Perspectives On the Role of the Lateral Pterygoid Muscle and the Sphenomandibular Ligament in Temporomandibular Joint Function

The lateral pterygoid muscle plays an important role in the movement of the mandible and has been studied from several points of view, including structural and functional anatomy. What matters clinically is the relative position of the muscle fibers attached medially to the mandibular condyle. In the following study, we observed not only the attachment of the lateral pterygoid muscle fibers to the articular disk, but also the relative position of the mandibular condyle to a base line set up on the mandibular condyle. According to our observations, the lateral pterygoid muscle fibers attach to the articular disk at the inner point of the medial pole. Based on this finding, we can say that the muscle fibers can both draw the articular disk anteriorly and balance it by supporting it posteriorly. That is to say, the lateral pterygoid muscle has two actions: to elevate the articular disk anteriorly and to support the articular disk. Furthermore, the sphenomandibular ligament has continuity with the articular disk tissue medially. This relationship suggests that the ligament fibers attached to the articular disk draw the disk posteriorly in its course of mandibular closing, thus enabling the articular disk to move smoothly.     

An Anatomical Study of a Muscle Bundle Separated from the Medial Pterygoid Muscle

When mandibular dentures are fabricated, marginal sealing should be taken into consideration for the stability of the denture. We selected specimens of the medial pterygoid muscle showing insertion of an independent small muscle bundle at its insertion site, and evaluated the anatomical relationship between the morphology of the insertion site and the denture. The insertion of the pterygoid muscle was classified according to the insertion morphology of the independent small muscle bundle into three types using the retromolar pad as a reference: Type I, insertion of the independent muscle bundle posterior to the retromolar pad; Type II, insertion immediately below the retromolar pad; and Type III, insertion into the fascia of the mylohyoid muscle. Types II and III muscles seem to affect the denture because of their closeness to the mandibular denture. In the oral cavity, the independent small muscle bundle studied appeared as a streak-like structure. When such a structure is detected during examination for denture fabrication, the following consideration is necessary. Since the medial pterygoid muscle is a mouth-closing muscle, this independent small muscle bundle may contract during mouth closing, appearing more markedly in the oral cavity. Therefore, examination should be performed not only with the mouth closed but also with assumed centric occlusion.     

Intraoperative cardiac assessment with transesophageal echocardiography for decision-making in cardiac anesthesia

Transesophageal echocardiography is an invaluable hemodynamic monitoring modality. Extended and anatomically based evaluation of cardiac function with transesophageal echocardiography is essential to prompt and accurate decision-making in anesthetic management during cardiac surgery. Fractional shortening and fractional area changes are indices widely used to assess the global systolic performance of the left ventricle. Monitoring regional function using semi-quantitative scoring has been demonstrated to be a more sensitive indicator of myocardial ischemia. Assessment of left ventricular diastolic function should be performed in a systematic way, measuring transmitral flow, pulmonary venous flow, transmitral color M-mode flow propagation velocity, and mitral annulus tissue Doppler imaging. The unique anatomical features of the right ventricle make echocardiographic evaluation complicated and therefore less frequently employed. Right ventricular fractional area change, tricuspid annular plane systolic excursion, maximal systolic tricuspid annular velocity with tissue Doppler imaging, and myocardial performance index are indices successfully incorporated into intraoperative right ventricular assessment. Left ventricular outflow tract obstruction with systolic anterior motion of the mitral valve may develop after cardiac procedures. Transesophageal echocardiography plays a central role in prevention as well as diagnosis of systolic anterior motion. Transesophageal echocardiography is extremely useful not only for detecting and locating intracardiac air, but also for guiding and evaluating the procedures to remove air. Air is likely to persist in the right and left superior pulmonary vein, left ventricular apex, left atrium, right coronary sinus of Valsalva, and ascending aorta. Accurate evaluation of cardiac function depends on performing TEE examination properly and obtaining optimal images.     

A Case of Age-Related Epstein–Barr Virus (EBV)-Associated B Cell Lymphoproliferative Disorder, so-called Polymorphous Subtype, of the Mandible, with a Review of the Literature

Epstein–Barr virus (EBV) is known to be associated with the development of lymphomas in immunocompromised patients. Recently, age-related immune impairment has been recognized as a predisposing factor in the development of EBV-driven lymphoproliferative disorders (LPDs) in elderly patients without any known immunodeficiency or prior lymphoma. In approximately 70 % of reported cases, the affected sites have been extranodal, such as the skin, lung, tonsil and stomach. However, age-related EBV-associated B cell (EBV + B cell) LPD is extremely rare in the oral cavity. Here we report a 71-year-old Japanese man who developed an EBV + B cell LPD resembling classical Hodgkin lymphoma (CHL)—so-called polymorphous subtype—of the mandible. Histopathologically, infiltration of large atypical lymphoid cells including Hodgkin or Reed-Sternberg-like cells into granulation tissue with marked necrosis was found in the mandibular bone. Immunohistochemical analysis revealed that the large atypical Hodgkin or Reed-Sternberg-like cells were CD3–, CD15–, CD20+, CD30+ and Epstein–Barr virus (EBV)-latent infection membrane protein-1 (LMP-1)+. In situ hybridization (ISH) demonstrated EBV-encoded small RNA (EBER) + in numerous Hodgkin or Reed-Sternberg-like cells. EBNA-2 was detected by polymerase chain reaction (PCR) using an extract from the formalin-fixed, paraffin-embedded specimen. To our knowledge, this is the first reported case of the polymorphous subtype of age-related EBV + B cell LPD affecting the mandible.