Transoral Endoscopic Plating for Orbital Blowout Fractures.

ABSTRACT: Orbital fractures account for up to 40% of craniofacial injuries. In this article, the authors present the transoral endoscopy-assisted plating technique for treating orbital blowout fractures (OBF). A retrospective analysis of 56 cases treated with transoral endoscopy-assisted approach was performed. Immediate versus delayed surgery decision-making was performed by using our 2-week algorithm. The surgical technique included only transoral incisions, forced duction and "pulse" tests, osteotomy, endoscopic inspections, the reduction with a curved elevator and an indwelling balloon, the retrieval of prolapsed fatty tissue back into the orbit, removal of sharp bony fragments, adaptation of the titanium mesh to the orbital floor and its fixation with screws to stable bony structures, reattachment of the osteotomized lateral wall, and postoperative computed tomography (CT) scan with 3D CT reconstruction. The overall success rate of surgeries was 96%. The resolution of comorbidities resulted in a normal globe position, normal eye movement, and the resolution of diplopia. Postoperative complications were insignificant with one case of surgical edema and one case of infection and sequestration that appeared six months after surgery. These results remained unchanged after 20 to 24 months of follow-up. The suggested minimally invasive transoral technique can be effectively implemented in cases of OBF as well as in cases when the medial wall of the orbit is involved. Our results presented a high success rate with minimal rate of complications, thus our technique is a safe way with minimal morbidity for treating OBF.

Complications of sialendoscopy: personal experience, literature analysis, and suggestions.

PURPOSE: This article describes our experience combined with analysis of the emerging literature, presenting suggestions of how to avoid the complications that may arise during or after endoscopic or endoscopy-assisted surgery of the salivary glands. MATERIALS AND METHODS: In a retrospective study, the surgical data of 498 consecutive patients who underwent surgery for calculus removal from the parotid, submandibular, and sublingual glands from 2010 to 2012 were collected and analyzed. The analysis was concentrated on specific complications of endoscopic or endoscopy-assisted operations. RESULTS: The patients were operated on by various sialendoscopy-involved techniques that included intraductal endoscopy and an endoscopy-assisted extraductal approach. The total percentage of complications associated with endoscopy was 3.23% (n = 17). In 1 case (0.2%) (submandibular gland surgery), severe bleeding occurred that required immediate gland resection. CONCLUSIONS: At present, sialendoscopic and endoscopy-assisted techniques produce a minimal number of postsurgical endoscopy-related complications, but they are not complication-free operations. Strictures, ranulas, and lingual nerve paresthesias are the most frequent of these complications. Further reduction of the number of complications is possible with careful preprocedural imaging analysis and correct endoscopic techniques.

Voltage-Dependent Anion Channel 1 Expression in Oral Malignant and Premalignant Lesions.

BACKGROUND: The voltage-dependent anion channel 1 protein (VDAC1) plays a role in cellular metabolism and survival. It was found to be down or upregulated (overexpressed) in different malignancies but it was never studied in application to oral lesions. The purpose of this study was to retrospectively evaluate the expression of VDAC1 in biopsies of oral premalignant, malignant, and malignancy-neutral lesions and to examine the possible correlations to their clinicopathological parameters. MATERIALS AND METHODS: 103 biopsies including 49 oral squamous cell carcinoma, 33 epithelial dysplasia, and 21 fibrous hyperplasia samples were immunohistochemically stained with anti-VDAC1 antibodies for semi-quantitative evaluation. The antibody detection was performed with 3,3'-diaminobenzidine (DAB). The clinicopathological information was examined for possible correlations with VDAC1. RESULTS: VDAC1 expression was lower in oral squamous cell carcinoma 0.63 ± 0.40 and in oral epithelial dysplasia 0.61 ± 0.36 biopsies compared to fibrous hyperplasia biopsies 1.45 ± 0.28 (p < 0.01 for both; Kruskal-Wallis test). CONCLUSION: Oral squamous cell carcinoma and epithelial dysplasia tissues demonstrated decreased VDAC1 protein expression if compared to fibrous hyperplasia samples, but were not different from each other, suggesting that the involvement of VDAC1 in oral carcinogenesis is an early stage event, regulating cells to live or die.

Intra-oral Acantholytic Squamous Cell Carcinoma: 55 Cases. Is this Variant more Aggressive?

We aimed to collect and analyze available cases of intraoral acantholytic squamous cell carcinoma (aSCC), that consisted of the authors' cases and cases derived from the existing literature, with an emphasis on the pathological staging and patient outcome. Our research question was whether aSCC is more aggressive than conventional SCC. The literature was searched for documented cases of aSCC involving the intra-oral mucosa, excluding those from the lips and tonsils, and seven new cases were added from our files. The authors compared the obtained aSCC data to existing data for conventional SCC. Fisher Exact or Pearson's χ2 tests were used for categorical variables. Fifty-five cases of intraoral aSCC were reviewed, of which 48 were retrieved from the literature. Analysis of the published cases was reinforced by contacting the authors of all the papers with incomplete data for further clarifications. The most common sites of aSCC were the tongue (24/55) and the maxilla/maxillary gingiva and/or palate (11/55). The overall survival rate was 36/53 (67.9%) with a mean follow-up period of 22 months against 62.5% for conventional SCC (p = 0.6). No statistically significant difference between the two variants of the tumor with respect to the oral cavity was detected. The differences in age, sex, survival rate, staging, and locations were not statistically significant. Based on the available data from 55 cases, there is no evidence to suggest that aSCC is more aggressive than conventional SCC in intraoral cases.

Endoscopic approach to dental implantology.

OBJECTIVE: To describe an innovative miniature visualization surgical endoscope and endoscopic techniques applicable to dental implant procedures. MATERIALS AND METHODS: A newly developed modular dental implant endoscope is introduced, and the first impressions from its use in different implant procedures are reported. RESULTS: Details of the device that combines an endoscope, irrigation cannulas, and a surgical microinstrument channel are presented. The advantages of using it in dental implant procedures are described, and examples of how miniature visualization and surgical endoscopic techniques can be applied to increase the success of implantation are outlined. The new modular implant endoscope accurately identified all microanatomical and pathological structures, and simplified dental implant procedures. CONCLUSION: Endoscopy should be considered not only for intraoperative observation and assessment of implant sites, but also should be applied for active assistance during implant placement procedures.

Endoscopic treatment of salivary glands affected by autoimmune diseases.

PURPOSE: To asses the possibility of an endoscopic technique to diagnose, treat, and maintain the salivary glands in patients with Sjögren syndrome and systemic lupus erythematosus. PATIENTS AND METHODS: A total of 8 patients with Sjögren syndrome and 2 with systemic lupus erythematosus with affected salivary glands were included in the present study. The treatment approach included parotid sialoendoscopy with thorough rinsing, and Stenson's duct dilation using hydrostatic pressure and a high-pressure balloon. Hydrocortisone 100 mg was injected through direct vision into the duct. The study was exempt by the Barzilai Medical Center review board. RESULTS: The main diagnosis of the patients was chronic recurrent parotitis, with the exception of 1 patient, who presented with salivary stones. CONCLUSIONS: The pathologic features of the salivary glands resulting from Sjögren syndrome and systemic lupus erythematosus can be managed successfully using an endoscopic approach.

Endoscopy in endodontics.

A successful outcome of endodontic treatment depends to a large extent on accurate intraoperative findings. Conventionally, micromirrors and microprobes have been used for this purpose. The dental operating microscope (DOM) has been implemented to enhance visibility during dental procedures. However, the microscope, a sizable tool, remains between operating field and the dental practitioner, making his ability to manipulate more complicated. Also, the interference of the hands and the handpiece with the visualization of the surgical field and inaccurate observation of the endodontic instruments during the procedure. Endoscopy reportedly provides the dentist with excellent vision and ease of use. It also provides a better intraoperative visualization in comparison with micromirrors. Further development of endoscopy made it possible to combine magnification, light, irrigation/suction and surgical microinstruments in one device. This combination could lead to an advanced root canal treatment technique.

Surgical approach to a severe case of sodium hypochlorite accident: a case report and review of the literature.

Sodium hypochlorite (NaOCl) is the most common irrigant used in modern endodontics due to the antimicrobial properties against bacteria, the powerful oxidative activity, and the ability to dissolve organic soft tissues. When NaOCl extrudes the apex of the root, commonly referred as "sodium hypochlorite accident," it can lead to devastating outcomes leading to long-term functional and esthetic deficits. Currently, no clear guidelines exist as to how these patients should be managed. The purpose of this paper is to present a case report and a review of literature and to propose an adequate surgical treatment protocol for this unfortunate event.

Combined external lithotripsy and endoscopic techniques for advanced sialolithiasis cases.

PURPOSE: To assess a combined external lithotripsy-sialoendoscopy method developed for advanced salivary gland sialolithiasis. MATERIALS AND METHODS: A total of 94 patients (43 males and 51 females) underwent these treatment methods. Of these 94 patients, 60 had pathologic features in the submandibular gland and 34 in the parotid gland. A miniature external lithotripter was used, combined with multifunctional sialoendoscopes and endoscopic-assisted techniques, to achieve effective removal/elimination of the stones in these difficult cases. RESULTS: Total elimination of the stone using lithotripsy alone was achieved in 32% of the cases; in 29%, intraductal endoscopic assistance was needed. In the remaining 39%, the removal of a stone was achieved with the help of an endoscopy-assisted extraductal approach (37 cases). At 6 months of follow-up, all patients who had undergone lithotripsy or lithotripsy plus intraductal endoscopy had an absence of symptoms. Of the 37 patients who had undergone an endoscopy-assisted extraductal approach, 35 (95%) remained asymptomatic. CONCLUSIONS: Lithotripsy plus intraductal or extraductal endoscopic treatment of sialolithiasis is a highly effective surgical method of eliminating/removing salivary stones, especially those attached to the surrounding tissue and in the secondary ducts. This method helps to avoid resection of the salivary glands and represents an additional development of minimal invasive surgical techniques.

Long-term experience with endoscopic diagnosis and treatment of juvenile recurrent parotitis.

PURPOSE: Juvenile recurrent parotitis (JRP) is characterized by intermittent swelling of one or both parotid glands simultaneously or on different occasions. The peak incidence of JRP is between the ages of 3 and 6 years, with predominance among males. The etiology and mechanism are still unknown. The diagnosis is made on a clinical basis and is confirmed by ultrasonography or sialography. Our objective was to present our long-term experience with endoscopic diagnosis and treatment of JRP. PATIENTS AND METHODS: In this clinical review we report our long-term experience in 70 children who were treated by a combined minimally invasive endoscopic method. Another 5 patients with adult-type JRP were included in the study. RESULTS: In 93% of the patients a single treatment was enough to resolve this phenomenon and prevent its recurrence. CONCLUSION: Sialoendoscopy and lavage of the parotid gland comprise the treatment of choice for JRP, achieving a high success rate with minimal morbidity.

Oral vs. pharyngeal dysphagia: surface electromyography randomized study.

BACKGROUND: A clear differential diagnosis between oral and pharyngeal dysphagia remains an unsolved problem. Disorders of the oral cavity are frequently overlooked when dysphagia/odybophagia complaints are assessed. Surface electromyographic (sEMG) studies were performed on randomly assigned patients with oral and pharyngeal pathology to evaluate their dysphagia complaints for the sake of differential diagnosis. METHODS: Parameters evaluated during swallowing for patients after dental surgery (1: n = 62), oral infections (2: n = 49), acute tonsillitis (3: n = 66) and healthy controls (4: n = 50) included timing and amplitude of sEMG activity of masseter, infrahyoid and submental muscles. RESULTS: The duration of swallows and drinking periods was significantly increased in dental patients and was normal in patients with tonsillitis. The electric activity of masseter was significantly lower in Groups 1 and 2 in comparison with the patients with tonsillitis and controls. The submental and infrahyoid activity was normal in dental patients but infrahyoid activity in patients with tonsillitis was high. CONCLUSION: Dysphagia following dental surgery or oral infections does not affect pharynx and submental muscles and has clear sEMG signs: increased duration of a single swallow, longer drinking time, low activity of the masseter, and normal range of submental activity. Patients with tonsillitis present hyperactivity of infrahyoid muscles. These data could be used for evaluation of symptoms when differential dental/ENT diagnosis is needed.

Endoscopic surgery of the salivary glands.

Obstructive sialadenitis, with or without sialolithiasis, represents the most common inflammatory disorder of the major salivary glands, and sialolithiasis is one of the major causes of sialadenitis. Calculi in the salivary glands can be found in 1.2% of the general population. Other common causes of salivary gland obstruction are ductal strictures and kinks. The diagnosis of these problems has been traditionally hampered by the limitations of standard imaging techniques. Satisfactory management depends on the surgeon's ability to reach a precise anatomic diagnosis and to accurately locate the obstruction.

Graftless sinus floor augmentation with an internal-port implant: long-term experience.

OBJECTIVE: The objective was to assess the outcome of graftless sinus floor augmentation associated with dental implant placement performed with an implant system that has an internal port and screw, combined with the osteotome technique. METHOD AND MATERIALS: Between 2012 and 2018, 722 titanium-aluminum-vanadium implants (Ti-6Al-4V ELI, diameter 3.75/4.20 mm) were placed in 331 patients. Implants 11.5 mm in length were inserted in maxillae with bone level ≤ 5 mm, and 13.0-mm-long implants were inserted in maxillae with bone level of > 5 to 8 mm. In all cases, no graft materials or bone substitutes were used for the sinus elevation. Implant condition was assessed at three different centers and the follow-up period ranged from 6 months to 7 years. RESULTS: In total, 412 11.5-mm-long implants and 310 13-mm-long implants were inserted. Implantation was successful in 689 implants (95.4%), based on cone beam computed tomography and clinical evaluation as well as the patients' experience, with no statistically significant difference between the 11.5-mm and 13.0-mm implants. The complication rates were comparable between cases with bone levels from 3 to 5 mm and the > 5- to 8-mm bone level cases. CONCLUSIONS: The port and screw implant system may allow maxillary sinus augmentation without grafting or bony substitute. This can simplify relatively major surgery, such as a sinus augmentation procedure, to a less invasive procedure and potentially reduce the risk of complications.

Oral variant of acantholytic squamous cell carcinoma-Histochemical and immunohistochemical features.

Acantholytic squamous cell carcinoma (ASCC) is an uncommon variant of squamous cell carcinoma (SCC). It is characterized by a combination of typical SCC and pseudoglandular structures, dyskeratotic cells and prominent acantholysis. The purpose of this study was to analyze the histochemical and immunohistochemical characteristics of the intraoral variant of ASCC. Cases of intraoral ASCC were retrieved from the English language literature. Four new cases from our files were added. In total, 35 cases were included and analyzed in this study. The mean age of the patients was 61.5 + 13 years (age range 38-92 years), with a male-to-female ratio of 1.7:1. According to the available data, histochemical and immunohistochemical stains for mucins were found to be consistently negative. E- cadherin, a marker of adherens junctions, was usually reported to be expressed in areas of "typical" (non acantholytic) SCC, but reduced in the acantholytic areas. We examined for the first time the expression of claudin 1, a marker of tight junctions, and found it to be reduced in the acantholytic areas, similar to E-cadherin. Several cases of oral ASCC also expressed vimentin and cytokeratin (CK) 19, markers associated with epithelial-mesenchymal transition. A wide range of non-epithelial markers yielded negative immunoreactions. In conclusion, ASCC is an uncommon variant of squamous cell carcinoma. The acantholytic process appears to involve reduced expression of molecular components of both adherens junctions and tight junctions. These findings could suggest a relation to the epithelial mesenchymal transition process and therefore further studies are needed in order to establish such a link and the subsequent possible impact on the clinical outcome of the patients.

Rare variants of head and neck squamous cell carcinoma -differential immunohistochemical profiles.

We aimed to immunohistochemically characterize the pattern of expression of epithelial markers in rare head and neck squamous cell carcinoma (HNSCC) variants: carcinoma cuniculatum (CC) and adenosquamous carcinoma (ASC). We also present an additional variant of HNSCC with concomitant basaloid and squamous components that has overlapping morphological features with odontogenic and non-odontogenic tumors, which we termed basalo-squamous carcinoma (BSC). The selected markers included CK5/6, p40, CK19, BerEP4, p16 and SOX10. All tumors were CK5/6 and p40 positive. CK19 and BerEP4 were positive in BSC and focally in ASC but negative in CC. p16 was positive in 3 (60%) of the CCs, focally positive in ASC and negative in BSC. SOX10 was negative in all three variants. Our results highlight the plasticity of the lining epithelium revealing differential profiles of immuno-expression of the selected molecular markers, possibly reflecting their diverse histopathogenesis.

Endoscopic treatment of salivary gland injuries due to facial rejuvenation procedures.

OBJECTIVE: The purpose of this article is to describe innovative surgical techniques for treatment of salivary gland injuries caused by facial rejuvenation procedures. METHODS: Between 2001 and 2007, a total of 14 patients, all females ages 46 to 70 who suffered from salivary gland injuries caused by facial rejuvenation procedures, were treated, primarily by an endoscopic-guided technique that involved location of the injury and endoscopic repair. RESULTS: There were four types of postsurgical injuries of the salivary glands that were caused by operations for facial rejuvenation: 1) compression of salivary ducts with temporary swelling (n = 1); 2) laceration of the capsule of the salivary gland (n = 3); 3) stretching and compression of the ducts with penetration of the capsule of the duct leading to sialocele and long-term swelling (types 1 and 2 combined) (n = 5); and 4) complete cut or penetration of the main salivary duct or of one of its main branches resulting in sialocele (n = 5). The endoscopic technique treatment was successful in all cases. CONCLUSION: The main reasons for salivary gland injuries due to facial rejuvenation procedures in our patients were: poor anatomical identification of the border between the superficial muscular aponeurotic system (SMAS) and the parotid capsule; penetration of the salivary gland capsule by blunt or sharp dissection; unnecessary use of sharp-tip scissors; and a tear of the salivary duct by hooks during a face-lift procedure. Plastic surgeons should be aware of these complications and try to improve their techniques accordingly. To avoid atrophy of the salivary gland, once the diagnosis it made, it is advisable to send the patient to a maxillofacial or ENT surgeon skilled in endoscopy.

Salivary gland injury subsequent to implant surgery.

Implant-based prosthetic restoration and oral rehabilitation is a very popular modality of treatment, with excellent success rates. Although a relatively safe procedure, implant insertion has its risks, which have been described in the literature. This article describes an as-yet unreported complication following implant insertion-salivary gland injury. The characteristics of salivary gland injury are examined, and 4 cases in which the salivary apparatus was injured or obstructed during 1 of the phases of implant therapy are presented.

Transimplant antral lavage as minimally invasive treatment of chronic rhinosinusitis: Preliminary report of 11 consecutive cases.

OBJECTIVE: The present article reports how a dental implant with an internal port dental implant valve approach (DIVA) can be utilized as oroantral port to treat chronic rhinosinusitis (CRS) in a minimally invasive manner. METHOD AND MATERIALS: Eleven patients (age mean 68.1 years) with CRS were subjected to the transimplant lavage technique. For three patients the CRS treatment was performed via previously installed dental implants, and for another eight patients the implantation procedure was combined with the CRS treatment. The moment the implant was fully installed, the sinus membrane was punctured via the implant channel. Upon completion of the pus drainage the sinus was irrigated with normal saline, followed by the injection of a steroid solution (100 mg hydrocortisone). RESULTS: Patients began to report symptomatic improvement from the first day after the first-session procedure. Nine patients had complete relief of most of their symptoms (nasal obstruction/discharge, anosmia/hyposmia) at day 30. The follow- up nasal endoscopy demonstrated no evidence of active sinus disease. All the implants used were found to be well-osseointegrated and still in use for prosthetic purposes. Clinical and radiologic results showed stability and no recurrence in the follow-up period. CONCLUSION: The dental implant with an internal central port and integral dedicated sealing screw may be used for irrigation, observation, and further treatment of the maxillary sinus in cases of CRS.