Surgical defect coverage in oral submucous fibrosis patients with single-stage extended nasolabial flap

Purpose

Long standing oral submucous fibrosis (OSMF) is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. The aim of the study was to evaluate the postoperative mouth opening in patients of OSMF after excision of fibrous bands followed by coronoidotomy and surgical defect coverage by extended nasolabial flap.

Methods

We evaluated the use of extended nasolabial flaps and coronoidectomy in the management of 11 randomly selected patients with histologically confirmed oral submucous fibrosis. They all had interincisal opening of less than 25 mm and were treated by bilateral release of fibrous bands, coronoidectomy or coronoidotomy, and extended grafting with a nasolabial flap.

Result

Their interincisal opening improved significantly from a mean of 8.68±7 mm to a mean of 36.75±4.05 mm at 6-month follow-up.

Conclusion

The procedure was effective in the management of patients with oral submucous fibrosis, the main disadvantage being the extraoral scars.

     

Efficacy of buccal fat pad in the surgical management of oral submucous fibrosis: a prospective study

Purpose

Various surgical treatment modalities have been advocated in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of buccal fat pad in the surgical treatment of oral submucous fibrosis.

Patients and Method

In the present study, 20 patients were treated for oral submucous fibrosis with interincisal mouth opening less than 16 mm. Surgical procedure included fibrotomy, all third molar extractions, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with buccal pad of fat. Postoperatively, patients were prescribed nutritional and antioxidant supplements along with vigorous mouth opening exercise for 6 months. Regular follow-up was carried out for 2 years.

Results

Excellent increase in the interincisal mouth opening was noticed relieving trismus. Patient’s ability of masticate and tolerance to regular food was increased significantly. Buccal fat pad underwent rapid epithelization within a period of 5–7 weeks.

Conclusion

Buccal fat pad can be used effectively in the surgical management of oral submucous fibrosis with good functional and esthetic outcome, with only drawback of supple lobulated fat, which requires delicate handling and its limitation to reach anteriorly beyond the canine region.

     

Efficacy of nasolabial flap in reconstruction of fibrotomy defect in surgical management of oral submucous fibrosis: a prospective study

Purpose

Various surgical modalities have been used in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of nasolabial flap in the reconstruction of fibrotomy defect in surgical treatment of oral submucous fibrosis in terms of functional and esthetic outcomes.

Material and method

In this prospective study, we treated 20 patients of oral submucous fibrosis surgically. The surgical protocol was consisting of bilateral fibrotomy, temporal myotomy, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with bilateral extended nasolabial flaps. All patients were prescribed with nutritional supplements and antioxidants. Vigorous mouth opening exercise was made compulsory for every patient. Preoperative and postoperative evaluation was done for interincisal mouth opening, function of mastication, and cosmetic results. Patient’s regular follow-up was done for 2 years.

Results

Postoperatively, we noted excellent increase in the interincisal mouth opening relieving trismus. Patient’s ability to chew solid food was increased significantly. Extraoral scar was minimal and well accepted by all the patients. There was no morbidity of the donor site. There was no injury to the facial nerve in all cases. The only drawback was intraoral hair growth which went on reducing with mucosalization of the graft tissue.

Conclusion

Random pattern nasolabial flap is a very good option for intraoral reconstruction of fibrotomy defect in surgical treatment of oral submucous fibrosis with excellent functional and cosmetic results with minimal complications.

     

First case of bilateral coronoid hyperplasia in monozygotic twin sisters—a new aetiological perspective?

Background

Mandibular coronoid hyperplasia is a rare condition associated with gradual reduction in mouth opening. Its aetiology is unknown but increased temporalis activity, endocrine stimulus, trauma and familial causes have been proposed.

Case report

In this article, we present a case of bilateral coronoid hyperplasia presenting with limited mouth opening in 16-year-old Caucasian twin sisters.

Discussion

This report gives a new perspective to the aetiology of coronoid hyperplasia since it describes its occurrence in monozygotic twins and hence provides a strong argument in support of a genetic aetiology.

     

Modified Le Fort III Osteotomy: Different Applications

Summary

Based on the new concepts of the modified Le Fort III osteotomy (MLFIIIO), Three variations of this technique are implemented: (A) the modified osteotomy Le Fort III Champy (1980) technique to be described with the use of surgical guides, and subciliary approach or an transconjunctival approach. Excellent technique for horizontal advancement no further to 6 mm, without requiring any type of graft.. (B) The modified Le Fort III osteotomy in “Z”: to solve horizontal (posterior anterior) problems of more than 6 mm without bone grafting. It is itself a modification of the technique described by Champy. (C) The modified Le Fort III osteotomy ascending: modified the original technique described by Bell and Epker with interpositional grafts, was modified by the called ascendant, making it higher in cases where the patient has an acceptable nasal bridge, but exorbitism the lateral wall of the orbit. Le Fort III osteotomy combined with a Le Fort I osteotomy and a front implant.

Method

As pointed out in Part I for the modified oblique Le Fort III osteotomy, methods for the design of the osteotomy Le Fort III property will depend on the requirements of individual patients, and this has led us to design specific techniques for the deformity.

Results

Patients have a right projection of the middle third, and protection of the eyeball.

Conclusions

The techniques presented for the advancement of the middle third have excellent results with the ability to be tailored to each patient deformity.

     

Re-Assessment of Coronoid as a Graft for Condylar Reconstruction in TMJ Ankylosis Patients: A Prospective Study and Literature Review

Introduction

Treatment for TMJ ankylosis aims at restoring joint function, improving the patient’s aesthetic appearance and quality of life and preventing re-ankylosis. To rebuild a structurally and functionally satisfactory neocondyle is a challenging problem. Aim of this study is to re-assess the coronoid as a graft for condyle reconstruction.

Materials and Methods

Twenty patients of TMJ ankylosis without involvement of the coronoid process in ankylotic mass, coming in age group elder than 14 years were selected for the study over a period 3 years from 2011 to 2014. Clinical examination, radiographs, and photographs were used postoperatively to evaluate the grafts and TMJ function. After osteoarthrectomy coronoid process was detached and fixed with a 4 hole L-shaped titanium miniplate to form neo condyle.

Result

No donor site morbidity was observed as reported with other autogenous grafts. Satisfactory mouth opening was observed during follow up period with mean mouth opening 37.33 ± 4.20 mm except one case which required graft removal due to postoperative infection. Radiographically moderate amount of resorption of grafted coronoid process was observed in nearly all the cases however satisfactory mandibular function and occlusion was observed.

     

“Oral Submucous Fibrosis Scoring Index” to Predict the Treatment Algorithm in Oral Submucous Fibrosis

Purpose

The main aim of the study is to propose a treatment protocol based on scoring system.

Materials and Methods

One hundred patients were selected randomly having oral submucous fibrosis. They were classified into five groups based on clinical signs and symptoms, radiological and histopathological grading and severity of fibrosis. Patients of particular group were subjected to specific treatment for each group and followed for 2 years regularly.

Results

We found that almost all patients got symptomatic relief and they are able to take regular diet. Patient’s interincisal mouth opening increased significantly.

Conclusion

Based on this scoring and grouping we can give definite and prompt treatment to the patients with satisfactory results. This proposed scoring and staging can play major role in controlling and treating this widespread global disease. Thus, OSMF scoring index is very effective to decide the severity of disease and progress.

     

“Modified Oblique Le Fort III Osteotomy” New Concepts

Introduction

The purpose of this study is to demonstrate the surgical technique for the correction of midfacial deformities; vertical excess and posteroanterior hypoplasia. This situation obligates the need to move the whole osseous structure in an oblique posteroanterior movement that should correct both midfacial deformities. This should also correct the lip incompetence while improving the malar projection on a profile view of the patient. We also present a mathematical formula that gives the angulation needed for moving the midface complex in a simultaneous vertical and posteroanterior direction. Once given the correct angulation for the desired oblique movement, the surgeon can reproduce this angulation with custom made surgical guides over the stereolithographic model, that can then be used during surgery to achieve the desired movement accurately. This technique exemplified on this paper will give maxillofacial surgeons a new and affordable tool for the correction of midfacial deformities in an accurate and easily reproducible manner and amplifying the surgical repertoire.

Materials and Methods

Patients seen in the specialty hospital “Dr. Bernardo Sepulveda” National Medical Center XXI Century, IMSS, during the period from February 2013 to November 2014 with Modified Oblique Le Fort III osteotomies, with the application of two trigonometric formulas for the accuracy of the technique.

Conclusions

The application of the formulas give accurate results as well as the enlargement of the upper airway and esthetic results.

     

A new approach to treat bone gaps after midfacial and zygomatic fractures with a collagen membrane

Purpose

The aim of the study was to analyze the eligibility of resorbable collagen membrane in the treatment of midfacial fractures to prevent gap formation and subsequent cheek tissue retraction.

Material and methods

We included nine patients (six males, three females; mean age 51; range 20–73 years; mean bone gap size 8.03 × 13.12 mm) in a retrospective study design. The defect size was assessed by ultrasound.

Results

After a healing period of 4 to 55 weeks, treatment resulted in a significant reduction of gap size (residual mean bone gap size 6.14 × 7.32 mm).

Conclusions

Native resorbable collagen membrane is a promising tool to reduce the size of bony gap in midfacial defects.

     

Outcome of amniotic membrane as an interpositional arthroplasty of TMJ ankylosis

Purpose

Temporomandibular joint ankylosis is a major disorder, mainly due to trauma and other reasons, which is responsible for the restriction of mandibular functional activities. The scope of the successful surgical correction of temporomandibular joint ankylosis with amniotic membrane is on the membrane’s being an interpositional material which we found not to elicit any host reaction, is capable of functional adaptation, and is very economical. Our purpose is to show the amniotic membrane as a suitable, biocompatible, and interpositional material alternative to the other materials, thereby reducing donor site morbidity.

Methods

A study was conducted in 13 patients with an age range of 10 to 35 years with unilateral and bilateral bony TMJ ankylosis confirmed by clinical and radiological evaluations. Preoperative and postoperative clinical assessments of TMJ functions were done. Amniotic membranes were collected from the tissue bank, sterilized by gamma radiation, and freeze-dried. Then, the prepared amniotic cap (10–15 layers of amniotic membrane) was placed over the condylar head and anchored loosely to the neck and the surrounding tissues with a 3/0 Vicryl suture.

Results

Measurements of postoperative maximum interincisal opening was taken with scale among the 13 patients. Preoperative interincisal distances ranged from 0 to 15 mm, and preoperative and immediate postoperative were 33–45 and 25–32 mm, respectively. Postoperative follow-up of interincisal opening after 1-, 6-, and 12-month intervals was found from 32 to 35 mm. Lateral excursions (left and right), protrusive movements, and functional recovery were all satisfactory.

Conclusion

Amniotic membrane graft as an interpositional material in temporomandibular joint ankylosis can be a good alternative as to prevent reankylosis and recover functionality.

     

Use of T.M.J. Disc as a Soft Tissue Interpositional Graft Material for Functional Rehabilitation of Ankylosed T.M. Joint

Introduction

Many surgical techniques have been described for the treatment of TMJ ankylosis, but no strategy has been uniformly agreed upon underscoring the difficulty of the problem. Despite new guidelines and updated methods, treating patients with TMJ Ankylosis remains a challenge as the incidence of recurrence after treatment is soaring. This study exemplifies our experience in using an unsullied method to treat TMJ Ankylosis to restore the structure of TMJ in conjunction with convalescing secondary maxillofacial deformity.

Materials and Methods

A total of 56 cases of unilateral bony TMJ ankylosis were included in the study, and postoperative results of T.M.J disc as a soft tissue interposition graft was evaluated. The operative protocol comprised of (1) resection of ankylotic mass, (2) intraoral ipsilateral coronoidectomy or contralateral coronoidectomy when needed, (4) interpositioning disc as soft tissue graft, (5) interposing and fixing sternoclavicular or costocondral graft with lag screws and (6) early mobilization, aggressive physiotherapy.

Results

The study assessed patients with regular follow‐up checks for a period of 3 years. The average preoperative mouth opening was found to be 5.46 mm (range 2–10 mm). Mean post-operative mouth opening was 33.05 mm (range 24–43 mm), while 3 years post operative mouth opening (mean) was 39.75 mm. No cases of reankylosis were reported during this period suggesting it as a viable and satisfactory approach.

Conclusion

The use of TMJ disc as a soft tissue interpositional graft material is an effectual method for functional rehabilitation of ankylosis cases and serves as an effective means of preventing recurrence.

     

A prospective assessment of outcomes following the use of autologous blood for the management of recurrent temporomandibular joint dislocation

Purpose

The objective of the study was to compare results of treatment for chronic recurrent temporomandibular joint dislocation (CRTMD) by autologous blood injection (ABI) using two different methods of administration (combination intra- and peri-articular, and peri-articular alone).

Materials and methods

Forty patients diagnosed with CRTMD were randomly divided into two groups of 20 each (A and B). Group A were treated by intra- and peri-articular blood injection, group B were treated by peri-articular injection alone. The follow-up was done at 1, 3, 6, and 12 months. The study assessed presence of dislocations, pain (VAS, 0–10), interincisal mouth opening (IMO), and the presence of sound phenomena. The treatment was considered successful in patients without the persistence of CRTMD symptoms, as well as with a VAS of 0–1.

Result

After 12 months, a beneficial therapeutic effect in group B was seen in 11 patients, while 16 patients from group A had a therapeutic effect.

Conclusion

Intra- and peri-articular ABI is more effective than peri-articular blood application alone in the treatment of CRTMD, although the difference was not statistically significant.

     

Versatility of uniplanar prearthoplastic distraction osteogenesis in the correction of post-ankylosis facial deformities—a report of five different cases

Purpose

Unilateral or bilateral ankylosis can lead to severe micrognathia and facial deformity that requires multiple, often, staged surgical corrections. To date, there is no ideal treatment modality that satisfactorily corrects the complex anatomy, restores the ramal height, and corrects the micrognathia and microgenia. Distraction osteogenesis has been acclaimed as a successful modality for the treatment of such deformities. It is a cost-effective approach with low morbidity and less relapse thus providing better functional and esthetic outcomes. It allows the surgeon to correct the deformity in various planes by using various devices by changing osteotomy designs and vectors, with simultaneous hard tissue and soft tissue reconstruction.

Patients and methods

Here, we present a series of five cases where different types of distraction osteogenesis were combined with various other procedures to correct post-ankylotic facial asymmetry. In one case, simultaneous maxillo-mandibular distraction [Molina’s technique] was used.

Results

All patients showed significant improvement in function and esthetics. Outcome assessment was made using clinical photographs and radiographs.

Conclusion

Pre-arthroplastic distraction osteogenesis is a versatile cost effective approach that can be customized for every patient based on their needs.

     

Long-Term Effect of Maxillary Distraction Osteogenesis (DO) on Nasal Index in Adult Patients with Cleft Lip and Palate Deformities

Purpose

To test the hypothesis that there is no immediate and long-term effects of maxillary distraction osteogenesis (DO) on nasal index among adult subjects with cleft lip and palate deformities.

Materials and Methods

Twelve adult subjects in the age range of 17–20 years with complete unilateral cleft lip and palate underwent advancement of maxilla by DO. The immediate and long-term effects of maxillary DO on nasal index were evaluated from extra-oral full face frontal photographs recorded prior to DO (T₀), at the end of active DO (T₁) and at least 2-years after the DO (T₂). The ANOVA, Post Hoc test (Bonferroni) and Pearson correlation coefficients were used. The probability value (P value) 0.05 was considered as statistically significant.

Results

SNM angle and Ptm-M distance increased significantly by DO (P < 0.001). The nasal index increased significantly (P < 0.01) by 13.85 % from T₀ value of 85.15 ± 4.49 to 99.02 ± 11.16 % at the end of active distraction (T₁) and by 12.69 to 97.84 ± 9.14 % at the end of long-term follow-up (T₂). The correlation between sagittal maxillary advancement and nasal index was statistically significant (P < 0.001). For each millimeter of maxillary advancement, the nasal index increased by 1.38 % and 1.8 % at the end of active distraction and long-term follow-up respectively.

Conclusion

The advancement of maxilla by distraction osteogenesis among subjects with cleft lip and palate deformities increased nasal index significantly.

     

Musculoskeletal Changes as a Sequel to Advancement Genioplasty: A Long-Term Cephalometric Prospective Study

Aims

The aim of this study was to evaluate cephalometrically the stability of hard tissues and soft tissue changes of advancement genioplasty 2 years after surgery.

Methods

A prospective study was conducted which comprised of 25 patients, who underwent advancement genioplasty alone with no other orthognathic surgical procedures. Immediate pre-operative, 6 months postoperative, and 2 years postoperative lateral cephalograms were compiled and assessed.

Results

The mean surgical advancement planned was around 8 mm. Six months post-surgery, the relapse rate was 15% of the surgical advancement which was considerably reduced in the following 18 months to 7%. The ratio of soft tissue to bony advancement at pogonion was 0.9:1. There are significant alterations in the soft tissue profile in terms of decrease in the soft tissue thickness, facial convexity angle, deepened mentolabial sulcus and minimal increase in the lower lip height.

Conclusion

Advancement genioplasty was considered as a relatively stable procedure, if adequate muscular pedicle and internal rigid fixation were maintained. The present study was of 2 years, and we can expect further changes in the hard and soft tissues, which are clinically irrelevant.

     

Myositis ossificans traumatica of the temporalis muscle: a case report and diagnostic considerations

Background

The present paper reported the case of a trauma-related myositis ossificans, with focus on considerations for a differential diagnosis process.

Case report

A 50-year-old male with a severe painful limitation (12 mm) of jaw opening referred a trauma to the right temporomandibular joint (TMJ) area occurring about 40 days before. Posttraumatic TMJ ankylosis was ruled out on the basis of negative magnetic resonance and cone-beam computerized tomography findings, and the patient underwent treatment with arthrocentesis, botulinum toxin injections, and physiotherapy on the basis of two diagnostic hypotheses, viz., an anchored disk phenomenon or a myofibrotic contracture of the right masseter muscle due to prolonged myospasm. After 4 months, jaw opening was slightly increased to 23 mm, but limitation and pain persisted. A new CT was performed to investigate for the emerging clinical picture compatible with traumatic myositis ossificans of the right temporalis muscle. Once the diagnosis was confirmed, the patient underwent surgery for coronoidectomy. At the 6-month follow-up, mouth opening was increased to up to 35 mm and pain was absent.

Discussion

It is fundamental that patients suspected of having uncommon clinical pictures leading to mouth opening restriction are promptly referred to specialized centers, where the differential diagnosis process should be based on a comprehensive assessment taking into account for the potential etiologic factors described in the literature.

     

Assessment of Alar Flare and Efficacy of Alar Cinch Suture in the Management of Alar Flare Following Le Fort 1 Superior Repositioning: A Comparative Study

Objectives

To prospectively analyze the amount of alar flare, factors contributing to alar flare and efficacy of cinch suture as an adjunctive procedure for alar flare reduction.

Study Design

Thirty adult patients with vertical maxillary excess, who underwent Le Fort 1 impaction, were divided into 2 groups of 15 each. Alar cinch was performed as an adjunct procedure in group 2 patients and results were compared to group 1 which was the control group. Measurements were made on the patients and on 1:1 standardized photographs.

Results

Group 2 showed a near pre-operative alar position compared to group 1. The alar flare resulting from every millimeter of impaction was significantly less in group 2 compared to group 1.

Conclusion

Alar cinch suture restores the normal alar width by preventing the lateral drift of the naso-labial muscle and thereby reducing the postoperative nasal flare significantly.

     

Increased local recurrence in advanced parotid malignancy treated with mastoidectomy without lateral temporal bone resection

Objective

We analyzed patients with advanced parotid malignancy requiring proximal facial nerve exposure undergoing mastoidectomy versus lateral temporal bone resection to determine differences in local and distant recurrence.

Study design

The study design is a case series with chart review.

Setting

The setting is in Tertiary care practice in Fort Worth, Texas from January1998 to January 2014.

Subjects and methods

The study included 120 patients with advanced parotid malignancy, 82 males between 19 and 87 years, and 38 females between 26 and 83 years. Patients with no overt bone involvement were treated with parotidectomy and mastoidectomy for exposure of the proximal facial nerve, and patients with clinically suspected (radiographic imaging or clinical fixation) bone involvement were treated with parotidectomy and lateral temporal bone resection. Follow up ranged from a minimum of 18 months to 11 years following surgery.

Results

Sixty patients were treated with mastoidectomy and 60 were treated with lateral temporal bone resection. In patients treated with mastoidectomy, 13 had local recurrence and 7 had distal recurrence. In patients treated with lateral temporal bone resection, 2 had local recurrence while 9 had distant recurrence. Statistical analysis revealed that patients treated with mastoidectomy developed local recurrence (p = 0.0022) more commonly than those treated with lateral temporal bone resection. There was no significant difference in distant recurrence between both groups (p = 0.5949).

Conclusions

Patients with advanced parotid malignancy should be treated aggressively with parotidectomy and lateral temporal bone resection regardless of bone involvement due to increased risk of local recurrence in those treated with mastoidectomy alone.

Level of evidence

Level of evidence is a 4 case series.

     

Reliability and validity of self-assessment of mouth opening: a validation study

Background

The objective of this study was to evaluate the reproducibility and validity of patients’ mouth opening measurements in a research setting.

Methods

Firstly, 68 patients made repeated self-measurements of mouth opening using a cardboard scale (Therabite Range of Motion Scale – TRMS). Secondly, 80 patients enrolled in a clinical trial on morbidity after lower third molar surgery, made daily assessments during the postoperative week. Patients’ measurements were then compared to gold-standard clinicians’ measurements.

Results

Reliability of patients’ measurements was excellent with an intraclass correlation coefficient of 0.92. The patient’s measurements correlated well with the gold-standard clinician’s measurements, both for the first 68 patients (Pearson’s rho ranging from 0.86 to 0.90, p < 0.0001) as well as for the 80 patients enrolled in the clinical trial (rho = 0.82, p < 0.0001 at day 2, rho = 0.83, p < 0.0001 at final visit).

Conclusions

TRMS can be used by patients to produce reproducible and valid mouth opening measurements.