Purpose: It is difficult to prevent intraoperative stress in the lower jaw during impacted wisdom tooth extraction surgery. We used a bispectral index (BIS) monitor (Aspect^®) to evaluate whether the possibility of stress varied according to operative stage.
Patients and Methods: The subjects were 68 healthy adults who gave consent for lower jaw wisdom tooth extraction. The extraction was performed under intravenous sedation and intraoperative changes in the BIS were analyzed. The frequency of cases in which deviation in the rising direction of the BIS index becomes larger was measured and analyzed.
Results: The rising direction of the BIS was high in the order of crown division, bone removal, root removal, local anesthesia, suturing, incision, mucoperiosteal flap peeling, and washing.
Discussion: Various methods have been used for stress evaluation during surgery. Changes in BIS values, which are considered to indicate potential stress, need to be evaluated in greater detail.
Conclusion: BIS monitoring is a feasible technique for evaluation of intraoperative stress during extraction of lower jaw impacted wisdom teeth under sedation.

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We report two extremely rare cases of wisdom tooth-germ infection in the mandible of young individuals. The first case was a 14-year-old male who presented with drainage from the left cheek at the Department of Oral Surgery in the National Hospital Organization Kumamoto Medical Center. After treatment with malar incision and drainage at another hospital, the patient was referred to our department because of an external dental fistula. Radiographic examination showed hypoplasia of the lower left wisdom tooth-germ. An extraction of the tooth-germ was performed under local anesthesia. The external dental fistula healed within 5 months of the surgery. The second case was a 12-year-old female who presented with trismus and swelling in the lower left mandibular region. Radiographic examination showed an increase in bone density, periosteal reaction of the left mandibular bone and destruction of the buccal cortical bone of the lower left wisdom tooth-germ. After treatment with antibiotics, the tooth-germ was surgically enucleated under general anesthesia. No signs of recurrence were observed at the 14-month postoperative follow-up. Although there are few reports on wisdom tooth-germ as a cause of chronic suppurative inflammation because external dental fistula and mandibular osteomyelitis are extremely rare, the possibility of an infected wisdom tooth-germ causing chronic suppurative inflammation should be considered.

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In this study, we encountered a case of vascular malformation with multiple phleboliths, which occurred in the left submandibular area. The patient was a 68-year-old male, who visited our department with a chief complaint of swelling in the left submandibular region. Panoramic radiography showed several radiopaque images in the inferior margin of the left mandible. CT detected a well-circumscribed, lobulated mass in the anterior area of the submandibular gland, and the internal area showed multiple calcified bodies of different sizes. T2-weighted MRI showed that the internal area was non-uniform, being rendered as a mass in the high intensity signal region, in comparison with the submandibular gland. Under a clinical diagnosis of hemangioma with phleboliths, tumor resection was performed under general anesthesia. The histopathologic diagnosis was hemangioma with calcification deposits. At present, two years and 2 months since the surgery, the course has been favorable without recurrence.

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Actinomycosis is an uncommon specific inflammation in the maxillofacial region, particularly arising in soft tissue around the mandible. In this paper, we report a case of maxillary actinomycosis with severe bone destruction and suspected malignant tumor. A 37-year-old man was referred to our hospital because of pain in the left molar region of the maxilla. Radiographic examination showed progressive bony destruction at the left maxillary sinus and alveolar process that were well enhanced by Gadolinium on the MRI. The clinical diagnosis was malignant tumor of the left maxillary sinus. Biopsy was performed under general anesthesia. Intraoperative frozen-section pathological examination revealed that it was inflammatory granulation tissue without malignancy. Accordingly, the operation was subsequently changed to sequestrectomy. Histological diagnosis of the permanent specimens was actinomycosis. No further signs or symptoms have been noted as of 48 months after surgery.

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Angiosarcoma of the breast is rare and the prognosis is poor. There are few reports of intraoral metastasis of breast cancer in Japan, and metastatic tumors of the oral region are rare, representing about 1% of malignant tumors in the oral cavity. We performed oral management on a patient that received chemotherapy for angiosarcoma, and reported diagnosable intraoral multiple metastases during the period. The patient received a medical examination at our department for oral management with chemotherapy in view of pulmonary metastasis and liver metastasis. The cancer metastasized to the rhinopharynx, oropharynx, and the brain, and so chemotherapy was administered. Multiple metastases in the oral cavity were found. We noted a neoplastic change to the right upper jaw, left lower molar and left lower anterior tooth gingiva. We performed an excisional biopsy on the left anterior gingiva tumor. It was pathological, and metastasis of angiosarcoma was diagnosed. A right upper jaw tumor and left lower jaw tumor closely resembled it macroscopically, and a metastatic tumor was thereby clinically diagnosed. She died of multiple organ failure 11 months after our first medical examination.

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Bloch-Sulzberger syndrome (Incontinentia pigmenti) is a genetic disease that displays multiple forms of symptoms including those of the skin, teeth and eyes. Here, we report the case of a patient with Bloch-Sulzberger syndrome on whom we performed orthognathic surgery under general anesthesia. The patient was a 21-year-old female. Oral cavity findings were congenital defects in the right upper jaw 7542, left upper jaw 12578, right lower jaw 754, and left lower jaw 125. Late-stage residual E in the left upper jaw, and abnormal crown morphology of tooth 23 in the right lower jaw and tooth 3 in the left upper jaw were observed. Right cephalometric radiographic analysis revealed marked skeletal mandibular protrusion at SNA: 77.6°, SNB: 89.1°, and ANB: −11.5°. Mandibular protrusion with anomaly in the number of teeth was diagnosed; sagittal split ramus osteotomy and Le Fort 1 osteotomy were performed under general anesthesia. At 18 months postsurgery, the patient is wearing the final prosthesis and occlusion has been confirmed. The present status of occlusion is good and the patient is also satisfied.

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Idiopathic thrombocytopenic purpura (ITP) is a blood disease in which the platelet count falls below 100,000/μl. When pregnancy is complicated by ITP, the reduced number of platelets increases the risk of bleeding during delivery. Here we report a successful tooth extraction procedure performed for a pregnant ITP patient.
The patient was a 34-year-old woman. The initial dental examination was in June 20XX at this clinic, where she was referred for treatment of tooth mobility.
Her medical history included the ITP diagnosis at age 33. Radiographic findings were a fracture line in the root of the left maxillary second premolar with root resorption and alveolar bone resorption. From these findings, conservation was judged to be difficult and extraction was indicated. The patient had maintained a platelet count of 60,000/μl, and the absence of a coagulation disorder was confirmed, so the extraction proceeded. The left maxillary second premolar was extracted. An absorbable hemostat was placed in the socket, which was then sutured. By the next day, bleeding had stopped, and the patient made a satisfactory recovery.

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An elongated styloid process, resulting from abnormal ossification of the stylohyoid ligaments, may cause various symptoms in the head and neck. We report two cases of a giant elongated styloid extending to the hyoid bone, resected using a transcervical approach. Case 1: A 35-year-old woman was referred by the internal medicine department to our department because of neuralgic pain extending from the left submandibular region to the neck. Panoramic radiography and CT revealed a hypertrophied styloid process and ossified styloid ligament extending to the hyoid bone on the left side. The styloid process was 85mm long. Case 2: A 65-year-old man was referred by the otorhinolaryngology department because of pain in the left pharynx. Panoramic radiography and CT revealed a hypertrophied styloid process and ossified styloid ligament extending to the hyoid bone on the left side. The styloid process was 71mm long. There were two sialoliths in the left submandibular gland duct, but no sialolith-related symptoms. An elongated styloid process was diagnosed in both patients and surgically resected via the transcervical approach, without adverse events. Pathological examination of the resected material suggested abnormal calcification of the stylohyoid chain derived from the Reichert cartilage. Symptoms resolved immediately after surgery.

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We present a case of a patient with post-traumatic malocclusion caused by a mandibular condylar fracture who was treated with a conventional osteotomy technique for jaw deformity to improve the malocclusion.
Case: A 63-year-old woman visited our hospital in 2007 with the chief complaint of malocclusion. She had been involved in a traffic accident in November 2006 and had been admitted to another hospital with a head injury, cerebral bleeding, and fracture of the clavicle and rib. However, since that time, she had been concerned about her malocclusion. We diagnosed an old mandibular condylar fracture and the patient underwent an intraoral vertical ramus osteotomy 6 months after the traffic accident. Following the surgery, functional occlusion could be secured and established. The postoperative course has been uneventful for the 5 years since then. Therefore, an intraoral vertical ramus osteotomy that is osteotomized in a different place from the original fracture line can be effective in improving post-traumatic malocclusion.

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Lichenoid changes, plate-like keratosis, and restriction of opening due to sclerotic lesion are typical lesions of oral GVHD. However, no case of opening failure due to masticatory muscle tone has been reported.
We report a case of chronic GVHD presenting with masticatory muscle symptoms on admission. The patient, a 67-year-old man, developed dry eye after allogeneic bone marrow transplantation for myelodysplastic syndrome （MDS）/acute myeloid leukemia （AML） skin GVHD. The tooth, which was the source of infection, was extracted at a nearby hospital. After receiving prosthetic treatment, he started to experience muscle tension of the masticatory muscle and accidentally bit under the lip. The results of a head MRI scan did not reveal any central neurodegenerative diseases such as dystonia. A stabilization splint was set and a partial denture inserted, which resulted in improvement. Although masseter hypertrophy and trismus occurred, there was no deterioration even during the course of observation.

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Synovial chondromatosis affects the knees and elbows and commonly occurs in distal parts near the long bones, such as the hip, and to a lesser extent in the jaw joints. Herein, we report a case of synovial chondromatosis due to long-term treatment for temporomandibular joint disorder （TMD）.
The patient, a 46-year-old woman, had consulted a physician for swelling and lack of movement in the left temporomandibular joint. She had been receiving long-term treatment for TMD; however, there was no improvement and so later she presented at our department for treatment.
Magnetic resonance imaging revealed a lesion, which was found to be cartilage-like tissue, between the lower left jaw fossa and the mandibular condyle. Histopathological analysis revealed that the lesion comprised typical cartilage cells. Therefore, the patient was diagnosed with synovial chondromatosis.
The patient underwent hysterectomy under general anesthesia. Currently, the patient has no temporomandibular joint symptoms and her prognosis is good.

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We present the case of rheumatoid nodules in the buccal region, in a 78-year-old female patient with rheumatoid arthritis, who presented with swelling of the left buccal region. Resection was performed under general anesthesia and revealed a mass that was a collection of nodules. The pathological diagnosis was rheumatoid nodules which had a central area of necrosis surrounded by palisades of histiocytes. To date, there has been no evidence of disease recurrence.

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We describe our experience with a case of acute septic arthritis of the temporomandibular joint （TMJ） from contiguous spread of odontogenic infection. An 80-years old woman was referred to our hospital because of swelling over the right TMJ and trismus. On the basis of clinical and imaging findings, acute septic arthritis of the TMJ associated with severe post-extraction infection and acute osteomyelitis of the right side of the mandible were diagnosed, surgical drainage and antibiotic therapy （ABPC/SBT and CLDM） were performed. Our experience suggests that cases with trismus are required for adequate differential diagnosis including imaging examination.

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