Search

Purpose The purpose of this study was to conduct a systematic review with meta-analysis to investigate the outcomes of direct lingual nerve repair after injury. Materials and Methods The studies in this review were compiled by using PubMed/Medline and ScienceDirect, which were searched by a single reviewer (M.K.) from their inception until March 10, 2020. Two independent reviewers (M.K. and V.B.Z.) who were blinded to each other's assessments reviewed full-text articles to assess for study inclusion. Outcomes were dichotomized as either functional sensory recovery (FSR) or no FSR. Clinical testing must have been assessed at a minimum of 6 months postoperatively. FSR was defined as grade S3, S3+, or S4 on the British Medical Research Council scale of neurosensory function. Studies were only eligible if they provided the number of patients treated with conduits or time from injury to repair and the associated rates of FSR with each intervention. Results The initial search using the key terms yielded 4,921 results, which was then eventually filtered down to 6 articles after multiple levels of appraisal. Five articles were retrospective cohort studies and 1 was a randomized controlled study. Four of the 6 studies reported an FSR of grade S3 or higher in 85% or more of the patients. Conduit use was not associated with a significantly greater likelihood of achieving FSR (pooled risk ratio = 1.10; 95% confidence interval, 0.96 to 1.27; P = .17). Repair within 6 months was associated with significantly improved likelihood of achieving FSR (pooled risk ratio = 0.84; 95% confidence interval, 0.71 to 0.99; P = .04). Conclusions The use of conduits during repair was not associated with clinically significant increased FSR. Early repair was associated with a beneficial effect on FSR; however, heterogeneity was an issue with the studies. There is a lack of strong evidence owing to the nature of studies analyzed and the need for further research is required.

Purpose During trigeminal nerve repair, a gap is sometimes encountered that prevents the tension-free apposition of nerve endings. The use of a processed acellular nerve allograft is a novel technique that shows promise in overcoming this problem. The goal of the present study was to support the slowly evolving body of evidence that acellular processed nerve allografts (Avance; Axogen, Alachua, FL) are a viable alternative to autogenous nerve grafting and the use of conduits for reconstructing defects of the trigeminal nerve. Patients and Methods The study design consisted of a retrospective review of the medical records of patients referred to Rutgers School of Dental Medicine for management of trigeminal nerve injuries from July 2008 to August 2014. Sixteen patients met the inclusion criteria for the present study. All patients underwent nerve grafting using a processed nerve allograft. All operations were performed by the same surgeon (V.Z.). Serial neurosensory testing was performed by 1 clinician (V.Z.) in a standardized fashion. The primary outcome variable was the interval to functional sensory recovery as defined by the Medical Research Council Scale. Results The participants ranged in age from 16 to 62 years (mean 32). Of the 16 patients, 12 were female (75%) and 4 were male (25%), and 3 were smokers (18.75%) and 13 were nonsmokers (81.25%). One half of the patients (n = 8; 50%) underwent surgery on the inferior alveolar nerve, and 8 (50%) underwent surgery on the lingual nerve. The most common mechanism of injury was impacted third molar removal (n = 9; 56.25%) Of the 16 patients, 15 (93.75%) achieved functional sensory recovery during the study period. Conclusions The results of the present study support the hypothesis that processed nerve allografts are effective in reconstructing small (

Purpose This study compared a type 1 collagen conduit (NeuraGen) with a porcine small intestinal submucosa conduit (AxoGuard) when used in lingual nerve microsurgery and any differences in achieving functional sensory recovery (FSR). Patients and Methods All patients who underwent lingual nerve microsurgery performed by 1 surgeon (V.B.Z.) from 2007 to 2014 had their surgical information obtained by a retrospective review of hospital records and office charts after institutional review board approval. Those patients whose surgery included the use of a nerve conduit were included in the study. Subjective neurosensory recovery was determined by neurosensory testing, including responses to hot, cold, wisp, brush, and pinprick. Objective recovery was determined by testing 2-point discrimination and fine touch threshold with von Frey fibers. The objective findings were correlated to a Medical Research Council System score, with grades S3, S3+, and S4 indicating FSR. Results The conduits were compared using a Student t test with a 2-tailed hypothesis. The von Frey fiber test had a preoperative mean of 6.29 (standard deviation [SD], 0.95), which improved to 3.97 (SD, 0.67) for the NeuraGen and 4.17 (SD, 0.56) for the AxoGuard. Two-point discrimination improved from a mean higher than 19.42 to 9.32 mm (SD, 2.96 mm) for the NeuraGen and 9.67 mm (SD, 2.13 mm) for the AxoGuard. The mean FSR was S3+. Conclusions There were no meaningful differences in outcomes between the 2 conduits studied, and all patients achieved FSR according to the Medical Research Council Scale.

The odontogenic keratocyst (OKC) is a benign but locally aggressive cyst that has a potentially high recurrence rate and morbidity associated with different treatment approaches. Decompression of odontogenic cysts is a well-established technique that has been shown to decrease the size of the cyst and need for sacrificing local structures during ensuing definitive treatment. Multiple devices have been previously described for decompression of OKCs utilizing varying drain material and modes of fixation, but have been complicated by device malposition, soft tissue overgrowth, poor hygiene, and suture dehiscence. This paper describes the application of a custom titanium drain (Biomet ® Jacksonville, FL) secured using bone screws for decompression of an OKC in a 77-year-old male.

Iatrogenic injury to the trigeminal nerve can remain a source of concern and litigation even for the most experienced oral and maxillofacial surgeons. This article provides the most up-to-date evidence-based recommendations for identification, prevention, and management of these injuries to help clinicians provide the highest level of patient care.

Purpose The specialty of oral and maxillofacial surgery (OMS) encompasses the diagnosis and surgical management of a variety of pathologic, functional, and esthetic conditions of the oral and maxillofacial region. Despite the specialty's prominent role in the field of dentistry, a lack of complete understanding still remains among dental and medical health professionals as to the exact scope and expertise of the oral and maxillofacial surgeon. The present study aimed to analyze a population of dental students' perceptions of OMS as a specialty with respect to treatment rendered, referral patterns, and a general opinion of the specialty as a whole. Materials and Methods A survey consisting of 10 multiple-choice questions was compiled and distributed to dental students through an on-line polling service (SurveyMonkey). A total of 5 dental student classes at a single dental school were polled using school-based electronic mail, including the graduating seniors. All answers were kept confidential, and no individual students were identified. The students were not able to retake the survey once completed. The final tallies of the survey results were compiled and submitted for statistical analysis. Results Statistically significant associations between the year of dental education and student perceptions of OMS were determined. As dental students progress through their undergraduate studies, their perceptions change with regard to the referral of dental implants. Periodontists were found to have statistically significantly greater rates of referral than oral and maxillofacial surgeons from dental students in the fourth year and recent graduates compared with younger dental students from the first, second, and third years for placement of dental implants. Statistically insignificant in terms of a changing dental student perception was the finding that third molar removal was within the domain of the oral and maxillofacial surgeon, as well as the management of cleft lip and palate deformities and mandibular fracture repair. Almost all the dental classes believed that the specialty of OMS was both medical and dental in nature and that it is a very important dental specialty. Conclusions Dental student perceptions of OMS change throughout their undergraduate training. The reasons for such a change are multivariate and might include factors such as the amount of didactic training and clinical exposure. It is vital to both recognize and address this change at an undergraduate level of training in an effort to increase educated referrals to a surgeon who might provide the best treatment options for the patient. A stronger understanding of the dental students' perception of OMS provides an opportunity for the oral and maxillofacial academic faculty to better educate students and, ultimately, strengthen our specialty.

Purpose We performed a retrospective study of lingual nerve injury assessment comparing the techniques of current perception threshold testing versus clinical sensory testing. Patients and Methods We designed and implemented a cross-sectional study and enrolled a patient sample with lingual nerve injuries presenting for treatment to the principal investigator. The predictor variables were clinical sensory testing modalities (ie, temperature, nocioception, vibration, 2-point discrimination, brush stroke, and von Frey monofilament perception). The primary outcome variable was the electrical current perception thresholds of the tongue dorsum (neurometer measurements at 5, 250, and 2,000 Hz). Comparisons were established with the ipsilateral affected and contralateral unaffected lingual nerve distributions. The associations between the clinical sensory testing and current perception threshold measurements were assessed using correlation coefficients, with the level of statistical significance set at P Results A total of 40 patients (13 males and 27 females) were included in the present study. The average age of these patients was 34 years (range 13 to 66). Significant correlations were observed between the electrical stimulation thresholds at 2,000 Hz and the 2-point discrimination, reaction to brushing, reaction to vibration, and von Frey fiber thresholds, between the electrical stimulation thresholds at 250 Hz to the nociceptive and thermal thresholds, and between the electrical stimulation thresholds at 5 Hz to thermal stimuli. Conclusions The significant correlations observed in the present study indicate that current perception threshold can be a complementary or alternative tool in the assessment and evaluation of lingual nerve injuries.

The trigeminal nerve and its peripheral branches are susceptible to injury from maxillofacial trauma and iatrogenic causes in the practice of dentistry and medicine. These injuries can be significant for patients due to their effects on speech, mastication, food and liquid incompetence, and social interactions. Many of these sensory disturbances often undergo spontaneous recovery; however, some may be permanent with varying outcomes ranging from mild hypoesthesia to complete paresthesia. Some patients can also develop untoward outcomes such as neuropathic responses, leading to chronic pain syndromes in addition to their sensory disturbances. The face and perioral region have one of the highest densities of peripheral nerve innervation in the body, which is why it is difficult for patients to tolerate neurologic disturbances in this region as compared with other areas. Pain, temperature, and proprioception are transmitted centrally via the lingual, mental, inferior alveolar, infraorbital, and supraorbital nerves. Each sensation is transmitted by different types of sensory receptors and nerve fibers with differing susceptibilities to injury and recovery. Each of these sensory modalities must be tested and monitored through serial examinations for spontaneous recovery in patients with peripheral trigeminal nerve injuries. The goal of trigeminal microsurgery is to create an environment in which those nerves not demonstrating spontaneous recovery are given the opportunity for regeneration and prevention of the development of neuropathies. This article reviews the indications and microsurgical techniques for repair of lingual and inferior alveolar nerve branch injuries.

Summary Background: A problem faced by health professions education throughout the world is a lack of full-time clinical teachers. This is particularly serious in dentistry and nursing, but is increasingly also true in medicine. To make up for this shortfall there is a growing reliance on part-time clinical teachers. Context: Part-time clinical teachers are essential for the education of students. However, compared with their full-time counterparts, the part-time teachers are often not adequately prepared for their roles as educators within the context of the clinical curriculum. They might not be trained in the latest educational practices, and may be unprepared for the time needed to excel as teachers and mentors. Implications: As part-time teachers take on more responsibility, it is important that they take part in orientation and training sessions to assist them in developing the skills they need to succeed. This will require a significant commitment from the institution as well as the part-time teacher, but is critical for maintaining the academic quality of the clinical training programmes. This also represents an untapped area for research into how to ensure the success of part-time clinical teachers.

This case report describes an interesting use of virtual surgical planning to fabricate tooth-borne cutting guides to assist in localization and enucleation of multiple recurrent odontogenic keratocysts close to the inferior alveolar nerve. The 3-dimensional models generated and cutting guides increased the accuracy and precision of the procedure and decreased surgical time and potential patient morbidity.

The goal of treatment for nasal fractures is to restore the pretraumatic state and normal function. The decision by the surgeon regarding the surgical approach should be based on the degree of injury, the presence of concomitant facial injuries, patient compliance, training of the surgeon, and the presence and degree of septal injury. The use of a closed or open approach will then depend on the extent of the injury.

Endoscopic-assisted open reduction/internal fixation of mandibular condylar fractures is a viable alternative to traditional closed or open reduction techniques. However, case selection is important. Ideally, the fracture undergoing EAORIF should be easily manipulated into reduction and have enough stable bone on either side of the fracture to support a bone plate. It is important to note that in all reprinted studies, authors note a steep "learning curve" with the EAORIF technique. Identical procedures took the novice surgeon two to three times as long when compared with an experienced surgeon. EAORIF is a technique that should be included in the armamentarium of the maxillofacial trauma surgeon when treating mandibular condylar fractures.

Purpose The antilingula is an important landmark in mandibular ramus surgery. Its relationship to the lingula provides useful clinical information as to the position of the mandibular foramen and inferior alveolar nerve. The purpose of this study was to determine the reliability of using the antilingula as a guide to osteotomy placement for intraoral vertical ramus osteotomies. Materials and Methods Eighteen cadaver mandibles were harvested and the antilingula was identified on each hemimandible by palpating the most prominent bulge on the lateral aspect of the mandible. In addition, the lingula (the entrance of the mandibular neurovascular bundle into the medial aspect of the ascending ramus of the mandible) was identified. A 1 mm fissure bur was used to drill a hole perpendicular to bone, from the deepest aspect of the concavity at the center of the lingula. The drill perforated both the medial and lateral cortices of the mandible. The distance from the antilingula to lingula was measured and recorded in both the anterior-posterior and the superior-inferior planes. Results There was complete concordance of the position of the lingula and antilingula in the anterior-posterior dimension in 11.1% of the specimens. In 33% of the specimens, the lingula was found anterior to the antilingula and in 45.6% the lingula was found posterior to the antilingula. There was complete concordance of the lingula and antilingula in the superior-inferior dimension in 2.8% of specimens. The lingula was found superior to the antilingula in 47.2% of the specimens and inferior to the antilingula in 50% of samples. Conclusion In most instances, the position of the lingula was posterior-inferior relative to the position of the antilingula. At a measurement of 5 mm posterior to the antilingula (at the level of the antilingula), there was no risk of damaging the neurovascular bundle in this cadaveric study.

Purpose The objective of this study was to investigate the analgesic effect of a collagen conduit (Neuragen, Integra LifeSciences Corp, Plainsboro, NJ) using duloxetine (Cymbalta, Lilly, Indianapolis, IN) with or without pregabalin (Lyrica, Pfizer, NY) on pain induced by partial sciatic nerve transection in a rat model. Material and Methods Adult male Sprague-Dawley rats were divided into 5 groups (n = 10 per group): group 1, nerve damage with no treatment; group 2, nerve damage treated with the application of a collagen conduit and saline; group 3, nerve damage treated with the application of a collagen conduit and duloxetine; group 4, nerve damage treated with the application of a collagen conduit and pregabalin; and group 5, nerve damage treated with the application of a collagen conduit and pregabalin plus duloxetine. Pain levels were evaluated by responses to mechanical and thermal stimuli at baseline before and 3 and 7 days after surgery. Interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF) levels were evaluated in blood, sciatic nerve, and dorsal root ganglion samples collected 7 days after surgery. Results The group treated with the collagen conduit and pregabalin exhibited markedly less pain 7 days postoperatively in response to mechanical and thermal stimuli compared with the other groups. IL-10 levels were considerably increased in the group treated with pregabalin. The groups treated with a collagen conduit and duloxetine and a combination of pregabalin and duloxetine also exhibited markedly less pain in response to mechanical and thermal stimuli 7 days after surgery compared with the group that had only nerve injury. The decrease in pain using duloxetine was not as robust but was associated with a decrease of TNF-α. The combination of pregabalin and duloxetine resulted in a substantial decrease in IL-6. Conclusion Using a collagen conduit and duloxetine, pregabalin, and their combination helped alleviate neuropathic pain. The mechanism of action might be associated, at least in part, to cytokines.

We present a case of a 14-year-old adolescent boy who has oral cavity after gunshot wound to the tongue presenting with hemorrhage from the tongue requiring coil embolization of the right lingual artery. The patient subsequently developed macroglossia, which was managed with maxillomandibular fixation for a period of 3 weeks with complete resolution of glossal edema.

Purpose This retrospective study was performed to assess the clinical outcome of patients who have undergone trigeminal nerve microsurgical repair of the inferior alveolar nerve. Materials and Methods This study includes all patients who underwent microsurgical repair of the inferior alveolar nerve at the University of Medicine and Dentistry of New Jersey from July 1, 1998 through June 30, 2003. Each patient underwent a thorough evaluation of sensory nerve function that included the type of injury, date of injury, and neurosensory testing. The evaluation was performed pre- and postoperatively to assess sensory improvement. Through chart review and quantitative statistical analysis, the outcome of inferior alveolar nerve microsurgical repair was assessed to ascertain which sensory variables were statistically significant in showing improvement from microsurgical procedures. Results Thirty-two patients underwent microsurgical repair of their inferior alveolar nerve injury by the same surgeon. The average period of time from initial nerve injury until primary surgical repair was 6.6 months. Four patients did not follow-up postoperatively and were excluded from the final data. Of the remaining 28 patients, mean follow-up period was 9.5 months. It was determined that 26 patients (92.9%) had statistically significant neurosensory improvement, with 14 reporting (50%) significant improvement, 12 patients (42.9%) with slight improvement, and 2 patients (7.1%) demonstrating no improvement. No statistical evidence was found to support that a decrease in time from injury to surgery had improved results in this limited patient population. Conclusion Microsurgical repair provides an improvement in neurosensory function in patients that present with an inferior alveolar nerve injury.

Purpose This laboratory study compared the performance of locking versus nonlocking Synthes (Synthes, Paoli, PA) 2-mm mandibular fixation plates. The purpose of the study was to determine if there are physical or mechanical properties to support the use of one rigid fixation device over the other. Materials and Methods A bovine rib model was selected for this study because they closely approximate characteristics of the human mandible. Two experimental groups composed of 10 locking and 10 nonlocking 2-mm plates were secured to randomly selected osteotomized bovine ribs using 10-mm monocortical screws. The specimens were loaded using a 4-point bending system to the point of failure using a MTS model 309.00 servo-hydraulic testing system (MTS Systems Corp, Eden Prairie, MN) with a custom fabricated fixator. The data was obtained with TestStar 2 version 4.0 and TestWare Sx 4.0 software (MTS Systems Corp), and analyzed to determine if there was any difference in performance between the 2 mandibular plate designs. Results Overall, there were no statistically significant differences between the locking and conventional 2-mm mandibular plate. Of the 20 samples tested, 1 (nonlocking) had a unique early screw failure (pullout) inconsistent with any other samples and was not analyzed. Of the remaining 19 samples, 17 produced a yield failure, bend, or stretch rather than a plate fracture. Both of the plate fractures occurred in the nonlocking plates. Although the data suggested that this mode of failure was more common in nonlocking plates, the difference between both groups in the mode of failure did not achieve statistical significance (χ2 = 2.0, P = .16). Thus, yield was the predominant mode of failure for both types of devices. The force at which each device failed was also similar in both groups. The force of failure for the nonlocking plates was 559.9 N (SD = 247.9), whereas the locking plate failure strength was 637.8 N (SD = 276.3; t (17) = 0.6, P = .53). The results indicated that there was no suggestion that one plate might be stronger than the other. Conclusions In this laboratory model, no significant differences were found between the 2 types of mandibular plates. Although studies have shown the locking system to be more rigid, this study suggested that the type and degree of failure are more likely related to bone quality and surgical technique when using the 2-mm mandibular plate. Additional prospective studies are needed to correlate these results in patient models.

Purpose The purpose of this study is to assess the anatomical spaces and causative micro-organisms responsible for deep fascial space head and neck infections and evaluate the resistance of antibiotics used in the treatment of these infections. Patients and Methods A 6-year retrospective study evaluated hospital records of 103 patients. All patients in this study underwent surgical incision and drainage, received IV antibiotics, and had culture and sensitivity performed. Patient demographics reviewed were gender, age, involved fascial space(s), micro-organisms identified and antibiotic resistance from culture and sensitivity testing. Results There were 56 male (54%) and 47 (46%) female patients. The submandibular space was the most frequent location for a single space abscess (30%), followed by the buccal space (27.5%) and the lateral pharyngeal space (12.5%). Sixty-three patients presented with multiple space involvement, totaling 142 spaces involved. A total of 269 bacterial strains were isolated from 103 patients. The bacteria were found to be 63.5% gram-positive. Gram-positive cocci were isolated 57.7% of specimens and gram-negative rods were isolated in 33% of cultures. There were 178 aerobes (65.7%) and 91 anaerobes (34.3%) isolated. The most common bacteria isolated were Viridans streptococci, Provetella, Staphylococci, and Peptostreptococcus. Culture and sensitivities were reviewed on 101 patients. Conclusion Patients who underwent surgical incision and drainage in the operating room had a tendency for involvement of multiple space abscesses with the submandibular space, submental, and lateral pharyngeal spaces effected most frequently. Cultures and sensitivities commonly showed greater growth in aerobes (65.7%) than in anaerobes. Gram positive cocci and gram negative rods had the greatest growth percentage in cultures.

This is a case report of a 12-year-old child with chromosome 22q11.2 syndrome who developed sarcoid dermatitis after tuberculosis exposure and Garre’s osteomyelitis from a carious tooth and odontogenic infection. Garre’s osteomyelitis is an uncommon form of osteomyelitis usually seen secondary to an exaggerated inflammatory response. Karl Garre first described this entity in 1893 as a suppurative condition in the tibia that exhibited focal thickening of the periosteum. Pell et al decribed its presence in the mandible in 1995 as a chronic isease with new periosteal bone formation. Gorman coined the term, periostitis ossificans, to specifically identify the formation of new bone overlying existing cortical bone. This term was extended from Gorman’s efinition by Nortje et al. Marx and Stern, however, tated that neither term is ideal because the periosteum oes not become ossified, but rather it deposits new one as infection-induced inflammation lifts off the corex. This condition may also develop in the mandible ue to genetic autoimmune diseases and in patients ho have an altered immune system.

Submental liposuction is an adjunctive surgical procedure that allows for the relatively predictable soft tissue recontouring of the cervicofacial region (Figs. 13 to 17). It may be performed independently as an outpatient procedure under intravenous sedation or as an adjunctive procedure during orthognathic surgery. Surgical complications are rare and are usually preventable with appropriate patient selection and surgical technique. Submental liposuction is a useful tool for enhancing the esthetic benefits of orthognathic surgery.

Purpose: The purpose of this double-blind, randomized study was to compare the efficacy and safety of a single dose of the following medications: 2 tablets of Vicoprofen (ibuprofen 200 mg/hydrocodone 7.5 mg; Knoll Pharmaceutical Co, Mount Olive, NJ), 2 tablets of acetaminophen with codeine phosphate (acetaminophen 300 mg/codeine 30 mg), and 2 tablets of placebo in the management of moderate to severe postoperative dental pain after surgical extraction of at least one impacted mandibular third molar. Patients and Methods: One hundred twenty-five patients (75 women, 50 men) participated in the study. The time of first perceptible pain relief and meaningful pain relief were measured using a stopwatch technique. Pain intensity and pain relief scores were recorded using standard verbal descriptors at 0.5, 1, 1.5, 2, 2.5, 3, 4, 5, 6, 7, and 8 hours after dosing. At the conclusion of the study, patients completed a global evaluation for the effectiveness of the study medication. Results: Both active treatments were superior to placebo for all analgesic measures. Pain relief scores were significantly better for Vicoprofen than placebo throughout the study and significantly better than for acetaminophen with codeine from 2 through 8 hours after dosing. The duration of analgesia (time to remedication) was significantly longer for Vicoprofen (median, 5.50 hours) compared with acetaminophen with codeine (median, 3.03 hours) and placebo (median, 1.00 hours). Mean global evaluation for Vicoprofen was significantly better than for placebo and acetaminophen with codeine. Overall, there were no significant differences in the adverse event profile among the 3 treatment groups. Conclusions: Vicoprofen was found to be an effective postoperative analgesic medication in the management of acute postoperative dental pain. Its total analgesic effect, duration of analgesia, and global evaluation were superior to acetaminophen with codeine and placebo in this study model. © 2000 American Association of Oral and Maxillofacial Surgeons

At most American centers, primary palatoplasty to repair a cleft palate is generally performed in patients by the age of 12 months to allow for appropriate speech development. Surgical access for the palatoplasty is often obtained with a Dingman mouth gag, which allows for maximum access and visibility of the surgical field. There are multiple techniques used by cleft surgeons to repair cleft palates, including War-dill-Kilner, von Langenbeck, Bardach, and Furlow Z-plasty. Common complications of these procedures in the immediate postoperative phase include bleeding and oropharyngeal edema. Airway obstruction is rare and most commonly results from laryngeal edema from a traumatic intubation. This case report documents severe glossal edema immediately after primary palatoplasty, causing airway obstruction and requiring reintubation in the immediate postoperative period. This is a rarely documented complication of palatoplasty, with only 4 reports noted in the medical literature since 1950, 3 in the anesthesia literature and 1 in the surgical literature. 1-4 .

The graft-versus-host disease reaction is an immunologic consequence resulting from the grafting of immunocompetent cells from one individual to an immunocompromised host. The oral manifestations of this disease process include severe oral pain, xerostemia, ulcerative lesions, and mucositis. With appropriate history and diagnostic testing, these lesions can be differentiated from other oral diseases having similar clinical appearance.

Introduction:The chin and submental region contribute to facial balance. Inadequate jaw projection and neck definition may compromise the aesthetic results of cosmetic surgical procedures. It was hypothesized that adjunctive mandibular setback procedures and reduction genioplasty would improve the aesthetic results of cosmetic surgery.Materials and Methods:A triangular excision for a V–Y advancement is outlined in the submental region using methylene blue. The triangle is oriented with the apex facing the chin and the base toward the thyroid cartilage in a natural neck crease. The triangle, oriented so that the base is toward the chin at the submental crease, left a small bulge at the apex of the vertical limb of the Y in the neck midline, which required a secondary excision to correct. Incisions in the shape of a pentagon or an ellipse can also be used. Local anesthetic with vascoconstrictor is deposited along the lines of the planned excision. The geometric skin is excised. If the platysma muscle is dehiscent, it can be sutured and platysmaplasty performed. The subplatysmal fat may be removed if visible only in the midline region with caution taken at this juncture not to be too aggressive to avoid potential profuse hemorrhage. The skin flaps are widely undermined. The fat excision is feathered. A two-layer closure is then performed.Discussion:In patients with adequate skin elasticity and thickness, liposuction may be indicated. Submental excision and direct lipectomy is another technique that can address the ptotic chin, lax skin, and submental lipomatosis. This technique is indicated for those patients in whom there is excess submental fat or skin laxity and in whom there is a contraindication or a lack of patient desire to undergo formal neck-lifting procedures.Conclusion:Submental recontouring is a useful adjunctive aesthetic procedure that can be readily performed in the office setting with instrumentation and technique currently available.

The purpose of this article is to describe the neural anatomy of the temporalis muscle as dissected along the intramuscular temporal fascial plane. This sagittal plane is a natural cleavage plane of the muscle, which is explored along with its relationship to the deep temporal nerve. Eight temporalis muscle specimens were removed in their entirety from 8 preserved cadavers. The muscles were selected based on whether they were grossly intact prior to procurement for processing. The muscle specimens were then processed over a 3-month period using Sihler's staining technique. Muscle dissection was performed along the intramuscular fascial plane under an operating microscope, taking care to preserve the underlying nerve and arterial anatomy. Dissections demonstrated an anterior and posterior division of the deep temporal nerve running within the deep portion of the muscle below the intramuscular fascial plane. This fascial layer provided a natural dissection plane to expose and evaluate the underlying nerve and arterial anatomy. In all specimens the deep temporal artery originated with the anterior temporal nerve and then branched into an anterior and posterior division. The innervation density and nerve caliber of the anterior portion of the muscle was much greater than that of the posterior, correlating with a greater anterior muscle bulk. This may have implications in differences in fiber type and functional regionalization of the muscle. The results of this anatomic study support the finding of an anterior and posterior division of the deep temporal nerve within the deep portion of the temporalis muscle. In addition, differences in the innervation density and muscle bulk lend credence to the possibility of regional muscle specialization. The natural cleavage plane of the intramuscular temporal fascia may have clinical ramifications for temporalis myofascial flaps while preserving the underlying neural anatomy to allow for normal residual temporalis muscle function.

Dento-alveolar surgeries can have short-term impacts on oral function and ability to eat and drink depending on the location and extent of surgery Maxillofacial trauma results in increased energy and nutrient needs for wound healing; depending on the location and extent of trauma, nutrition support may be needed Treatment following orthognathic surgery typically requires diet consistency modification and additional calories and nutrients for wound healing Patients with cleft lip and palate require modified feeding strategies preoperatively and initially postoperatively Nutrition support following oral surgery is typically achieved using oral liquid nutrition supplements or an enteral tube feeding

Alloplastic materials are widely used in augmentation genioplasty. They are readily available and routinely placed through intraoral incisions, resulting in optimal cosmesis. There has been an evolution in the materials used for this purpose, resulting in an exclusion of some of the earlier materials and development of more scientifically sound biomaterials. The purpose of this paper is to describe some of the currently popular alloplastic implant materials and elaborate on individual inherent benefits and disadvantages, as well as to discuss the treatment planning procedures for alloplastic augmentation genioplasty.

Dentigerous cysts are commonly encountered in the practice of dentistry and oral and maxillofacial surgery. Treatment modalities range from enucleation to marsupialization, and are based on the premise that the pathological process can be controlled locally with minimal injury to the adjacent host structures. In a child, however, loss of permanent tooth buds in the management of a large dentigerous cyst can be devastating. This article describes the technique of fenestration, which removes this entity and preserves the developing dentition.

The purpose of this study is to demonstrate an intramuscular fascial layer within the temporalis muscle. This can be used as an inferior plane when developing a temporalis myofascial flap for temporomandibular joint reconstruction. The advantages of using this plane include relatively bloodless zone, adequate thickness of flap for reconstructive purposes, and residual temporalis muscle to prevent the temporal concavity deformity. Cadaveric and clinical examples are presented.

High-density porous polyethylene has been used successfully as an alloplastic implant in orbital reconstruction and as an onlay implant in the augmentation of the facial skeleton. This paper describes the utilization of the polyethylene implant in the reconstruction of an ear that was partially avulsed from a dog bite. Complications arising from the use of a firm implant material in this auricular reconstruction occurred. Management of this difficult posttraumatic reconstruction is presented.

Many etiologies have been postulated to explain the pathogenesis of Trigeminal Neuralgia (TN). Most theories focus on a demyelinating process resulting in ephaptic transmission and recruitment of small pain fibers or a restrictive relationship of the superior cerebellar arteries and the trigeminal nerve roots at the level of the pons which may lead to demyelination. It is postulated that vasodilation or constriction of these vessels in a confined bony canal can create localized regions of demyelination and restrictive relationships creating painful stimuli. It is the purpose of this study to grossly investigate the relationship of the infraorbital nerve and vessels passing through the infraorbital canal to discuss whether their relationship may play a role in the pathogenesis of idiopathic TN. Patterns of relationship have been elucidated and will be described. This preliminary gross anatomical study should set the framework from which to base further microscopic and clinical studies.

The lingual nerve (LN) is a branch of the mandibular division of the trigeminal nerve, which is formed from afferent branches from the body of the tongue that travel along the lateral surface of the tongue [1]. Injury to the LN may cause significant patient morbidity and is one of the leading causes of litigation in dentistry and oral and maxillofacial surgery. Injury to the LN can occur during a multitude of surgical procedures including third molar extraction, local anesthetic injections, preprosthetic surgery, placement of dental endosseous implants, orthognathic surgery, excision of maxillofacial pathology, and penetrating trauma to the floor of mouth and tongue. There have also been infrequent reports of LN injury secondary to laryngoscopy for intubation and placement of a laryngeal mask airway [2, 3]. The vast majority of LN injuries that are routinely seen by trigeminal nerve microsurgical specialists are those that are iatrogenic in nature occurring with mandibular third molar extractions and dentoalveolar surgery. During mandibular third molar surgery, the LN is not generally visualized intraoperatively and is usually protected through the judicious placement of incisions and subperiosteal plane flap elevation. With anatomical aberrancy, iatrogenic injury to the LN can occur even in the most skilled surgeon’s hands. Injury to the LN can occur in situations where the nerve is located in a “high-risk” position, namely, at or above the level of the lingual crest or medial and contiguous with the lingual cortical plate (Fig. 13.1) [4]. Numerous anatomic studies have reported on the variable position of the LN with regard to third molar extraction. In a study by Pogrel and colleagues, the LN was located above the lingual crest in 15 % of cadavers within a 3.45 mm mean horizontal distance from the lingual crest in the third molar region [5]. Miloro and colleagues using magnetic resonance imaging (MRI) identified the LN above the lingual alveolar crest in about 10 % of specimens, and in direct contact with the lingual plate in approximately 25 % of specimens [6]. Therefore, medially directed crestal incisions, fractures, or perforations of the lingual cortex, aggressive dissection, and curettage on the medial tissues of the surgical site can all potentially result in an LN injury [4]. A frequently cited study using a questionnaire reported that LN injuries occur in 11 % of cases involving the removal of a mandibular third molar [7]. In these cases, the authors reported that approximately 50 % of patients made full neurosensory recovery within 36 weeks, and all but 6 (0.5 %) of the cases ultimately recovered sensation. There is a wide range of LN injury incidence reported in the literature, dependent upon varying measurements and classifications of injury utilized. Unfortunately, most of the past literature has been retrospective in nature with no standardization in measuring sensory levels until more recent publications utilizing the British Medical Research Council (MRC) scale [8]. The British MRC scale was developed for grading sensation subsequent to peripheral nerve injuries since neurosensory function cannot be assessed directly [8–10]. This scale takes into account the sensations of vibration, pinprick, light touch, two-point discrimination, and temperature and is ranked on scale of S0–S4 (functional sensory recovery defined as greater than S3).

Obstruction of the lacrimal drainage apparatus may result in excessive tearing or epiphora. This may occur as a result of a traumatic injury or accumulation of debris, mucus, or pus. In nuclear dacryoscintigraphy, a radioactive solution is introduced into the conjunctival sac by pipette and allowed to follow the flow of the tear solution through the lacrimal drainage system. This article will review normal lacrimal anatomy and indications for nuclear dacryoscintigraphy in oral and maxillofacial surgery.

This report describes a case of lingual nerve injury repair using a novel technique in which Tisseel fibrin glue was used to stabilize an Axoguard nerve conduit placed around the site of primary neurorrhaphy to decrease the number of sutures required for stabilization. Five months postoperatively, the patient subjectively had increased sensation and improved taste in the left lingual nerve distribution. At neurosensory examination, the patient exhibited functional neurosensory recovery (S3+ on the Medical Research Council Scale).

Summary Atypical facial pain (AFP) is characterized by a constant, poorly defined anatomically aching pain, lacking the paroxysmal quality, trigger point activation, and well-defined anatomical distribution of trigeminal neuralgia. This study examines a set of AFP patients with respect to their responses to external decompression (4 patients) and neurectomy (11 patients). Criteria for trigeminal nerve exploration were: failure of non-operative treatments, the ability to control pain temporarily with local anesthetic nerve blocks, and pain generally located within the anatomical distribution of the affected nerve. Decision as whether to perform an external decompression or neurectomy was based on gross anatomical findings during exploration. A retrospective interview was conducted to evaluate the effects of the chosen procedure in regard to subjective level of pain, freedom from restrictions placed on activities of daily living, and past medical history, including history of the facial pain. The neurectomy procedure (p = 0.022), medical history of autoimmune disease (p = 0.004), and preoperative pain distribution on the left side (p = 0.042), were all found to have a positive effect on outcome. History of psychiatric treatment (p = 0.055) and preoperative affected activities of daily living (p = 0.026) significantly adversely affected the outcome.

The oral and maxillofacial surgeon occasionally is called to treat a burn victim with concomittant facial injuries. Successful management necessitates a thorough understanding of burn pathophysiology and the resultant hemodynamic and metabolic alterations. In addition, the recognition of potential sequelae and their appropriate management is imperative. This article describes the general protocol in burn trauma management as it pertains to the oral and maxillofacial surgeon.

Purpose To survey physicians who participated in humanitarian missions as residents to assess the value of this experience on residency training and future career choices. Materials and Methods An anonymous 26-question survey was electronically mailed to 45 individuals identified as having participated in a cleft lip/palate mission during residency. The survey was created and distributed, and the data were collected using the online survey engine Survey Monkey. Results Thirty-nine individuals (86.7%) completed the survey. Of these, 27 were men (69.2%) and 12 were women (30.8%). Thirty-two (82.1%) were oral and maxillofacial surgeons, 4 (10.3) were plastic and reconstructive surgeons, 1 (2.6%) was an otolaryngologist, and 2 (5.1%) were pediatric dentists. Twenty-five respondents (64.1%) stated that, before their first mission, they had not operated on a primary cleft lip; 21 (53.8%) noted that they had not operated on a primary cleft palate before their first mission. Thirty-six (92.3%) noted that their mission experience improved their ability to repair facial clefts. Thirty-seven (94.9%) believed their mission experience improved their overall surgical skill. All respondents (n = 39, 100%) believed their mission experience improved their overall ability to evaluate patients with cleft. Thirty-six (92.3%) believed their experience in humanitarian missions made them more culturally sensitive/competent health care providers. Thirty-eight respondents (97.4%) believed these missions made them more socially aware of the differences in access/availability of health care globally. Thirty-eight (97.4%) believed that participation in a humanitarian mission was a high point of their residency. Thirty-seven (94.9%) planned to participate in humanitarian medical missions during their career after residency. Conclusion All respondents believed that participation in a humanitarian mission during residency was a positive part of their training. In addition, these missions allowed the residents to develop as surgeons and improve their awareness of global health care and cultural competence. Given these important educational aspects, participation in a humanitarian mission should be considered a required part of residency training.

Purpose To survey chief residents in accredited oral and maxillofacial surgery (OMS) training programs to assess their satisfaction with their surgical training and analyze their career plans after residency. Materials and Methods A 19-question anonymous survey was electronically mailed to 212 individuals identified as graduating chief residents in accredited OMS training programs. Results Ninety-four individuals (44%) completed the survey. Of these 85 were men (90.4%) and 9 were women (9.6%). Average age was 32 years. Forty-seven respondents (50%) completed the 4-year traditional OMS programs, 37 respondents (39.4%) completed the 6-year MD integrated programs, 9 respondents (9.6%) completed the 4-year MD option programs, and 1 listed “other” as a program type. Fifty-two individuals (55.3%) planned a full-time private practice career, 5 (5.3%) planned a full-time academic career, 3 (3.2%) planned a military career, 27 (28.7%) planned a combined private practice and academic career, and 7 (7.4%) planned to complete a fellowship after residency. Seventy-nine of all respondents (84%) were satisfied with their OMS training program, whereas 15 (16%) were not. Conclusion Most participants of this survey were satisfied with their training program and OMS as a career. However, it is important to note that less than half (44%) of chief residents who received this survey completed it. This short survey is a pilot survey; a more involved evaluation of OMS resident satisfaction is planned, further assessing satisfaction and burnout during residency.

Purpose The purpose of the present study was to investigate the role of a type I collagen nerve conduit in the repair of lingual nerve injuries compared with those lingual nerve repairs performed without a collagen membrane and to identify the prognostic factors for functional sensory recovery (FSR). Materials and Methods This was a retrospective cohort study evaluating a sample derived from the population of patients who had undergone lingual nerve microsurgery from March 17, 2000, to February 23, 2010 by the same surgeon (V.B.Z.) with complete records available, including follow-up assessments. The primary outcome variable was the interval to successful FSR according to the British Medical Research Council criteria for FSR. The predictor variables were categorized into demographic, surgical, and clinical sensory testing. Appropriate descriptive statistics and univariate and multivariate Cox proportional hazards survival statistics were computed in analyzing the patient age at lingual nerve injury repair (in years), gender, timing of surgical intervention, mechanism of injury, specific surgical procedures, and application of a type I collagen conduit. Results The study cohort included 41 patients with 42 lingual nerve injuries who underwent surgical repair. Their mean age was 28.3 ± 8.3 years (range 13 to 44), with 88% females (n = 32). In the multivariate model, the injury to surgery interval per 1-month increase (hazard ratio 1.23, 95% confidence interval 1.02 to 1.48, P = .029) and injury to surgery interval of 9 months or longer (hazard ratio 4.67, 95% confidence interval 1.04 to 20.87, P = .04) remained significantly associated statistically with successful FSR. Conclusions The results of the present study have demonstrated that the injury to surgery interval is the most significant prognostic factor in the repair of lingual nerve injuries. The use of the collagen membrane demonstrated a greater level of FSR compared with those treated without the use of the membrane. However, the results from the collagen conduit were not statistically significant.

Purpose To study the safety of deep sedation in an urban-based oral maxillofacial surgery training program. Materials and Methods Charts of patients undergoing an intravenous sedation from January 2005 through December 2009 were reviewed. Data recorded included age, gender, type of procedures performed, and intravenous medications. Patients were divided in 2 groups depending on whether they received a general anesthetic agent (propofol or ketamine) or not. Anesthesia complications and failures were recorded and categorized. Results In total, 1,167 intravenous sedations were recorded. Eight patients developed adverse reactions, 3 of which required further evaluation in the emergency department. In addition, 7 intravenous sedations needed to be aborted because of patient agitation and combativeness. No deaths or long-term morbidities were reported. Conclusions The safety of deep sedation in an urban-based oral maxillofacial training program is similar to office-based anesthesia. Sedations failures may be attributed to paradoxical benzodiazepine reactions.