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Competing interests

None 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 literatureand report of a case. J Oral MaxillofacSurg 2002: 60: 10831088.

2. Arima R, Shiba R, Hayashi T. Traumaticmyositis ossificans in the masseter muscle.J Oral Maxillofac Surg 1984:42: 521526.

3. Arrington ED, Miller MD. Skeletalmuscle injuries. Orthop Clin North Am1995: 26: 411422.

4. Carey EJ. Multiple bilateral parostealbone and callus formations of the femurand left innominate bone. Arch Surg

1924: 8: 592603.5. Conner GA, Duffy M. Myositis ossifi-

cans: a case report of multiple recurrencesfollowing third molar extractions and

review of the literature. J Oral MaxillofacSurg 2009: 67: 920926.

6. Cushner FD, Morwessel RM. Myositisossificans traumatica. Orthop Rev 1992:21: 13191326.

7. Dimitroulis G. The interpositional der-mis-fat graft in the management of tem-

poromandibular joint ankylosis. Int J OralMaxillofac Surg 2004: 33: 755760.

8. Kim DD, Lazow SK, Berger JR Har-ELG. Myositis ossificans traumatica ofthe masticatory musculature: a case reportand literature review. J Oral MaxillofacSurg 2002: 60: 10721076.

9. Narang R, Dixon RA. Myositis ossifi-cans: medial pterygoid musclea casereport. Br J Oral Surg 1974: 12: 229234.

10. Parkash H, Goyal M. Myositisossificansof medial pterygoidmuscle.Oral SurgOralMed Oral Pathol 1992: 73: 2728.

11. Rattan V, RaiS, VaipheiK.Useofbuccalpad of fat to prevent heterotopic bone for-mation after excision of myositis ossificansof medial pterygoid muscle. J Oral Max-

illofac Surg 2008:66

: 15181522.12. Shirkhoda A, Armin AR, Bis KG,Makris J, Irwin RB, Shetty AN. MRimaging of myositis ossificans: variable

patterns at different stages. J Magn ResonImaging 1995: 5: 287292.

13. Spinazze RP, Heffez LB, Bays RA.Chronic progressive limitation of mouthopening. J OralMaxillofac Surg1998:56:11781186.

14. Takahashi K, Sato K. Myositis ossifi-cans traumatica of the medial pterygoidmuscle. J Oral Maxillofac Surg 1999: 57:

451456.15. Woolgar JA, Beirne JC, Triantafyl-

lou A. Myositis ossificans traumatica ofsternocleidomastoid muscle presenting ascervical lymph-node metastasis. Int JOral Maxillofac Surg 1995: 24: 170173.

Address:Annamalai ThangaveluDivision of Oral and Maxillofacial SurgeryRajah Muthiah Dental College and HospitalChidambaram 608002Tamil Nadu

IndiaTel.: +91 94432 44213

Fax: +91 41442 38080.Email: omfsvat@hotmail.com

doi:10.1016/j.ijom.2010.10.024

Case Report

Trauma

Transmucosal fixation of thefractured edentulous mandibleG. A. Wood, D. F. Campbell, L. E. Greene: Transmucosal fixation of the fracturededentulous mandible. Int. J. Oral Maxillofac. Surg. 2011; 40: 549552. # 2010Published by Elsevier Ltd on behalf of International Association of Oral andMaxillofacial Surgeons.

G. A. Wood, D. F. Campbell,L. E. Greene

Regional Maxillofacial Unit, Southern GeneralHospital, Glasgow, UK

Abstract. Transmucosal fixation is a new strategy for the treatment of edentulous

mandibular fractures using external fixation principles within the oral cavity. Thecomponent parts of this technique are not new. External fixation, locking plates andtransmucosal implants represent the foundations of this technique; the authorsdevelopment has been to bring these established methods together as a transmucosalintra oral locking plate fixation technique. The first eight patients treated with thistechnique have achieved bony union, they have no long-term sensory deficit and allpatients 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 confirmedradiographically. For the remainder and subsequent patients, radiographs have notbeen scheduled at review, in the absence of symptoms.

Accepted for publication 29 October 2010Available online 23 December 2010

Myositis ossificans traumatica of the medial pterygoid 549

mailto:omfsvat@hotmail.comhttp://dx.doi.org/10.1016/j.ijom.2010.10.024http://dx.doi.org/10.1016/j.ijom.2010.10.024mailto:omfsvat@hotmail.com

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Treatment of the edentulous fracturedmandible presents special difficulties3,8.Many methods of immobilisation havebeen suggested over the years, most ofhistoric interest1 given the modern accep-tance of rigid plate fixation. Patients areoften elderly9 with acute and chronic co-morbidities frequently complicating man-agement and adding to anaesthetic risks5.The specific problems of edentulous man-dibular fractures relate to the remainingmandibular bone height. The difficulty ofachieving bony union is well known. Frac-tures amenable to mini-plate fixation oftenleave a plate near the denture bearing areaand/or place a screw near the inferioralveolar neurovascular bundle riskinganaesthesia or paraesthesia in the distribu-

tion of the nerve4. Since the screws areangled laterally in the posterior area, thebenefit of bi-cortical fixation may beachieved and there is less risk to theneurovascular bundle. Anteriorly, thescrews are medial to the inferior dentalcanal. In the authors experience, stabilityis sufficient with fixation through one

cortical plate as STOELINGA et al. describedin the fixation of mandibular osteo-tomies10. Bi-cortical fixation wouldincrease the firmness of fixation and canbe achieved with this technique.

The aim of this study was to establishwhether rigid fixation could be achievedtransmucosally using existing lockingplatesand established external fixationcon-cepts. The first eight cases are reported.

Materials and method

Patients with an edentulous fractured

mandible that required fixation wereselected. If they were unfit for a generalanaesthetic the procedure could be carriedout under local anaesthetic with or withoutsedation. An impression taken before sur-gery can facilitate plate contouring prior toplate placement, alternatively the platecan be contoured intra-operatively.

The fracture site(s) were palpated and ifthere was any problem with the accuracyof reduction a small incision was made tovisualize the fracture line. A suitably longmini-locking plate straddling the fracturesite was placed and fixed (Fig. 1). Post-

operative and 6-month review radiographswere taken. There was a buried premolarin the area of this fracture, the authorsavoided extracting the tooth at the time offixation, as this would have increased therisk of non-union. Bony union was con-firmed by radiography and the toothremained buried and asymptomatic. Inlater 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 associatedwith an unerupted tooth, an ink mark represents the clinical estimate of the fracture position, alsoshowing 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 downwardsand slightly buccally.

550 Wood et al.

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ideally extended from retro-molar to retro-molar region where screws were groupedin three specific regions, both retro-molarregions and the bone anterior to the mentalforamina. In the retro-molar region thescrews are angled from a lingual entrydirected downwards and slightly buccallyand may engage the lateral cortex butmono-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). Thelocking screw could then be engaged fullywithout compressing the mucosa.Although initially two screws were usedon either side of the fracture line, theauthors considered that a minimum of

three mono-cortical screws in the ramusregions and in the anterior mandible wouldbe better.

Postoperatively, orthopantomogramswere carried out to confirm satisfactoryreduction. At review, following fixationremoval, patients were assessed for mobi-lity or pain at the fracture site. If patientsremained symptom free 2 weeks after fixa-tion removal they were discharged. Thefirst three patients returned for follow-upand 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 significantpain.

After fixation removal, carried outunder local anaesthesia, all patients hadclinical bony union so radiography wasnot considered appropriate at this stage onclinical grounds and no patient requiredfurther follow-up beyond 3 months. The

first three patients were recalled at 6months and agreed to assist the study byallowing clinical examination and areview radiograph, all had achieved bonyunion (Figs 1c and3b).

Of the first eight patients (Table 1), onehad a dense unilateral sensory deficit in thedistribution of the mental nerve followingbilateral fracture fixation, but this hadresolved by the time fixation wasremoved. One patient had evidence ofplate bending with plate fracture (Synthes2.0 locking) at 7 weeks but this did notcause any significant discomfort and did

not affect the outcome.One of the early bilateral fracture

cases had a screw placed in the leftfracture line (Fig. 3a) but the patientreported no problems and bony unionis seen on the 6-month review radiograph(Fig. 3b).

Discussion

Treating the fractured edentulous mand-ible is a challenge and the more atrophicthe mandible the greater the challenge11.Problems include the risks of general

anaesthesia in the elderly, nerve injury,non-rigid union resulting in pain, denturerehabilitation 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 withopen reduction with internal fixation forsimilar fractures and followed this up witha retrospective questionnaire to determinethe significant morbidities associated withconventional techniques. All had sensorydeficits as a result of surgery and two hadproblems with drooling and would nolonger eat in public. One had returned totheatre and another was re-admitted withinfection. Five had problems with den-tures and four had chronic pain.

The authors conclude that the simpletechnique of transmucosal fixation canreduce operative complications and out-come in the treatment of fractures of theedentulous mandible, including buckethandle fractures6,7. The authors have con-tinued withthis technique and reportfurthersuccess in the fixation of two patients trea-ted under local anaesthesia becauseof med-ical co-morbidities rendering them unfit 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 8Plating type Synthes 2.0 lockingPlate fracture 1/8 (patient 3)Plate bending 1/8 (patient 3)Rigid union at time of removal 8/8Subjective sensory deficit following surgery Temporary (2 months)Postoperative infection Nil

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general anaesthesia. The 2 mm lockingplate showed bending with subsequentfracture in one case and as a result a moresuitable plate and locking device are beingdeveloped to enhance the technique.

Competing interests

The authors are seeking to commercializea new plate based on what they havelearned from this research.

Funding

Scottish Health Innovations Ltd havefunded a patent application total fundingcirca US$7K.

Ethical approval

Not required.

References

1. Barber H. Part I: Conservative manage-ment of the fractured atrophic edentulousmandible. J Oral Maxillofac Surg 2001:59: 789791.

2. Borstlap WA, Stoelinga PJW, Hop-penreijs TJM, vant Hof MA. Stabili-zation of sagittal split advancementosteotomies with miniplates: a prospec-tive study with two-year follow-up. PartII: Radiographic parameters. Int J OralMaxillofac Surg 2004: 33: 535542.

3. Bruce RA, Ellis 3rd E. The secondChalmers J. Lyons Academy study of

fractures of the edentulous mandible. JOral Maxillofac Surg 1993: 51: 904911.

4. Gerbino G, Roccia F, De Gioanni PP,Berrone S. Maxillofacial trauma in theelderly. J Oral Maxillofac Surg 1999: 57:777782.

5. Jones RL. Anesthesia risk in the geriatricpatient. In: McLeskey CH, ed: Perio-perative Geriatrics Problems in Anesthe-sia, vol. 3. Philadelphia: PA Lippincott1989: 529.

6. Luhr HG, Reidick T, Merten HA.Results of treatment of fractures of theatrophic edentulous mandible by com-

pression plating: a retrospective evalua-tion of 84 consecutive cases. J OralMaxillofac Surg 1996: 54: 250254.

7. Mathog RH, Toma V, Clayman L,Wolf S. Nonunion of the mandible: ananalysis of contributing factors. J OralMaxillofac Surg 2000: 58: 746752.

8. Nasser M, Fedorowicz Z, Ebadifar A.Management of the fractured edentulousatrophic mandible. Cochrane DatabaseSyst Rev 2007 Issue 1. Art . No.CD006087.

9. Scott RF. Oral and maxillofacial traumain the geriatric patient. In: Fonseca RJ,Walker RV, Betts NJ, eds: Oral andMaxillofacial Trauma, vol. 2. Philadel-

phia: PA Saunders 1997: 10451072.11. Wittwer G, Adeyemo WL, Turhani D,

Ploder O. Treatment of atrophic man-dibular fractures based on the degree ofatrophyexperience with different plat-ing systems: a retrospective study. J OralMaxillofac Surg 2006: 64: 230234.

Address:Duncan CampbellRegional Maxillofacial UnitSouthern General Hospital1345 Govan RoadGlasgowG51 4TFScotlandUKTel: +44 7801568946Fax: +44 0141 232 7508Email: duncan@zygomatics.net

doi:10.1016/j.ijom.2010.10.027

Case Report

Oral Medicine

Non-alcoholic steatohepatitis(NASH) and oral lichen planus:a rare occurrenceD. 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: 552555. # 2010 International Association of Oral and MaxillofacialSurgeons. Published by Elsevier Ltd. All rights reserved.

D. Conrotto1, E. Bugianesi2,L. Chiusa3, M. Carrozzo4

1Division of Otorhinolaryngology, Departmentof Clinical Physiopathology, Oral MedicineSection, University of Turin, Italy; 2Division ofGastro-Hepatology, Department of InternalMedicine, University of Turin, Italy;3Department of Biomedical Sciences andHuman Oncology, Pathology Section,University of Turin, Italy; 4Department of OralMedicine, University of Newcastle upon Tyne,UK

Abstract. Oral lichen planus (OLP) is frequently associated with hepatitis C virusinfection but uncommonly with other causes of liver disorder. The authors report thecase of a 41-year-old male patient with a clinical and histological diagnosis of OLPwho presented with a marked alteration of the transaminase values, with no signs ofpast or present HBV, HCV, HGV or TTV infection. The patient did not consumealcohol and no exposure to hepatotoxic substances was reported. All autoantibodieswere negative. Hepatic fine needle biopsy showed macrovesicular steatosis with aslight chronic portal inflammatory infiltrate and signs of siderosis. Iron metabolismwas slightly altered. Genetic tests showed a heterozygotic mutation for hereditary

552 Wood et al.

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