An air-turbine handpiece is used for bone cutting and tooth dissection during extraction of an impacted lower third molar. However, subcutaneous emphysema and mediastinal emphysema may develop as advanced complications. Six patients had emphysema caused by the use of an air-turbine handpiece in our department during the last 10 years. Mediastinal emphysema developed in 3 patients. The route of the air was examined by CT scanning. The findings suggested that the air extended from a lingual sparse part of the extraction cavity to the sublingual space, submandibular space, masticator space, pterygomandibular space, lateral parapharyngeal space, carotid sheath, retropharyngeal space, and finally to the mediastinum. Since the pterygomandibular space communicates with the contralateral side, air easily invades this region.
A case of gas gangrene is reported. A 66-year-old man was referred to our hospital because of swelling and dull pain in the right cheek region. He had been receiving treatment for diabetes mellitus, hypertension, and heart failure. Hemodialysis had been performed because of diabetic nephropathy. Antibiotics were given and surgical drainage was performed with the patient under local anesthesia on the first day of hospitalization. A microbiological examination revealed Streptococcus intermedius, Bacteroides species, and Fusobactelium sp. in the abscess. Despite treatment, the swelling and dull pain did not resolve. On the 7th day of hospitalization, a computed tomography examination revealed extended gas bubbles and an abscess in the soft tissues of the submandibular and cervical regions. Surgical drainage was performed under general anesthesia. Microbiological examination of the abscess revealed Gemella sp. and Provotella sp. The patient was discharged after 90 days of hospitalization. This report emphasizes the importance of rapid diagnosis of gas gangrene by computed tomography, followed bysurgical drainage, and the appropriate administration of antibiotics, especially in patients with diabetic nephropathy.
Recently, osteonecrosis of the jaw (ONJ) has been reported in some patients who receive bisphosphonates. We report a case of ONJ associated with the use of bisphosphonates in a patient with multiple myeloma (MM). A 70-year-old man with MM was referred to our department because of a non-healing socket after extraction of the lower left second molar. We performed curettage of the dental socket. Two weeks later, oral examination showed exposed necrotic bone at the lower left first molar region. A panoramic radiograph showed osteonecrosis of the lower left first molar region. A biopsy showed only necrotic bone, with no histologic evidence of MM disease. Because the patient had received intravenous bisphosphonates 27 times, we suspected that the ONJ was caused by bisphosphonate therapy. We repeatedly performed local irrigation and minimal sequestrectomy. The socket at the lower left first molar region underwent good epithelization with residual necrotic bone. There is no consensus on the management of ONJ associated with the use of bisphosphonates. Further investigations are needed to establish a satisfactory therapy for ONJ.
Bisphosphonates, nonmetabolized analogues of pyrophosphate, have been widely used to treat patients with hypercalcemia caused by malignancy, bone metastasis, multiple myeloma, and osteoporosis. Recent studies have documented that bisphosphonates can cause osteonecrosis of the jaws. We report a case of bisphosphonateassociated osteonecrosis of the maxilla. A 72-years-old woman was referred to our clinic for further examination of the upper left premolar region. Intraoral examination revealed necrotic alveolar bone in the upper left premolar region, with swelling of the surrounding soft tissue and exposed necrotic bone at the right side of the upper jaw. The patinet had a past medical history of breast cancer with bone metastases to the ribs and received intravenous pamidronate at a dose of 30 mg every 2 weeks. We suspected bisphosphonate-associated osteonecrosis and performed sequestrectomy after antibiotic therapy and local irrigation. Because the number of patients who receive bisphosphonates is increasing in Japan, dentists, especially oral surgeons, should be careful about bisphosphonate-associated osteonecrosis of the jaw bones.
Hyoid bone fracture is very rare because the hyoid bone is anatomically movable and protected by the mandible, cervical vertebrae, and clavicle. We report a case of jaw fractures with a hyoid bone fracture. The patient was a 56-year-old man who was injured by a traffic accident. He was transported to the nearest emergencyhospital. Under the diagnosis of multiple fractures of facial bones and general contusion, he was hospitalized andreceived anti-inflammatory treatment. He was referred to our department for treatment of his intraoral wound.Intraoral examination revealed luxation of the mandibular anterior teeth and detition of the surrounding gingival. CT imaging showed fractures in the left great horn of the hyoid bone, maxilla, orbital floor, nasal bone, and alveolarbone of the mandible. As the patient had only slight swallowing pain, anti-inflammatory treatment was administeredduring hospitalization, without surgery. Half a year since the accident, CT imaging showed slight restorationof the hyoid bone, and the patient has had no symptoms.
We report a case of glandular odontogenic cyst (GOC) arising in the mandible. The patient was a 55-year-old woman who presented with a painful swelling of the right premolar region of the mandible.Roentgenographic examination revealed a multilocular radiolucent lesion from the right first molar across themidline to the left second premolar region. The clinical diagnosis was a mandibular cyst. Enucleation of the cystand extraction of the teeth were performed with the patient under general anesthesia. Histological examinationshowed a multicystic lesion partially lined by non-keratinized epithelium with focal plaque-like thickening. Thesurface epithelium included eosinophilic cuboidal and ciliated cells. Cyst-like spaces and glandular structureswere also observed within the epithelium. Epithelial islands were also seen in connective tissue of the cyst.Immunohistochemically, epithelial cells were strongly positive for cytokeratin (CK) 13 and 19, but almost negativefor CK18. The histological diagnosis was GOC. The postoperative course was satisfactory, and no recurrencehas been noted 4 years 6 months after the operation.
A 44-year-old woman was referred to our hospital because of a suspected left mandibular cyst.Panoramic radiography revealed three ill-defined unilocular radiolucent lesions in the mandible and maxilla. Allthree biopsies were not revealed to the cyst wall, however cemento-osseous dysplasia was diagnosed at only onelesion. After surgical curettage, panoramic radiography demonstrated bone regeneration at the sites of bothlesions. One year 2 months later, a new lesion was detected in the mandible, but a biopsy showed that it lacked acyst wall. These findings indicated that this patient had very rare multiple simple bone cysts of the mandible andmaxilla.
We describe a case of ossifying fibroma arising at the inferior border of the left zygomatic arch. A 22-year-old woman presented with a swelling and pain in her left cheek. A bony hard mass was found in the diffuseswelling of the cheek, adjacent to the zygomatic arch. CT imaging showed a bony, dense lesion in the left zygomaticimassetericregion. Interposition of soft tissue between the bony tumor and the zygomatic arch was recognized.Under a diagnosis of a benign bony tumor, the tumor was enucleated with the patient under general anesthesia.The histopathological diagnosis was an ossifying fibroma. An ossifying fibroma arising at the inferior borderof the zygomatic arch has not been reported previously, and the origin of the tumor is unclear. The patient hasremained relapse free for more than 2 years after the operation.
Neurilemoma is an uncommon benign tumor of the oral and maxillofacial region. We report a hugeneurilemoma, measuring 40×35mm, in the palate of a 22-year-old man. The lesion was surgically excised withthe patient under general anesthesia. The tumor was confirmed to communicate with the greater palatine nerve atsurgery. Histopathologically, it was diagnosed as a neurilemoma, Antoni A and B type. There has been no recurrenceduring postoperative follow-up of 36 months.
Traumatic neuroma is a hyperplastic lesion caused by the superfluous regeneration of nerve cells at acut surface. We report a case of traumatic neuroma arising in the lower lip of a 7-year-old boy. The patient wasinvolved in a traffic accident in May 2003, causing a bone fracture of the femoral region and laceration of the lowerlip. The lower lip was sutured surgically. Shortly after treatment, the patient noticed a swelling in the right side ofhis lower lip and consulted our clinic for a detailed examination on January 7, 2004. Macroscopically, an elasticand hemispheric painless soft mass with a diameter of 1.0cm was noticed at the suture line. Under a clinical diagnosisof mucocele, we performed enucleation of the tumor. Histologically, irregular proliferation of the peripheralnerve cells and nodular formation of Schwann cells were observed. The tumor was diagnosed to be a traumaticneuroma. During 2 years of postoperative follow-up, the patient has had no evidence of recurrence.
Superselective intra-arterial infusion therapy using Seldinger's technique is frequently performed atmany institutions to improve treatment outcomes in patients with advanced head and neck cancer. However, complicationsrelated to control nerve dysfunction and local toxicity have been reported in association with the use ofthe one-shot infusion procedure. We report a case of bone necrosis of the mandible after superselective intra arterialinfusion therapy in a 74-year-old woman with carcinoma of the upper gingiva. She received conventional concomitantextrabeam radiotherapy (36 Gy) and superselective intra-arterial infusion therapy with CBDCA (300mg) via the maxillary artery. After superselective intra-arterial infusion chemotherapy, necrosis of the medial pterygoid muscle, extending tothe area around the mandible, was recognized. Thereafter, sequestration and a fracture of the mandible developedtwo times within 1 year after this treatment. Sequestrotomy and intramaxillary fixation for the fracture were performed.Thereafter, both new bone formation and bone remodeling were confirmed. We suspect that this side effect was caused by leakage of CBDCA to the surrounding tissue, moving thecatheter to another artery, or spasm of the maxillary artery.
A 68-year-old woman with buccal carcinoma had consciousness disorder, appendicular ankylosis, andspasm just after chemotherapy with cisplatin (CDDP) and 5-FU. Brain CT and MRI showed no abnormalities. Onlaboratory studies, the serum sodium was 106 mEq/1 and the urine sodium 160 mEq/l. Osmolalities of plasma andurine were 238 and 603 mOsm/kgH2O, respectively. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) secondary to chemotherapy with CDDP was diagnosed. To avoid central pontine myelinolysis (CPM) due to the rapid rise in the serum sodium concentration, we provided adequate fluid supplementation according toher urine volume and hypertonic saline transfusion. Four days after starting hypertonic saline transfusion, theserum sodium concentration rose to 135 mEq/1 and her symptoms almost disappeared. Serum sodium should bemeasured frequently for the early detection and treatment of SIADH during and after chemotherapy with CDDP.
A case of severely limited mouth opening after craniotomy is reported. A 48-year-old woman wasreferred to our department for treatment of limited mouth opening. She had a medical history of a subtemporaland a lateral suboccipital craniotomy, with decreased mouth opening developing a month after the cranial surgery. The maximum inter-incisal distance was 7 mm, and no movement of the left temporomandibular joint wasdetected. Radiographic images revealed hyperplasia of the left mandibular head and lack of interarticular space. We planned treatment in 3 stages: initial operation (gap arthroplasty and insertion of an artificial membrane), physiotherapy after the operation, and secondary surgery (elimination of the membrane). During the initial surgery, maximum opening of the mouth increased from 7 mm to 21 mm, but muscle contracturewas suspected to prevent further improvement. Therefore, coronoidectomy and removal of the masseter musclewere performed additionally. These procedures increased maximum opening to 47 mm. She started mouth-opening exercises with a gag on the next day. The range of active motion increased from 22mm to 35 mm. After discharge from our hospital, she continued home rehabilitation. Secondary surgery was performed 3 months after the initial surgery. She continued the same exercises, withless pain. Maximum opening of 41 mm has been maintained for 7 months after the initial surgery.
We report a surgical technique for habitual temporomandibular joint dislocation. Cortical bone was shaved at the anterior slope of the tubercle, and a piece of an autogenous bone block wasgrafted to augment the tubercle. The grafted bone was fixed with a titanium plate and screws. This method preservedthe original posterior slope of the tubercle, permitting smooth condylar movement. We used this technique in two patients and followed them for 15 and 5 years, respectively. Postoperative examinationsshowed no resorption of the grafted bone and no recurrence of dislocation in either patient.
Aplastic anemia is a blood disease characterized by pancytopenia due to a decrease in hematopoieticstem cells. We describe a patient who presented with submucosal hematoma of the tongue and was given a diagnosisof aplastic anemia. The patient was a 24-year-old man who visited our department because of a hematoma ofthe tongue. Two days before presentation, a dark reddish tumor with a diameter of 1-2mm was noticed at the leftmargin of the tongue. At presentation, a 20×11mm dark reddish elevation was seen at the left lateral margin ofthe tongue. On the basis of the above course and findings, a hematoma was diagnosed, and blood tests were conducted.A blood disease was suspected. The white blood cell count was 500/μl, the red blood cell count was320×104/μl, the Hb was 11.2g/dl, the Ht was 31.1%, the MCV was 96.9 fl, the MCH was 35.0 pg, the MCHCwas 36.1%, and the platelet count was 0.3×104/μl, indicating pancytopenia. A submucosal hematoma of thetongue accompanied by pancytopenia was diagnosed, and detailed examinations were performed at the hematologydepartment. A bone marrow puncture test showed that the bone marrow cell count was 4, 000/μl and themegakaryocyte count was 0/μl; aplastic anemia was thus diagnosed, and the patient received immunosuppressivetherapy. Even when the onset is gradual, aplastic anemia can be lethal if detection is late and appropriate therapyis not administered. Therefore, if the regional cause of an oral hematoma is not clear, close follow-up is necessary.If systemic factors are suspected, blood tests should be promptly performed.
Foreign bodies entering the maxillary sinus have often been reported. However, it is very rare that theyare naturally dislodged from the maxillary sinus. We report a case of a foreign body entering the maxillary sinus on extraction of an upper wisdom tooth. On theday after entrance of the foreign body, we attempted to remove it surgically, but could not locate the object in themaxillary sinus. On x-ray film, the foreign body was found in the stomach. The foreign body was apparently dislodgedfrom the maxillary hiatus and swallowed. In cooperation with a surgeon and internist, the foreign body wasremoved endoscopically and identified to be a dental cutting bar.