The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
4. 5. 6.
7. FIGURE 8. Postoperative orthopantomograph showing the residual mandible.
(as the maxillary sinus), and exclusion of a distant metastasis.2,4Y11 Because of their rarity, it is difficult to assess the real incidence of the different subtypes of PIOSCC.1 According to the scientific literature, 200 cases of PIOSCC are described as of today: 113 of cyst origin and 87 de novo cases.12,13 Tumors affecting the maxilla are more likely of cyst origin, whereas those affecting the mandible arise de novo.13,14 As observed in our patients, PIOSCC is more likely to affect adult males. The mean age for patients with PIOSCC is 55 years, and it is slightly slower for de novo tumors (60.2 vs 53.7%).13,15 Similarly, PIOSCCs derived from KCOT are also encountered in adult male patients who are generally older than 40 years.13 Lymph node metastasis is higher in the de novo group (4.4% vs 36.4%), although the overall 5-year survival rate is superimposable (38.0% vs 36.3%, respectively).10Y14 Clinical symptoms are variable, including pain, mandibular swelling, and paresthesia/anesthesia of the lower lip due to the perineural invasion of the inferior alveolar nerve.1Y3,6Y9,12,13,15,16 However, most cases are asymptomatic and are discovered incidentally during normal routine radiography.3Y9,15,17,18 Primary intraosseous odontogenic squamous cell carcinoma is an aggressive tumor with a poor clinical outcome affected by a 5-year survival rate ranging between 36.3% and 38.0%.16 These findings may advocate for an initial aggressive surgical treatment to decrease local recurrence rate. Metastatic spread involving cervical lymph nodes has been described in up to 50% of cases of PIOSCC arising de novo, and elective neck dissection is therefore recommended.10Y14 The peculiarity of our cases relies in the superior 5-year survival rate as compared with the data derived from the literature. In particular, our patients did not undergo adjuvant therapy because surgical resection margins and specimens of neck dissection were free from disease, thus suggesting a possible key role of radical surgery in PIOSCC management. Giuseppe Spinelli, MD Francesco Arcuri, MD Davide Rocchetta, MD Tommaso Agostini, MD Department of Maxillofacial Surgery Azienda Ospedaliero-Universitaria Careggi Centro Traumatologico Ortopedico Florence, Italy [email protected]
REFERENCES 1. Eversole LR. Malignant epithelial odontogenic tumors. Semin Diagn Pathol 1999;16:317Y324 2. Eversole LR, Siar CH, van der Waal I. Primary intraosseous squamous cell carcinomas. In: Barnes L, Evson JW, Reichart P, et al., eds. World Health Organization classification of tumors: pathology and genetics of head and neck tumors. Lyon: World Health Organization International Agency for Research on Cancer (IACR) Press, 2005:290Y291 3. Suei Y, Tanimoto K, Taguchi A, et al. Primary intraosseous carcinoma:
8.
9.
10.
11.
12. 13.
14.
15.
16.
17.
18.
Correspondence
review of the literature and diagnostic criteria. J Oral Maxillofac Surg 1994;52:580Y583 Barnes L, Evenson JW, Reichart P. Pathology and genetics of head and neck tumours. Lyon: IARC Press, 2005:283Y328 Muller S, Waldron CA. Primary intraosseous squamous carcinoma. Report of two cases. Int J Oral Maxillofac Surg 1991;20:362Y365 Bodner L, Manor E, Shear M, et al. Primary intraosseous squamous cell carcinoma arising in an odontogenic cystVa clinicopathologic analysis of 116 reported cases. J Oral Pathol Med 2011;21:733Y738 Huang JW, Luo HY, Li Q, et al. Primary intraosseous squamous cell carcinoma of the jaws. Clinicopathologic presentation and prognostic factors. Arch Pathol Lab Med 2009;133:1834Y1840 Sengupta S, Vij H, Vij R. Primary intraosseous carcinoma of the mandible: a report of two cases. J Oral Maxillofac Pathol 2010;14:69Y72 Thomas G, Pandey M, Mathew A, et al. Primary intraosseous carcinoma of the jaw: pooled analysis of world literature and report of two new cases. Int J Oral Maxillofac Surg 2001;30:349Y355 Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer: European Organization for Research and Treatment of Cancer trial 22931. N Engl J Med 2004;350:1945Y1952 Cooper J, Pajak T, Forastiere A, et al. Postoperative concurrent radiotherapy for high risk squamous cell carcinoma of the head and neck: Radiation Therapy Oncology Group 9501/Intergroup. N Engl J Med 2004;350:1937Y1944 Lo Muzio L, Mangini F, De Falco V, et al. Primary intraosseous carcinoma of the mandible: a case report. Oral Oncol 2000;36:305Y307 Gonza´lez-Garcı´a R, Sastre-Pe´rez J, Nam-Cha SH, et al. Primary intraosseous carcinomas of the jaws arising within an odontogenic cyst, ameloblastoma, and de novo: report of new cases with reconstruction considerations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:29Y33 Scheer M, Koch AM, Drebber U, et al. Primary intraosseous carcinoma of the jaws arising from an odontogenic cyst: a case report. J Craniomaxillofac Surg 2004;32:166Y169 Kaffe L, Ardekian I, Peled M, et al. Radiological features of primary intraosseous carcinoma of the jaws. Analysis of the literature and report of a new case. Dentomaxillofac Radiol 1998;27:209Y214 Nomura T, Monobe H, Tamaruya N, et al. Primary intraosseous squamous cell carcinoma of the jaw: two new cases and review of the literature. Eur Arch Otorhinolaryngol 2013;270:375Y379 Lugakingira M, Pytynia K, Kolokythas A, et al. Primary intraosseous carcinoma of the mandible: case report and review of the literature. J Oral Maxillofac Surg 2010;68:2623Y2629 Chaisuparat R, Coletti D, Kolokythas A, et al. Primary intraosseous odontogenic carcinoma arising in an odontogenic cyst or de novo: a clinicopathological study of six new cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:194Y200
Treatment of Unilateral Mandibular Angle Fracture by Closed Reduction To the Editor: Fractures of the mandibular angle represent the largest percentage of mandibular fractures in many studies.1,2 Furthermore, studies have also shown that the angular area is subject to a higher occurrence of postoperative complications3 such as infection and nonunion mainly attributed to the presence of teeth in the fracture line. A 16-year-old adolescent boy was referred to the oral and maxillofacial surgery department of Santa Casa de Ara0atuba Hospital, with complaints of a limited mouth opening and pain caused after an accident at work. Results of an extraoral clinical examination revealed
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1139
Correspondence
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
FIGURE 1. Panoramic radiograph showing the fracture in the region of the mandibular angle involving the tooth 37 (white arrow). FIGURE 3. Frontal image of the patient showing clinically satisfactory mouth opening.
that there was a wound with laceration on the chin and edema. Clinical examination findings verified intraoral alterations and occlusion, possessing premature contacts, with reported pain on mandibular movements of laterality and swelling in the region of the mandibular angle on the left side. After the clinical examination and a radiographic evaluation, the diagnosis of fracture of the region of the left angle of the jaw with a presence of a tooth 37 on discontinued bone line was confirmed (Fig. 1). After a discussion of the case between the team members and the patient’s family, it was decided that a conservative treatment be established because the case was a unilateral angle fracture that was favorable and with no other lines of fracture, the patient seemed to be cooperative with good oral hygiene, and there was little development of the masseter muscle, that is, without much muscular force. It was asked to install braces to start the treatment using heavy rubber bands to minimize the movement of the fractured stumps and guide the occlusion considering canine guidance with dietary restriction. After 5 weeks of accompaniments of trauma, an elastic lighter incentive associated with physical therapy of the jaw was placed, which helped the patient to have a normal lateral movement of the mandible, normal opening and closing of the mouth, as well as a more stable occlusion, even with a restricted diet. In a panoramic radiogram obtained after 8 weeks of conservative treatment (Fig. 2), we observed that the fracture lines were consolidated, similar to the occlusion before the trauma, and that the patient had a satisfactory mouth opening (Fig. 3), mandibular movements of laterality, restored protrusion as well as retrusion without complaints of pain, and no sign of infection. The tooth 37 was subjected to sensitivity tests and pulp vitality, obtaining satisfactory results. The primary goals for the treatment of mandibular fractures are the restoration of occlusion and healing of the fracture.4 Treatment
FIGURE 2. Panoramic radiograph after 8 weeks of treatment showing bone healing achieved with excellent aspect of the region (white arrow).
1140
modalities range from intermaxillary fixation to internal fixation of the bones fragments,5 and these fractures are currently treated through plate/screw osteosynthesis; depending on the case, the bone segmentsare secured through 1-miniplate fixation, through 2miniplate fixation, using a lag screw, or using a single rigid plate at the inferior border of the mandible.6 For the authors, this form of treatment has some advantages such as low cost because there is no need for general anesthesia and for all the necessary support to such a procedure, in addition to not using internal fixation material, as well as the need to return home and be assisted more quickly to daily activities. Obviously, the patient was successfully treated because certain criteria were observed as such as age, physical characteristics, cooperation, and good patient hygiene beyond the biomechanical characteristics of the fracture. Ju´lio Ce´sar Silva de Oliveira, DDS, MSc Patrı´cia Rota Bermejo, DDS, MSc Willian Morais de Melo, DDS, MSc Ana Paula Farnezi Bassi, DDS, MSc ´ vila de Souza, DDS, MSc Francisley A Idelmo Rangel Garcia Ju´nior, DDS, MSc Department of Surgery and Integrated Clinic Ara0atuba Dental School Universidade Estadual Paulista Ju´lio de Mesquita Filho Ara0atuba Sao Paulo, Brazil [email protected]
REFERENCES 1. Ellis E III. Treatment methods for fractures of the mandibular angle. Int J Oral Maxillofac Surg 1999;28:243Y252 2. Patil PM. Lower third molar in the line of mandibular angle fractures treated with stable internal fixation: to remove or retain? J Oral Maxillofac Surg Med Pathol 2013;25:115Y118 3. Bobrowski AN, Sonego CL, Chagas Junior OL. Postoperative infection associated with mandibular angle fracture treatment in the presence of teeth on the fracture line: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 2013;42:1041Y1048 4. Cillo JE Jr, Ellis E 3rd. . Management of bilateral mandibular angle fractures with combined rigid and nonrigid fixation. J Oral Maxillofac Surg 2013;72:106Y111 5. De Melo WM, Antunes AA, Sonoda CK, et al. Mandibular angle fracture treated with new three-dimensional grid miniplate. J Craniofac Surg 2012;23:e416Ye417 6. Chrcanovic BR. Fixation of mandibular angle fractures: clinical studies. Oral Maxillofac Surg [published ahead of print November 24, 2012] doi:10.1007/s10006-012-0374-1
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 25, Number 3, May 2014
4. 5. 6.
7. FIGURE 8. Postoperative orthopantomograph showing the residual mandible.
(as the maxillary sinus), and exclusion of a distant metastasis.2,4Y11 Because of their rarity, it is difficult to assess the real incidence of the different subtypes of PIOSCC.1 According to the scientific literature, 200 cases of PIOSCC are described as of today: 113 of cyst origin and 87 de novo cases.12,13 Tumors affecting the maxilla are more likely of cyst origin, whereas those affecting the mandible arise de novo.13,14 As observed in our patients, PIOSCC is more likely to affect adult males. The mean age for patients with PIOSCC is 55 years, and it is slightly slower for de novo tumors (60.2 vs 53.7%).13,15 Similarly, PIOSCCs derived from KCOT are also encountered in adult male patients who are generally older than 40 years.13 Lymph node metastasis is higher in the de novo group (4.4% vs 36.4%), although the overall 5-year survival rate is superimposable (38.0% vs 36.3%, respectively).10Y14 Clinical symptoms are variable, including pain, mandibular swelling, and paresthesia/anesthesia of the lower lip due to the perineural invasion of the inferior alveolar nerve.1Y3,6Y9,12,13,15,16 However, most cases are asymptomatic and are discovered incidentally during normal routine radiography.3Y9,15,17,18 Primary intraosseous odontogenic squamous cell carcinoma is an aggressive tumor with a poor clinical outcome affected by a 5-year survival rate ranging between 36.3% and 38.0%.16 These findings may advocate for an initial aggressive surgical treatment to decrease local recurrence rate. Metastatic spread involving cervical lymph nodes has been described in up to 50% of cases of PIOSCC arising de novo, and elective neck dissection is therefore recommended.10Y14 The peculiarity of our cases relies in the superior 5-year survival rate as compared with the data derived from the literature. In particular, our patients did not undergo adjuvant therapy because surgical resection margins and specimens of neck dissection were free from disease, thus suggesting a possible key role of radical surgery in PIOSCC management. Giuseppe Spinelli, MD Francesco Arcuri, MD Davide Rocchetta, MD Tommaso Agostini, MD Department of Maxillofacial Surgery Azienda Ospedaliero-Universitaria Careggi Centro Traumatologico Ortopedico Florence, Italy [email protected]
REFERENCES 1. Eversole LR. Malignant epithelial odontogenic tumors. Semin Diagn Pathol 1999;16:317Y324 2. Eversole LR, Siar CH, van der Waal I. Primary intraosseous squamous cell carcinomas. In: Barnes L, Evson JW, Reichart P, et al., eds. World Health Organization classification of tumors: pathology and genetics of head and neck tumors. Lyon: World Health Organization International Agency for Research on Cancer (IACR) Press, 2005:290Y291 3. Suei Y, Tanimoto K, Taguchi A, et al. Primary intraosseous carcinoma:
8.
9.
10.
11.
12. 13.
14.
15.
16.
17.
18.
Correspondence
review of the literature and diagnostic criteria. J Oral Maxillofac Surg 1994;52:580Y583 Barnes L, Evenson JW, Reichart P. Pathology and genetics of head and neck tumours. Lyon: IARC Press, 2005:283Y328 Muller S, Waldron CA. Primary intraosseous squamous carcinoma. Report of two cases. Int J Oral Maxillofac Surg 1991;20:362Y365 Bodner L, Manor E, Shear M, et al. Primary intraosseous squamous cell carcinoma arising in an odontogenic cystVa clinicopathologic analysis of 116 reported cases. J Oral Pathol Med 2011;21:733Y738 Huang JW, Luo HY, Li Q, et al. Primary intraosseous squamous cell carcinoma of the jaws. Clinicopathologic presentation and prognostic factors. Arch Pathol Lab Med 2009;133:1834Y1840 Sengupta S, Vij H, Vij R. Primary intraosseous carcinoma of the mandible: a report of two cases. J Oral Maxillofac Pathol 2010;14:69Y72 Thomas G, Pandey M, Mathew A, et al. Primary intraosseous carcinoma of the jaw: pooled analysis of world literature and report of two new cases. Int J Oral Maxillofac Surg 2001;30:349Y355 Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer: European Organization for Research and Treatment of Cancer trial 22931. N Engl J Med 2004;350:1945Y1952 Cooper J, Pajak T, Forastiere A, et al. Postoperative concurrent radiotherapy for high risk squamous cell carcinoma of the head and neck: Radiation Therapy Oncology Group 9501/Intergroup. N Engl J Med 2004;350:1937Y1944 Lo Muzio L, Mangini F, De Falco V, et al. Primary intraosseous carcinoma of the mandible: a case report. Oral Oncol 2000;36:305Y307 Gonza´lez-Garcı´a R, Sastre-Pe´rez J, Nam-Cha SH, et al. Primary intraosseous carcinomas of the jaws arising within an odontogenic cyst, ameloblastoma, and de novo: report of new cases with reconstruction considerations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:29Y33 Scheer M, Koch AM, Drebber U, et al. Primary intraosseous carcinoma of the jaws arising from an odontogenic cyst: a case report. J Craniomaxillofac Surg 2004;32:166Y169 Kaffe L, Ardekian I, Peled M, et al. Radiological features of primary intraosseous carcinoma of the jaws. Analysis of the literature and report of a new case. Dentomaxillofac Radiol 1998;27:209Y214 Nomura T, Monobe H, Tamaruya N, et al. Primary intraosseous squamous cell carcinoma of the jaw: two new cases and review of the literature. Eur Arch Otorhinolaryngol 2013;270:375Y379 Lugakingira M, Pytynia K, Kolokythas A, et al. Primary intraosseous carcinoma of the mandible: case report and review of the literature. J Oral Maxillofac Surg 2010;68:2623Y2629 Chaisuparat R, Coletti D, Kolokythas A, et al. Primary intraosseous odontogenic carcinoma arising in an odontogenic cyst or de novo: a clinicopathological study of six new cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:194Y200
Treatment of Unilateral Mandibular Angle Fracture by Closed Reduction To the Editor: Fractures of the mandibular angle represent the largest percentage of mandibular fractures in many studies.1,2 Furthermore, studies have also shown that the angular area is subject to a higher occurrence of postoperative complications3 such as infection and nonunion mainly attributed to the presence of teeth in the fracture line. A 16-year-old adolescent boy was referred to the oral and maxillofacial surgery department of Santa Casa de Ara0atuba Hospital, with complaints of a limited mouth opening and pain caused after an accident at work. Results of an extraoral clinical examination revealed
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1139
Correspondence
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
FIGURE 1. Panoramic radiograph showing the fracture in the region of the mandibular angle involving the tooth 37 (white arrow). FIGURE 3. Frontal image of the patient showing clinically satisfactory mouth opening.
that there was a wound with laceration on the chin and edema. Clinical examination findings verified intraoral alterations and occlusion, possessing premature contacts, with reported pain on mandibular movements of laterality and swelling in the region of the mandibular angle on the left side. After the clinical examination and a radiographic evaluation, the diagnosis of fracture of the region of the left angle of the jaw with a presence of a tooth 37 on discontinued bone line was confirmed (Fig. 1). After a discussion of the case between the team members and the patient’s family, it was decided that a conservative treatment be established because the case was a unilateral angle fracture that was favorable and with no other lines of fracture, the patient seemed to be cooperative with good oral hygiene, and there was little development of the masseter muscle, that is, without much muscular force. It was asked to install braces to start the treatment using heavy rubber bands to minimize the movement of the fractured stumps and guide the occlusion considering canine guidance with dietary restriction. After 5 weeks of accompaniments of trauma, an elastic lighter incentive associated with physical therapy of the jaw was placed, which helped the patient to have a normal lateral movement of the mandible, normal opening and closing of the mouth, as well as a more stable occlusion, even with a restricted diet. In a panoramic radiogram obtained after 8 weeks of conservative treatment (Fig. 2), we observed that the fracture lines were consolidated, similar to the occlusion before the trauma, and that the patient had a satisfactory mouth opening (Fig. 3), mandibular movements of laterality, restored protrusion as well as retrusion without complaints of pain, and no sign of infection. The tooth 37 was subjected to sensitivity tests and pulp vitality, obtaining satisfactory results. The primary goals for the treatment of mandibular fractures are the restoration of occlusion and healing of the fracture.4 Treatment
FIGURE 2. Panoramic radiograph after 8 weeks of treatment showing bone healing achieved with excellent aspect of the region (white arrow).
1140
modalities range from intermaxillary fixation to internal fixation of the bones fragments,5 and these fractures are currently treated through plate/screw osteosynthesis; depending on the case, the bone segmentsare secured through 1-miniplate fixation, through 2miniplate fixation, using a lag screw, or using a single rigid plate at the inferior border of the mandible.6 For the authors, this form of treatment has some advantages such as low cost because there is no need for general anesthesia and for all the necessary support to such a procedure, in addition to not using internal fixation material, as well as the need to return home and be assisted more quickly to daily activities. Obviously, the patient was successfully treated because certain criteria were observed as such as age, physical characteristics, cooperation, and good patient hygiene beyond the biomechanical characteristics of the fracture. Ju´lio Ce´sar Silva de Oliveira, DDS, MSc Patrı´cia Rota Bermejo, DDS, MSc Willian Morais de Melo, DDS, MSc Ana Paula Farnezi Bassi, DDS, MSc ´ vila de Souza, DDS, MSc Francisley A Idelmo Rangel Garcia Ju´nior, DDS, MSc Department of Surgery and Integrated Clinic Ara0atuba Dental School Universidade Estadual Paulista Ju´lio de Mesquita Filho Ara0atuba Sao Paulo, Brazil [email protected]
REFERENCES 1. Ellis E III. Treatment methods for fractures of the mandibular angle. Int J Oral Maxillofac Surg 1999;28:243Y252 2. Patil PM. Lower third molar in the line of mandibular angle fractures treated with stable internal fixation: to remove or retain? J Oral Maxillofac Surg Med Pathol 2013;25:115Y118 3. Bobrowski AN, Sonego CL, Chagas Junior OL. Postoperative infection associated with mandibular angle fracture treatment in the presence of teeth on the fracture line: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 2013;42:1041Y1048 4. Cillo JE Jr, Ellis E 3rd. . Management of bilateral mandibular angle fractures with combined rigid and nonrigid fixation. J Oral Maxillofac Surg 2013;72:106Y111 5. De Melo WM, Antunes AA, Sonoda CK, et al. Mandibular angle fracture treated with new three-dimensional grid miniplate. J Craniofac Surg 2012;23:e416Ye417 6. Chrcanovic BR. Fixation of mandibular angle fractures: clinical studies. Oral Maxillofac Surg [published ahead of print November 24, 2012] doi:10.1007/s10006-012-0374-1
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
