Osteoma of mandible: A case report.

Authors' response.

Introduction: Ameloblastoma is a benign odontogenic tumor that appears in the mandible and maxilla. Ameloblastoma has slow growth that takes several years for symptoms to appear, but ameloblastoma in the maxilla has a more aggressive clinical course compared to the mandible. The lack of initial symptoms leading to diagnosis at an advanced disease when the tumour has already extended beyond maxilla. The cancellous structure of the maxillary bone makes it easier for tumors to spread to the nasal cavity, paranasal sinuses, orbitals, parapharyngeal tissue and skull base. This article reports a case of resection of maxillary ameloblastoma. Case Report: A 63 year old female patient came with complaints of a lump on her right cheek since 2 years back that gradually increased in size. Since 2 months ago, pus and blood have been coming out of the lump. Extra oral examination revealed a well-defined mass with a solid and hard consistency, there were no ulcers or fistulas. Intraorally, a mass measuring 5x5x3cm was found in the region of teeth 12 to 15 which extended to the buccal-palatal area. History of allergies and weight loss was denied. Supporting examinations including panoramic radiography, PA chest radiography, CT-Scan, FNAB, and biopsy resulted in a diagnosis of ameloblastoma. Treatment was carried out by resection of the right maxillary tumor mass under general anesthesia. Discussion: In this case, the patient's clinical examination showed a hard and large palpable swelling in the right maxilla area which extended from the region of tooth 12 to tooth 15 which caused facial asymmetry and no tooth mobility was found. This hard and painless swelling takes about 2 years before the patient experiences symptoms of pus and blood discharge. The post-maxillectomy defect in this case was covered with an intraoral prosthesis in the form of a post-surgical obturator made of acrylic resin. The obturator functions to hold the surgical packing, and prevent food or dirt contamination in the defect area which can cause infection and slow healing. The use of a prosthesis also helps restore swallowing and speech function to the patient. Conlussion: In principle, the treatment for ameloblastoma is resection of the involved bone, as in this case the action taken is a maxillectomy. Maxillectomy can result in facial and oral cavity deformities characterised by facial disfigurement and alterations in oral functionality.Therefore, maxillary reconstruction is needed to treat maxillary defects after surgical procedures involving the loss of part or all of the maxilla.

Peripheral osteoma arising from the lateral surface of the mandibular ramus

Osteoma is a slow growing benign tumor consisting of well differentiated compact or cancellous bone that increases in size by continuous growth. It can be of a central, peripheral, or extraskeletal type. The peripheral type arises from the periosteum and is rarely seen in mandible. Although completely curable with adequate surgical treatment, osteomas precede the clinical radiographic evidence of colonic polyposis/Gardner's syndrome. Therefore they may be sensitive markers for the disease. Recurrence of peripheral osteoma after surgical excision is extremely rare. However it is appropriate to provide both clinical and radiographic follow up after surgical excision of peripheral osteoma. This article describes the case of a 45year old male who presented with painless swelling of the right body of mandible and resultant cosmetic facial disfigurement and functional impairment.

Evaluation of facial asymmetry in patients with juvenile idiopathic arthritis: Correlation between hard tissue and soft tissue landmarks.

Objective To measure and analyze the distribution and significance of the microhardness of the lower cervical vertebrae. Methods The three fresh adult cadaver C3-C7 vertebrae specimens were selected and the soft tissue was removed . Each vertebra was divided into a vertebral body area and an attachment area, and then was cut into three 3 mm-thickness slices (1 in the vertebral body area and 2 in the attachment area) by a high-precision slow saw. A total of 45 bone slices were cut from 15 vertebrae. The Vickers method was used to measure the microhardness values of cortical bone and cancellous bone in different areas of bone sections. Five effective microhardness values were selected for each region, and the average value of all effective values was used to be the hardness value of the region. Results A total of 825 effective hardness values were performed on 15 vertebrae. The hardness range of C3-C7 was (11.10-47.80)HV. The hardness of cortical bone and cancellous bone were (26.04±4.84)HV and(22.92±4.78)HV, respectively. The hardness of cortical bone and cancellous bone in the vertebral body area were (25.46±4.86)HV and (21.10±4.97)HV, respectively. The hardness of cortical bone and cancellous bone in the attachment area were (26.50±4.78)HV and (24.75±3.80)HV, respectively. The bone hardness of the cortical bone/ cancellous bone in the attachment area was higher than that of the cortical bone/ cancellous bone in the vertebral body area, and the difference was statistically significant(t=2.800, 4.978, P<0.05). The microhardness values of the lower cervical vertebrae of three cadavers in different regions were different, but the hardness values of the cortical bone and cancellous bone in the vertebral body area were significantly lower than those in the attachment area. The differences of the hardness in cancellous bone were statistically significant(tA=4.316, tB=2.364, tC=2.107, P<0.05), while in the cortical bone, only Donor B was statistically significant(t=2.498, P<0.05). The distribution of the hardness values in different regions of each vertebrae was consistent with the whole: the hardness value of the vertebral body area was lower than those of the attachment area.The differences of the cancellous bone in C3, C5, C6 and C7 were statistically significant(t=3.220, P<0.05). In the accessory area, the hardness of the superior articular process was significantly lower than those of other regions (F=8.590, P<0.05); in the vertebral body area, the hardness of the lower endplate was significantly higher than those of other regions (F=16.365, P<0.05). Conclusions This study reveals that the microhardness of bone in different regions of the lower cervical vertebrae are different.The bone hardness of the cortical bone/cancellous in the attachment area is higher than that in the vertebral body area. This distribution law is a physiological change which adapts to the stress and strain during the human daily activities. It can provide data support for the modeling of the finite element analysis, 3D printing and preoperative simulation. Key words: Cervical vertebra; Lower cervical vertebra; Vickers hardness; Microhardness; Biomechanics; Hardness tests

Endoscopic Transoral Resection of Parapharyngeal Osteoma: A Case Report

Osteoma is a benign, slow-growing tumor characterized by proliferation of compact or cancellous bone. Solitary osteomas are classified as peripheral, central, or extraskeletal. Peripheral osteomas of the oral cavity are unusual and the maxilla is rarely affected. They manifest as asymptomatic, fixed tumors of bony-hard consistency that may be sessile or pedunculated. Radiographically, a well-circumscribed round or oval radiopaque mass is seen that is microscopically composed of cancellous or trabecular bone. A case of a compact, peripheral osteoma arising from the buccal plate of the alveolar ridge of the maxilla in a 64-year-old patient is presented. According to our literature review, this is the seventh case reported in the maxillary ridge.

The refractory port-wine stains are often associated with soft and hard tissue hypertrophy leading to facial asymmetry and psychological problems. The authors describe and illustrate a surgical strategy for the treatment of both hard and soft tissue malformations in patients with port-wine stains to restore facial symmetry. The medical records, photographs of two patients with soft and hard tissue hypertrophy were reviewed. After physical examinations, 3-dimensional computed tomography was conducted to evaluate bony asymmetry. The surgical strategy was designed according to individual malformation and requests. Both patients had congenital port-wine stains that were resistant to laser therapy. As they grew up, they developed both soft and hard tissue hypertrophy. Zygoma, maxilla, nose, and lips are involved, causing facial asymmetry, deviated nose, increased dental show and malocclusion. To correct bony malformation, orthognathic surgery, and facial bone contouring including zygomatic reduction, mandibular angles osteotomy and genioplasty were performed. After the correction of the bony factor, soft tissue symmetry was improved via resection, autologous fat grafting, liposuction, and rhinoplasty. Both patients were satisfied with the surgical result. To acquire facial symmetry, surgical correction is inevitable for patients with port-wine stains associated with soft and hard tissue hypertrophy. The authors describe the successive correction of bony and soft tissue asymmetry to achieve harmonious surgical outcomes.

To evaluate whether the selenium detector (Thoravision) provides sufficient diagnostic confidence in digital pelvic imaging compared with a conventional screen-film combination. In 75 patients, pelvic imaging with conventional screen-film and isodose selenium radiography using a dedicated postprocessing mode was compared independently by three radiologists. The depiction of cortical and cancellous bone was evaluated in the iliac wings, sacral and pubic bones, acetabulum, femoral head, and trochanter. Demarcation of soft tissue was assessed in the iliac and trochanteric region. Visualization of cortical bone and soft tissue in the iliac area as well as soft tissue and cortical and cancellous bone in the trochanteric region was significantly superior with the selenium detector. However, conventional imaging was better in the trabecular bone of the sacral region, where results with the selenium system were particularly poor. The selenium detector (Thoravision) is advantageous in imaging soft tissue adjacent to the iliac wings and the trochanter, but results for the cancellous sacral bone are poor. Further modifications of postprocessing modes may lead to improved depiction of this critical pelvic area.

The goal of this study was to evaluate the effects of chronically-elevated male levels of the potent androgen testosterone on the quality and quantity of both cancellous and cortical bone in a young (mean age 8.0 years), nonhuman female primate model (M. fascicularis). Thirteen intact female monkeys received continuous testosterone supplementation via subcutaneous implants over a 24-month period. A group of 16 untreated, intact, age-matched female monkeys served as controls. At sacrifice, the lumbar vertebrae and femora were recovered in order to analyze the bone mineral quality and quantity of cancellous and cortical bone, respectively, and compared to the control group. Mineralization profiles of the vertebrae and femora were obtained using the density fractionation technique. Chemical analysis of the three largest fractions retrieved by density fractionation was performed to evaluate differences in %Ca, %P, Ca/P ratio, and mineral content (%Ca + %PO4) between the control and experimental groups. In addition, unfractionated bone powder was examined by X-ray diffraction to identify any changes in crystal size. Coronal sections of vertebrae were analyzed for structural parameters using histomorphometry and image analysis. Cross sections taken at the midshaft diaphyseal femora were analyzed for structural macroscopic and intracortical parameters. A nonsignificant shift in the mineralization profile of the vertebrae was observed whereas there was a significant shift in the mineralization profile towards more dense bone in the treated femora as compared with controls (P < 0.05). There was no difference in terms of size/strain of the cortical or cancellous bone crystal as detected by X-ray diffraction. There was a trend towards an increase in cancellous bone area (B.Ar.) in the testosterone-treated vertebrae (P = 0.08) as compared with controls. The architecture of the cancellous bone remained nonsignificantly different between the treatment and control groups as evaluated by image analysis. There was a decrease in osteoid perimeter (P = 0.05) in the experimental group as compared with controls. There was a significant decrease in eroded perimeter measurements in the experimental group as compared with controls (P < 0.03). Although there was a trend towards an increase in cancellous bone area, mineralization was not significantly different in the vertebrae of testosterone-treated female monkeys, indicating that the newly-formed bone tissue became relatively normally mineralized over the two-year period. An increase in bone area, with indices of an overall decreased remodelling pattern as compared with controls, suggests that cancellous bone in the young, nonhuman female primate had been receptive to supraphysiologic levels of testosterone supplementation over the two-year period. There was a trend for an increase in cortical bone area and width with an increased periosteal perimeter in the testosterone-treated group as compare with controls. There was an increase in intracortical remodelling activity with a significant increase in percent porosity (P < 0.05), osteonal bone (P < 0.05), and mean wall width (P < 0.05) in the testosterone-treated group. In conclusion, the cancellous bone from female monkeys appeared to respond to the antiresorptive stimulus of male levels of testosterone with significantly diminished turnover parameters in this compartment. In contrast, the cortical bone compartment responded by displaying significant intracortical remodelling over a two-year period.

Objective To explore the distribution characteristics and clinical application prospects of micro-hardness of the human thoracolumbar segments. Methods Three fresh adult cadaver T11-L2 vertebrae specimens were selected and the soft tissue was removed. Each vertebra was divided into a vertebral body region and an attachment region. All of the bones were prepared in to a plurality of 3 mm bone tissue slices by using a high-precision slow saw and then sanded by sandpaper.A total of 72 bone tissue sections were generated from 12 vertebral specimens. The Vickers method was used to measure the microhardness values of cortical bone and cancellous bone in different areas of bone sections. Five effective microhardness values were selected for each region, and the average value of all effective values was used as the hardness value of the region. Results A total of 660 effective indentation experiments were performed on 12 vertebrae. (1) The total hardness of the thoracolumbar segment was 11.6-48.3 HV, including the average hardness of the cortical bone was 13.8-48.3 (31.62±5.66) HV, and the average hardness of the cancellous bone was 11.6-44.9 (29.62±5.38) HV. (2) The average hardness of the cortical bone in the vertebral body region and the accessory region were (29.99±5.27)HV and (32.92±5.63) HV, respectively. The average hardness of cancellous bone were (28.44±4.79) HV and (30.81±5.71)HV, respectively. The attachment area was higher than the vertebral body area, and the difference was statistically significant(t=5.098, 2.011, all P values<0.05). (3)The hardness of the cortical bone in the vertebral body region from high to low was the lower endplate (33.94±4.31) HV, the upper endplate (29.76±4.35) HV, and the peripheral endplate (28.13 ±5.07) HV. The bone hardness of the lower endplate was higher than that of the upper endplate and the peripheral endplate.The difference was statistically significant (all P values<0.05). (4)In the cortical bone of the attachment area, the hardness from high to low was the pedicle cortex(34.78±5.30) HV, the upper articular process (33.73±5.68) HV, the vertebral plate(33.15±5.28) HV, the transverse process(31.69±5.37) HV and the inferior articular process (31.26±5.91) HV. The bone hardness of the pedicle cortex was significantly different from those of the transverse process and the inferior articular process(all P values<0.05). Conclusions This study is the first to apply the Vickers microhardness method to study the distribution of microhardness of human thoracolumbar segments. It is found that the cortical bone hardness and cancellous bone hardness of the attachment region are higher than those of the vertebral body region. There are differences in the microhardness of the T11-L2 and the thoracolumbar segments of different people, but the distribution law is relatively consistent.It is the result of the joint action of microstructure and mechanical load, which is consistent with the normal physiological and weight-bearing functions of the human body. The results of this study provide data support for the preparation of artificial vertebrae with gradient hardness in 3D printing. Key words: Spine; Thoracolumbar spine; Vertebrae; Bone hardness test; Vickers hardness; Microhardness; Human skeleton

The purpose of this study was to evaluate the accuracy and efficacy of a new wireframe template methodology in analyzing three-dimensional facial soft tissue asymmetry. Three-dimensional facial soft tissue data were obtained for 24 patients. The wireframe template was established by identifying 34 facial landmarks and then forming a template on the face with the MeshLab 2020 software. The angle asymmetry index was automatically scored using the template. The mirroring and overlapping technique is accepted as the golden standard method to diagnose facial asymmetry by acquiring deviation values of one's face. Consistency rates between the two methodologies were determined through a statistical comparison of the angle asymmetry index and deviation values. Overall consistency rates in the labial, mandibular angle, cheek, chin, and articular regions were 87.5%, 95.8%, 87.5%, 91.7%, and 100%, respectively. Regions with consistency rates in three dimensions of more than 85% are the x-axis and the z-axis of all regions and the y-axis of the mandibular angle, chin, and articular region. Soft tissue facial asymmetry can be diagnosed accurately and effectively by using a three-dimensional soft tissue spatial angle wireframe template. Precise localization of asymmetry can be offered, and indiscernible tiny asymmetry can be identified.

Facial asymmetry is a common finding in healthy subjects and in esthetically pleasing faces. It is believed that normal craniofacial skeletons have some degree of asymmetry which is compatible with normal dental occlusion, and mild facial asymmetry is often disregarded by clinicians. In parallel with increasing demand for facial aesthetics and recent advances in facial aesthetic surgery, patients have become more sensitive to facial asymmetry which may occur after the operation. In this context, objective evaluation of facial asymmetry by extended facial analysis before and after the operation has gained importance. Facial asymmetry analysis can be performed as objective and/or subjective. Soft tissues of the face can be evaluated by subjective analysis; however, skeletal asymmetries compensated by the overlying soft tissue may not be recognized most of the time. Objective assessment of the asymmetry degree of both soft and hard tissues of the face before facial operations, aesthetic and orthodontic procedures in particular, will allow a more accurate analysis of the treatment results. Anthropometric measurement is one of the methods used for the quantitative analysis of facial asymmetry. Although anthropological studies on face have been extensively addressed in the literature, anthropologists have rarely examined facial asymmetry. The concept of facial asymmetry and anthropometric measurement of facial asymmetry will be reviewed in this chapter.

Accurate assessment of facial symmetry is a key component of successful rhinoplasty surgery but is often overlooked by both surgeon and patient. Up to three-quarters of patients with a significantly crooked nose have been found to have concurrent marked facial asymmetry. Whilst not a contraindication to rhinoplasty, provided that facial asymmetry is identified in advance and expectations realistic, the correction of nasal deformities can improve perceived facial asymmetry. In the aging face, aside from soft tissue and bony resorption that can amplify facial asymmetry, there are specific surgical challenges to the aging nose; the normal tip support mechanisms deteriorate with age giving rise to distinctive changes to the aging nose-typically tip ptosis and a hanging columella; bone quality becomes more brittle and skin overlying this area becomes thinner. There is also weakening of the external nasal valve thus causing functional impairment too. As a result, rhinoplasty techniques used in younger patients may not be suitable in the aging nose. In this article, the authors describe their experience and outline the evidence on the management of the aging patient with facial and nasal asymmetry.