Predeposit autologous blood transfusion combined with recombinant human erythropoietin (r-HuEPO) has been used at our department since 1995 in patients undergoing operations for oral malignant tumors. This decision was based on studies of blood loss and homologous transfusions in past operations. In this report we discuss the indications, methods and issues of autologous blood transfusion in patients undergoing operations for oral malignant tumors. Among 88 patients who underwent operations for oral malignant tumors between 1993 and 1995, 40 had blood loss of over 600ml and 24 (60%) received homologous transfusions. We estimated the average blood loss according to the operation procedure by dividing the patients into seven groups depending on the extent of resection of the primary lesion and whether or not radical neck dissection and reconstruction were performed. Predeposit autologous blood transfusion combined with recombinant human erythropoietin (r-HuEPO) was given to 13 patients who suffered blood loss of over 600ml during operations performed 1 year since June 1995. The volume of predeposit blood ranged from 400 to 1600ml, averaging 1015ml. As for the effect of rHuEPO, five patients showed an excellent response and three showed a moderate response; the response rate was 67%(8/13). Blood loss up to 2200ml could be compensated by predeposit autologous blood transfusion of 1600ml. Therefore, predeposit autologous blood transfusion combined with r-HuEPO was considered safe and effective when used in patients who undergo operations for oral malignant tumors and have a large volume of blood loss. Based on our clinical experience, we established schedules for collection of 800, 1200, and 1600 ml of predeposit autologous blood within 6 weeks with the use of MAP preservative solution.
A rat model was used to study a technique for constructing prefabricated vascularized bone grafts using vascularized periosteum, atelocollagen, and bone marrow. The animals were divided into two groups, A and B. Group A received vascularized periosteal grafts combined with atelocollagen, and group B received composite grafts of atelocollagen and bone marrow. Grafts in the controls were prepared only with periosteum. Histological, radiographic, and biochemical observations were made between 3 and 5 days and at 1, 2, 3, 5, 7 and 9 weeks. The results were as follows: Alkaline phosphatase activity appeared in the periosteum 3 days after operation, and osteoid ossification formed from the periosteum was noted 5 days after operation in all groups. Active bone formation occurred in all animals during the 2 weeks after surgery. Grafts in the two experimental groups produced a greater amount of new bone than they did in the controls between 5 and 9 weeks after surgery. Although in group A a larger amount of bone was formed with endochondral and membranous ossification than in group B, which showed membranouse ossification only, the rate of bone formation in group B was faster than that in group A. It was concluded that atelocollagen may serve as an effective carrier of vascularized periosteum and that bone marrow accelerates the growth of bone in the periosteum.
A total 150 patients with obstructed abscesses in the oral and maxillofacial region were studied with respect to the relation between clinical symptons and the isolation of organisms. Various kinds of anaerobes were isolated from almost all patients. Mixtures of grampositive cocci and anaerobic gram-negative rods were most frequent in severe cases. Patients in whom few organisms were isolated were characterized by chronic, mild inflammation and prior chemotherapy. All patients with postoperative maxillary cysts had chronic infections The results suggested that anaerobes were necessary for the occurrence of infection in the oral and maxillofacial region and that pathogenic synergy between gram positive cocci and gram negative rods contributed to increased severity of infection.
The microbiological characteristics of 90 patients with odontogenic closed abscesses were studied retrospectively during the 4-year period from January 1992 to December 1995. Of 64 specimens obtained by needle aspiration before antimicrobial therapy, 51 (80%) showed bacterial growth. A total of 279 bacterial strains, consisting of 236 (84.6%) anaerobes and 43 (15.6%) aerobes, were isolated, with an average of 4.7 anaerobes and 0.8 aerobes per specimen. A total of 152 (54.5%) anaerobic gram-negative rods were isolated. Anaerobic bacteria were isolated from 49 (96.1%) of 51 specimens. About 88% of specimens were polymicrobial. The predominant anaerobes isolated were Fusobacterium nucleatum (12.5%), blackpigmented anaerobic gram-negative rods (15.8%), Peptostreptococcus micros (11.1%), and Eubacterium spp.(10.4%). Of 26 specimens obtained after antimicrobial therapy, 22 (85%) had bacterial growth. The bacteria isolated after antimicrobial therapy were almost similar to those isolated before antimicrobial therapy. Susceptibility testing demonstrated that Peptostreptococcus micros and Eubacterium spp. were susceptible to a wide range of antibiotics, including chloramphenicol, minocycline, clindamycin, and β-lactams. Most anaerobic gram-negative rods were sensitive to chloramphenicol, minocycline, and clindamycin, and about 28% were resistant to β-lactams. These results indicate that odontogenic infections associated with abscess formation are usually polymicrobial, caused by mainly anaerobic gram-negative rods, gram-positive cocci, and rods accompanied by aerobic gram-positive cocci.
Mandibular movements are produced by a combination of condylar translation and rotation. The relationship between condylar translation and rotation during opening jaw movement and border movement was studied in 10 controls (4 men and 6 women), aged 20 to 26, without signs or symptoms of masticatory disorders and 61 patients (5 men and 56 women), aged 19 to 64 (average age 37.5), with closed lock of the temporomandibular joint (TMJ). The patterns of condylar movement and clinical findings were evaluated by means of multivariate analysis. Mandibular movements were recorded with an electronic jaw tracking system (JKN-1) consisting of 5000-pixel linear charge-coupled-device (CCD) cameras that register the position of six light-emitting diodes (LEDs) muted on two facebows separately attached to the upper and lower jaws. A computer produced plots of the opening angle versus the anterior condylar translation as well as the condylar path in the sagittal plane. The condylar translation/rotation patterns were analyzed visually for differences in trace patterns. The patterns on visual analysis could by classified into six types. Type I: At the begining and at the end of opening, rotation was more pronounced than translation. Type II: At the end of opening, translation was more pronounced than rotation. Type III: At the begining of opening, rotation was more pronouced than translation. Type IV: The condylar translation/rotation patterns were almost linear. Type V: At the end of opening, rotation was pronounced and translation was severely limited. Type VI: At opening, rotation was pronounced and translation was completely limited. These patterns in the patients with closed lock of the TMJ differed from those in the controls. Of the controls, 50% were found to be type I, and 30% were type II. In contrast, 44% of the patients with closed lock were found to be Type V, and 33% were Type VI. As for opening movement of patients with closed lock of the TMJ, abnomalities of condylar movement were more pronounced than those of movements at the incisive point. The results indicate that it is possible to diagnose the condition of closed lock disease. Moreover, our statistical evidence shows that it is possible to predict the patterns of condylar movement depending on age, degree of pain at opening, and deformity of the condyle.
We clinically studied 30 patients (34 joints) with closed lock who underwent arthroscopic surgery (lysis and lavage operations) of the superior joint compartment of the temporomandibular joint (TMJ). Arthroscopic surgery was studied as compared with arthrocenthesis and pumping manipulation by double-contrast arthrotomography and magnetic resonance imaging (MRI). The results were as follows: 1. There was arthrographic evidence of marked narrowing of the anterior recess and lateral portion, of the upper joint compartment in patients who underwent arthrocenthesis and pumping, whereas narrowing of the posterior compartment and medial portion was found in patients who underwent arthroscopic surgery. 2. In patients who underwent arthrocenthesis, MRI showed that anterior disk displacement and disk deformity were severer than after arthroscopic surgery. 3. There was arthroscopic evidence of extensive synovitis, and osteoarthrosis and adhesionwere severe in the anterior recess. We found that upper joint arthroscopy of the TMJ was an important additional diagnostic method and that arthroscopy was effective in the diagnosis of synovitis and osteoarthrosis within the superior cavity and permitted the observation of adhesion.
Clinically, the standard value for maximal mouth opening has been detined as either a 35- to 40-mm incisal edge distance or three fingers, but these values have, for the most part, been used empirically. A total of 446 men and 470 women between 20 and 69 years of age were examined to study the relations been maximal mouth opening and age, stature, sex, mouth width, mandibular length, and three-finger width. Persons with no history of temporomandibular joint diseases and pain or dysfunction in the masticatory system were examined. The results were as follows: 1. The mean values for maximal mouth opening differed significantly between men and women. 2. Maximal mouth opening was found to be correlated with stature, age, mouth width, mandibular length, and three-finger width. 3. Maximal mouth opening was found to be correlated with stature, sex, age, mouth width, and mandibular length on multiple regression analysis. 4. Maximal mouth opening can be estimated on the basis of stature and sex by multiple regression analysis: maximal mouth opening of men=stature (cm) ×0.206+20.7, maximal mouth opening of women=stature (cm) ×0.206+18.5.
Purpose: The effect of lubrication on the biomechanical function of the temporomandibular joint (TMJ) was examined. Materials and Methods: A two-dimensional finite element model of the TMJ was constructed with the use of sajittal tomograms and magnetic resonance images of a normal human TMJ. In this model, the GAP elements allow slip and separation effect between the contact surface of the articular disk and the articular surface of the condyle or eminence. The stress distribution on the cortical bone of the condyle, articular fossa, and eminence was analyzed under different loading directions with respect to the condyle, various coefficients of friction, and with or without GAP elements. Compressive and tensile stress in perpendicular directions and shearing stress in a tangential direction to the bone surface were estimated along with von Mises equivalent stress. Results: 1. The standard TMJ model with a lubrication mechanism showed that compressive stress was distributed mainly on the anterior slant surface of the condyle, the intermediate zone of the articular disc, and the posterior slant surface of the articular eminence. 2. The stress distribution was stably maintained by the lubrication mechanism irrespective of loading direction between 0 and 50 degrees. 3. The shearing stress on the condyle increased markedly with coefficients of friction of over 0.05 to 0.1. The change in the coefficient of friction of the lower joint space influenced the stress distribution more than did a change in that of the upper joint space. Conclusions: This study suggests that the lubrication mechanism of the TMJ maintains an optimal stress distribution on the condyle and the articular fossa and eminence, which contributes to a rational and protective loading pattern in the TMJ.
Local anesthetics are frequently used in dental treatment. Allergic reactions to local anesthetics are very rare, and reportedly accounts for about 0.6% of all drug-induced adverse reactions. Amide-type local anesthetics, such as lidocaine, which are used in recent years, are estimated to have an even lower incidence of allergic reactions. However, patients who have once had on allergic reaction to a local anesthetic are sometimes concerned about such reactions when visiting a doctor. We interview such patients about the conditions when the local anesthetic was used, the condition of resuscitation, the presence or absence of systemic diseases, history of allergic reactions, familial history, and others. During the past 10 years, nine patients (four males and five females) were finally suspected to have allergies to local anesthetics. Allergic reactions occurred during dental treatment in four patients and during surgical operations in five patients. The type of allergy was I in eight patients and IV in one patient. In the patients with type I allergy, definitive diagnosis by patch test and intradermal reaction test had been performed at other medical institutions. At our department, we performed patch test, drug lymphocyte stimulation test (DLST), intradermal reaction test, and other tests in the nine patients. Based on the results of these tests, challenge tests with lidocaine were done in eight patients, and dental treatment was performed safely. In one patient, type N allergy occurred, and we now have difficulty treating this patient. In the remaining one patient, promethazine hydrochloride was used instead of local anesthetics, and we were able to successfully complete dental treatment because adequate aresthesia was induced.
Sixty patients with idiopathic trigeminal neuralgia (ITN) were clinically investigated and the following results were obtained. 1) The 3rd branch of the trigeminal nerve was involved in 33 patients (55%), the 2nd branch in 23 patients (38.3%), and 1st+2nd or 2nd +3rd branches in 4 patients (6.7%). 2) Most patients underwent nerve block of the infraorbital and mental nerves and received carbamazepine. After frequent nerve block with 0.5% bupivacaine hydrochloride, analgesia of the nerve-inervated tissues persisted for a long period, similar to that during nerve block with 100% alcohol. 3) Within 6 months after successful treatment, pain recurred in 25 patients (41.7%), and re-recurrence occurred in 14 of these 25 patients (56.0%). In addition, ITN recurred three times in 9 of the 14 patients (61.3%). 4) In patients with recurrence, the face and oral cavity were broadly involved and, pain attacks were more frequent than those in patients without recurrence. These results indicate that blockade of the infraorbital and mental nerves by local anesthetics is useful in the management of ITN, that severe ITN tends to recur, and that ITN sometimes worsens during the course of recurrence, which complicates the treatment of ITN.
Recently, there is a increasing need for effective screening procedures for psychosomatic disorders such as burning mouth syndrome in patients presenting at departments of oral surgery. Oral surgeons often use self-assessment rating scales such as CMI and SDS to psychologically evaluate patients. Although these scales have several advantages, some are complex and others are affected by the physiological condition of the patient. In this study, clinical evaluation was carried out using a Hospital Anxiety and Depression Scale (HADS), which can simultaneously evaluate anxiety and depression. This scale is independent of physiological condition. The prevalence of patients who require psychosomatic treatment and the relationship between diagnosis and pshycological disorders were investigated in patients visiting the Department of Oral Surgery, Nagoya University Hospital in July and August 1995. The following results were obtained: 1) Twenty-two percent of patients were considered to require psychosomatic approaches to anxiety, and 16% had a depressive tendency on the basis of HADS among all outpatients at our department. 2) The results of HADS showed that patients with burning mouth syndrome had higher frequencies of anxiety and depression than other patients. 3) The levels of anxiety and depression were unrelated to age and sex. 4) Generally, patients with complications had higher frequencies of anxiety or depression than did patients without complications. 5) HADS appears to be a simple and useful device for the screening of patients with psychosomatic disorders at departments of oral surgery.
A rare case of adenosquamous carcinoma.occurring in the nasal cavity is reported. A 67-year-old man consulted our hospital because of ulceration of the palate. The histologic diagnosis of a biopsy specimen was keratinized squamous cell carcinoma, and the patient underwent surgical excision of the tumor. Histologic examination of the surgical specimen revealed findings of both squamous cell carcinoma and adenocarcinoma, and adenosquamous carcinoma of the nasal septum was finally diagnosed. He was tumor free for 44 months, but died of pneumonia.
To evaluate the accuracy of imaging diagnosis, we compared cervical lymph nodes with clinical evidence of metastasis on palpation, computed tomography (CT), and magnetic resonance imaging (MRI). The subjects comprised 28 patients with oral cancer who underwent radical neck dissection. The clinical criteria for positive lymph nodes was a diameter of 15mm or more in the submental and submandibular region, or 10mm or more in the deep cervical region. Lymph nodes with ring-like or heterogeneous enhancement on CT or MRI and those that were hard on palpation was also considered positive. Histopathologically, 55 lymph nodes were confirmed to have metastasis. Among these 55 positive nodes, 27 were diagnosed positive by palpation, 35 were diagnosed positive by CT, and 38 were diagnosed positive by MRI. There was a significant difference between palpation and MRI (p<0.05). Lymph nodes were divided into two regions: the submental and submandibular region and the deep cervical region. In the submental and submandibular region, 17 lymph nodes were diagnosed positive by palpation, 18 were diagnosed positive by CT, and 19 were diagnosed positive by MRI among 23 lymph nodes with patholosic evidence of metastasis. In the deep cervical region, 10 lymph nodes were diagnosed positive by palpation, 17 were diagnosed positive by CT, and 19 were diagnosed positive by MRI among 31 lymph nodes with pathologic evidence of metastasis. In the deep cervical region, there was a significant difference between palpation and MRI (p<0.05). We found MRI to be more effective than palpation, especially in the deep cervical region.
Cervical metastatic cancer of unkown primary origin is rare. We report the case of a 44-year-old woman with cervical metastatic cancer of unkown primary origin. Two masses appeared in the right cervical region, but the primary tumor could not be identified by the examinations we performed. Total neck dissection of the right side was performed. Histopathologically, only the two masses were malignant tumors, diagnosed as squamous cell carcinomas. However, the primary site of the tumor remains unknown. The patient is free of recurrence and metastasis 1 and a half years after the operation.
A male newborn was referred to Fujita Health University Hospital shortly after birth because of a huge tumor, 80×50×40mm in size, extending from his mouth. A great number of tumors were found throughout his body. Alimentary and respiratory difficulties and the risk of septicemia due to the oral tumor necessitated excision of the tumor when the patient was 3 days old. The tumor was composed mainly of undifferentiated, small, round cells, which had partly formed rosettes around blood vessels. A fibrous stroma and myxoid changes were found in some parts of the tumor. After histological, immunohistological, and electron-microscopical examinations, the tumor was diagnosed as an unclassified sarcoma. After an initial response to aggressive chemotherapy, most of the remaining tumors grew to the extent that it seemed incredible that the boy was still alive at nearly 1 year of age
Dermoid cyst is a congenital cyst with an appendage of the skin caused by impaction of the embryonal ectoderm. It usually appears in soft tissue and is extremely rare in the jaw. We recently encountered one case of dermoid cyst with numerous hairs in the left maxillary incisor region in a 17-year-old boy. Here we describe this case along with a discussion based on the literature.
We report a rare case of bilocular epidermoid cyst occurring in the uvula of an 11-month-old male infant. The patient previously visited a pediatric clinic because of a common cold, and a tumorous mass of the uvula was pointed out. He was referred to our clinic. Clinical examination revealed a yellow-white, bilocular lesion of the uvula, with each lobe measuring about 6×5mm. There was no problem with movement of the uvula. The clinical diagnosis was a benign tumor, and the lesion was excised under general anesthesia. Histologically, the lesion contained two cysts enclosed by the membrane of the uvula. It was diagnosed to be an epidermoid cyst.
The case of a female infant with an unusual chromosome 7 associated with cleft lip and palate is reported. The patient was the first child of nonconsanguineous healthy parents and was born when her father was 37 years old and her mother was 30 years old. The family history was unremarkable. Delivery was induced at 40 weeks after an uneventful pregnancy. Abnormal findings were cleft lip and palate, a bulbous nose, ocular hypertelorism, abnormal skull shape and long eyebrows. Chromosome analysis showed her karyotype to be 46, XX, -7, +der (7), t (Y:7)(q11.2:q36.3)
Cytomegalovirus infection is an opportunistic infections that occurs at an incidence of 40% in acquired immunodeficiency syndrome. It is very rare in the oral cavity. We describe the case of a 39-year-old man who had cytomegalovirus gingivitis. At presentation, the patient complained of pain of the left side of the upper and the right side of the lower gingiva. We found large depressions and edematous granulation tissue at these sites. Large bone defects appeared on panorama X-ray film. Clinically, malignant lymphoma was suspected, but pathological examination revealed cytomegalovirus gingivitis. Ganciclovir was prescribed for 4 weeks, and the right lower third molar was extracted. After treatment, edematous guanulation and gingival pain disappeared. Cytomegalovirus had apparently invaded the endothelium of blood vessels, inducing circulatory failure, which resulted in the formation of large bone defects.
Catheter-related infection is the most common, serious complication in patientsreceiving intravenous hyperalimentation (IVH). We investigated catheter-related infections during IVH. All patients who underwent catheterization at the department of oral and maxillo facial surgery of Ehime University Hospital with the use of a central venous catheter (CVC) for total parenteral nutrition between April 1989 and March 1997 were studied retrospectively. The incidence of catheter-related infection was 16.2%(17 patients) among 105 patients. Staphylococcus and Candida accounted for 90% of the causative microorganisms, detected in 11 cases. Catheter-related infection was not significantly associated with the duration of catheterization. In oral and maxillofacial surgery, IVH is given mainly to postoperative patients with oral cancer or patients in the terminal stage of disease. Therefore, opportunistic infections in immunocompromised hosts may be an important factor for IVH catheter-related infection.
Antiphospholipid antibody syndrome (APS) is characterized by thrombocytopenia, habitual abortion, and arteriovenous thrombosis. We report the case of a 32-year-old man with APS in whom an erupted maxillary third molar had to be extracted. The tooth was extracted while carefully monitoring hemostasis because of the presence of thrombocytopenia (2.4×104/μl). The wound healed without any local or systemic complications. When patients with APS are referred to oral and maxillofacial surgeons, it is important to be aware of APS, especially with regard to the perioperative care of general arteriovenous thrombosis and oral hemostasis.
An analysis of 47 third molars in the line of mandibular fractures was undertaken. The results were as follows: 1) There were 31 impacted teeth and 16 erupted teeth among the total of 47 third molars. Thirteen of these third molars were extracted; 11 teeth were impacted, and 2 teeth had erupted. Subluxation had occurred in 2 almost all extracted third molars. 2) Five of the 47 third molars had postoperative complications; postoperative infection occurred in 3 cases and malocclusion in 2 cases. These third molars in the line of mandibular fractures were retained when the mandibular fractures were treated. Our results suggest that it is not necessary to retain third molars in the line of mandibular fractures unless they are impacted and show no signs of luxation, as they do not participate in occlusion and because this region is prone to infection due to debris.