Multimodal Approach in Treating Trismus Owing to Oral Submucous Fibrosis

 Edward Chengchuan KO
ko.edward.kaseizen@gmail.com 

Division of Oral and Maxillofacial Surgery, Kaohsiung Medical University Hospital, Kaohsiung, TAIWAN

Dept. of FUJISOFT Cartilage and Bone Regeneration, Tissue Engineering, The University of Tokyo, Tokyo, JAPAN

Backgrounds

Submucous fibrosis, is associated with the use of betel nut-slake lime preparations. This entity may be severe and produce a significant limitation of jaw opening. It is thought to be due to the Areca catecha component in the betel nut, which is known specifically to stimulate collagen synthesis. Marx RE advocates that the only two effective approaches to submucous fibrosis are (I) no treatment with follow-up and discontinuation of the betel nut-slake lime habit (behavior modification), and (2) total excision with soft tissue myocutaneous or free microvascular flaps transposing viable elastic skin. Approaches using injections of steroids, chymotrypsin, hyaluronidase or alcohol, and surgeries using mucosal or nonvascularized split-thickness skin grafts have not only been ineffective but have often worsened the condition with added scar tissue. Headache over the bilateral temporal areas might also limit the effect of post-operative mouth opening exercise. Since the expression of the mucosa actually is determined by the signal from the underlying connective tissue, most the skin graft would eventually become scar. With high morbidity of the recipient site of vascularized free flap, we actually could not agree with Marx’s protocol.

Protocol

My protocol is 
(1) Coronoidotomies 
(2) Stripping off the temporalis muscle and tendon from the ramus 
    (3) few multiple tiny incisions 
    (4) Autogenous fat grafting 
    (5) Mouth opening exercise 
    (6) intraoperative and postoperative botulism toxin injection 
    (7) post-op acupuncture.

Results and Perspectives

Postoperative result according to this new protocol shows satisfactory regarding the mouth opening dimension as well as the elasticity of the soft tissue. Limited numbers of patients made no statistical conclusion as far. Multicenter studies might be required. Further molecular marker studies shall be investigated as well.

Keywords: trismus, submucous fibrosis, oral submucous fibrosis, coronoidotomy, mouth opening exercise, autogenous fat grafting, botulism toxin injection, acupuncture 

The Buccal Branch of Facial Nerve and its Relationship with the Emergence of Stenson’s Duct: Anatomic Study on Adult Taiwanese Cadaver and its Clinical Significance

蔡 承熹 CHEN-HSI TSAI

Background:

For close proximity of the buccal branch (of facial nerve) to Stensen’s duct, knowledge of surgical anatomy would be very important in surgical exploration of this area, including parotidectomy, retrograde dissection of the parotid and surgical repair of the Stensen’s duct, etc.

The aim of this study is to attempt to depict the distribution of buccal branch on Taiwanese adult cadavers.

Method:

Thirty-five cadaveric hemi-faces were included in our research. Facial defect owing to tumor and trauma were excluded. Buccal branch of facial nerve was defined according to the textbook of Gray’s anatomy 40^th edition. The observation of the relationship between buccal branch and Stensen’s duct was mainly focused on the intersection along the Stensen’s duct and the emergence from the anterior border of parotid gland. Intraobervational and interobservational errors were found both negligible.

Result:

The number of intersection ranged from 1-5, and 2 intersections showed the highest proportion, 37%. The distance between the intersection and emergence of Stensen’s duct ranged from 2.56 to 58.95mm. At the anterior border of parotid gland, we found the number of buccal branch ranged from 1-3 superior to the emergence of Stensen’s duct, and 0-2 inferior to duct. In 12(34%) cases, single buccal branch was superior to duct, and the mean distance between the emergence was 15.31±5.25mm, and 21(60%) cases showed two buccal branch superiorly, the mean distance were 8.18±5.96mm and 17.90±5.77mm. In 24(69%) cases, single buccal branch was inferior to duct, the mean distance was 10.44±5.64mm. There were 6(17%) cases absent of buccal branch inferior to the emergence of Stensen’s duct. We could not find direct anastomosis or communicating fibers between upper and lower buccal branch in 11(31%) of cases.

Conclusion:

We depicted the emergence of Stensen’s duct to analyze the distribution of buccal branch, and we found that there is a larger variation in distribution among our Taiwanese cadaver than that of previous studies in other countries. Surgeons shall be advised to take the utmost caution when dissecting either Buccal branch or Stenson’s duct.

Keywords: emergence of Stenson's duct; Stenson's duct, facial nerve; buccal branch; intersection,  

Professor Fu-Chuan WEI 魏福全教授

Dr. Fu-Chan Wei received his medical degree from Kaohsiung Medical College in 1972, and completed his plastic surgery training in 1978. Subsequently, he had two years of Fellowships in microsurgery and hand surgery at the University of Toronto, and the University of Louisville.

Dr. Wei became Chairman of the Department of Plastic and Reconstructive Surgery in 1994, vice superintendent in 1997 at Chang Gung Memorial Hospital, and Chancellor of the College of Medicine in 2003 at Chang Gung University. During his tenure as the Chief of the Department of Plastic and Reconstructive Surgery, through his efforts in leading and coordination, his institution developed into a world leading microsurgical center renowned for extensive cases with an unattested level of quality in head and neck reconstruction, facial palsy, brachial plexus, upper and lower extremity, and breast reconstructions.

Dr. Wei developed many ground-breaking concepts, techniques, and innovations which have revolutionized cancer and trauma patient care, and laid the scientific foundation for this medical discipline with major contributions in toe-to-hand transplantation for traumatic digital amputations, fibula osteosepto-cutaneous

flaps for long bone and mandibular reconstruction, and perforator flaps and free style flaps for coverage reconstruction of various defects around the body.

Professor Wei has published more than 400 peer-reviewed journal articles, 94 textbooks chapters and has edited a total of 12 books in English. His most recent volume on “Flaps and Reconstructive Surgery” published by Elsevier in 2009 and Co-Edited by Dr. Samir Mardini is regarded as one of the leading textbooks in reconstructive surgery today and has been translated into Spanish. Professor Wei served as the chief editor for Microsurgery for 6 years and is a member of the editorial board for nine professional journals. In 2011, Dr. Wei was appointed as the international associate editor of Plastic and Reconstructive Surgery Journal. Dr. Wei has won numerous awards both internationally and nationally including the Founder’s Lecture at American Society of Reconstructive Microsurgery in 1996, the first Tord Skoog Lecture at the Scandinavian Society of Plastic Surgery in 2000, the Maliniac Lecture at the American Society of Plastic Surgery in 2001, and the Buncke Lecture Award.

Professor Wei was selected as one of the 20 most significant innovators in plastic surgery’s 400 years of history by the American Society of Plastic Surgery with the citation: his “accomplishments have left an indeniable impact on the specialty” and this “legend’s work serves patients for generations”. Professor Wei has trained 110 fellows and mentored 1438 visiting surgeons from 77 countries, many of whom have returned to their respective countries to hold leadership positions. 

Distraction Osteogenesis with Dental Implant over the Osteotomized Fibular Osteocutaneous Flap for Continuity Defect of Mandible

Chen-ping ZHANG

Dept. of Oral and Maxillofacial Surgery

Shanghai Ninth People’s Hospital

Shanghai JiaoTong University

Shanghai (200011), China

【Abstract】　

Objective: To study the application of Dental Implant Distracter (DID) with fibula in mandibular functional reconstruction. 

Materials and Methods: We designed a new device named DID (Dental Implant Distracter), which including the permanent dental implant and the temporary distracter in itself. It’s specially designed for fibula wider distraction in mandible reconstruction. Eighty-nine sets of DID devices were used in 29 patients (18 males and 11 females). 11 patients suffered from ameloblastoma of mandible, 7 from malignant tumor, 6 from odontogenic cyst of mandible, 3 from fibrous dysplasia, and the other 2 from trauma cases. The age of 29 patients is from 16 to 67 (average 35.6) years old.

Results: During postoperative 1-8.5 years follow up; the free flaps of all cases were survived. The clinical examination and X-ray film showed normal contour of mandible. Most cases showed good osteointegration surround DID, but 15.7% (14/89) of the DID devices were removed because of the inflammation. The other (84.3%) implants were solid enough to load the denture force. 12 patients were successfully worn the fixed dental prosthesis. The outcomes were satisfied.  

Conclusion: DID device, which specially designed for mandibular functional reconstruction with fibula flap, can help us to simplify convenient procedures to a simultaneous surgery.

【Key words】 mandibular reconstruction; dental implant, distracter; fibular flap

Functional and Esthetic Reconstruction of Segmental Mandibular Defect

Fu-Chan Wei MD, FACS

Distinguished Chair Professor

Department of Plastic Surgery

Chang Gung Memorial Hospital

Chang Gung University, College of Medicine

 

 

Vascularized bone graft has become gold standard for reconstruction of segmental defect of the mandible. Among various donor sites, the fibula harvested as an osteoseptocutaneous flap is the most popular one especially when the reconstruction of intraoral lining is also needed.

With accumulation of experience, we are able to achieve not only function with osteointegration teeth either as a primary or a secondary procedure, but also satisfactory esthetic results, through various techniques to overcome the inherent height discrepancy between native mandible and new mandible reconstructed with fibula.

This presentation shall highlight all those related technical modifications.