Morbidity of Chin Bone Transplants Used for Reconstructing Alveolar Defects in Cleft Patients

Objective

The aim of this study was to evaluate the objective and subjective morbidity of symphyseal chin bone harvesting used for reconstruction of alveolar defects in young cleft patients.

Design

All patients who had undergone chin bone harvesting for alveolar cleft reconstruction in the period from 1992 through 2000 at the Department of Oral and Maxillofacial Surgery of the University Hospital Groningen, Groningen, The Netherlands, were invited to participate in this retrospective study. Patients’ acceptance, perioperative and postoperative morbidity were evaluated. A survey of the medical records was performed. In addition, the patients completed a questionnaire for their appreciation of the procedure. They were also subjected to a clinical and radiographic examination.

Patients

Thirty patients (21 males and 9 females; mean age 11.8 ± 3.6 years) participated in this study.

Results

Neither the medical records nor the experiences of the patients showed significant morbidity. The procedure was appreciated with 6.8 ± 3.5 (scale 0 to 10). Postoperative pain was scored as 1.2 ± 2.5 (scale 0 to 10). Three patients reported transient sensory disturbances at the donor site. Two patients showed a slight sensibility disorder in the symphyseal region. In three patients, an endodontic problem had developed in a lower incisor.

Conclusion

This study showed that chin bone harvesting for reconstructing alveolar cleft in young patients is a well-accepted procedure with low objective and subjective morbidity. Notwithstanding this low morbidity, the patients (and their parents) have to be informed about the risk of objective and subjective disturbances of the sensibility in the donor region and the risk of dental pulp necrosis.

Autogenous femoral head as grafting material for mandibular augmentation

Bone grafting is commonly used for augmentation of the atrophic edentulous maxilla and mandible. Although bone substitutes and allogeneic frozen bone grafts have been applied successfully, fresh autogenous bone grafts remain the 'gold standard' in maxillofacial reconstructive surgery. A disadvantage of harvesting autogenous bone is the resulting donor-site morbidity. The authors present a case in which an autogenous femoral head, which was removed because of a prosthetic hip replacement, was used for augmentation of the extreme atrophic mandible. Using this procedure avoids donor-site morbidity.

Parotid gland biopsy compared with labial biopsy in the diagnosis of patients with primary Sjogren's syndrome

OBJECTIVE

To assess the value of the parotid biopsy as a diagnostic tool for primary Sjögren's syndrome (pSS), and to compare the parotid biopsy and the labial biopsy with regard to diagnostic value and biopsy-related morbidity.

METHODS

In 15 consecutive patients with pSS and 20 controls, the parotid biopsy was assessed as a diagnostic tool based on the presence of lymphocytic foci, benign lymphoepithelial lesions and lymphoid follicles. These new histological criteria were compared with established diagnostic criteria for the labial biopsy in 35 consecutive patients suspected for pSS who underwent simultaneous biopsies from both sites. In addition, both biopsies were compared for morbidity.

RESULTS

The first analysis revealed a focus score of >or=1 or lymphocytic infiltrates (not fulfilling the criterion of a focus score of 1) combined with benign lymphoepithelial lesions as diagnostic criteria for pSS. When comparing the parotid biopsy with the labial biopsy sensitivity and specificity were comparable (sensitivity 78%, specificity 86%). Level of pain was comparable and no loss of motor function was observed. No permanent sensory loss was observed after parotid biopsy, while labial biopsy led to permanent sensory loss in 6% of the patients. Malignant lymphoma was detected in one parotid biopsy by chance, without involvement of the labial salivary gland.

CONCLUSION

A parotid biopsy has a diagnostic potential comparable with that of a labial biopsy in the diagnosis of pSS, and may be associated with less morbidity.

Progression of salivary gland dysfunction in patients with Sjogren's syndrome

BACKGROUND

Salivary gland dysfunction is one of the key manifestations of Sjögren's syndrome.

OBJECTIVES

(1) To assess prospectively loss of function of individual salivary glands in patients with primary and secondary Sjögren's syndrome in relation to disease duration and use of immunomodulatory drugs. (2) To study changes in sialochemical and laboratory values and subjective complaints over time.

METHODS

60 patients with Sjögren's syndrome were included in this study. Whole and gland-specific saliva (parotid and submandibular/sublingual (SM/SL)), samples were collected at baseline and after a mean of 3.6 (SD 2.3) years of follow-up. Disease duration was recorded for all patients.

RESULTS

Patients with Sjögren's syndrome with short disease duration had significantly higher stimulated flow rates at baseline than those with longer disease duration (p<0.05). When compared with healthy controls, the decrease in SM/SL flow rates at baseline was more prominent than that in parotid flow rates (p<0.05). Over time, there was a significant further decrease of stimulated flow rates, especially of the parotid gland, accompanied by increasing problems with swallowing dry food (p<0.05). The decrease was independent of the use of corticosteroids or disease-modifying antirheumatic drugs (DMARDs). Sialochemical variables remained stable.

CONCLUSIONS

Early Sjögren's syndrome is characterised by a decreased salivary gland function (parotis>SM/SL), which shows a further decrease over time, regardless of the use of DMARDs or steroids. Patients with Sjögren's syndrome with longer disease duration are characterised by severely reduced secretions of both the parotid and SM/SL glands. These observations are relevant for identifying patients who would most likely benefit from intervention treatment.

[A schizophrenic patient with loss of teeth]

A 53-year-old woman, known with a schizophrenic disorder and a history of drug addiction, was referred because of progressive hematomas of the lower extremities and fatigue. Her medical history included hyperplastic gums, tooth hypermobility and anaemia. Scurvy was diagnosed as a result of an insufficient diet due to drug addiction and a paranoid psychosis. After suppletion of vitamin C and starting highly nutritious food a rapid amelioration of the scurvy related complaints was observed. While dreaded and often fatal in earlier eras, in the 21st century scurvy is easily treatable if this diagnosis is recognised.

[Bruises, loose teeth and fatigue in a patient with schizophrenia]

A 53-year-old woman was referred because of progressive haematomas of the lower extremities and fatigue. Her medical history included hyperplastic gums and tooth loss. Scurvy was diagnosed; this was the result of an insufficient diet due to a paranoid psychosis. There was a dramatic improvement within a few days after addition of vitamin C and starting highly nutritious food. Scurvy is easily treated, but is not a disease of the past.

Trismus in head and neck oncology: a systematic review

The aim of this review was to identify systematically, criteria for trismus in head and neck cancer, the evidence for risk factors for trismus and the interventions to treat trismus. Three databases were searched (time period 1966 to June 2003) for the text "trismus" or "restricted mouth opening". Included in the review were clinical studies (> or = 10 patients). Two observers independently assessed the papers identified. In 12 studies nine different criteria for trismus were found without justifying these criteria. Radiotherapy (follow-up: 6-12 months) involving the structures of the temporomandibular joint and or pterygoid muscles reduces mouth opening with 18% (sd: 17%). Exercises using a therabite device or tongue blades increase mouth opening significantly (no follow-up), effect sizes (ES) 2.6 and 1.5 respectively. Microcurrent electrotherapy (follow-up 3 months) and pentoxifylline (no follow-up) increases mouth opening significantly (ES for both: 0.3).

[Distraction osteogenesis of the maxilla in cleft patients. Worth considering]

Three cleft patients were treated with RED-distraction for maxillary hypoplasia. In all patients, the desired advancement could be achieved easily. The occlusion, the lip relation and the facial profile improved remarkably post treatment. Although the treatment was well tolerated by the patients, some limitations of the treatment were also noted, such as a nasal speech and discomfort by the head frame. Distraction osteogenesis in the maxilla has several advantages when compared to the conventional Le Fort 1-osteotomy: atraumatic advancement of the maxilla, absence of need for an autogeneous bone transplant, and applicability at relatively young age. The advantages and disadvantages of distraction osteogenesis must be considered for each individual patient.

Sialometry and sialochemistry: a non-invasive approach for diagnosing Sjögren's syndrome

BACKGROUND

Analysis of salivary variables has frequently been proposed as a diagnostic tool for Sjögren's syndrome (SS). Because univocal salivary reference values are lacking, it is currently rather difficult to use sialometry and sialochemistry for diagnosing SS unless major changes have occurred in salivary secretion and composition.

OBJECTIVE

To define reference values of several salivary variables, which offer a possible new and non-invasive means of diagnosing SS.

METHODS

Cut off points were selected from receiver operating characteristic curves of gland-specific sialometrical and sialochemical variables, which have proved to be potentially relevant for diagnosing SS in a previous study-that is, sodium, chloride, and phosphate concentration in stimulated parotid and submandibular/sublingual (SM/SL) saliva, unstimulated and stimulated SM/SL flow rates, and lag phase of parotid secretion, respectively. By combining the most discriminating variables, two different diagnostic approaches for SS were applied in a group of 100 patients and subsequently evaluated in a second group of 20 patients. The first approach was to combine variables by applying their cut off points into sets of criteria for a positive diagnosis of SS. The second approach was to construct a logistic regression model that predicts the true state of a patient (SS or non-SS). From both approaches, the tests with highest likelihood ratio combined with the smallest number of rejected cases were selected for clinical use.

RESULTS

The most accurate test combined the stimulated SM/SL flow rate and parotid sodium and chloride concentration as salivary variables for diagnosing SS; it had a sensitivity of 0.85 and a specificity of 0.96. The selected tests proved equally accurate in the second group of patients.

CONCLUSIONS

Because the proposed non-invasive diagnostic tools can be easily applied, do not need a laboratory other than for routine blood testing, and are very accurate, gland-specific sialometry and sialochemistry may eventually replace other, more invasive, diagnostic techniques for diagnosing SS.