Treatment guidelines for temporomandibular joint ankylosis with secondary dentofacial deformities in adults

Temporomandibular joint (TMJ) ankylosis with secondary dentofacial deformities in adult patients is a severely disfiguring condition and surgical treatment of this disease remains a great clinical challenge. Treatment goals are to restore the joint function, to improve facial appearances and to correct malocclusion, as well as to re-establishing harmony among them. Currently, various surgical techniques, such as arthroplasty with or without interpositional material, orthognathic surgery, distraction osteogenesis, autologous bone or bone replacement materials graft and plastic surgery, have been described in the literature. In most cases these techniques should be used in combination to achieve satisfactory outcomes. The biggest difficulty for most clinicians is to determine the proper sequence of these procedures because no uniform treatment protocol has been established. Based on the published literature and our own clinical experiences, we have prepared this review article to provide some guidelines for the surgical management of TMJ ankylosis with dentofacial deformities in adults, which will be modified and updated periodically to provide the best treatment options to benefit our patients.     

Anatomic shoulder arthroplasty

Arthroplasty has become a reliable treatment for degenerative joint diseases of the shoulder. Implant designs have developed over the last 60 years to address the initial problems encountered in arthroplasty: restoration of function and implant loosening. Although reverse shoulder arthroplasty (RSA) has become the most commonly performed type of shoulder replacement in the UK, total anatomical shoulder arthroplasty (TSA) has remained as a well-established treatment for osteoarthritis in patients with a competent rotator cuff. Patients with osteoarthritis treated with TSA can nowadays expect a lasting, significant improvement in pain and function. Nonetheless, controversies exist regarding the indications for humeral hemiarthroplasty and the use of stemless prostheses and other, newer implant designs. Interestingly, changes in the design of glenoid components have not led to significant improvements in clinical performance with time, and cemented all-polyethylene components remain the most reliable option. Lower glenoid aseptic loosening rates are probably best achieved by optimizing the restoration of natural humeral head anatomy.     

Metal-on-metal hips: current status

One of the greatest technological advances in the history of medicine is the total joint replacement. Hip, knee, and shoulder replacements are routine throughout the world. They reduce pain in a cost-effective way and improve quality of life for millions of patients with end stage arthritis. Total hip replacement (THR) is considered a landmark surgery in modern medical history. The THR has developed with research and experimentation over the last 40–50 years with progressive improvement in materials used, fixation techniques, and peri-operative care. With improving life expectancy and increasing demand at a younger age, clinicians and scientists are always trying to find better performing implants to reduce the revision burden. This paper provides an up-to-date account of the relevant history of metal-on-metal (MoM) hips, problems associated with their use, current status, and guidance about how to continue surveillance of patients with MoM hip replacements.     

Factors associated with implant recommendation for single-tooth replacement

The use of dental implants for single-tooth replacement has been established as a predictable treatment option; yet, limited data are available as to how frequently this option is recommended to patients. The aim of the present study was to examine the frequency of implant recommendation by general dental practitioners after single-tooth extraction and factors influencing their decision to recommend an implant. All single-tooth extractions performed in 26 general dental practice clinics in Kuwait over a 30-day period were examined. Dentists in these centers used the study form to record demographic data, the type of tooth extracted, reason for extraction, and replacement options presented to the patients. Univariate and logistic regression analyses were used to examine associations between background factors and decisions to recommend implant therapy. A total of 1367 patients (mean age, 37.9 +/- 11.8 years) had an extraction of one tooth during the study period. Forty-three patients were offered implants as a replacement option (3.3% of the total sample; 8.6% of patients who were offered tooth replacement options). Factors associated significantly with the recommendation of an implant by Kuwaiti dentists to their patients included younger age, regular dental maintenance visits, and adequate oral hygiene practices (P < 0.05; binary logistic regression). Dental implant recommendation for single-tooth replacement in the present sample of dentists was low. Factors associated significantly with dentist recommendation of an implant for single-tooth replacement included age, history of dental maintenance, and oral hygiene practices.     

Complications in shoulder surgery

Shared decision-making in orthopaedic surgery involves an honest and open discussion between the surgeon and patient concerning the treatment options (including no treatment) and the risks and rewards of each option. This includes a frank discussion of the potential complications of surgery and this often creates a conundrum for the patient – surgery may only offer pain relief and improved function but the list of potential complications seems endless. However the discussion of complications can itself be problematic – most are rare and the surgeon may have little or no experience of them, or at least insufficient to give the patient their own personal figures in percentage terms. An overview of the literature is helpful but, as this article will discuss, the data published can only be a guide. It is incumbent on all surgeons to consider their own skills, setting, access to equipment and technologies and the team they work with to develop an effective consent process that fully informs patients and helps them to make their choice comfortably. Data are discussed that aid the surgeon in developing their own personalized process for discussing the potential complications of shoulder surgery with their patients.     

Septic complications of knee replacements and their treatment

The introduction of the modern total knee replacement has been revolutionary in treatment of degenerative joint disease. Over recent years there has been a significant increase in the number of primary replacements and revision procedures. Prosthetic joint infection is an important and devastating complication which has not been eliminated by modern day practice. Patient selection, operating environment, surgical technique and soft tissue management can reduce but not eliminate the incidence of infection. When infection occurs, it should be managed as part of a multidisciplinary team to ensure an optimal outcome. Revision for infection can be performed as a single-stage or two-stage procedure. When revision surgery fails, salvage options should be considered including: salvage arthroplasty, arthrodesis, resection arthroplasty and amputation. The challenges for the surgeon to overcome include: a poor soft tissue envelope, ligamentous or extensor mechanism disruption and bone loss. Complications are not uncommon with salvage options and therefore meticulous preoperative planning and a thorough consent process are mandatory. The management of patients with an infected implant should performed by consultants who have specialized expertise and who work in networks. This is necessary to achieve the best results. This article will also discuss the salvage options.     

Shoulder complaints after nerve sparing neck dissections

The purpose of the study was to analyse the prevalence of shoulder complaints after nerve sparing neck dissection at least 1 year after surgery, and to analyse the influence of radiation therapy on shoulder complaints. Patients were interviewed for shoulder complaints, and patients filled out the shoulder disability questionnaire to evaluate shoulder disability in daily activities. In total 137 patients; 51 after modified radical neck dissection (MRND), 21 after postero-lateral neck dissection (PLND), and 65 after supraomohyoid neck dissection (SOHND) were analysed. After MRND 33.3% of the patients experienced shoulder complaints, after PLND 66.7%, and after SOHND 20% of the patients experienced shoulder complaints. Type of neck dissection was significantly (P < 0.001) related to shoulder complaints. Outcome on the shoulder disability questionnaire also showed a significant (P < 0.01) difference in outcome for type of neck dissection. The prevalence of shoulder complaints after SOHND are low, and reduce disability in daily activities. Radiation therapy does not have a significant effect on shoulder complaints and disability.     

Perioral soft-tissue rejuvenation techniques to enhance esthetic restorative dentistry

Every practitioner has the obligation to offer his or her patients the latest advances in their profession. Dentistry has made a shift over the past 50 years from caries restoration and prosthetic replacement to preventative and esthetic rejuvenation. Related dental specialties have also blossomed with new procedures and an expanded scope of practice. This shift has also included more comprehensive care and treatment of the oral and maxillofacial region. Modern esthetic dentists realize the facial soft tissues serve as a frame for their restorative artwork. Contemporary oral and maxillofacial surgery includes cosmetic facial surgery. Procedures for such surgery are taught in oral and maxillofacial surgery residency programs, are part of the oral and maxillofacial surgery board exams, and are covered by oral and maxillofacial surgery malpractice companies. Esthetic dentists should understand facial aging, as well as the basic procedures available for facial rejuvenation by the oral and maxillofacial surgeon. Contemporary esthetic dentistry goes beyond the oral cavity, and the smile is truly enhanced by simultaneous facial rejuvenation. This article discusses the process of perioral facial aging and various cosmetic facial surgery options.     

Fixed-bearing medial partial knee replacement: patient selection and surgical technique

Partial knee replacement (PKR) surgery has become the treatment of choice for patients with isolated medial or lateral compartment osteoarthritis with less surgical risk, more favourable functional outcomes and revision rates approaching those of total knee replacement (TKR) in experienced hands. Patient selection remains a concern for many surgeons and training opportunities are unfortunately less common for PKR than TKR. This review from four, highly experienced, partial knee surgeons seeks to clarify selection criteria and offers a simple reproducible surgical technique for fixed-bearing medial partial knee replacement.     

Fractures of the scapula

Scapular fractures are relatively uncommon fractures, which often are a result of high-energy trauma. The majority of fractures of the scapula can be successfully treated without operation and require a short period of immobilization before physiotherapy to regain function. The indications for surgery are based on the general principles of trauma surgery; to reduce significant intra-articular fractures and restore the necessary alignment of extra-articular fractures. There is an absence of compelling studies that define the threshold for surgical intervention, making the treatment of these fractures difficult. This is further complicated by the complexity of the structures which interact with the scapula to allow the shoulder girdle to function. In this article, the anatomy and fracture patterns which affect the scapula and treatment options, will be discussed.     

(i) The management of irreparable rotator cuff tears

The management of massive irreparable rotator cuff tears can be challenging. There are, however, a number of operative and non-operative options available to the shoulder surgeon.Non-operative management with simple analgesics, steroid injections and a deltoid re-education programme may be appropriate for patients with few symptoms, particularly elderly, lower demand patients with lower expectations. In more symptomatic patients, especially younger patients with higher demands, surgical intervention may be considered. Arthroscopic debridement and/or, sub-acromial decompression (with or without biceps tenotomy) may suffice, but partial or augmented rotator cuff repair or tendon transfer surgery is available. In the presence of arthrosis, cuff tear arthroplasty or reverse geometry arthroplasty are valid options.Treatment should be individualized depending on the patient's symptoms, age, expectations, needs and the presence or absence of associated glenohumeral joint arthrosis.     

Maxillary impacted canine with congenitally absent premolars

Multiple treatment options are available to patients who have impacted canines in addition to congenitally absent premolars. Management options for impacted maxillary canines can include (1) continued observation, (2) extraction of the primary canine to aid spontaneous eruption, (3) uncovering and bonding of the impacted tooth and its eruption using orthodontic traction, (4) autotransplantation, and (5) extraction followed by prosthetic replacement. The options for the treatment of missing premolars can include the following: (1) maintaining the primary molars, (2) spontaneous space closure after early extraction of the primary molar, (3) autotransplantation, (4) prosthetic replacement, and (5) orthodontic space closure. In this case report, treatment of a patient with an impacted maxillary canine and agenesis of three second premolars will be presented.     

Need for dental treatment following cardiac valve surgery: a clinical study.

AIM: The aim of the present study was to evaluate the long-term need for dental treatment following non-radical treatment modes prior to cardiac valve surgery. PATIENTS: From 1995 to 2001, a total of 305 patients were screened prior to cardiac surgery. After an average period of 36 months, 80 of these patients could be re-evaluated clinically (26%). Another 117 patients (38%) and their family doctors were contacted by telephone. METHODS: Dental evaluation prior to cardiac valve replacement was performed clinically and radiographically. Tooth extraction was recommended in cases of carious or periodontal destruction, root remnants, partial retention or apical osteolysis despite endodontic treatment with poor prognosis for apicectomy. Periodontal therapy was recommended if attachment loss was less than 1/2 of the root length. No measures were undertaken for endodontically treated teeth without apical osteolysis and impacted teeth. In October 2002, oral health was re-evaluated in 80 patients. Dental treatment carried out in the follow-up period was documented and compared with the current findings. RESULTS: At the time of re-evaluation, 60 of the total of 80 patients required dental treatment in 155 teeth; oral surgery was indicated in 51 of these 60 patients, mostly due to periodontal pathology. During the follow-up period, only 99 of the 142 dental interventions having taken place had been carried out with prophylactic antibiotic treatment. CONCLUSION: From the results of this study it may be concluded that non-radical dental treatment modes prior to cardiac valve replacement can only be successful over the long-term if adequate postoperative dental care is provided. To achieve this aim, common follow-up monitoring forms, similar to those used for care of cancer patients, could facilitate communication.     

Three-dimensional treatment planning for maxillary and mandibular segmental surgery for an adult Class III: Where old meets new

Class III open bite malocclusion can be among the most difficult case types to obtain an excellent occlusal, skeletal, and facial outcome. Treatment options include growth modification, extraction for orthodontic camouflage, and orthognathic surgery. For the most severely affected and non-growing patients, orthognathic surgery is often the most predictable and, in some situations, the only viable way of achieving an optimal result. The risks and benefits of surgical treatment options can occasionally be difficult to assess particularly for providers with limited experience. Two-dimensional surgical predictions can assist but do not permit the third dimension to be visualized. New techniques of computer-aided surgical simulation can enable the surgeon, orthodontist, and patient to better visualize and understand the treatment approach and enable them to make the most effective and efficient treatment related decisions. This case merges knowledge of the full spectrum of historical surgical techniques with the new approach of computer-aided surgical simulation (CASS) to perform complex segmental maxillary and mandibular surgery to obtain an excellent functional and esthetic result.     

The incidence of total hip replacement in orthognathic surgery patients receiving short-term steroid therapy.

It is well known that long-term corticosteroid therapy can lead to avascular necrosis of the femoral head. There is suspicion among orthopedic surgeons that short-term, high-dose steroid use poses similar risks. The records of 2,773 patients (1,497 who had total hip replacement and 1,276 who had orthognathic surgery) were retrospectively reviewed. No hip replacements had been done in the orthognathic surgery group and none of the patients in the total hip replacement group had undergone orthognathic surgery. The use of short-course, systemic corticosteroids to reduce postoperative swelling in orthognathic surgery did not seem to cause avascular necrosis of the femoral head.     

Management of the stiff elbow

Stiffness of the elbow is a relatively common problem that can result in disability. The elbow is prone to stiffness after injury or surgery and there is limited scope for compensatory motion in the shoulder and wrist. Despite advances in knowledge of the pathogenesis of elbow contractures and the development of new treatment regimens, elbow stiffness remains a challenging problem. To regain functional elbow motion several non-operative and operative treatments are available. Non-operative treatment modalities consist of static and dynamic splinting, both having comparable results and a low risk of complications. Surgical release is performed open or arthroscopically, depending on the severity of the contracture, the presence of concomitant pathology of the ulnar nerve and osseous deformity, as well as the surgeon's preference. The open lateral column procedure has been the gold standard for a number of years. With the increasing popularity and experience of arthroscopy, a shift is seen towards arthroscopic capsular release for some indications. Outcomes of both techniques are largely comparable, with low complication rates, although the rate of complications increases with the extent of the surgical procedure. With regard to the rehabilitation programme after surgical release, different protocols are used in different hospitals and countries and may include extensive physical therapy with or without the use of continuous passive motion. The current recommendation is to continue postoperative rehabilitation as long as the range of motion is improving and until no further increase is expected. The aim of this article is to provide an overview of the aetiology, treatment, rehabilitation options and outcome of elbow stiffness. Current treatment options are discussed and future perspectives are provided.     

THE MANAGEMENT OF DROOLING IN CHILDREN AND PATIENTS WITH MENTAL AND PHYSICAL DISABILITIES: A LITERATURE REVIEW

Amongst the duties of the paediatric dentist is the provision of oral care to patients with the problem of drooling. Many, but certainly not all, of these patients have physical and/or learning disabilities. Various methods have been advocated for the management of drooling in the paediatric patient and older patients with disabilities, including behavioural programmes, biofeedback techniques, physiotherapy, biofunctional oral appliances, medication and surgery. It is of paramount importance that the patients and/or carers understand the advantages and disadvantages of any treatment method being considered. The paediatric dentist has an important role to play in explaining the different options to the patients and carers, and in implementing some treatment modalities, particularly non-surgical approaches. Referral to surgical specialists should be seen as 'a last resort' and suggested only if other treatment methods have been exhausted. If pharmacological or surgical treatment is carried out, careful monitoring for the development of dental caries and other problems is essential. The aim of this paper is to provide the paediatric dentist with concise overall knowledge of the causes of drooling and treatment options available.     

Congenitally missing mandibular second premolar: treatment outcome with orthodontic space closure

Orthodontic treatment for patients with congenitally missing mandibular second premolars can be challenging. Treatment options include keeping the deciduous second molar, extracting the molars and allowing the space to close spontaneously, autotransplantation, prosthetic replacement, and orthodontic space closure. Space closure with orthodontic appliances is demonstrated in this case report.     

Irreparable cuff tears: an update on treatment options

The management of irreparable cuff tears can be challenging. Decision-making can be difficult, especially in the young patient, where every effort should be made to preserve the native joint surface and its function. There are a number of options available to the shoulder surgeon, including non-operative and operative. Non-operative options include analgesics, intra-articular steroid injections and physiotherapist-guided rehabilitation. Minimally invasive interventions include arthroscopic debridement, biceps tenotomy, subacromial decompression and suprascapular nerve ablation. Surgical options include partial rotator cuff repair, bridging grafts and superior capsular reconstruction. In the younger patient, various tendon transfer options are available to reduce pain and improve range of motion. In the presence of arthrosis, reverse geometry shoulder arthroplasty offers long-term pain relief and good functional outcome. The surgeon should be aware of the possible treatment options when deciding on management and should tailor the management to the individual's needs and expectations. This article aims to summarize the current practice and literature surrounding this topic.