The Journal of Craniofacial Surgery
& Volume 24, Number 6, November 2013
Correspondence
Solitary Osteoma in the Zygomatic Arch To the Editor: Osteoma is a common benign neoplasm characterized by the proliferation of compact or cancellous bone, and one of the most common tumors of the nose and paranasal sinuses.1 Anatomically, it can be peripheral, central, or extraskeletal, and the growth behavior is dependent on the activity of the periosteum or endosteum.2 In a recent series of 116 patients with craniofacial osteomas, only 10 cases involved the middle third of the face.2 To date, only 2 reports of solitary osteoma arising in the zygomatic arch have been described in the international literature.3,4 Here, the authors describe a patient with zygomatic arch osteoma and emphasize the surgical approach. The case was a 32-year-old black woman with a 6-year history of a slow-growing painful swelling in the right side of the face. The patient reported associated headache and chronic facial pain related to the right masticatory muscles. The onset was spontaneous and there was no history of trauma. Clinical examination revealed a firm bony hard swelling above the right zygomatic arch, approximately 3 cm in diameter (Fig. 1A). CT scan showed a well-defined, very dense tissue image mainly composed of a homogeneous mass on the right zygomatic arch (Fig. 1B). The approach to the zygomatic arch was performed by means of an extended preauricular incision. After incision of the superficial temporal fascia over the zygomatic arch, a complete view of the lesion was obtained (Fig. 1C). With the use of periosteal elevators, the lesion was easily excised. After osteotomy and tumor removal, rigid internal fixation with 2.0 titanium plate was used to restore the normal bone architecture (Fig. 1D). A masseter
FIGURE 1. A, Clinical view showing a swelling in the zygomatic arch region. B, CT scan showing a well-defined very dense tissue image mainly composed of a homogeneous mass on the right zygomatic arch. C, Aspect of the lesion. D, Placement of a 2.0 titanium plate.
FIGURE 2. A, Masseteric flap. B, Suture of the muscular planes, C, Photomicrography showing a cancellous-type osteoma with trabeculae of bone containing numerous osteocytes (HE, original magnification 100). D, Clinical view after a 7-year period.
muscle flap was performed (Figs. 2A, B): the lateral muscle bundle was placed medially above the zygomatic arch, embracing all this structure, the medial muscular bundle was placed above both the zygomatic arch and the first muscle bundle in lateral direction, and then suture was performed in both muscle bundles below the zygomatic arch making ‘‘U’’ stitches with Vicryl 2.0. Upon microscopic examination of the surgical specimen, cancellous-type osteoma was diagnosed (Fig. 2C). Postoperative recovery was uneventful, and during a follow-up of 7 years after surgery the patient has been completely symptom free (Fig. 2D). The etiology of the osteoma has not been established, but several explanations have been suggested for the origin of these neoplasms such as osteogenic, traumatic, and infective sources.5 The first theory agrees with the cartilaginous or stem cell origin from the junctional area between frontal bone and ethmoid. The second hypothesis suggests that osteomas are the expression of hypertrophic bone resulting from infection, which determines chronic inflammatory tissues. In the present case, the onset was spontaneous and no trauma or infectious episodes were reported. Asymptomatic osteomas may be treated conservatively. However, cases characterized by a rapid growth pattern and symptomatic lesions should be excised.6 In our patient, surgical treatment was performed due to the symptoms and compromised esthetics. A preauricular approach with extension to the temporal region offered an easy flap retraction, adequate visualization of the anatomy, as well as reduced nerve damage. Moreover, restoration of the zygomatic arch with rigid internal fixation and masseter flap interpolation over the titanium plate provided good esthetic results. Osteoma is a benign tumor with low tendency to recur when treated by an adequate surgical technique. In this case, the resection performed was completely effective and no complications with the preauricular approach have been observed after a follow-up of
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
2209
The Journal of Craniofacial Surgery
Correspondence
& Volume 24, Number 6, November 2013
7 years. In addition, the headache, chronic facial pain, and muscular dysfunction have been resolved. Adriano Duarte Quintans, DDS Jorge Antoˆnio Diaz Castro, DDS Pedro Esau´ Macedo Machado, DDS Specialization Program in Oral and Maxillofacial Surgery Senador Humberto Lucena Emergency and Trauma Hospital Dental Association of Paraı´ba, Joa˜o Pessoa Paraı´ba, Brazil Fa´bio Wildson Gurgel Costa, DDS, MS Division of Stomatology Federal University of Cearaa´ Sobral Campus Ceara´, Sobral, Brazil Specialization Program in Oral and Maxillofacial Surgery Senador Humberto Lucena Emergency and Trauma Hospital Dental Association of Paraı´ba, Joa˜o Pessoa Paraı´ba, Brazil [email protected]
REFERENCES 1. Savastano M, Guarda-Nardini L, Marioni G, et al. The bicoronal approach for the treatment of a large frontal sinus osteoma. A technical note. Am J Otolaryngol Head Neck Med Surg 2007;28:427Y429 2. Larrea-Oyarbide N, Valmaseda-Castello E, Berini-Ayte L, et al. Osteomas of the craniofacial region. Review of 106 cases. J Oral Pathol Med 2008;37:38Y42 3. Furlaneto EC, Rocha JR, Heitz C. Osteoma of the zygomatic archVreport of a case. Int J Oral Maxillofac Surg 2004;33:310Y311 4. Dura˜o AR, Chilvarquer I, Hayek JE, et al. Osteoma of the zygomatic arch and mandible: report of two cases. Rev Port Estomatol Med Dent Cir Maxilofac 2012;2:103Y107 5. Castelnuovo P, Valentini V, Giovannetti F, et al. Osteomas of the maxillofacial district: endoscopic surgery versus open surgery. J Craniofac Surg 2008;19:1446Y1452 6. Gay-Escoda C, Bescos-Atin MS. Osteomas de los senos paranasales. Av Odontoestomatol 1990;6:698Y700
Sutureless Technique in Third Molar Surgery: An Overview Postoperative consequences of mandibular third molar (M3M) surgery and prevention of pain and swelling are a matter of great interest in oral and maxillofacial surgery. Many authors published articles regarding improvements that could influence the postoperative outcome, such as decreasing symptoms after M3M surgery. The use of sutureless technique has been introduced to address this point. In this article, an overview of sutureless technique in M3M surgery is presented: main controversies are discussed. Main topics introduced with these articles are shown in Figure 1.
INFECTION Alveolar osteitis (AO) is a severe complication after M3M removal: in cases of fibrinolysis, loss of blood clotting, and alveolar bone exposure in the surgical site, AO may arise.1 The absence of suture easily leads to loss of the blood clot, if this event is not prevented in another way. Waite and Cherala2 reported an AO occurrence in 13.1% of patients.2 Ghoreishian et al3 compared standard suture and sutureless technique with cyanoacrylate but did not evaluate postoperative infection; Osunde et al4 did not
2210
FIGURE 1. Summary timeline in the knowledge of sutureless technique in third molar surgery; main articles that influence the use of sutureless technique are reported, with their substantial findings for each theme.
evaluate AO too. In the study of Hashemi et al,5 no cases of AO resulted, even if they did not report the variables they evaluated. Anyway, all patients in all studies received antibiotics and antimicrobials, a condition that masks a possible greater AO appearance rate in sutureless groups compared with control groups. Thus, while in standard M3M surgery this concept is discussed,6 antibiotic prescription with sutureless technique appears to be mandatory. On the basis of these articles, little is known about the AO occurrence with sutureless technique. This matter deserves more investigation. Further studies should be encouraged.
POSTOPERATIVE RECOVERY Delayed healing after M3M surgery has been identified as a condition worsening health-related quality of life,7 and secondary healing has been correlated with delayed recovery. Thus, sutureless technique is less than ideal to guarantee fast healing and is related with a delayed recovery for lifestyle, oral function, and pain.8 Waite and Cherala2 reported a delayed recovery with sutureless technique. Neither Ghoreishian et al,3 Hashemi et al,5 nor Osunde et al4 reported data about postoperative delayed healing:3Y5 This should be due to their short follow-up, even if the study of Hashemi et al5 had a 6 months’ follow-up.5 Thus, regarding swelling and pain, sutureless technique allows lesser values2Y5 but delays complete symptom recovery. Patients experience less symptoms but go on to have a poorer quality of life.7,8
SUTURELESS FLAP In the use of sutureless technique, a proper flap must be taken into account. Mandibular third molars requiring extensive flaps are not eligible for this technique, and standard suture is preferred.8 On this matter, controversy exists. Karaca et al9 underlined that flap does not influence the second molar periodontium, and Hashemi et al5 confirmed this theory for sutureless technique. Waite and Cherala2 used a V-shaped incision and expressed the need of small incision (Fig. 2), whereas Ghoreishian et al3 used an envelope flap closed by cyanoacrylate. Osunde et al4 used a triangular flap and advocated sutureless technique to be routinely used in M3M surgery (Fig. 2); Hashemi et al5 used in their study the same standard flap both for sutureless and control groups. Donlon and Truta10 suggested its use for interventions that needed minimal incision only. Standard sutureless flap would leave an extensive socket that, without a hemostasis with sutures, leads to delayed recovery and increases complication rate. Small sutureless flap would reduce symptoms and occurrence of delayed healing, but the reduced exposed area and the * 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 24, Number 6, November 2013
Correspondence
Solitary Osteoma in the Zygomatic Arch To the Editor: Osteoma is a common benign neoplasm characterized by the proliferation of compact or cancellous bone, and one of the most common tumors of the nose and paranasal sinuses.1 Anatomically, it can be peripheral, central, or extraskeletal, and the growth behavior is dependent on the activity of the periosteum or endosteum.2 In a recent series of 116 patients with craniofacial osteomas, only 10 cases involved the middle third of the face.2 To date, only 2 reports of solitary osteoma arising in the zygomatic arch have been described in the international literature.3,4 Here, the authors describe a patient with zygomatic arch osteoma and emphasize the surgical approach. The case was a 32-year-old black woman with a 6-year history of a slow-growing painful swelling in the right side of the face. The patient reported associated headache and chronic facial pain related to the right masticatory muscles. The onset was spontaneous and there was no history of trauma. Clinical examination revealed a firm bony hard swelling above the right zygomatic arch, approximately 3 cm in diameter (Fig. 1A). CT scan showed a well-defined, very dense tissue image mainly composed of a homogeneous mass on the right zygomatic arch (Fig. 1B). The approach to the zygomatic arch was performed by means of an extended preauricular incision. After incision of the superficial temporal fascia over the zygomatic arch, a complete view of the lesion was obtained (Fig. 1C). With the use of periosteal elevators, the lesion was easily excised. After osteotomy and tumor removal, rigid internal fixation with 2.0 titanium plate was used to restore the normal bone architecture (Fig. 1D). A masseter
FIGURE 1. A, Clinical view showing a swelling in the zygomatic arch region. B, CT scan showing a well-defined very dense tissue image mainly composed of a homogeneous mass on the right zygomatic arch. C, Aspect of the lesion. D, Placement of a 2.0 titanium plate.
FIGURE 2. A, Masseteric flap. B, Suture of the muscular planes, C, Photomicrography showing a cancellous-type osteoma with trabeculae of bone containing numerous osteocytes (HE, original magnification 100). D, Clinical view after a 7-year period.
muscle flap was performed (Figs. 2A, B): the lateral muscle bundle was placed medially above the zygomatic arch, embracing all this structure, the medial muscular bundle was placed above both the zygomatic arch and the first muscle bundle in lateral direction, and then suture was performed in both muscle bundles below the zygomatic arch making ‘‘U’’ stitches with Vicryl 2.0. Upon microscopic examination of the surgical specimen, cancellous-type osteoma was diagnosed (Fig. 2C). Postoperative recovery was uneventful, and during a follow-up of 7 years after surgery the patient has been completely symptom free (Fig. 2D). The etiology of the osteoma has not been established, but several explanations have been suggested for the origin of these neoplasms such as osteogenic, traumatic, and infective sources.5 The first theory agrees with the cartilaginous or stem cell origin from the junctional area between frontal bone and ethmoid. The second hypothesis suggests that osteomas are the expression of hypertrophic bone resulting from infection, which determines chronic inflammatory tissues. In the present case, the onset was spontaneous and no trauma or infectious episodes were reported. Asymptomatic osteomas may be treated conservatively. However, cases characterized by a rapid growth pattern and symptomatic lesions should be excised.6 In our patient, surgical treatment was performed due to the symptoms and compromised esthetics. A preauricular approach with extension to the temporal region offered an easy flap retraction, adequate visualization of the anatomy, as well as reduced nerve damage. Moreover, restoration of the zygomatic arch with rigid internal fixation and masseter flap interpolation over the titanium plate provided good esthetic results. Osteoma is a benign tumor with low tendency to recur when treated by an adequate surgical technique. In this case, the resection performed was completely effective and no complications with the preauricular approach have been observed after a follow-up of
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
2209
The Journal of Craniofacial Surgery
Correspondence
& Volume 24, Number 6, November 2013
7 years. In addition, the headache, chronic facial pain, and muscular dysfunction have been resolved. Adriano Duarte Quintans, DDS Jorge Antoˆnio Diaz Castro, DDS Pedro Esau´ Macedo Machado, DDS Specialization Program in Oral and Maxillofacial Surgery Senador Humberto Lucena Emergency and Trauma Hospital Dental Association of Paraı´ba, Joa˜o Pessoa Paraı´ba, Brazil Fa´bio Wildson Gurgel Costa, DDS, MS Division of Stomatology Federal University of Cearaa´ Sobral Campus Ceara´, Sobral, Brazil Specialization Program in Oral and Maxillofacial Surgery Senador Humberto Lucena Emergency and Trauma Hospital Dental Association of Paraı´ba, Joa˜o Pessoa Paraı´ba, Brazil [email protected]
REFERENCES 1. Savastano M, Guarda-Nardini L, Marioni G, et al. The bicoronal approach for the treatment of a large frontal sinus osteoma. A technical note. Am J Otolaryngol Head Neck Med Surg 2007;28:427Y429 2. Larrea-Oyarbide N, Valmaseda-Castello E, Berini-Ayte L, et al. Osteomas of the craniofacial region. Review of 106 cases. J Oral Pathol Med 2008;37:38Y42 3. Furlaneto EC, Rocha JR, Heitz C. Osteoma of the zygomatic archVreport of a case. Int J Oral Maxillofac Surg 2004;33:310Y311 4. Dura˜o AR, Chilvarquer I, Hayek JE, et al. Osteoma of the zygomatic arch and mandible: report of two cases. Rev Port Estomatol Med Dent Cir Maxilofac 2012;2:103Y107 5. Castelnuovo P, Valentini V, Giovannetti F, et al. Osteomas of the maxillofacial district: endoscopic surgery versus open surgery. J Craniofac Surg 2008;19:1446Y1452 6. Gay-Escoda C, Bescos-Atin MS. Osteomas de los senos paranasales. Av Odontoestomatol 1990;6:698Y700
Sutureless Technique in Third Molar Surgery: An Overview Postoperative consequences of mandibular third molar (M3M) surgery and prevention of pain and swelling are a matter of great interest in oral and maxillofacial surgery. Many authors published articles regarding improvements that could influence the postoperative outcome, such as decreasing symptoms after M3M surgery. The use of sutureless technique has been introduced to address this point. In this article, an overview of sutureless technique in M3M surgery is presented: main controversies are discussed. Main topics introduced with these articles are shown in Figure 1.
INFECTION Alveolar osteitis (AO) is a severe complication after M3M removal: in cases of fibrinolysis, loss of blood clotting, and alveolar bone exposure in the surgical site, AO may arise.1 The absence of suture easily leads to loss of the blood clot, if this event is not prevented in another way. Waite and Cherala2 reported an AO occurrence in 13.1% of patients.2 Ghoreishian et al3 compared standard suture and sutureless technique with cyanoacrylate but did not evaluate postoperative infection; Osunde et al4 did not
2210
FIGURE 1. Summary timeline in the knowledge of sutureless technique in third molar surgery; main articles that influence the use of sutureless technique are reported, with their substantial findings for each theme.
evaluate AO too. In the study of Hashemi et al,5 no cases of AO resulted, even if they did not report the variables they evaluated. Anyway, all patients in all studies received antibiotics and antimicrobials, a condition that masks a possible greater AO appearance rate in sutureless groups compared with control groups. Thus, while in standard M3M surgery this concept is discussed,6 antibiotic prescription with sutureless technique appears to be mandatory. On the basis of these articles, little is known about the AO occurrence with sutureless technique. This matter deserves more investigation. Further studies should be encouraged.
POSTOPERATIVE RECOVERY Delayed healing after M3M surgery has been identified as a condition worsening health-related quality of life,7 and secondary healing has been correlated with delayed recovery. Thus, sutureless technique is less than ideal to guarantee fast healing and is related with a delayed recovery for lifestyle, oral function, and pain.8 Waite and Cherala2 reported a delayed recovery with sutureless technique. Neither Ghoreishian et al,3 Hashemi et al,5 nor Osunde et al4 reported data about postoperative delayed healing:3Y5 This should be due to their short follow-up, even if the study of Hashemi et al5 had a 6 months’ follow-up.5 Thus, regarding swelling and pain, sutureless technique allows lesser values2Y5 but delays complete symptom recovery. Patients experience less symptoms but go on to have a poorer quality of life.7,8
SUTURELESS FLAP In the use of sutureless technique, a proper flap must be taken into account. Mandibular third molars requiring extensive flaps are not eligible for this technique, and standard suture is preferred.8 On this matter, controversy exists. Karaca et al9 underlined that flap does not influence the second molar periodontium, and Hashemi et al5 confirmed this theory for sutureless technique. Waite and Cherala2 used a V-shaped incision and expressed the need of small incision (Fig. 2), whereas Ghoreishian et al3 used an envelope flap closed by cyanoacrylate. Osunde et al4 used a triangular flap and advocated sutureless technique to be routinely used in M3M surgery (Fig. 2); Hashemi et al5 used in their study the same standard flap both for sutureless and control groups. Donlon and Truta10 suggested its use for interventions that needed minimal incision only. Standard sutureless flap would leave an extensive socket that, without a hemostasis with sutures, leads to delayed recovery and increases complication rate. Small sutureless flap would reduce symptoms and occurrence of delayed healing, but the reduced exposed area and the * 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
