Behnam Aghabeigi on the management of unilateral condylar fractures

No area of maxillofacial trauma stimulates more controversy than the management of a fractured mandibularcondyle. Fractures of the mandibular condyle are thought to account for about 35% of all mandibular fractures, but our experience suggests that this is an overestimate.

A recent multicentre national audit in the UK2reported a suboptimal outcome in up to 30% of patients with unilateral condylar fracture managed by the traditional techniques of either closed reduction or observation, although the follow-up period was short. If the findings are true then this is an unacceptably high complication rate. Consequently the pendulum has swung towards accurate anatomical relocation of the fractured segments by open reduction and internal fixation (ORIF) in the hope that this will improve outcome.

Whilst the proponents of both open and closed reduction passionately debate the appropriate choice of treatment, a review of publications showed a paucity of good quality scientific evidence to support either treatment.

This prospective study was designed to investigate the outcome of treatment of unilateral condylar fractures with ORIF on the hypothesis that such treatment may convey superior results by allowing adaptive processes to act maximally during the recovery period.

Patients and Methods used by Ben Aghabeigi Birmingham

Adult patients who presented to the maxillofacial units at University College London Hospitals and the Queen Victoria Hospital, East Grinstead were recruited prospectively.

According to Aghabeigi dentist all patients over 16 years of age with unilateral condylar fractures were examined. Those with unilateral condylar fractures and normal occlusions were managed conservatively, by instituting a soft diet for 6 weeks and early mobilization. These patients were not entered into the study.

Patients who had an isolated unilateral condylar fracture and deranged occlusion were placed in elastic traction for 7–10 days, the exact time being decided by the date of the next available clinic. Any patient with a deranged occlusion at review was offered open reduction and internal fixation. It was felt that sufficient time would have elapsed since the original presentation that compounding factors such as tissue oedema, muscle spasm and effusion or haemarthrosis would have resolved, and that any resultant malocclusion was caused solely by condylar malposition.

A second group of patients was also recruited into the study. Adult patients who presented with deranged occlusion, and a unilateral displaced or dislocated condylar fracture plus another mandibular fracture that itself required osteosynthesis, were offered ORIF of all fracture sites. The criteria for offering ORIF of the associated condyle were the same as those described by Eckelt and Rasse,3namely medial dislocation of the condyle ; displaced fractures with 95 mm bone overlap; or complete loss of bone contact.

The surgical technique used was standardized and five surgeons operated on the patients. All concerned were either of consultants grade or had at least 3 years’ registrar experience. Surgical access was by a retromandibular approach, which was occasionally supplemented with a standard preauricular skin incision. The fractures were fixed with 2-mm titanium miniplates.

Outcome measures involved each patient being examined according to a standard protocol together with standardized radiographic assessment (orthopantomograms and posterior–anterior mandibular radiographs).

All authors assessed the preoperative and postoperative radiographs for each patient.

The outcome measures considered to be important were broadly akin to those described by Walker5and comprised:

1. The restoration of the preinjury occlusion. This was assessed by the operating surgeon together with questions to the patient.

2. Restoration of normal mouth opening in excess of 40 mm. Inter-incisal clearance was measured with a Willis gauge.

3. Pain-free mouth opening, which was assessed by asking the patients.

4. Full range of mandibular excursions, assessed clinically by the operating surgeon.

5. Restoration of facial and mandibular symmetry, assessed clinically by the operating surgeon. We accept that some of the above are subjective and open to inter-operator variation, and therefore criticism, but on a pragmatic level this was the best we thought that we could achieve.

Checking the Results with Ben Aghabeigi gdc

A total of 54 consecutive patients was entered into the study: 24 had isolated unilateral fractures, and the remaining 30 had a synchronous parasymphyseal fracture. Forty-two of the patients were males (78%). Thirty-three of the 54 patients underwent ORIF of their condylar fracture with miniplate osteosynthesis. The remaining 21 condylar fractures were treated with elastic traction alone. No patient in this latter group had a synchronous mandibular fracture. No patient whose conservative treatment had failed refused ORIF at the 7–10 day appointment.

The nomenclature we used to classify the subsets of condylar fracture was the same as that proposed by Lindahl6: intracapsular, condylar neck or subcondylar. These fractures were further subdivided by assessing the relationship of the condylar fragment to the rest of the mandible. This led to a subclassification of undisplaced, displaced medially or laterally, over-riding anteriorly or posteriorly, or complete loss of bony contact. Afurther subset was also generated when we assessed the rela- tionship of the condylar head to the glenoid fossa, giving undisplaced, displaced and dislocated categories.

A branch of the facial nerve was encountered during 19 retromandibular dissections (35%), which is similar to the figure quoted by Ellis and Dean.7With careful surgical technique and gentle retraction the nerve branch can be mobilized without compromising its function or impeding access to the fracture site. All patients had normally functioning facial nerves at 1-month review. In the case of fracture dislocations the retromandibular approach occasionally has to be supplemented by a standard preauricular approach to gain control of the condylar fragment and to facilitate accurate anatomical reduction.

Several authors have combined miniplate osteosynthesis with intermaxillary fixation (IMF). This negates one of the main advantages of ORIF, and contravenes the established principle of early mobilization to prevent ankylosis. Therefore our patients were not placed in wire IMF during the postoperative period, but three of them (10%) did require guiding elastic traction for the first 10 postoperative days to achieve their premorbid occlusion.

Only 32 of 54 patients attended for review; such poor compliance is not unusual in this group of patients. Of those reviewed 25 had ORIF, and the remaining 7 had been managed with elastic traction alone. The follow-up period ranged from 1 month to 3 years with a median of 14.5 months. All patients treated with ORIF had good postoperative occlusion assessed both objectively (by clinical assessment) and subjectively (by asking the patient how the bite felt). Nineteen patients (60%) had some degree of mandibular deviation on opening (all 7 in the conservative group and 12/25 in the ORIF group).

However, this was of greater concern to the clinicians than to the patients. Two patients (6%) have been left with chronic pain at the condylar fracture site, both of whom were conservatively treated.

Mouth opening varied between the two groups. In the ORIF group the mean interincisal opening was 42 mm (range 37–52), and in the elastic traction group the mean was 32 mm (range 28–36). These figures compare favourably with those previously reported4which showed interincisal clearance to be significantly improved in patients with bilateral condylar fractures treated by ORIF (mean 44 mm) compared with IMF (mean 28 mm).

One of the criticisms of ORIF has been the length of time taken to do this procedure in view of the limited access. Whilst we accepted this initially, with increasing exposure to the technique our operative time decreased from a mean of 120 minutes/condyle to 40 minutes/condyle.

DISCUSSION

The management of unilateral condylar fractures remains controversial. There have been as many studies published in the world that favour ORIF as there have been that oppose it. Indeed, Hayward and Scott quoted a similar discussion reported in the American Journal in 1945, debating just this issue. It has been our previous experience that an unacceptably large number of patients who have been managed conservatively have had suboptimal functional outcomes. This view has been supported in a recently published national survey. We therefore felt it necessary to compare outcome in the two groups prospectively.

Zide and Kent11described their indications for plating condylar fractures, which included displacement of the condyle into the middle cranial fossa, lateral extra-capsular displacement of the condyle, inability to achieve adequate reduction using closed techniques, and invasion of the joint by a foreign body such as a gunshot. We have found that these criteria are seldom met in everyday maxillofacial practice, so we used the criteria described by Eckelt and Rasse3to decide who would be offered ORIF, with the aims of treatment being those previously described by Walker.5

ORIF of the condyle has not gained widespread popularity with surgeons, as it is perceived to be a difficult and time-consuming operation. Our experience has shown that although there is a fairly steep learning curve we were able to reduce our operating time considerably from 120 minutes to about 40 minutes/condyle.

Surgical access to the condyle was by a retromandibular approach, and our initial fears of damaging the facial nerve have not been realized. This technique provides good access to the condylar fracture and we have extended its application to include inverted ‘L’ ramus osteotomies and costochondral grafting procedures.

Three of 25 patients (12%) had a transient weakness of the buccal branch of the facial nerve that recovered fully within 3 weeks. This indicates a low incidence of facial nerve morbidity associated with this approach. The retromandibular incision is associated with good cosmesis as assessed by both patient and surgeon.

For more information about Behnam Aghabeigi visit here : http://benaghabeigi.co.uk/

Behnam Aghabeigi studies patients with chronic facial pain

Facial arthromyalgia (FAM) or the temporomandibular joint pain dysfunction syndrome is a common condition in which patients complain of pain and tenderness in one or both temporomandibular joints (TMJ), often with limitation of jaw opening informs Dr. Behnam Aghabeigi Birmingham. The condition is four times more common in females than males and there are many reports linking these symptoms to adverse life events, stress or the lack of emotional support. This condition can occur independently or with other non-muscular non-joint pain in the face (atypical facial pain, AFP) or teeth (atypical odontalgia, AO). These are also commonly related to idiopathic head, neck and back pain, irritable bowel and pruritus. The facial pains are best controlled with tricyclic antidepressants even in the absence of depression. Recently we have shown that these patients also have impaired excretion of conjugated tyramine, a biological trait marker seen in endogenous depression suggesting a common metabolic disturbance predisposes to both pain and depression.

However, the precise underlying biochemical mechanisms leading to both pain and joint dysfunction remain to be established. In an attempt to account for the joint pain and dysfunction Dr. Ben Aghabeigi Birmingham’s attention was drawn to studies claiming to demonstrate that emotional stress and pain in animals were associated with an increased generation of free radical@-’ and by the observation that stress induced damage to the gastric mucosa was related to free radical production. ‘,i” Furthermore, there have been reports that free radical activity in synovial fluid from the knee joints of rheumatoid patients correlates with the severity of the disease.” A free radical is any molecule or atom that contains one or more unpaired electrons rendering it highly reactive. Most biological molecules such as O2 or H,O are non-radicals, containing only paired electrons.

In addition to causing pain in animals, in vitro experiments have shown that free radicals depolymerise hyaluronic acid producing lower synovial fluid viscosity,” which might impair lubrication and lead to meniscal hesitation and clicking, as originally proposed by Toller.i3 There has also been evidence that free radicals are associated with cartilage damage14 and that they can stimulate bone resorption.” Furthermore, the demonstration of the presence of eicosanoids in various inflammatory joint diseases,” which could be the product of a free radical and or neuropeptide synovitis, would fit their known role as one of the important mediators of chronic algesia and hyperalgesia. Therefore we have examined the possibility that FAM may, in part, result from the inappropriate production of free radicals in susceptible individuals.

Three parameters of free radical generation were measured in patients presenting with overt symptoms of FAM and/or a history of idiopathic oro-facial pain (AFP and AO): (I) Systemic free radical activity was studied by a comparison of the free radical production of 2,3-dihydroxybenzoic acid (DHB) from an oral dose of aspirin as opposed to the normal aspirin metabolic product 2,5-DHB.17

Intra-articular free radical activity was investigated by two methods.

One was a thiobarbituric acid (TBA) assay of saline TMJ aspirates to test for intra-articular production of lipid peroxidation products” and (III) the second was measurement of the production of intra-articular hyperalgesic eicosanoids PGE,, LTB, and 15-HETE.

Materials and Methods used by Dr. Ben Aghabeigi Birmingham

Patients

Three sets of patients were recruited for this study. Systemic free radical activity was studied in the first group of patients who were diagnosed as having chronic FAM and/or other idiopathic oro-facial pain of more than 3 months duration. Intra-articular free radical activity was studied in groups II and III which comprised patients with unilateral symptoms of TMJ pain which had been unresponsive to 12 weeks tricyclic antidepressant therapy and were undergoing TMJ arthroscopy under general anaesthesia. All the subjects gave their informed consent and none had any other joint disease or known or suspected history of allergy to aspirin. Ethical approval was obtained for all procedures.

Group I (systemic free radical activity): 10 pain patients (age range 26-64, mean 41.8 + 11; 9 females, 1 male) and 10 healthy, age- and sex-matched volunteers with no prior history of idiopathic pain were recruited as controls (age range 29-60, mean 42.129.6). These patients and control subjects had 10 ml of venous blood drawn in heparinised tubes and voided their bladders to provide a urine sample. Each subject was then administered an oral dose of 1.2 g of aspirin and after 2 h repeat blood and urine samples were collected. The blood samples were centrifuged immediately and the plasma and urine samples stored at – 70°C until assayed for 2,3-DHB.

Group II consisted of 18 patients (age range 22-49, mean 33.2+ 8.1; 13 females, 5 males). Two hours before arthroscopy the patients were administered 1.2 g of Aspirin orally in order to ensure equilibration between the plasma and synovial fluid. At arthroscopy 1 ml of normal saline was injected into the joint spaces bilaterally, allowed time to mix with the synovial fluid and aspirated through the same needle. Specimens with overt contamination with blood were discarded. The aspirate volumes were determined, 50 ul removed for haemoglobin assay and the remainder was centrifuged immediately before the supernatants were stored at -70°C. A venous blood sample was drawn into heparinised tubes at the same time as the synovial aspirates were collected, centrifuged and the plasma stored at -70°C until assayed for lipid peroxidation products by TBA assay.

Group III consisted of 15 patients (age range 15-41, mean 28.3 +7.4; 9 females, 6 males). Synovial aspirates were collected as described above and retained for hyperalgesic eicosanoid analysis, specifically prostaglandin E2 (PGE2), leukotriene B, (LTB,) and 15-hydroxyeicosatetraenoic acid ( 15HETE). These subjects did not receive aspirin because of its potential inhibitory effect on eicosanoid production.

Biochemical analyses

(a) Measurement of plasma and urine Measurement of plasma and urine 2,3- and 2,5-dihydroxybenzoic acid (DHB) was by a modification of the methods of Grootveld and Halliwell” using HPLC coupled to electrochemical detection. All samples were used immediately or stored at – 70°C until analysed.

(i) Plasma sample preparation for the DHB assay. Samples (1 ml) were acidified with 50 ul of 1 M HCI and 20 ul of an internal standard of 3,4-DHB (100 PM) added before the samples were extracted with 10 ml of ethyl acetate. The samples were then centrifuged at 1500 g for 10 min before the upper organic layer was decanted into a clean dry tube and reduced to dryness under a stream of air in a water bath at 40°C. Once dry the samples were redissolved in 200 nl of mobile phase and 50 ~1 of 1 M HCl was added prior to analysis.

(ii) Urine sample preparation for DHB assay. Samples (5 ml) were acidified with 1 ml 1 M HCl before being extracted twice with 10 ml of ethyl acetate. The combined ethyl acetate extracts were taken to dryness under a stream of air in a water bath at 40°C. The residues were reconstituted in 250 ul of 0.2 M HCl and subsequently diluted 1 in 20 or 1 in 50 with 0.2 M HCl before final analysis.

(iii) HPLC purification and electrochemical detection of DHBs. After the initial extraction of both the plasma and the urine samples, the HPLC purification of 2,3- and 2,5-DHBs were the same, with a minor modification to the detection system to facilitate a single run determination of the urinary levels of 2,5-DHB due to the large amounts of this aspirin metabolite found in urine. HPLC separations were run under isocratic conditions using a SpectraPhysics SP8800 pump with a Brownlee 5 pm ODS reverse phase column (250 x4.6 mm) coupled to an EDT instruments LCA 16 electrochemical detector equipped with a glassy carbon working electrode and a Ag/AgCl reference electrode operated in the oxidation mode. The mobile phase was 30 mM sodium titrate/27.7 mM sodium acetate buffer (pH 4.75) at a flow rate of 1 ml min- i. The mobile phase was sparged with helium gas and the eluent monitored electrochemically at an electrode potential of + 0.6 V.

When the urine samples were analysed it was found to be possible to obtain quntifiable peaks equivalent to 2,3- and 2,5-DHBs in a single run when the recorder sensitivity was decreased lo-fold after the elution of the 2,3-DHB peak.

Synovial analyses for lipid peroxidation

(b) Thiobarbituric acid test

A modified method of Rowley et al.” was used in this study; briefly, 125 yl of sample-plasma or synovial Auid- was added to 250 ul of TBA solution (1% w/v in 50 mM sodium hydroxide), 250 ul hydrochloric acid (25% v/v) and 200 ul of water; 125 ul of water was used in the place of sample as a negative control. The tubes were tightly capped and heated at 100°C for 1 h, after which they were allowed to cool to room temperature before being extracted into 1.5 ml l-butanol with vigorous mixing for 2 min. The samples were then centrifuged at 1500 g at 4°C for 15 min and the absorbance of upper organic layer determined at 532 nm.

(c) Haemoglobin measurement

Haemoglobin levels in the samples were quantified using a commercial calorimetric assay (Sigma Chemical Co.). Some of the samples were found to have low levels of haemoglobin which could only be measured by increasing the volume of the sample in the assay system from 20 ul to 50 ~1.

(d) Salicylate assat,

Salicylate was measured in both joint aspirate and venous blood by a modified method of Grootveld and Halliwelli7 using high performance liquid chromatography (HPLC) and UV detection. Samples (200 ~1) were treated with 25 ul of 1 M HCl before being extracted with 10 ml of diethyl ether. After separation, the ether layer was evaporated in a water bath at 40°C and the residue was dissolved in 225 ulof the HPLC mobile phase containing 5% (v/v) 1 M HCl. Samples not assayed immediately were stored at -70°C until used. Separation was done on a SpectraPhysics SP8800 HPLC pump operated in isocratic mode using a Shandon 5 m ODS reverse-phase column (250 x 4.6 mm). The mobile phase was 30 mM sodium titrate/27.7 mM sodium acetate buffer (pH 4.75) and methanol (94: 6) at a flow rate of 1 ml min-‘. The mobile phase was sparged with helium gas and the eluent monitored at 254 nm.

(e) Measurement of eicosanoids

Synovial aspirates from symptomatic and symptomfree joints were analysed for the presence of PGE,, LTB, and 15-HETE using commercial radioimmunoassay kits (Amersham International). The assays were conducted according to the manufacturer’s instruction.

Statistical analysis

A student’s r-test was used for analysing the parametric data in patients vs controls and symptomatic vs asymptomatic joints.

Results

Group I

Healthy control subjects and patients presenting with chronic idiopathic oro-facial pain did not have statistically different circulating levels of the principle 2,5-DHB metabolite of aspirin indicating that the metabolic factors governing aspirin clearance were not different between the two groups. However, the circulating levels of 2,3-DHB, the suggested product of free radical activity,” was significantly elevated in the pain patients, whereas 5 out of 10 of the control subjects were found to have no detectable levels of this compound. The urine concentrations of both metabolites did not differ between the groups.

Group II

The yield of aspirate ranged from 500 ul to 1050 ul, there being no significant volumetric difference between the symptomatic and symptom-free joints. There was no significant difference in the levels of TBA-RS between the synovial fluids from the symptomatic and symptomless joints. Approximately half of the samples had haemoglobin contamination, but the contribution to the measured levels of TBA-RS did not significantly alter the analysis of the data. The synovial fluid volume was calculated using a concentration volume equation based on the plasma to TMJ aspirate salicylate ratio.ig This ratio was not significantly different between the symptomatic and symptomless joints, reflecting the absence of any difference in synovial fluid volume between painful and pain-free joints.

Group III

The presence of high levels of 15-HETE, but unmeasurable amounts of both PGE, and LTB, were found in both symptomatic and symptom-free synovial aspirates (Table 2). There was no statistical difference between the levels of 15-HETE in the synovial fluids from symptom-free and painful joints.

Discussion with Aghabeigi dentist

We have measured the levels of 2,3-DHB in both the circulation and in the urine of a group of 10 patients attending a clinic for chronic idiopathic oro-facial pain, before and after the administration of 1.2 g of aspirin and these levels have been compared to ageand sex-matched control subjects (Table 1). There was no indication that either group had differences in their innate abilities to metabolise Aspirin, as assessed by the production of 2,5-DHB, the major product of mammalian metabolism of aspirin. However, there were significantly higher levels of the free radical generated 2,3-DHB in the plasma of the patient group as compared to the control subjects. It has been proposed that the production of 2,3-DHB from an oral dose of aspirin results from a free radical reaction with salicylate.” This would support the hypothesis that patients with chronic idiopathic pain which is commonly stress related appear to generate increased free radicals or have some impairment in their scavenging metabolism.

The urinary levels of 2,3-DHB was higher in patients as compared to the controls. Although this was not statistically significant, it could be biologically important. We are not competent to comment further on the complexity of urinary free radical metabolism, which probably required some form of clearance measurement. During the past decade, saline aspirates of the upper joint space of the TMJ have been analysed for the presence of various mediators of pathological conditions.20-24 In this study we have also analysed saline aspirates, from patients presenting with a history of chronic FAM who were undergoing arthrostopic examination, for the potential to generate, in vivo, free radicals and intra-articular eicosanoids. We believe that this approach is fraught with difficulties, especially as the volumetric yield from a collection of TMJ aspirate is variable, in our case ranging from 500 ul to 1050 ~1. The volume collected is probably dependent on operator technique and the patency of the joint space.

However, the mean volume of the aspirates collected in this study is much higher than previously reported” or than that collected in a pilot study done in our laboratory.” Arthroscopic joint trauma, giving rise to haemoglobin and cellular contamination of some of the samples was an indication of an important source of error. This was controlled by the preoperative aspirin and by ensuring that centrifugation of the aspirates was carried out immediately, and would also explain, at least in part, previously reported unusually high levels of inflammatory mediators that are not appropriate to this condition.21 This is an important observation that has not previously been commented on by other workers, who have found levels of neuropeptides, prostaglandins and leukotrienes to be higher in TMJ synovial fluid than those found in the synovial fluid collected from the inflamed knee joint in gout.

Although measurement of TBA-RS is one of the most widely used single assays for determining lipid peroxidation indicating free radical activity, it has been criticised for its lack of specificity when applied to human body fluids. i9 It is interesting that we have also found TBA-RS in the saline aspirates from both symptomatic and non-symptomatic TMJs of patients with FAM and that there is no statistical difference between the sides. This suggests that other as yet unknown algesic factors contribute to the localisation of the pain and dysfunction. An alternative influence may be the suspension of masticatory activity by a patient who has fasted overnight prior to the general anaesthetic.

An interesting piece of supporting evidence for the involvement of free radicals in the pathogenesis of FAM is our demonstration of high intra-articular concentrations of the hyperalgesic mediator 15-hydroxyeicosatetraenoic acid ( 15-HETE), whose synthesis involves the free radical mediated process of lipid peroxidation of arachidonic acid, in synovial fluid. We were unable to demonstrate the presence of either prostaglandin E2 (PGE,) or leukotriene B4 (LTB,). It is worth repeating that the eicosanoid levels found by previous investigators seem to be artifactually raised even when compared to severe inflammatory disease in other joints.“j It is of importance that hyperalgesia induced by 15-hydroperoxyeicosatetraenoic acid ( 15-HPETE) in an experimental animal can substantially prolong the algesic effect of substance P(SP) producing a chronic pain model not dissimilar to FAM. This is not inhibited by non-steroidal anti-inflammatory analgesics apart from dipyrone.

Furthermore, a SP antagonist can block this effect. These findings correlate with other studies which have identified neuropeptides in the synovial fluid from the TMJ27,28 and our own observations2’ which have demonstrated that the TMJ capsule is not only richly innervated by SP neuronal tissue, but also other neurogenic peptides including calcitonin gene-related peptide, neuropeptide Y and vasoactive intestinal polypeptide. One of the major clinical problems in controlling FAM is the poor response to non-steroidal anti-inflammatory analgesics, which would correlate with the role of hyperalgesic 15-HPETE as being more important than the prostaglandins such as PGE,. As stated there were no significant differences between the symptomatic and symptom-free joints with respect to TBA-RS, 15-HETE or synovial fluid volume.

Unfortunately, as it was not ethically possible to obtain saline aspirates from the joints of healthy age- and sex-matched pain-free adults, one can only speculate that these levels found represent the pathological process. This absence of difference is not completely surprising considering that a systemic biochemical disorder would be reflected in both joints at the ends of a single bone. Furthermore, the mirror imaging of inflammatory responses in other paired joints in the body which lack the unique anatomical and functional characteristics of TMJ has been attributed to neurophysiological influences.30 However, the presence of potential pain mediators in the symptomless joints also suggests the importance of other factors such as local neuropeptide or cytokine release which may be dependant on asymmetrical masticatory function and bruxism, or personality factors which influence central modulation of the pain experience.

For more information about Behnam Aghabeigi visit here : http://behnamaghabeigi.co.uk/research–publications.html

Behnam Aghabeigi’s research on TMJ dysfunction syndrome

According to Behnam Aghabeigi Facial arthromyalgia (FAM) or perhaps the temporomandibular joint pain malfunction symptoms is a type of symptom in which sufferers complain associated with soreness and tenderness in one or perhaps each temporomandibular joints (TMJ), generally with restriction regarding jaw opening. The illness is definitely four times more established in ladies as compared to men in addition to certainly, there are many studies relating these kind of signs and symptoms to damaging life events, stress or deficit of mental support. This disorder can happen separately as well as together with different non-muscular non-joint pain in the face area (atypical facial pain, AFP) or teeth (atypical odontalgia, AO).

They are also regularly associated with idiopathic head, back and neck soreness, cranky intestinal and pruritus. The particular facial discomfort would be better governed together with tricyclic antidepressants even during the absence of depression4 Lately we have now found these particular patients in addition have disadvantaged removal of conjugated tyramine, a organic trait marker observed in endogenous depression5 suggesting a standard metabolic disturbance predisposes to each pain and depression. Nevertheless, the particular underlying biochemical components producing both pain and joint dysfunction continue being proven.

To try to account for the particular joint pain and also dysfunction our interest had been drawn to studies claiming to indicate that psychological pressure as well as pain inside animals had been connected with an improved generation of free radical and by the actual observation that stress activated damage to the actual gastric mucosa was linked to free radical production. ‘,i”

Furthermore according to Dr. behnam aghabeigi Birmingham, there are reports that free radical exercise within synovial fluid through the knee joints of rheumatoid people correlates with the seriousness of the ailment.” A free radical is any chemical as well as atom that contains one or more unpaired electrons making it significantly reactive. The majority of organic substances for example O2 or H,O are nonradicals, comprising simply matched electrons. In addition to triggering agony in animals, in vitro experiments have demostrated that toxins depolymerise hyaluronic acid generating reduce synovial fluid viscosity,” which can impair lube in addition to be responsible for meniscal hesitation along with clicking, as initially suggested by Toller.i3 There has also been proof that free radicals are linked with cartilage damage plus they could motivate bone resorption.

Again, the particular illustration showing the inclusion of eicosanoids in numerous inflamation related joint diseases,” that could be the product of a free radical and or neuropeptide synovitis, might fit their particular known role as one of the crucial mediators of chronic algesia and hyperalgesia.

And now we have analyzed the chance that FAM may, partially, result from the actual inappropriate production of free radicals in inclined folks. Three parameters of free radical generation are measured inside patients showing together with overt symptoms of FAM and/or a history of idiopathic orofacial soreness (AFP and AO):

MATERIALS And Techniques

Sufferers

Three teams of sufferers ended up enrolled just for this research. Systemic free radical activity had been examined inside 1st band of sufferers that were diagnosed as having chronic FAM and/or other idiopathic orofacial discomfort greater than 3-4 months length. Intra-articular free radical activity was researched inside groups II and III which made up sufferers together with unilateral signs of TMJ pain which had been less competent to 12 weeks tricyclic antidepressant therapy as well as were going through TMJ arthroscopy under general anaesthesia. Each of the subjects gave their educated agreement and also none had any other joint disease or known or suspected reputation of sensitivity to aspirin. Ethical approval was acquired for all those treatments.

Group I (systemic free radical activity): 10 pain patients (age range 26-64, mean 41.8 + 11; 9 females, 1 male) and 10 healthful, age and sex-matched volunteers without any prior reputation idiopathic pain were enrolled as controls (age range 29-60, mean 42.129.6). These kind of people in addition to control subjects had 10 ml of venous blood used heparinised tubes and voided their bladders to provide a urine test. Each subject ended up being given an oral dose of 1.2 g of aspirin and after 2 h repeat blood and urine trials had been collected. The particular blood samples were centrifuged quickly and also the plasma along with urine samples kept at – 70°C until assayed for 2,3-DHB.

Group II was comprised of eighteen patients (age range 22-49, mean 33.2+ 8.1; 13 females, 5 males). 2 hours prior to arthroscopy the patients were given 1.2 g of Aspirin orally in order to ensure equilibration between the plasma as well as synovial fluid. At arthroscopy 1 ml of normal saline had been shot into the joint spaces bilaterally, permitted time to mix with the synovial fluid and aspirated through the same needle. Specimens using overt contamination along with blood were discarded. The aspirate quantities had been determined, 50 ul eliminated for haemoglobin assay along with the rest was centrifuged straight prior to the supernatants were stored at -70°C. A venous blood sample was drawn into heparinised tubes simultaneously as the synovial aspirates were collected, centrifuged plus the plasma stored at -70°C until assayed for lipid peroxidation products by TBA assay.

Group III was comprised of 15 sufferers (age range 15-41, mean 28.3 +7.4; 9 females, 6 males). Synovial aspirates were amassed as described above and maintained for hyperalgesic eicosanoid analysis, exclusively prostaglandin E2 (PGE2), leukotriene B, (LTB,) and 15-hydroxyeicosatetraenoic acid ( 15HETE). These subjects did not receive aspirin because of its potential inhibitory effect on eicosanoid production.

Outcomes

Group I

Healthy control subjects along with people presenting with chronic idiopathic orofacial pain didn’t have statistically diverse circulating amounts of the principle 2,5-DHB metabolite of aspirin showing that this metabolic factors governing aspirin clearance weren’t different between the two groups. Even so, the circulating levels of 2,3-DHB, the encouraged product of free radical activity,” was much raised within the soreness clients, although 5 out of 10 of the control subjects were found to have no evident amounts of this kind of compound. The urine concentrations of each metabolites would not vary involving the groups.

Group II

The yield of aspirate varied through 500 ul to 1050 ul, there being absolutely no significant volumetric distinction between the actual symptomatic and symptom free joints. There wasn’t any considerable variation inside the levels of TBA-RS relating to the synovial fluids from the symptomatic and also symptomless joints. Around half of the samples had haemoglobin contamination, however the contribution to the calculated numbers of TBA-RS didn’t significantly affect the analysis of the data. The synovial fluid volume was calculated employing a concentration volume equation depending on the plasma to TMJ aspirate salicylate ratio. This ratio was not tremendously diverse between the symptomatic and symptomless joints, reflecting the absence of virtually any improvement in synovial fluid volume between painful and comfortable joints.

Group III

There wasn’t any mathematical contrast between the levels of 15-HETE in the synovial fluids from symptom free or painful joints.

During the past 10 years, saline aspirates on the upper joint space of the TMJ have been analysed for the existence of a variety of mediators of pathological conditions. Within this research we’ve additionally evaluated saline aspirates, through sufferers showing with a reputation of chronic FAM who were considering arthrostopic assessment, for your possible ways to create, in vivo, free radicals as well as intra-articular eicosanoids. We believe that this method is filled together with difficulties, specifically as the volumetric yield from the number of TMJ aspirate will be varied, inside our situation ranging from 500 ul to 1050 ~1.

An appealing little bit of encouraging facts for your engagement of free radicals in the pathogenesis of FAM is our illustration showing high intra-articular concentrations of the hyperalgesic mediator 15-hydroxyeicosatetraenoic acid ( 15-HETE), whose functionality requires the free radical mediated procedure for lipid peroxidation of arachidonic acid, in synovial fluid. We’ve been not able to illustrate the inclusion of both prostaglandin E2 (PGE,) or leukotriene B4 (LTB,). It can be worth repeating that the eicosanoid levels found by previous investigators are generally artifactually raised even though compared to significant inflammatory illness in other joints. It is of importance that hyperalgesia induced by 15-hydroperoxyeicosatetraenoic acid ( 15-HPETE) in the trial and error animal may drastically lengthen the algesic effect of substance P(SP) producing a chronic pain model not dissimilar to FAM. This isn’t inhibited by nonsteroidal anti-inflammatory analgesics besides dipyrone. Furthermore, a SP antagonist can block this effect.

These bits of information associate with other reports which have identified neuropeptides in the synovial fluid from the TMJ27,28 and each of our observations that have demonstrated that the TMJ capsule is not just richly innervated by SP neuronal tissue, but additionally some other neurogenic peptides which includes calcitonin gene related peptide, neuropeptide Y and vasoactive intestinal polypeptide. Certainly one of the key clinical problems in managing FAM is the inadequate reaction to nonsteroidal anti-inflammatory analgesics, which will associate with the role of hyperalgesic 15-HPETE for being more important as opposed to prostaglandins such as PGE,.

As mentioned by Dr. aghabeigi Birmingham there were simply no substantial distinctions between the symptomatic as well as symptom free joints when it comes to TBA-RS, 15-HETE or synovial fluid volume. Sadly, since it wasn’t morally simple to get saline aspirates from the joints of healthy age and sex-matched pain-free adults, one can possibly just speculate that these levels found represent the pathological procedure. This particular deficiency of difference just isn’t entirely shocking considering that a systemic biochemical disorder will be reflected in both joints in the ends of a single bone. Furthermore, the particular mirror imaging of inflammatory responses in other paired joints within the body which usually lack the one of a kind anatomical and functional qualities of TMJ continues to be caused by neurophysiological impacts. Nonetheless, the presence of potential pain mediators from the symptomless joints also suggests the value of additional circumstances for example local neuropeptide or cytokine release that could be based upon asymmetrical masticatory function along with bruxism, or perhaps personality aspects that influence central modulation of the soreness encounter.

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Behnam Aghabeigi talks on the Rehabilitation of resorbed maxilla

The zygomatic implant placement procedure does not require any adjunctive procedures. Furthermore, the ability to immediately use existing dentures and the lack of need for bone grafting and prolonged hospitalisation makes this treatment modality more acceptable to the patient. Four cases are reported that demonstrate the successful treatment of a severely atrophic maxilla with either a fixed prosthesis supported by two zygomatic and a minimum of three standard dental implants or an over-denture supported by two zygomatic and one standard dental implant.

According to Behnam aghabeigi Birmingham placement of dental implants in the posterior maxilla is often jeopardised by the size and extension of the sinus cavities and inadequate amounts of bone. Atrophic processes can be accelerated by removable dentures as well. Surgical procedures were therefore developed to elevate the floor of the sinus and fill the hereby created cavity with bone or a substitute material, in order to subsequently install dental implants. Autogenous bone, harvested from the iliac crest, remains the optimum bone grafting procedure including maxillary sinus augmentation techniques. In view of the extreme maxillary atrophy, the conventional surgical approach would have been maxillary augmentation with or without a titanium mesh and particulate cancellous bone marrow graft from the iliac bone. Another option could have been a Le Fort osteotomy with an interpositional iliac corticocancellous block graft.

Extraoral bone harvesting necessitates increased hospitalisation, financial costs, donor site morbidity and functional limitations. Moreover, there is up to 8.6%5 risk of complications following iliac crest bone graft harvesting. Even higher morbidity rates6 including pain (14%) and neurosensory deficits (26%) have been reported lately. Finally, unpredictable reduction in size of the bone graft, because of resorption, is a frequent finding.

The acceptance of this approach is low by both patients and clinicians due to the following reasons:

1. The psychological fear of being subjected to a relatively major surgical procedure

2. The need for hospitalisation and morbidity associated with a distant donor site, particularly the restricted mobility associated with an iliac bone graft

3. Inability to use the existing denture during the graft healing period. This precaution is intended to minimise graft resorption by eliminating transmission of occlusal loads to the grafted site during the healing phase

4. Increased costs of the procedure including the cost of hospital stay, use of in-patient operating facilities and a second surgical team for the bone harvest

5. Extended treatment time with delayed implant placement four to six months following the grafting procedure.

Simultaneous placement of dental implants at the time of bone grafting is avoided due to a lower success rate than delayed placement.

An alternative treatment for this group of patients is the zygomaticus implant, introduced by Branemark. The implant is a titanium endosteal implant ranging in length from 30 mm to 52.5 mm. The surgical procedure is carried out under general anaesthesia as described elsewhere.9 Briefly, following bilateral elevation of the buccal mucoperiosteal tissue, removal of the lateral sinus bony window posteriorly and reflection of the antral mucosal lining, two zygomatic implants are inserted engaging the dense bone of the body of zygomatic arch, emerging intraorally in the upper premolar region just palatal to the alveolar crest. Each implant is introduced into the second premolar area, traversing the maxillary sinus, and is placed into the body of the zygomatic bone.

Synchronous placement of a minimum of four dental implants in the canine and the central incisor maxillary area, allows for fabrication of fixed hybrid prosthesis. Alternatively, placement of two zygomatic implants and at least two standard dental implants at the pyriform buttresses allows construction of a bar to support a maxillary overdenture without the need for any bone grafting. In case more root form dental implants can be placed in the pre-maxilla a fixed prosthesis could be fabricated.

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Differences examined by Behnam Aghabeigi in assessment and self-assessment

This particular description of a paper aims to examine the difference of assessment and self assessment scores in oral and maxillofacial surgery trainees and MSc postgraduates following the surgical removal of lower third molar teeth.

Subjects and Methods

A total of 17 trainees and MSc postgraduates were assessed when surgically removing lower third molar teeth under general anesthesia. The teeth were selected on the basis that their removal would necessitate raising of a flap and removal of bone. Assessors were members of staff of the department. One assessor was scrubbed, assisting and, where necessary, training the operator; the second observed the procedure closely. Where necessary, the assessor/trainer instructed and/or took over the procedure in the normal way.

Operators were shown the assessment forms prior to the surgery. They were told that the assessment would not count in any way towards their continuous assessment.

Methods of assessment were:

1.An objective assessment of whether 20 components of the procedure were correctly or incorrectly performed. In cases where the trainer corrected the operative technique or took over, the relevant parts of the procedure were judged incorrectly performed.

2.An operative global rating scale (1-5). The scale is anchored by descriptors and measures different aspects of performance, i.e. respect for tissue, time and motion, instrument handling, knowledge of instruments, flow of operation, use of assistants, knowledge of procedure, overall performance.

Both types of assessment were marked by the two assessors during or immediately postoperatively. The operator was asked to assess his performance using the same assessment form immediately postoperatively. The results were correlated using standard statistical techniques.

Results

A total of 22 lower third molar teeth were removed by 17 different operators. There were 8 different assessors using both the objective checklist and global rating scales. In 18 cases, operators assessed their performance using both scales.

There was no evidence of a difference between the marks of the two assessors. Using a two-way analysis of variance P = 0.70 and P = 0.68 for the objective and global rating scales, respectively. The level of agreement between assessors was 86.36% (kappa = 0.79, P <0.001) in the objective checklist scale and 90.91% (kappa = 0.83, P<0.001) in the global rating scale.

Two-way analysis of variance shows that there was evidence of a difference between assessors’ and self-assessment marks using both types of scores (objective checklist score, P < 0.001; global rating score, P < 0.001).

Discussion

Although there was evidence of good agreement between assessors, there was poor agreement between assessors and operators when using both the objective checklist and global rating scales. Operators almost invariably scored themselves higher than the assessors. Some of these differences were substantial and some operators who were scored very low by assessors scored themselves extremely high. In the objective scale scores were up to 10.5 marks higher (maximum 20) than those of the assessors. They were up to 12.5 marks higher (maximum 40) in the global scale.

These results suggest that some operators have poor judgment and over-rate their surgical ability even when assessed for a specific procedure and given rigid criteria against which to mark.

Little work appears to have been done on self-assessment of specific clinical procedures, especially when marking the self-assessment after the procedure concerned was performed. There have, however, been reports45 of relatively poor agreement between external measures of medical students’ clinical performance and students’ self-assessment of their performance. Additionally, lower performing medical students tended to rate their clinical performances higher than did their peers at initial self-assessment.

In the present study, objective checklist scores although having very rigid criteria tended to be overscored more than the global rating scale where operators were perhaps reluctant to give themselves marks at the extremes of the scale. Certainly over-scoring of checklist criteria suggests that either operators did not know what was expected of them or in some cases exhibited a considerable degree of self-deception. Alliteratively, they may have scored potential or ideal performance or even tried to compensate for poor performance as a defense mechanism.

Conclusions

The results of this study found evidence of a surprising and worrying over-rating of their own surgical skills by many trainees and postgraduates in oral and maxillofacial surgery. There can be little doubt that there is a need to evaluate further the accuracy of self-assessment of operative skills. In conjunction with this, we must train surgeons to evaluate critically their performance and self-assessment can form an excellent basis for constructive feedback between trainer and trainee.

It may be found that some individuals will never develop the judgment to assess accurately their performance. It would be invaluable to have a way to identify these individuals so that they could be redirected at an early stage in their careers.

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Behnam Aghabeigi talks on measures for anterior open bite

According to Behnam Aghabeigi a retrospective survey of 83 patients with an anterior open bite who underwent orthognathic surgery was carried out. Records were examined for the prevalence of abnormal TMJ signs and symptoms, including pain. A survey was mailed to these patients that consisted of: (1) the TMJ Scale, (2) the Symptom Checklist 90 (SCL90), (3) the Spielberger State-Trait Anxiety Inventory (STAI), and (4) a visual analog scale on which patients indicated their degree of satisfaction with the procedure. Thirty-seven (42%) patients responded to the survey, and 13 (15%) also attended a clinical and radiographic examination.

Multiple regression analysis was used for statistical analysis of the factors contributing to the presence and/or persistence of pain. In the preoperative group, the prevalence of pain was 32%, dysfunction 40%, and limitation of opening 7%. Age and gender were significantly associated with the presence of pain. The overall prevalence of abnormal TMJ signs and symptoms was not significantly different after orthognathic surgery. An abnormal psychologic profile was the most significant factor associated with the presence and/or persistence of pain. It is concluded that that the prevalence of temporomandibular disorders in anterior open bite patients increases with age, is significantly higher in females, and is not influenced by other occlusal variables. Furthermore, orthognathic surgery does not significantly influence temporomandibular disorders in patients with anterior open bite. Female patients, particularly those with an abnormal psychologic profile, are at a higher risk of persistent

Behnam Aghabeigi told us that it is generally agreed that the etiology of temporomandibular disorders (TMD) is multifactorial. Various emotional and mechanical factors have been implicated. There has been debate as to whether peripheral factors, such as occlusal disharmony, are of primary importance or whether central factors, such as psycho-logic variables, play the key role. Depending on the different concepts of etiology, different treatment regimens have been advocated. The dental profession historically has favored the peripheral factors and therefore embraced treatment modalities directed toward correction of occlusal dis-crepancies. Some authors1,2 even advocated orthognathic surgery for cases of TMD in combination with dysgnathia. However, it is unclear whether any association exists between the maxillomandibular relationship and TMD.3,4 Certain types of malocclusion have been reported as more likely to be associated with TMD5,6 and therefore such patients are more likely to benefit from treatment strategies addressing the occlusal disharmony. However, to date there is no randomized controlled prospective study demonstrating the efficacy of occlusal therapy in the manage-ment of TMD. Part of the difficulty in epidemiologic studies and clinical trials in relation to patients with TMD is the het-erogenous nature of the patients with regard to etiologic factors, such as occlusal or psychometric variables.

Pullinger and Seligman5 compared the role of occlusal variables between a large group of TMD patients and control subjects. They found that, except for anterior open bite (AOB), overbite and overjet char-acteristics did not distinguish the TMD patient group. Anterior open bite was rare among control subjects, and the authors reported the complete absence of AOB in the asymptomatic non-patients, as did several other authors.8–10 However, the low incidence of AOB in the general population could lead to sampling errors in such studies; this precipitates a need to study the prevalence of TMD in AOB patients.

Furthermore, the influence of orthognathic surgery on the temporomandibular joint (TMJ) has attracted a considerable amount of interest. Symptoms of TMJ disorders before and after orthognathic surgery have been documented in several clinical studies, but the reported incidence varies widely. There are reports of various degrees of improvement or deterioration, or no change at all in TMJ symptoms after orthognathic surgery. It has been suggested that orthognathic surgery may stimulate the progress of joint disease by microbleeding in the upper joint space, increased loading, disc displacement, and immobilization. Differences in the type of malocclusion, method and duration of post-operative fixation, type of osteotomy (eg, Le Fort I versus bimaxillary osteotomy15), and choice of mandibular setback procedure (eg, subcondylar versus sagittal split ramus procedure16) are among the factors that have been cited to account for the differences in TMJ symptoms after orthognathic surgery.
It has been suggested that the condyles of patients with anterior open bite may be very sensitive to functional loading, and their adaptive capacity is probably lower than in patients with deep bites. However, an analysis of the data published in relation to mixed patient groups reveals that in relation to correction of AOB, the published literature is contradictory. There are reports of significant improvement in TMD17 as well as reports of development of a significant number of new TMD cases after orthognathic surgery. Therefore, this study was carried out to assess the influence of orthognathic surgery on the TMJ in a relatively large number of patients with AOB.

Materials and methods

The clinical records of patients with an AOB who underwent orthognathic surgery during a 6-year period were examined; all patients had at least a 1-year post-operative follow-up period. The majority of cases were treated with a Le Fort I maxillary impaction, either alone (46%) or in combination with a mandibular procedure such as bilateral intraoral oblique (37%) or bilateral sagittal split osteotomy (14%). Only a very small number underwent segmental procedures (2%). In bimaxillary procedures, maxillomandibular fixation was used for a period of 4 to 6 weeks. Permission was granted by the Massachusetts General Hospital Human Studies Committee to review patient records, administer a mailed questionnaire, and recall patients for a review examination.

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