Can Alloplastic Total Temporomandibular Joint Reconstruction be Used in the Growing Patient? A Preliminary Report.

INTRODUCTION: Although primarily reserved for adult patients, temporomandibular joint (TMJ) total joint reconstructive (TJR) surgery is rarely used in the pediatric population due to its many challenges; it is only performed after all other non-invasive or invasive procedures have been exhausted. Although autogenous grafting has been discussed in the literature, there is very little regarding synthetic or alloplastic materials. In this study, we performed alloplastic TMJ reconstruction on 5 patients with severe ankylosis due to various craniofacial deformities and prior traumatic injuries. MATERIALS AND METHODS: This is a retrospective case series analysis of skeletally immature patients who received alloplastic TMJ reconstruction for recurrent and advanced ankylosis. Our inclusion criteria were as follows: less than 16 years of age, diagnosis of TMJ ankylosis, skeletally immature patients, and unilateral/bilateral total alloplastic TMJ reconstruction. We used the maximum incisal opening (MIO) changes as 1 component to assess for functional improvement. RESULTS: Since many of these cases involved gross discrepancies from the normal variants, it was difficult to quantitatively compare the patients with one another. Nevertheless, we used cephalometric analysis to compare pre- and postoperative results on each patient. For this study, we used MIO as our primary assessment: the preoperative average for MIO was 7.4 mm, and the postoperative average 24 mm. CONCLUSION: It is our experience that the use of alloplastic material will not result in harm to either the growth of the mandible or patient's ability to achieve an improved MIO based on our long- and short-term results. These results demonstrate that for even complex craniofacial deformities and traumatic injuries, our patients experienced a significant improvement in MIO, 1 of the main indicators for TMJ function. We conclude that the alloplastic joint can provide a predictable pathway to restore patient's MIO and obviate the need for repeated surgeries, which can be a more challenging alternative with poorer outcomes.

Contemplations and Ruminations of Methodological Error.

PURPOSE: Journal articles in our field of oral and maxillofacial surgery are rife with case studies, cohort reviews, meta-analysis, basic science studies, surgical techniques, and anatomic studies. The data found in these studies often rely on multiple measurements by which the authors draw their conclusions. Accurate measurements play a critical role in the design of the study, which in turn affects the conclusion that the author is attempting to convey. Investigators must determine and develop the processes to determine the methodological errors associated with each project to help with determining the accuracy of these measurements. The aim of this study is to highlight some of the methodological errors contained in the material and methods in oral and maxillofacial surgery studies over the calendar years of 2018 and 2019 and how best to evaluate them. MATERIALS AND METHODS: The inclusion criteria involved articles that used measurements where discrepancies could exist such as clinical measurements, histological measurements, and radiological measurements. The number of specimens or subjects measured in each study was tabulated. RESULTS: Over the 2-year period considered, 744 articles were published, and 116 (15.6%) of them met the inclusion criteria. Of these articles, 37 (32%) reported a methodological error, while 79 (68%) did not. In addition, 31 (84%) of the articles with a methodological error were radiographic, while only 6 (16%) were not radiographic. Among the studies that reported methodological error, there were approximately 7 different types used with no rationale given for the choice. CONCLUSIONS: We believe that it is important to ensure sound methods and materials, including a stated methodological error. An attempt at standardization will help to serve to enhance and strengthen the different research studies seen in our field.

Tumorigenic Potential of Granulocyte Colony-Stimulating Factor Therapy-A Case Report and Review of Literature.

An association between granulocyte colony-stimulating factor therapy (G-CSFT) in patients with glycogen storage disease type Ib (GSDIb) and the development of giant cell lesions of the maxillofacial complex has emerged. We have reported, to the best of our knowledge, the fourth case of giant cell granuloma (GCG) in a patient with GSDIb undergoing G-CSFT. GSDIb can present with hypoglycemia, hypertriglyceridemia, and neutropenia. G-CSFT has often been used in the treatment of recurrent infections or sepsis caused by neutropenia and to treat inflammatory bowel disease and diarrhea. The current reported data are lacking in both the association and the potential causation of G-CSFT and the development of giant cell tumors. Given the prevalence of GSDIb and its therapy, oral and maxillofacial surgeons should be aware of the tumorigenic potential of G-CSFT in patients with GSDIb. In the present report, we have described the case of a 17-year-old patient with GSDIb undergoing GCSFT who presented with a peripheral and central GCG. She was treated but presented again 13 months later with concerns for a new primary lesion. We have also discussed GSDIb, G-CSFT, and the current data, highlighting the association between G-CSFT for GSDIb, the potential mechanism of GCG development, the use of adjuvant therapy, and the need for close follow-up of this population. The purpose of the present case report is to highlight the presentation, management, and follow-up of giant cell lesions in patients with GSDIb treated with G-CSFT.

Anatomic Variability of the Human Orbit.

PURPOSE: Knowledge of the bony orbit and how its volume changes are clinically important in addressing traumatic injuries. Restoration of orbital volume in some patients is critical to achieving successful outcomes after such injuries. In this large cadaveric study, we aimed to assess the average volume, range of bony orbit volumes, degree of volume discrepancy between the right and left orbits, and percentage of skulls with 1- and 1.5-mL orbital volume differences via alginate impressions and volume displacement. MATERIALS AND METHODS: This study used 121 skulls (242 orbits) from the University of Texas Southwestern Department of Cell Biology/Anatomy. Seal-press wrap was first adapted to each bony orbit to ensure no damage to the internal orbits, foramina, or fissures. Alginate impressions were then taken and trimmed to encompass the bony orbit. The volume of each impression was calculated via the volume-displacement method. RESULTS: The average orbital volume was 26.75 mL for the right side and 26.65 mL for the left. The average right-to-left difference between orbits was 0.8 mL, with a range from 0.02 to 3.64 mL. The calculated methodologic error was 0.91% for the right orbit and 1.05% for the left. Approximately 14% and 21% of skulls showed normal left-to-right orbital volume differences of 1.5 mL or greater and 1.0 mL or greater, respectively. CONCLUSIONS: Our data suggest that the average normal asymmetry between the right and left orbital volumes is 0.8 mL, which is 50 to 80% of the orbital volume increase implicated in traumatic enophthalmos. Of the skulls, 17 (14%) showed a right-to-left orbital volume asymmetry of 1.5 mL or greater and 25 (21%) showed an asymmetry of 1.0 mL or greater. The skull-to-skull orbital volume range approached 200%. Thus, this study provides surgeons with important information to consider when reconstructing a traumatized orbit using a computed tomography scan of the unaffected, contralateral orbit.

Evaluation of the Safety and Efficacy of Soft Tissue Augmentation With a Compressive-Resistant Collagen Matrix in a Nonhuman Primate Model.

PURPOSE: The purpose of the present study was to evaluate the safety and efficacy of the compression-resistant collagen-based cross-linked matrix for augmentation of maxillary and mandibular soft tissue defects in an animal model. MATERIALS AND METHODS: Six rhesus macaque monkeys were subjected to soft tissue grafting in 4 sites intraorally; the anterior maxilla was subjected to hard and soft tissue grafting with implant placement. Each site was randomly assigned 1 of 3 treatments: a compressive-resistant collagen matrix membrane (CM), a subepithelial connective tissue autograft (SCTG), or sham treatment, in which a partial-thickness flap was elevated and then sutured closed with no further treatment (control). The following methods were used for data collection: in vivo evaluation by periodontal probing, ultrasound, shear modulus elasticity, polyether impressions for volumetric analysis, and in vitro analysis by histologic biopsy examinations. In vitro analysis provided by histologic measurements and evaluations was performed on nondecalcified sections. The follow-up period was 6 months. RESULTS: The SCTG and CM showed favorable tissue integration. No adverse reaction to or deviation from the normal healing processes was detected. The CM integrated well in all sites, with a variable range of soft tissue volume increases. Volumetric discrepancies were appreciated in the histologic analyses and differences were found when the CM and SCTG were applied in the anterior maxilla in combination with hard tissue grafting and implant placement. Histologic evaluation showed favorable integration, no immunogenic response to the CM, and stable volumetric retention in autograft and CM sites during the experimental period. CONCLUSION: The compressive-resistant CM could be a safe and efficacious alternative for soft tissue augmentation by obviating a donor site and the consequent morbidity. Although a similar performance between the CM and SCTG was observed, further studies will be necessary to estimate the clinical potentiality and describe the limits of the technique.

Mandibular fractures: an analysis of the epidemiology and patterns of injury in 4,143 fractures.

PURPOSE: The objective of this study was to complete a comprehensive retrospective review of the epidemiology and patterns of injury in mandibular trauma based on the Parkland Memorial Hospital trauma database over a 17-year period. The authors identified 4,143 fractures in 2,828 patients from the databank. In mandibular trauma, the mechanism of injury and several other variables can be an important point of differentiation with regard to fracture pattern. By showing the statistical relation between these and fracture pattern, the authors hope to provide surgeons with a better understanding of such a relation. MATERIALS AND METHODS: Mandibular fracture data were collected from the Parkland Memorial Hospital trauma registry using International Classification of Diseases, Ninth Revision codes (802.21 to 802.39). Information included fracture type, age, gender, mechanism of injury, and associated injuries. The Parkland Memorial Hospital trauma registry yielded 4,143 mandibular fractures in 2,828 patients managed at Parkland Memorial Hospital from 1993 through 2010. RESULTS: Based on retrospective analysis, results were obtained for age, gender, monthly distribution, anatomic distribution, and mechanism of injury. The average age was approximately 38 years, with most patients (33%) in the third decade. An overwhelming majority of patients were men (83.27%), with only 16.27% consisting of women. Most injuries occurred in the summer months, with July being the most common month of occurrence. The mechanism of injury predominantly involved low-velocity blunt injuries (62%) compared with high-velocity blunt injuries (31%). The anatomic distribution of fractures evaluated was the angle (27%), symphysis (21.3%), condyle and subcondyle (18.4%), and body (16.8%). CONCLUSION: This study helps provide and support the relation between several variables associated with many common traumatic injuries seen in the mandible. This analysis can be used to help surgeons identify and anticipate injuries based on age, gender, and mechanism of injury.

The case for advanced physics topics in oral and maxillofacial surgery.

Research in oral and maxillofacial surgery has focused mainly on principles founded in the biological and chemical sciences, which have provided excellent answers to many questions. However, recent technologic advances have begun to gain prominence in many of the medical sciences, providing clinicians with more effective tools for diagnosis and treatment. The era of modern physics has led to the development of diagnostic techniques that could provide information at a more basic level than many of the current biochemical methods used. The goal of this report is to introduce 2 of these methods and describe how they can be applied to oral and maxillofacial surgery.

Outcome of comminuted mandibular fracture repair using an intraoral approach for osteosynthesis.

PURPOSE: Traditionally, the treatment of comminuted mandibular fractures involves both closed and open reduction. However, modern treatment principles increasingly tend toward open reduction and internal fixation to shorten oro-functional rehabilitation. Although this method increasingly gained popularity to date, a controversy regarding the extraoral versus the intraoral surgical approach still exists. The current study aimed to objectively evaluate the outcome of comminuted mandibular fracture treatment involving open reduction and internal fixation using an intraoral approach. PATIENTS AND METHODS: Consecutive patients treated at the Department of Cranio-Maxillofacial and Oral Surgery, University Hospital of Zurich, between 2005 and 2012 were included. Demographic, presurgical, perisurgical, and postsurgical data were tabulated and statistically evaluated using the χ test and the Mann-Whitney U test. RESULTS: Forty-five patients could be included. Excellent postoperative results were seen in 84% (38 patients) of the total cohort. Postoperative complications were seen in 16% (7 patients). These 7 patients had the following complications: wound dehiscence (7% [n = 3]), osteomyelitis (7% [n = 3]), abscess development (4% [n = 2]), bone necrosis (2% [n = 1]), and severe nonocclusion (2% [n = 1]). CONCLUSION: Present data showed that the intraoral approach for open reduction and internal fixation in comminuted mandibular fractures represents a comparable surgical technique regarding fracture repositioning and occlusal rehabilitation. Considerably, the risk of concomitant neurovascular damage or even facial scarring, as demonstrated in the extraoral approach, can be neglected by using this technique. Nevertheless, each case has to be judged on its own accord as to which technique can best treat the underlying fracture.

Recombinant human bone morphogenetic protein-2 promote and stabilize hard and soft tissue healing for large mandibular new bone reconstruction defects.

Numerous autogenous bone-grafting procedures are available for the recovering of large continuity defects of the mandible. However, these surgical techniques present several limitations involving postoperative morbidity and pain. The development of new bone technique reconstruction not involving autogenous bone graft would offer new opportunities for facial bone reconstruction. This report highlights the possibility of recombinant human bone morphogenetic protein type 2 (rhBMP-2) application without concomitant bone grafting material in the restoration of continuity critical-sized defects after tumor resection in the mandible. The presented case shows a large mandibular reconstruction after tumor removal in a 31-year-old white man affected by ameloblastoma. In this case, the rhBMP-2 application with a carrier consisted on absorbable collagen sponge gives excellent newly formed bone at 18 months of control clinical and radiologic follow-up. The results indicated that the use of rhBMP-2 without concomitant autogenous bone grafting materials in large critical-sized mandibular defects secondary to large mandibular tumor produced excellent regeneration of the treated area.

Successful Cardiac Surgical Management in a Trisomy 21 Child After Long-Term Hospitalization Associated With Bronchopneumonia and Hepatitis C Virus Seropositivity: A Case Report.

A 31-month-old girl with trisomy 21 (Down syndrome) was seen in the emergency department of pediatrics because of oxygen desaturation associated with features of lower respiratory tract infections. She was born at full term and diagnosed with congenital heart disease (CHD) having ventricular septal defect (VSD), and patent ductus arteriosus (PDA); consequently, she underwent corrective surgery after adequate optimization of treatment. Incidentally, she was detected to have the presence of anti-hepatitis C virus (HCV) antibodies. In this case report, we mainly focus on the multi-modal approach to medical and surgical management.

Closure of large palatal defect using a tongue flap.

The aim of this study is to report the effectiveness of a tongue flap for covering a large hard and soft tissue defect following cleft of the palate. A young patient diagnosed with acute lymphoblastic leukemia underwent a surgical reconstruction of the cleft palate by Le Fort I osteotomy and palatal closure utilizing a tongue flap. The flap provided sound and lasting closure after the surgery, and the patient successfully healed. Our goal is to present this unique case and highlight how postoperative results were good, safe, and predictable. We also hope to show that tongue transplantation as flap for hard and soft tissue reconstruction represents a valuable option in reconstruction, given the proper circumstances.

Immediate distraction osteogenesis: the sandwich technique in combination with rhBMP-2 for anterior maxillary and mandibular defects.

The goal of this study was to demonstrate the technique and effectiveness of incorporating recombinant human bone morphogenetic protein-2 (rhBMP-2) to the established sandwich osteotomy technique. Although the success of the sandwich osteotomy procedure has been well documented, we hope to show that the addition of rhBMP-2 will enhance bone formation.We performed a sandwich osteotomy technique in patients who had been treated initially by grafting with suboptimal results. Only defects involving the anterior maxilla (3 patients) or the anterior mandible (1 patient) were included. There were 4 patients, 2 men and 2 women, with an age range of 19 to 62 years. The causes of the ridge deficiencies ranged from pathology to trauma. The height (distance) of distracted transport bone segment was measured. The amount of relapse was measured 6 months after the surgery.All patients exhibited a significant increase in bone height. The amount distracted was 6.75 mm (range, 5-11 mm). The amount of relapse was 8.5% (range, 0%-18%). Dental implants were placed in the reconstructed ridges in all patients. There were no instances of permanent paresthesia. Two patients had exposure of a portion of the hardware, which healed uneventfully.The sandwich osteotomy technique has proven to be an effective method for augmenting deficient alveolar ridges. The addition of rhBMP-2 may aid in its success rate by promoting osteogenesis at the osteotomy site, especially in multiple-operated patients where other traditional techniques have failed to gain the desired ridge height.

Treatment of severe frontobasilar fractures in growing patients: a case series evaluation.

OBJECTIVE: The treatment of frontobasilar fractures is a demanding aspect of craniofacial fracture management. A sequel of inadequate or improper fracture management presents cosmetic and functional problems which are very difficult to correct. The aim of this manuscript was to examine a group of growing patients treated for frontobasilar fractures and provide clinicians a possible therapeutic option for the treatment of these challenging fractures. METHODS: In this investigation, 12 patients under the age of 16 years treated for severe injuries to the frontobasilar region were included. Their records were reviewed to evaluate the clinical diagnosis, preoperative findings, hospital course, postoperative results, and long-term follow-up. Preoperative and postoperative CT scans were performed in all children treated. Postoperative complications were reviewed in detail. Surgical procedures were evaluated for type and location of fixation. All complications and treatments were recorded. RESULTS: Three of the patients presented with a cerebrospinal fluid (CSF) leak and required pericranial flaps. Only 3 patients underwent removal of plates and screws due to palpability in 1 patient, loose hardware in 1 patient, and limited disturbance on growth in the rest patient. Seven patients underwent open reduction and internal fixation with resorbable plates, 4 patients with titanium plates, and 1 patient with a combination. Follow-up ranged from 6 months to 5 years. No patients with a preoperative CSF leak developed any recurrence of the leak. CONCLUSION: According to basic craniofacial principles, reducing and stabilizing the fractures should reconstruct the anterior cranial base. However, the treatment of paediatric maxillofacial trauma requires the evaluation of several factors. The facial skeleton of a child is constantly evolving and its growth depends on the balance of basal bone and soft tissues.

Parenteral vs Oral Vitamin B12 in Children With Nutritional Macrocytic Anemia: A Randomized Controlled Trial.

BACKGROUND: There is limited literature in children on efficacy of different routes of vitamin B12 administration for vitamin B12 deficiency macrocytic-megaloblastic anemia. OBJECTIVE: To compare parenteral with oral vitamin B12 therapy in children with macrocytic-megaloblastic anemia. STUDY DESIGN: Single-center, open-label randomized controlled trial. PARTICIPANT: 80 children aged 2 month-18 year with clinical and laboratory features of nutritional macrocytic anemia. INTERVENTION: All children received an initial single parenteral dose of 1000 µg vitamin B12 followed by randomization to either parenteral or oral vitamin B12 for subsequent doses. Group A was given 1000 µg intramuscular (IM) vitamin B12 (3 doses on alternate days for those aged <10 year, five doses for age >10 year), followed by monthly 1000 µg IM for the subsequent two doses. Group B was given daily oral vitamin B12 1500 µg (500 µg in <2 years age) for three months. Folic acid and iron supple-mentation, and relevant dietary advice were given to both groups in a similar fashion. OUTCOME: Improvement in serum vitamin B12 levels and total hemoglobin was compared three months post-treatment. RESULT: The median(IQR) increase in serum vitamin B12 level was significantly higher in group A [600 (389,775) vs 399 (313, 606) pg/mL; P= 0.016]. The median (IQR) rise of hemoglobin was also more in group A [2.7 (0.4,4.6) vs 0.5 (-0.1,1.2) g/dL; P=0.001]. CONCLUSION: Increase in serum vitamin B12 levels and hemoglobin was better in children with nutritional macrocytic anemia receiving parenteral as compared to oral vitamin B12.

Guillain-Barre syndrome following subclinical COVID-19 infection in a child.

The entire world is coping up with the challenges imposed by COVID-19 pandemic caused by a novel coronavirus, which started from a single case in Wuhan city of China in November 2019. Its outcomes range from asymptomatic cases to most severe diseases like severe acute respiratory syndrome. Neurological manifestations have also been reported as an outcome of coronavirus infection and Guillain-Barre Syndrome (GBS) is one of them. In our present case, we describe the correlation of GBS with subclinical SARS-CoV-2 in a pediatric patient. The patient was successfully managed with intravenous immunoglobulin and physiotherapy. In the current pandemic, any case of GBS should be evaluated for recent or remote SARS-CoV-2 infection.

On-Pump Bidirectional Glenn Shunt Compared to Off-Pump Shunt Is a Better Influencing Determinant of Perioperative Morbidity During Palliation of Univentricular Heart: Compilation of Two Cases.

The bidirectional Glenn (BDG) or hemi-Fontan technique, performed under cardiopulmonary bypass (CPB) and often utilized as first-stage palliation for various cyanotic congenital heart diseases, as a part of the single-ventricle repair is associated with adverse side effects and high expenditures. Previous studies have shown that BDG is safe even without CPB, which thus necessitates further investigation. This manuscript presents the case of two patients with complex cyanotic congenital heart diseases. The first case was an 11-month-old baby who presented with fever, cough, and cold, while the second case was a two-year-old baby who was underweight due to poor feeding status. Both patients underwent a BDG and main pulmonary artery partial ligation following the requisite preoperative medical evaluations on CPB. Moreover, case 1 had atrial septectomy, while case 2 had significant aortopulmonary collateral arteries ligation. Both patients were discharged following an uneventful postoperative outcome. We found that an adequate selection of patients for the BDG procedure, with or without CPB, could lead to identical postoperative outcomes with regard to mortality, morbidity, and supply usage.

Is it time to incorporate physics into the Dental Admissions Test?

Although physics is a pre-requisite for dental students prior to matriculation it is not tested on the Dental Admissions Test (DAT). The concepts of physics are found throughout the dental profession, and by testing it on the DAT dental students will be better equipped to relate physics to their field and help advance it. The purpose of this paper is to make the argument for why it should be tested, as well as eliminating some of the superfluous topics on the DAT (ecology, environmental sciences, and plant physiology). This paper will focus on a few of concepts already taught in dentistry, and explore how physics principles apply to several of them. We want to emphasize the importance of physics and how testing even the most basic concepts will help prepare students to "think outside the box". Classical physics, specifically Newtonian Mechanics, has several applications in nearly all areas of dentistry: restorative, orthodontics, prosthodontics, and surgery. The testing of basic formulas studied in the pre-requisite physics classes will help ease the transition from college to dental school. Modern physics, namely Quantum Mechanics, also plays a significant role in current dental diagnostics and therapeutics. Additionally, with the development of the Integrated National Board Dental Examination (INBDE) as a replacement for the old NBDE part 1 and 2, there are topics tested that specifically focus on physics: Foundational Knowledge Areas 2 and 3. Thus, it is critical that the student dentist be familiar with these concepts. It is important to note that scientific changes occurring in the health sciences almost mandates students be familiar with concepts rooted in physics. It is then proposed that physics be incorporated into the exam, either with the natural sciences or within the quantitative reasoning section, in addition to eliminating topics not relevant to the dental field.

Glutaric Aciduria Type II With Ketosis in a Male Infant.

Glutaric aciduria type II (GA II) also known as multiple acyl-CoA dehydrogenase deficiency is an inborn metabolic disorder belonging to the family of organic acidurias. It is a disorder that interferes with the body's ability to break down proteins and fats to produce energy. Tandem mass spectrometry (TMS) acts as a screening tool, while the diagnosis of GA-II with ketosis is confirmed by a combination of tests like organic acids, quantitative random urine, and a full urine panel. Early diagnosis, compliance to specialized diet, affordability, and regular follow-ups are required to tackle this potentially life-threatening condition. Herein, we report a case of glutaric aciduria type-II with ketosis in a 4.5 months old male infant who was managed with a low-protein diet, which was free of tryptophan, lysine, and other specific dietary supplements.

Rare manifestation of common disease: An adolescent girl with transient ischemic attack (TIA) like presentation in multiple tuberculoma.

Central nervous system (CNS) tuberculosis is a life-threatening infection and has a wide variety of presentations in children. We report a case of intracranial tuberculomas with tuberculous cervical lymphadenitis in an adolescent girl with a recurrent transient ischemic attack (TIA) like unusual presentation managed with antitubercular therapy and anti-convulsant.