The Journal of Craniofacial Surgery • Volume 25, Number 6, November 2014
CONCLUSIONS The AC is an effective procedure for a short-term reduction of pain in TMD cases. It seems that AC using Ringer solution with or without corticosteroids may have the same effect on pain relief.
REFERENCES 1. Al-Belasy FA, Dolwick MF. Arthrocentesis for the treatment of temporomandibular joint closed lock: a review article. Int J Oral Maxillofac Surg 2007;36:773–782 2. Monje-Gil F, Nitzan D, González-Garcia R. Temporomandibular joint arthrocentesis. Review of the literature. Med Oral Patol Oral Cir Bucal 2012;17:e575–e581 3. Frost DE, Kendell BD. The use of arthrocentesis for treatment of temporomandibular joint disorders. J Oral Maxillofac Surg 1999;57:583–587 4. Tozoglu S, Al-Belasy FA, Dolwick MF. A review of techniques of lysis and lavage of the TMJ. Br J Oral Maxillofac Surg 2011;49:302–309 5. Nitzan DW. Arthrocentesis–incentives for using this minimally invasive approach for temporomandibular disorders. Oral Maxillofac Surg Clin North Am 2006;18:311–328 6. Dolwick MF. Temporomandibular joint surgery for internal derangement. Dent Clin North Am 2007;51:195–208 7. DM, CS, WL, eds. Temporamandibular disorders: an evidence-based approach to diagnosis and treatment. Chicago Quintessence 2006; 441–481 8. Alpaslan GH, Alpaslan C. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate in treatment of internal derangements. J Oral Maxillofac Surg 2001;59:613–618 9. Cavalcanti do EgitoVasconcelos B, Bessa-Nogueira RV, Rocha NS. Temporomandibular joint arthrocententesis: evaluation of results and review of the literature. Braz J Otorhinolaryngol 2006;72:634–638 10. Manfredini D, Rancitelli D, Ferronato G, et al. Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols. J Oral Rehabil 2012;39:245–251 11. Hersh EV, Balasubramaniam R, Pinto A. Pharmacologic management of temporomandibular disorders. Oral Maxillofac Surg Clin North Am 2008;20:197–210 12. Dimitroulis G, Dolwick MF. Temporomandibular disorders. Part3. Surgical treatment. Aust Dent J 1996;41:16–20 13. Murakami K, Hosaka H, Moriya Y, et al. Short-term treatment outcome study for the management of temporomandibular joint closed lock. A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:253–257 14. Dimitroulis G, Dolwick MF, Martinez A. Temporomandibular joint arthrocentesis and lavage for the treatment of closed lock: a follow-up study. Br J Oral Maxillofac Surg 1995;33:23–26 15. Sanromán JF. Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy. Int J Oral Maxillofac Surg 2004;33:344–348 16. Neeli AS, Umarani M, Kotrashetti SM, et al. Arthrocentesis for the treatment of internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 2010;9:350–354 17. McCain JP. TMJ arthroscopy. J Am Dent Assoc 1990;121:10–12 18. Aceves-Avila FJ, Chávez-López M, Chavira-González JR, et al. Temporomandibular joint dysfunction in various rheumatic diseases. Reumatismo 2013;65:126–130 19. Kuruvilla AVE, Prasad K. Arthrocentesis in TMJ internal derangement: a prospective study. J Oral Maxillofac Surg 2012;11:53–56 20. Barkin S, Weinberg S. Internal derangements of the temporomandibular joint: the role of arthroscopic surgery and arthrocentesis. J Can Dent Assoc 2000;66:199–203 21. Sanroman JF. Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy. Int J Oral Maxillofac Surg 2004;33:344–348
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22. Emshoff R, Puffer P, Rudisch A, et al. Temporomandibular joint pain- relationship to internal derangement type, osteoarthrosis, and synovial fluid mediator level or tumor necrosis factor-alpha. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:442–449 23. Nitzan DW, Price A. The use of arthrocentesis for the treatment of osteoarthritic temporomandibular joints. J Oral Maxillofac Surg 2001;59:1154–1159 24. Vos LM, Huddleston Slater JJ, Stegenga B. Arthrocentesis as initial treatment for temporomandibular joint arthropathy: a randomized controlled trial. J Craniomaxillofac Surg 2013;29:205–209 25. Diraçoğlu D, Saral IB, Keklik B, et al. Arthrocentesis versus nonsurgical methods in the treatment of temporomandibular disc displacement without reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:3–8 26. Giraddi GB, Siddaraju A, Kumar B, et al. Internal derangement of temporomandibular joint: an evaluation of effect of corticosteroid injection compared with injection of sodium hyaluronate after arthrocentesis. J Oral Maxillofac Surg 2012;11:258–263 27. Huddleston Slater JJ, Vos LM, Stroy LP, et al. Randomized trial on the effectiveness of dexamethasone in TMJ arthrocentesis. J Dent Res 2012;91:173–178 28. Mina R, Melson P, Powell S, et al. Effectiveness of dexamethasone iontophoresis for temporomandibular joint involvement in juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2011;63:1511–1516 29. Trieger N, Hoffman CH, Rodriguez E. The effect of arthrocentesis of the temporomandibular joint in patients with rheumatoid arthritis. J Oral Maxillofac Surg 1999;57:537–540 30. Reid KI, Dionne RA, Sicard-Rosenbaum L, et al. Evaluation of iontophoretically applied dexamethasone for painful pathologic temporomandibular joints. Oral Surg Oral Med Oral Pathol 1994;77:605–609 31. Swift JQ, Roszkowski MT, Alton T, et al. Effect of intra-articular versus systemic anti-inflammatory drugs in a rabbit model of temporomandibular joint inflammation. J Oral Maxillofac Surg 1998;56:1288–1295 32. El-Hakim IE, Abdel-Hamid IS, Bader A. Tempromandibular joint (TMJ) response to intra-articular dexamethasone injection following mechanical arthropathy: a histological study in rats. Int J Oral Maxillofac Surg 2005;34:305–310
General and Stomatologic Aspects of Bardet-Biedl Syndrome Cristhiane Olivia Ferreira do Amaral, DDS, MSc,* Gustavo de Almeida Logar, DDS, MSc,* Arlete Gomes Parisi, DDS, MSc,* Karine Takahashi, DDS, MSc,† Fabiana Gouveia Straioto, DDS, MSc‡
From the Departments of *Special Care Dentistry, †Pediatric Dentistry, and ‡Prosthodontics and Geriatic Dentistry, Dental School, University of Western Sao Paulo, Presidente Prudente, Sao Paulo, Brazil. Received April 29, 2014. Accepted for publication June 19, 2014. Address correspondence and reprint requests to Cristhiane Olivia Ferreira do Amaral, DDS, MSc, Department of Special Care Dentistry, University of Western Sao Paulo, Rua Jose Bongiovani, 700, Presidente Prudente, SP, Brazil 19050-920; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001169
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Objective: The purpose of this study is to present a clinical report of a patient with Bardet-Biedl syndrome, aiming to help the dentist to identify the general aspects, systemic changes, alterations. Clinical Report: Bardet-Biedl syndrome is defined as a genetic disorder of autosomal recessive condition; this case is a male patient, 20 years old. The general features presented by the patient were strabismus, polydactyly, hypogonadism, obesity, cognitive impairment, and autistic behavior. Dentally, this patient presents with hypotonic face, high-arched palate, dental crowding, unilateral crossbite, and difficulty in cleaning but with good-quality oral health. Conclusions: Many patients with this syndrome have compromised oral hygiene, difficulty in addressing dental cases, developmental delay, and autistic behavior. Thus, it is important to pay attention to these early children from an early age and encourage preventive approach. Key Words: Bardet-Biedl syndrome, oral health, facial dimorphisms, behavioral disorder
B
ardet-Biedl syndrome (BBS) was named in the '20s by Arthur and Georges Bardet Biedl. They described this syndrome with a large spectrum of clinical characteristics.1,2 This syndrome is autosomal recessive, occurring in both sexes, in a 3:1 ratio for men. The etiology is still unknown, but it is described in the literature as 35% to 48% of parental consanguinity in patients with this syndrome. The BBS is a rare clinical condition, and its prevalence is 1 of 160,000,3 with a wide variation around the world.4,5 The highest incidence was reported in an isolated population in a Canadian island, Newfoundland, with a prevalence of 1 of 13,000 inhabitants, and Kuwait, where the occurrence is also high, 1 of 17,000 inhabitants, mainly because of a high consanguinity rate.6 The pathophysiology of this syndrome is not completely clear. Fourteen different genes were identified as the cause of BBS.7,8 Clinical and molecular genetic testing were used to diagnose this syndrome.9–11 The clinical expression of BBS is variable. Patients can have eye disorders, retinopatia,12,13 polydactyl, obesity, learning difficulties, male hypogenitalism, complex female genitourinary malformations, and kidney malfunction, which are frequently the main reasons of mortality in these patients.14 There are a wide number of secondary characteristics associated with the syndrome, including speech and language impairments, hearing problems, strabismus, brachydactyly, hand and feet syndactyly, and dental alterations. Patients with BBS may have behavioral changes such as emotional immaturity and poor reasoning. Many of these behaviors can be seen on the autistic spectrum.15–17 It is also common for these patients to have systemic diseases such as diabetes, cardiovascular disorders, epilepsy, and liver impairment.5,14 Patients also present buccodental anomalies such as malocclusion, anterior crowding, micrognathia, deep palate, hypodontia, small tooth roots, enamel hypoplasia, and microdontia.18,19 Because of the oral manifestations, dentists must get acquainted with this syndrome. In the literature, a few studies reported facial features on patients with this syndrome. According to them, BBS patients display a long philtrum, thin upper lip, small mouth, brachycephaly, macrocephaly, large ears, palpebral fissures, bitemporal narrowing, and front baldness in male patients.7,12,20,21 In the past decades, research on syndromes concentrated in phenotype, genotype, growth, development, function, and treatment. No dental issues were described.22,23 The low occurrence of this syndrome and the necessity to help dentists to provide better assistance to BBS patients justify reporting this clinical report. The aim of this clinical report is to portray general aspects, systemic
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disorders, oral diseases, and dental problems of a BBS patient treated in the University of Western Sao Paulo.
CLINICAL REPORT This project was approved by the ethics committee of the University of Western Sao Paulo (253.473/2013). The patient DSO, male, Brazilian, and 20 years old, presented in the clinic for treatment. The patient was diagnosed with BBS since the age of 3 years. According to family background, parents were not related and had 6 children, five of which nonsyndromic. In prenatal medical history, both pregnancy and delivery were reported without any complications. In postnatal medical history, the mother reported that, between 4 and 9 months old, the child had abnormal development. The symptoms included a bending neck, rapid eye movements (nystagmus), and inability to follow a moving object. Due to a deficit in global development, there was a late onset of the speech and walking abilities, only starting at the age of 4 and 5 years, respectively. In the general physical examination, the patient weighed 76.9 kg and was 1.68 cm in height, with a body mass index of 27.6, which is classified as overweight, but not obese, like most of the cases described in the literature. He had polydactyly, an extra digit, in the ulnar side of the right hand (Fig. 1) and hypogenitalism, reported by the tutor. The ophthalmologist detected convergent strabismus in the left eye, according to a medical report. However, pigmentary retinopathy as well as any other eye condition could not be diagnosed because of the difficulty in handling the patient. No anomaly, malformation, systemic disorder, or kidney dysfunction, which are not only the major but also the worst systemic features, was found. Regarding cognitive and mental development, the patient presented an IQ lower than the normal, speech impairment, and development delay, including disabled motor and fine motor and psychosocial skills. The patient had an autistic behavior and the habit of biting fingers (Fig. 2). A daily routine, as well as the ability to follow schedules properly, was observed. Data obtained from clinical examination using headgear reported aspects of some hypotonia of the facial muscles (Fig. 3A), front overhang, brachycephaly, and straight-to-concave profile (Fig. 3B). Intraoral examination revealed the presence of dental calculus, extrinsic pigmentations spots, and small active carious lesions. The occlusion was checked, and severe problems were detected, characterized by the presence of anterior crowding, posterior crossbite, mandible atresia, and deep palate (Fig. 4). During dental treatment, the patient had a resistant and noncooperative behavior (Fig. 5). Panoramic x-ray was not taken. Highly lit places, noises from high- and low-speed dental handpieces, sucking, ultrasound, and prophy caused discomfort to the patient. It was only possible to use scalers, curettes, and other hand instruments as well gauze and cotton. For a successful dental treatment in this type of patient, it is necessary, previously, to teach and practice with the tutor how to control the dental hygiene at home and prepare the patient for dental treatment. First, oral environment stabilization procedures were conducted. Cavities on the buccal of 18, 19, 30, and 31 were removed and
FIGURE 1. Patient’s hand after surgery to remove the extra digit on the ulnar side of the right hand.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 2. Image of the upper hand being checked for the injuries caused by the habit of finger biting.
sealed with cement-based glass ionomer. Scalers and curettes, associated with topical applications of antimicrobials (chlorhexidine gluconate of 0.12%), were used to remove plaque and dental calculus. The patient used neutral topical fluoride of 2% for 4 consecutive weeks at home. In addition to the clinical procedures performed, oral care education and dietary guidance for the caregiver were provided. This patient was advised to return every 3 months to the Dental Care Clinic for Patients with Special Needs in the School of Dentistry, University of Western Sao Paulo.
DISCUSSION The BBS presents relevant characteristics to be observed by a dentist as this syndrome can influence patient's behavior that may complicate dental treatment. Although the patient did not present any major systemic disease, many patients with BBS commonly manifest nephropathy, hypertension, diabetes, and heart problems, which may influence the treatment plan. Kidney abnormalities may be an important cause of morbidity and mortality in these patients,21 but there is no evidence of any kidney disorder in this reported patient. Despite obesity being a recurring clinical characteristic of this syndrome and despite that the incidence is reported to be in between 72% and 86% in the BBS population,12 the reported patient was just overweight. The percentage of patients with polydactyly is 69%, with at least 1 digit accessory.2,14,21 Our study's patient had 1 additional digit on the ulnar side of his right hand, which was surgically removed.
FIGURE 5. Picture showing the behavior of the nonemployee patient who refused to sit on the dental chair.
Development delay and cognitive impairment are common in this syndrome. According to the literature, 62% of BBS patients need to attend special schools.24 The patient in this clinical report attended a special school because of severe cognitive impairment. Many patients with this syndrome have serious behavior deviance and tend to develop autism spectrum disorders or psychosis. In this case, the patient only had autistic behavior. According to several authors,2,7,14,20 the typical facial features are often subtle and not always present. This particular patient had most of the features mentioned in the literature such as deep eyes in the presence of convergent strabismus, flat midface and maxillary atresia, brachycephaly, and macrocephaly. The presence of these features made the patient's profile range from straight to slightly concave. In this clinical report, problems to treat the patient were faced given the autistic behavior and the development delay. Ambulatory care was chosen, and several forms of approach and management were tried to achieve better behavior. The frequency of returning may change according to the risk/caries activity of the patient and the difficulty of an effective cleaning at home. The daily oral hygiene was difficult to implement as reported by the tutor. The family was advised to return every 3 months to the dentist.
CONCLUSIONS Individuals with BBS presenting development delay, autistic behavior, poor oral hygiene, and limitations in dental care providing highlight the importance of early treatment care. A multidisciplinary team must perform the complete treatment because most individuals have complex systemic problems as well as behavioral and dental issues.
REFERENCES
FIGURE 3. Front image of the patient showing muscular hypotonia. B, Picture showing brachycephaly and straight profile.
FIGURE 4. Occlusal image of the upper dental arch, highlighting the nonocclusal alignment of the teeth.
1. Nishimura DY, Swiderski RE, Searby CC, et al. Comparative genomics and gene expression analysis identifies BBS9, a new Bardet-Biedl syndrome gene. Am J Hum Genet 2005;77:1021–1033 2. Moore SJ, Green JS, Fan Y, et al. Clinical and genetic epidemiology of Bardet-Biedl syndrome in Newfoundland: a 22-year prospective, population-based, cohort study. Am J Med Genet A 2005;132:352–360 3. Siopa l, Manuelagrego JAP. Síndroma de Bardet–Biedl. Acta Med Port 2002;15:51 4. M’hamdi O, Redin C, Stoetzel C, et al. Clinical and genetic characterization of Bardet-Biedl syndrome in Tunisia: defining a strategy for molecular diagnosis. Clin Genet 2013;83:121–129 5. Sowjanya B, Sreenivasulu U, Naidu JN, et al. End stage renal disease, differential diagnosis, a rare genetic disorder: Bardet-Biedl syndrome: case report and review. Indian J Clin 2011;26:214–216 6. Kumar S, Mahajan BB, Mittal J. Bardet-Biedl syndrome: a rare case report from North India. Indian J Dermatol Venereol Leprol 2012;78:228
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7. Beales PL, Warner AM, Hitman GA, et al. Bardet–Biedl syndrome: a molecular and phenotypic study of 18 families. J Med Genet 1997;34:92–98 8. Lavinsky J, Goldhardt R, Ariente SK, et al. Síndrome de Bardet-Biedl: relato de dois casos. Arq Bras Oftalmol 2003;66:675–680 9. Beales PL, Elcioglu N , Woolf AS, et al. New criteria for improved diagnosis of Bardet-Biedl syndrome: results of a population survey. J Med Genet 1999;36:437 10. M’hamdi O, Maazoul IOF, Chaabouni-Bouhamed H. Prevalence of Bardet–Biedl syndrome in Tunisia. Community Genet 2011;2:97–99 11. Lee BH, Liu J, Wong D, et al. Hyperactive neuroendocrine secretion causes size, feeding, and metabolic defects of C. elegans Bardet-Biedl syndrome mutants. PLoS Biol 2011;9:e1001219 12. Cassart M, Eurin D, Didier F, et al. Antenatal renal sonographic anomalies and postnatal follow-up of renal involvement in Bardet-Biedl syndrome. Ultrasound Obstet Gynecol 2004;24:51–54 13. Beales PL, Katsanis N, Lewis RA, et al. Genetic and mutational analyses of a large multiethnic Bardet-Biedl cohort reveal a minor involvement of BBS6 and delineate the critical intervals of other loci. Am J Hum Genet 2001;68:606–616 14. Halac U, Herzog D. Bardet-Biedl syndrome, Crohn disease, primary sclerosing cholangitis, and autoantibody positive thyroiditis: a case report and a review of a cohort of BBS Patients. Case Rep Med 2012;2012:209–827 15. Riise R, Andreasson S, Borgstrom M, et al. Intrafamilial variation of the phenotype in Bardet-Biedl syndrome. J Ophthalmol 1997;81:378–385 16. Waters AM, Beales PL. Bardet-Biedl syndrome. In: Pagon RA, Bird TD, Dolan CR, eds. GeneReviews [Internet]. Seattle, WA: University of Washington, Seattle. Available at: http://www.ncbi.nlm.nih.gov/books/ NBK1363/ 17. Barnett S, Reilly S, Carr L, et al. Behavioural phenotype of Bardet-Biedl syndrome . J Med Genet 2002;39:76 18. Borgström MK, Riise R, Tornqvist K, et al. Anomalies in the permanent teeth and other oral findings in 29 individuals with Laurence -Bardet-Biedl. J Oral Pathol Med 1996;25:86–89 19. Majumdar U, Arya G, Singh S, et al. Oro-dental findings in Bardet-Biedl syndrome. BMJ Case Rep 2012;23:20–12 20. Lorda-Sanchez I, Ayuso C, Sanz R, et al. Does Bardet-Biedl syndrome have a characteristic face? J Med Genet 2001;38:E14 21. Tobin JL, Di Franco M, Eichers E, et al. Inhibition of neural crest migration underlies craniofacial dysmorphology and Hirschsprung’s disease in Bardet-Biedl syndrome. 2008;105:6714–6719 22. Forsythe E, Beales PL. Bardet-Biedl syndrome. Eur J Hum Genet 2013;21:8–13 23. Mahajan R, Kumar Batra Y, Kumar S, et al. Anesthetic management of a patient with Bardet-Biedl syndrome and dilated cardiomyopathy. Minerva Anestesiol 2007;73:191–194 24. Kjær I. Dental approach to craniofacial syndromes: how can developmental fields show us a new way to understand pathogenesis? Kjær I. Int J Dent 2012;2012:145–749
Surgical Management of Immature Teratoma Involving the Oral Cavity and Orbit in a Neonate Cemal Firat, MD,* Ahmet Hamdi Aytekin, MD,* Ayşe Nur Akatli, MD,† Ahmet Karadağ, MD,‡ Emine Şamdanci, MD† Abstract: Teratomas are congenital germ cell tumors composed of elements from 1 or more of the embryonic germ layers and contain
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tissues usually foreign to the anatomic site of origin. In the head and neck region, these lesions are rare, and 90% of head and neck teratomas present during the neonatal and infantile periods. Besides, in neonates, it carries serious risk for respiratory distress as well as feeding problems due to oral cavity and airway obstruction. Here, an unusual case of intraoral teratoma involving the orbit in a newborn who underwent immediate surgical excision successfully is described. Key Words: Immature teratoma, maxillectomy, intraoral mass
T
eratomas are congenital germ cell tumors composed of diverse tissues of ectodermal, mesodermal, and endodermal origin with variable levels of maturity. The incidence of teratomas is approximately 1:4000 in live births with an 18% of life-threatening malformations.1,2 A mature teratoma is typically benign and found more commonly in females, whereas an immature teratoma is typically malignant and is more often found in males. The most common sites of teratomas are the sacrococcygeal region, gonads, and mediastinum, respectively. In the head and neck region, these lesions are rare, and 90% of head and neck teratomas present during the neonatal and infantile periods.3 Besides, in neonates, it carries serious risk for respiratory distress as well as feeding problems due to oral cavity and airway obstruction.4 Therefore, surgical excision should be considered initially for definitive treatment. In the present study, we describe a neonate born with a large intraoral mass extending from the mandibular alveolar ridge to orbita who underwent surgical excision resulting in acceptable cosmetic and functional outcomes.
CLINICAL REPORT A 3-day-old female neonate born by normal vaginal delivery was referred to the neonatal intensive care unit with chief complaint of large intraoral mass causing feeding difficulties accompanied with breathing disorder. Intraoral examination revealed a soft, pedunculated tumoral mass with a rubber consistency that protruded from the left mandibular alveolar ridge and obliterated almost the whole oral cavity extending to the hard palate. On examination, the intraoral lesion measured 6 4 4 cm (Fig. 1). The magnetic resonance imaging findings revealed a mass including cystic solid areas that extended from the anterior mandibular alveolar ridge to the left orbita through the left maxillary sinus and nasal space. It had extended on from the optic channel adjacent to the left cavernous sinus, making destruction on the bony tissues and protruding the left orbita anterosuperiorly (Figs. 2A, B). The radiologic and clinical findings of the mass made us think of a soft tissue tumor, most likely to be a teratoma. Soon after the initial diagnosis, the patient underwent surgery under general anesthesia. A type IIIA maxillectomy was planned, and an intraoral lower gingivobuccal incision followed by Weber-Ferguson incision was made. A meticulous From the Medical Faculty, Departments of *Plastic Surgery, †Pathology, and ‡Paediatrics, Inonu University, Malatya, Turkey. Received May 1, 2014. Accepted for publication June 19, 2014. Address correspondence and reprint requests to Ahmet Hamdi Aytekin, MD, Inonu University, Turgut Ozal Medical Center, Department of Plastic Reconstructive and Aesthetic Surgery, 44280, Malatya, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001171
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CONCLUSIONS The AC is an effective procedure for a short-term reduction of pain in TMD cases. It seems that AC using Ringer solution with or without corticosteroids may have the same effect on pain relief.
REFERENCES 1. Al-Belasy FA, Dolwick MF. Arthrocentesis for the treatment of temporomandibular joint closed lock: a review article. Int J Oral Maxillofac Surg 2007;36:773–782 2. Monje-Gil F, Nitzan D, González-Garcia R. Temporomandibular joint arthrocentesis. Review of the literature. Med Oral Patol Oral Cir Bucal 2012;17:e575–e581 3. Frost DE, Kendell BD. The use of arthrocentesis for treatment of temporomandibular joint disorders. J Oral Maxillofac Surg 1999;57:583–587 4. Tozoglu S, Al-Belasy FA, Dolwick MF. A review of techniques of lysis and lavage of the TMJ. Br J Oral Maxillofac Surg 2011;49:302–309 5. Nitzan DW. Arthrocentesis–incentives for using this minimally invasive approach for temporomandibular disorders. Oral Maxillofac Surg Clin North Am 2006;18:311–328 6. Dolwick MF. Temporomandibular joint surgery for internal derangement. Dent Clin North Am 2007;51:195–208 7. DM, CS, WL, eds. Temporamandibular disorders: an evidence-based approach to diagnosis and treatment. Chicago Quintessence 2006; 441–481 8. Alpaslan GH, Alpaslan C. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate in treatment of internal derangements. J Oral Maxillofac Surg 2001;59:613–618 9. Cavalcanti do EgitoVasconcelos B, Bessa-Nogueira RV, Rocha NS. Temporomandibular joint arthrocententesis: evaluation of results and review of the literature. Braz J Otorhinolaryngol 2006;72:634–638 10. Manfredini D, Rancitelli D, Ferronato G, et al. Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols. J Oral Rehabil 2012;39:245–251 11. Hersh EV, Balasubramaniam R, Pinto A. Pharmacologic management of temporomandibular disorders. Oral Maxillofac Surg Clin North Am 2008;20:197–210 12. Dimitroulis G, Dolwick MF. Temporomandibular disorders. Part3. Surgical treatment. Aust Dent J 1996;41:16–20 13. Murakami K, Hosaka H, Moriya Y, et al. Short-term treatment outcome study for the management of temporomandibular joint closed lock. A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:253–257 14. Dimitroulis G, Dolwick MF, Martinez A. Temporomandibular joint arthrocentesis and lavage for the treatment of closed lock: a follow-up study. Br J Oral Maxillofac Surg 1995;33:23–26 15. Sanromán JF. Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy. Int J Oral Maxillofac Surg 2004;33:344–348 16. Neeli AS, Umarani M, Kotrashetti SM, et al. Arthrocentesis for the treatment of internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 2010;9:350–354 17. McCain JP. TMJ arthroscopy. J Am Dent Assoc 1990;121:10–12 18. Aceves-Avila FJ, Chávez-López M, Chavira-González JR, et al. Temporomandibular joint dysfunction in various rheumatic diseases. Reumatismo 2013;65:126–130 19. Kuruvilla AVE, Prasad K. Arthrocentesis in TMJ internal derangement: a prospective study. J Oral Maxillofac Surg 2012;11:53–56 20. Barkin S, Weinberg S. Internal derangements of the temporomandibular joint: the role of arthroscopic surgery and arthrocentesis. J Can Dent Assoc 2000;66:199–203 21. Sanroman JF. Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy. Int J Oral Maxillofac Surg 2004;33:344–348
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22. Emshoff R, Puffer P, Rudisch A, et al. Temporomandibular joint pain- relationship to internal derangement type, osteoarthrosis, and synovial fluid mediator level or tumor necrosis factor-alpha. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:442–449 23. Nitzan DW, Price A. The use of arthrocentesis for the treatment of osteoarthritic temporomandibular joints. J Oral Maxillofac Surg 2001;59:1154–1159 24. Vos LM, Huddleston Slater JJ, Stegenga B. Arthrocentesis as initial treatment for temporomandibular joint arthropathy: a randomized controlled trial. J Craniomaxillofac Surg 2013;29:205–209 25. Diraçoğlu D, Saral IB, Keklik B, et al. Arthrocentesis versus nonsurgical methods in the treatment of temporomandibular disc displacement without reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:3–8 26. Giraddi GB, Siddaraju A, Kumar B, et al. Internal derangement of temporomandibular joint: an evaluation of effect of corticosteroid injection compared with injection of sodium hyaluronate after arthrocentesis. J Oral Maxillofac Surg 2012;11:258–263 27. Huddleston Slater JJ, Vos LM, Stroy LP, et al. Randomized trial on the effectiveness of dexamethasone in TMJ arthrocentesis. J Dent Res 2012;91:173–178 28. Mina R, Melson P, Powell S, et al. Effectiveness of dexamethasone iontophoresis for temporomandibular joint involvement in juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2011;63:1511–1516 29. Trieger N, Hoffman CH, Rodriguez E. The effect of arthrocentesis of the temporomandibular joint in patients with rheumatoid arthritis. J Oral Maxillofac Surg 1999;57:537–540 30. Reid KI, Dionne RA, Sicard-Rosenbaum L, et al. Evaluation of iontophoretically applied dexamethasone for painful pathologic temporomandibular joints. Oral Surg Oral Med Oral Pathol 1994;77:605–609 31. Swift JQ, Roszkowski MT, Alton T, et al. Effect of intra-articular versus systemic anti-inflammatory drugs in a rabbit model of temporomandibular joint inflammation. J Oral Maxillofac Surg 1998;56:1288–1295 32. El-Hakim IE, Abdel-Hamid IS, Bader A. Tempromandibular joint (TMJ) response to intra-articular dexamethasone injection following mechanical arthropathy: a histological study in rats. Int J Oral Maxillofac Surg 2005;34:305–310
General and Stomatologic Aspects of Bardet-Biedl Syndrome Cristhiane Olivia Ferreira do Amaral, DDS, MSc,* Gustavo de Almeida Logar, DDS, MSc,* Arlete Gomes Parisi, DDS, MSc,* Karine Takahashi, DDS, MSc,† Fabiana Gouveia Straioto, DDS, MSc‡
From the Departments of *Special Care Dentistry, †Pediatric Dentistry, and ‡Prosthodontics and Geriatic Dentistry, Dental School, University of Western Sao Paulo, Presidente Prudente, Sao Paulo, Brazil. Received April 29, 2014. Accepted for publication June 19, 2014. Address correspondence and reprint requests to Cristhiane Olivia Ferreira do Amaral, DDS, MSc, Department of Special Care Dentistry, University of Western Sao Paulo, Rua Jose Bongiovani, 700, Presidente Prudente, SP, Brazil 19050-920; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001169
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Objective: The purpose of this study is to present a clinical report of a patient with Bardet-Biedl syndrome, aiming to help the dentist to identify the general aspects, systemic changes, alterations. Clinical Report: Bardet-Biedl syndrome is defined as a genetic disorder of autosomal recessive condition; this case is a male patient, 20 years old. The general features presented by the patient were strabismus, polydactyly, hypogonadism, obesity, cognitive impairment, and autistic behavior. Dentally, this patient presents with hypotonic face, high-arched palate, dental crowding, unilateral crossbite, and difficulty in cleaning but with good-quality oral health. Conclusions: Many patients with this syndrome have compromised oral hygiene, difficulty in addressing dental cases, developmental delay, and autistic behavior. Thus, it is important to pay attention to these early children from an early age and encourage preventive approach. Key Words: Bardet-Biedl syndrome, oral health, facial dimorphisms, behavioral disorder
B
ardet-Biedl syndrome (BBS) was named in the '20s by Arthur and Georges Bardet Biedl. They described this syndrome with a large spectrum of clinical characteristics.1,2 This syndrome is autosomal recessive, occurring in both sexes, in a 3:1 ratio for men. The etiology is still unknown, but it is described in the literature as 35% to 48% of parental consanguinity in patients with this syndrome. The BBS is a rare clinical condition, and its prevalence is 1 of 160,000,3 with a wide variation around the world.4,5 The highest incidence was reported in an isolated population in a Canadian island, Newfoundland, with a prevalence of 1 of 13,000 inhabitants, and Kuwait, where the occurrence is also high, 1 of 17,000 inhabitants, mainly because of a high consanguinity rate.6 The pathophysiology of this syndrome is not completely clear. Fourteen different genes were identified as the cause of BBS.7,8 Clinical and molecular genetic testing were used to diagnose this syndrome.9–11 The clinical expression of BBS is variable. Patients can have eye disorders, retinopatia,12,13 polydactyl, obesity, learning difficulties, male hypogenitalism, complex female genitourinary malformations, and kidney malfunction, which are frequently the main reasons of mortality in these patients.14 There are a wide number of secondary characteristics associated with the syndrome, including speech and language impairments, hearing problems, strabismus, brachydactyly, hand and feet syndactyly, and dental alterations. Patients with BBS may have behavioral changes such as emotional immaturity and poor reasoning. Many of these behaviors can be seen on the autistic spectrum.15–17 It is also common for these patients to have systemic diseases such as diabetes, cardiovascular disorders, epilepsy, and liver impairment.5,14 Patients also present buccodental anomalies such as malocclusion, anterior crowding, micrognathia, deep palate, hypodontia, small tooth roots, enamel hypoplasia, and microdontia.18,19 Because of the oral manifestations, dentists must get acquainted with this syndrome. In the literature, a few studies reported facial features on patients with this syndrome. According to them, BBS patients display a long philtrum, thin upper lip, small mouth, brachycephaly, macrocephaly, large ears, palpebral fissures, bitemporal narrowing, and front baldness in male patients.7,12,20,21 In the past decades, research on syndromes concentrated in phenotype, genotype, growth, development, function, and treatment. No dental issues were described.22,23 The low occurrence of this syndrome and the necessity to help dentists to provide better assistance to BBS patients justify reporting this clinical report. The aim of this clinical report is to portray general aspects, systemic
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disorders, oral diseases, and dental problems of a BBS patient treated in the University of Western Sao Paulo.
CLINICAL REPORT This project was approved by the ethics committee of the University of Western Sao Paulo (253.473/2013). The patient DSO, male, Brazilian, and 20 years old, presented in the clinic for treatment. The patient was diagnosed with BBS since the age of 3 years. According to family background, parents were not related and had 6 children, five of which nonsyndromic. In prenatal medical history, both pregnancy and delivery were reported without any complications. In postnatal medical history, the mother reported that, between 4 and 9 months old, the child had abnormal development. The symptoms included a bending neck, rapid eye movements (nystagmus), and inability to follow a moving object. Due to a deficit in global development, there was a late onset of the speech and walking abilities, only starting at the age of 4 and 5 years, respectively. In the general physical examination, the patient weighed 76.9 kg and was 1.68 cm in height, with a body mass index of 27.6, which is classified as overweight, but not obese, like most of the cases described in the literature. He had polydactyly, an extra digit, in the ulnar side of the right hand (Fig. 1) and hypogenitalism, reported by the tutor. The ophthalmologist detected convergent strabismus in the left eye, according to a medical report. However, pigmentary retinopathy as well as any other eye condition could not be diagnosed because of the difficulty in handling the patient. No anomaly, malformation, systemic disorder, or kidney dysfunction, which are not only the major but also the worst systemic features, was found. Regarding cognitive and mental development, the patient presented an IQ lower than the normal, speech impairment, and development delay, including disabled motor and fine motor and psychosocial skills. The patient had an autistic behavior and the habit of biting fingers (Fig. 2). A daily routine, as well as the ability to follow schedules properly, was observed. Data obtained from clinical examination using headgear reported aspects of some hypotonia of the facial muscles (Fig. 3A), front overhang, brachycephaly, and straight-to-concave profile (Fig. 3B). Intraoral examination revealed the presence of dental calculus, extrinsic pigmentations spots, and small active carious lesions. The occlusion was checked, and severe problems were detected, characterized by the presence of anterior crowding, posterior crossbite, mandible atresia, and deep palate (Fig. 4). During dental treatment, the patient had a resistant and noncooperative behavior (Fig. 5). Panoramic x-ray was not taken. Highly lit places, noises from high- and low-speed dental handpieces, sucking, ultrasound, and prophy caused discomfort to the patient. It was only possible to use scalers, curettes, and other hand instruments as well gauze and cotton. For a successful dental treatment in this type of patient, it is necessary, previously, to teach and practice with the tutor how to control the dental hygiene at home and prepare the patient for dental treatment. First, oral environment stabilization procedures were conducted. Cavities on the buccal of 18, 19, 30, and 31 were removed and
FIGURE 1. Patient’s hand after surgery to remove the extra digit on the ulnar side of the right hand.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 2. Image of the upper hand being checked for the injuries caused by the habit of finger biting.
sealed with cement-based glass ionomer. Scalers and curettes, associated with topical applications of antimicrobials (chlorhexidine gluconate of 0.12%), were used to remove plaque and dental calculus. The patient used neutral topical fluoride of 2% for 4 consecutive weeks at home. In addition to the clinical procedures performed, oral care education and dietary guidance for the caregiver were provided. This patient was advised to return every 3 months to the Dental Care Clinic for Patients with Special Needs in the School of Dentistry, University of Western Sao Paulo.
DISCUSSION The BBS presents relevant characteristics to be observed by a dentist as this syndrome can influence patient's behavior that may complicate dental treatment. Although the patient did not present any major systemic disease, many patients with BBS commonly manifest nephropathy, hypertension, diabetes, and heart problems, which may influence the treatment plan. Kidney abnormalities may be an important cause of morbidity and mortality in these patients,21 but there is no evidence of any kidney disorder in this reported patient. Despite obesity being a recurring clinical characteristic of this syndrome and despite that the incidence is reported to be in between 72% and 86% in the BBS population,12 the reported patient was just overweight. The percentage of patients with polydactyly is 69%, with at least 1 digit accessory.2,14,21 Our study's patient had 1 additional digit on the ulnar side of his right hand, which was surgically removed.
FIGURE 5. Picture showing the behavior of the nonemployee patient who refused to sit on the dental chair.
Development delay and cognitive impairment are common in this syndrome. According to the literature, 62% of BBS patients need to attend special schools.24 The patient in this clinical report attended a special school because of severe cognitive impairment. Many patients with this syndrome have serious behavior deviance and tend to develop autism spectrum disorders or psychosis. In this case, the patient only had autistic behavior. According to several authors,2,7,14,20 the typical facial features are often subtle and not always present. This particular patient had most of the features mentioned in the literature such as deep eyes in the presence of convergent strabismus, flat midface and maxillary atresia, brachycephaly, and macrocephaly. The presence of these features made the patient's profile range from straight to slightly concave. In this clinical report, problems to treat the patient were faced given the autistic behavior and the development delay. Ambulatory care was chosen, and several forms of approach and management were tried to achieve better behavior. The frequency of returning may change according to the risk/caries activity of the patient and the difficulty of an effective cleaning at home. The daily oral hygiene was difficult to implement as reported by the tutor. The family was advised to return every 3 months to the dentist.
CONCLUSIONS Individuals with BBS presenting development delay, autistic behavior, poor oral hygiene, and limitations in dental care providing highlight the importance of early treatment care. A multidisciplinary team must perform the complete treatment because most individuals have complex systemic problems as well as behavioral and dental issues.
REFERENCES
FIGURE 3. Front image of the patient showing muscular hypotonia. B, Picture showing brachycephaly and straight profile.
FIGURE 4. Occlusal image of the upper dental arch, highlighting the nonocclusal alignment of the teeth.
1. Nishimura DY, Swiderski RE, Searby CC, et al. Comparative genomics and gene expression analysis identifies BBS9, a new Bardet-Biedl syndrome gene. Am J Hum Genet 2005;77:1021–1033 2. Moore SJ, Green JS, Fan Y, et al. Clinical and genetic epidemiology of Bardet-Biedl syndrome in Newfoundland: a 22-year prospective, population-based, cohort study. Am J Med Genet A 2005;132:352–360 3. Siopa l, Manuelagrego JAP. Síndroma de Bardet–Biedl. Acta Med Port 2002;15:51 4. M’hamdi O, Redin C, Stoetzel C, et al. Clinical and genetic characterization of Bardet-Biedl syndrome in Tunisia: defining a strategy for molecular diagnosis. Clin Genet 2013;83:121–129 5. Sowjanya B, Sreenivasulu U, Naidu JN, et al. End stage renal disease, differential diagnosis, a rare genetic disorder: Bardet-Biedl syndrome: case report and review. Indian J Clin 2011;26:214–216 6. Kumar S, Mahajan BB, Mittal J. Bardet-Biedl syndrome: a rare case report from North India. Indian J Dermatol Venereol Leprol 2012;78:228
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7. Beales PL, Warner AM, Hitman GA, et al. Bardet–Biedl syndrome: a molecular and phenotypic study of 18 families. J Med Genet 1997;34:92–98 8. Lavinsky J, Goldhardt R, Ariente SK, et al. Síndrome de Bardet-Biedl: relato de dois casos. Arq Bras Oftalmol 2003;66:675–680 9. Beales PL, Elcioglu N , Woolf AS, et al. New criteria for improved diagnosis of Bardet-Biedl syndrome: results of a population survey. J Med Genet 1999;36:437 10. M’hamdi O, Maazoul IOF, Chaabouni-Bouhamed H. Prevalence of Bardet–Biedl syndrome in Tunisia. Community Genet 2011;2:97–99 11. Lee BH, Liu J, Wong D, et al. Hyperactive neuroendocrine secretion causes size, feeding, and metabolic defects of C. elegans Bardet-Biedl syndrome mutants. PLoS Biol 2011;9:e1001219 12. Cassart M, Eurin D, Didier F, et al. Antenatal renal sonographic anomalies and postnatal follow-up of renal involvement in Bardet-Biedl syndrome. Ultrasound Obstet Gynecol 2004;24:51–54 13. Beales PL, Katsanis N, Lewis RA, et al. Genetic and mutational analyses of a large multiethnic Bardet-Biedl cohort reveal a minor involvement of BBS6 and delineate the critical intervals of other loci. Am J Hum Genet 2001;68:606–616 14. Halac U, Herzog D. Bardet-Biedl syndrome, Crohn disease, primary sclerosing cholangitis, and autoantibody positive thyroiditis: a case report and a review of a cohort of BBS Patients. Case Rep Med 2012;2012:209–827 15. Riise R, Andreasson S, Borgstrom M, et al. Intrafamilial variation of the phenotype in Bardet-Biedl syndrome. J Ophthalmol 1997;81:378–385 16. Waters AM, Beales PL. Bardet-Biedl syndrome. In: Pagon RA, Bird TD, Dolan CR, eds. GeneReviews [Internet]. Seattle, WA: University of Washington, Seattle. Available at: http://www.ncbi.nlm.nih.gov/books/ NBK1363/ 17. Barnett S, Reilly S, Carr L, et al. Behavioural phenotype of Bardet-Biedl syndrome . J Med Genet 2002;39:76 18. Borgström MK, Riise R, Tornqvist K, et al. Anomalies in the permanent teeth and other oral findings in 29 individuals with Laurence -Bardet-Biedl. J Oral Pathol Med 1996;25:86–89 19. Majumdar U, Arya G, Singh S, et al. Oro-dental findings in Bardet-Biedl syndrome. BMJ Case Rep 2012;23:20–12 20. Lorda-Sanchez I, Ayuso C, Sanz R, et al. Does Bardet-Biedl syndrome have a characteristic face? J Med Genet 2001;38:E14 21. Tobin JL, Di Franco M, Eichers E, et al. Inhibition of neural crest migration underlies craniofacial dysmorphology and Hirschsprung’s disease in Bardet-Biedl syndrome. 2008;105:6714–6719 22. Forsythe E, Beales PL. Bardet-Biedl syndrome. Eur J Hum Genet 2013;21:8–13 23. Mahajan R, Kumar Batra Y, Kumar S, et al. Anesthetic management of a patient with Bardet-Biedl syndrome and dilated cardiomyopathy. Minerva Anestesiol 2007;73:191–194 24. Kjær I. Dental approach to craniofacial syndromes: how can developmental fields show us a new way to understand pathogenesis? Kjær I. Int J Dent 2012;2012:145–749
Surgical Management of Immature Teratoma Involving the Oral Cavity and Orbit in a Neonate Cemal Firat, MD,* Ahmet Hamdi Aytekin, MD,* Ayşe Nur Akatli, MD,† Ahmet Karadağ, MD,‡ Emine Şamdanci, MD† Abstract: Teratomas are congenital germ cell tumors composed of elements from 1 or more of the embryonic germ layers and contain
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tissues usually foreign to the anatomic site of origin. In the head and neck region, these lesions are rare, and 90% of head and neck teratomas present during the neonatal and infantile periods. Besides, in neonates, it carries serious risk for respiratory distress as well as feeding problems due to oral cavity and airway obstruction. Here, an unusual case of intraoral teratoma involving the orbit in a newborn who underwent immediate surgical excision successfully is described. Key Words: Immature teratoma, maxillectomy, intraoral mass
T
eratomas are congenital germ cell tumors composed of diverse tissues of ectodermal, mesodermal, and endodermal origin with variable levels of maturity. The incidence of teratomas is approximately 1:4000 in live births with an 18% of life-threatening malformations.1,2 A mature teratoma is typically benign and found more commonly in females, whereas an immature teratoma is typically malignant and is more often found in males. The most common sites of teratomas are the sacrococcygeal region, gonads, and mediastinum, respectively. In the head and neck region, these lesions are rare, and 90% of head and neck teratomas present during the neonatal and infantile periods.3 Besides, in neonates, it carries serious risk for respiratory distress as well as feeding problems due to oral cavity and airway obstruction.4 Therefore, surgical excision should be considered initially for definitive treatment. In the present study, we describe a neonate born with a large intraoral mass extending from the mandibular alveolar ridge to orbita who underwent surgical excision resulting in acceptable cosmetic and functional outcomes.
CLINICAL REPORT A 3-day-old female neonate born by normal vaginal delivery was referred to the neonatal intensive care unit with chief complaint of large intraoral mass causing feeding difficulties accompanied with breathing disorder. Intraoral examination revealed a soft, pedunculated tumoral mass with a rubber consistency that protruded from the left mandibular alveolar ridge and obliterated almost the whole oral cavity extending to the hard palate. On examination, the intraoral lesion measured 6 4 4 cm (Fig. 1). The magnetic resonance imaging findings revealed a mass including cystic solid areas that extended from the anterior mandibular alveolar ridge to the left orbita through the left maxillary sinus and nasal space. It had extended on from the optic channel adjacent to the left cavernous sinus, making destruction on the bony tissues and protruding the left orbita anterosuperiorly (Figs. 2A, B). The radiologic and clinical findings of the mass made us think of a soft tissue tumor, most likely to be a teratoma. Soon after the initial diagnosis, the patient underwent surgery under general anesthesia. A type IIIA maxillectomy was planned, and an intraoral lower gingivobuccal incision followed by Weber-Ferguson incision was made. A meticulous From the Medical Faculty, Departments of *Plastic Surgery, †Pathology, and ‡Paediatrics, Inonu University, Malatya, Turkey. Received May 1, 2014. Accepted for publication June 19, 2014. Address correspondence and reprint requests to Ahmet Hamdi Aytekin, MD, Inonu University, Turgut Ozal Medical Center, Department of Plastic Reconstructive and Aesthetic Surgery, 44280, Malatya, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001171
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
