Competing interestsNone declared. Ethical approval Not required. References 1. Aoki T, Naito H, Ota Y, Shiiki K. Myositis ossificans traumatica of the mas- ticatory muscles: review of the literature and report of a case. J Oral Maxillofac Surg 2002: 60: 1083–1088. 2. Arima R, Shiba R, Hayashi T. Traumatic myositis ossificans in the masseter muscle. J Oral Maxillofac Surg 1984: 42: 521–526. 3. Arrington ED, Miller MD. Skeletal muscle injuries. Orthop Clin North Am 1995: 26: 411–422. 4. Carey EJ. Multiple bilateral parosteal bone and callus formations of the femur and left innominate bone. Arch Surg 1924: 8: 592–603. 5. Conner GA, Duffy M. Myositis ossifi- cans: a case report of multiple recurrences following third molar extractions and review of the literature. J Oral Maxillofac Surg 2009: 67: 920–926. 6. Cushner FD, Morwessel RM. Myositis ossificans traumatica. Orthop Rev 1992: 21: 1319–1326. 7. Dimitroulis G. The interpositional der- mis-fat graft in the management of tem- poromandibular joint ankylosis. Int J Oral Maxillofac Surg 2004: 33: 755–760. 8. Kim DD, Lazow SK, Berger JR Har- ELG. Myositis ossificans traumatica of the masticatory musculature: a case report and literature review. J Oral Maxillofac Surg 2002: 60: 1072–1076. 9. Narang R, Dixon RA. Myositis ossifi- cans: medial pterygoid muscle—a case report. Br J Oral Surg 1974: 12: 229–234. 10. ParkashH, GoyalM. Myositis ossificans of medial pterygoidmuscle. Oral SurgOral Med Oral Pathol 1992: 73: 27–28. 11. RattanV, Rai S, Vaiphei K. Useof buccal pad of fat to prevent heterotopic bone for- mation after excision of myositis ossificans of medial pterygoid muscle. J Oral Max- illofac Surg 2008: 66: 1518–1522. 12. Shirkhoda A, Armin AR, Bis KG, Makris J, Irwin RB, Shetty AN. MR imaging of myositis ossificans: variable patterns at different stages. J Magn Reson Imaging 1995: 5: 287–292. 13. Spinazze RP, Heffez LB, Bays RA. Chronic progressive limitation of mouth opening. J Oral Maxillofac Surg 1998: 56: 1178–1186. 14. Takahashi K, Sato K. Myositis ossifi- cans traumatica of the medial pterygoid muscle. J Oral Maxillofac Surg 1999: 57: 451–456. 15. Woolgar JA, Beirne JC, Triantafyl- lou A. Myositis ossificans traumatica of sternocleidomastoid muscle presenting as cervical lymph-node metastasis. Int J Oral Maxillofac Surg 1995: 24: 170–173. Address: Annamalai Thangavelu Division of Oral and Maxillofacial Surgery Rajah Muthiah Dental College and Hospital Chidambaram 608002 Tamil Nadu India Tel.: +91 94432 44213 Fax: +91 41442 38080. E–mail:
[email protected] doi:10.1016/j.ijom.2010.10.024 Case Report Trauma Transmucosal fixation of the fractured edentulous mandible G. A. Wood, D. F. Campbell, L. E. Greene: Transmucosal fixation of the fractured edentulous mandible. Int. J. Oral Maxillofac. Surg. 2011; 40: 549–552. # 2010 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons. G. A. Wood, D. F. Campbell, L. E. Greene Regional Maxillofacial Unit, Southern General Hospital, Glasgow, UK Abstract. Transmucosal fixation is a new strategy for the treatment of edentulous mandibular fractures using external fixation principles within the oral cavity. The component parts of this technique are not new. External fixation, locking plates and transmucosal implants represent the foundations of this technique; the authors’ development has been to bring these established methods together as a transmucosal intra oral locking plate fixation technique. The first eight patients treated with this technique have achieved bony union, they have no long-term sensory deficit and all patients were able to eat a soft diet with minimal discomfort the day after surgery. The first five of eight patients on long-term review showed bony union confirmed radiographically. For the remainder and subsequent patients, radiographs have not been scheduled at review, in the absence of symptoms. Accepted for publication 29 October 2010 Available online 23 December 2010 Myositis ossificans traumatica of the medial pterygoid 549 Treatment of the edentulous fractured mandible presents special difficulties 3,8 . Many methods of immobilisation have been suggested over the years, most of historic interest 1 given the modern accep- tance of rigid plate fixation. Patients are often elderly 9 with acute and chronic co- morbidities frequently complicating man- agement and adding to anaesthetic risks 5 . The specific problems of edentulous man- dibular fractures relate to the remaining mandibular bone height. The difficulty of achieving bony union is well known. Frac- tures amenable to mini-plate fixation often leave a plate near the denture bearing area and/or place a screw near the inferior alveolar neurovascular bundle risking anaesthesia or paraesthesia in the distribu- tion of the nerve 4 . Since the screws are angled laterally in the posterior area, the benefit of bi-cortical fixation may be achieved and there is less risk to the neurovascular bundle. Anteriorly, the screws are medial to the inferior dental canal. In the authors’ experience, stability is sufficient with fixation through one cortical plate as STOELINGA et al. described in the fixation of mandibular osteo- tomies 10 . Bi-cortical fixation would increase the firmness of fixation and can be achieved with this technique. The aim of this study was to establish whether rigid fixation could be achieved transmucosally using existing locking plates and establishedexternal fixationcon- cepts. The first eight cases are reported. Materials and method Patients with an edentulous fractured mandible that required fixation were selected. If they were unfit for a general anaesthetic the procedure could be carried out under local anaesthetic with or without sedation. An impression taken before sur- gery can facilitate plate contouring prior to plate placement, alternatively the plate can be contoured intra-operatively. The fracture site(s) were palpated and if there was any problem with the accuracy of reduction a small incision was made to visualize the fracture line. A suitably long mini-locking plate straddling the fracture site was placed and fixed (Fig. 1). Post- operative and 6-month review radiographs were taken. There was a buried premolar in the area of this fracture, the authors avoided extracting the tooth at the time of fixation, as this would have increased the risk of non-union. Bony union was con- firmed by radiography and the tooth remained buried and asymptomatic. In later cases, longer plates were used, which Fig. 1. A suitably long mini-locking plate straddling the fracture site was placed and fixed. Transmucosal fixation of a mobile fracture through the right body of the mandible associated with an unerupted tooth, an ink mark represents the clinical estimate of the fracture position, also showing fixation in position and 6-month review x ray. Fig. 2. In the retro-molar region the screws are angled from a lingual entry directed downwards and slightly buccally. 550 Wood et al. ideally extended fromretro-molar to retro- molar region where screws were grouped in three specific regions, both retro-molar regions and the bone anterior to the mental foramina. In the retro-molar region the screws are angled from a lingual entry directed downwards and slightly buccally and may engage the lateral cortex but mono-cortical engagement is adequate (Fig. 2) 2 . The authors now avoid the man- dibular body for screw placement. To avoid mucosal compression a peri- osteal elevator was used (Fig. 1). The locking screw could then be engaged fully without compressing the mucosa. Although initially two screws were used on either side of the fracture line, the authors considered that a minimum of three mono-cortical screws in the ramus regions and in the anterior mandible would be better. Postoperatively, orthopantomograms were carried out to confirm satisfactory reduction. At review, following fixation removal, patients were assessed for mobi- lity or pain at the fracture site. If patients remained symptom free 2 weeks after fixa- tion removal they were discharged. The first three patients returned for follow-up and radiography to confirm bony union. Results All patients were able to eat a soft break- fast on the first postoperative day, seemed untroubled by the procedure and did not complain of any significant pain. After fixation removal, carried out under local anaesthesia, all patients had clinical bony union so radiography was not considered appropriate at this stage on clinical grounds and no patient required further follow-up beyond 3 months. The first three patients were recalled at 6 months and agreed to assist the study by allowing clinical examination and a review radiograph, all had achieved bony union (Figs 1c and 3b). Of the first eight patients (Table 1), one had a dense unilateral sensory deficit in the distribution of the mental nerve following bilateral fracture fixation, but this had resolved by the time fixation was removed. One patient had evidence of plate bending with plate fracture (Synthes 2.0 locking) at 7 weeks but this did not cause any significant discomfort and did not affect the outcome. One of the early bilateral fracture cases had a screw placed in the left fracture line (Fig. 3a) but the patient reported no problems and bony union is seen on the 6-month review radiograph (Fig. 3b). Discussion Treating the fractured edentulous mand- ible is a challenge and the more atrophic the mandible the greater the challenge 11 . Problems include the risks of general anaesthesia in the elderly, nerve injury, non-rigid union resulting in pain, denture rehabilitation problems, and psychologi- cal issues. The authors reviewed the notes avail- able for patients in the preceding 2 years (seven patients) who had been treated with open reduction with internal fixation for similar fractures and followed this up with a retrospective questionnaire to determine the significant morbidities associated with conventional techniques. All had sensory deficits as a result of surgery and two had problems with drooling and would no longer eat in public. One had returned to theatre and another was re-admitted with infection. Five had problems with den- tures and four had chronic pain. The authors conclude that the simple technique of transmucosal fixation can reduce operative complications and out- come in the treatment of fractures of the edentulous mandible, including ‘bucket handle’ fractures 6,7 . The authors have con- tinuedwiththis technique andreport further success in the fixation of two patients trea- ted under local anaesthesia because of med- ical co-morbidities rendering themunfit for Fig. 3. (a) One of the early bilateral fracture cases had a screw placed in the left fracture line; and (b) the 6-month review radiograph shows bony union. Table 1. Clinical outcomes from the first eight patients are listed. Total number of patients 8 Plating type Synthes 2.0 locking Plate fracture 1/8 (patient 3) Plate bending 1/8 (patient 3) Rigid union at time of removal 8/8 Subjective sensory deficit following surgery Temporary (2 months) Postoperative infection Nil Transmucosal fixation of the fractured edentulous mandible 551 general anaesthesia. The 2 mm locking plate showed bending with subsequent fracture in one case and as a result a more suitable plate and locking device are being developed to enhance the technique. Competing interests The authors are seeking to commercialize a new plate based on what they have learned from this research. Funding Scottish Health Innovations Ltd have funded a patent application total funding circa US$7K. Ethical approval Not required. References 1. Barber H. Part I: Conservative manage- ment of the fractured atrophic edentulous mandible. J Oral Maxillofac Surg 2001: 59: 789–791. 2. Borstlap WA, Stoelinga PJW, Hop- penreijs TJM, van’t Hof MA. Stabili- zation of sagittal split advancement osteotomies with miniplates: a prospec- tive study with two-year follow-up. Part II: Radiographic parameters. Int J Oral Maxillofac Surg 2004: 33: 535–542. 3. Bruce RA, Ellis 3rd E. The second Chalmers J. Lyons Academy study of fractures of the edentulous mandible. J Oral Maxillofac Surg 1993: 51: 904– 911. 4. Gerbino G, Roccia F, De Gioanni PP, Berrone S. Maxillofacial trauma in the elderly. J Oral Maxillofac Surg 1999: 57: 777–782. 5. Jones RL. Anesthesia risk in the geriatric patient. In: McLeskey CH, ed: Perio- perative Geriatrics Problems in Anesthe- sia, vol. 3. Philadelphia: PA Lippincott 1989: 529. 6. Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic edentulous mandible by com- pression plating: a retrospective evalua- tion of 84 consecutive cases. J Oral Maxillofac Surg 1996: 54: 250–254. 7. Mathog RH, Toma V, Clayman L, Wolf S. Nonunion of the mandible: an analysis of contributing factors. J Oral Maxillofac Surg 2000: 58: 746–752. 8. Nasser M, Fedorowicz Z, Ebadifar A. Management of the fractured edentulous atrophic mandible. Cochrane Database Syst Rev 2007 Issue 1. Art. No. CD006087. 9. Scott RF. Oral and maxillofacial trauma in the geriatric patient. In: Fonseca RJ, Walker RV, Betts NJ, eds: Oral and Maxillofacial Trauma, vol. 2. Philadel- phia: PA Saunders 1997: 1045–1072. 11. Wittwer G, Adeyemo WL, Turhani D, Ploder O. Treatment of atrophic man- dibular fractures based on the degree of atrophy—experience with different plat- ing systems: a retrospective study. J Oral Maxillofac Surg 2006: 64: 230–234. Address: Duncan Campbell Regional Maxillofacial Unit Southern General Hospital 1345 Govan Road Glasgow G51 4TF Scotland UK Tel: +44 7801568946 Fax: +44 0141 232 7508 E–mail:
[email protected] doi:10.1016/j.ijom.2010.10.027 Case Report Oral Medicine Non-alcoholic steatohepatitis (NASH) and oral lichen planus: a rare occurrence D. Conrotto, E. Bugianesi, L. Chiusa, M. Carrozzo: Non-alcoholic steatohepatitis (NASH) and oral lichen planus: a rare occurrence. Int. J. Oral Maxillofac. Surg. 2011; 40: 552–555. # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. D. Conrotto 1 , E. Bugianesi 2 , L. Chiusa 3 , M. Carrozzo 4 1 Division of Otorhinolaryngology, Department of Clinical Physiopathology, Oral Medicine Section, University of Turin, Italy; 2 Division of Gastro-Hepatology, Department of Internal Medicine, University of Turin, Italy; 3 Department of Biomedical Sciences and Human Oncology, Pathology Section, University of Turin, Italy; 4 Department of Oral Medicine, University of Newcastle upon Tyne, UK Abstract. Oral lichen planus (OLP) is frequently associated with hepatitis C virus infection but uncommonly with other causes of liver disorder. The authors report the case of a 41-year-old male patient with a clinical and histological diagnosis of OLP who presented with a marked alteration of the transaminase values, with no signs of past or present HBV, HCV, HGV or TTV infection. The patient did not consume alcohol and no exposure to hepatotoxic substances was reported. All autoantibodies were negative. Hepatic fine needle biopsy showed macrovesicular steatosis with a slight chronic portal inflammatory infiltrate and signs of siderosis. Iron metabolism was slightly altered. Genetic tests showed a heterozygotic mutation for hereditary 552 Wood et al.