Indications for open reduction of condylar process fractures in adults are controversial. In patients without displacement of the condylar process, consensus has been reached that the method of choice is closed treatment. However, open reduction followed by rigid fixation is indicated in condylar process fractures with substantial displacement, dislocation, or both. Once open reduction has been chosen, it is necessary to select the incision and fixation methods. The conventional incision for open reduction of condylar process fractures is made via the submandibular or the preauricular approach. However, these incisions are associated with difficulty in manipulating fragments in a small area and have the risk of damaging the facial nerve. We used a retromandibular approach to circumvent these problems, as described by Ellis et al., in a series of patients prospectively studied between 1995 and 1997. The aim of this study was to evaluate clinical results in 11 patients who were followed up for longer than 1 year. The retromandibular surgical approach was successful in all but one patient (miniplate fracture). All patients had satisfactory mouth opening and occlusion. Permanent facial nerve palsy did not occur. Our results indicate that open reduction via the retromandibular approach is a safe and useful technique in patients with displaced or dislocated condylar process fractures (or both).
Mesenchymal chondrosarcoma rarely occurs in the maxillofacial region. We describe a 30-yearold man with a mesenchymal chondrosarcoma arising in the maxilla and invading the anterior-middle part of the skull base. Histopathologic examination of the tumor showed premature mesenchymal tissue and chondroid cells. The patient received induction chemotherapy with CDDP and THP-ADM and underwent wide excision of the maxilla with resection of the anterior-middle part of the skull base. He has been free of tumor for 48 months after the operation.
Fibrosarcoma is a rare non-epithelial malignant tumor in the oral cavity. We describe a case of intraosseous fibrosarcoma of the mandible in a 37-year-old man. Diffuse swelling of the left side of the mandible and hypesthesia of the left side of the lower lip were present. X-ray examination revealed a poorly defined radiolucent lesion in the left side of the mandible. Histologically, the tumor was composed of atypical spindle cells resembling fibroblasts. There was no evidence of metastasis to the regional lymph nodes. Histopathological examination indicated that the tumor arose within the central portion of the mandible. There has been no evidence of recurrence as of 4 years 6 months after surgery.
We report a case of malignant melanoma of unknown primary origin that was found in the submandibular lymph nodes. A 63-year-old man presented on April 19, 1996 because of a swelling in the right submandibular region. The lesion measured 48 × 38mm and had no spontaneous pain. We planned to perform an excisional biopsy for histological diagnosis, but the patient refused the operation because the lesion had shrunk to about one half of its maximal size. The patient was therefore followed up. By June 1997, the lesion had grown rapidly, measuring 60 × 50mm. We suspected a malignant lesion, probably malignant lymphoma, from the results of a computed tomographic scan and 67Ga scintigraphy. On July 3, 1997, we performed surgical excision and made a histopathological diagnosis of malignant melanoma with lymph node metastasis. However, there was no evidence of a primary lesion of malignant melanoma in the skin, mucosa, eyes, or digestive system.
Malignant ameloblastoma is a very rare odontogenic carcinoma of the jaws. We describe a case of ameloblastoma of the maxilla in which malignant transformation from ameloblastoma not detected on biopsy was found on histological examination of surgical specimens. A 77-year-old Japanese woman presented with a swelling of the palate. The swelling measured 3 cm in diameter and was associated with spontaneous pain and an ulcer. The histological diagnosis of a biopsy specimen was ameloblastoma, with no evidence of malignant features. There was no adenopathy of the regional lymph nodes. The tumor was removed by partial resection of the maxilla. The patient received 60Gy of 60Co postoperatively because malignant transformation was found on histological examination of surgical specimens. Microscopic examination showed malignant transformation of ameloblastoma. The tumor cells consisted of ameloblast-like cells in the benign area, but showed pleomorphism, atypism, squamous metaplasia, and keratin pearl formation in the malignant area. There was transition between the two areas. These findings suggest that the malignant ameloblastoma developed from a preexisting ameloblastoma.
We recently encountered a rare case of osteoma of the mandibular. The patient was a 19-year-old woman. Nine years earlier, she had noticed a mass in the left mandibular region. She had an operation. After 29 years, she had a relapse. Treatment was repeated. The pathological examination of a specimen of the mandible showed spongiosum.
A case of proliferative verrucous leukoplakia (PVL) in the oralmucosa of a 67-year-old woman is reported. PVL was first described in 1985 as an unique type of oral leukoplakia that has a high risk of malignant transformation. In our patient, the initial lesion was hyperkeratosis associated with mild dysplasia of the buccal mucosa. This condition recurred repeatedly and spread to the upper and lower gingivas, lower lip, and palate. The lesions changed to verrucous hyperplasia and finally developed into verrucous carcinomas. The patient was not cured of the disease, though she received surgical excision 6 times over a period of 7 years 10 months. She died of rupture of a thoracic aortic aneurysm. Immunohistochemical staining for human papillomavirus type 16 (HPV16)-related protein was positive in the epithelial cells of the lesions, suggesting that HPV16 was involved in the pathogenesis of PVL.
The Beckwith-Wiedemann syndrome, also called EMG syndrome, is characterized by umbilical cord hernia, macroglossia, and gigantism. It may be accompanied by deformity of the ear lobe, hypertrophy of the internal organs, low blood sugar, and hemihypertrophy. We report a case of Beckwith-Wiedemann syndrome in a 1-year-3-month-old girl. The diagnosis was made at the Department of Pediatrics, Kansai Medical College Hospital. She had no erupted teeth, and could not close her mouth completely because of macroglossia. There was also hemihypertrophy on her right side at presentation. The patient had occasional cramps because of low blood sugar (33mg/dl). Vshaped resection of the tongue was performed with the patient under general anesthesia after the blood sugar level had recovered to 76mg/dl. The patient made an uneventful recovery and was able to close her mouth. Eleven years after surgical treatment, she had no difficulty in mastication, swallowing, and speech. However, there was some impairment in the ability to sense acid and bitter tastes, and eruption of the permanent teeth was delayed.
We describe a case of first and second branchial arch syndrome in a patient whose profile and occlusion improved in response to orthognatic surgery. A 2-year-9-month-old boy was referred to our clinic for the treatment of open bite. Because symptoms were mild the patient was placed under observation. However, open bite and bird face became severer as he grew older. Cephalometric analysis indicated mandibular micrognathia. Before operation, we made and analyzed computer tomography-based three-dimensional models. The models were very useful for operation planning. After preoperative orthodontic treatment, sagittal splitting ramus osteotomy and horizontal sliding advancement genioplasty were performed in two stages.
Intracranial and intraorbital complications of paranasal sinusitis constitute true surgical and medical emergencies. Owing to the availability of improved antibiotics, however, oral surgeons seldom encounter severe infections leading to death. We present a severe case of cavernous sinus syndrome associated with intraorbital cellulitis, intraorbital abscess, and cavernous sinus thrombosis primarily due to odontogenic sinusitis. This syndrome was considered to have a mortality rate of 100% before the development of improved antibiotics. Even now, the mortality rate is 13.6%, and the rate of sight loss is 22.7%. That patient was a 29-year-old man with multiple caries. We drained the maxillary sinus and intravenously administered antibiotics with gamma globulins. We were fortunately able to save his life without compromising the patient's quality of life, by collaborating with neurosurgeons, ophthalmologists, and otolaryngologists.
A case of tetanus in a patient with mandibular trismus is reported. The patient was a 58-yearold woman who was referred to our department. Cervical tetany with abnormal myotonus of the neck was present. Anteflexion and retroflexion were impossible. Except for a markedly elevated CPK level (468 IU/l), there were no laboratory abnormalities. Electromyography showed abnormal discharges in the masseter muscle, sternocleidomastoid muscle, paraspinal muscle, and trapezius muscle at rest. An intravenous dose of penicillin-G 1200000 units was administered on the day of admission and 3000 units of antitetanic human immunoglobulin was intravenously administered 4 days later. The patient was discharged 27 days later. A critical condition was prevented by initiating treatment for tetanus before the onset of generalized spasms. Electromyography was quite useful in establishing an early diagnosis of tetanus. Although rare, tetanus should be included in the differential diagnosis when treating patients who have trismus. Severe trismus associated with clenching is an important sign for dif f erenting of tetanus from other lesions.
A hemophilic pseudotumor was found in the mandible a of a 13-year-old boy with a known history of moderate hemophilia A. Intraorally, the alveolus was enlarged buccally and lingually in the left retromolar region. Hypesthesia of the left mental region was noted. Panoramic X-ray film revealed a lytic bone lesion from 7 to the left angle of the mandible. Computed tomography revealed marked enlargement of the left side of the body of the mandible, associated with a low density area, and irregular absorption of the lingual cortex. A malignant tumor was suspected, so a biopsy was done during replacement therapy with coagulation factor (Factor VIII). The bone cavity contained a hematoma and was surrounded by granulation-like tissue. A histopathologic diagnosis of hemophilic pseudotumor was made. One year after curretage, the patient's condition was normal, both clinically and radiologically. The pathogenetic mechanism was hypothesized to be a pressure-necrosis phenomenon due to intraosseous bleeding.
Lavage manipulation technique was performed in 33 joints of patients with temporomandibular joint disorders. The subjects were 3 males and 30 females 14 to 68 years of age (average, 31.2 years). The procedure was as follows: 18-gauge and 21-gauge needles were inserted into the superior articular cavity for lavage with 200 ml of saline. One week, 1 month, and 3 months after this procedure, the clinical symptoms were evaluated. In patients with pain or limited mouth opening persisting for more than 3 months after initial lavage manipulation treatment, the procedure was repeated. We compared the effects of initial lavage manipulation technique with the effects of repeat procedure. Pain or limited mouth opening remained in 9 of the 33 patients after initial lavage manipulation technique. We performed this procedure 2 times in these 9 patients. Pain or limited mouth opening remained in 6 of the 9 patients, and we performed this procedure 3 times or more in these 6 patients. Pain or limited mouth opening remained in all 6 patients who underwent the lavage manipulation technique procedure 3 times or more. Our findings suggest that the lavage manipulation technique is not effective for patients who have persistent symptoms after the procedure is performed 3 times or more.
Generally, en bloc zygomatic fractures are treated by open reductionwith incisions of theinfraorbital rim and supraorbital eyebrow regions. However this method is associated with postoperativecomplications such as facial scars. An intraoral approach requiring only a maxillary vestibular incision, has been reported in several articles. This method is simple and results in adequate bone reduction and fixation. However, the position of bone fragments in the infraorbital rim cannot be observed. We used anintraoral approach, during intraoperative ultrasonic examination to confirm the condition of infraorbitalfragments in 17 patients who had simple en bloc fractures of the zygoma bone body. Ultrasonographyshowed dynamic bone reduction as distinct real-time images and bone fixation was performed exactly. Inselected patients the intaroral approach during ultrasonography, is recommended for en bloc zygomaticfractures.
A case of orbital and palpebral emphysema caused by fracture of the orbital floor is presented. The patient was a 4-year-old boy. He fell from a slide and struck the left side of his face. The patient presented with swelling of the left lower eyelid. A computed tomographic scan revealed a low density area inthe orbit and under the skin of the lower eyelid. Although mild exophthalmusand upward esodeviation ofthe eyeball had been caused by left orbital emphysema, no disorder of ocular movement was observed, andocular tension was normal. We administered antibiotics for 5 days to prevent infection and observed thepatient's grogress, giving instructions not to sneeze or blow his nose. Subsequent progress was favorable, and the swelling of the lower eyelid disappeared on the 7 th day after the injury. A computed tomographicscan obtained in the third week showed no remaining gas.
Cherubism is an uncommon disease in Japan that was first described by Jones as a familialmultilocular cystic disease of the jaws. The disease is classified as a non-neoplastic bone lesion in the World Health Organization histological typing of odontogenic tumors, but diagnostic criteria have notbeen established. We report a non-familial case of cherubism in a 10-year-old boy. The patient clinically showed fullness of the cheeks, slightly upturned eyes, and multiple swellings of the submandibular and cervical lymphnodes. Intraorally, there was bilateral bone expansion from the mandibular first molar region to the ascendingramus. The right first molar was dislocated laterally and the left first molar was unerupted. Radiographically, multilocular radiolucent lesions were found bilaterally from the mandibular firstmolar region to the coronoid process. In addition, there were unilocular radiolucent lesions from the maxillary molar region to the tuberosity on both sides. Biopsy specimens obtained from the mandibular lesionswere diagnosed as giant cell granuloma. The patient is being examined periodically with no treatment. The lesions have shown no evidence of growth for 16 months.
We report a rare case of a congenital lateral fistula of the upper lip at the vermilion in a 2-month-old boy with cleft lip. Under general anesthesia, fistulectomy was carried out with cheiloplasty bythe modified Millard technique. The fistulous tract terminated in the cartilaginous membrane of the nasalseptum. Histological examination revealed that the fistula was lined by stratified squamous epithelium, similar to the epithelium of the lip vermilion.
Congenital insensitivity to pain with anhidrosis belongs to the category of hereditary sensoryautonomic neuropathy type IV (HSAN N). This disorder is characterized by global insensitivity to pain, anhidrosis, unknown fever, and mental retardation. We report a case of congenital insensitivity to pain associated with a huge decubitus ulcer of the buccalmucosa. The patient was a 16-year-old boy. Because he had extracted his teeth by himself, he had beenunder the care of pedodontists since he was 3-year-old. All mandibular teeth, excluding the right secondmolar and the maxillary bilateral central incisors, had been lost. He had a huge decubitus ulcer measuring 40mm×30mm and extending deep to the buccinator muscle in the buccal mucosa. The ulcer was caused bydisplaced eruption of the left maxillary third molar, but he did not complain of any pain in this area. Afterantibiotic therapy, the tooth was extracted without local anesthesia. The extraction wound healed withoutcomplications, and the ulcer disappeared in 14 days. Oral health care required for patients with this type of disorder is discussed.
Unilateral atrophy of the masseter, temporal, medial pterygoid muscles, and the coronoid process is comparatively rare. We present such a case in a 58-year-old woman. She was referred to our department for examination of the left ramus of the mandible. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed atrophy of the left masseter, temporal, and medial pterygoid muscles andthe coronoid process. Electromyography showed no potential in the masseter or temporal muscles. Themandible did not deviate to the right. Dental Prescale indicated that the masticatory ability was lower onthe left side. There was no facial assymetry or trismus. This condition seems congenital, and she may haveestablished her own masticatory movement.
Clinical statistical studies were performed in 166 patients who visited our clinic from 1988 to 1996 because of breathing disorders during sleep. The patients consisted of 118 males and 48 females with a mean age of 45 years. Most of them (91%) were referred to us by physicians (43%), dentists (16%), otorhinolaryngologists (10%), and pediatricians (7%). Fifty-seven of the 73 patients who underwent sleep studies by polysomnography were given a diagnosis of sleep apnea, including 19 patients with severe sleep apnea syndrome (SAS)(AHI>40), 13 patients with moderate SAS (AHI: 20-39), and 25 patients with mild SAS (AHI: 5-19). The clinically evaluated scores of snoring and sleep apnea correlated with the degree of SAS
Two patients with isolated bone fragments in the maxillary sinus are described and discussed with a review of the literature. One patient was a 46-year-old woman, and the other was a 57-year-old woman. These patients had no symptoms, but had fallen on their faces. Orthopantomography revealed calcified structures in the molar region near the maxillary sinus. Osteoma of the maxillary sinus was suspected. Under local anesthesia, the lesions were removed from the maxillary sinus and examined histopathologically. The structures were comfirmed to be isolated bone fragments consisting of mature bone tissue. After surgical treatment, complications improved.
Salivary duct cysts are acquired cysts that are believed to develop from marked cystic dilation of a salivary gland duct. The majority occur in the parotid gland, followed by the submandibular gland, and various other salivary glands. Here we report a case of salivary duct cyst of the tongue, together with a review of the literature. A 68-year-old woman was referred to us because of swelling of the tongue. On examination, a lesion measuring about 30×30mm was found at the front of the tongue. When palpated, the lesion was soft and slightly tender. The clinical diagnosis was a cystic lesion. The cyst was totally extirpated with the patient under general anesthesia. The histopathological diagnosis was a salivary duct cyst. This case apparently arose from the anterior lingual gland.