Study Design: Case report. Objective: By reporting such a rare vascular variation of the radial artery, we aim to make other surgeons aware of comparable vascular variations in radial forearm free flap harvesting. Methods: In this case report, we present an 84-year-old male patient, with a rare distal branching of the radial artery into the deep palmar branch, approximately 7 cm from the wrist. In order to visualize the vascular variation, intraoperative photo documentation took place. Results: The radial free flap harvesting was successful and no postoperative complications were noted. Conclusions: Distal branching of the radial artery into the deep palmar branch may occur in radial forearm free flap harvesting. Since no restrictions in flap perfusion and/or hand perfusion were observed in our case, we recommend radial forearm free flap raising in the traditional way. No changes concerning the design and the positioning of the skin paddle need to be made.
Sport-related mandibular fracture is a common injury in the field of maxillofacial surgery. However, the treatment of mandibular condylar fractures in professional soccer goalkeepers is rarely reported. A 32-year-old male professional soccer goalkeeper was referred for malocclusion after collision with an opponent player during a game. The patient’s mandible was displaced between the left lower lateral incisor and left lower canine. Computed tomography showed right condylar base fracture with medial displacement and left para-symphysis fracture. Internal fixation using retromandibular anterior trans-parotid approach via 25-mm skin incision immediately below the earlobe and intraoral vestibular approach were performed under general anesthesia 2 days after the injury. The patient was discharged without complications 3 days after surgery, with mandibular protrusion and diduction exercises with limitation of mouth opening. Soft diet and limitation of mouth opening was performed for 4 weeks after surgery. To achieve early return-to-play, rehabilitation based on Fowell and Earls’ return-to-play guidelines following facial fractures was started, with moderate exercise 5 days after surgery, and progressively full exercise without contact 8 days after surgery. He started normal team training with individualized jaw-guard 4 weeks after surgery. His body weight decreased by 2.2 Kg 1 week after surgery, gradually recovered, and became normal 4 weeks after surgery. The patient returned to a game 2 months after surgery. This case report can be a reference case in condylar fractures of professional soccer players, as the available scientific literature is limited with regard to return-to-play after maxillofacial fracture in professional athletes.
Myositis Ossificans Traumatica (MOT) is a rare condition that affects soft tissues after a trauma and hardly affects the mastication muscles. The occurrence in the temporal muscle is uncommon, and trismus is the most prevalent symptom. The diagnosis of the pathology is sufficiently obtained through the collection of clinical history, physical and imaging exams. Differential diagnosis is important mainly to rule out more aggressive diseases, such as osteosarcoma. Treatment becomes more invasive as the ossification matures, and resection of structures adjacent to the tumor, such as coronoidectomy, is well indicated for promoting good results on the mouth opening amplitude. However, to maintain this amplitude, aggressive myofunctional therapy is required. Nevertheless, the literature has no well-defined protocol for this physiotherapy. Therefore, this article reports a rare case of MOT in the temporal muscle that was treated conservatively, with bilateral coronoidectomy and mouth opening physiotherapy, and obtained a satisfactory result. Consequently, it also presents a suggestion of a postoperative physiotherapy protocol.
Chronic inflammatory diseases, including periodontitis, are the most common causes of bone tissue destruction. Periodontitis often leads to loss of connective tissue homeostasis and reduced alveolar bone levels. Human periodontal ligament stem cells (PDLSCs), a population of multipotent stem cells derived from periodontal ligament tissues, are considered as candidate cells for the regeneration of alveolar bone and periodontal tissues. Periodontitis impairs the osteogenic differentiation of human PDLSCs. Noncoding RNAs (ncRNAs), including long noncoding RNA (lncRNA), microRNA (miRNA), and circular RNA (circRNA), have been proposed as vital regulators influencing several differentiation processes including bone regeneration. Still, the molecular mechanisms of ncRNAs regulating osteogenic differentiation of human PDLSCs remain poorly understood. Exploring the influence of ncRNAs in the process of osteogenic differentiation of human PDLSCs may provide novel therapeutic strategies for tissue regeneration as the regeneration of the lost periodontium is the ultimate goal of periodontal therapy.
Background: Oral squamous cell carcinoma is the main malignancy of the oral cavity; floor of the mouth and the lateral border of the tongue being the most affected sites. This kind of oral neoplasms may require mandibular resection and reconstruction. Treatment options for such mandibular defects include bone grafts, free flaps, and reconstruction plates. Today, the commonly used treatment method is vascularized fibula flaps due to its many advantages when compared to other methods. However, it is a complex procedure and demands much of both practitioners and the patient. Case Presentation: In this report, we present a case of oral squamous cell carcinoma of the gingiva of the mandible which was treated with a partial mandibulectomy and resection. Because of the patients age and fragility an immediate mandibular reconstruction with a pre-shaped reconstruction plate, without hard or soft tissue transfer, was performed. Yearly controls showed pleasing results both aesthetically and functionally and the patient showed no plate-related complications up until the patient’s death, 9 years later. Conclusion: With this case, we would like to illustrate that using reconstruction plates only may be a viable option in selected cases for continuity defects of the mandible, specifically in fragile patients less suitable for more demanding surgical interventions.
Le Fort fractures in pediatric patients are rare, and their management has increased complexity due to the development of the maxillofacial musculoskeletal complex and dentition. The authors present a case using historic circum-zygomatic wiring with 21st century surgical planning in a 18 month old, who sustained complex Le Fort II and III fractures. Treatment involved surgical planning with dental and stereolithographic models, and the fabrication of a retention modified, occlusal splint. Closed reduction with circum-zygomatic wiring retained by the occlusal splint, for a 3 week period, prior to removal. At 12 month review, the patient had good facial symmetry, cosmesis, profile, and function. The use of circum-zygomatic wiring provided a conservative operative approach, achieving excellent functional and cosmetic results without the potential morbidity of more invasive surgery.
Study Design: Retrospective data analysis study. Objective: Attending continuing professional development (CPD) and continuing medical education (CME) activities is a necessity for practicing surgeons in most parts of the world. To enhance best practices in conducting CME/CPD, objective evaluation of these events is crucial. This article aims to evaluate one such international standardized CPD course conducted for facial surgeons across the globe. The Management of Facial Trauma course was developed by an international planning committee of experienced surgeons and has been implemented in all regions of the world. Method: This 2-day course is delivered using a combination of short lectures, small group discussions, and practical hands-on activities. Data collected from pre- and post-course evaluations of 86 Management of Facial Trauma courses conducted worldwide from 2017-2019 were collated and analyzed. Results: Participant demographics and experience levels varied slightly across the regions. Evaluation of the course effectiveness revealed overall high ratings for educational impact, content usefulness, and faculty performance. Conclusion: Our results indicated that this standardized course met the audience needs and enabled participants to plan changes in clinical practice. In addition, it confirmed that the course was relevant across different specialties and across different cultures and countries.
Background: Kaposi’s sarcoma is a common malignancy in HIV patients. Oral manifestation of AIDS-associated Kaposi’s sarcoma occurs in up to 65% of HIV/AIDS patients and is a poor prognostic factor. We report the case of a patient with a progressive bulky manifestation of oral Kaposi’s sarcoma. Case Presentation: A 48-year-old male presented with dysphagia due to progressive indolent swelling of the palate. Intraoral inspection revealed an uneven, partially ulcerated, livid mass, approximately 5 cm in diameter, extending antero-posteriorly from the superior vestibulum to the soft palate and across the hard palate, thereby overgrowing remaining teeth and the alveolar arch. Serological testing revealed an HIV infection, and further tests showed HHV8-positivity. The patient underwent surgical debulking of the oral lesions and, following complete remission, received full mouth reconstruction with an implant-supported prosthesis. Conclusions: Understanding the relation of HIV and HHV8-infection in terms of disease onset and clinical presentation is important to increase awareness of oral Kaposi’s sarcoma and ensure subsequent appropriate management of affected patients. Clinical staging represents the most important factor for choosing the optimal treatment. The introduction of combined antiretroviral therapy has proven to be efficient in curing oral Kaposi’s sarcoma, while several additional locoregional treatment options, including debulking surgery, may be necessary for symptom relief or to improve cosmesis. Radiotherapy should be applied restrictively due to potentially severe toxic mucosal reactions, whereas additional chemotherapy must be considered in severe cases that present with widespread disseminated disease. A multidisciplinary approach to the treatment of functionally and aesthetically impairing oral Kaposi’s sarcoma is highly recommended.
Study Design: A case report with 2 year follow up. Objective: The aim of this paper is to present a case of bilateral TMJ ankylosis with coexisting dentofacial deformity and occlusal cant, and 2 years follow-up evaluation for changes and relapse in the facial skeletal and airway. Methods: The patient was planned preoperatively by computer simulation for bilateral interposition arthroplasty and surgical jigs, coronoidectomy, detachment of masseter and medial pterygoid muscles from ramus, LeFort 1 osteotomy, temporary maxillomandibular fixation, counter-clockwise rotation of the maxillomandibular complex, maxillary fixation and iliac crest graft, reconstruction of bilateral TMJ with custom-made total joint prosthesis, dermal fat interposition in the joint, reattachment of muscles, maxillomandibular fixation, and active physiotherapy. Results: Average ramal length improved by 28.35 mm (81%) in the immediate postoperative and 25.6 mm (73.45%) at 2 years, showing 2.75 mm (4.4%) vertical bone resorption at the angle region. Point A advanced by 1.3 mm, but showed 4.5% horizontal relapse; Point B advanced by 10.2 mm, but showed 9.5% relapse at 2 years. Pogonion advanced by 26.3 mm (70%) but presented 7 mm (10.9%) horizontal relapse; and menton by 28.6 mm (89%) with 5.4 mm (8.9%) relapse at 2 years. The mean mandibular plane angle decreased by 33.5° (42%) after surgery and by 32° (40%) at 2 years. Pharyngeal airway increased by 49% after surgery and by 75.6% at 2 years follow-up. Conclusion: This computer simulated approach for the management of bilateral TMJ ankylosis with facial deformity and occlusal cant improves aesthetics, function and airway in a single surgery, thereby reducing the management cost and time, and deliver precise results.
Study Design: Technical note. Objective: Computer-aided design and computer-aided manufacturing (CADCAM) is commonly used in craniomaxillofacial (CMF) surgery because of its advantage in customizing medical devices. We used this technology to create individualized, resin-bonded 3-dimensionally printed titanium arch bars. Method: This article describes a patient specific, three-dimensionally (3D) printed, resin-bonded arch bar as an alternative to the classical intermaxillary fixation systems. Results: The ease of application and removal, as well as the protection of the periodontal and cheek tissues, and operator fingers, made this a comfortable technique for both the patient and practitioner. Conclusions: A patient-specific 3D-printed titanium arch bar can be useful in the arsenal of the maxillofacial surgeon.
Introduction: Orbital roof fractures are uncommon and normally associated with high energy trauma in which multiple other injuries are present. Most can be managed non-operatively with close observation. However, in a small proportion the defect is such that it permits the development of a meningoencephalocele, which can cause exophthalmos, a reduction in visual acuity and pain, all of which are unlikely to improve without surgical treatment. In light of their scarcity and the potential of serious risks with surgery that includes meningitis and visual disturbance (or even loss), thorough planning is required so that the meningoencephalocele can be reduced safely and the orbital roof adequately reconstructed. Methods: We report a case of a patient with a frontal bone defect, orbital roof fracture and associated meningoencephalocele that presented years after being involved in a road traffic accident in another country, who complained of a significant headache and orbital pain. The use of 3D modeling to help plan the surgery, and intraoperative 3D navigation to help negotiate the anterior skull base are described along with the reconstruction of the frontal bone and orbital roof using titanium mesh contoured on the 3D model. Conclusions: Although conservative management of orbital roof fractures predominates; those that are symptomatic, have associated neurologic symptoms or pose a risk to the eyesight warrant a surgical approach. The methods of repair, which center around separating the intracranial and intraorbital contents, are described in the context of this patient and previous cases, and a treatment algorithm is proposed.
Study design: Application of Damage Control Surgery (DCS) in Oral and maxillofacial surgery is still evolving, therefore, the current study hopes to share our experience in the management of bomb blast patients. Objectives: The objectives of the current study is to share our experience in the management of maxillofacial bomb blast injuries emphasizing on DCS. Methods: This was a retrospective study of combatant Yemeni war patients who were transported across the border from Yemen and treated in Najran, Kingdom of Saudi Arabia from December 2015 to December 2019. Information such as etiology of injury, age, zone of injury and mechanisms of bomb blast associated injuries, treatment protocol and complications. The treatment protocols adopted include; DCS in which exploration to control soft tissue bleeding was done and when bone bleeding could not be controlled, immediate reduction and osteosynthesis of bone fractures was carried out. Early Definitive Surgery (EDS) was done in patients that were hemodynamically stable with open reduction and internal fixation (ORIF) of all facial bone fractures. Closed reduction and fixation were done with the use of arch bars while in conservative approach, patients were placed only on soft diet. Data was stored and analyzed using IBM SPSS Statistics for IOS Version 25 (Armonk, NY: IBM Corp). Results: A total of 235 (57.6%) patients sustained bomb blast injuries from the 408 war casualties. Other patients (42.4%) sustained other types of injuries. All the patients were males. Their ages ranged from 21 to 53 years with mean (SD) at 27.3 (5.6) years. DCS was carried out in a large proportion of the patients totaling 78 (33.2%) patients, while EDS was carried out in 58 (24.7%) hemodynamically stable patients. ORIF was the main treatment modality for the fractures in 136 (57.9%) of the patients. Conclusion: The result of the study showed a large proportion of the patients were managed with DCS. DCS should be seen as a strategy in stabilizing the patients before definitive surgery is performed.
Temporomandibular joint (TMJ) arthroscopy is considered a safe, minimally invasive procedure for the treatment of certain TMJ derangements. However, as TMJ arthroscopy is being popularized, more complications are being reported. Though exceedingly rare, arteriovenous fistula (AVF) can occur. We describe a case of superficial temporal artery (STA) fistula formation successfully treated with coil embolization.
Evaluation of the airway is the first step in any trauma protocol, and this is particularly important in instances of facial trauma. While airway compromise is not uncommon in blunt or penetrating facial trauma, it is rarely a significant concern in instances of an isolated mandibular fracture. We report a rare case of immediate airway compromise in an elderly, edentulous female who sustained an isolated mandibular subcondyle fracture, complicated by her history of a remote hemimandibulectomy for management of her oral cancer. Initial airway management was performed conservatively with prone or lateral positioning under continuous pulse oximetry monitoring in the intensive care unit, followed promptly by open anatomic reduction and internal fixation of the fracture under more optimal operative conditions. After stabilizing the subcondylar fracture, the patient followed a mechanical soft/no-chew diet for 6 weeks until the fracture was healed. She has experienced no airway concerns since her surgery. This case report stresses the importance of a comprehensive evaluation of the airway in facial trauma patients with altered baseline anatomy, as well as highlights the considerations for emergent surgical airway versus immediate or delayed surgical fracture fixation.
Objective: The anterolateral thigh (ALT) flap is a workhorse in microsurgical reconstruction. However, a flap width greater than 8 centimeters limits primary closure and discourages some surgeons from using this flap for larger defects to avoid a large and unsightly skin grafted donor site. ALT donor site closure can be made even more challenging when a more circular shaped flap is required. Methods: This study examines the use of the keystone perforator flap to close large ALT free flap donor sites in 6 patients who underwent reconstruction for various purposes who otherwise would have required donor site skin grafting. Results: Average flap dimensions were 10.5 cm × 17 cm and mean keystone flap dimensions were 12.2 cm × 22.5 cm. Average operative time of cases was 528.3 minutes and average BMI of patients was 24.8 kg/m2. There was 1 case of partial keystone flap dehiscence that required local wound care, and 1 case of drain replacement for thigh seroma. Conclusions: This series demonstrates that keystone perforator flap closure allows the thigh to maintain a relatively normal appearance, reduces postoperative pain associated with skin grafting, and can be performed in higher BMI patients with minimal complications and without increasing operative time or sensory or motor deficits. This series to date also has the largest defects closed with keystone flaps demonstrating the feasibility of this type of closure in very large ALT donor sites.
Study Design: Case Report. Objective: The Temporalis muscle (TM) Flap is a reliable, versatile flap with adequate bulk and flexibility. However, temporal hollowing is the most common postoperative complication after harvesting the flap. We describe a surgical modification for harvesting the split TM flap to prevent postoperative temporal hollowing and report 2 cases with up to 18 months of follow-up. Method: This study discusses the posterior ⅔ split temporalis muscle flap in preventing temporal hollowing. We report 2 well-documented cases with up to 18 months of postoperative follow-up. Also, the authors discuss the key points regarding the technique’s indication and limitation. Results: The posterior ⅔ split temporalis muscle flap is reliable in both benign and malignant disease processes. The results demonstrate the flap’s reliability with minimum donor site morbidity. Conclusion: The use of the posterior ⅔ of the TM flap is a viable technique to prevent the flap’s harvest’s temporal hollowing.
Study Design: Ameloblastoma is a benign odontogenic tumor of epithelial origin, with locally aggressive behavior; and due to its invasiveness has increased recurrence rates. It is more frequent in the mandible than the maxilla. Surgical treatment is performed with approaches ranging from conservative to radical surgery, either followed by microvascular reconstruction, or not. Adjuvant treatment has shown better local control in refractory cases. Multiple relapses are associated with BRAF gene mutation at codon 600. Objective: This case series aimed to describe the clinical, imaging, histopathological, therapeutic and mutational characterization of 3 patients with refractory ameloblastoma in the maxilla. Methods: Data of 3 patients were collected, and descriptions were provided of procedures such as clinical, imaging, surgical technique, histopathological subtype and molecular analysis for detection of BRAFV600E mutation. Results It was obtained a locoregional control after RT of two cases described. After BRAF mutation molecular analysis, no patient presented it. Conclusion: Surgery remains the gold standard for the treatment of ameloblastomas, even in refractory cases; however, an expanded approach to obtain free surgical margins, and reconstruction of the maxilla itself may be challenging. Adjuvant radiotherapy is still a controversial topic, but could favor reduction of the local recurrence rate in cases where the surgical margins are compromised after surgical resection. Further studies will be necessaries for analysis of the BRAFV600E mutation, for therapeutic purposes.
Immediate obturation of the patient undergoing maxillectomy who is not undergoing formal autologous reconstruction is important for immediate form and function of the patient. Exophytic tumors, that are large in dimension can make pre-operative obturator formation challenging. Traditional methods of obturator fabrication involve a physical or digital impression. Preoperative virtual surgical planning for tumor resection and reconstruction using free tissue transfer has become a mainstay in head and neck reconstruction. We describe a variation of this for a patient unable to undergo free tissue transfer where the authors used preoperative virtual surgical planning and CAD/CAM technologies to perform tumor resection, and fabricated an obturator based on the CT imaging alone.
Camurati-Engelmann Disease is a rare congenital sclerosing bone dysplasia condition. Affected patients manifest bony abnormalities including thickening of the skull base and orbital bones. The resulting orbital volume reduction associated with this condition can cause exophthalmos, distorting the facial profile. The authors report a 33-year-old man with a diagnosis of Camurati-Engelmann Disease exhibiting exophthalmos who was successfully treated with the insertion of bilateral lateral orbital wall patient specific PEEK implants via a bi-coronal flap approach. This case highlights the novel application of modern cutting-edge technology in the treatment of proptosis in Camurati-Engelmann Disease.
The purpose of this retrospective study was to determine postoperative volume differences associated with orthognathic surgery after controlling for time, gender, age, and side of face. Three-dimensional (3D) photographs of 10 patients submitted to simultaneous Le Fort I + Bilateral Sagittal Split osteotomies were analyzed. The images were obtained using a Vectra® M3 device (Canfield, NJ, USA) and were captured postoperatively, at 1 week (1S), 1 month (1M), 2 months (2M), 6 months, (6M) and 1 year (1A). The photo taken at 1A was used as the basis of comparison for the other photos (1S, 1M, 2M, and 6M). Greatest facial volume was observed at 1 week after surgery (42.54 cm3, SD = 29.71 cm3), with men in this period showing higher values (60.20 cm3, SD = 36.75 cm3) than women (30.76 cm3, SD = 19.04 cm3). The most extensive facial volume reduction occurred between the first week and the first month; postoperatively (52.1%). No significant difference was found between age and side groups.
