Trigeminal neuralgia is a chronic pain condition associated with sharp, shock-like pain in one or more divisions of the trigeminal nerve. For patients who do not respond well to pharmacotherapy, there is growing evidence that Botulinum toxin type A injections into the trigeminal ganglion provide pain relief for several weeks up to several months at a time. One option is to administer injections into the trigeminal ganglion in Meckel’s cave by inserting a needle through the Pterygopalatine Fossa using fluoroscopy to guide and confirm the proper needle placement. However, there is evidence that Botulinum toxin travels across nerve synapses; thus, injecting directly into the trigeminal ganglion may not be necessary. We present two patients with a confirmed diagnosis of trigeminal neuralgia who were treated by injecting Botulinum toxin type A intraorally into the mental foramen which resulted in 6 months or longer of pain relief. Injections into the mental foramen are much easier to administer than those administered directly into the trigeminal ganglion, and both patients treated with this technique experienced comparable results to what can be expected from traditional fluoroscopy-guided botulinum toxin injections. Though more research is needed, these cases potentially imply that a less-invasive injection may be sufficient in managing trigeminal neuralgia-related pain.
Dentofacial deformities (DFD) and obstructive sleep apnea (OSA) are two entities which can be intricately related and require complex management. It can be argued that in the subset of patients in which these two entities overlap and require intervention, an orthognathic surgery first approach (SFA) should be considered a primary treatment modality. With respect to isolated dentofacifal deformities undergoing orthognathic surgery first, the literature and cases completed by the authors resulted in an overall decrease in orthodontic treatment time, on average one year. This is in comparison to the average orthodontic treatment length in those who undergo orthognathic surgery after completion or near completion of orthodontic treatment. In addition, advantages of this treatment modality are immediate resolution of the dentofacial deformity and easier decompensation of the malocclusion after surgery. In relation to OSA, it is known that orthognathic surgery can decrease the apnea-hypopnea index (AHI) in the range of 50-90% resulting in improvement or resolution of symptoms in approximately 90% of patients. Therefore, in the subset of patients with both OSA and DFD requiring intervention and who undergo surgery first intervention, assessing both objective and subjective outcomes (i.e., improvement in AHI, length of treatment, patient satisfaction and QOL) can be utilized to further evaluate the value in this approach as a primary treatment modality.
Craniofacial defects require a treatment approach that provides both robust tissues to withstand the forces of mastication and high geometric fidelity that allows restoration of facial architecture. When the surrounding soft tissue is compromised either through lack of quantity (insufficient soft tissue to enclose a graft) or quality (insufficient vascularity or inducible cells), a vascularized construct is needed for reconstruction. Tissue engineering using customized 3D printed bioreactors enables the generation of mechanically robust, vascularized bony tissues of the desired geometry. While this approach has been shown to be effective when utilized for reconstruction of non-load bearing ovine angular defects and partial segmental defects, the two-stage approach to mandibular reconstruction requires testing in a large, load-bearing defect. In this study, 5 sheep underwent bioreactor implantation and the creation of a load-bearing mandibular defect. Two bioreactor geometries were tested: a larger complex bioreactor with a central groove, and a smaller rectangular bioreactor that were filled with a mix of xenograft and autograft (initial bone volume/total volume BV/TV of 31.8 ± 1.6%). At transfer, the tissues generated within large and small bioreactors were composed of a mix of lamellar and woven bone and had BV/TV of 55.3 ± 2.6% and 59.2 ± 6.3%, respectively. After transfer of the large bioreactors to the mandibular defect, the bioreactor tissues continued to remodel, reaching a final BV/TV of 64.5 ± 6.2%. Despite recalcitrant infections, viable osteoblasts were seen within the transferred tissues to the mandibular site at the end of the study, suggesting that a vascularized customized bony flap is a potentially effective reconstructive strategy when combined with an optimal stabilization strategy and local antibiotic delivery prior to development of a deep-seated infection.
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