Allogenic Grafts Versus Autogenous Bone: Comparing Costs and

Issue HighlightsThese articles have been selected by theCoordinating Editor as Key Reviews.

Critical Discussion and Commentary

Lag Screw Versus Plate Fixation for Mandibular Symphysis Fractures

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• Pediatric Facial Fractures Portend Concomitant Trauma

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• Is Cryoanalgesia Effective for Intractable TMJ Pain?

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more…

Literature Reviews

• Can Extracted Teeth Be Used as Grafts?

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• Treatment of Necrotizing Fasciitis Requires Aggressive Surgical Intervention

page 8

• New Photodynamic Laser Therapy for Oral Precancer-ous Lesions Shows Promise

page 10

more…

Practice Quiz

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Vol. 28 No. 2

E-quiz code: 31694N

Critical Discussion and Commentary

January 30, 2012 Original Rel.: January 2012 Termination: January 2014

Most of us have faced a patient withan edentulous but atrophic maxillathat finally decides they want im-

plants. Our clinical and radiographic exami-nation reveals adequate bone height, butinsufficient buccal-lingual width necessitat-ing the need for some type of bone graft.Reconstructing the atrophic maxilla has tra-ditionally been done withautogenous iliac crest bonegrafts. Although effective,the technique is expensiveand results in some donorsite morbidity. Alternativemethods exist, including theuse of alloplastic or allo-genic grafting materials withor without membranes.

This was a five-year retrospective study in-volving 26 patients. Thirteen received thetraditional iliac crest bone grafting, whichwas harvested from the medial surface ofthe anterior ilium in monocortical blocks.The other 13 patients received demineral-ized freeze-dried bone grafts with tentingscrews and resorbable collagen mem-branes. In both groups the grafts were al-lowed to mature for six months prior toimplant placement. These implants were leftburied for four months prior to abutmentconnection and prosthesis construction. Im-plant survival was assessed at the stage 2abutment connection surgery, as well asfive years post-function.

At five years there was no statistical differ-ence in the number of implants that sur-vived, and in both groups they were in the

high 90%. The authors had access to timein the operating room, as well as personnelexpenses, and analyzed these in addition tothe costs of the bone grafts and associatedmaterials. Not surprisingly, when they ana-lyzed costs, the demineralized freeze-driedbone group was significantly less, in fact,22% of the costs of the iliac crest bone graft

with the authors thereforeconcluding that whenfaced with this clinical situ-ation, surgeons shouldconsider the use of sometype of alloplastic or allo-geneic agents opposed toiliac crest bone grafting.

I believe several additionalpoints need to be made.

One, obviously the allogeneic agent had nodonor site morbidity and could likely be per-formed in an office setting, two significantpluses for that technique over the more tra-ditional iliac crest graft. The paper wasfairly light in details, not really explainingthe type of prostheses nor even giving thetotal number of implants placed in the re-constructive arch. It also failed to list thesize of the implants placed or provide anyradiographs. Finally, I would have liked tosee some type of pre- and post-operativeCT scans showing how much bone was ac-tually augmented in each group. However,in cases where perhaps all we need is 2 to3 mm of additional width, surgeons shouldat least consider using some type of bonein a bottle as opposed to the more tradi-tional iliac crest grafting.

At five years there was no

statistical difference in the

number of implants

that survived.

Allogenic Grafts Versus Autogenous Bone: ComparingCosts and OutcomesWhen augmenting bone for future implants, consider using allogenicbone, tenting screws, and membranes instead of iliac crest

By J. Bruce Bavitz, DMDBased on: Dahlin C, Johansson A. Iliac Crest Autogenous Bone Graft Versus Alloplastic Graftand Guided Bone Regeneration in the Reconstruction of Atrophic Maxillae: A 5-Year Retro-spective Study on Cost-Effectiveness and Clinical Outcome. Clin Implant Dent Relat Res2011; 13 (December): 305-310.

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Literature review and critical analysis from the publisher of Practical Reviews

Oral & Maxillofacial Surgery

As is commendable by the ACCME criteria, CME is integrated into the process for improving professionalpractice with educational strategies implemented to remove, overcome or address barriers to physicianchange. Physicians are unable to consistently integrate new information into their practices because ofthe ways new medical knowledge is structured and disseminated, and the time it takes to completelyscan for new information. Select publications select and translate peer reviewed literature for practicaluse therefore diminishing the barrier of time.

Method of Participation: To receive credit for this activity, answer the practice quiz questions, read the con-tent, and complete the online post activity quiz at www.practicalreviews.com. Log in using your email ad-dress and password, click on take a quiz and enter quiz code located on the front page or above the quizquestions. To obtain documentation of participation, you are required to submit an activity evaluation.

Hardware/Software requirements: The web-based activity requires a version 4.x web browser or newerand is best experienced using a current generation browser such as Internet Explorer 6.0 or newer or Firefox1.5 or newer. The presentation component is designed for 1024X768 screen resolution or better. Cookiesmust be enabled to take the self-assessment, complete the evaluation, and print the CME certificate.

Media: Internet access to pdf.

Intended Audience: Oral and maxillofacial surgeons, orthodontists and others interested in oral andmaxillofacial surgery.

Learning Objectives: At the conclusion of this activity, participants will demonstrate the ability to:• Discuss current trends in the diagnosis and treatment of diseases of the facial structures and oral cavity.

• Describe significant clinical developments and advances in the diagnosis and treatment of diseases andtrauma to the facial structures and oral cavity.

• Interpret advantages and disadvantages of new dentoalveolar, orthognathic, preprosthetic and temporo-mandibular surgical techniques as presented in the current literature.

Special Prerequisites for Participants: There are no prerequisites for participants.

Accreditation: Oakstone Medical Publishing is accredited by the ACCME to provide continuing medicaleducation for physicians.

Oakstone Medical Publishing designates this enduring material for a maximum of 2 AMA PRA Category1 Credits™. Physicians should claim only the credit commensurate with the extent of their participationin the activity.

Estimated time to complete each issue: 2 hours.

This activity is also eligible for 2 credit hours in Category 2-B of the Continuing Medical Education Programof the American Osteopathic Association, provided it is completed in its entirety.

Minimum Performance Level: Questions should be answered based on the information presented in theissue within 24 months of publication date and 70% of the questions must be answered correctly to pass thequiz and receive credit for the issue.

Disclaimer: The opinions and recommendations expressed by the faculty and other experts whose input isincluded in this program are their own. This enduring material is produced for educational purposes only. Useof Oakstone Medical Publishing name implies review of educational format design and approach. Please re-view the complete prescribing information of specific drugs or combination of drugs, including indications,contraindications, warnings and adverse effects before administering pharmacologic therapy to patients.

Full Disclosure Policy: Oakstone Medical Publishing has assessed conflict of interest with its faculty, au-thors, editors, and any individuals who were in a position to control the content of this CME activity. Anyidentified relevant conflicts of interest were resolved for fair balance and scientific objectivity of studies uti-lized in this activity. Oakstone Medical Publishing’s planners, medical reviewers, and editorial staff discloseno relevant commercial interests.

Dr Michael L. Ellis reports: Board Membership: American Board of Oral and Maxillofacial Surgery;Employment: TAMHSC/Baylor College of Dentistry; Expert Testimony: various medical malpracticedefense.

Dr Melanie S. Lang reports: Consultant: American Dental Association Medical Advisory Committee, andAmerican Association of Oral and Maxillofacial Surgery Committee on Hospital & Interprofessional Affairs.

The following faculty report no relevant financial interests: Drs J. Bruce Bavitz, and Rod M. Griffeth.

12 issue subscription price: $199 Oakstone Publishing, LLC 100 Corporate Parkway • Suite 600 • Birmingham, AL 35242 • (800) 633-4743

Copyright Oakstone Publishing, LLC, 2012. Copyright strictly reserved. The content of this newsletter maynot be reproduced in whole or in part without written permission of Oakstone Publishing, LLC. Note: Content largely consists of abstracts from the medical literature and is not intended to be an exhaus-tive dissertation on the articles discussed.

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Coordinating Editor J. Bruce Bavitz, DMDChair, Department of Surgical SpecialtiesUniversity of NebraskaCollege of DentistryLincoln, NE

ReviewersMichael L. Ellis, DDSAssociate Professor, Program Director-

Oral and Maxillofacial SurgeryTexas A&M Health Science CenterBaylor College of Dentistry Department of OMSDallas, TX

Rod M. Griffeth, DDSOral & Maxillofacial Surgeon Partner in Private PracticeBillings, MT

Melanie S. Lang, DDS, MDSurgeon/OwnerSpokane Oral and Maxillofacial SurgerySpokane, WA

Lag Screw Versus Plate Fixationfor Mandibular Symphysis FracturesLag screw fixation is equal to plate fixation forocclusal and osseous healing with less post-operative dehiscence, plate exposure, andneed for hardware removal

By Rod M. Griffeth, DDSBased on: Ellis E III. Is Lag Screw Fixation Superior to PlateFixation to Treat Fractures of the Mandibular Symphysis? JOral Maxillofac Surg 2011; December 29: epub ahead of print.

There is an old adage that states, “there is power in num-bers.” If that saying is true, a recent article by Dr. EdwardEllis definitely has power. It is a retrospective cohort

study spanning over 20 years comparing two internal fixationmethods for treatment of mandibular symphysis fractures.

An outstanding 887 patients met the inclusion criteria. Thestudy compares lag screw to bone plate fixation for fracturesof the mandibular symphysis. While treatment outcomes foreach method have been previously reported separately, nostudy in the literature until now directly compares them anddefinitely not with this number of patients. The purpose ofthis study was to compare the frequency and types of com-plications between the two groups to determine if onemethod was superior to the other. Fractures of the mandibu-lar symphysis are extremely common. The unique anatomyof this region allows for various internal fixations schemes.

Mandibular symphysis in this paper is defined as a fracturebetween but not including the mental foramen. Patientsmeeting inclusion criteria had simple, noncomminuted frac-tures with teeth present in the area and were approached viaan intraoral incision. All had an arch bar placed during sur-gery, which was maintained for at least 5 weeks with no post-operative intermaxillary fixation. The patients had a minimumof five weeks of follow-up. Besides a comparison betweenthe demographic data, outcomes collected and comparedwere postoperative infection, dehiscence, exposure to hard-ware, and need for hardware removal. Also compared wasdamage to tooth roots, malocclusion attributable to the sym-physis fracture and clinical union at the last visit. Roughly anequal number of patients had either lag screw or plate fixa-tion method with more than 400 participants in each group.In the plate fixation group, approximately half received two,2.0 miniplates, and half were treated with one larger inferiorbicortical plate. All lag screw patients had a minimum of twoscrews placed. All patients had intraoperative maxillo-mandibular fixation with arch bars, and the arch bar was keptin place for a minimum of five weeks, but no patient hadpostoperative intermaxillary fixation. Patients were not ran-domly assigned to the treatment groups, but rather were cho-sen on the whim of the faculty or resident surgeon.

There were no statistical differences between the two treat-ment groups for any demographic variables. Also, and moreimportant, no difference was found for clinical union andpostoperative malocclusions. However, patients treated withbone plates had significantly higher rates of infection, inci-sion dehiscence, hardware exposure, and need for hardware

Approved PACE Program ProviderFAGD/MAGD CreditApproval does not imply acceptance by a state orprovincial board of dentistry or AGD endorsement. (6/1/2009) to (5/31/2013)

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Oral & Maxillofacial Surgery

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removal when compared to the lag screw group. The rate waslow in both groups at 3% versus 1% between the two groups.

An interesting discussion point highlighted in the article wasthe increased intraoperative difficulties associated with thelag screw technique. These include inability for fracture sta-bilization due to over counter sinking the near cortex orover drilling of the far cortex. Damage to the inferior alveo-lar nerve due to iatrogenic placement of the lag screw wasalso a complication. Until recently, placement of lag screwswas a partially blind technique requiring estimation of theexiting location of the screw. A recent drill guide instrumentwith exit locator has made this a more predictable proce-dure. The take home message of this paper is that the plat-ing and lag screw techniques for fixation of mandibularsymphysis fractures both showed excellent outcomes withlow complication rates. The plating method had greaterpostoperative complications, but less intraoperative difficul-ties. New advances with instrumentation may make the lagscrew technique more predictable. Not discussed was thedifference in the expense between the two methods, whichshould favor the lag screw technique.

Oral Piercings Often Done on MinorsWithout Parental ConsentBe aware when discussing oral piercing onminors that the parents may not be aware ofthe piercings

By Melanie S. Lang, DDSBased on: Vieira EP, Ribeiro ALR, et al. Oral Piercings: Im-mediate and Late Complications. J Oral Maxillofac Surg2011; 69 (12): 3032-3037.

Historically, piercings have been performed for variousreligious, sexual, and cultural identification indica-tions. However, in more recent years, total piercings

both in the body and oral region have become more popular,mainstream, and socially acceptable. Various body partsfrom the ears, nostrils, eyebrows, naval, and tongue aregenerally the preferred sites. Currently in the Western World,oral piercings are becoming more popular with piercings ofthe cheeks, lips, tongue, lingual frenum, and uvula. Thetongue and lips are the most frequently pierced oral sites.Unfortunately, there are certainly potential, both early andmore long term, local and systemic complications with oralpiercings. However, relatively little dental or medical profes-sional literature is available concerning these complicationsand even less public knowledge.

The objective of this study was assessing the prevalence ofimmediate and late complications of oral piercings done inthe tongue and lips. The study involved 39 adult dental stu-dents. Study participants were identified between Octoberand November of 2009. During that time, detailed interviewsand clinical evaluations were conducted for associated datacollection. The participant’s ages at the time of the study

ranged from ages 18 to 24. A total of 42 oral piercings wereidentified and included in this study. Sixty percent of thestudy participants were female, and 33% were male. Of theoriginal 42 oral piercings, 88% of these piercings were in thetongue and 12% in the lips. Of the original piercings, 64%had been removed at the time of this study with 36% re-maining for an average time of use of 15 months, rangingfrom as short as two months to as long as four years. In theindividuals where a piercing had been removed, a visiblescar remained in 78% of those individuals. Based on a retro-spective recollection, original healing time ranged from fourto six weeks with reported complications occurring in 41 of42 of the piercings for a total rate of complications at 97.6%.Immediate complications included excessive prolongedbleeding, pain, and several episodes of syncope. Late com-plications included pain, bleeding, swelling, ongoing dis-charge, reactive tissue, and surrounding oral tissue trauma.There was a 90% incidence of surrounding oral tissue injury,which encompassed dental pain, tooth fracture, gingival re-section, and local trauma to the tongue, palate, gums, andfloor of mouth. Eighty-one percent of the piercings weredone on minors with 59.5% of these piercings being donewithout parental consent.

In day-to-day practice, I certainly see various oral and facialpiercings, and, as noted in this study, oral piercings are nowquite mainstream and socially acceptable, particularly in theyounger population. In the U.S., piercing regulations varyfrom state to state. However, when performed by unli-censed, relatively inexperienced individuals with limitedknowledge of anatomy, sterile technique, and managementof emergency situations, a higher incidence of complicationsmay occur. Although this study only identified oral piercingsrelated to the tongue and lips, which are certainly the mostfrequently encountered sites, other oral piercing sites includ-ing the lingual frenum, cheeks, and uvula are being encoun-tered. I found it of particular interest as to the number of oralpiercings done on minors, particularly without parental con-sent in nearly 60% of this study in Brazil. This number maycertainly be different here in the U.S., however, it is certainlyoccurring, as in clinical practice on a number of occasions Ihave seen patients under 18 accompanied by a parent orguardian for routine clinical evaluation in which an oralpiercing has been noted on clinical exam. Frequently theseoral piercings require removal prior to upcoming associatedsurgical procedures, and in discussing this with the patientand parent or legal guardian, it becomes evident that theparent or guardian was previously not aware of the oralpiercing. In my clinical experience, this seems to be morefrequent with piercings of the lingual frenum since this site issomewhat easier to disguise. This study concluded that oralpiercings are frequently associated with local complications,and individuals choosing to proceed with various oral pierc-ings should be made aware of these potential complicationsand undergo routine dental visits on a regular basis to as-sure prompt detection of any associated complications.

Pediatric Facial Fractures Portend Concomitant TraumaPediatric facial fractures account for approxi-mately 15% of all facial fractures

By Michael L. Ellis, DDSBased on: Grunwaldt L, Smith DM, et al. Pediatric FacialFractures: Demographics, Injury Patterns, and Associated In-juries in 772 Consecutive Patients. Plast Reconstr Surg2011; 128 (December): 1263-1271.

Pediatric patients with a facial fracture that present to theemergency room for evaluation and treatment can suf-fer a variety of injuries. Concussive injuries and cervical

spine trauma should always be considered no matter the de-scribed mechanism of injury. Injury patterns to the facial bonesin a pediatric population are unique due to dynamic anatomicaldifferences based on age and development. Grunwaldt, Smith,and others provide an excellent review of a large pediatricpopulation assessed in a children’s hospital for facial and otherfractures. Their objective was to review and describe compre-hensive demographic data on pediatric facial fractures througha retrospective chart review.

The participants in this study included all patients from birthto 18 years admitted through the emergency room at a chil-dren’s hospital with a –9 code indicating any facial fracture.Seven hundred seventy-two patients met the inclusion crite-ria, presenting with at least one facial fracture. Three groupswere identified–patient age of zero to five years, six to 11years, and 12 to 18 years. Demographics, mode of injury,fracture type, additional injuries, and outcomes were allrecorded for statistical analysis.

Sixty-three percent of the patients were hospitalized, andthere were 11 deaths. The mean age of the entire study pop-ulation was 10.7 years, and 70% were male. The largestgroup of patients presenting with a facial fracture was the 12-to 18-year age group, representing 47% of the injuries.Twenty percent of the injuries were found in the zero- to five-year age group, and 33% in the six- to 11-year age group.Eighty-two percent of the injuries were suffered by Cau-casians, 15% by African Americans, and 3% by other ethnic-ities. The predilection of fractures by ethnicity wasstatistically different than the ethnic representation in the cityof the study, Pittsburg, where 68% are Caucasian, 27% areAfrican American, and 5% are other ethnicities. Orbital frac-ture was the most common fracture found in all threegroups, with concomitant skull fractures seen more com-monly in younger patients and zygomaticomaxillary complexfractures seen in the older age groups. Fall was the mostcommon mechanism of injury in the zero- to five-year-olds;motor vehicle related injuries were most common in the six-to 11-year-olds; and violence or sports-related injuries werethe most common mechanisms in the 12- to 18-year-olds.About one-third of patients required operative intervention, alittle less in the zero- to five-year-olds, and a little more inthe 12- to 18-year-olds. More zero- to five-year-olds, about28%, were admitted to the ICU than the older groups, aver-aging 20% or less. Neurologic trauma was the most fre-quently seen additional injury in all groups, mostly

concussions. Two percent had C-spine injuries, and one-halfof one percent, or 4 patients, experienced blindness.

Pediatric facial fractures are associated with significant andsevere concomitant injuries and are predominantly seen inmales. About one-third require operative intervention. Frac-tures secondary to violence, as expected, are seen morefrequently in older children, while falls account for a signifi-cant percentage of injury in those less than five years old.This is a great review of a significant sample size of pediatricfacial fractures. The authors report a preponderance of or-bital fractures in this study, whereas other studies report themandible as most commonly fractured. Take a look at thispaper; this is a good one.

Is Cryoanalgesia Effective for IntractableTMJ Pain?Hyperstimulation analgesia through the use ofcryoprobes can result in positive, but only tem-porary, improvements for intractable TMJ pain

By Michael L. Ellis, DDSBased on: Sidebottom AJ, Carey EC, Madahar AK. Cryoanal-gesia in the Management of Intractable Pain in the Temporo-mandibular Joint: A Five-Year Retrospective Review. Br JOral Maxillofac Surg 2011; 49 (December): 653-656.

Patients with intractable temporomandibular joint (TMJ)pain are often difficult management issues. With thefailure of conservative therapy, whether it involves en-

couragement, nonsteroidal antiinflammatory agents, and dietalteration, or is stepped up to orthotic therapy followed byarthrocentesis or arthroscopy, many surgeons remain reticentto progress to total joint replacement. In many cases, patientfinances and ability to obtain any needed therapies play alarge role in the selection of therapy. Discriminating tests andimaging are important to identify the exact source and etiol-ogy of the malady, and this may result in multiple referrals ofthis patient base to orthodontists, prosthodontists, endodon-tists, neurologists, and pain specialty clinics. The surgeon isleft with only a few treatment options. Sidebottom, Carey, andMadahar in their article explore the use of hyperstimulationtherapy with cryoprobes as a possible treatment alternative inthis population of pain patients. The authors’ objective was todescribe the efficacy of cryoanalgesia for the relief and man-agement of TMJ pain in a retrospective clinical report of 17patients with intractable TMJ pain treated with cryoanalgesiaat a single medical center between 2002 and 2006.

Demographics and multiple clinical parameters were as-sessed pre- and post-operatively including, but not limited to,maximum incisal opening, visual analog scale (VAS), dura-tion of relief, complications, and long-term outcomes. Diag-nostic intraarticular nerve blocks were utilized to identifyinclusion into the cryoanalgesia treatment regimen. If theblock temporarily relieved the TMJ pain, the patient was of-fered the cryoanalgesia approach. Cryoanalgesia involved

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surgical access to the joint capsule and three freeze-thaw cy-cles with the cryoprobe for 90 seconds each to the exposedcapsule. Arthrocentesis followed prior to closure, and the pa-tients were followed at six weeks and up to one year.

At six weeks the maximum incisal opening increased from amean of 35.4 mm to only 36.7 mm representing an insignifi-cant difference. The mean VAS pre-operatively was 6.8 on azero to 10 scale and reduced to 2.0 at six weeks. A mean of4.8 improvement in the VAS was found in the group of 17 pa-tients representing a statistically significant improvement ofdecreased pain intensity. Two patients did not improve, andtwo others had complete relief from pain at six weeks. Themean length of pain relief was 14.7 months in this populationfollowing cryoanalgesia. Twelve of seventeen patients re-ported returned pain at 12 months, and six of these gradu-ated to total joint replacement. Two had complications, onehad temporary temporal numbness, and one had temporalbranch palsy that completely resolved.

What can we conclude from this paper? Cryoanalgesia withsimultaneous arthrocentesis may result in a temporary de-crease of symptoms in those with intractable TMJ pain. Thetechnique provides variable pain relief over time with minimalmorbidity. Cryoanalgesia was considered by the authors as atreatment of last resort prior to joint replacement. The out-comes in this retrospective report are confounded by poorlyexplained concomitant arthrocentesis. Additionally, range ofmotion data illustrates no significant improvement after sur-gery. It is an interesting technique that may provide an addi-tional, albeit temporary, therapeutic adjunct in themanagement of this difficult cohort of patients.

Are Implants Placed at LowerTorque Values Better Than What We Previously Believed?The insertion torque value of 35 Ncm accepted by many as the value needed for immediate loading may be higher thannecessary and may actually contribute tomarginal bone loss

By J. Bruce Bavitz, DMDBased on: Norton MR. The Influence of Insertion Torque onthe Survival of Immediately Placed and Restored Single-Tooth Implants. Int J Oral Maxillofac Implants 2011; 26 (No-vember): 1333-1343.

Ijust placed an implant, and the patient and his dentistwant it restored as soon as possible. When can thissafely be done? Does insertion torque make a differ-

ence? A currently accepted tenant is insertion torque valuesof 35 Ncm or higher portends a favorable prognosis forearly temporization and loading.

In a recent article, the author’s hypothesis was tighter is notnecessarily better and in fact may exacerbate marginal boneloss. His study was performed on 61 patients who had ex-tractions, implants immediately placed, temporary crownsfabricated, and all had insertion torques of less than or equalto 25 Ncm. The vast majority of these teeth were anterior,and I believe it is important to emphasize that the averageimplant length was more than 15 mm long with 4.5 mm aver-age diameter. Antibiotics, typically amoxicillin, were givenpreoperatively and continued for five days. Success rate andmarginal bone loss were assessed. The average insertiontorque was only 22.5 Ncm with an overall survival rate of theimplants an impressive 95.5% measured at an average of 46months. Two years postoperatively the mean marginal anddistal bone loss was a scant 0.2 mm. Relative to marginalbone loss, the age of the patient, gender, tooth position, im-plant length, nor measured insertion torque, had any statisti-cal difference. His conclusion based on this interesting studywas that the 35 Ncm insertion torque value, currently held tobe a necessary value, is too high.

While I was certainly impressed by this article, again it bearsemphasizing that the teeth were extracted, the implantsplaced, and temporized immediately at this low torque value.Most of the cases were temporized by the author, and I amsure he paid careful attention at keeping them out of occlu-sion. He also had some intraoperative techniques that I foundvery interesting. He would soak a gauze in chlorhexidine andleave it in the socket for about five minutes prior to placingthe implant, obviously with the goal of disinfecting the implantrecipient site. In addition, on selected infected cases, hewould irrigate or lavage the socket with a tetracycline slurryas advocated by many who perform immediate implants, andhe kept the implant palatal or lingual to the labial plate, aim-ing for about a 1 mm distance.

I have several additional thoughts relative to this intriguingpaper. Most people now believe that the type of integrationthat is achieved initially, while still important, may not reflectwhat is going on with the implant after several months. Muchof the initial bone implant contact is remodeled in response tothe initial trauma. I certainly get a good feeling when my im-plants torque down tight initially, but realize that if the bonesuffered serious thermal trauma during osteotomy creation,that the implant probably will not survive at six months. An-other factor that I have increasing appreciation for is that eachindividual implant design probably has a different ideal inser-tion torque. Conical implants by their design tend to tighten upas they are inserted, and if our osteotomy is perhaps under-sized, this can lead, if over tightened, to early marginal boneloss. Again, it is important to emphasize that these implantsused in this study were performed on immediate extractions,where some of us are somewhat nervous and tend to want tohave those implants torque out as high as possible.

The author also discussed whether resonance frequencyanalysis, as suggested by many, may be an even bettermeasure of when an implant should be loaded as opposed toinsertion torque. Certainly the answer to this question isbeing investigated by many skilled clinicians. Finally, to di-gress somewhat, I find it extremely interesting that when Ifirst started placing implants some 20 years ago, a case likethis would have been treated by extraction, waiting for about

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Background: Oral and maxillofacialsurgeons are often called on to graftbone before implant placement, withcurrent research always striving to doaway with autogenous sources withtheir known limitations. Tissue engi-neering holds promise, requiring theacquisition of only small quantities ofpluripotent cells.

Objective: To compare the efficacy ofgrafts engineered from 3 differentsources: periosteal cells (PC), bonemarrow stem cells (BMSC), or dentalpulp stem cells (DPSC).

Design: This animal study was per-formed with dogs.

Methods: The pulp cells were ob-tained from extracting posterior teeth.Periosteal cells were harvested fromthe mandible, and bone marrow was

obtained from the iliac crest. Thesecells were cultured, with different tech-niques, and then mixed (at a concen-tration of 1 × 107 cells /mL) withplatelet-rich plasma and used to graftdefects created in the mandible withtrephine burs. The control defect re-ceived no graft. After graft healing,dental implants were placed with corebiopsies taken at the same time.Eight weeks after implantation, theosteogenic potential of each graftwas evaluated by assessing bone-im-plant contact.

Results: The core biopsies taken fromthe control group and the PC grafts re-vealed fibrous tissue but little newbone compared to good bony regener-ation with the BMSC and DPSC grafts.These results were not quantitated orstatistically analyzed. However, thebone-implant contact was quantifiedand found to be statistically superiorwith the BMSC and DPSC grafts com-pared to the PC or the control sites.

Conclusions: “DPSC showed thehighest osteogenic potential and maybe a useful cell source for tissue-engi-neered bone around dental implants.”

Reviewer’s Comments: All thingsbeing equal, most surgeons wouldprefer to use bone grafts composed oflive autogenous cells. The morbidity ofharvesting from other sites, as well asthe finite quantity of available bone,has made the use of “bone in a bottle”products increasingly popular. Theability to obtain small quantities ofpluripotent cells, grow them outside ofthe patient’s body, and then re-implantthem has made the field of regenera-tive medicine explode over the last 10years. This study showed that it is pos-sible to use dental pulp cells as asource to grow bone in dogs. It is rea-sonable to believe it can be done inhumans, with the pulp of third molarsand the obvious donor source. This isfascinating in principle, with cost effec-tiveness a probable major hurdle.

Reviewer: J. Bruce Bavitz, DMDArticle Reviewed: Ito K, Yamada Y, et al. Osteogenic Potential of EffectiveBone Engineering Using Dental PulpStem Cells, Bone Marrow Stem Cells,and Periosteal Cells for Osseointegrationof Dental Implants. Int J Oral MaxillofacImplants 2011; 26 (November): 947-954.

Literature Reviews reviewsHow Effective Is Cell-Based Bone Engineering?

Take Home Pearl:

The pulp from teeth extractedfrom patients may be used togrow cells capable of acting asan effective tissue-engineeredbone graft.

Basic Science & Research

three or four months for osseous fill of the socket, implantplacement, then waiting approximately three to four monthsin the mandible and six months in the maxilla, and finally re-ferring the patient for their final restoration. I still tend to be alittle conservative relative to when I suggest my patients have

their implants restored, but certainly there is very good evi-dence that early temporization and function can occur muchsooner than previously thought. I would certainly encouragereaders to look at this well-done article.

Background: The pathogenesis ofbisphosphonate-associated os-teonecrosis of the jaw (BON) is cer-tainly better understood now versuseven 5 years ago. Recently, teri-paratide (Forteo; Eli Lilly and Com-pany) has shown some promise in thetreatment of this disease, giving fur-ther hints and insight into the patho-physiology of BON.

Objective: To propose a theory onwhy this disease occurs, and why teri-paratide may help.

Methods: The authors performed athorough review of the current BON literature.

Conclusions: According to this paper,there is ineffective bone remodeling inpatients suffering from BON that isthought to be the result of 3 interre-lated things: (1) suppression of os-teoblast function, typically secondaryto the patient’s underlying disease (os-teoporosis, cancer, etc); (2) suppres-sion of osteoclast function, typicallysecondary to the bisphosphonates;

Discover Why Teriparatide May Help ResolveBisphosphonate-Associated Osteonecrosis

Take Home Pearl:

Teriparatide stimulates os-teoblasts, whose improvedfunction is known to help recruitand activate osteoclasts; thisfits in well with the proposedmodel of bisphosphonate-asso-ciated osteonecrosis and ex-plains why teriparatide may beof some help.

Bone

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and (3) impaired communication, sig-naling, and recruitment between thecells responsible for physiologic boneremodeling leading to impaired func-tion. In patients suffering from this triadof pathosis, BON is ready to occur.Often, the demands placed upon themaxillofacial bones in response totrauma, such as an extraction or pres-sure from an ill-fitting prosthesis, tipthe scale in favor of breakdown andlead to necrotic and secondarily in-fected bone; BON occurs. The antian-giogenic actions of thebisphosphonates likely exacerbate thiswhole problem. Teriparatide, an os-teoanabolic drug, is known to stimu-late osteoblast function and also

recruit and activate osteoclasts. It isgiven via a once daily subcutaneousinjection for a period of up to 2 years.It may, based upon early and prelimi-nary results, tip the scale back in favorof bone healing.

Reviewer’s Comments: There are atleast 6 papers suggesting that teri-paratide may help in the treatment ofBON. Surgeons should stay alert forthe results of some well done clinicaltrials using this osteoanabolic agent,as they are sure to be published soon.As the authors point out, other antire-sorptive agents, such as denosumab,are associated with osteonecrosis,prompting some to suggest that the

term antiresorptive agent-induced os-teonecrosis of the jaw (ARONJ) ismore appropriate than BON. It will beinteresting to see if teriparatide is help-ful in treating denosumab-associatednecrosis. This whole relatively newdisease spectrum isn’t going awayanytime soon.

Reviewer: J. Bruce Bavitz, DMDArticle Reviewed: Subramanian G,Cohen HV, Quek SYP. A Model for thePathogenesis of Bisphosphonate-Asso-ciated Osteonecrosis of the Jaw andTeriparatide’s Potential Role in Its Reso-lution. Oral Surg Oral Med Oral PatholOral Radiol Endod 2011; 112 (Decem-ber): 744-753.

Background/Objective: Socketpreservation, or the grafting of freshextraction sockets, has become popu-lar over the last decade with the goalof preventing alveolar bone loss. Myri-ads of grafting products exist, eachwith advantages and disadvantages.This study investigates using the ex-tracted tooth itself as a graft source.

Design/Methods: A rat model wasused, with results evaluated both his-tologically and with 3-D micro-CTscans. The incisors were extracted,frozen, ground, or milled to a particlesize between 10 and 50 µm, mixedwith hydroxypropyl cellulose (HPC)and injected back into the fresh sock-ets. Control sites received no graft orjust the HPC alone. The animals were

scanned and sacrificed at either 2 or4 weeks.

Results: The CT scans were evalu-ated in a way to measure the regener-ating bone volume to total tissuevolume (BV/TV) ratio, as well as thebone mineral content (BMC) or den-sity. The experimental group had a sig-nificantly higher BV/TV ratio than bothcontrols at week 2, and more than theno graft control at week 4. However atweek 4, there was no statistical differ-ence in BMC, but the trend favored theexperimental group. Histologically, theexperimental group exhibited moremature and more rapid healing com-pared to either control.

Conclusions: Ground extracted toothmixed with an HPC carrier showspromise as a graft material.

Reviewer’s Comments: The idea ofgrinding up the tooth you just ex-tracted, somehow sterilizing it, then in-jecting it back into the fresh socket isappealing. No bone product derivedfrom other humans or animals isneeded, eliminating the rare, but

possible, transmission of graft-derivedinfectious diseases. This proof of prin-ciple article shows some promise.Dentin is composed of type 1 collagen,calcium, bone morphogenic proteins,and other possible growth factors; logi-cally, it should work as a grafting mate-rial. The carrier itself was chosen, inpart, because it showed some efficacyin preserving the socket, which wasverified in the results of this study.Pragmatic subplots in the humanmodel included disinfecting the donorteeth, removing any restorations or en-dodontic filling materials, and having aquick and cost-effective way of grind-ing it into the ideal particle size. Thegrinding apparatus would also have tobe sterilized between patients, but ifthese hurdles can be overcome, thisgrafting option may become viable.

Reviewer: J. Bruce Bavitz, DMDArticle Reviewed: Miyata Y, Ozawa S,et al. An Experimental Study of BoneGrafting Using Rat Milled Tooth. Int JOral Maxillofac Implants 2011; 26 (No-vember): 1210-1216.

Can Extracted Teeth Be Used as Grafts?

Take Home Pearl:

Freezing, grinding, and mixingextracted teeth with a cellulosecarrier shows some promise forbone grafting, at least in a ratmodel.

Bone

Background: Oral and maxillofacialsurgeons have a long and successful

history of providing advanced anesthe-sia to our patients. Albeit rare, compli-cations can sometimes occur.Complications involving the respiratorysystem, specifically, airway obstructionand depression in rate and depth, arethe most common culprits.

Design/Objective: This review articlediscusses strategies to prevent andtreat respiratory complications duringIV sedation.

Results: The authors stress the im-portance of obtaining a thorough med-ical history and documenting

How to Prevent & Manage Anesthetic-RelatedRespiratory Complications

Take Home Pearl:

Although rare, sedation-relatedrespiratory complications dooccur.

Complications

8

pre-sedation vital signs, including ini-tial oxygen saturations. Assessment ofthe airway should also be made. Theauthors strongly suggest recording theMallampati classification and notingany unusual potential mask seal prob-lems (eg, heavy beards or obese pa-tients with short thyromentalprojection). The proper equipment formanaging complications includesportable oxygen tanks (E cylinders)and airway adjuncts. The relativelynew supraglottic laryngeal mask air-way device is useful in the uncon-scious patient who cannot have theirairway opened with oropharyngeal air-ways, and it is preferable to endotra-cheal intubation in most scenarios. Auseful formula for estimating the re-serve in the E cylinder is 0.3 times theremaining tank volume (in pound-forceper square inch) divided by the flowrate. Oxygen should be delivered toensure the oxygen saturation is >90%,with the current thinking that its use in

the patient with chronic obstructivepulmonary disease is no longer a rela-tive contraindication. For respiratorydepression caused by drugs, the re-versal agents, naloxone and flumaze-nil, should be available. However, thepractitioner must also have the skillsto use a bag valve mask (BVM) de-vice in the hypoxic or apneic patient.This skill can, and should be, prac-ticed on the now widely available highfidelity human simulators. On rare oc-casions, laryngospasm will occur inthe deeply sedated patient. This ob-struction may result in a bucking orrocking ventilatory motion. Thoroughsuctioning with a tonsillar suction, ag-gressive opening of the airway, andBVM ventilation will often reverse theproblem. However, low-dose succinyl-choline may be needed at a sug-gested dose of 0.1 to 0.2 mg /kg.Laryngeal edema is manifested bycrowing sounds, with bronchospasmexhibiting wheezing. The former will

respond to low-dose intramuscularepinephrine (0.3 mg), with the latter re-sponding best to inhaled bronchodila-tors like albuterol. Final mention ismade for surgical airways in the “cannotventilate and cannot intubate” patient.This is extremely rare and is perhapsmost likely in a foreign body aspirationscenario. The needle cricothyrotomy isthe advised route in this situation; acommercially available kit just for thispurpose is recommended.

Reviewer’s Comments: Subscribersare encouraged to read this well-writ-ten review article by these respectedauthors. The diagnosis and manage-ment of complications are conciselysummarized.

Reviewer: J. Bruce Bavitz, DMDArticle Reviewed: Becker DF, Haas DA.Recognition and Management of Compli-cations During Moderate and Deep Se-dation Part 1: RespiratoryConsiderations. Anesth Prog 2011; 58(Summer): 82-92.

Background: Necrotizing fasciitis(NF) is rare in the head and neck area,but has dire consequences when itdoes occur.

Objective/Methods: This review arti-cle discusses contemporary knowl-edge of risk factors, microbiology,diagnostic criteria, pathophysiology,treatment, and prognosis of NF andreports on a case of NF.

Case Report: The patient is a 58-year-old African-American woman.She has a history of poorly controlledinsulin-dependent diabetes. In additionto her diabetes, she has chronic renalinsufficiency and hypertension. Shepresented to the emergency depart-ment with lower lip swelling.

Results: Certainly, compromised hostresistance is a known risk factor withthe patient in this report having poorlycontrolled insulin-dependent diabetesand chronic renal failure. What differ-entiates NF from other common head

and neck infections is the primary in-volvement of the superficial muscu-loaponeurotic system (SMAS) fascia,with much lesser involvement of thebone and muscle. Subcutaneousliquifactive necrosis and skin under-mining result, during which time thepatient is often numb. Modern microbi-ological identification indicates the in-fection is usually polymicrobial, and itis important to differentiate this dis-ease from methicillin-resistant Staphy-

lococcus aureus, which is morecommon but initially involves the skin.Aggressive surgical management re-mains the cornerstone of therapy, withdebridement of necrotic tissue andpacking of the wound; this typicallyneeds to be repeated several times.Unless cultures dictate otherwise,triple antibiotic empiric therapy is em-ployed, using a penicillinase-/methicil-linase-resistant penicillin, an agentaimed at gram-negative organismssuch as a third generationcephalosporin, as well as somethingfor anaerobes (eg, clindamycin ormetronidazole). Factors impacting theprognosis of NF of the head and neckare similar to those of other serious in-fections, with the securing of the air-way an early and critical necessarystep. Spread into the mediastinum is

associated with a poor prognosis. Thiscase report was noteworthy for a 3-week inpatient stay, with irrigation anddressing changes required the major-ity of that time. Fortunately, the out-come was positive, with no need forreconstructive surgery.

Conclusions: It is important to recog-nize necrotizing fasciitis early and topromptly provide surgical and medicaltreatment as this disease process canprogress rapidly.

Reviewer’s Comments: The man-agement of head and neck infectionsremains an important part of the oraland maxillofacial surgeon’s (OMFS)practice, and indeed can often savethe life of our patients. Fortunately, NFis quite rare; this review article nicelysummarizes contemporary thoughts.In a patient with swelling and no obvi-ous odontogenic etiology, the possibil-ity of NF should be entertained. Otherthan perhaps for gunshot wounds, theOMFS may never need to use packingand dressing changes like they do forthe effective management of this dis-ease. Mention is made of using hyper-baric oxygen therapy, but the resultsare too preliminary to recommend thisat the present time. Aggressive de-bridement of necrotic fascia and skin

Treatment of Necrotizing Fasciitis Requires Aggressive Surgical Intervention

Take Home Pearl:

In a patient with swelling andno obvious odontogenic etiol-ogy, the possibility of necrotiz-ing fasciitis should beentertained.

General

9

along with aggressive antibiotic ther-apy is often lifesaving. Soft tissue re-construction of the resulting tissuedeficits, which was not addressed in

this paper, is often needed once theinfection has resolved.

Reviewer: J. Bruce Bavitz, DMD

Article Reviewed: Weiss A, Nelson P, et al. Necrotizing Fasciitis: Review ofthe Literature and Case Report. J OralMaxillofac Surg 2011; 69 (November):2786-2794.

Background: Classically, the graftingof alveolar clefts involved harvestingbone from the ilium. Although patientsdid reasonably well afterward, and thegrafts yielded predictable results, re-searchers have looked for a way toavoid obtaining bone and viable osteo-progenitor cells from a second surgicalsite. Xenogenic, allogenic, and allo-plastic products do not transplant liveprogenitor cells, and, therefore, re-quire that the recipient site supplythem for a successful outcome.

Objective: To examine another option,harvesting stem cells, growing them invitro, and then injecting them back intothe patient along with platelet-derivedgrowth factors (PDGF).

Participants/Methods: 3 patientswere studied, one of whom had bilat-eral clefts. Preoperative CT scanswere obtained, and aspirates of the

posterior ileum were performed to ob-tain the mesenchymal stem cells.These cells were cultured in a mannerto make them osteogenic and thenwere loaded onto a hydroxyapatite/tri-calcium phosphate scaffold; the scaf-fold particle size was 0.3 to 0.5 mm.This cell/scaffold substrate was mixedwith PDGF collected and prepared inthe usual fashion, and all three materi-als were used as the only graftingagent. The cleft repair was performedusing the typical soft tissue flaps andclosure. Postoperative CT scans wereobtained at 3 months, with bone fill as-sessed by comparison of the preoper-ative and postoperative scans.

Results: The soft-tissue closure wassuccessful in all cases, with no fistulaformation. The reported defect fillwas 51%.

Conclusions: Although the 51% bonefill rate was not outstanding, this studyshows some promise of an alternativemethod to conventional grafting options.

Reviewer’s Comments: This was alabor intensive study, and the authorsshould be commended. I am con-cerned about assessing bone fill with

CT scans when hydroxyapatite is usedas a scaffold, as some of the radi-ographic density may be due to thisvery slowly resorbing substance. Incontrast, although autogenous iliaccrest grafts are invasive, there is noquestion on what is filling up the cleftwhen postoperative radiographs areobtained. The authors mention usingbone morphogenic protein as anothernew grafting option for clefts; althoughexpensive, it may be less so thanthese tissue engineering techniques.Transforming mesenchymal cells intobone forming cells and then cultivatingthem into numbers large enough toserve as a graft is a fascinatingprocess. I encourage you to read theoriginal article for details. The quest toreplace autogenous bone graft with acheap and effective product will con-tinue for some time.

Reviewer: J. Bruce Bavitz, DMDArticle Reviewed: Behnia H, KhojastehA, et al. Repair of Alveolar Cleft DefectWith Mesenchymal Stem Cells andPlatelet Derived Growth Factors: A Pre-liminary Report. J CraniomaxillofacialSurg 2012; 40 (January): 2-7.

Aspirate and Grow Cells From Iliac Crest Before Your Next Cleft Graft

Take Home Pearl:

Growing the patient’s own os-teogenic cells in vitro and usingthem to graft clefts is a viableoption.

Grafting

Background: Despite numerous clini-cal studies by Ellis and others support-ing minimal fixation for the treatmentof mandibular angle fractures, signifi-cant controversy still exists.

Objective: This article uses a detailedbiomechanical model to compare andcontrast 3 fixation methods: (1) a 4-hole tension band at the superior bor-der; (2) a 6-hole bicortical

compression plate at the inferior bor-der; and (3) a combination of platesused in schemes 1 and 2.

Methods: A finite element analysis wasused to measure complex biomechan-ics of mandibular fracture deformationusing the 3 fixation scheme. The studymeasured stress and strain relation-ships common to postoperative compli-cations with rigid internal fixation.

Results: The combination plate sys-tem provided the greatest degree offracture stabilization but the highestbone-to-screw stress. The single ten-sion band has more stability than thebicortical inferior border plate but hashigher plate stress, leading to possibleplate failure.

Conclusions: Taking into accountprevious clinical studies showing in-creased infection rates with the 2-platemethod, results from this study sug-gest that placing an additional inferiorborder plate is not worth the minimalincrease in stability gained. Biome-chanical results from this study sup-port the use of single tension bandfixation for mandibular angle fractures.

Reviewer’s Comments: The contro-versy of plating schemes for fixationof mandibular angle fractures remaindespite many articles supporting theuse of less invasive techniques.Through a complex biomechanicalanalysis of stress/strain relationshipscreated during unilateral molar masti-cation, this study supports the use of

Single-Tension Band Plate at the Superior Borderfor Treatment of Mandibular Angle Fractures

Take Home Pearl:

Single-tension band plating ofthe superior border provides aless invasive fixation approachfor fixation of mandibular anglefractures with biomechanicaladvantages.

Mandible

10

the single-tension band plating tech-nique. While this study does a goodjob explaining the biomechanics of anuncomplicated angle fracture for theCT model of a 22-year-old man with afull dentition and normal occlusion,several other complicating factors areoften encountered that should influ-ence the decision-making process forthe treatment of angle fractures. My

concern, and one that I have seen withmultiple complications related to thetreatment of mandibular angle frac-tures, is that less experienced traumasurgeons will read a study like this andtry to apply it to all angle fractures. Inmy experience, this happens all toooften and leads to complications thatmost likely could be avoided ratherthan a “one size fits all” mentality.

Many factors must be consideredwhen treating trauma patients, includ-ing facture pattern (ie, comminution),bone quality, patient compliance, abil-ity to heal, etc.

Reviewer: Rod M. Griffeth, DDSArticle Reviewed: Kimsal J, Baack B, et al. Biomechanical Analysis of Mandibu-lar Angle Fractures. J Oral MaxillofacSurg 2011; 69 (December): 3010-3014.

Background: Maxillary squamouscell carcinoma (SCC) is relatively rareand often grows undetected until itreaches a large size (eg, T3 or T4)before treatment. As classicallytaught, the higher the stage and histo-logical grade at the time of surgery,the worse the prognosis.

Objective/Participants: To evaluatethe prognosis of 93 patients treatedbetween 1992 and 2007 by evaluatingthe impact of size, therapy rendered,and grade on prognosis.

Methods: Neck dissections were per-formed only when suspicious nodeswere present. Radiation was em-ployed when clear surgical margins <5mm were obtained.

Results: The 93 patients were com-posed of 60 men and 33 women with amean age of 63 years. The overall 5-year survival rate was 71%. Neitherthe initial size of the lesion nor histo-logical grade impacted prognosis. Sur-prisingly, the less aggressive grade 1lesions trended toward a poorer prog-nosis than grade 2 and 3 lesions.

Conclusions: At least with respect toSCC of the maxillary complex, initialsize and grade should not deter ag-gressive surgery as a rational treat-ment option.

Reviewer’s Comments: SCC of themaxillary complex is rare, making stud-ies on treatment options difficult. This15-year study involving 93 patients istherefore important. New nonsurgicaloptions are always being investigated.Immunotherapy using monoclonal anti-bodies is currently in vogue. Untilgood, long-term data on such therapyare known, aggressive surgery (al-though disfiguring) remains an option.Seven of the 93 patients followed in

this study had no surgery because ofintracranial extension, poor systemichealth, or refusal, and all died second-ary to tumor-related reasons. As ex-pected, patients whose tumorsrecurred had a very poor prognosis (5-year survival rate, 40%) versus an ex-cellent prognosis for those withoutrecurrence (10-year survival rate,96%). The most important variablefound in this study that impacted prog-nosis was the obtainment of tumor-free margins. Surgeons need to notethis when planning procedures so asto be appropriately aggressive. Thesize of the initial lesion, assuming freemargins are obtainable, should not bea deterrent.

Reviewer: J. Bruce Bavitz, DMDArticle Reviewed: Poeschl PW, Russ-mueller G, et al. Staging and Grading asPrognostic Factors in Maxillary Squa-mous Cell Carcinoma. J Oral MaxillofacSurg 2011; 69 (December): 3038-3044.

Clear Surgical Margins Trump Staging, Gradingfor Prognosis of Maxillary SCC

Take Home Pearl:

Obtaining clear surgical mar-gins is the most important vari-able in the prognosis ofmaxillary squamous cell carci-noma patients.

Neoplasia

Background: Large areas of oralleukoplakia are difficult to surgicallyexcise, and the use of topical medi-cines has been disappointing.

Objective: To evaluate the effective-ness and the safety of “photodynamic

therapy in the treatment of oral leuko-plakia with 5-aminolevulinic acid (5-ALA) and pulsed dye laser.”

Design: Prospective, nonrandomized,single-arm, single-site, phase 1&2 pilotstudy.

Participants/Methods: 17 patientswith biopsy-confirmed hyperkeratosisor dysplasia were enrolled. For eachpatient, a gauze was saturated with 5-ALA and topically applied to the lesionfor 1.5 hours or had the 5-ALA injecteddirectly into the lesion. A pulse dyelaser with a 585-nm wavelength was

targeted at the lesion (8 J/cm2, 7 mmspot size, 1.5 ms pulse time). At 90days, a clinical examination for effec-tiveness was performed, and biopsiesof the lesion, as well as from a normalsite, were obtained.

Results: Following treatment with 5-ALA and photodynamic therapy, 7 pa-tients showed significant clinicalimprovement, 9 showed partial im-provement, and only 1 patient failed toimprove. The biopsy results looked atthe expression of p53 and Ki-67 mark-ers, but not enough data were obtained

New Photodynamic Laser Therapy for OralPrecancerous Lesions Shows Promise

Take Home Pearl:

Photodynamic therapy using 5-aminolevulinic acid and lasersis fast, minimally invasive, andreasonably effective for treatingoral leukoplakia.

Neoplasia

11

to make any conclusions. There wereno significant adverse effects, withonly approximately 50% of the patientsneeding local anesthesia for proce-dural pain control.

Conclusions: With the laser treat-ment time taking only minutes andwith good preliminary results, the useof 5-ALA and a laser that is set at thespecified wavelength, power, and spotsize, shows promise in treating oralleukoplakia.

Reviewer’s Comments: The 5-ALAused in this study is taken up preferen-tially by dysplastic cells as compared

to normal cells and metabolized intoprotoporphyrin IX (PPIX). The PPIXabsorbs energy at wavelengths of 585nm, for which a pulse dye laser can beset. Cells with high concentration ofPPIX produce cytotoxic free radicalswhen exposed to such laser energy,making this therapy harmful to the pre-cancerous cells but less toxic to thenormal cells of the host. Such targetedtherapy that harms the bad but leavesthe good is appealing, with the abilityto administer the drug topically or byintralesional injection conducive to le-sions found in the mouth. (Systemicadministration of photodynamic agents

often leads to photosensitivity.) Asnoted by the authors, the 1 lesion thatfailed to improve was thick, likely ne-cessitating several 5-ALA applicationsand subsequent laser sessions for ef-fective treatment. As most surgeonssee patients with leukoplakia, thistechnique could quickly become an ef-fective new tool against this difficult totreat malady.

Reviewer: J. Bruce Bavitz, DMDArticle Reviewed: Shafirstein G, Fried-man A, et al. Using 5-Aminolevulinic Acidand Pulsed Dye Laser for PhotodynamicTreatment of Oral Leukoplakia. ArchOtolaryngol Head Neck Surg 2011; 137(November): 1117-1123.

Background: The inferior alveolarnerve (IAN) is occasionally perma-nently damaged following maxillofacialsurgery. The resultant anesthesia, orworse dysesthesia, often motivatespatients to seek a surgical solution.The classic nerve repair proceduresfrequently mandate harvesting thegreater auricular or sural nerve to ob-tain a tension-free anastomosis, but,by necessity, leave the donor site withan area of anesthesia and increaseoperating room time and costs.

Objective: To evaluate the efficacy ofpolyglycolic nerve conduits as an aidin repairing the IAN.

Design/Participants: This retro-spective study involved 5 patients.Costs, assessment of pain medicinesused, and self-reported recoverywere analyzed.

Methods: The procedure was donevia an extraoral approach, with an os-teotomy made at the site of the nerveinjury. The damaged portion of the

nerve was resected, and the nerveconduit was placed over the proximaland distal ends. An 8-0 suture wasused to align the nerve ends within thetube, but a direct anastomosis was notaccomplished. Functional recoverywas determined by patients self-ratingusing a “Ten Test,” a self-reportingtouch test, where the normal side ofthe face is given a value of 10 and therepaired side is then assessed usingthe same light touch to the lip and chin.

Results: All patients stopped takingthe narcotic and neuropathic painmedications they were on prior to theprocedure. Functional improvementwas modest, with Ten Test results av-eraging 3.3.

Conclusions: For cases where directanastomosis of injured nerves is notpossible, the use of polyglycolic nerveconduits should be considered as an al-ternative to autogenous nerve grafting.

Reviewer’s Comments: Damage tothe lingual nerves and IANs is some-times permanent, prompting the needfor microsurgical repair. The IAN,being encased in a bony conduit, isgenerally regarded as having superiorself-repair capabilities, as the dam-aged ends are rigidly held in proximity.However, this same anatomic realitymakes resecting the damaged portion

and affording a tension-free reanasto-mosis problematic, except in cases ofsmall resections. Various nerve con-duits have been experimented with forat least 20 years, with the authors re-porting their experience with a bioab-sorbable polyglycolic acid form. Theextremely small number of these op-erations performed worldwide makesdesigning powerful studies challeng-ing, and this retrospective paper suf-fers from some flaws. There is noobjective pre- and postoperative as-sessment of nerve function; the pa-tient performing their own Ten Test isthe only data obtained. It should benoted, however, that 3 of the 5 pa-tients had previous nerve repair at-tempts, and the time from injury torepair using this technique averaged14 months. Improvement in pain wasimpressive, with the patient surveyyielding an average of a 50% reduc-tion in pain. Surgeons should considerthis reconstructive method whenfaced with repairing the IAN.

Reviewer: J. Bruce Bavitz, DMDArticle Reviewed: Mundinger GS, PruczRB, et al. Reconstruction of the InferiorAlveolar Nerve With BioabsorbablePolyglycolic Acid Nerve Conduits. PlastReconstr Surg 2012; 129 (January):110e-117e.

Are Sural or Greater Auricular Nerve Grafts aThing of the Past?

Take Home Pearl:

For cases of dysesthesia fol-lowing damage to the inferioralveolar nerve, bioabsorbablenerve conduits show promise atrelieving pain.

Nerve

12

Background: Facial soft-tissue vol-ume enhancement for cosmetic orpost-traumatic indications with variousfillers has become more commonplacein recent years. However, there arevarious potential side effects with pro-longed periorbital edema, with perior-bital rejuvenation being one of these.

Objective: To review the incidence,clinical features, and treatment of pro-longed edema (≥1 month) in the peri-orbital region after hyaluronic acid gelinjection in the infraorbital area.

Design/Methods: A retrospectivechart review of 4 ophthalmologicphysician practices over a 3-year pe-riod was completed, identifying pa-tients with prolonged periorbital edemaafter isolated hyaluronic acid gel ad-ministration to the infraorbital hollows.All injections were pre-periosteal via alinear threading and/or serial puncturetechnique along the length of the infra-orbital rim.

Results: 51 charts of patients treatedfor cosmetic enhancement of the lowerperiorbital region from 2008 to 2011were reviewed; 12 patients were iden-tified (24%) with prolonged periorbitaledema. Length of follow-up rangedfrom 1.5 to 15.3 months, with 3 of the12 patients being treated withhyaluronidase at 3.0 to 5.7 monthsafter their initial hyaluronic acid geltreatment. The average length of pro-longed post-injection periorbitaledema was approximately 6 months.No pretreatment clinical signs orsymptoms were noted to consistentlycorrelate with increased patient sus-ceptibility for post-injection prolongedperiorbital edema.

Conclusions: In this study, about 1 in4 individuals experienced prolongedperiorbital edema after hyaluronic acidgel injections, with no consistent pre-treatment risk factors being identified.

Reviewer’s Comments: As with anyretrospective review, this study haslimitations, and the sample size wasrelatively small. Soft-tissue fillers suchas hyaluronic acid are used fairly oftenduring facial cosmetic rejuvenationprocedures. However, potential com-plications may occur, such as bruising,color differential, under-contouring,and over-contouring; in the periorbital

region, retinal artery occlusion or pro-longed periorbital edema may exist. Inthis study, Juvederm Ultra or UltraPlus XC was used for the majority ofinjections. With 1 in 4 patients experi-encing prolonged periorbital edema, itis certainly important to discuss thisnot uncommon complication with pa-tients preoperatively. In addition, itwould be beneficial if pre-treatment his-tory and clinical exam could help iden-tify potentially higher-risk patients.However, despite looking at a history oflower eyelid of midface procedures,seasonal allergies, history of fluid reten-tion, or festooning on clinical exam, thisstudy was inconclusive in identifyingconsistent pre-treatment risk factors.The valuable note I found in this articlewas that 2 of 12 patients with pro-longed periorbital edema did undergosubsequent re-treatment with an infra-orbital filler. They were premedicatedwith 30 mg of prednisone for 3 daysand had no subsequent issues withprolonged periorbital edema during re-treatment, despite comparable mate-rial, dosing, and injection techniques.

Reviewer: Melanie S. Lang, DDSArticle Reviewed: Griepentrog GJ, Lu-carelli MJ, et al. Periorbital Edema Fol-lowing Hyaluronic Acid Gel Injection: A Retrospective Review. Am J CosmeticSurg 2011; 28 (4): 251-254.

Consider Prednisone Premedication forHyaluronic Acid Injection

Take Home Pearl:

One in four individuals experi-ence prolonged periorbitaledema after hyaluronic acid gelinjections, with no consistentpre-treatment risk factors beingidentified.

Other

To receive credit for this activity, answer the practicequiz questions below, read the content, and complete theonline post activity quiz at www.practicalreviews.com.Log in using your email address and password, click ontake a quiz and enter the e-quiz code located below.

E-quiz code: 31694N

1. Demineralized freeze-dried bone (DFDB) grafts costonly about one fourth of the cost of iliac crest grafts;however, at 5 years, implant survival using theDFDB graft is statistically much lower.

Practice: T F Answer Submitted: T F

2. Surprisingly, sockets grafted with the milledtooth/hydroxypropyl cellulose carrier show delayedhealing relative to controls.


3. Bone grafts using cells derived from the pulp are nobetter at improving the bone implant contact valuescompared to the no graft control sites.


4. Using plating for the treatment of mandibular sym-physis fractures instead of lag screw fixation has sig-nificantly better occlusal and osseous results.


5. Using a single-tension band superior border plate forfixation of mandibular angle fractures creates sig-nificantly less stability than the two plate model.


6. According to a recent study, approximately one in fourindividuals undergoing hyaluronic acid gel injectionsexperience prolonged periorbital edema, with no con-sistent pre-treatment risk factors being identified.


7. Patients with oral piercings should be informed ofthe importance of regular dental visits for early de-tection of local complications.


8. Intensive care unit admissions are more common inchildren aged 0 to 5 years with a facial fracture thanin older children with similar injuries.


9. Cryoanalgesia of the TMJ results in a predictable return of pain symptoms at 12 months.


10. Using a low torque technique of 22.5 Ncm, the average marginal bone loss measure at 2 years is approximately 0.2 mm.


11. Hyperbaric oxygen therapy is now the standard ofcare in the management of necrotizing fasciitis of thehead and neck area.


12. Denosumab is a new agent that stimulates osteoblast function.


13. Obtaining clear surgical margins is the most impor-tant variable that affects the prognosis of patientswith maxillary squamous cell carcinoma.


14. For laryngospasms recalcitrant to bag valve mouthventilation, succinylcholine at a dose of 1 to 2 mg/kgis recommended.


15. Due to the poor bone fill rate, using a patient’s stemcells with a scaffold and platelet-derived growth fac-tors for bone grafting does not seem to be an alter-native to conventional bone grafting methods.


16. For cases where direct anastomosis of injured nervesis not possible, the use of polyglycolic nerve conduitsshould not be considered as an alternative to auto-genous nerve grafting.


17. 5-Aminolevulinic acid is converted into protopor-phyrin IX by dysplastic cells, making such cells pref-erentially absorb 585-nm laser light.


13

Oral & Maxillofacial Surgery quiz Vol. 28 No. 2

™

presents

in


1. T Minor neurosensory disturbances are commonwith both chin and ramus bone donor sites.

2. T The removal of impacted mandibular third molars improves the periodontal condition ofthe second molar.

3. F In a military environment, the posteriormandible is most often fractured due to blasttrauma exposure.

4. T Marked improvement in symptoms can followopen reduction of the temporomandibular jointwith replacement of the disk in its normal position using Mitek mini anchors.

5. T Aerosolized intraoral or buccal midazolam is effective for pediatric sedation.

6. F A Le Fort I maxillary osteotomy results in a decrease in alar width of about 3 mm.

7. T Postoperative pain after the removal of a thirdmolar can be predicted by simple preoperativetesting of pain sensitivity.

8. T Mandibles <10 mm in height may fracture inimplant sites.

9. T About 73% of medical students report that theyhave never received instruction in examinationof the oral cavity.

10. T The length of the upper airway after maxillo-mandibular advancement can be accuratelymeasured using a lateral cephalometric x-ray.

11. F Both the lip advancement and lip lift proce-dures can help restore a senile upper lip to amore natural and youthful appearance, thoughthe results are not stable over the long term.

12. F Childhood tracheotomy has no effect on facialgrowth patterns.

13. F Recombinant activated factor VII has no effecton clopidogrel-induced bleeding.

14. T Salvage rates for maxillary squamous carcinomawith neck involvement are low.

15. T Use of zoledronic acid in adjuvant managementof breast cancer does not improve survival ordisease-free rates.

16. T Utilizing microdialysis for monitoring, approx-imately 16% of microvascular free-flap recon-structions are returned to the operating roomfor re-establishment of a blood supply.

17. F Administration of intramuscular nervegrowth factor leads to marked increases inmyelinated axonal density of the inferior alve-olar nerve after only a single week of distrac-tion osteogenesis.

18. T Virtual planning for fibular reconstructions allows superimposition of the digital fibula overthe intended ablative mandibular site to enhance fit and contour of the graft.

19. T The most frequently encountered tumor of infancy is the hemangioma, with a 73% femalepredilection.

20. T Up to 12% of patients taking warfarin for anti-coagulation to prevent thromboembolic eventsassociated with cardiac valve replacement arenot within the prescribed international nor-malized ratio therapeutic range.

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