.8), whereas in 32 diseased sides, the average angle was 152 degrees (SD = 14.0, P < 3.8E-09). With half-beard malformations, the diseased side averaged 153.9 and the nondiseased side averaged 140.8 (P = .008). The average condylar displacement was 8.5 mm versus 5.9 mm (diseased vs. nondiseased), and the average mandibular dentoalveolar height to face ratio was 0.37 (control = 0.34). CONCLUSIONS: Cervicofacial lymphatic malformations in the "beard" distribution are associated with significant bony abnormalities leading to both functional and aesthetic sequelae. Our study is the first quantitative analysis of these changes. This is the first step in planning for dentofacial orthopedics, orthodontics, and orthognathic surgery.

Repair of critical size defects in the rabbit calvarium with the use of a novel scaffold material.

A number of materials have been implanted into skull defects to determine if improved healing outcomes can be achieved. In some instances, packing or implanting bone-inducing alloplasts into a standardized skull defect results in better healing than an untreated defect. AlloDerm is a skin derived acellular collagen membrane and has characteristics that are known to be effective in promoting bone growth. It has not been previously investigated for use in cranial bone healing. The aim of the investigation was to determine if implanting this novel scaffold into skull defects will improve the quality of bone repair. Six rabbits received AlloDerm grafts into critical-sized calvarial defects. The rabbits were sacrificed at two months and the specimens examined histologically and radiographically. At the time of sacrifice, it was found that while bony growth had commenced at the margins of the defect and as isolated islands within the graft, there did not appear to be a major benefit in using the material described.

Utilization of three-dimensional computed tomography for craniofacial phenotypic analysis in children with velocardiofacial syndrome.

OBJECTIVES: To analyze variants of the craniofacial phenotypes in children with velocardiofacial syndrome (VCFS) and children with cleft palates with a new protocol of landmarks using a three-dimensional computed tomography (CT)-reconstructed model in a cross-sectional group experimental design. MATERIALS AND METHODS: We present a retrospectively reviewed case series of 21 patients with VCFS, verified by short-tandem repeat techniques, and 20 children with cleft palate with age- and sex-matched controls from the Craniofacial Cleft Department of Oral and Maxillofacial Surgery of the 9th Shanghai People's Hospital. The records during the period between January 2005 and December 2008 were analyzed. The sample population of 41 children in this study was scanned with spiral CT. These images were reconstructed into three-dimensional models by SimPlant 11.2 and were analyzed with a new protocol of landmarks to test the variants of craniofacial phenotypes. RESULTS: All of the children with VCFS demonstrated velopharyngeal incompetence and craniofacial deformities. Measurements in the standard coordinate system demonstrated significant shorter cranial base, cervical vertebrae, longer maxilla height, and palatal angle. For the velopharyngeal variants, greater depth but lesser width of the pharyngeal cavity was shown in the VCFS group. CONCLUSIONS: Three-dimensional CT can provide precise data on craniofacial variants in children with distinctive morphologic features of VCFS.

Skeletal facial balance and harmony in the cleft patient: Principles and techniques in orthognathic surgery.

The management of the palatal cleft, dental arch, and subsequent maxillary form is a challenge for the craniomaxillofacial surgeon. The purpose of this paper is to present the experience of a senior surgeon (KES) who has treated over 2000 patients with cleft lip and palate. This paper focuses on the experience of a recent series of 103 consecutive orthognathic cases treated by one surgeon with a surgical-orthodontic, speech-oriented approach. It will concentrate on not only correcting the occlusion, as others have described, but also on how a surgeon who was trying to achieve optimal aesthetic balance, harmony, and beauty, approached this problem.

Reviewing the orthognathic surgical care of the patient with cleft lip and palate: the single surgeon experience.

Patients with cleft lip and palate are best treated in a multidisciplinary setting and benefit from being treated by experienced surgeons in high-volume centers. We present the evaluation of 103 consecutive patients with cleft lip and palate treated by a senior craniofacial surgeon. The results of orthognathic surgery in respect to function, stability, cosmesis, and complications are audited.