The Journal of Craniofacial Surgery
Correspondence
Volume 26, Number 3, May 2015
Renata de Albuquerque Cavalcanti Almeida, DDS, MSc Jose´ Rodrigues Laureano-Filho, DDS, MSc Ricardo Jose´ de Holanda Vasconcellos, DDS, MSc School of Dentistry (UPE/FOP) University of Pernambuco Camaragibe Pernambuco, Brazil
REFERENCES 1. Trope M. Avulsion of permanent teeth: theory to practice. Dent Traumatol 2011;27:281–294 2. de Lima Ludgero A, de Santana Santos T, Fernandes AV, et al. Knowledge regarding emergency management of avulsed teeth among elementary school teachers in Jaboata˜o dos Guararapes, Pernambuco, Brazil. Indian J Dent Res 2012;23:585–590 3. Cobankara FK, Ungor M. Replantation after extended dry storage of avulsed permanent incisors: report of a case. Dent Traumatol 2007;23:251–256 4. Van der Weijden F, Dell’Acqua F, Slot DE. Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review. J Clin Periodontol 2009;36:1048–1058
Epithelioid Sarcoma on the Face in an Elderly Patient To the Editor: Epithelioid sarcoma (ES) is a rare malignant tumor first described in 1970.1 It accounts for less than 1% of all soft tissue sarcoma and rarely develops on the face.1 It is difficult for pathologists to diagnose the tumor because it tends to grow slowly and shows little symptoms.1 When it develops in the face, it is difficult to diagnose the disease accurately because it typically occurs in the distal extremities of young adults A 76-year-old woman received treatment for 2 months at a local clinic for this lesion in the left cheek that appeared 2 months ago. The patient complained of intermittent pain in the protruded lesion. The local clinic misdiagnosed the lesion and applied an antibiotic ointment and disinfected the lesion. However, the patient was referred to our hospital because she showed no improvement. The patient had a 2 2-cm round lesion in the left cheek that did not involve oppressive pain. A 1.2 1.2-cm necrotic ulcer (central necrosis) was shown in the center of the lesion (Fig. 1). The authors performed a wide excision and frozen biopsy under local anesthesia to diagnose the lesion accurately (Fig. 2). The wide excision (with a 5-mm free margin) and frozen biopsy were performed, and the surgical defect was covered by a full-thickness skin graft (Fig. 3). The authors concluded that it was French Federation Nationale des Centres de Lutte Contre le Cancer histologic grade 2 ES because they have found subcutaneous tissue invasion and extensive necrosis in the biopsy. In an immunohistochemical analysis, it was positive for cytokeratin, vimentin, epithelial membrane antigen (EMA), and cyclin D1 as well as negative for S-100 protein, HMB-45, P63, CD34, CD31, and desmin. It was focally positive in SMA and 70% positive in Ki-67. On the basis of the previously mentioned histopathologic opinion, we concluded that it was ES with areas of necrosis (Fig. 4). The authors conducted enhanced neck and chest computed tomographic (CT) scan because the patient was old and showed poor prognosis with invasion of the deep, subcutaneous tissue. In the CT scan, bilateral hilar lymph
956
FIGURE 1. Preoperative photographic finding shows 1.2 1.2-cm necrotic ulcer.
node enlargement was found. However, high attenuation on the unenhanced CT scan indicated that it was benign. No metastatic manifestation to other ES was found. Generally, ES are rare, mesenchymal tumors of unknown histogenesis and display multidirectional differentiation, which is predominantly epithelial.1 It exhibits immunohistochemical reactivity for epithelial markers and mesenchymal markers. Epithelioid sarcoma is characterized by a nodular proliferation of uniform, polygonal, or epithelioid cells with eosinophilic cytoplasm and pleomorphic nuclei with occasional mitoses.1 Central necrosis and ulceration are typical, and calcification, osseous metaplasia, or myxoid changes are observed.1 Epithelioid sarcoma can develop in those with ages between 4 years and 90 years. However, 74% of the patients presented between the ages of 10 and 39 years. In most cases (58%), ES occurs at the distal parts of the upper extremities such as the hands and forearms, followed by the distal lower extremities (15%), proximal lower extremities (12%), trunk (3%), as well as head and neck (1%).1 –3 Like any other soft tissue
FIGURE 2. Intraoperative finding shows the excised mass (for frozen biopsy).
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
Correspondence
FIGURE 3. Intraoperative finding shows defect coverage using full-thickness skin graft. A, After excision. B, After full-thickness skin grafting.
sarcoma, the prognosis for patients with ES depends on several factors: patient’s age, size and histologic grade of the tumor, tumor invasion of the postoperative surgical margin, and so on. Factors associated with a poorer prognosis include age older than 60 years, tumors larger than 5 cm in greatest dimension, high-grade histology with high mitotic activity, postoperative margin, and the like. These mostly result in local recurrence and distant metastasis within the first 2 years of treatment.2 The prognosis of ES is poor because a substantial number of patients present with high recurrence, lymph node metastases, and hematogenous metastasis.1 Epithelioid sarcoma is a malignant tumor with an already poor prognosis, aggravated by the commonly delayed diagnosis and resulting in inadequate treatment.3 Therefore, biopsy is needed and further histologic investigation as well as immunohistochemistry may help diagnose ES. In our case, biopsy was performed. The biopsy sample revealed histologic and immunohistochemical changes typical of ES. It shows a high expression of vimentin and, in most cases, is positive for cytokeratins and EMA. Coexpression of cytokeratin and vimentin is observed in the majority of ES cases. In more than half of the cases, staining for CD34 is positive.1 It was positive for cytokeratin, vimentin, EMA, and cyclin D1 as well as negative for
FIGURE 4. A, Microphotograph showing a relatively well-circumscribed ulcerated nodule confined to skin and subcutaneous fat, with no involvement of deep soft tissues (hematoxylin and eosin, 12.5). B, Microphotograph showing a granuloma-like fashion with large areas of ulcer and necrosis (hematoxylin and eosin, 40). C, Microphotograph showing epithelioid tumor cells arranged in a haphazard pattern (hematoxylin and eosin, 100). D, Microphotograph showing epithelioid tumor cells composed primarily of large epithelioid cells with prominent nucleoli (hematoxylin and eosin, 200).
#
2015 Mutaz B. Habal, MD
FIGURE 5. Immunohistochemical staining is positive for cytokeratin (A, 400), vimentin (B, 400), EMA (C, 400), and cytokeratin 5/6 (D, 400).
S-100 protein, HMB-45, P63, CD34, CD31, and desmin, leading us to conclude that it was ES (Fig. 5). This case had ES at the head and neck site, a body part where the disease is least likely to develop. Although most patients generally have 2 years and 5 months of duration, the patient had only 2 months of duration. Like most other patients with ES, her lesion was firm but had no solid mass with necrotic ulcer in the center and mild diffuse swelling in the margin. Like most patients, she experienced no symptoms but had pain and tenderness. In this case, the patient revealed that she received 2 months of antibiotic treatment for ulceration at the local clinic that misdiagnosed the lesion, which showed no improvement. It was a primary cancer developed in the face without spreading to other parts. Lymphadenectomy is indicated in the presence of lymph node metastases. Despite the use of radical surgery, this tumor is associated with a high incidence of locoregional failure. Local recurrence often develops within 1 to 2 years after primary treatment.2 Chase and Enzinger1 reported the results of 202 cases of ES: 77% of the patients had recurrence as well as 45% had metastasis to lungs (51%), lymph nodes (34%), scalp and other skin areas (22%), bone, brain, liver, and pleura. Thus, adjuvant postoperative radiation therapy is recommended if the surgical margin is not satisfactory or the histology of the lesion is high-grade. Adjuvant chemotherapy is indicated for patients with metastatic disease, but its usefulness in nonmetastatic ES remains unclear.1 In conclusion, facial ES is extremely rare and difficult to diagnose correctly. So, the authors report a case of a 76-year-old woman with a facial ES on the temple area. Hwan Jun Choi, MD, PhD Department of Plastic and Reconstructive Surgery College of Medicine Soonchunhyang University Cheonan, South Korea [email protected] Jin Young Kim, MD Department of Plastic and Reconstructive Surgery College of Medicine Soonchunhyang University Cheonan, South Korea
957
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Correspondence
Volume 26, Number 3, May 2015
Hyun Ju Lee, MD, PhD Department of Pathology College of Medicine Soonchunhyang University Cheonan, South Korea Supported by the Soonchunhyang University Research Fund.
REFERENCES 1. Chase DR, Enzinger FM. Epithelioid sarcoma. Diagnosis, prognostic indicators, and treatment. Am J Surg Pathol 1985;9:241–263 2. de Visscher SA, Ginkel RJ, Wobbes T, et al. Epithelioid sarcoma: still an only surgically curable disease. Cancer 2006;107:606–612 3. Halling AC, Wollan PC, Pritchard DJ, et al. Epithelioid sarcoma: a clinicopathologic review of 55 cases. Mayo Clin Proc 1996;7:636–642
The Contact of Third Molar and Mandibular Nerve: Health Related Quality of Life Differentials To the Editor: A condition that makes third molar extraction more difficult is the close communication of mandibular third molar roots with inferior alveolar nerve. Many authors evidenced a lower quality of life after extraction on patients with third molar in close proximity to the mandibular nerve1; this condition has always been compared with health related quality of life (HRQOL) parameters of other patients.2 Our purpose is to present our outcome on patients with mandibular nerve involvement on one side and no involvement on the other side. A total of 10 patients with bilateral impacted mandibular third molars were enrolled in this study; inclusion criteria were the close communication with inferior alveolar nerve on one side and no nerve involvement on the other side. Surgical interventions were performed by the same surgeon with the Neuronal Feedback (NF) technique.3 HRQOL scores were assessed for 14 days after surgical extraction, recording HRQOL and complications score. Mean time for extraction of third molar with nerve involvement was 49 12.9 minutes (range 20–119 minutes), while mean time for extraction of third molar without nerve involvement was 28 7.5 minutes (range 12–47 minutes). None of the patients presented neuronal lesions and all patients fully recovered presenting HRQL levels that reduced at the post-surgical visits. HRQOL scores and complication rates showed higher results for interventions with mandibular nerve involvement (P < 0.05) (Fig. 1). The presence of third molar roots in contact with mandibular nerve is an adverse condition related to a possible postoperative hypoestesia.4 Postoperative hypoestesia has been reported to be related to preoperative recognized local risk factors.5 For this purpose, in this study we performed the surgery of teeth with inferior alveolar nerve contact with a previous described NF technique3; this technique allows to minimize the possible mandibular nerve damage, but leads to a prolonged surgery. Our results confirm previous studies where a prolonged surgery is related with a worse postoperative outcome6; nevertheless, the absence of neuronal lesions that we reported balances the time occurred for surgery and is recognized as the main goal of this kind of surgery. Glauco Chisci, DDS Tuscan School of Dental Medicine University of Siena Siena, Italy [email protected]
958
FIGURE 1. Graph showing the differential reduction of health related quality of life (HRQOL) parameters after the surgery of the different teeth with and without nerve involvement (A) and the differential reduction of complication parameters after the surgery (B); nerve involvement group is characterized by significant high values for all the postoperative times.
Francesco D’Ambrosio, DDS Tuscan School of Dental Medicine University of Florence Florence, Italy Alberto Busa, DDS Department of Surgery and Interdisciplinary Medicine University of Milano-Bicocca Milan, Italy
REFERENCES 1. Negreiros RM, Biazevic MG, Jorge WA, et al. Relationship between oral health-related quality of life and the position of the lower third molar: postoperative follow-up. J Oral Maxillofac Surg 2012;70:779–786 2. Shugars DA, Gentile MA, Ahmad N, et al. Assessment of oral health-related quality of life before and after third molar surgery. J Oral Maxillofac Surg 2006;64:1721 3. Chisci G, Parrini S, Gennaro P, et al. The neuronal feedback (NF) technique in third molar surgery. J Craniofac Surg 2013;24: 2221–2223 4. Janakiraman EN, Alexander M, Sanjay P. Prospective analysis of frequency and contributing factors of nerve injuries following third-molar surgery. J Craniofac Surg 2010;21:784–786 #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
Volume 26, Number 3, May 2015
Renata de Albuquerque Cavalcanti Almeida, DDS, MSc Jose´ Rodrigues Laureano-Filho, DDS, MSc Ricardo Jose´ de Holanda Vasconcellos, DDS, MSc School of Dentistry (UPE/FOP) University of Pernambuco Camaragibe Pernambuco, Brazil
REFERENCES 1. Trope M. Avulsion of permanent teeth: theory to practice. Dent Traumatol 2011;27:281–294 2. de Lima Ludgero A, de Santana Santos T, Fernandes AV, et al. Knowledge regarding emergency management of avulsed teeth among elementary school teachers in Jaboata˜o dos Guararapes, Pernambuco, Brazil. Indian J Dent Res 2012;23:585–590 3. Cobankara FK, Ungor M. Replantation after extended dry storage of avulsed permanent incisors: report of a case. Dent Traumatol 2007;23:251–256 4. Van der Weijden F, Dell’Acqua F, Slot DE. Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review. J Clin Periodontol 2009;36:1048–1058
Epithelioid Sarcoma on the Face in an Elderly Patient To the Editor: Epithelioid sarcoma (ES) is a rare malignant tumor first described in 1970.1 It accounts for less than 1% of all soft tissue sarcoma and rarely develops on the face.1 It is difficult for pathologists to diagnose the tumor because it tends to grow slowly and shows little symptoms.1 When it develops in the face, it is difficult to diagnose the disease accurately because it typically occurs in the distal extremities of young adults A 76-year-old woman received treatment for 2 months at a local clinic for this lesion in the left cheek that appeared 2 months ago. The patient complained of intermittent pain in the protruded lesion. The local clinic misdiagnosed the lesion and applied an antibiotic ointment and disinfected the lesion. However, the patient was referred to our hospital because she showed no improvement. The patient had a 2 2-cm round lesion in the left cheek that did not involve oppressive pain. A 1.2 1.2-cm necrotic ulcer (central necrosis) was shown in the center of the lesion (Fig. 1). The authors performed a wide excision and frozen biopsy under local anesthesia to diagnose the lesion accurately (Fig. 2). The wide excision (with a 5-mm free margin) and frozen biopsy were performed, and the surgical defect was covered by a full-thickness skin graft (Fig. 3). The authors concluded that it was French Federation Nationale des Centres de Lutte Contre le Cancer histologic grade 2 ES because they have found subcutaneous tissue invasion and extensive necrosis in the biopsy. In an immunohistochemical analysis, it was positive for cytokeratin, vimentin, epithelial membrane antigen (EMA), and cyclin D1 as well as negative for S-100 protein, HMB-45, P63, CD34, CD31, and desmin. It was focally positive in SMA and 70% positive in Ki-67. On the basis of the previously mentioned histopathologic opinion, we concluded that it was ES with areas of necrosis (Fig. 4). The authors conducted enhanced neck and chest computed tomographic (CT) scan because the patient was old and showed poor prognosis with invasion of the deep, subcutaneous tissue. In the CT scan, bilateral hilar lymph
956
FIGURE 1. Preoperative photographic finding shows 1.2 1.2-cm necrotic ulcer.
node enlargement was found. However, high attenuation on the unenhanced CT scan indicated that it was benign. No metastatic manifestation to other ES was found. Generally, ES are rare, mesenchymal tumors of unknown histogenesis and display multidirectional differentiation, which is predominantly epithelial.1 It exhibits immunohistochemical reactivity for epithelial markers and mesenchymal markers. Epithelioid sarcoma is characterized by a nodular proliferation of uniform, polygonal, or epithelioid cells with eosinophilic cytoplasm and pleomorphic nuclei with occasional mitoses.1 Central necrosis and ulceration are typical, and calcification, osseous metaplasia, or myxoid changes are observed.1 Epithelioid sarcoma can develop in those with ages between 4 years and 90 years. However, 74% of the patients presented between the ages of 10 and 39 years. In most cases (58%), ES occurs at the distal parts of the upper extremities such as the hands and forearms, followed by the distal lower extremities (15%), proximal lower extremities (12%), trunk (3%), as well as head and neck (1%).1 –3 Like any other soft tissue
FIGURE 2. Intraoperative finding shows the excised mass (for frozen biopsy).
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
Correspondence
FIGURE 3. Intraoperative finding shows defect coverage using full-thickness skin graft. A, After excision. B, After full-thickness skin grafting.
sarcoma, the prognosis for patients with ES depends on several factors: patient’s age, size and histologic grade of the tumor, tumor invasion of the postoperative surgical margin, and so on. Factors associated with a poorer prognosis include age older than 60 years, tumors larger than 5 cm in greatest dimension, high-grade histology with high mitotic activity, postoperative margin, and the like. These mostly result in local recurrence and distant metastasis within the first 2 years of treatment.2 The prognosis of ES is poor because a substantial number of patients present with high recurrence, lymph node metastases, and hematogenous metastasis.1 Epithelioid sarcoma is a malignant tumor with an already poor prognosis, aggravated by the commonly delayed diagnosis and resulting in inadequate treatment.3 Therefore, biopsy is needed and further histologic investigation as well as immunohistochemistry may help diagnose ES. In our case, biopsy was performed. The biopsy sample revealed histologic and immunohistochemical changes typical of ES. It shows a high expression of vimentin and, in most cases, is positive for cytokeratins and EMA. Coexpression of cytokeratin and vimentin is observed in the majority of ES cases. In more than half of the cases, staining for CD34 is positive.1 It was positive for cytokeratin, vimentin, EMA, and cyclin D1 as well as negative for
FIGURE 4. A, Microphotograph showing a relatively well-circumscribed ulcerated nodule confined to skin and subcutaneous fat, with no involvement of deep soft tissues (hematoxylin and eosin, 12.5). B, Microphotograph showing a granuloma-like fashion with large areas of ulcer and necrosis (hematoxylin and eosin, 40). C, Microphotograph showing epithelioid tumor cells arranged in a haphazard pattern (hematoxylin and eosin, 100). D, Microphotograph showing epithelioid tumor cells composed primarily of large epithelioid cells with prominent nucleoli (hematoxylin and eosin, 200).
#
2015 Mutaz B. Habal, MD
FIGURE 5. Immunohistochemical staining is positive for cytokeratin (A, 400), vimentin (B, 400), EMA (C, 400), and cytokeratin 5/6 (D, 400).
S-100 protein, HMB-45, P63, CD34, CD31, and desmin, leading us to conclude that it was ES (Fig. 5). This case had ES at the head and neck site, a body part where the disease is least likely to develop. Although most patients generally have 2 years and 5 months of duration, the patient had only 2 months of duration. Like most other patients with ES, her lesion was firm but had no solid mass with necrotic ulcer in the center and mild diffuse swelling in the margin. Like most patients, she experienced no symptoms but had pain and tenderness. In this case, the patient revealed that she received 2 months of antibiotic treatment for ulceration at the local clinic that misdiagnosed the lesion, which showed no improvement. It was a primary cancer developed in the face without spreading to other parts. Lymphadenectomy is indicated in the presence of lymph node metastases. Despite the use of radical surgery, this tumor is associated with a high incidence of locoregional failure. Local recurrence often develops within 1 to 2 years after primary treatment.2 Chase and Enzinger1 reported the results of 202 cases of ES: 77% of the patients had recurrence as well as 45% had metastasis to lungs (51%), lymph nodes (34%), scalp and other skin areas (22%), bone, brain, liver, and pleura. Thus, adjuvant postoperative radiation therapy is recommended if the surgical margin is not satisfactory or the histology of the lesion is high-grade. Adjuvant chemotherapy is indicated for patients with metastatic disease, but its usefulness in nonmetastatic ES remains unclear.1 In conclusion, facial ES is extremely rare and difficult to diagnose correctly. So, the authors report a case of a 76-year-old woman with a facial ES on the temple area. Hwan Jun Choi, MD, PhD Department of Plastic and Reconstructive Surgery College of Medicine Soonchunhyang University Cheonan, South Korea [email protected] Jin Young Kim, MD Department of Plastic and Reconstructive Surgery College of Medicine Soonchunhyang University Cheonan, South Korea
957
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Correspondence
Volume 26, Number 3, May 2015
Hyun Ju Lee, MD, PhD Department of Pathology College of Medicine Soonchunhyang University Cheonan, South Korea Supported by the Soonchunhyang University Research Fund.
REFERENCES 1. Chase DR, Enzinger FM. Epithelioid sarcoma. Diagnosis, prognostic indicators, and treatment. Am J Surg Pathol 1985;9:241–263 2. de Visscher SA, Ginkel RJ, Wobbes T, et al. Epithelioid sarcoma: still an only surgically curable disease. Cancer 2006;107:606–612 3. Halling AC, Wollan PC, Pritchard DJ, et al. Epithelioid sarcoma: a clinicopathologic review of 55 cases. Mayo Clin Proc 1996;7:636–642
The Contact of Third Molar and Mandibular Nerve: Health Related Quality of Life Differentials To the Editor: A condition that makes third molar extraction more difficult is the close communication of mandibular third molar roots with inferior alveolar nerve. Many authors evidenced a lower quality of life after extraction on patients with third molar in close proximity to the mandibular nerve1; this condition has always been compared with health related quality of life (HRQOL) parameters of other patients.2 Our purpose is to present our outcome on patients with mandibular nerve involvement on one side and no involvement on the other side. A total of 10 patients with bilateral impacted mandibular third molars were enrolled in this study; inclusion criteria were the close communication with inferior alveolar nerve on one side and no nerve involvement on the other side. Surgical interventions were performed by the same surgeon with the Neuronal Feedback (NF) technique.3 HRQOL scores were assessed for 14 days after surgical extraction, recording HRQOL and complications score. Mean time for extraction of third molar with nerve involvement was 49 12.9 minutes (range 20–119 minutes), while mean time for extraction of third molar without nerve involvement was 28 7.5 minutes (range 12–47 minutes). None of the patients presented neuronal lesions and all patients fully recovered presenting HRQL levels that reduced at the post-surgical visits. HRQOL scores and complication rates showed higher results for interventions with mandibular nerve involvement (P < 0.05) (Fig. 1). The presence of third molar roots in contact with mandibular nerve is an adverse condition related to a possible postoperative hypoestesia.4 Postoperative hypoestesia has been reported to be related to preoperative recognized local risk factors.5 For this purpose, in this study we performed the surgery of teeth with inferior alveolar nerve contact with a previous described NF technique3; this technique allows to minimize the possible mandibular nerve damage, but leads to a prolonged surgery. Our results confirm previous studies where a prolonged surgery is related with a worse postoperative outcome6; nevertheless, the absence of neuronal lesions that we reported balances the time occurred for surgery and is recognized as the main goal of this kind of surgery. Glauco Chisci, DDS Tuscan School of Dental Medicine University of Siena Siena, Italy [email protected]
958
FIGURE 1. Graph showing the differential reduction of health related quality of life (HRQOL) parameters after the surgery of the different teeth with and without nerve involvement (A) and the differential reduction of complication parameters after the surgery (B); nerve involvement group is characterized by significant high values for all the postoperative times.
Francesco D’Ambrosio, DDS Tuscan School of Dental Medicine University of Florence Florence, Italy Alberto Busa, DDS Department of Surgery and Interdisciplinary Medicine University of Milano-Bicocca Milan, Italy
REFERENCES 1. Negreiros RM, Biazevic MG, Jorge WA, et al. Relationship between oral health-related quality of life and the position of the lower third molar: postoperative follow-up. J Oral Maxillofac Surg 2012;70:779–786 2. Shugars DA, Gentile MA, Ahmad N, et al. Assessment of oral health-related quality of life before and after third molar surgery. J Oral Maxillofac Surg 2006;64:1721 3. Chisci G, Parrini S, Gennaro P, et al. The neuronal feedback (NF) technique in third molar surgery. J Craniofac Surg 2013;24: 2221–2223 4. Janakiraman EN, Alexander M, Sanjay P. Prospective analysis of frequency and contributing factors of nerve injuries following third-molar surgery. J Craniofac Surg 2010;21:784–786 #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
