Japanese Journal of Oral and Maxillofacial Surgery
Online ISSN : 2186-1579
Print ISSN : 0021-5163
ISSN-L : 0021-5163
Volume 32 , Issue 5
Showing 1-21 articles out of 21 articles from the selected issue
  • Fumihiko SHINOZAKI, Yoshikazu HAYATSU, Hitoshi TANABE, Masamichi IDA, ...
    1986 Volume 32 Issue 5 Pages 709-712
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Recent studies have shown that hepatitis B virus exists not only in the blood but also in the saliva and other body fluids. They also pointed out the possibility of transmission through these fluids.
    Because of this we tried to detect hepatitis B surface antigen (HBsAg) in saliva, urine and its alteration throughout the day in asymptomatic carrier patients.
    Salivary and urinary HBsAg were shown by radioimmunoassay in five patients. After rinsing the mouth, the samples of mixed saliva were collected in the morning on rising, before lunch and before sleeping from each carrier patient. Urine was collected only in the morning.
    Each time, the HBsAg was found in the saliva of 3 out of 5 carrier patients, although in the other two patients it was detected only once or twice in a day.
    All saliva samples were tested for occult blood but it was not related to the detection of HBsAg.
    Urinary HBsAg was not found in all patients.
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  • Masahiro YAMASHIRO, Takashi KINJO, Tomio AZUMA, Yoshiaki TANI
    1986 Volume 32 Issue 5 Pages 713-717
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Five salivary calculi from the submandibular gland were studied with the polalization microscope, the scanning electron microscope, the X-ray microanalyzer and the X-ray diffractor.
    The composition of salivary calculus showed a lamellar and concentric structure. Two nuclei were present in the central part of the structure. From the results of the X-ray diffraction pattern, the crystallines of the calculi were composed of hydroxyapatite, but one calculus was composed of whitlockeit and hydroxyapatite. By using the X-ray microanalyzer, the detected component elements in calculi were Ca, P, Na, Mg, S, Cl and K.
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  • Masashi SUGISAKI, Eiichi KOMORI, Masahiro NAKAZAWA, Haruyasu TANABE, S ...
    1986 Volume 32 Issue 5 Pages 718-730
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    There have been a number of physiological and anatomical reports on the lateral pterygoid muscle. They include some unclear points, and no agreement has been reached from the results so far. Most of the pevious studies have been performed by the lateral approach. Few reports have been made by the superior approach which is useful for investigation of the muscle.
    We dissected 26 temporomandibular joints from 14 adult cadavers by the superior approach and studied the muscle, as well as its functions, reviewing the literature.
    The lateral pterygoid muscle varied with the cadaver in the number of the head as follows; 7.7% of all specimens had single head, 3.8% had the lateral and medial heads, 57.6% had the superior and inferior heads, and 30.7% had three heads, i.e. superior, inferior and medial. This result indicates that the lateral pterygoid muscle was substantially different from cadaver to cadaver. The muscle fibers were so crowded with each other and with those of the temporal muscle that only 8 cases had the superior and inferior head's muscle which could be completely separated from each other. The superior head laid at an angle of 7.0 degrees medially with respect to the line perpendicular to the horizontal long axis of the mandibular head, the inferior head was at an angle of 19.1°, and the medial head was at an angle of about 37.7° to this reference line, on average. The superior head of the muscle was attached to the pterygoid fovea of the mandibular head except that the superficial layer of the superior head was attached to the inferior surface of the disk. The medial head of the muscle appeared to be inserted into the medial border of the disk and the medial capsule. In addition to the lateral pterygoid muscle, the temporal muscle of some specimens were attached to the anterosuperior stratum of the disk through the fibrous tissues and, sometimes, directly to the anterolateral part of the disk.
    We support, in principle, the previous reports that the lateral pterygoid muscle has generally two heads. We observed that, however, many variations of the muscle existed in terms of the individual their age, and their sex, and that the muscle fibers considerably crossed each other. Therefore, although we cannot deny the possibility that the superior head and inferior head of the lateral pterygoid muscle would function differently, we do not support that the superior and inferior heads of the muscle move antagonistically on electromyogram.
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  • Kazuhiko OHSHIMA
    1986 Volume 32 Issue 5 Pages 731-742
    Published: May 20, 1986
    Released: September 13, 2011
    JOURNALS FREE ACCESS
    Prostaglandin (PG) synthetic activities in mouse salivary glands were studied. When mouse submandibular gland homogenate was incubated with radioactive arachidonic acid, three radioactive metabolites were detected which were identified with PGE2, PGF, and PGI2. Thromboxane A2 (TXA2) and PGD2 were not detected. Optimal biosynthesis was obtained in an 0.05M sodium phosphate buffer at pH7.4. Under this condition PG formation was linear up to the arachidonic acid concentration of 40μM. Reduced glutathion did not affect the biosynthesis, but catecholamines i.e. L-adrenaline, L-noradrenaline and L-isoproterenol produced only a small stimulation of all three PG synthesis in the submandibular gland homogenate. Major cyclooxygenase products of the parotid gland and the sublingual gland were also PGE2, PGF, and PGI2. Total PG synthetic activities of three PGs in both the submandibular gland and the parotid gland were higher than those in the pancreas, liver and brain, and that of the submandibular gland was the highest of the examined tissues. Both PGE2 and PGI2 synthetic activities were higher in the order of submandibular gland>parotid gland>sublingual gland. PGF synthetic activity was higher in the order of parotid gland>submandibular gland>sublingual gland PGI2 synthetic activity in the submandibular gland of male mouse was about 1.5 times higher than that of female one.
    Next, the relationship between PG metabolism and DNA synthesis in isoproterenol (IPR)-stimulated salivary glands was investigated. Administration of indomethacin, a PG synthesis inhibitor, suppressed the effect of IPR on the DNA synthesis in the submandibular gland and the parotid gland. Cyclooxygenase activity did not change in IPR-stimulated salivary glands. From these results, it is suggested that PGs are involved in the stimulation of the DNA synthesis by IPR in the salivary glands. It is also possible that IPR activates not a cyclooxygenase, but a phospholipase, in the salivary glands.
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  • Hidemi MIYATA
    1986 Volume 32 Issue 5 Pages 743-761
    Published: May 20, 1986
    Released: September 13, 2011
    JOURNALS FREE ACCESS
    I. Analysis of the responses of clinically healthy dental pulps to electrostimulation revealed a distinct tendency as described below. It was confirmed by examination of the electrical characteristics of the commonly used electric pulp test that the test reading was proportional to the output voltage. On the basis of this finding, investigation were made into the false diagnosis rate for vital pulps, the difference in threshold between the test tooth and the contralateral homonymous tooth, the mean threshold in different groups of teeth and the presence or absence of a significant difference in threshold among groups, sex-dependent difference in threshold, age-dependent difference in threshold, relationship between age and threshold, and correlationship of threshold among different tests.
    A certain fixed tendency was detected in the above examinations.
    II. Pain threshold on the electric pulp test for clinically healthy dental pulps was compared with that for dental pulps affected by a disease or within reach of the pain, such as pain with cold or warm stimulation of the tooth, alveolar pyorrhoea, acute and chronic pulpitis, glossodynia, trigeminal neuralgia and facial pain with unknown etiology.
    III. The mean chronaxy value for clinically healthy pulps, determined with the electrical stimulator, was O.226±O.095. In comparison of chronaxy between dental pulps involved in various painful diseases and clinically healthy dental pulp, the values for the former were widely scattered above and below the mean value puls there was a standard deviation for the latter.
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  • Hidemi MIYATA
    1986 Volume 32 Issue 5 Pages 762-781
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    There are various methods of investigating the process of healing oro-maxillary tissue injured by trauma, disease or surgery. The author tried to calrify the healing process of affected tissue by analyzing the responses to electrostimulation of dental pulps planted in the invaded region.
    Cases of trauma chosen for the study were those of fracture of the jaw, fracture of the alveolar bone and luxation of the tooth. Dental pulps near the site of the trauma were examined in respect to the mode of response to electrostimulation and time-course changes in it. In these cases, electric dental pulp testing turned positive in 46. 5% of dental pulps that had been negative. The testing became positive most frequently at 1-4 months and at 8 months after the trauma.
    Among diseases of the maxillary sinus, maxillary sinusitis and postoperative maxillary cyst were chosen for the study. The electrostimulation threshold for dental pulps on the affected side was compared with that for clinically healthy dental pulps. As a result, in the cases of maxillary sinusitis, the figure scattered in-and outside of the mean±standard deviation extensively. On the other hand, in the cases of postoperative maxillary cyst, 60. 8% of the cases showed higher threshold than average threshold for clinically healthy dental pulps, among others, premolars showed high frequency of 84. 1%.
    Radical operation on the maxillary sinus was performed for the aforesaid diseases of the maxillary sinus, and the effect of the operation on dental pulps was evaluated by electrostimulation. Negative response to electric pulp testing was exhibited by 32.9% of the pulps on the surgically treated side, with the second premolar affected most strongly by operation. In the postoperative follow up, electric pulp testing became positive in 50. 0% of the teeth with negative response, most frequently at 1-4 months after the operation.
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  • Takashi TSURUKI, Yoshimi ICHINOKAWA, Hiromichi YOSHIOKA, Nobutaka ISHI ...
    1986 Volume 32 Issue 5 Pages 782-788
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    The sagittal splitting technique of the mandibular ramus was developed by Obwegeser (1955) and introduced in Japan by Takahashi (1969). Today this operation technique is widely used to correct, not only mandibular prognathism, but also mandibular retrusion, open bite, facial asymmetry, abnormal occlusal plane, disharmony between centric occlusion and centric relation, decortication for mandibular osteomyelitis and extirpation of mandibular cysts. However this technique is said to be the most difficult among the osteotomy techniques. Application of this technique to small Japanese women whose mandibular ramus are thin, with minimum spongiosa on the superior portion and V-shaped, is often difficult.
    So, we developed the improved technique suitable for Japanese's small mandible. We use the disposable, thin, saw blade for oscilating bone saw (Aesculap-Werke, W-Germany) according to following procedures. 1) inducting bone grooves are made on the inner and outer surface of the mandibular ramus with Lindemann bur. 2) small holes are drilled in the anterior surface of the mandibular ramus. 3) osteotomy of the mandibular ramus, except the posterior part of the mandibular canal, is performed. 4) then splitting of the mandibular ramus is completed with a fine microchisel. The osteotomized surface was found to be always flat and smooth. The osteosynthesis with AO rag screws was always possible. Our technique is simple and easy even for operators with little experience, and also effective for preventing the relapse and to shorten the period of the intermaxillary fixation.
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  • Shinya ITO, Saburo KAKUTA, Akiyuki NISHIMURA, Hiroki GOTO, Yoshitaka K ...
    1986 Volume 32 Issue 5 Pages 789-794
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Two cases of herpes zoster treated with different applications of Adenine arabinoside (Ara-A) were described.
    One case was the Ramsay Hunt syndrome with facial palsy and blisters in the palatal mucous alone. The other was herpes zoster involving the fifth cranial nerve. The earlier was administrated Ara-A intravenously and the latter was applied by 3% Ara-Aointment for several days.
    As the results of Ara-A usage, we concluded that this agent was valuable for the therapy of herpes zoster developing in the maxillofacial region because of the rapid recovery from serious clinical condition. There were not any side effects in the course of applications of this agent.
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  • Takayuki KAMEI, Yutaka SAKURABA, Noriko KIMURA, Katsuyuki OTSUKA, Keny ...
    1986 Volume 32 Issue 5 Pages 795-798
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    In a case of a thyloglossal duct cyst and a epidermoid cyst, the conponents within the cyst fluid and the structure of the epithelial cyst wall are investigated. Some differences are noted between the two cysts. It is suggested that the difference between the components within the cyst fluid is derived from the difference between the structures of the epithelial cyst wall. This investigation shows that it is possible by examing the components within the cyst fluid to determine the differential diagnosis of the cystic diseases.
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  • Yoshio TAKAHASHI, Hiroshi KAWAMURA, Tomoko SHINBO, Setsu KIKUCHI, Susu ...
    1986 Volume 32 Issue 5 Pages 799-808
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    This study investigated the changes of the masticatory function, after sagittal splitting ramus osteotomy for mandibular prognathism.
    1. Masticatory efficiency was measured by means of a gravimetric sieve analysis, after masticating raw rice weighing 2.0 g on the habitual chewing side. The masticatory efficiency tended to improve following the operation.
    2. Absorbance of the filtrate was measured, after masticating the ATP particle weighing 5.0g on the usual chewing side and diluting it with water. The absorbance of the postoperation group tended to increase.
    3. Occlusal contact area using a silicone impression material was measured. The occlusal contact area of the post operation group was enlarged.
    After orthognathic surgery, the masticatory function of mandibular prognathism tended to improve by means of investigating the masticatory efficiency, absorbance of the filtrate using ATP particle, and the occlusal contact area.
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  • Natsuki SEGAMI, Masaru HOSODA, Sumihisa KOWAKA, Tsuyoshi HATA, Hideki ...
    1986 Volume 32 Issue 5 Pages 809-812
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    The authors gained fine postoperative results from closure, by tongue flap against the palatal fistula, and of a bilateral cleft lip and palate, in a case which could not be improved by two previous palatoplasties. The patient was a 20-year-old woman with a large fistula of the hard palate, measuring 25×25mm. An operation was performed to reconstruct the nasal side by mucoperiosteal flaps of the nasal septum and the nasal floor with free skin graft, and the oral side by an anteriorly based median dorsal tongue flap.
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  • Yoshiaki KOMATSU
    1986 Volume 32 Issue 5 Pages 813-817
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    A woman, aged 56, had squamous cell carcinoma of the tongue and metastasis on the right side of her neck. After combination chemotherapy with vincristine, methotraxate, pepleomycin and mitomicin-C and radiation, the tongue tumor disappeared macroscopically but metastasis remained. So, immediate tongue reconstruction, with a modified cervical island skin flap, was performed after hemiglossectomy and radical neck disection. Partial necrosis (20% volumme) on the tip of the flap occured but the other survived well. This necrosis was caused by rotated neck of the flap under the mandible and a little longer flap.
    The paciant has been asymptomatic for 30 months without serious disorder of tongue movement and other complications.
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  • Masahiro MAKI, Kiminori KATAYAMA, Akira TAEN
    1986 Volume 32 Issue 5 Pages 818-828
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Median mandibular cyst is relatively uncommon among cysts developing in the oralmaxillary region. Two types, namely fissural and odontogenic cysts, have been suggested as the origin of this condition, and differentiation between the two types is considered to be clinically and histopathologically difficult.
    A patient with a median mandibular cyst, which was considered clinically and histopathologically to have originated from d fissural cyst, was examined. The patient, a 25-year-old Negro, showed a cyst-like radiolucent image over the 4-3 region. The teeth in the 4-4 were all normal and free of caries. Histopathologically, the cystic wall was lined with stratified squammous epithelium and covered externally with a layer of connective tissue. Part of the wall was rich in nerve tissue and exhibited a 3-layer structure.
    Criteria for a differential diagnosis has been suggested by various investigators, and the lesion in the present patient showed all the signs of a median mandibular cyst. Based also on histopathological findings, the lesion was diagnosed as a median mandibular cyst of fissural origin.
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  • Norifumi NAKAMURA, Yoshinori HIGUCHI, Hideo TASHIRO
    1986 Volume 32 Issue 5 Pages 829-836
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Since the occurrence of ameloblastoma in the alveolar region is rare, little is known about its properties. We experienced 6 such cases in 24 years.
    Patients' ages at first visit ranged from 9 to 53 years old. Five cases were found in the mandible and one in the maxilla. Five of 6 patients complained of an enlargement of the alveolus whose size ranged from the tip of the little finger to that of the thumb. In 4 cases, the teeth which had been related to the tumor had been extracted and in one child, the tumor-related tooth germ was not evident.
    Radiographic examinations revealed that 3 cases had unilocular appearance, 1 had large multilocular, and 2 had honeycomb appearance. Unilocular and multilocular cases had well defined peripheral margins with radiopaque figures, but the honeycomb cases had poorly definable margins. It was interesting to note that the former cases preferentially located in the molar edenturous region expanded to the mandibular body, while the latter in the anterior denturous portion.
    Histological examination revealed that the unilocular or multilocular tumors were surrounded by connective tissues and showed an expansive growth pattern, while the honeycomb tumors infiltrated the interspace of bone trabecules and destroyed these structures.
    The above findings suggested a possibility that the histological growth pattern of ameloblastoma was destined by the condition of bone trabecules in the alveolus.
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  • Takamichi YANAGISAWA, Yumi BAN, Kazunari SAKURAI, Jun NATORI, Naoki KI ...
    1986 Volume 32 Issue 5 Pages 837-841
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Lymphoepithelial cysts are usually found on the lateral region of the neck. Rarely, however, lymphoepithelial cysts can be found in the oral cavity. Here, we report a case of lymphoepithelial cyst located in the floor of the mouth, in a 57-year-old man. The patient complained of a painless swelling of the floor of the mouth. During the course of the first medical examination, a circumscribed oval mass was found in the floor of the mouth just at the right side of the lingual frenum, measuring approximately 9×8mm. The clinical diagnosis was a cystic lesion. Under local anesthesia, the lesion was totally excised. Histologically, the cyst was lined with stratified squamous epithelium, and the surrounding area revealed large amounts of lymphoid tissue showing a various germinal center. The histopathological diagnosis was a lymphoepithelial cyst. There was no evidence of recurrence in the patient for 10 months after the operation.
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  • Tadashi TAGAMI, Masazumi MIYAZAWA, Masaru HORIKOSHI, Mikio KUSAMA, Sei ...
    1986 Volume 32 Issue 5 Pages 842-847
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Three cases of one-stage reconstruction with a free forearm flap were reported. The first of three cases was a 61-year-old man and he had a 20×35mm primary cancer lesion in the left border of his tongue (T2NOM0). The second case was a 64-old-year old woman and she had 27×22mm primary cancer lesion in the right border of her tongue (T2N0M0). They received an operation for the partial resection of the tongue and mouth floor, and an upper neck dissection. The last case was a 51-old-year woman and she had 25×12mm primary cancer lesion on the mouth floor and a tumor invation to the mandible was observed by X-P (T4N0M0). She received an operation for the partial resection of her mouth floor, marginal resection of the mandible and a bilateral neck disection after radiotherapy.
    We used a free-skin flap from the forearm to replace the loss of tongue and mouth floor. The flap was revascularized by anastomosing the radial artery and cephalic vein to facial vessels. Then, the flap was well revascularized and there were no functionary morbidities after the replacement of the flap. The donor-site defect was closed with a free skin graft.
    We think, consequently, that the radial free forearm flap is ideal for intra-oral reconstruction, offering thin, pliable and predominantly hairless skin to replace oral mucosa.
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  • Akio UEDA, Toshitaka KAGE, Junichiro YOSHIDA, Takashi YAGASAKI, Takehi ...
    1986 Volume 32 Issue 5 Pages 848-853
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Ameloblastic fibroma is generally classified in an odontogenic mixed tumor, which is much less common than the ordinary type of ameloblastoma.
    The authors studied a case of this tumor by means of histological and electron-microscopic techniques.
    The patient was a 10-year-old male, with a diffuse swelling of the gingiva at the left premolar region of the mandible.
    By roentgenographic examination, a unilocular hen-egg-sized radio-lucent area was observed in the region from the lateral incisor to the first premolar of the left mandible.
    15 months after marsupialization, ossification was seen in the roentgenogram, so a peripheral osteotomy was performed. The postoperative course was uneventful and during the 37-month interval since surgery, there has been no evidence of recurrence.
    Pathological examination revealed ameloblastic fibroma.
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  • Kazuyoshi UEMURA, Akira TAKEUCHI, Kitaru TAKEUCHI, Shinsuke YAMAMOTO, ...
    1986 Volume 32 Issue 5 Pages 854-860
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Statistical analysis was made in 85 patients with malar bone fracture referred to the department of oral and maxillofacial surgery, Nara Medical University Hospital from October, 1981 to September 1985. The following results were obtained:
    1) Fractures of the malar bone were diagnosed in 35% of 238 patients with maxillofacial fractures during this period.
    2) Traffic accidents were the most frequent cause (68.2%), especially by motor cycles. Then falling and working accidents followed.
    3) Fifty-seven cases (67.1%) were referred to the clinic within a week after injury. 4.7% were referred over 2 months after injury.
    4) Thirty-eight cases (44.7%) were complicated with a maxillary fracture, and 15.3% with mandibular fracture.
    5) According to the classification by Knight & North, the group III (unrotated body fracture) was most frequent (36.2%), and then the group II (arch fracture) was followed (23.1%).
    6) In zygomatic arch fractures, a v-shaped depression type and vertical depression type were dominant in simple fractures. The other cases, combined with body fractures, were mostly of overlapped and greenstick type.
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  • Kitaru TAKEUCHI, Kazuyoshi UEMURA, Shinsuke YAMAMOTO, Yasuki YASUDA, T ...
    1986 Volume 32 Issue 5 Pages 861-866
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    In the malar bone fracture, conventional radiographic methods has the limitation to analyze the pattern of displacement in an anteroposterior direction of the face. Thirty-four patients with malar bone fractures were examined with the biplane computed tomography (CT), i. e. the axial CT combined with the coronal CT, to analyze the displacement of the fragments.
    Malar bone fractures were classified into five groups according to the location and direction of the fragments.
    It is possible to establish a more complete three-dimensional pattern of displacement in malar bone fractures using the biplane CT.
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  • Takashi KAKIZAWA, Yoshiaki SEKIKAWA, Hideaki HAYASHI, Souichi SHIMIZU, ...
    1986 Volume 32 Issue 5 Pages 867-872
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    The ameloblastic fibroma is an uncommon tumor which is known as one of the odontogenic mixed tumors. Our case of ameloblastic fibroma of the right mandibular molar in a male (11 year-old) was referred to our hospital because the first right mandibular permanent molar delayed eruption. The treatment was simple exision under local anesthesia. After the operation the patient has been checked for a further 1 year 4 months.
    The first permanent molar has erupted and there is no sign of recurrence. The ameloblastic fibroma have been reported on 35 occasions in the Japanese literature and we added one case. We reviewed and discussed the 36 cases of ameloblastic fibroma with this report.
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  • Tomoko KAWAMATA, Hideo KUSHIRO, Kaname WAKI, Masatoshi RAI, Toshio HOS ...
    1986 Volume 32 Issue 5 Pages 873-877
    Published: May 20, 1986
    Released: July 25, 2011
    JOURNALS FREE ACCESS
    Pleomorphic adenoma is common neoplasm in the oral cavity. The most frequently affected gland is the parotid in major salivary glands and the palate in minor salivary glands, but the tumor originating in lip is reported to be rare. We experienced a case of pleomorphic adenoma of the lip.
    The patient, a 33-year-old man, visited our clinic. The tumor originated in his upper lip and was elastically hard and mobile with a clear cut off margin. The tumor was removed clearly and completely under local anesthesia.
    The removed mass measured 1. 8 cm×1. 2 cm×1. 0 cm and was elastically hard, the surface was plain and membranous. The cutting plane was yellow-grey and solid.
    The fibrous membrane, myxoid-like tissue and keratosquamous tissue were observed by microscopy.
    The recurrence of the tumor was not noticed two years after the operation.
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