CORRESPONDENCE
Condensed Autogenous Bone Particles: Modified Technique To the Editor: The most favorable graft for the reconstruction of mandibular defects is the autogenous bone graft. It may be used in posttraumatic bone defects, infection, and alveolar reconstruction as well as in the treatment of postoperative complications such as malunion or nonunion.1 Corticocancellous autogenous bone grafts stimulate bone union, which provides osteogenic cells to the recipient bed, allowing greater release of growth factors and rapid neovascularization.2 However, handling these bone particles is a challenge. Autogenous bone particles can disperse from the recipient bed many times during surgery or postoperative time, leading to less bone volume than expected.3 The aim of this article was to show that compressed bone particles of autogenous cancellous bone graft using a syringe Luer-Lok is a simple way to handle the graft and a viable treatment option for mandibular bone defects.
FIGURE 2. Bone graft particles being condensed into a syringe.
FIGURE 3. The autogenous bone mass.
TECHNIQUE In 2011, a total of 4 male patients who had gunshot wounds underwent mandibular reconstructive surgery for mandibular bone defects (2 right-sided and 2 left-sided defects) under general anesthesia at the General Hospital of Nova Iguac¸u, Rio de Janeiro, Brazil. Autogenous bone blocks from the anterior iliac crest were harvested using a reciprocating saw. Afterward, the block was milled for obtaining smaller bone particles (Fig. 1). Then, these bone particles were condensed in a plastic syringe (60 mL) LuerLok (Fig. 2). The syringe piston was pressed to compress and condense the bone, resulting in an easy manipulated bone mass to be placed at the mandibular defect (Fig. 3). The bone mass was removed from the syringe using negative pressure, removing the piston or cutting the edge of the syringe. After mandibular fixation with 2.4-mm system, the bone mass was placed at the recipient bed and then shaped using a spatula (Fig. 4). Protection and nutrition for this graft should be provided by an intact periosteum. Mandibular fractures caused by gunshot wounds represent 9.4% of all mandible fractures, increasing day by day in urban centers.4,5 These injuries are characterized by bone explosion, resulting in bone gaps, tissue necrosis, and loss of local vascularization.6,7 Thus, mandibular reconstruction should be performed by a load-bearing system associated with autologous bone graft.8 The most predictable treatment for these types of injuries is fracture fixation, under a good quality soft tissue coverage and reconstruction of the original architecture of mandibular bone.8 Autologous bone graft particles allow bone repair, permit dental implant rehabilitation, promote fracture stability, and prevent pathologic fractures.2 When cancellous autologous bone graft
FIGURE 4. The autogenous bone graft shaped in the mandibular defect.
is condensed, it simplifies its manipulation during surgical procedures; therefore, it avoids bone graft spreading and better adaptation. Maxillomandibular fixation with arch bars was kept for 2 weeks to avoid mandibular movements. This could harm the graft neovascularization process and allow early bone graft resorption. During this period, patients were oriented to adhere to liquid diet as indicated by Alpert et al.9 In conclusion, condensed corticocancellous bone grafts compacted in a syringe are more viable to be shaped, thus increasing its osteogenic characteristics and, when associated to adequate bone fixation, it allows a better quality of bone healing. Rodrigo dos Santos Pereira, DDS, MSc Univ. Estadual Paulista Arac¸atuba Dental School Sao Paulo, Brazil [email protected] Hernando Valentim da Rocha, Jr, DDS, MSc Nicolas Homsi, DDS, MSc Universidade Federal Fluminense Nova Friburgo Dental School Rio de Janeiro, Brazil
FIGURE 1. Autogenous bone graft particles.
942
Eduardo Hochuli Vieira, DDS, MSc Department of Oral and Maxillofacial Surgery Araraquara Dental School Univ. Estadual Paulista Sao Paulo, Brazil The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
REFERENCES 1. Tatum HJ. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207–229 2. Ellis E 3rd, Price C. Treatment protocol for fractures of the atrophic mandible. J Oral Maxillofac Surg 2008;66:421–435 3. Alpert B, Tiwana PS, Kushner GM. Management of comminuted fractures of the mandible. Oral Maxillofac Surg Clin North Am 2009;21:185–192 4. Shinohara EH, Gaia BF, Landgraf H, et al. Interpersonal violence and motor vehicle crashes caused the most significant amount of maxillofacial trauma. J Trauma 2007;62:1062 5. Martini MZ, Takahashi A, de Oliveira Neto HG, et al. Epidemiology of mandibular fractures treated in a Brazilian level I trauma public hospital in the city of Sao Paulo, Brazil. Braz Dent J 2006;17:243–248 6. Khalil AF. Civilian gunshot injuries to the face and jaws. Br J Oral Surg 1980;18:205–211 7. Cohen MA, Shakenovsky BN, Smith I. Low velocity hand-gun injuries of the maxillofacial region. J Maxillofac Surg 1986;14:26–33 8. Merkx MA, Fennis JP, Verhagen CM, et al. Reconstruction of the mandible using preshaped 2.3 mm titanium plates, autogenous particulate cortico-cancellous bone grafts and platelet rich plasma: a report on eight patients. Int J Oral Maxillofac Surg 2004;33:733– 739 9. Alpert B, Kushner GM, Tiwana PS. Contemporary management of infected mandibular fractures. Craniomaxillofac Trauma Reconstr 2008;1:25–29
The Effect of Adenoidectomy Operation Made on Patients With Adenoid Hypertrophy on Cardiovascular Risk Reduction To the Editor: With great eagerness, we have read the study in your journal entitled ‘‘Mean Platelet Volume Levels in Children With Adenoid Hypertrophy’’ by Kucur et al.1 We would like to make some comments about this study. In recent years, many studies that state there is a significant relation between the increase in mean platelet volume (MPV) and the increase in cardiovascular disease risk have been published.2,3 Besides this, some studies that search for the relation between adenoid hypertrophy, MPV, and cardiovascular disease risk have been reported.1,4 In the results of these studies, there are conflicting comments about the effect of MPV value to the cardiovascular disease risk. Although a good number of assertive results have been announced in these studies, sufficient usage area of MPV value measurement has not occurred in the follow-up and treatment of patients clinically as there is no fully standardized method of this parameter. Some of the factors that affect the standardization of MPV measurement are the environment of blood taking, type and amount of anticoagulant in the blood collection tube, the duration between blood taking and examination, the device used in examination, and the calibration time of the device.3 It has been reported that there are measurement differences up to 40% even among the devices in the studies in which different devices were used.5,6 In this study, the fact that MPV value has been found higher in patients with adenoid hypertrophy in proportion to the control group
#
2015 Mutaz B. Habal, MD
Correspondence
is agreeable to literature information. Besides this, we think that it is an assertive statement that the decrease in MPV value measured in the third month in comparison with preoperative period in patients on whom adenoidectomy operation have been performed would enable cardiovascular risk reduction, and for that reason, MPV value may be a parameter for this situation. Because, as stated before, MPV value is a very variable parameter, and if we think that the lifetime of thrombocytes is between 7 and 10 days, this change in MPV expressed at the end of the study may arise from many other factors, as waiting for 3 months for control MPV can cause variance at hemogram parameters. While hemoglobin and thrombocyte count values between the control and patient groups were stated in the study, the values of preoperative and postoperative patient groups and the changes in these values were not stated. Moreover, it is not clear how long blood samples taken from test subjects stayed in the tube with EDTA and when the blood count was made. At the same time, the patients chosen for the study were well excluded in terms of cardiac disease, and it is not easy to say that cardiovascular disease risk will decrease on the third months in this case group that has essentially no cardiovascular disease risk. As a consequence, even if MPV has been associated with many illnesses recently, it does not seem possible for now to evaluate these results with cardiovascular diseases in the limited studies that state MPV value is increased in patients with nasal septum deviation. In order to make better comments about this issue, we think that different studies should be made on the cases that have equal high cardiovascular disease risk and evaluate the long-term follow-up results of these. Murat Sereflican, MD Veysel Yurttas, MD Department of Otolaryngology Abant Izzet Baysal University Faculty of Medicine Bolu, Turkey [email protected] Fatma Erdem, MD Department of Cardiology Abant Izzet Baysal University Faculty of Medicine Bolu, Turkey
REFERENCES 1. Kucur M, Kulekci S, Zorlu A, et al. Mean platelet volume levels in children with adenoid hypertrophy. J Craniofac Surg 2014;25: e29–e31 2. Chu SG, Becker RC, Berger PB, et al. Mean platelet volume as a predictor of cardiovascular risk: a systematic review and meta-analysis. J Thromb Haemost 2010;8:148–156 3. Vizioli L, Muscari S, Muscari A. The relationship of mean platelet volume with the risk and prognosis of cardiovascular diseases. Int J Clin Pract 2009;63:1509–1515 4. Cengiz C, Erhan Y, Murat T, et al. Values of mean platelet volume in patients with chronic tonsillitis and adenoid hypertrophy. Pak J Med Sci 2013;29:569–572 5. Lance´ MD, Sloep M, Henskens YM, et al. Mean platelet volume as a diagnostic marker for cardiovascular disease: drawbacks of preanalytical conditions and measuring techniques. Clin Appl Thromb Hemost 2012;18:561–568 6. Jackson SR, Carter JM. Platelet volume: laboratory measurement and clinical application. Blood Rev 1993;7:104–113
943
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Condensed Autogenous Bone Particles: Modified Technique To the Editor: The most favorable graft for the reconstruction of mandibular defects is the autogenous bone graft. It may be used in posttraumatic bone defects, infection, and alveolar reconstruction as well as in the treatment of postoperative complications such as malunion or nonunion.1 Corticocancellous autogenous bone grafts stimulate bone union, which provides osteogenic cells to the recipient bed, allowing greater release of growth factors and rapid neovascularization.2 However, handling these bone particles is a challenge. Autogenous bone particles can disperse from the recipient bed many times during surgery or postoperative time, leading to less bone volume than expected.3 The aim of this article was to show that compressed bone particles of autogenous cancellous bone graft using a syringe Luer-Lok is a simple way to handle the graft and a viable treatment option for mandibular bone defects.
FIGURE 2. Bone graft particles being condensed into a syringe.
FIGURE 3. The autogenous bone mass.
TECHNIQUE In 2011, a total of 4 male patients who had gunshot wounds underwent mandibular reconstructive surgery for mandibular bone defects (2 right-sided and 2 left-sided defects) under general anesthesia at the General Hospital of Nova Iguac¸u, Rio de Janeiro, Brazil. Autogenous bone blocks from the anterior iliac crest were harvested using a reciprocating saw. Afterward, the block was milled for obtaining smaller bone particles (Fig. 1). Then, these bone particles were condensed in a plastic syringe (60 mL) LuerLok (Fig. 2). The syringe piston was pressed to compress and condense the bone, resulting in an easy manipulated bone mass to be placed at the mandibular defect (Fig. 3). The bone mass was removed from the syringe using negative pressure, removing the piston or cutting the edge of the syringe. After mandibular fixation with 2.4-mm system, the bone mass was placed at the recipient bed and then shaped using a spatula (Fig. 4). Protection and nutrition for this graft should be provided by an intact periosteum. Mandibular fractures caused by gunshot wounds represent 9.4% of all mandible fractures, increasing day by day in urban centers.4,5 These injuries are characterized by bone explosion, resulting in bone gaps, tissue necrosis, and loss of local vascularization.6,7 Thus, mandibular reconstruction should be performed by a load-bearing system associated with autologous bone graft.8 The most predictable treatment for these types of injuries is fracture fixation, under a good quality soft tissue coverage and reconstruction of the original architecture of mandibular bone.8 Autologous bone graft particles allow bone repair, permit dental implant rehabilitation, promote fracture stability, and prevent pathologic fractures.2 When cancellous autologous bone graft
FIGURE 4. The autogenous bone graft shaped in the mandibular defect.
is condensed, it simplifies its manipulation during surgical procedures; therefore, it avoids bone graft spreading and better adaptation. Maxillomandibular fixation with arch bars was kept for 2 weeks to avoid mandibular movements. This could harm the graft neovascularization process and allow early bone graft resorption. During this period, patients were oriented to adhere to liquid diet as indicated by Alpert et al.9 In conclusion, condensed corticocancellous bone grafts compacted in a syringe are more viable to be shaped, thus increasing its osteogenic characteristics and, when associated to adequate bone fixation, it allows a better quality of bone healing. Rodrigo dos Santos Pereira, DDS, MSc Univ. Estadual Paulista Arac¸atuba Dental School Sao Paulo, Brazil [email protected] Hernando Valentim da Rocha, Jr, DDS, MSc Nicolas Homsi, DDS, MSc Universidade Federal Fluminense Nova Friburgo Dental School Rio de Janeiro, Brazil
FIGURE 1. Autogenous bone graft particles.
942
Eduardo Hochuli Vieira, DDS, MSc Department of Oral and Maxillofacial Surgery Araraquara Dental School Univ. Estadual Paulista Sao Paulo, Brazil The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
REFERENCES 1. Tatum HJ. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207–229 2. Ellis E 3rd, Price C. Treatment protocol for fractures of the atrophic mandible. J Oral Maxillofac Surg 2008;66:421–435 3. Alpert B, Tiwana PS, Kushner GM. Management of comminuted fractures of the mandible. Oral Maxillofac Surg Clin North Am 2009;21:185–192 4. Shinohara EH, Gaia BF, Landgraf H, et al. Interpersonal violence and motor vehicle crashes caused the most significant amount of maxillofacial trauma. J Trauma 2007;62:1062 5. Martini MZ, Takahashi A, de Oliveira Neto HG, et al. Epidemiology of mandibular fractures treated in a Brazilian level I trauma public hospital in the city of Sao Paulo, Brazil. Braz Dent J 2006;17:243–248 6. Khalil AF. Civilian gunshot injuries to the face and jaws. Br J Oral Surg 1980;18:205–211 7. Cohen MA, Shakenovsky BN, Smith I. Low velocity hand-gun injuries of the maxillofacial region. J Maxillofac Surg 1986;14:26–33 8. Merkx MA, Fennis JP, Verhagen CM, et al. Reconstruction of the mandible using preshaped 2.3 mm titanium plates, autogenous particulate cortico-cancellous bone grafts and platelet rich plasma: a report on eight patients. Int J Oral Maxillofac Surg 2004;33:733– 739 9. Alpert B, Kushner GM, Tiwana PS. Contemporary management of infected mandibular fractures. Craniomaxillofac Trauma Reconstr 2008;1:25–29
The Effect of Adenoidectomy Operation Made on Patients With Adenoid Hypertrophy on Cardiovascular Risk Reduction To the Editor: With great eagerness, we have read the study in your journal entitled ‘‘Mean Platelet Volume Levels in Children With Adenoid Hypertrophy’’ by Kucur et al.1 We would like to make some comments about this study. In recent years, many studies that state there is a significant relation between the increase in mean platelet volume (MPV) and the increase in cardiovascular disease risk have been published.2,3 Besides this, some studies that search for the relation between adenoid hypertrophy, MPV, and cardiovascular disease risk have been reported.1,4 In the results of these studies, there are conflicting comments about the effect of MPV value to the cardiovascular disease risk. Although a good number of assertive results have been announced in these studies, sufficient usage area of MPV value measurement has not occurred in the follow-up and treatment of patients clinically as there is no fully standardized method of this parameter. Some of the factors that affect the standardization of MPV measurement are the environment of blood taking, type and amount of anticoagulant in the blood collection tube, the duration between blood taking and examination, the device used in examination, and the calibration time of the device.3 It has been reported that there are measurement differences up to 40% even among the devices in the studies in which different devices were used.5,6 In this study, the fact that MPV value has been found higher in patients with adenoid hypertrophy in proportion to the control group
#
2015 Mutaz B. Habal, MD
Correspondence
is agreeable to literature information. Besides this, we think that it is an assertive statement that the decrease in MPV value measured in the third month in comparison with preoperative period in patients on whom adenoidectomy operation have been performed would enable cardiovascular risk reduction, and for that reason, MPV value may be a parameter for this situation. Because, as stated before, MPV value is a very variable parameter, and if we think that the lifetime of thrombocytes is between 7 and 10 days, this change in MPV expressed at the end of the study may arise from many other factors, as waiting for 3 months for control MPV can cause variance at hemogram parameters. While hemoglobin and thrombocyte count values between the control and patient groups were stated in the study, the values of preoperative and postoperative patient groups and the changes in these values were not stated. Moreover, it is not clear how long blood samples taken from test subjects stayed in the tube with EDTA and when the blood count was made. At the same time, the patients chosen for the study were well excluded in terms of cardiac disease, and it is not easy to say that cardiovascular disease risk will decrease on the third months in this case group that has essentially no cardiovascular disease risk. As a consequence, even if MPV has been associated with many illnesses recently, it does not seem possible for now to evaluate these results with cardiovascular diseases in the limited studies that state MPV value is increased in patients with nasal septum deviation. In order to make better comments about this issue, we think that different studies should be made on the cases that have equal high cardiovascular disease risk and evaluate the long-term follow-up results of these. Murat Sereflican, MD Veysel Yurttas, MD Department of Otolaryngology Abant Izzet Baysal University Faculty of Medicine Bolu, Turkey [email protected] Fatma Erdem, MD Department of Cardiology Abant Izzet Baysal University Faculty of Medicine Bolu, Turkey
REFERENCES 1. Kucur M, Kulekci S, Zorlu A, et al. Mean platelet volume levels in children with adenoid hypertrophy. J Craniofac Surg 2014;25: e29–e31 2. Chu SG, Becker RC, Berger PB, et al. Mean platelet volume as a predictor of cardiovascular risk: a systematic review and meta-analysis. J Thromb Haemost 2010;8:148–156 3. Vizioli L, Muscari S, Muscari A. The relationship of mean platelet volume with the risk and prognosis of cardiovascular diseases. Int J Clin Pract 2009;63:1509–1515 4. Cengiz C, Erhan Y, Murat T, et al. Values of mean platelet volume in patients with chronic tonsillitis and adenoid hypertrophy. Pak J Med Sci 2013;29:569–572 5. Lance´ MD, Sloep M, Henskens YM, et al. Mean platelet volume as a diagnostic marker for cardiovascular disease: drawbacks of preanalytical conditions and measuring techniques. Clin Appl Thromb Hemost 2012;18:561–568 6. Jackson SR, Carter JM. Platelet volume: laboratory measurement and clinical application. Blood Rev 1993;7:104–113
943
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
