Challenging the Orthodoxy of Mandibular Reconstructions Comparing Functional Outcomes in Osseous versus Soft Tissue Reconstructions of the Posterolateral Mandible.

BACKGROUND: Appropriate reconstruction of the posterolateral mandible remains controversial. Both osseous and soft tissues are vital components for an overall successful outcome and are often combined in complex defects. Their respective effect on oromandibular function in the reconstruction of different degrees of mandibular defects has been less evaluated. This study aimed to compare patient-perceived oromandibular function in osseous and soft tissue-only reconstructions following posterolateral mandibular defects, defined as limited or extended. PATIENTS AND METHODS: A 10-year retrospective review of consecutive patients undergoing mandibular reconstructions of the posterolateral mandible were identified. Limited defects were defined as reaching from the ipsilateral parasymphysis to anterior of the coronoid (sparing insertion of muscles of mastication). Extended defects were defined as reaching from the ipsilateral parasymphysis to posterior of the coronoid (sacrificing the muscle insertions). Functional outcomes were assessed using the University of Washington Quality of Life questionnaire, version 4. RESULTS: A total of 163 patients were identified, of which 41 patients had the particular posterolateral mandibular resections sought after. In 23 limited resections, there was no difference in functional outcome between osseous and soft tissue-only reconstructions. In 18 patients undergoing extended resections, osseous reconstructions demonstrated significantly better outcomes (p = 0.011). There were no significant differences in patient demographics between the groups. CONCLUSION: Our study highlights the interest of soft tissue-only reconstructions of the posterolateral mandible. Limited resections seem not to benefit from complex osseous reconstruction for adequate function. Conversely, there is a noteworthy positive impact on functional outcomes in extended posterolateral mandibulectomies reconstructed with osseous tissue, compared with soft tissue only. Although a larger study is needed to identify a stronger relationship, these preliminary results could aid reconstructive decisions, particularly when considering patient morbidity.

Oral cancer involving masticator space (T4b): Review of literature and future directions.

The oral cancer with masticator-space involvement is classified as T4b disease. The limited data suggest that the masticator space is a complex anatomic area and tumors with varying degrees of infiltration may have different oncologic outcomes. It is not advisable to group all T4b tumors as one and consider them for palliative-intent treatment. A group of patients with limited spread (infra-notch) has potential for good outcome. These cancers can be considered for downstaging to T4a classification based on best available data and clinical considerations. The radical surgical resection remains the mainstay of curative-intent treatment and the ability to achieve negative margins at the skull base remains the most important prognostic factor. The alternative approaches to either increase radicality of surgery or to downsize the tumor with neoadjuvant therapies have shown encouraging trends but larger, well designed, and prospective studies will be needed to make meaningful conclusions. It is important to rationalize and form common ground for further research.

Observation of Effects of Different Surgical Treatments on Unilateral Masticatory Muscle Spasm.

BACKGROUND: Unilateral masticatory muscle spasm is a rare disease without a generally accepted and efficacious treatment plan. OBJECTIVE: We sought to compare the effects of different surgical treatments on unilateral masticatory muscle spasm. METHODS: A retrospective analysis of the surgical treatment and effects of 10 cases of unilateral masticatory muscle spasm occurred between February 2010 and September 2016. Three cases underwent complete amputation of the trigeminal motor branch, 3 cases underwent partial amputation of the trigeminal motor branch, and 4 cases received only vascular decompression. All patients were followed up by telephone interview after surgery. RESULTS: In the simple vascular decompression group, 3 cases were cured and 1 was cured after a delay. Of these 3 cases, 1 case became aggravated 2 years after the operation, 1 case became aggravated 5 years after the operation, and 1 case showed no change during the follow-up period. In the partial amputation group, 2 cases were cured and 1 case was alleviated. Of the 2 patients who were cured, 1 suffered recurrence 2 years later, while the other case showed no recurrence during the follow-up period. In the complete amputation group, 1 case was cured with a delay and 2 cases were cured immediately with no recurrence during the follow-up. Mild atrophy of the temporal muscle occurred gradually with no restriction of the mouth opening in 2 cases. CONCLUSIONS: Complete amputation of the trigeminal nerve did achieve better effects than pure microvascular decompression and partial amputation of the trigeminal motor branch, but it may lead to mild temporal muscle atrophy.

Masticator Space Foreign Body in a Child Presenting With Otorrhea and Granulation Tissue of the External Auditory Canal.

OBJECTIVE: We report an unusual case of masticator space foreign body in a patient presenting with otorrhea and granulation tissue within the external auditory canal (EAC). METHODS: Case report. RESULTS: A 16-month-old male presented with fever, unilateral otorrhea, facial swelling, leukocytosis, and granulation tissue within the EAC that failed to respond to conventional medical treatment. Computed tomography scan showed EAC and middle ear opacification and soft tissue swelling involving the masticator space. Given concerns for malignancy, biopsies of tissue within the EAC and of a newly detected right buccal mass were performed, revealing granulation tissue. Concern persisted for neoplasm, however, and magnetic resonance imaging was obtained, showing a masticator space foreign body and possible osteomyelitis of the mandible and pterygoid plates. The patient underwent urgent operative removal of a 3 cm crayon fragment from the masticator space and debridement of granulation tissue arising from a small defect at the inferior medial cartilaginous EAC. He likely sustained foreign body injury several weeks earlier upon falling from standing height while biting a crayon. Postoperatively, he was observed in hospital on intravenous antibiotics and improved significantly. He has since fully recovered. CONCLUSION: Masticator space foreign bodies may present with erosion and granulation tissue of the EAC.

Microvascular Decompression for Hemimasticatory Spasm: A Case Report and Review of the Literature.

BACKGROUND: Hemimasticatory spasm is a rare clinical entity characterized by involuntary and paroxysmal contractions of the jaw-closing muscles on 1 side of the face. Although its cause is not fully known, vascular compression of the trigeminal nerve has been speculated. CASE DESCRIPTION: Here, we report 1 case of hemimasticatory spasm that was cured by microvascular decompression of the motor branch of the trigeminal nerve; a relevant literature review was also performed. CONCLUSIONS: Hemimasticatory spasm is a rare disease that may be recalcitrant to conservative medical therapy, and vascular decompression of the trigeminal nerve may be required to relieve the spasm.

Pathology of advanced buccal mucosa cancer involving masticator space (T4b).

BACKGROUND: Buccal mucosa cancer involving masticator space is classified as very advanced local disease (T4b). The local recurrence rate is very high due to poor understanding of the extent of tumor spread in masticator space and technically difficult surgical clearance. The objective of this study is to understand the extent of tumor spread in masticator space to form basis for appropriate surgical resection. MATERIALS AND METHODS: All consecutive patients with T4b-buccal cancer underwent compartment resection, with complete anatomical removal of involved soft-tissue structures. Specimens were systematically studied to understand the extent of invasion of various structures. The findings of clinical history, imaging and pathologic evaluation were compared and the results were evaluated. RESULTS: A total of 45 patients with advanced buccal cancer (T4b) were included in this study. The skin, mandible and lymph nodes were involved in 30, 24 and 17 cases respectively. The pterygoid muscles were involved in 34 cases (medial-pterygoid in 12 and both pterygoids in 22 cases) and masseter-muscle in 32 cases. Average distance for soft-tissue margins after compartment surgery was 2 cm and the margins were positive in 3 cases. The group with involvement of medial pterygoid muscle had safest margin with compartment surgery while it was also possible to achieve negative margins for group involving lateral pterygoid muscle and plates.The involvement of pterygomaxillary fissure was area of concern and margin was positive in 2 cases with one patient developing local recurrence with intracranial extension. At 21 months median follow-up (13-35 months), 38 patients were alive without disease while two developed local recurrence at the skull base. CONCLUSIONS: T4b buccal cancers have significant soft-tissue involvement in the masticator space. En bloc removal of all soft-tissues in masticator space is advocated to remove tumor contained within space. The compartment surgery provides an opportunity to achieve negative margins for cancers actually contained within masticator space.It is inappropriate to club all patients with masticator space involvement in one group.

Free flap reconstruction after surgical release of oral submucous fibrosis: long-term maintenance and its clinical implications.

BACKGROUND AND AIM: Oral submucous fibrosis (OSF) is an insidious disease with progressive limitation of mouth opening and potential malignant change of the oral mucosa. Cancer surveillance is of utmost importance, but it is often limited by severe trismus. Surgical release and free flap reconstruction is effective but its long-term efficacy has not been completely established. This work aims to review our experience in the past 15 years in surgical release of OSF-related trismus followed by free flap reconstruction. METHODS: Patient's age, gender, smoking history, drinking history and betel-nut consumption history were retrieved. Surgical release and reconstructive procedures were detailed. Inter-incisor distances (IIDs) were measured preoperatively (PO-IID), intra-operatively after maximal release (IO-IID) and during the last follow-up (FU-IID). Subsequent development of oral cancers (oral squamous cell carcinoma, OSCC) and relevant details were documented. Potential predictors of long-term IID gain were analysed. RESULTS: A total of 92 patients were included in our study. There was a significant difference (p = 0.000) in PO-IID (13.8 ± 6.6 mm) and FU-IID (27.2 ± 8.8 mm) indicating the long-term efficacy of the release procedure. The mean long-term IID gain was 13.0 ± 7.5 mm. Bilateral coronoidectomy resulted in a greater degree of intra-operative gain in IID (p = 0.025). PO-IID (r = -0.277, p = 0.001) and intra-operative gain in IID (r = 0.198, p = 0.001) were found to be predictive of long-term IID gain. Ten patients (11%) developed OSCC during our study period. CONCLUSIONS: Aggressive surgical release (with bilateral coronoidectomy if necessary) followed by free flap reconstruction is an effective treatment for OSF-related trismus. Our study has confirmed its long-term efficacy and its important role in cancer surveillance.

Treatment of hemimasticatory spasm with microvascular decompression.

Hemimasticatory spasm is a rare disorder characterized by paroxysmal involuntary contraction of the jaw-closing muscles. As the ideology and pathogenesis of the disease are still unclear, there has been no treatment that could give rise to a good outcome so far. Herein, we tried to use surgical management to cure the disease. Six patients with the disease were included in this study. These patients underwent microvascular decompression of the motor fibers of the trigeminal root. After the operation, all faces of the patients felt relaxed at varied degrees, except for 1 patient. Our study showed that microvascular decompression of the trigeminal nerve could lead to a better outcome. However, a control study with a large sample is needed before this technique is widely used.

Subperiosteal midface-lift.

The subperiosteal midface-lift has benefited from significant technological advances in medicine. The endoscope now allows extensive subperiosteal undermining of facial soft tissue through minimal access incisions. Improved understanding of facial anatomy and the facial aging process now allow repositioning and remodeling of the soft tissue envelope with excellent aesthetic results. The subperiosteal midface-lift by a temporal approach is a procedure designed to rejuvenate the middle third of the face. After subperiosteal detachment, the soft tissues of the cheek, jowls, lateral canthus, and inferior orbital rim can be lifted to reestablish their youthful relationship with the underlying skeleton. It is a technique that produces satisfactory cosmetic results in most cases, causing malar augmentation, nasolabial fold improvement, and mild jowl improvement. We describe our preferred technique in detail and discuss its indications, complications, advantages, and limitations.

[Marionette fold treatment by depressor anguli oris section: technical note]. / Traitement des plis d'amertume par section du depressor anguli oris: note technique.

Marionette folds are typical signs of facial aging. They result from contraction of depressor anguli oris (DAO) muscle, which tracts the corner of the mouth inferiorly and laterally. Marionette folds express sadness, contrary to the real mood of patient, and constitute a purpose of consultation. A systematic classification of facial aging types has been developed by Glogau in 1994. It differentiates four types of wrinkles according to their severity. Type IV of marionette folds resists to treatment with filler injection or botulinum toxin type A. Some authors, like Le louarn C., have developed surgery techniques to correct those types IV of marionette folds. In this article, we describe the DAO section technique we use. Intervention occurs under local anaesthesia, by intrabuccal approach. Horizontal mucosal incision is performed 1cm long, at the vestibular projection of DAO insertion. Orbicularis oris and buccinator muscles are retracted horizontally to let appear the DAO fibers, which are cut until subdermal fat is seen. This technique must be completed by botulinum toxin type A injection in the inferior part of the DAO to avoid muscular regeneration. DAO section is an easy, quick and efficient surgery, which allows perennial correction in marionette folds treatment. It completes other less invasive techniques to enlarge therapeutic possibilities available for surgeons and patients.

Myositis ossificans traumatica of the masticatory muscles.

Myositis ossificans traumatica (MOT) is a disease in which muscular ossification develops following trauma. Almost all cases of MOT are found in skeletal muscle. The authors report in a 39-year-old man MOT involving several muscles in the head and neck, namely, bilateral masseter muscles, the left temporal muscle, the left lateral pterygoid muscle, and the left frontal muscle. Involvement of the lateral pterygoid muscle is especially rare.

Coronoidectomy, masticatory myotomy and buccal fat pad graft in management of advanced oral submucous fibrosis.

The purpose of this study is to evaluate coronoidectomy, masticatory myotomy and buccal fat pad graft in advanced (Stage III-IV) oral sub mucous fibrosis (OSF). 10 patients with clinically and histologically confirmed advanced OSF underwent surgery entailing bilateral coronoidectomy, masticatory muscle myotomy and closure with a pedicled buccal fat pad graft followed by vigorous mouth opening exercises. The result was evaluated using the interincisal distance at maximum mouth opening as the objective outcome measure over a follow up period of 12 months. Results showed a mean interincisal opening of 14.7 mm preoperatively and 32.5 mm at 12 months postoperatively. Relapse was encountered in one patient who did not cooperate with the postoperative exercise regime. Results suggest this regime is effective.

Myositis ossificans circumscripta involving bilateral masticatory muscles.

Myositis ossificans (MO), as its name implies, is ossification and bone formation within a muscle. Pathogenesis is not all clear, but trauma is universally recognized as a trigger event. Myositis ossificans can be divided into 2 classifications: MO progressiva and MO traumatica. When it affects the muscles of mastication, it causes severe trismus. This rare disorder and its limited treatment options can potentially have debilitating effects to the patient's normal oral functioning and health. A computed tomographic scan and panoramic radiographs are essential diagnostic aids for evaluating conditions such as MO. Myositis ossificans can be one of the causes of extra-articular temporomandibular joint ankylosis. Surgical excision of the ossification is the main treatment modality. This is a case report of a patient who developed MO of the muscles of mastication.

[Diagnostics and treatment of patients with mandible salient angles].

Problem of diagnostics and treatment of patients with disproportion of lower face zone was discussed which was expressed in the form of mandible salient angles and produced aesthetic problem to many people especially to womanhood. Complex of diagnostic methods was offered that gave the possibility to differentiate types of pathology into groups for easing method of treatment chose. Methods of treatment were listed allowing to receive high aesthetic and functional results.

Activities of masticatory muscles in patients before orthognathic surgery.

AIM: To compare the influence of occlusal versus craniofacial characteristics on the functionality of the stomatognathic apparatus. MATERIALS AND METHODS: Two groups of subjects were selected: 27 patients (13 women and 14 men), 18 to 42 years old, all candidates for orthognathic surgery, 7 with prognathic syndrome and 20 with progenic syndrome; and 26 healthy young adults (13 women and 13 men) of corresponding age (control group). To verify the neuromuscular equilibrium induced by occlusion, the electromyographic activities of both right and left masseter and anterior temporal muscles were recorded and analyzed, calculating the percentage overlapping coefficient (an index of the symmetric distribution of the muscular activity determined by the occlusion) and TORS (index of the presence of mandibular torque). Data were compared with Student t-test for independent samples. RESULTS: Between the 2 groups of patients, no statistically significant differences were found, whereas the statistical analysis showed differences between patients and control subjects (P < 0.05): overall, the control subjects had a better neuromuscular stability than the patients who were candidates for orthognathic surgery. CONCLUSIONS: The electromyographic evaluations revealed that there was a neuromuscular imbalance determined by an occlusal instability in the patients candidates for orthognathic surgery, thus indicating that occlusion plays a more important role than any possible mechanical disadvantages due to altered craniofacial morphology.