Safety and Systemic Exposure of Triamcinolone Acetonide Following Ultrasound-Guided Intra-Articular Injection of Triamcinolone Extended-Release or Standard Triamcinolone Acetonide in Patients with Shoulder Osteoarthritis: An Open-Label, Randomized Study

BACKGROUND AND OBJECTIVES

Osteoarthritis (OA) is a major public health burden. While knee and hip joints are most commonly affected, the glenohumoral (shoulder) joint is also frequently involved. We evaluated the pharmacokinetics and safety/tolerability of triamcinolone acetonide extended-release (TA-ER) and triamcinolone acetonide crystalline suspension (TAcs) in patients with shoulder OA.

METHODS

In this phase 2, randomized, open-label, single-dose study (NCT03382262), adults with moderately-to-severely symptomatic shoulder OA for ≥ 6 months randomly received a single ultrasound-guided intra-articular (IA) injection of TA-ER 32 mg or TAcs 40 mg. Safety was evaluated throughout 12 weeks post-injection; blood samples for pharmacokinetic evaluations were collected pre-injection and through Day 85 post-injection.

RESULTS

Among 25 randomized patients, 12 received TA-ER and 13 received TAcs. Most patients were female (60%), and all had moderate (72%) or severe (28%) shoulder OA. Adverse events (AEs) were reported by four (33%) patients following TA-ER and three (23%) following TAcs injection. No AE was serious or led to study discontinuation. Systemic exposure following TAcs was approximately 1.5-fold higher than that following TA-ER injection (geometric mean [GM] AUC0-last 873,543 vs 557,602 h × pg/mL). GM Cmax was also higher in TAcs- than TA-ER-treated patients (2034 vs 1283 pg/mL). Bioequivalence testing confirmed lower systemic TA exposure following TA-ER than TAcs IA injection.

CONCLUSION

These pharmacokinetic data confirm protracted release of TA from TA-ER following IA injection in patients with shoulder OA. Lower peak and systemic TA exposure following TA-ER suggests TA-ER could potentially confer an improved systemic safety profile over TAcs.

TRIAL REGISTRATION NUMBER

NCT03382262 (December 22, 2017 retrospectively registered).

P–612 Transdermal testosterone vs. Placebo (lubricant gel) pre-treatment in improving IVF outcomes in diminished ovarian reserve patients (POSEIDON group 3 and 4): a randomised controlled trial

Study question

To compare the efficacy of transdermal testosterone with placebo (lubricant gel) in improving IVF outcomes using GnRH antagonist protocol in POSEIDON group 3 and 4 patients.

Summary answer

Patients receiving pre-treatment with testosterone gel had higher mean number of oocytes retrieved and grade A embryos as compared to the patients receiving lubricant gel.

What is known already

Diminished ovarian reserve (DOR) is associated with suboptimal ovarian response, higher cycle cancellation rate and lower clinical pregnancy rate following IVF cycles. Various treatment regimens have been devised for management of such patients and use of adjuvants in the form of oral or transdermal androgen is one of them. Androgens improves follicular response to gonadotropin stimulation as well as increase FSH receptor expression in granulosa cells, in turn leading to better oocyte yield and pregnancy rate. Aim was to compare the effect of transdermal testosterone gel with placebo gel on ART outcome in DOR patients (POSEIDON Group 3 and 4).

Study design, size, duration

A prospective, randomised controlled trial was carried out from 1st September 2019 to 31st October 2020 at a tertiary infertility centre in India. 50 patients fulfilling the criteria of Group 3 and Group 4 of POSEIDON classification were included in the study. Patients with endocrine disorders (thyroid, prolactin), endometrioma, history of surgery on the ovaries, sensitivity to testosterone gel, male factor infertility and deranged liver and renal function tests were excluded.

Participants/materials, setting, methods

Enrolled patients were randomised into two groups of 25 patients each, one group was pretreated (TTG group) with transdermal testosterone gel, 12.5 mg/day from day 6th of previous cycle to day 2nd of stimulation cycle while patients in other group took lubricant gel for the same duration before stimulation with GnRH antagonist fixed protocol followed by fresh Day 3 transfer.

Main results and the role of chance

The baseline characteristics of the two groups were comparable. The primary outcome measures were the number of oocytes retrieved and number of grade A embryos formed (according to Istanbul consensus). The secondary outcome measures were implantation rate, clinical pregnancy rate, miscarriage rate and ongoing pregnancy rate. The mean number of oocytes retrieved in TTG group was 5±1.02 which was significantly higher than placebo group–3.5±1.2, (p < 0.001). The mean number of Grade A embryos were also significantly higher (4.78±0.54 vs 3.00±0.23, p < 0.001) in TTG group. The TTG group had higher implantation rate (28% vs 20%, p = 0.49), clinical pregnancy rate (32% vs 18%, p = 0.41), ongoing pregnancy rate (32% vs 16%, p = 0.38) and lower miscarriage rate (0% vs 20%, p = 0.38), however, these differences were not statistically significant.

Limitations, reasons for caution

The study was done at a single centre with small sample size, replication with more subjects and in different centers is needed.

Wider implications of the findings: Pre-treatment with testosterone gel in DOR patients improves ovarian response to stimulation and results in higher number of oocytes retrieved and good quality embryos resulting in improved clinical pregnancy rates. Transdermal testosterone is advantageous because of better bioavailability, easy application, patient friendly and less adverse effects.

Trial registration number

MCDH/2019/54

Efficacy and Safety of Tedizolid and Linezolid for the Treatment of Acute Bacterial Skin and Skin Structure Infections in Injection Drug Users: Analysis of Two Clinical Trials

INTRODUCTION

Injection drug users (IDUs) often develop acute bacterial skin and skin structure infections (ABSSSI) and use emergency departments as their primary source for medical care.

METHODS

A post hoc subgroup analysis of two randomized trials examined the efficacy and safety of tedizolid in the treatment of ABSSSI in IDUs. IDUs (n = 389) were identified from two pooled phase 3 trials (NCT01170221, NCT01421511) in patients with ABSSSI (n = 1333). Patients were randomly assigned to tedizolid phosphate (200 mg once daily, 6 days) or linezolid (600 mg twice daily, 10 days). Primary endpoint was ≥ 20% reduction in lesion area from baseline at 48 -72 h. Secondary endpoints included investigator-assessed clinical and microbiological response at the post-therapy evaluation (PTE).

RESULTS

Wound infection was more common in IDUs (52.2%), while cellulitis/erysipelas was more common in non-IDUs (55.9%). Most infections were due to Staphylococcus aureus (IDUs, 75.2%; non-IDUs, 85.6%), while oral pathogens were more prevalent in IDUs. Early clinical success rates for tedizolid and linezolid were 82.5% and 79.6% in IDUs and 81.3% and 79.3% for non-IDUs, respectively; responses at PTE were similar. Microbiological response per pathogen was similar between treatment groups. Rates of treatment-emergent adverse events (AEs) in IDUs were comparable between tedizolid (46.2%) and linezolid (47.8%) arms, while lower incidence of gastrointestinal AEs was observed with tedizolid (20.3%) than with linezolid (25.1%).

CONCLUSION

Efficacy and safety of tedizolid and linezolid in the treatment of ABSSSI was similar in IDUs and non-IDUs, supporting the use of oxazolidinones in treating ABSSSIs in IDUs.

FUNDING

Merck & Co., Inc., Kenilworth, NJ, USA.

Volumetric changes of the upper airway following maxillary and mandibular advancement using cone beam computed tomography

The objective of this project was to retrospectively evaluate changes in volume of different compartments of the upper airway in response to maxillary, mandibular, and bimaxillary advancement surgeries and to predict the extent of volumetric changes associated with these surgical movements. Pre- and post-surgical cone beam computed tomography scans of 36 patients were evaluated for changes in nasal cavity, nasopharyngeal, oropharyngeal, and hypopharyngeal compartments. The amount of movement for each surgery was measured from skeletal landmarks to reference planes and was correlated with volumetric changes. Maxillary advancement of 4.0±2.2mm increased the oropharyngeal volume significantly (41.40%), and mandibular advancement of 3.8±1.6mm also significantly increased the oropharyngeal volume (21.17%). Bimaxillary advancement of 5.1±1.3mm for the maxilla and 6.4±3.1mm for the mandible significantly increased nasopharyngeal (27.45%), oropharyngeal (66.39%), and hypopharyngeal (52.48%) volumes. Furthermore, for every millimeter anterior movement, oropharyngeal volume increased by 2319.2±771.8mm³. Bimaxillary advancement showed a greater increase than isolated maxillary and mandibular advancement in all pharyngeal compartments. Every millimeter of advancement in the bimaxillary group led to a significant increase in oropharyngeal volume, while every millimeter downward movement showed a significant increase in nasopharyngeal volume.

Rice and chickpea GDPDs are preferentially influenced by low phosphate and CaGDPD1 encodes an active glycerophosphodiester phosphodiesterase enzyme

Rice and chickpea GDPD s are transcriptionally influenced by mineral deficiencies; especially, by phosphate starvation and CaGDP1 encodes an active glycerophosphodiester phosphodiesterase enzyme. Glycerophosphodiester phosphodiesterases (GDPDs) are enzymes involved in the degradation of glycerophosphodiesters into sn-glycerol-3-phosphate and corresponding alcohols. These phospholipid remodeling genes have been suggested to play important roles in phosphate homeostasis. However, comprehensive information about the role of GDPDs under low phosphate (P) and other nutrient deficiencies (N, K, Fe, Zn) in rice and chickpea is missing. Here, we identified 13 OsGDPDs and 6 CaGDPDs in rice and chickpea, respectively, and partly characterized their roles in multiple nutrient stresses. Expression profiling after 7 and 15 days of deficiency treatments revealed unique and overlapping differential expression patterns of OsGDPDs and CaGDPDs under different nutrient stresses. Principal component analysis on the expression patterns of OsGDPDs and CaGDPDs revealed their preferential role in P starvation. Some of the GDPDs were also induced by N, K, Fe and Zn deficiency in temporal manner in both crops suggesting their roles in multiple nutrient stresses. Biochemical characterization of highly responsive chickpea GDPD, CaGDPD1, confirmed its in vitro GDPD activity and revealed its optimal temperature, pH and cofactor requirements. Further, CaGDPD1 showed its accumulation in ER and endomembranes. We hereby propose CaGDPD1 and various OsGDPDs as low P responsive marker genes in chickpea and rice, respectively. Our data uphold role of GDPDs in multinutrient responses and suggest them as candidates for rice and chickpea improvement for tolerance to various nutrient deficiencies.

A randomized, double-blind, Phase 2 study to evaluate subjective and objective outcomes in patients with acute bacterial skin and skin structure infections treated with delafloxacin, linezolid or vancomycin

Objectives

Delafloxacin is an investigational anionic fluoroquinolone being developed to treat infections caused by Gram-positive and -negative organisms. This clinical trial evaluated the efficacy and safety of delafloxacin in the treatment of acute bacterial skin and skin structure infections (ABSSSIs).

Methods

In a double-blind, Phase 2 trial, 256 patients were randomized (1 : 1 : 1) to 300 mg of delafloxacin, 600 mg of linezolid or 15 mg/kg vancomycin (actual body weight), each administered intravenously twice daily for 5–14 days. Randomization was stratified by infection category. The primary endpoint was the investigator's assessment of cure, defined as complete resolution of baseline signs and symptoms at follow-up. Secondary endpoints included reductions in the total areas of erythema and induration and assessments of bacterial eradication. This trial has been registered at ClinicalTrials.gov under registration number NCT01283581.

Results

Cure rates were significantly greater with delafloxacin versus vancomycin (mean difference: −16.3%; 95% CI, −30.3% to −2.3%; P = 0.031); differences were significant for obese patients (BMI ≥30 kg/m²; mean difference: −30.0%; 95% CI, −50.7% to −9.3%; P = 0.009), but not for non-obese patients. Cure rates with delafloxacin and linezolid were similar. Using digital measurement, the percentage decrease in total erythema area was significantly greater with delafloxacin versus vancomycin at follow-up (−96.4% versus −84.5%; P = 0.028). There were no differences in bacterial eradication among the treatment groups. The most frequently reported treatment-emergent adverse events were nausea, diarrhoea and vomiting.

Conclusions

These data show that delafloxacin is effective in the treatment of ABSSSIs and is well tolerated.

Single-dose oritavancin in the treatment of acute bacterial skin infections

BACKGROUND

Oritavancin is a lipoglycopeptide with bactericidal activity against gram-positive bacteria. Its concentration-dependent activity and prolonged half-life allow for single-dose treatment.

METHODS

We conducted a randomized, double-blind trial in which adults with acute bacterial skin and skin-structure infections received either a single intravenous dose of 1200 mg of oritavancin or a regimen of intravenous vancomycin twice daily for 7 to 10 days. Three efficacy end points were tested for noninferiority. The primary composite end point was defined as cessation of spreading or reduction in lesion size, absence of fever, and no need for administration of a rescue antibiotic 48 to 72 hours after administration of oritavancin. Secondary end points were clinical cure 7 to 14 days after the end of treatment, as determined by a study investigator, and a reduction in lesion size of 20% or more 48 to 72 hours after administration of oritavancin.

RESULTS

The modified intention-to-treat population comprised 475 patients who received oritavancin and 479 patients who received vancomycin. All three efficacy end points met the prespecified noninferiority margin of 10 percentage points for oritavancin versus vancomycin: primary end point, 82.3% versus 78.9% (95% confidence interval [CI] for the difference, -1.6 to 8.4 percentage points); investigator-assessed clinical cure, 79.6% versus 80.0% (95% CI for the difference, -5.5 to 4.7 percentage points); and proportion of patients with a reduction in lesion area of 20% or more, 86.9% versus 82.9% (95% CI for the difference, -0.5 to 8.6 percentage points). Efficacy outcomes measured according to type of pathogen, including methicillin-resistant Staphylococcus aureus, were similar in the two treatment groups. The overall frequency of adverse events was also similar, although nausea was more common among those treated with oritavancin.

CONCLUSIONS

A single dose of oritavancin was noninferior to twice-daily vancomycin administered for 7 to 10 days for the treatment of acute bacterial skin and skin-structure infections caused by gram-positive pathogens. (Funded by the Medicines Company; SOLO I ClinicalTrials.gov number, NCT01252719.).

IDX184 in combination with pegylated interferon-α2a and ribavirin for 2 weeks in treatment-naive patients with chronic hepatitis C

BACKGROUND

IDX184 is a liver-targeted nucleotide prodrug that selectively inhibits HCV NS5B polymerase.

METHODS

This randomized, double-blind, placebo-controlled, ascending-dose study investigated the antiviral activity, safety and pharmacokinetics of IDX184 plus pegylated interferon-α2a and ribavirin (P/R) in treatment-naive patients with genotype-1 HCV. A total of 81 patients with baseline HCV RNA≥5 log10 IU/ml, alanine aminotransferase ≤3× upper limit of normal and compensated liver disease were dosed. Sequential cohorts of 20 patients, randomized 16:4 (active:placebo), received IDX184 for 14 days at rising daily doses of 50, 100, 150 or 200 mg in combination with P/R for 14 days.

RESULTS

At the end of triple dosing, HCV RNA changes from baseline (mean ±sd log10) and proportion of patients achieving undetectable viral load (<15 IU/ml) based on the efficacy-evaluable population were -2.7 ±1.3 (13%), -4.0 ±1.7 (50%), -4.2 ±1.9 (50%), -4.1 ±1.2 (40%), -4.3 ±1.5 (29%) and -3.7 ±1.2 (25%) for the 50 mg once daily, 50 mg twice daily, 100 mg once daily, 150 mg once daily, 100 mg twice daily and 200 mg once daily IDX184 doses, respectively. P/R alone resulted in a reduction of -1.5 ±1.3 log10 with only 6% of patients with undetectable viral load. Patients with genotypes-1a or -1b responded similarly. No viral breakthrough or resistance associated with IDX184 was observed. Anti-HCV activity of IDX184 correlated with plasma exposure of its nucleoside metabolite 2'-methylguanosine. Most adverse events were mild or moderate in severity and were consistent with those associated with P/R. The most common adverse events were fatigue and headache.

CONCLUSIONS

IDX184 in combination with P/R for 14 days was well tolerated and demonstrated greater antiviral activity with more patients achieving undetectable viral load than P/R.

Tedizolid phosphate vs linezolid for treatment of acute bacterial skin and skin structure infections: the ESTABLISH-1 randomized trial

IMPORTANCE

Acute bacterial skin and skin structure infections (ABSSSIs), including cellulitis or erysipelas, major cutaneous abscesses, and wound infections, can be life-threatening and may require surgery and hospitalization. Increasingly, ABSSSIs are associated with drug-resistant pathogens, and many antimicrobial agents have adverse effects restricting their use. Tedizolid phosphate is a novel oxazolidinone in development for the treatment of ABSSSIs.

OBJECTIVES

To establish the noninferiority of tedizolid phosphate vs linezolid in treating ABSSSIs and compare the safety of the 2 agents.

DESIGN, SETTING, AND PATIENTS

The Efficacy and Safety of 6-day Oral Tedizolid in Acute Bacterial Skin and Skin Structure Infections vs 10-day Oral Linezolid Therapy (ESTABLISH-1) was a phase 3, randomized, double-blind, noninferiority trial that was conducted from August 2010 through September 2011 at 81 study centers in North America, Latin America, and Europe. The intent-to-treat analysis set consisted of data from 667 adults aged 18 years or older with ABSSSIs treated with tedizolid phosphate (n = 332) or linezolid (n = 335).

INTERVENTIONS

A 200 mg once daily dose of oral tedizolid phosphate for 6 days or 600 mg of oral linezolid every 12 hours for 10 days.

MAIN OUTCOME MEASURES

The primary efficacy outcome was early clinical response at the 48- to 72-hour assessment (no increase in lesion surface area from baseline and oral temperature of ≤37.6°C, confirmed by a second temperature measurement within 24 hours). A 10% noninferiority margin was predefined.

RESULTS

In the intent-to-treat analysis set, the early clinical treatment response rates were 79.5% (95% CI, 74.8% to 83.7%) of 332 patients in the tedizolid phosphate group and 79.4% (95% CI, 74.7% to 83.6%) of 335 patients in the linezolid group (a treatment difference of 0.1% [95% CI, -6.1% to 6.2%]). The sustained clinical treatment response rates at the end of treatment (day 11) were 69.3% (95% CI, 64.0% to 74.2%) in the tedizolid phosphate group and 71.9% (95% CI, 66.8% to 76.7%) in the linezolid group (a treatment difference of -2.6% [95% CI, -9.6% to 4.2%]). Results of investigator-assessed clinical treatment success rates at a posttherapy evaluation visit (1-2 weeks after the end-of-treatment visit) were 85.5% (95% CI, 81.3% to 89.1%) in the tedizolid phosphate group and 86.0% (95% CI, 81.8% to 89.5%) in the linezolid group (a treatment difference of -0.5% [95% CI, -5.8% to 4.9%), and were similar for 178 patients with methicillin-resistant Staphylococcus aureus isolated from the primary lesion.

CONCLUSIONS AND RELEVANCE

Tedizolid phosphate was a statistically noninferior treatment to linezolid in early clinical response at 48 to 72 hours after initiating therapy for an ABSSSI. Tedizolid phosphate may be a reasonable alternative to linezolid for treating ABSSSI.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01170221.

Phase 2, randomized, double-blind, dose-ranging study evaluating the safety, tolerability, population pharmacokinetics, and efficacy of oral torezolid phosphate in patients with complicated skin and skin structure infections

Torezolid (TR-700) is the active moiety of the prodrug torezolid phosphate ([TP] TR-701), a second-generation oxazolidinone with 4- to 16-fold greater potency than linezolid against Gram-positive species including methicillin-resistant Staphylococcus aureus (MRSA). A double-blind phase 2 study evaluated three levels (200, 300, or 400 mg) of oral, once-daily TP over 5 to 7 days for complicated skin and skin structure infections (cSSSI). Patients 18 to 75 years old with cSSSI caused by suspected or confirmed Gram-positive pathogens were randomized 1:1:1. Of 188 treated patients, 76.6% had abscesses, 17.6% had extensive cellulitis, and 5.9% had wound infections. S. aureus, the most common pathogen, was isolated in 90.3% of patients (139/154) with a baseline pathogen; 80.6% were MRSA. Cure rates in clinically evaluable patients were 98.2% at 200 mg, 94.4% at 300 mg, and 94.4% at 400 mg. Cure rates were consistent across diagnoses, regardless of lesion size or the presence of systemic signs of infection. Clinical cure rates in patients with S. aureus isolated at baseline were 96.6% overall and 96.8% for MRSA. TP was safe and well tolerated at all dose levels. No patients discontinued treatment due to an adverse event. Three-stage hierarchical population pharmacokinetic modeling yielded a geometric mean clearance of 8.28 liters/h (between-patient variability, 32.3%), a volume of the central compartment of 71.4 liters (24.0%), and a volume of the peripheral compartment of 27.9 liters (35.7%). Results of this study show a high degree of efficacy at all three dose levels without significant differences in the safety profile and support the continued evaluation of TP for the treatment of cSSSI in phase 3 trials.

Ameloblastic carcinoma of the mandible with metastasis to the skull and lung: advanced imaging appearance including computed tomography, magnetic resonance imaging and positron emission tomography computed tomography

Ameloblastic carcinoma is a very rare malignant odontogenic tumour with characteristic histopathological and clinical features, which requires aggressive surgical treatment and surveillance and, therefore, differs from ameloblastoma. Metastasis typically occurs in the lung. Only one patient with metastasis to the skull has previously been described and no prior case reports have presented MRI and positron emission tomography-CT (PET-CT) imaging findings. We describe a case of ameloblastic carcinoma with metastasis to the skull and lung with emphasis on imaging features including MRI and PET-CT.

Changes in quality of life after surgical removal of impacted mandibular third molar teeth

BACKGROUND

The decision to get impacted teeth removed is not straightforward because of the concerns about its possible outcome. Assessment of quality of life is now regarded as an essential component for assessing outcomes of dental health care. The purpose of this paper is to assess the effect of impacted third molar teeth surgery on a number of health related outcomes.

PATIENTS AND METHODS

A total of 72 patients undergoing surgical removal of their unilateral impacted mandibular third molar teeth were recruited to participate in this study. Patients were asked to complete two questionnaires, 14-item Oral Health Impact Profile (OHIP-14) and the 16-item UK Oral Health related Quality of Life measure questionnaire (OHQOLUK-16) daily for one week following surgery.

RESULTS

There was significant decrease in the mean OHQOLUK-16 score and OHIP-14 scores for the first five postoperative days. There were no significant differences in changes in the mean OHIP-14 scores or OHQOLUK-16 scores on postoperative day 6 and 7.

CONCLUSION

There was a significant deterioration in oral health related quality of life in the immediate postoperative period, which slowly returned to preoperative level by day 6. This information may be useful in creating realistic expectation for patients who are considering third molar surgery.

Effect of leukotriene modifier drugs on the safety of oral aspirin challenges

BACKGROUND

Aspirin-exacerbated respiratory disease can be diagnosed with oral aspirin challenges and treated with aspirin desensitization.

OBJECTIVE

To evaluate whether controller medications, particularly leukotriene modifier drugs, taken during oral aspirin challenges can reduce the risk of severe asthmatic responses.

METHODS

The medical records of 676 patients who had undergone oral aspirin challenges, followed by aspirin desensitization, were reviewed. Asthmatic responses were stratified based on severity of bronchospastic response or lack of response. The effect of pretreatment with controller medications on the outcome of oral aspirin challenges was measured.

RESULTS

Leukotriene modifier drugs had the most significant effect in protecting the lower airways from severe reactions (P = .004). The protective effect of leukotriene modifier drugs was observed in patients already taking systemic corticosteroids, where the addition of leukotriene modifier drugs significantly shifted the response toward a milder asthmatic response (P < .001).

CONCLUSION

Protection from significant aspirin-induced bronchospasm during oral aspirin challenge can be accomplished with leukotriene modifier drugs. The use of a combination of inhaled corticosteroids, long-acting beta-agonists, systemic corticosteroids, and leukotriene modifier drugs stabilized underlying airways in preparation for a reasonably safe and accurate oral aspirin challenge. However, only pretreatment with leukotriene modifier drugs enhanced the safety of oral aspirin challenge in patients with aspirin-exacerbated respiratory disease by significantly decreasing the degree of asthmatic responses. Therefore, outpatient oral aspirin challenges in most well-selected patients appear to be a reasonable decision.

Surgical management of obstructive sleep apnea

Obstructive sleep apnea (OSA) syndrome is a common disorder that has recently received much attention by the medical community due to its potentially serious physiological consequences. The clinical significance of OSA results from hypoxemia and sleep fragmentation caused by collapse of the airway, which leads to apnea or hypopnea during sleep. This paper reviews common surgical techniques used for clinical management of OSA patients, with emphasis on jaw advancement surgical procedures.

Stability of maxillary advancement using rigid fixation and porous-block hydroxyapatite grafting: cleft palate versus non-cleft patients

This study was undertaken to evaluate the stability of maxillary advancement using bone plates for skeletal stabilization and porous block hydroxyapatite (PBHA) as a bone graft substitute for interpositional grafting in cleft and non-cleft patients. The records of 74 patients (41 females, 33 males) who underwent Le Fort I maxillary advancement using rigid fixation and PBHA interpositional grafting were evaluated retrospectively. All patients also underwent simultaneous sagittal split mandibular ramus osteotomies. Patients were divided into 2 groups for study purposes: group 1 consisted of 17 cleft palate patients and group 2 consisted of 57 non-cleft patients. Each group was further subdivided into 2 subgroups based on the concurrent vertical positioning of the maxillary incisors: groups 1a and 2a, where the maxilla underwent 3 mm or more of inferior repositioning, and groups 1b and 2b, where the maxilla underwent minimal vertical change (< or = 1 mm). Presurgery, immediate postsurgery, and longest follow-up lateral cephalometric tracings were superimposed and analyzed to calculate surgical change and long-term stability of results by assessing horizontal and vertical changes at point A, incisor superius, and the mesial cusp tip of maxillary first molar. The average follow-up time in group 1 was 37.9 months (range 12 to 136) and in group 2 was 28.77 months (range 17 to 88). Average maxillary advancement at point A was: group 1a, 5.4 mm; group 1b, 5.25 mm; group 2a, 5.48 mm; group 2b, 5.46 mm. Average relapse at point A was: group 1a, -0.75 mm; group 1b, -1 mm; group 2a, -0.47 mm; group 2b, -0.48 mm. Average horizontal and/or vertical relapse at the central incisors and first molars was 1 mm or less in group 1 and less than 0.5 mm in group 2. Although there was a slightly greater relapse in group 1, no statistically significant difference was observed between the groups. Maxillary advancement with Le Fort 1 osteotomies using rigid fixation and interpositional PBHA grafting during bimaxillary surgery is a stable procedure with good predictability in cleft and non-cleft patients, regardless of the direction of vertical maxillary movement.

The Mitek mini anchor for TMJ disc repositioning: surgical technique and results

This study evaluated our treatment outcomes in 105 patients (188 discs) using the Mitek mini anchor for temporomandibular joint (TMJ) articular disc repositioning surgery, with 88 patients having simultaneous orthognathic surgery. Criteria for inclusion into the study were: (1) Presurgical TMJ disc displacement with salvageable disc; (2) No prior TMJ surgery; (3) TMJ disc repositioning with the Mitek mini anchor; (4) Absence of connective tissue/autoimmune disease; (5) Absence of postsurgical trauma; and (6) Minimum of 12 months postsurgery follow up. Presurgery (T1), immediately postsurgery (T2), and longest follow up (LFU) clinical and radiographic evaluations were performed. The mean age of the patients was 32.6 years (range 14-57 years), and mean follow-up time was 46.2 months (range 14-84 months). Radiographic evaluation at LFU demonstrated no significant condylar resorption or positional changes of the anchors. At LFU, there was a statistically significant reduction in: TMJ pain, facial pain, headaches, TMJ noises and disability, and improvement in jaw function and diet. Maximum incisal opening improved slightly and lateral excursive movements decreased slightly. The Mitek mini anchor provides a predictable method for stabilizing the TMJ articular disc to the condyle and a high success rate in decreasing TMJ dysfunction and pain in patients with no previous TMJ surgery.

Mitek anchors for treatment of chronic mandibular dislocation

OBJECTIVE

The purpose of this study was to present a new technique for limiting mandibular translation in patients with chronic mandibular dislocation. TECHNIQUE DESIGN: This relatively simple procedure uses 2 Mitek mini bone anchors with osseointegration potential. One anchor is placed in the lateral pole of the condyle, and the other is placed in the posterior root of the zygomatic arch. Heavy suture material is threaded through the eyelet of each anchor and tightened to function as a restraining ligament.

RESULTS

This technique has been used on 5 patients with a follow-up of 2 to 4 years, with no failures.

CONCLUSIONS

This technique provides an effective method for the prevention of condylar dislocation while permitting some controlled translation.

Complications of the mandibular sagittal split ramus osteotomy associated with the presence or absence of third molars

PURPOSE

This study compared the number of unfavorable fractures after sagittal split osteotomies (SSOs) of the mandible when third molars were present or absent.

PATIENTS AND METHODS

The treatment records of 262 patients (500 SSOs) were retrospectively evaluated. Group 1 consisted of 250 SSOs and concomitant removal of impacted mandibular third molars and group 2 consisted of 250 SSOs with absence of third molars. A modified SSO technique with inferior border cuts was used on all patients, and the third molars, when present, were removed after separation of the proximal and distal segments. Rigid fixation was applied using bicortical bone screws. Bone plates with monocortical screws were additionally used to secure the free bony segments of the proximal segment in cases with unfavorable fracture.

RESULTS

There were 11 (2.2%) unfavorable fractures in 500 SSO procedures. The incidence of unfavorable splits was 3.2% in group 1 and 1.2 % in group 2. In group 1, all fractures occurred in teenagers, with 7 of 8 fractures extending through the extraction socket in the distal segment. Six of the 8 fractures were associated with completely impacted third molars, and 2 involved partially impacted teeth. All 3 fractures in group 2 occurred in the proximal segment. No significant difference was seen in the amount of relapse in patients with unfavorable or favorable splits.

CONCLUSIONS

The occurrence of unfavorable splits is uncommon when using a modification of the SSO that includes an inferior border osteotomy. Although more unfavorable fractures occurred in teenage patients with third molars, this had no impact on the stability of the final result.

Pharyngeal airway space changes after counterclockwise rotation of the maxillomandibular complex

The purpose of this study was to evaluate the effects of double-jaw surgery with counterclockwise rotation of the maxillomandibular complex on the pharyngeal airway space and velopharyngeal anatomy in patients with high occlusal plane facial morphology. Fifty patients (22 men, 28 women) with high occlusal plane facial morphology underwent double-jaw surgery with counterclockwise rotation of the maxillomandibular complex. The patients were divided into 2 groups: group 1, 30 patients (8 men, 22 women) who underwent maxillary and mandibular advancement and group 2, 20 patients (14 men, 6 women) who underwent maxillary advancement and mandibular setback. Presurgery and postsurgery lateral cephalometric radiographs were analyzed to correlate changes in pharyngeal airway space dimensions and velopharyngeal anatomy with maxillary and mandibular positional changes. The calibration showed a more than 0.94 correlation for both intra- and interoperator error. The average follow-up time was 29.6 months in group 1 and 22.2 months in group 2. Mean maxillary surgical change at point A was 4.15 mm in group 1 and 2.5 mm in group 2. Mean mandibular surgical change at the genial tubercles was 7.5 mm in group 1 and -4.95 mm in group 2. After surgery, group 1 patients had an increase in pharyngeal airway space of 47% at the soft palate and 76% at the base of the tongue relative to the amount of mandibular advancement. Group 2 patients had a decrease in pharyngeal airway space of 47% at the soft palate and 65% at the base of the tongue relative to the amount of mandibular setback. Double-jaw surgery with counterclockwise rotation of the maxillomandibular complex significantly affects the pharyngeal airway space and velopharyngeal anatomy in patients with high occlusal plane facial morphology, with both mandibular advancement and setback.

Use of Gore-Tex tubing as a conduit for inferior alveolar and lingual nerve repair: experience with 6 cases

PURPOSE

This report evaluates treatment outcomes associated with the use of Gore-Tex (GT; W.L. Gore & Associates, Flagstaff, AZ) vein graft tubing as a conduit for repair of inferior alveolar nerve (IAN) and lingual nerve (LN) continuity defects.

PATIENTS AND METHODS

Six patients (5 female and 1 male) with painful dysesthesia secondary to injuries of the IAN (n = 3) or LN (n = 3) underwent surgical exploration and resection of pathologic tissue. Reconstruction of the resultant continuity defects was performed using 3-mm diameter GT tubing sutured to the epineurium of the proximal and distal nerve trunks. Nerve reconstruction was performed an average of 20 months after injury (range, 4 to 48 months). Patients were tested before and after surgery with the following tests: subjective pain level using an analogue scale, sharp stimulus, touch, cold sensation, directional sense, and 2-point discrimination.

RESULTS

Four patients reported no change in subjective pain level, and 2 patients had minimal decrease in pain. Two patients reported some sensation to sharp stimulus, and 1 patient was hypersensitive. Three patients responded to touch, and 3 had no response. Four patients had no response to cold sensation, and 2 had a delayed response. Only 1 patient could detect brushstroke direction. Three patients had no response to 2-point discrimination, and 3 responded at greater than 20 mm.

CONCLUSIONS

Use of GT tubing in this group of patients produced poor clinical outcomes and is not recommended for nerve reconstruction of IAN and LN continuity defects.

Considerations for orthognathic surgery during growth, part 2: maxillary deformities

The growing patient can present to the clinician with significant dentofacial deformities that require surgical correction. In some cases, certain functional, esthetic, and psychosocial factors may necessitate early surgical intervention. Although there is extensive literature on the effects and stability of orthognathic surgical correction of maxillary deformities in adults, the same is not true for the pediatric and adolescent growing patient. Not much is known about the predictability of orthognathic surgical procedures performed during growth or the effects such procedures have on subsequent facial growth. There is always the possibility that secondary corrective procedures may be required after the initial corrective surgery. This article presents recommendations based on available research and personal clinical experience in surgical correction of maxillary deformities in growing patients. The common maxillary dentofacial deformities, age considerations, and surgical alternatives and sequencing are presented. The treatment of mandibular deformities is addressed in Part 1 of this article.