The efficacy of mylohyoid muscle flap use in surgical treatment of ‘krokodil’ drug-related osteonecrosis of the mandible

The aim of this study is to show the effectiveness of the use of mylohyoid muscle flap in surgical treatment of stage 1 and 2 Krokodil drug-related ON of mandible.Retrospective study of patients with stage 2 Krokodil drug-related ON of distal mandible was performed. Regarding to the used surgical technique the patients were divided into two groups (groups 1 and 2). In group 1(control group) the wound was closed only by the local mucoperiosteal flaps, while in group 2 (experimental group) the wound was closed by combining mylohyoid muscle flap and local mucoperiosteal flaps.24 patients were included in this study (15 patients in the group 1 and 9 patients in the group 2). In all patients of experimental group the postoperative period was uneventful and no recurrence occurred. In group 1 recurrence was found in 7 patients, which is significantly higher than in group 2 (χ²=5.9, p=0.015). Disease recurrence occurred as wound dehiscence during 4-10 postoperative days.Within the limitations of the study it seems that the adoption of the mylohyoid muscle flap as double-layer closure technique is an effective and predictable method for the treatment of such patients and, therefore, should be chosen whenever deemed appropriate.     

Surgical treatment of 61 consecutive patients with maxillary stage 3 medication–related osteonecrosis of the jaws using a pedicled buccal fat pad

Oral and Maxillofacial Surgery - Buccal fat pad (BFP) is used for the closure of large oroantral defects caused by surgical removal of the necrotic bone in patients with medication-related...     

Surgical treatment of jaw osteonecrosis in “Krokodil” drug addicted patients

Retrospective study of jaw osteonecrosis treatment in patients using the “Krokodil” drug from 2009 to 2013.On the territory of the former USSR countries there is widespread use of a self-produced drug called “Krokodil”. Codeine containing analgesics (“Sedalgin”, “Pentalgin” etc), red phosphorus (from match boxes) and other easily acquired chemical components are used for synthesis of this drug, which used intravenously. Jaw osteonecrosis develops as a complication in patients who use “Krokodil”. The main feature of this disease is jawbone exposure in the oral cavity. Surgery is the main method for the treatment of jaw osteonecrosis in patients using “Krokodil”.40 “Krokodil” drug addict patients with jaw osteonecrosis were treated. Involvement of maxilla was found in 11 patients (27.5%), mandible in 21 (52.5%), both jaws in 8 (20%) patients. 35 Lesions were found in 29 mandibles and 21 lesions in 19 maxillas. Main factors of treatment success are: cessation of “Krokodil” use in the pre- (minimum 1 month) and postoperative period and osteonecrosis area resection of a minimum of 0.5 cm beyond the visible borders of osteonecrosis towards the healthy tissues. Surgery was not delayed until sequestrum formation. In the mandible marginal or segmental resection (with or without TMJ exarticulation) was performed. After surgery recurrence of disease was seen in 8 (23%) cases in the mandible, with no cases of recurrence in the maxilla.According to our experience in this case series, surgery is the main method for the treatment of jaw osteonecrosis in patients using “Krokodil”. Cessation of drug use and jaw resection minimize the rate of recurrences in such patients.     

The use of ‘viscoelastic tests’ in driving transfusion needs in major trauma patients

Haemorrhage can be attributed to approximately 50% of the 5 million trauma deaths worldwide every year. The development of damage control resuscitation techniques and major haemorrhage protocols has revolutionized trauma resuscitation. In this review we aim to explore the phenomenon of acute traumatic coagulopathy, the history and development of ‘viscoelastic tests’, the theory behind their use, the basic nomenclature and the role of these tests within the clotting cascade. We also look at the assessment of acute traumatic coagulopathy and the role of viscoelastic tests within goal-directed trauma resuscitation. Of particular interest is a review of the current recommendations for the implementation of thromboelastic tests in major haemorrhage guidelines and protocols.     

Immediate versus delayed aggressive physical therapy following buccal fat pad interposition in oral submucous fibrosis—a prospective study in Central India

Purpose

Oral submucous fibrosis is a disease of an Indian subcontinent with obscure aetiology and poorly treated with varying signs and symptoms. OSMF occurs at any age but is most commonly seen in teenagers and adults in the age ranging between 16 and 35 years. A number of surgical treatments have been used for the treatment of oral submucous fibrosis with unpredictable results.

Patients and method

In this study, 220 patients were randomly divided into two groups with mouth opening less than 16 mm and evaluated with immediate and delayed aggressive physiotherapy with buccal fat pad interposition after fibrotomy. Group A (n = 110) patients underwent aggressive mouth opening exercise from the next postoperative day while in group B (n = 110), patients underwent physiotherapy 7th day postoperatively. Pain and discomfort, mucosalization, infection, flap dehiscence and necrosis were noted. Patients were followed for 1 year on a regular interval basis.

Results

At the end of 1-year follow up, the post-operative mean mouth opening in group A was 38.63 mm and 34.19 mm in group B. In group A, the immediate physiotherapy results in mild to moderate pain and discomfort to the patients as compared to no apparent pain in the group B. The mean mucosalization time in group A and group B was 4.2 and 5.1 weeks, respectively. Postoperatively, all patients achieve satisfactory mouth opening.

Conclusion

Immediate aggressive physiotherapy yields a comparatively superior result than delayed physiotherapy with respect to mouth opening in 1 year of follow-up.

     

Somatic genomic imbalances in ‘tumour-free’ surgical margins of oral cancer

Up to 30% of oral squamous cell carcinoma (OSCC) patients develop local recurrence and distant metastasis. The molecular status of histologically cancer-free tumour margins could be a critical factor in predicting tumour behaviour. The aim of this study was to detect somatic genomic imbalances in OSCC with emphasis on the surgical margins. DNA was isolated from tumour tissues, margin tissues, and blood samples (used as control) obtained from 11 OSCC patients, and genome-wide array comparative genomic hybridization was performed. Imbalances were present in both tumours and margins, although, as expected, they were more prevalent in tumours (duplications, P = 0.0002; deletions, P = 0.0001). Duplications were more frequent than deletions in both tumours and margins, but without statistical significance. Fifteen imbalances in tumour tissues were recurrent and all of them were duplications. Four of these were found both in tumours and margins and involved chromosomes 1q, 8p, Xp, Yp, and Yq. Four imbalances were recurrent in margin tissue and all of them were duplications (autosomes 8 and 17 and both sex chromosomes). Histologically ‘cancer-free’ margins hide genomic alterations consistent with unexplained OSCC recurrences. Establishing the molecular status of the margins could improve outcome prediction.     

Patients’ quality of life improves after surgical intervention of stage III medication-related osteonecrosis of the jaw

Oral and Maxillofacial Surgery - The treatment of advanced stages of medication-related osteonecrosis of the jaw (MRONJ) remains challenging. In order to improve decision making concerning the...     

Medication‐related osteonecrosis of the jaw: Surgical or non‐surgical treatment?

Medication‐related osteonecrosis of the jaw (MRONJ) is a severe side effect of antiresorptive (bisphosphonates and denosumab) and anti‐angiogenic therapy used in the management of oncologic and, less frequently, osteoporotic patients. While there is good international agreement on the diagnostic and staging criteria of MRONJ and the cessation of antiresorptive/anti‐angiogenic treatments, the gold standard of treatment is still controversial, in particular between non‐surgical and surgical approaches. The former usually includes antiseptic mouth rinse, cyclic antibiotic therapy, low‐level laser therapy and periodic dental checks; the latter consists of surgical necrotic bone removal. The purpose of this retrospective study was to describe the therapeutic approaches and outcomes of 131 lesions from 106 MRONJ patients treated at the Policlinic of Bari. Non‐surgical treatments were chosen for 24 lesions that occurred in 21 patients who, due to comorbidities and/or the impossibility of stopping oncologic therapies, could not undergo surgical treatment. As to the outcome, all the surgically treated lesions (107) showed complete healing, with the exception of 13.5% of the lesions, all of which were stage III, which did not completely heal but showed reduction to stage I. The 24 non‐surgically treated lesions never completely healed and, rather, generally remained stable. Only two cases exhibited a reduction in staging. Based on our observations, MRONJ occurring both in neoplastic and non‐neoplastic patients benefits more from a surgical treatment approach, whenever deemed possible, as non‐surgical treatments do not seem to allow complete healing of the lesions.     

Is buccal fat pad a better option than nasolabial flap for reconstruction of intraoral defects after surgical release of fibrous bands in patients with oral submucous fibrosis? A pilot study: A protocol for the management of oral submucous fibrosis

PurposeThe aim this study was to compare the buccal fat pad (BFP) and nasolabial flap for reconstruction of intraoral defects after release of fibrous bands in patients with oral submucous fibrosis (OSF).Materials and methodsThis is a comparative study. The study sample was derived from the population of patients who presented, with restricted mouth opening of less than 20 mm, to the Department of Oral and Maxillofacial Surgery, Swargiya Dada Saheb Kalmegh Dental College and Hospital Hingna Nagpur. The patients were divided into two groups. In Group I (n = 10) reconstruction was performed with a nasolabial flap and in Group II (n = 10) with BFP. Both groups were analysed separately for mouth opening (interincisal distance in millimetres) preoperatively and 20 months postoperatively, time taken for epithelialization of BFP and nasolabial flaps. Statistical analysis was performed with SPSS statistical software for Windows, version 8.0 (SPSS, Inc, Chicago, IL) using the _2 test and Student's t test.ResultsIn all 20 patients the interincisal mouth opening was (mean) 11 mm (3–19 mm) preoperatively which improved to a mean of 42 mm (23–52 mm). In Group I there were more complications as compared to Group II such as partial flap necrosis particularly at the tips, temporary widening of oral commissure and subluxation of TMJ. The unsightly extraoral scar and intraoral growth of hairs were not seen in Group II.ConclusionBFP is the better choice for reconstruction in comparison to nasolabial flap.     

Buccolam(®) (buccal midazolam): a review of its use for the treatment of prolonged acute convulsive seizures in the dental practice

This article is published in response to a query from reader Sarah Clements, based at Golding House Dental Practice Ltd in Kent, regarding the BDJ paper entitled 'Updated guidance on medical emergencies and resuscitation in the dental practice' (BDJ 2012; 212: 41-43). Sarah wished to be provided with further clarification on the ordering, prescribing and administration of midazolam.     

Evolutionary steps in the design and biofunctionalization of the additively manufactured sub-periosteal jaw implant ‘AMSJI’ for the maxilla

The purpose of this prospective registry case-series study was to determine the biological, mechanical, and aesthetic improvements made to the additively manufactured sub-periosteal jaw implant (AMSJI) after timed installation. A total of nine patients received maxillary AMSJIs in three sessions over a 2-year period. Architectural changes, topological optimization, and amendments to biofunctionalization were performed after each phase through the use of computer-aided design, finite element analysis, and growing clinical experience. Biological improvements included sandblasting (large grit alumina) and acid-etching; increased hydrophilicity by plasma surface activation; deletion of the crestal connecting struts; relocation of the anterior post in front of the anterior part of the basal loop; protection of the Schneiderian membrane from fixation screw penetration; high polishing of the posts; major platform switch with equigingival connections; the use of removable posts that require local anaesthesia and do not inflict major biological damage; scaffolding for secondary stability; and the provision of an incision guide. Mechanical improvements included the creation of a generic design based on finite element analysis and the resulting topological optimization, a shortening of the wings, and a reduction in the number of fixation screws. Aesthetic improvements included relocation of the anterior post, as described above, and pink anodization of the posts.     

Surgical challenges in the treatment of advanced cases of ameloblastoma in the developing world: The authors’ experience

Total mandibulectomy was carried out in 32 patients with extensive oro-facial lesions histologically diagnosed as ameloblastoma in four specialist centres in south-eastern Nigeria from January 2001 to December 2006. All the patients presented at an advanced stage with the whole mandible affected so the treatment of choice was total mandibulectomy. The patients gave informed consent for surgery. The standard surgical procedure was the same in all cases and was performed by the same surgeons. Of the 32 mandibles removed, there were 13 male (41%) and 19 female (59%) patients, giving a male-to-female ratio of 1:1.6. Three (9%) patients died due to problems relating to anaesthesia while five (16%) had postsurgical-related psychosomatic problems. Generally, the postoperative recovery was characterized by reduction in the quality of life of these patients because immediate jaw reconstruction was not feasible. This article highlights the challenges in the surgical management of advanced cases of ameloblastoma in the developing world and proposes a middle ground for professional interactions and exchange programmes among oral and maxillofacial surgeons across the world to assist poorer countries in the management of these advanced cases of oro-facial tumours.     

Outcomes of alveolar segmental ‘sandwich’ osteotomy with interpositional particulate allograft for severe vertical defects in the anterior maxilla and mandible

The purpose of this study was to report the outcomes of interpositional osteotomy with mineralized allograft in the treatment of alveolar vertical defects in preparation for implant placement. Thirteen defects (11 maxillary and two mandibular) were treated with osteotomy segments ranging in length from two to five missing teeth. The segments were positioned 5–7 mm coronally, with the gap space filled with allograft and then fixated with titanium hardware. Vertical bone augmentation was analyzed by superimposing pre- and post-surgical cone beam computed tomography images and stratified based on the length and number of missing teeth in each edentulous segment. The mean vertical bone gain was 3.7 ± 1.6 mm in the area of greatest vertical defect and the mean length of the transport segment was 20.5 ± 8.1 mm. These segments represented two-, three-, four-, or five-tooth edentulous sites; the mean vertical bone gain for these segments was 1.7 ± 0.5 mm, 3.8 ± 1.0 mm, 4.6 ± 0.9 mm, and 6.7 ± 0.0 mm, respectively. Stability of vertical height gain was found to be directly proportional to the span length of the osteotomy segment, with the largest five-tooth segment achieving the greatest gain. Vertical bone gain in two-tooth segments was minimal, indicating a moderate amount of resorption.     

The outcome after surgical therapy of bisphosphonate-associated osteonecrosis of the jaw—results of a clinical case series with an average follow-up of 20 months

Objectives

The present case series evaluates the success rate of osteotomy and primary wound closure in patients with bisphosphonate-associated osteonecrosis of the jaw (BRONJ).

Materials and methods

Eighty patients suffering from BRONJ were included in the study. All patients received intravenous bisphosphonate therapy and underwent osteotomy and primary wound closure according to a standardised protocol. After discharge, the patients were reviewed on a regular basis over an average time period of 20 months.

Results

During follow-up in 11 patients, a recurrence of BRONJ occurred in the former operation field. Seventeen patients died due to their underlying disease. The success rate of osteotomy and primary wound closure in the treatment of BRONJ was calculated at 84.2 % 20 months after surgery. The results showed non-significant difference concerning the outcome of surgery in the different clinical stages of BRONJ.

Conclusions

In accordance with previous studies, stage-independent osteotomy and primary wound closure combined with antibiotics shall be deemed a viable treatment option in patients suffering from BRONJ.

Clinical relevance

With a high success rate, osteotomy in combination with primary wound closure seems to be a viable alternative to more conservative protocols in the treatment of BRONJ.