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14. Watcha MF, White PF. Postoperative nausea and vomiting: its etiology, treatment, and prevention. Anesthesiology 1992;77:162Y184 15. Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003;97:62Y71 16. Pandey CK, Priye S, Ambesh SP, et al. Prophylactic gabapentin for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a randomized, double blind, placebo-controlled study. J Postgrad Med 2006;52:97Y100 17. Turan A, Karamanlio B, Memi D, et al. Analgesic effects of gabapentin after spinal surgery. Anesthesiology 2004;100:935Y938 18. Mathiesen O, MLiniche S, Dahl JB. Gabapentin and postoperative pain: a qualitative and quantitative systematic review, with focus on procedure. BMC Anesthesiology 2007;7:2253Y2257 19. Balfour JA, Goa KL. Dolasetron: a review of its pharmacology and therapeutic potential in the management of nausea and vomiting induced by chemotherapy, radiotherapy or surgery. Drugs 1997;54:273Y298 20. Perrott DL, Yuen JP, Andresen RV, et al. Office-based ambulatory anesthesia: outcomes of clinical practice of oral and maxillofacial surgeons. J Oral Maxillofac Surg 2003;61:983 21. Carrol NV, Miederhoff P, Cox FM. Postoperative nausea and vomiting after discharge from outpatient surgery centers. Anesth Analg 1995;80:903Y909 22. Tramer MR. A rational approach to the control of postoperative nausea and vomiting: evidence from systematic reviews. Part I. Efficacy and harm of antiemetic interventions, and methodological issues. Acta Anaesthesiol Scand 2001;45:4Y13 23. Hornby PJ. Central neurocircuitry associated with emesis. Am J Med 2001;111(suppl 8A):106SY112S 24. McQuaid KR. Alimentary tract. In: Tierney LM, ed. Current Medical Diagnosis and Treatment. 42nd ed. New York: Lange Medical Books/ McGraw-Hill, 2003:573Y575 25. Flake ZA, Scalley RD, Bailey AG. Practical selection of antiemetics. Am Fam Physician 2004;69:1169Y1174 26. Bsat FA, Hoffman DE, Seubert DE. Comparison of three outpatient regimens in the management of nausea and vomiting in pregnancy. J Perinatol 2003;23:531 27. Kvisselgaard N. Chlorpromazine and chlorcyclizine in the prevention of postoperative nausea and vomiting. Acta Anaesth Scand 2007;51:979Y988 28. McKay WP, Surtie E, Al-Rawwaf M, et al. A pilot randomized controlled trial of chlorpromazine to prevent postoperative nausea and vomiting. Internet J Anesthesiol 2010;24:10 29. Watcha MF, Smith I. Cost-effectiveness analysis of antiemetic therapy for ambulatory surgery. J Clin Anesth 1994;6:370Y377 30. Rang HP, Dale MM, Ritter JM, et al. Pharmacology. 5th ed. Edinburgh: Churchill Livingstone, 2003:223 31. Ferrari LR, Donlon JV. Metoclopramide reduces the incidence of vomiting after tonsillectomy in children. Anesth Analg 1992;75:351Y354 32. Alexander R, Fennelly M. Comparison of ondansetron, metoclopramide and placebo as premedicants to reduce nausea and vomiting after major surgery. Anaesthesia 1997;52:695Y698 33. Sandhu T, Tanvatcharaphan P, Cheunjongkolkul VI. Ondansetron versus metoclopramide in prophylaxis of nausea and vomiting for laparoscopic cholecystectomy: a prospective double-blind randomized study. Asian J Surg 2008;31:50Y54 34. Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg 2000;90:186Y194 35. Furst SR, Rodarte A. Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy. Anesthesiology 1994;81:799Y803 36. Wang JJ, Ho ST, Lee SC, et al. The prophylactic effect of dexamethasone on postoperative nausea and vomiting in women undergoing thyroidectomy: a comparison of droperidol with saline. Anesth Analg 1999;89:200Y203 37. Kang L, Chi CH, Yuan YC. The effective dose of dexamethasone for antiemesis after major gynecological surgery. Anesth Analg 1999;89:1316Y1318 38. Guttuso T Jr, Roscoe J, Griggs J. Effect of gabapentin on nausea induced by chemotherapy in patients with breast cancer. Lancet 2003;361:1703Y1705
Brief Clinical Studies
39. Cruz FM, de Iracema Gomes Cubero D, Taranto P, et al. Gabapentin for the prevention of chemotherapy-induced nausea and vomiting: a pilot study. Support Care Cancer 2012;20:601Y606 40. Rubenstein EB, Gralla RJ, Hainsworth JD, et al. Randomized, double-blind, dose response trial across four oral doses of dolasetron for the prevention of acute emesis after moderately emetogenic chemotherapy. Cancer 1998;79:1216Y1224 41. Montvale NJ. 2003 Drug Topics Red Book. Montvale, NJ: Medical Economics, 2003 42. Kovac AL. The prophylactic treatment of postoperative nausea and vomiting in oral and maxillofacial surgery. J Oral Maxillofac Surg 2005;63:1531 43. Burlacu CL, Healy D, Buggy DJ, et al. Continuous gastric decompression for postoperative nausea and vomiting after coronary revascularization surgery. Anesth Analg 2005;100:321Y326 44. Kerger K-H, Mascha E, Steinbrecher B, et al. Routine use of nasogastric tubes does not reduce postoperative nausea and vomiting. Anesth Analg 2009;109:768Y773 45. Cheatham ML, Chapman WC, Key SP, et al. A metaanalysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995;221:469Y476; discussion 476Y468 46. Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg 2005;92:673Y680 47. Magner JJ, McCaul C, Carton E, et al. Effect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after gynaecological laparoscopy: comparison of 30 and 10 ml kg(j1). Br J Anaesth 2004;93:381Y385 48. Precious DS, Multari J, Finley GA, et al. A comparison of patient-controlled and fixed schedule analgesia after orthognathic surgery. J Oral Maxillofac Surg 1997;55:33Y39 49. Fujii Y, Toyooka H, Tanaka H. Prophylactic antiemetic therapy with a combination of granisetron and dexamethasone in patients undergoing middle ear surgery. Br J Anaesth 1998;81:754Y756 50. Janknegt R, Pinckaers JW, Rohof MH, et al. Double-blind comparative study of droperidol, granisetron and granisetron plus dexamethasone as prophylactic anti-emetic therapy in patients undergoing abdominal, gynaecological, breast or otolaryngological surgery. Anaesthesia 1999;54:1059Y1068 51. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999;91:109Y118 52. Silva AC, Ryan FO, Poor DB. Postoperative nausea and vomiting (PONV) after orthognathic surgery: a retrospective study and literature review. J Oral Maxillofac Surg 2006;64:1385Y1397
Surgical Management of Synchronous Central Giant Cell Granuloma and Ossifying Fibroma of the Mandible Massimo Fasolis, MD, Emanuele Zavattero, MD, Paolo Garzino-Demo, MD, Guglielmo Ramieri, MD, DDS, Sid Berrone, MD, DDS Abstract: We describe the surgical management of an uncommon case of synchronous presentation of central giant cell granuloma and ossifying fibroma in the mandible. A mandibular resection was performed and a fibula-free flap was harvested to reconstruct the defect. Key Words: Mandible, surgery, synchronous central giant cell granuloma, ossifying fibroma
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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O
ssifying fibroma (OF) is a well-demarcated benign neoplasm primarily found in the jaw and composed of fibrocellular tissue and mineralized material showing different morphologic appearance.1 Most cases occur during the third and fourth decades of life. The mandible (especially the molar region) is affected more often than the maxilla. Central giant cell granuloma (CGCG) is a benign lesion of the jaws, consisting of multinucleated giant cells and cellular fibrous tissue.2 It is most prevalent in patients younger than 40 years and is more common in the anterior area of the jaw. For both lesions, complete surgical resection is the treatment of choice to avoid recurrence.1Y3 Although CGCG and OF are relatively common diseases, synchronous presentation of CGCG and OF in the jaws is an extremely rare occurrence.4,5 The aim of the present report was to present an unusual case showing synchronous presentation of CGCG and OF in the mandible and to discuss the surgical management.
FIGURE 1. Preoperative facial contour.
CLINICAL REPORT A 46-year-old male patient was referred to Maxillofacial Division, University of Turin, for a painless swelling of the right mandibular region. The patient’s chief complaint was a slowly progressive growth in the right mandible. Clinically, his face showed severe asymmetry at the right mandible area and the maximum oral opening was 2.5 cm (Fig. 1). Oral examination revealed a smooth-surfaced swelling with brown to purple coloration of the overlying mucosa in the right mandibular body. A panoramic radiograph showed a large radiolucent defect involving the symphysis and the right mandibular body until the condyle (Fig. 2). Computed tomography revealed an extensive multiunilocular and hypodense image associated with the clinical expansion of the mandible (Fig. 3). Incisional biopsies were performed in the reported lesion under general anesthesia, and all specimens showed a similar histopathologic pattern. Hematoxylin and eosinYstained sections showed well-demarcated lesions that were separated from the surrounding bone by a thin zone of fibrous tissue. The lesions were mainly composed of cellular fibrous tissue rich in fibroblasts, with occasional areas showing a storiform pattern. There were also multinucleated giant cells in a stroma mainly composed of ovoid mesenchymal cells, with a prominent endothelial component. Based on the clinical, imaging, and histopathologic features, a diagnosis of fibrosseus neoplasm was rendered. A surgical procedure was then planned with the aid of a stereolithographic model (Fig. 4).
From the Division of Maxillofacial Surgery, Head and Neck Department, San Giovanni Battista Hospital, University of Turin, Turin, Italy. Received May 23, 2013. Accepted for publication June 16, 2013. Address correspondence and reprint requests to Dr Emanuele Zavattero, Division of Maxillofacial Surgery, Head and Neck Department, San Giovanni Battista Hospital, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2ddc4
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FIGURE 2. Panoramic radiograph shows a large, quite well-demarcated radiolucency surrounded by a sclerotic border.
Leg angiography to evaluate peroneal circulation was performed preoperatively Under general anesthesia, surgical resection of the lesion in the mandible was performed. Arch bars and intermaxillary fixation were placed to maintain the occlusion after mandibulectomy. The defect was reconstructed with a fibula-free flap. The fibula flap was harvested according to the standard lateral approach described by Gilbert,6 and 2 osteotomies were performed. The fibula was placed at the inferior mandibular margin to permit an excellent contour. The graft stabilization to the mandible and the fibular osteotomies were performed using titanium plates.
FIGURE 3. CT scan shows an extensive multiunilocular and hypodense image.
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 24, Number 6, November 2013
Brief Clinical Studies
FIGURE 7. Panoramic radiograph: initial bone distraction.
Osteoclast-type giant cells are a prominent component of CGCG and have also been associated with a wide a range of odontogenic and
nonodontogenic jaw lesions. The association of CGCG with fibroosseous lesions has rarely been reported.7 CGCG is a relatively common disease, which accounts for 7% to 10% of benign lesions in the jaws. However, CGCG associated with other fibro-osseous lesions of the jaws is uncommon.8 Radiologically, OF is a well-defined and unilocular lesion. It may present as radiolucent; more often it exhibits varying degrees of radiopacity, depending on the degree of calcification. Histopathological findings in this case revealed interconnecting bony trabeculae or cementum-like materials as well as a few multinucleated giant cells in the left mandibular area. OF may exhibit localized giant cells, but giant cells were observed scattered on fibrous stroma in combined lesion.9 The most frequent presentation of CGCG was a well-defined unilocular or multilocular radiolucency. Radiological features associated with an aggressive behavior (perforation, root resorption, and poorly defined margins) were frequent in CGCG cases. A variety of histological features were observed in CGCG, characterized by the presence of multinucleated giant cells in a stroma mainly composed of ovoid mesenchymal cells, with a prominent endothelial component. Conservative surgery was addressed for small lesions, whereas larger lesions required radical surgery. Both surgical methods of treatment for OF and CGCG, conservative or radical, are acceptable by most authors in the Englishlanguage literature during the past 30 years, as reported in their clinical studies.10Y14 A small and well-defined OF associated with CGCG can be cured by curettage or enucleation, whereas larger lesions such as that present in this case in the right mandibular body, which show a more aggressive pattern, require more radical surgery. Therefore, complete surgical resection is the treatment of choice in this case for CGCG and OF. Complete surgical resection and simultaneous reconstruction with a fibula-free flap were performed to achieve functional and morphological restoration. Recurrence was not evident in this case at the 30-month follow-up. Therefore, surgical resection proved to be an effective treatment in considering aggressive behavior in this case.
FIGURE 6. Facial contour, with a good aesthetic outcome.
FIGURE 8. Panoramic radiograph: final bone distraction.
FIGURE 4. Preoperative stereolithographic model.
FIGURE 5. Panoramic radiograph: mandibular bone reconstruction with fibula-free flap.
The recipient vessels used for anastomosis were the facial artery and the internal jugular vein. The microscopic findings of the lesion showed also different features to those described in the previous incisional biopsies. The diagnosis of OF associated with GCGC was rendered. No remarkable postoperative complications were reported. A good bone reconstruction and aesthetic outcome were reached (Figs. 5, 6). The patient was free of local recurrence at the 30-month follow-up. One week after the intervention, no pain was reported and her maximal incisal opening was 30 mm. The patient is still under periodic clinical and radiographic follow-up. To obtain a suitable height for dental implants 8 months after the main operation, vertical distraction osteogenesis technique was applied (Figs. 7, 8). After 4 months, 6 dental implants were placed in the distracted fibula bone.
DISCUSSION
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Because of the small number of these cases, the biologic behavior of the combined lesions is uncertain. However, because recurrences are rare in OF, there is some indication to suggest that the CGCG component in the lesions may drive the clinical behavior toward a more aggressive behavior than that of classical COF. Therefore, it is recommended that the combined cases are treated by radical surgery and closely followed up.
REFERENCES 1. Barnes L, Eveson JW, Reichart P, Sidransky D, eds. In: World Health Organization. Classification of Tumours. Pathology and Genetics of Head and Neck Tumours. Lyon: IARC, 2005:319 2. Crusoe-Rebello I, Torres MG, Burgos V, et al. Hybrid lesion: central giant cell granuloma and benign fibro-osseous lesion. Dentomaxillofac Radiol 2009;38:421Y425 3. Vegas-Bustamante E, Gargallo-Albiol J, Berini-Ayte´s L, et al. Benign fibro-osseous lesions of the maxillas: analysis of 11 cases. Med Oral Patol Oral Cir Bucal 2008;13:E653YE656 4. Waldron CA. Fibro-osseous lesions of the jaws. J Oral Maxillofac Surg 1993;51:828Y835 5. Su L, Weathers DR, Waldron CA. Distinguishing features of focal cemento-osseous dysplasias and cemento-ossifying fibromas: I. A pathologic spectrum of 316 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:301Y309 6. Gilbert A. Vascularised transfer of the fibular shaft. Int J Microsurg 1979;1:100 7. Taylor AM, Flores VB, Franco AMD. Combined central odontogenic fibroma and giant cell granuloma-like lesion of the mandible: report of a case and review of the literature. J OralMaxillofac Surg 1999;57:1258Y1262 8. Penfold CN, McCullagh P, Eveson JW, et al. Giant cell lesions complicating fibro-osseous conditions of the jaws. Int J Oral Maxillofac Surg 1993;22:158Y162 9. Speight PM, Carlos R. Maxillofacial fibro-osseous lesions. Curr Diagn Pathol 2006;12:1Y10 10. Kaplan I, Manor I, Yahalom R, et al. Central giant cell granuloma associated with central ossifying fibroma of the jaws: a clinicopathologic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e35Ye41 11. Mintz S, Velez I. Central ossifying fibroma: an analysis of 20 cases and review of the literature. Quintessence Int 2007;38:221Y227 12. Chang CC, Hung HY, Chang JY, et al. Central ossifying fibroma: a clinicopathologic study of 28 cases. J Formos Med Assoc 2008;107:288Y294 13. Zachariades N, Vairaktaris E, Papanicolaou S, et al. Ossifying fibroma of the jaws. Review of the literature and report of 16 cases. Int J Oral Surg 1984;13:1Y6 14. Sciubba JJ, Younai F. Ossifying fibroma of the mandible and maxilla: review of 18 cases. J Oral Pathol Med 1989;18:315Y321
Reconstruction of Congenital Vomeral Bone Defect Using the Outer Table of the Skull Satoshi Onoda, MD, Yoshihiro Kimata, MD, Shogo Azumi, MD, Yuki Otsuki, MD Abstract: A congenital nasal septal defect involving vomeral bone is a rare nasal anomaly, and few reconstructed cases have been reported. Reconstruction of the nasal septum using the outer table
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of skull to allow the use of glasses was performed. The patient’s postoperative course was uneventful, and the patient was discharged on the tenth postoperative day. A transferred bone remains and shows no deviation to the right or left in the ninth postoperative month. The tubercle of the nasal part remains, and the patient is satisfied with the cosmetic result 9 months postoperatively. The timing of the operation and the surgical procedure are discussed. Key Words: Congenital vomeral bone defect, outer table of the skull, reconstruction
T
he nasal septum is composed of septal cartilage, vomeral bone, and perpendicular bone. A defect of the nasal septum results in a functional and cosmetic disorder. An acquired defect of the nasal septum may be due to causes such as trauma,1 infection, and resection of tumor.2 However, a congenital nasal septal defect of vomeral bone is a very rare nasal anomaly,3Y5 and few reconstructed cases have been reported. There has been a report of a congenital nasal septal defect in a patient with thalassemia.6 Because reconstruction of the nasal septum for a sporadic congenital vomeral defect was performed using the outer table of the skull and good results were obtained, this case is reported.
CLINICAL REPORT A 56-year-old man was known to have a nasal anomaly at birth. He had no particular symptoms, and the nasal anomaly was pointed out by a friend in later childhood, after which he became conscious of having a flat nose. Later, a nasal anomaly was noted during a school health survey. Then, a neighborhood doctor diagnosed an abnormality of the nasal septal cartilage during a checkup but told him that it was difficult to cure. Forty years later, he hoped to wear glasses for farsightedness so that he could continue to work. He was referred by a local doctor for a checkup at our department, where a marked saddle nose was noted at the initial visit (Fig. 1). On computed tomography, a vomeral defect and a perpendicular bone defect were seen. Operative methods were discussed with the patient, and reconstruction of the nasal septum using the outer table of the skull was performed.
Operation A W incision was first made in the scalp, with separation of the galea and upper periosteum. The separated layer was changed to the subperiosteum near the hairline, and separation was performed to the base of the nasal bone. The periosteum of the skull in the top right corner was separated, and the outer table of the skull was
From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Science, University of Okayama, Okayama, Japan. Received April 8, 2013. Accepted for publication June 23, 2013. Address correspondence and reprint requests to Satoshi Onoda, MD, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Science, University of Okayama, 2-5-1 Shikata, Okayama 700-8558, Japan; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a238e0
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 24, Number 6, November 2013
14. Watcha MF, White PF. Postoperative nausea and vomiting: its etiology, treatment, and prevention. Anesthesiology 1992;77:162Y184 15. Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003;97:62Y71 16. Pandey CK, Priye S, Ambesh SP, et al. Prophylactic gabapentin for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a randomized, double blind, placebo-controlled study. J Postgrad Med 2006;52:97Y100 17. Turan A, Karamanlio B, Memi D, et al. Analgesic effects of gabapentin after spinal surgery. Anesthesiology 2004;100:935Y938 18. Mathiesen O, MLiniche S, Dahl JB. Gabapentin and postoperative pain: a qualitative and quantitative systematic review, with focus on procedure. BMC Anesthesiology 2007;7:2253Y2257 19. Balfour JA, Goa KL. Dolasetron: a review of its pharmacology and therapeutic potential in the management of nausea and vomiting induced by chemotherapy, radiotherapy or surgery. Drugs 1997;54:273Y298 20. Perrott DL, Yuen JP, Andresen RV, et al. Office-based ambulatory anesthesia: outcomes of clinical practice of oral and maxillofacial surgeons. J Oral Maxillofac Surg 2003;61:983 21. Carrol NV, Miederhoff P, Cox FM. Postoperative nausea and vomiting after discharge from outpatient surgery centers. Anesth Analg 1995;80:903Y909 22. Tramer MR. A rational approach to the control of postoperative nausea and vomiting: evidence from systematic reviews. Part I. Efficacy and harm of antiemetic interventions, and methodological issues. Acta Anaesthesiol Scand 2001;45:4Y13 23. Hornby PJ. Central neurocircuitry associated with emesis. Am J Med 2001;111(suppl 8A):106SY112S 24. McQuaid KR. Alimentary tract. In: Tierney LM, ed. Current Medical Diagnosis and Treatment. 42nd ed. New York: Lange Medical Books/ McGraw-Hill, 2003:573Y575 25. Flake ZA, Scalley RD, Bailey AG. Practical selection of antiemetics. Am Fam Physician 2004;69:1169Y1174 26. Bsat FA, Hoffman DE, Seubert DE. Comparison of three outpatient regimens in the management of nausea and vomiting in pregnancy. J Perinatol 2003;23:531 27. Kvisselgaard N. Chlorpromazine and chlorcyclizine in the prevention of postoperative nausea and vomiting. Acta Anaesth Scand 2007;51:979Y988 28. McKay WP, Surtie E, Al-Rawwaf M, et al. A pilot randomized controlled trial of chlorpromazine to prevent postoperative nausea and vomiting. Internet J Anesthesiol 2010;24:10 29. Watcha MF, Smith I. Cost-effectiveness analysis of antiemetic therapy for ambulatory surgery. J Clin Anesth 1994;6:370Y377 30. Rang HP, Dale MM, Ritter JM, et al. Pharmacology. 5th ed. Edinburgh: Churchill Livingstone, 2003:223 31. Ferrari LR, Donlon JV. Metoclopramide reduces the incidence of vomiting after tonsillectomy in children. Anesth Analg 1992;75:351Y354 32. Alexander R, Fennelly M. Comparison of ondansetron, metoclopramide and placebo as premedicants to reduce nausea and vomiting after major surgery. Anaesthesia 1997;52:695Y698 33. Sandhu T, Tanvatcharaphan P, Cheunjongkolkul VI. Ondansetron versus metoclopramide in prophylaxis of nausea and vomiting for laparoscopic cholecystectomy: a prospective double-blind randomized study. Asian J Surg 2008;31:50Y54 34. Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg 2000;90:186Y194 35. Furst SR, Rodarte A. Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy. Anesthesiology 1994;81:799Y803 36. Wang JJ, Ho ST, Lee SC, et al. The prophylactic effect of dexamethasone on postoperative nausea and vomiting in women undergoing thyroidectomy: a comparison of droperidol with saline. Anesth Analg 1999;89:200Y203 37. Kang L, Chi CH, Yuan YC. The effective dose of dexamethasone for antiemesis after major gynecological surgery. Anesth Analg 1999;89:1316Y1318 38. Guttuso T Jr, Roscoe J, Griggs J. Effect of gabapentin on nausea induced by chemotherapy in patients with breast cancer. Lancet 2003;361:1703Y1705
Brief Clinical Studies
39. Cruz FM, de Iracema Gomes Cubero D, Taranto P, et al. Gabapentin for the prevention of chemotherapy-induced nausea and vomiting: a pilot study. Support Care Cancer 2012;20:601Y606 40. Rubenstein EB, Gralla RJ, Hainsworth JD, et al. Randomized, double-blind, dose response trial across four oral doses of dolasetron for the prevention of acute emesis after moderately emetogenic chemotherapy. Cancer 1998;79:1216Y1224 41. Montvale NJ. 2003 Drug Topics Red Book. Montvale, NJ: Medical Economics, 2003 42. Kovac AL. The prophylactic treatment of postoperative nausea and vomiting in oral and maxillofacial surgery. J Oral Maxillofac Surg 2005;63:1531 43. Burlacu CL, Healy D, Buggy DJ, et al. Continuous gastric decompression for postoperative nausea and vomiting after coronary revascularization surgery. Anesth Analg 2005;100:321Y326 44. Kerger K-H, Mascha E, Steinbrecher B, et al. Routine use of nasogastric tubes does not reduce postoperative nausea and vomiting. Anesth Analg 2009;109:768Y773 45. Cheatham ML, Chapman WC, Key SP, et al. A metaanalysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995;221:469Y476; discussion 476Y468 46. Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg 2005;92:673Y680 47. Magner JJ, McCaul C, Carton E, et al. Effect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after gynaecological laparoscopy: comparison of 30 and 10 ml kg(j1). Br J Anaesth 2004;93:381Y385 48. Precious DS, Multari J, Finley GA, et al. A comparison of patient-controlled and fixed schedule analgesia after orthognathic surgery. J Oral Maxillofac Surg 1997;55:33Y39 49. Fujii Y, Toyooka H, Tanaka H. Prophylactic antiemetic therapy with a combination of granisetron and dexamethasone in patients undergoing middle ear surgery. Br J Anaesth 1998;81:754Y756 50. Janknegt R, Pinckaers JW, Rohof MH, et al. Double-blind comparative study of droperidol, granisetron and granisetron plus dexamethasone as prophylactic anti-emetic therapy in patients undergoing abdominal, gynaecological, breast or otolaryngological surgery. Anaesthesia 1999;54:1059Y1068 51. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999;91:109Y118 52. Silva AC, Ryan FO, Poor DB. Postoperative nausea and vomiting (PONV) after orthognathic surgery: a retrospective study and literature review. J Oral Maxillofac Surg 2006;64:1385Y1397
Surgical Management of Synchronous Central Giant Cell Granuloma and Ossifying Fibroma of the Mandible Massimo Fasolis, MD, Emanuele Zavattero, MD, Paolo Garzino-Demo, MD, Guglielmo Ramieri, MD, DDS, Sid Berrone, MD, DDS Abstract: We describe the surgical management of an uncommon case of synchronous presentation of central giant cell granuloma and ossifying fibroma in the mandible. A mandibular resection was performed and a fibula-free flap was harvested to reconstruct the defect. Key Words: Mandible, surgery, synchronous central giant cell granuloma, ossifying fibroma
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery
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& Volume 24, Number 6, November 2013
O
ssifying fibroma (OF) is a well-demarcated benign neoplasm primarily found in the jaw and composed of fibrocellular tissue and mineralized material showing different morphologic appearance.1 Most cases occur during the third and fourth decades of life. The mandible (especially the molar region) is affected more often than the maxilla. Central giant cell granuloma (CGCG) is a benign lesion of the jaws, consisting of multinucleated giant cells and cellular fibrous tissue.2 It is most prevalent in patients younger than 40 years and is more common in the anterior area of the jaw. For both lesions, complete surgical resection is the treatment of choice to avoid recurrence.1Y3 Although CGCG and OF are relatively common diseases, synchronous presentation of CGCG and OF in the jaws is an extremely rare occurrence.4,5 The aim of the present report was to present an unusual case showing synchronous presentation of CGCG and OF in the mandible and to discuss the surgical management.
FIGURE 1. Preoperative facial contour.
CLINICAL REPORT A 46-year-old male patient was referred to Maxillofacial Division, University of Turin, for a painless swelling of the right mandibular region. The patient’s chief complaint was a slowly progressive growth in the right mandible. Clinically, his face showed severe asymmetry at the right mandible area and the maximum oral opening was 2.5 cm (Fig. 1). Oral examination revealed a smooth-surfaced swelling with brown to purple coloration of the overlying mucosa in the right mandibular body. A panoramic radiograph showed a large radiolucent defect involving the symphysis and the right mandibular body until the condyle (Fig. 2). Computed tomography revealed an extensive multiunilocular and hypodense image associated with the clinical expansion of the mandible (Fig. 3). Incisional biopsies were performed in the reported lesion under general anesthesia, and all specimens showed a similar histopathologic pattern. Hematoxylin and eosinYstained sections showed well-demarcated lesions that were separated from the surrounding bone by a thin zone of fibrous tissue. The lesions were mainly composed of cellular fibrous tissue rich in fibroblasts, with occasional areas showing a storiform pattern. There were also multinucleated giant cells in a stroma mainly composed of ovoid mesenchymal cells, with a prominent endothelial component. Based on the clinical, imaging, and histopathologic features, a diagnosis of fibrosseus neoplasm was rendered. A surgical procedure was then planned with the aid of a stereolithographic model (Fig. 4).
From the Division of Maxillofacial Surgery, Head and Neck Department, San Giovanni Battista Hospital, University of Turin, Turin, Italy. Received May 23, 2013. Accepted for publication June 16, 2013. Address correspondence and reprint requests to Dr Emanuele Zavattero, Division of Maxillofacial Surgery, Head and Neck Department, San Giovanni Battista Hospital, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2ddc4
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FIGURE 2. Panoramic radiograph shows a large, quite well-demarcated radiolucency surrounded by a sclerotic border.
Leg angiography to evaluate peroneal circulation was performed preoperatively Under general anesthesia, surgical resection of the lesion in the mandible was performed. Arch bars and intermaxillary fixation were placed to maintain the occlusion after mandibulectomy. The defect was reconstructed with a fibula-free flap. The fibula flap was harvested according to the standard lateral approach described by Gilbert,6 and 2 osteotomies were performed. The fibula was placed at the inferior mandibular margin to permit an excellent contour. The graft stabilization to the mandible and the fibular osteotomies were performed using titanium plates.
FIGURE 3. CT scan shows an extensive multiunilocular and hypodense image.
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 7. Panoramic radiograph: initial bone distraction.
Osteoclast-type giant cells are a prominent component of CGCG and have also been associated with a wide a range of odontogenic and
nonodontogenic jaw lesions. The association of CGCG with fibroosseous lesions has rarely been reported.7 CGCG is a relatively common disease, which accounts for 7% to 10% of benign lesions in the jaws. However, CGCG associated with other fibro-osseous lesions of the jaws is uncommon.8 Radiologically, OF is a well-defined and unilocular lesion. It may present as radiolucent; more often it exhibits varying degrees of radiopacity, depending on the degree of calcification. Histopathological findings in this case revealed interconnecting bony trabeculae or cementum-like materials as well as a few multinucleated giant cells in the left mandibular area. OF may exhibit localized giant cells, but giant cells were observed scattered on fibrous stroma in combined lesion.9 The most frequent presentation of CGCG was a well-defined unilocular or multilocular radiolucency. Radiological features associated with an aggressive behavior (perforation, root resorption, and poorly defined margins) were frequent in CGCG cases. A variety of histological features were observed in CGCG, characterized by the presence of multinucleated giant cells in a stroma mainly composed of ovoid mesenchymal cells, with a prominent endothelial component. Conservative surgery was addressed for small lesions, whereas larger lesions required radical surgery. Both surgical methods of treatment for OF and CGCG, conservative or radical, are acceptable by most authors in the Englishlanguage literature during the past 30 years, as reported in their clinical studies.10Y14 A small and well-defined OF associated with CGCG can be cured by curettage or enucleation, whereas larger lesions such as that present in this case in the right mandibular body, which show a more aggressive pattern, require more radical surgery. Therefore, complete surgical resection is the treatment of choice in this case for CGCG and OF. Complete surgical resection and simultaneous reconstruction with a fibula-free flap were performed to achieve functional and morphological restoration. Recurrence was not evident in this case at the 30-month follow-up. Therefore, surgical resection proved to be an effective treatment in considering aggressive behavior in this case.
FIGURE 6. Facial contour, with a good aesthetic outcome.
FIGURE 8. Panoramic radiograph: final bone distraction.
FIGURE 4. Preoperative stereolithographic model.
FIGURE 5. Panoramic radiograph: mandibular bone reconstruction with fibula-free flap.
The recipient vessels used for anastomosis were the facial artery and the internal jugular vein. The microscopic findings of the lesion showed also different features to those described in the previous incisional biopsies. The diagnosis of OF associated with GCGC was rendered. No remarkable postoperative complications were reported. A good bone reconstruction and aesthetic outcome were reached (Figs. 5, 6). The patient was free of local recurrence at the 30-month follow-up. One week after the intervention, no pain was reported and her maximal incisal opening was 30 mm. The patient is still under periodic clinical and radiographic follow-up. To obtain a suitable height for dental implants 8 months after the main operation, vertical distraction osteogenesis technique was applied (Figs. 7, 8). After 4 months, 6 dental implants were placed in the distracted fibula bone.
DISCUSSION
* 2013 Mutaz B. Habal, MD
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Because of the small number of these cases, the biologic behavior of the combined lesions is uncertain. However, because recurrences are rare in OF, there is some indication to suggest that the CGCG component in the lesions may drive the clinical behavior toward a more aggressive behavior than that of classical COF. Therefore, it is recommended that the combined cases are treated by radical surgery and closely followed up.
REFERENCES 1. Barnes L, Eveson JW, Reichart P, Sidransky D, eds. In: World Health Organization. Classification of Tumours. Pathology and Genetics of Head and Neck Tumours. Lyon: IARC, 2005:319 2. Crusoe-Rebello I, Torres MG, Burgos V, et al. Hybrid lesion: central giant cell granuloma and benign fibro-osseous lesion. Dentomaxillofac Radiol 2009;38:421Y425 3. Vegas-Bustamante E, Gargallo-Albiol J, Berini-Ayte´s L, et al. Benign fibro-osseous lesions of the maxillas: analysis of 11 cases. Med Oral Patol Oral Cir Bucal 2008;13:E653YE656 4. Waldron CA. Fibro-osseous lesions of the jaws. J Oral Maxillofac Surg 1993;51:828Y835 5. Su L, Weathers DR, Waldron CA. Distinguishing features of focal cemento-osseous dysplasias and cemento-ossifying fibromas: I. A pathologic spectrum of 316 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:301Y309 6. Gilbert A. Vascularised transfer of the fibular shaft. Int J Microsurg 1979;1:100 7. Taylor AM, Flores VB, Franco AMD. Combined central odontogenic fibroma and giant cell granuloma-like lesion of the mandible: report of a case and review of the literature. J OralMaxillofac Surg 1999;57:1258Y1262 8. Penfold CN, McCullagh P, Eveson JW, et al. Giant cell lesions complicating fibro-osseous conditions of the jaws. Int J Oral Maxillofac Surg 1993;22:158Y162 9. Speight PM, Carlos R. Maxillofacial fibro-osseous lesions. Curr Diagn Pathol 2006;12:1Y10 10. Kaplan I, Manor I, Yahalom R, et al. Central giant cell granuloma associated with central ossifying fibroma of the jaws: a clinicopathologic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e35Ye41 11. Mintz S, Velez I. Central ossifying fibroma: an analysis of 20 cases and review of the literature. Quintessence Int 2007;38:221Y227 12. Chang CC, Hung HY, Chang JY, et al. Central ossifying fibroma: a clinicopathologic study of 28 cases. J Formos Med Assoc 2008;107:288Y294 13. Zachariades N, Vairaktaris E, Papanicolaou S, et al. Ossifying fibroma of the jaws. Review of the literature and report of 16 cases. Int J Oral Surg 1984;13:1Y6 14. Sciubba JJ, Younai F. Ossifying fibroma of the mandible and maxilla: review of 18 cases. J Oral Pathol Med 1989;18:315Y321
Reconstruction of Congenital Vomeral Bone Defect Using the Outer Table of the Skull Satoshi Onoda, MD, Yoshihiro Kimata, MD, Shogo Azumi, MD, Yuki Otsuki, MD Abstract: A congenital nasal septal defect involving vomeral bone is a rare nasal anomaly, and few reconstructed cases have been reported. Reconstruction of the nasal septum using the outer table
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of skull to allow the use of glasses was performed. The patient’s postoperative course was uneventful, and the patient was discharged on the tenth postoperative day. A transferred bone remains and shows no deviation to the right or left in the ninth postoperative month. The tubercle of the nasal part remains, and the patient is satisfied with the cosmetic result 9 months postoperatively. The timing of the operation and the surgical procedure are discussed. Key Words: Congenital vomeral bone defect, outer table of the skull, reconstruction
T
he nasal septum is composed of septal cartilage, vomeral bone, and perpendicular bone. A defect of the nasal septum results in a functional and cosmetic disorder. An acquired defect of the nasal septum may be due to causes such as trauma,1 infection, and resection of tumor.2 However, a congenital nasal septal defect of vomeral bone is a very rare nasal anomaly,3Y5 and few reconstructed cases have been reported. There has been a report of a congenital nasal septal defect in a patient with thalassemia.6 Because reconstruction of the nasal septum for a sporadic congenital vomeral defect was performed using the outer table of the skull and good results were obtained, this case is reported.
CLINICAL REPORT A 56-year-old man was known to have a nasal anomaly at birth. He had no particular symptoms, and the nasal anomaly was pointed out by a friend in later childhood, after which he became conscious of having a flat nose. Later, a nasal anomaly was noted during a school health survey. Then, a neighborhood doctor diagnosed an abnormality of the nasal septal cartilage during a checkup but told him that it was difficult to cure. Forty years later, he hoped to wear glasses for farsightedness so that he could continue to work. He was referred by a local doctor for a checkup at our department, where a marked saddle nose was noted at the initial visit (Fig. 1). On computed tomography, a vomeral defect and a perpendicular bone defect were seen. Operative methods were discussed with the patient, and reconstruction of the nasal septum using the outer table of the skull was performed.
Operation A W incision was first made in the scalp, with separation of the galea and upper periosteum. The separated layer was changed to the subperiosteum near the hairline, and separation was performed to the base of the nasal bone. The periosteum of the skull in the top right corner was separated, and the outer table of the skull was
From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Science, University of Okayama, Okayama, Japan. Received April 8, 2013. Accepted for publication June 23, 2013. Address correspondence and reprint requests to Satoshi Onoda, MD, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Science, University of Okayama, 2-5-1 Shikata, Okayama 700-8558, Japan; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a238e0
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
