This technical note describes an innovation that addresses a clinical problem in iatrogenic inferior alveolar nerve (IAN) repair. The options for IAN exposure (Miloro, 1995) are less than ideal since ...they offer limited access and visibility and/or the exposure itself has a risk of inducing iatrogenic IAN injury. This technical note offers the option to perform IAN exposure via a unilateral sagittal split osteotomy (SSO). There are inherent risks of mild transient IAN paresthesia, malocclusion, bad splits, and the additional cost of rigid fixation hardware (Peleg et al., 2021). The significance of this technique is that it permits wide access for IAN reconstruction in cases where the IAN injury is in the posterior mandible (eg. due to mandibular third molar removal) where another option for access is limited. This technique will improve patient care by facilitating IAN exposure and repair. There should be no challenges or delays to implementing this innovation for surgeons who perform orthognathic surgery and nerve repair.
Purpose Mandibular retrognathia may cause upper airway obstruction in the pediatric patient due to tongue collapse and physical obstruction in the hypopharyngeal region. Mandibular distraction ...osteogenesis (DO) may be a useful treatment option to avoid tracheostomy. This study reviews 35 patients who underwent DO as treatment for concomitant jaw discrepancy and corrective airway management. Patients and Methods Thirty-five consecutive patients, 20 male and 15 female, with airway obstruction were evaluated retrospectively using clinic and hospital records. The mean age was 3.5 months (range, 36 weeks' gestation to 4 years). The group consisted of patients with Pierre Robin sequence, Stickler syndrome, Opitz's syndrome, Down syndrome with obstructive sleep apnea, Goldenhar's syndrome, Treacher Collins syndrome, and mandibular retrognathia. All patients had obstruction limited to the upper airway related to severe retrognathia and posterior tongue-base displacement confirmed with direct laryngoscopy. All patients underwent mandibular DO to avoid or remove a tracheostomy and allow development of speech and normal feeding. Each patient underwent bilateral mandibular corticotomies and placement of 2 percutaneous Kirchner wires and extraoral distraction devices. Following a 0-day latency, DO was performed at 3 to 5 mm per day (mean: 4 mm per day) for a mean total of 22.5 mm (range, 15-32 mm). The mean consolidation period was 28 days (range, 20-42 days). Preoperative radiographs (lateral cephalometric radiograph and/or CT scan) were obtained in all cases preoperatively and at least 3 months postoperatively for analysis. Results All patients experienced resolution of obstructive upper airway symptoms during the DO process. No patient required tracheostomy, and pre-existing tracheostomy devices were decannulated before DO completion. Apnea monitors failed to trigger in any patient postdistraction, and sleep studies were normal. The mean follow-up period was 9 months (range, 4-18 months). Radiographic analysis revealed the mean increase in posterior airway space was 12 mm. The mean decrease in overjet was 12 mm. Mandibular length increased a mean of 15 mm, and the sella-nasion-B point angle increased a mean of 16 degrees. DO complications included premature consolidation requiring manual refracture, hypertrophic scarring, device replacement, apertognathia with resolution within 8 to 12 weeks following device removal, and intraoral pin exposure. There were no cases of pin site infections or development of temporomandibular ankylosis. Conclusion Mandibular distraction osteogenesis is a viable option for the pediatric patient with upper airway obstruction due to mandibular deficiency to avoid a tracheostomy or other surgical intervention. Mandibular DO treats the etiology of the disease process and may allow for future growth.
Purpose Contemporary management of ablative jaw defects includes not only hard and soft tissue reconstruction, but also restoration of neurosensory function. The goal of this study was to determine ...the outcomes of immediate reconstruction of long-span defects (≥50 mm) of the inferior alveolar nerve (IAN) after ablative mandibular resection using allogeneic nerve grafts. Materials and Methods A retrospective cohort study of patients who underwent immediate reconstruction of IAN gaps of at least 50 mm with allogeneic nerve graft (AxoGen Avance, Alachua, FL) at a single academic medical center by a single surgeon (M.M.) from September 2013 to March 2015 was completed. Demographic and clinical data were collected for each patient and analyzed using clinical neurosensory testing and were reported using the Medical Research Council Scale (MRCS) for functional sensory recovery. In addition, patient subjective perception of neurosensory recovery was recorded using a visual analog scale (VAS). Subjective (VAS) and objective (MRCS) measurements of functional sensory recovery were recorded and compared across the study population. In addition, examined demographic and clinical data included patient age, gender, pathology, length of nerve allograft, and follow-up period. Results Of 12 with nerve repairs, 7 patients met the inclusion criteria. The average age was 34.7 years (range, 18 to 61 yr) and 71.4% were men. All IAN defects resulted from resection of mandibular pathology (6 benign lesions, 1 malignant lesion). Six of the 7 IAN defects were reconstructed with a 70-mm nerve allograft, and 1 nerve defect was reconstructed with a 50-mm graft. Mean follow-up time was 17.7 months (range, 10 to 27.5 months). Mean VAS score reported was 3.7 (range, 0 to 7). In addition, 85.7% of patients displayed return of some superficial pain and tactile sensation without over-response (S3), with 14.3% displaying good stimulation localization (S3+). The patient who displayed S3+ recovery underwent reconstruction with the 50-mm graft. Only 1 of the 7 patients had no neurosensory recovery (S0). Conclusions Immediate reconstruction of the IAN with allogeneic nerve grafting of long-span defects (≥5 cm) is a viable and predictable option to achieve useful functional sensory recovery.
This technical note describes an innovation that addresses a clinical problem in inferior alveolar nerve (IAN) reconstruction. In some cases of mandibular resection, there is a need to resect a ...significant amount of the IAN along with the pathologic lesion and this may result in a lack of a distal nerve stump for completion of the neural anastomosis. This technical note offers the option to perform the distal neurorrhaphy into the residual soft tissues with the expectation that axonal sprouting will occur and result in lower lip and chin sensory reinnervation. There are no inherent risks or additional costs. The significance of this technique is that it permits IAN reconstruction in cases where the actual nerve stump is not available and improves patient care. There should be no challenges or delays to implementing this innovation for surgeons who reconstruct the IAN during ablative mandibular resection.
Patients with end-stage temporomandibular joint (TMJ) pathology require TMJ reconstruction, which can be accomplished with autogenous tissue or alloplastic materials. This survey study evaluates ...experienced TMJ surgeons' preferences for autogenous costochondral grafts (CCGs) and/or alloplastic prostheses for TMJ reconstruction.
This cross-sectional study used an online public survey domain to query an anonymous cohort of volunteer surgeons from the American and European Societies of Temporomandibular Joint Surgeons about their TMJ reconstruction preferences. The survey questioned these surgeons' current and previous use of CCG for TMJ reconstruction, changes in practice pattern in this regard over the years, indications for CCG, and postoperative CCG outcomes. The responses were subsequently catalogued, means were calculated, descriptive statistics were analyzed, and trends were identified.
Of 150 surgeons contacted, 92 responded to the survey. Of the respondents, 84 (91.3%) reported that they had performed total TMJ reconstruction in the past or continue to perform total TMJ reconstruction. However, only the 66 surgeons who completed the survey in its entirety were included in the analysis. Among these surgeons, 95.5% (63 of 66) reported that their current preferred method for TMJ reconstruction was an alloplastic TMJ replacement prosthesis; 86.4% (57 of 66) preferred a custom TMJ prosthesis, whereas 9.1% (6 of 66) preferred a stock TMJ prosthesis. Only 4.5% of the respondents (3 of 66) currently preferred CCG for TMJ reconstruction.
Of the respondents, 95.5% preferred alloplastic TMJ replacement. This preference was reported based on fewer postoperative complications and more predictable outcomes using alloplastic TMJ prostheses. In cases in which CCG revision was indicated, an alloplastic TMJ prosthesis was used, indicating that surgeons should consider an alloplastic TMJ replacement device as the primary option for TMJ reconstruction for the management of most end-stage TMJ diseases.
Abstract Purpose To determine why women chose to enter an academic career in oral and maxillofacial surgery (OMS). Materials and Methods An online questionnaire was developed and emailed to female ...?OMS surgeons to assess the reasons why women choose to pursue an academic career, the perceived positive and negative features of academia for women, and proposed measures to increase the percentage of women choosing to specialize in OMS and pursue an academic career. Results 31 female OMS surgeons completed the questionnaire; one additional participant accessed the survey but did not respond to any of the questions. There were 25 full-time academics and 6 part-time academics (50% time commitment or more). 72% of the responders were married, and of those 72% were married prior to entering academics. 47%% of the women had children, all during their academic tenure. Among the full time academicians with children, only 2 (7.7%) reported moderate difficulty finding the time for childbirth and maternity leave, while 3 out of the 5 part time academics with children, reported moderate or significant difficulty with childbirth and maternity leave. Factors associated with choosing and enjoying an academic career are involvement in resident-student teaching (78%), followed by colleague camaraderie and collaboration (65.6%), research potential (50%), time flexibility and not having to deal with excessive “business” practice issues (33%). The main reason for considering leaving an academic OMS career and/or amongst the least enjoyable aspects of being in academics were the potential for a higher income in private practice (56%). Less significant reasons for considering leaving an academic OMS career were a more flexible work schedule in the private sector and less institutional red tape (37.5%), independence/being in control, and more family time (22%), Engaging residents and students by female OMS, better mentorship from academic OMS and increase in the number of women serving in leadership positions in organized OMS, were identified as the most important measures to increase female involvement in academic OMS. Conclusion This study shows that among the major motivating factors for choosing an academic career are: the involvement in resident-student teaching and colleague camaraderie and collaboration. Additional important factors for making this career choice were the research potential in academia, time flexibility and not having to deal with excessive “business” practice issues. The reasons that deter women from entering OMS as a specialty and choosing a full-time academic OMS career are not significantly related to childbirth and family life. The main reason for potentially considering leaving an academic OMS career and/or among the least enjoyable aspects of being in academics, were the potential for a higher income in private practice. Other reasons for potentially considering leaving an academic OMS career indicated by this study were the lack of institutional red tape as well as independence/being in control, and more family time. It appears that engaging female residents and students by female OMS, better mentorship by (both male and female) academic OMS and increasing the number of female surgeons who can serve as role models, may be beneficial in increasing the number of female OMS interested in an academic career.
Purpose The goal of this study was to evaluate outcomes of patients who underwent temporomandibular joint (TMJ) discectomy without replacement as the primary treatment for internal derangement after ...failure of nonsurgical therapy. Patients and Methods Thirty consecutive patients with TMJ internal derangement were treated with discectomy from 2001 to 2007. Four patients were lost to follow-up, and 2 were excluded because of prior joint surgery. Using the standardized Helkimo Anamnestic and Clinical Dysfunction Indexes, 24 patients, or 32 joint surgeries, were evaluated postoperatively, with an average follow-up of 30.8 months (range, 2 to 60 months). Results All 24 patients showed improvement in mandibular mobility and joint function, as well as reduction in TMJ and muscular facial pain, represented by a clinical dysfunction index of DiO, DiI, or DiII. Preoperatively, all patients had an anamnestic index of AiII, which represented moderate to severe pain in the TMJ and masticatory muscles, and/or locking of the joint before surgery. Postsurgically, 20 of the 24 patients scored an index of DiO or DiI, which correlated with a clinically symptom-free state or only a small, minor dysfunction. TMJ pain, muscle pain, and pain with mobility scored the lowest point index, indicating a subjectively successful outcome. Conclusions Discectomy of the TMJ as a primary surgical option significantly reduces pain and improves function.
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