野口 忠秀

Anteromedial maxillectomy is typically performed in conjunction with low-dose radiotherapy and intraarterial chemotherapy. In doing so, the extent of surgical defects is reduced. However, nasal deviation and oral incompetence may ensue, due to cicatricial contracture of wounds, and may be distressing to these patients. Herein, we report a series of eight free perforator flap procedures (anterolateral thigh [ALT] flap, 6; thoracodorsal artery perforator [TAP] flap, 2) used to correct such deformities. The TAP flap was combined with scapular tip [ST] osseous flap in patients with added zygomatic prominence defects. Three adipocutaneous parts developed from each perforator flap were applied as follows: two to reconstruct nasal lining and oral vestibule, and one to augment cheek volume. All aesthetic results proved satisfactory, although orbital dystopia and contracture of mimic muscles were not resolved completely. These secondary interventions are suitable for sequelae of simple anteromedial maxillectomy. Immediate reconstruction should be considered if orbital floor and mimic muscles are involved. (C) 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

In maxillo-mandibular reconstruction, it is difficult to achieve patient satisfaction solely through surgical treatment. We should also perform prosthetic rehabilitation in addition to surgical treatment to restore chewing, deglutition, and aesthetics. It is necessary that the alveolar ridge required for a stable prosthesis be reconstructed at the time of reconstructive surgery. The purpose of this article is to introduce our maxillo-mandibular reconstructive procedure and postoperative prosthodontics with dentures. The vascularized bone is positioned using a guide splint of the ideal alveolar ridge, preopera- tively made from a dental plaster cast. The alveolar ridge is covered with thin, soft tissue. The goals of maxillary reconstruction are closure of the oroantral fistula and reconstruction of the natural alveolar ridge, suitable for the use of simple, removable dentures. In mandibular reconstruction, we reconstruct two different arches for aesthetics - the mandibular inferior border and the dental arch - And prosthodontics for masticatory function. Because additional surgery often places an extra burden on the patient, secondary alveolar vestibu-loplasty is rarely carried out. For reliable prosthodontics, not only alveolar surgery with maxillo- mandibular reconstruction, but also presurgical planning, such as making guide splints or a pre- bent plate, is important.

3年間に周術期口腔機能管理外来にコンサルトのあった1873名(男女比3:2、平均63歳)を対象とした。年度別患者推移では、2013年度は493人、2014年度622人、2015年度749人と推移し、患者数は年度毎に増加傾向を示した。年齢別患者分布では、60歳代が34.6%と他の年代と比較して多く、次に70歳以上34.2%、50歳代17%となった。処置内容は歯科治療と予防的口腔ケアであった。歯科治療では、歯科医師が義歯の調整・修理や保存困難な歯の抜歯、応急的処置として暫間固定や齲蝕処置を行った。特に放射線治療を行っている患者に対して保存困難な歯があった場合、照射部位に含まれる治療前に抜歯を行った。口腔ケアでは、治療による有害事象の予防・軽減を目的とし、歯科医師が口腔内診断を行ったうえで歯科衛生士が中心となって口腔ケアを行った。

積極的治療を行った口腔がん患者118例(男性65例、女性53例、14〜91歳)を対象とした。原発部位は、舌が61例と最も多く、次いで歯肉38例、頬粘膜10例、口底部6例、唾液腺2例、上唇1例であった。治療内容は、手術療法58例、手術+放射線療法37例、手術+化学放射線療法21例、手術+化学療法2例であった。初診時のStage分類では、Stage Iは37例、Stage IIは34例、Stage IIIは23例およびStage IVは24例であった。23例に術後せん妄が生じ、このうちの92%が70歳以上の高齢者であり、発症平均年齢は78歳であった。治療前は106例が自宅在住で、その平均年齢は67歳であった。治療後の療養先は自宅107例、病院7例、老人介護福祉施設3例であった。死亡退院は1例であった。術後の摂食嚥下機能低下に伴い胃瘻使用となったのは12例で、胃瘻+経口摂取となったのは15例であった。

1-day-old male infant was referred to our department for evaluation of multiple malformations in his oral cavity. He was diagnosed duplication of the pituitary gland-plus syndrome with epignathus, cleft palate, duplication of the mandible, and a lobulated tongue. A thumb-sized mass lesion was visible on the hard palate. The duplicated mandible and lower lip was fused at the midline. The alveolar ridge was protruding through a wide-cleft soft palate involving the uvula. Further examination showed a lobulated tongue, which was seen behind the duplicated part of the mandible. Five days after birth, tracheotomy and epignathus resection were performed. At 7 months of age, the excess tissue of the duplicated mandible was resected at the area of adhesion on the lingual side, and the duplicated tongue and lip were reconstructed. A palatoplasty was performed at 20 months of age. Thereafter, the patient's progress was uneventful, with no abnormality in swallowing. No recurrence of epignathus has been observed during 2 years of follow-up.

We report a very rare case of systemic amyloidosis occurring in bilateral mandibular condyles and showing condylar bone destruction and lesions in the buccal mucosa bilaterally. The patient was a 61-year-old man complaining of malocclusion in which the lower teeth extended abnormally over the upper teeth. He first noticed this about 1 year earlier. Medical history included renal cancer, rheumatic myalgia in multiple joints, osteoporosis, hypothyroidism, chronic hepatitis, malignant lymphoma and hemodialysis for renal failure. Panoramic radiography and computed tomography showed bone destruction in bilateral mandibular condyles and a soft tissue mass lesion around the condyle. Slightly raised mass lesions with areas of whitish and purplish coloration were also observed on the buccal mucosa bilaterally. Histopathological examination revealed amyloid deposition in these lesions, and AA and/or Aβ2M amyloidosis was diagnosed. However, we were informed that the patient died within 3 months from when he had a last check-up at our clinic due to systemic problems.

Small cell carcinoma in the oral and maxillofacial region is an extremely rare, high-grade malignancy. We report a case of small cell carcinoma in the palatal mucosa. An 80-year-old man was referred to our clinic with swelling in the right maxilla. An 80-mm lymph node was seen in the right neck. The clinical diagnosis was malignant tumor of the palatal mucosa and biopsy was performed. The histopathological diagnosis was small cell carcinoma. Systemic examination diagnosed cervical lymph node metastasis, liver metastasis and multiple bone metastases. Considering the clinical stage and performance status, best supportive care was selected. The patient died of multiple-organ failure 3 months after the first visit.

The patient was a 69-year-old woman. She initially consulted our institute with a chief complaint of swelling in bilateral submandibular glands and dry mouth. A localized, movable hard elastic mass was observed in bilateral submandibular and parotid glands. Oral dryness and atrophy of the lingual papilla were observed. The patient had a history of malignant lymphoma (mucosa-associated lymphoid tissue (MALT) lymphoma), for which she had undergone two courses of CHOP therapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) in addition to radiotherapy at 48 years of age. Biopsy of the submandibular gland was performed in our department. The extracted submandibular gland was accompanied by elastic, hard induration. Amyloid deposition accompanying lymphocytic infiltration was histopathologically observed from the submandibular gland.

Objective: The purpose of this study was to investigate the relationship between habitual chewing side and perception of the oral mucosa following reconstruction with dental implants. Study Design: Five patients comprised 2 males and 3 females, with ameloblastoma in 2 patients, odontogenic myxoma in 2 patients, and oral squamous cell carcinoma in 1 patient. They were treated using mandibular reconstruction with bare bone graft after segmental resection of the mandible. Perception (tactile, warm, and cold) was measured at 8 points (chin, lower lip, gingiva, and lateral edge of the tongue, bilaterally). Habitual chewing side was evaluated using a computerized index, the first chewing cycle, and a question on chewing. Results: Perception on resected sides was improved at all measurement points for tactile and cold sensitive evaluation, although sensitivities on the resected side remained below the normal range. In the relationship between habitual chewing side and implanted prostheses in reconstructed bone, the chewing side was the resected side in 2 of the 5 patients. When those 2 patients underwent prosthesis implantation after removal of denture, the chewing side changed from the nonresected side to the resected side. Implant prostheses on resected side were suggested to contribute to masticatory function. Perception in those patients was incomplete but was improved compared with other patients. When prosthesis implantation is performed on the reconstructed side, the resected side may become the habitual chewing side. Conclusions: Recovery of perception can influence acquisition of the habitual chewing side.

66歳男(インプラント埋入時)。右下顎5～7相当部に3本のインプラントを通法どおり埋入し、5年後、インプラント上部構造の動揺を主訴に来院した。右下5・7相当部にアバットメントからの動揺を認め、また右下6相当部にインプラント体からの動揺を認めた。右下6相当部はインプラント体を除去し、上部構造の粘膜面を修理して再度仮着した。その1年後、右下7相当部インプラントの上部構造の動揺を主訴に来院した。インプラント体アバットメント接合部の一部破損を認めたが、対応として、上部構造をアバットメントと合着後にアクセスホールを作製しセメントリテインからスクリューリテイン改造することにより、このインプラント体を継続して使用することができた。

45歳女。7歳頃から口が開きにくいことを自覚していたが、生活に支障はなかったので放置していた。今回、大臼歯部に生じた齲蝕の治療を希望して近医歯科医院を受診したところ、開口障害のため歯科治療が困難であったことから、開口障害の精査加療目的に当科紹介となった。開口量(自力開口域)は26mmで、関節雑音や開口時痛は認めなかった。パノラマX線検査で両側筋突起に著明な骨過形成を認め、CT検査で開口時に筋突起が頬骨弓に干渉している所見を認めた。これらの所見から、両側筋突起過形成症が開口障害の原因と診断し、筋突起切除術を口内法で行い、開口量は40mmに改善した。術後合併症として末梢性顔面麻痺を生じ、その原因については、筋突起切除時に上方部骨片を下方へ引っ張ったさい側頭筋に炎症が起き、この炎症が顔面神経管に波及したことが考えられた。ビタミンB12製剤を投与することで麻痺症状はほぼ消失した。

31歳女。某歯科医院で下顎左8周囲炎と診断され、抜歯術を受けた。術後1日目に嚥下痛が出現し、2日目に発熱と食事摂取困難が出現した。4日目に同医院休診であったため某耳鼻咽喉科を受診し、抗菌薬を処方されたが、症状は増悪し、5日目に歯科医院を受診した際、呼吸苦の訴えがあったため当科に紹介された。左頬部および左下8抜歯窩から左口蓋扁桃にかけて著明な腫脹を認め、抜歯後感染による扁桃周囲膿瘍と診断した。ABPC/SBTの投与を開始し、全身麻酔下に口腔内外からドレナージを施行した。術後は挿管のまま気道確保しICU管理とした。術後2日目に腫脹が軽減したため抜管し、術後3日目にICU退出とした。ABPC/SBT投与を継続し、炎症の再燃なく術後2週間で退院となった。

Objective: Swallowing statuses in patients with advanced cancers that require reconstruction have not been studied well. The relationship between topography of the reconstructed upper airway and swallowing status was evaluated. Material and methods: Subjects comprised 19 cases of tongue cancer and 10 cases of mandibular cancer who underwent resection of the primary lesion and reconstructive surgery with the vascularized free flap. CT image data preoperatively and postoperatively were utilized to evaluate morphological airway changes. Videofluorographic swallowing study (VFSS) was performed postoperatively. Aspiration and laryngeal penetration were noted and compared with morphological airway changes. Results: Regarding postoperative airway morphology, no significant differences in postoperative airway changes were apparent between tongue and mandibular cancers. In postoperative VFSS, aspiration and/or laryngeal penetration was seen in 32% of the tongue cancer cases and 20% of the mandibular cancer cases. Conclusion: Cases with aspiration and/or laryngeal penetration revealed less reduction of postoperative cross-sectional area compared to other cases.

The natural mandible has 2 arcs, the marginal arc and the occlusal arc. The marginal arc is situated along the lower margin of the mandible and affects the contour of the lower third of the face. The occlusal arc is situated along the dental arc and affects the stability of prosthodontics. The gap between these 2 arcs widens in the molar area. Our developed concept of "double arc reconstruction" involves making these 2 arcs for the reconstructed mandible. For the double-barrel fibula reconstruction, 2 bone segments are used to make both arcs. For reconstructions using the iliac crest, the double arc is made by inclination of the top of the bone graft toward the lingual side. Ten patients underwent double arc reconstruction: 2 underwent reconstruction with the double-barrel fibula, and 8 underwent reconstruction with the iliac crest. Four patients had a removable denture prosthesis, 1 had an osseointegrated dental implant, and 5 did not require further prosthodontic treatment. The shape of the reconstructed mandible after double arc reconstruction resembles the native mandible, and masticatory function is good with the use of a dental implant or removable denture prosthesis, or even without prosthodontics.

We encountered a very rare case involving a 67-year-old male with Richter's syndrome showing transformation of B-cell chronic lymphocytic leukemia (B-CLL) to diffuse large B-cell lymphoma (DLBCL) in the left mandibular condyle region. CLL had been diagnosed at another hospital 9 years before visiting our hospital. He had not received positive treatment for CLL. Local examination revealed a mass in the left preauricular region. Histological and immunohistological examination of biopsy tissue from the left preauricular region revealed infiltration of DLBCL, in this case caused by transformation of B-CLL. We diagnosed Richter's syndrome with transformation of B-CLL to DLBCL. Although local irradiation was performed and intravenous cyclophosphamide, vincristine, doxorubicin, and prednisone were administered, the patient died 12 months after diagnosis of Richter's syndrome.

Oral lichen planus (OLP) and oral lichenoid contact lesions (OLCL) are chronic inflammatory mucocutaneous reactions with a risk of malignant transformation that alter the epithelium. OLP and OLCL have similar clinical and histopathological features and it is difficult to distinguish one from the other. Metallic restorations are suspected to generate OLCLs. Trace metal analysis of OLCL specimens may facilitate the discrimination of symptoms and identification of causative metallic restorations. The purpose of this study was to assess OLCL tissue samples for the prevalence of metallic elements derived from dental restorations, and to discriminate OLCL from OLP by using synchrotron radiation-excited X-ray fluorescence analysis (SR-XRF), particle-induced X-ray emission (PIXE), and X-ray absorption fine structure (XAFS). Typical elements of dental materials were detected in the OLCL, whereas no obvious element accumulation was detected in OLP and negative control specimens. The origin of the detected metallic elements was presumed to be dental alloys through erosion. Therefore, our findings support the feasibility of providing supporting information to distinguish OLCL from OLP by using elemental analysis.

症例1は86歳男で、左側頬部の腫脹・疼痛と開口障害を主訴に受診した。左側頬部・顎下部・頸部に腫脹と熱感があり、血液検査でCRPの著明高値を認めた。パノラマX線で左側下顎第一大臼歯と第二大臼歯の根尖部に透過像を認め、同部からの感染と考えられた。症例2は79歳男で、近歯科で右側下顎第二大臼歯を抜歯されたあと同部の疼痛と右側顔面の腫脹が増悪し、抗菌薬を投与されたが改善なく、当科に紹介された。右側頭部・頬部・顎下部・頸部に腫脹と熱感を認め、血液検査で白血球数とCPRの著明高値を認めた。パノラマX線で右側下顎第二大臼歯部に抜歯窩を認め、同部からの感染と考えられた。治療は2例とも全身麻酔下に切開・排膿術を行い、両例とも残存膿瘍や新たな膿瘍形成を認めたため拡大ドレナージ手術を要したが、最終的に消炎が得られた。

The effects of dissolved elements from metal dental restorations are a major concern in lesions of the oral mucosa, and the evaluation of accumulated metal elements, especially their distribution and chemical state, is essential for determining the precise effects of trace metals. In this study, X-ray fluorescence with synchrotron radiation (SR-XRF) and particle-induced X-ray emission (PIXE) were applied for distribution analysis of the trace metal elements contained in the oral mucosa, and the chemical states of the elements were estimated using X-ray absorption fine structure (XAFS) analysis. Appropriate combination of these analysis techniques, particularly SR-XRF and PIXE, to visualize the distributions of the elements in the oral mucosa allowed for the observation and evaluation of accumulated metal ions and debris. Importantly, the analyses in this study could be carried out using conventional histopathological specimens without damaging the specimens. Therefore, this method would be applicable for the detection of accumulated trace metal elements in biopsy specimens from the oral mucosa.

We retrospectively assessed the utility of the LigaSure^TM Vessel Sealing System compared with conventional surgery in 40 cases of free osseous flap harvest comprising 17 fibula flaps ( LigaSure : conventional, 11 : 6 ), 13 scapula flaps ( 4 : 9 ), and 10 iliac crest flaps ( 8 : 2 ). Postoperative duration of suction drain, total fluid collection volume by drain, and avascularized time during fibula flap harvest with a tourniquet did not differ significantly between the LigaSure^TM and conventional techniques. In one case, additional surgery due to hematoma was required 23 days postoperatively in a donor site following scapular tip flap harvest without LigaSure^TM. Reconstructive surgery with free flap transfer is performed with recipient surgery, such as tumor ablation or contracture release; therefore, intraoperative blood loss and total surgical time, which are reportedly significantly decreased by LigaSure^TM, could not be evaluated in this study. LigaSure^TM enables complete hemostasis to be easily accomplished, and the results of hemostasis are at least as favorable as those with the conventional technique.

病気の治療を標準化するためには，何よりもその治療の目的，エンド・ポイントを明確にしなければ議論が不可能である。下顎切除・再建においては，新しい高度な技術が導入されている一方で，多くの症例で大きな機能障害が残存しないため，さまざまな治療法が選択可能となる。これらの多くは治療法として問題ないものなので，優先順位をつけた具体的な治療目標を達成できるかどうかを基準にして選択できるようにするのがこの論文の目的である。具体的には目標を絶対的，標準的，努力目標の3段階に設定し，それぞれに達成率を併記した。

頸動脈の動脈硬化による頸部頸動脈狭窄は，脳梗塞の原因となることが多いとされ，近年重要視されている。自覚症状を認めにくいことから，発見されにくい病変であるが，症例により，パノラマX線画像で異常を指摘できることがある。今回われわれは，2011年4月から2013年3月までに当院歯科口腔外科を受診し，パノラマX線画像および頸部CTを撮影した105例について，頸動脈の石灰化について評価を行った。CT画像では，62例について頸動脈の石灰化を認め，パノラマX線画像で，20例に石灰化物を認めた。また，脳梗塞や，脳梗塞のリスクとされる既往の有無に関わらず認められるほか，年齢に比例して増加することが示された。パノラマX線画像は，歯科・口腔外科を受診する患者で一般的に撮影されており，パノラマX線画像を読影する上では，自覚症状のない頸動脈の硬化性変化がみられる可能性を考慮し読影に当たる必要がある。

A case showing reinforcement of the action of warfarin and potassium in a patient administered S-1 is reported. The patient was a 71 -year-old man with left upper gingival cancer. He had ventricular tachycardia (VT), hypertrophic cardiomyopathy, and a cerebellar infarction. He underwent a pacemaker implantation, and was administered warfarin. After the operation, in mid-March 2010, he was administered with S-1 and warfarin. However, the international normalized ratio of prothrombin time (PT-INR) increased to an extremely high level of 5.82, and S-1 and warfarin were stopped. They were re-administered at the end of April, and the PT-INR stabilized to approximately 2.

Eight patients~6 males, 2 females median age, 78 years age range, 31 ~ 94 years)were treated by mold radiotherapy with a prosthetic apparatus for oral cancers between October 2006 and March 2013. The primary sites were the tongue in 3 cases, hard palate and buccal mucosa in 2 cases each, and oral floor in 1 case. The type of treatment consisted of radical radiotherapy and palliative radiotherapy in 2 cases each, and preoperative radiotherapy, postoperative radiotherapy, additional radiotherapy after external beam radiotherapy and systemic chemotherapy in 1 case each. Patients received 40 ~ 50 Gy in 8 ~ 10 fractions with mold radiotherapy. Two patients who received radical radiotherapy showed no signs of recurrence or metastasis. The present therapy contributed to patients’palliative, postoperative, and preoperative therapy. Mold radiotherapy with a prosthetic appliance was performed safely and was a useful treatment for several types of oral cancer.

The present study aimed to verify the importance of postoperative articulatory rehabilitation in patients with oral cancer and to clarify the neurological changes underlying articulatory functional recovery. A longitudinal assessment of oral function and accompanying brain activity was performed using non-invasive functional magnetic resonance imaging (fMRI). We assessed 13 patients with cancers of the tongue and oral floor before and after ablative surgery. Articulatory function was assessed preoperatively and postoperatively using a conversation intelligibility test and the Assessment of Motor Speech for Dysarthria test. Patients also performed a verbal task during fMRI scans. The assessments were then repeated after the patients had undergone 4-6 months of articulatory rehabilitation therapy. Compared to pretreatment levels, articulatory rehabilitation resulted in a significant increase in activation in the supplementary motor cortex, thalamus, and cingulate cortex. The present study offers a quantitative assessment of the effects of speech rehabilitation by investigating changes in brain activation sites.

Objective. To clarify whether intraoral ultrasonography (I-US) is effective for predicting metastasis of tongue cancer to the cervical lymph nodes. Study Design. Participants comprised 29 patients with tongue carcinoma classified as T1-T4 using the TNM staging system. All patients underwent I-US preoperatively. Postoperatively, resected specimens were evaluated histopathologically. Results. I-US found that cases with invasive depth >= 3 mm had higher potential for cervical lymph node metastasis than those with invasive depth <3 mm (P < .05). No other significant relationships were identified between observations on I-US and cervical lymph node metastasis. Cases with histopathologic blood vessel infiltration or lymph duct infiltration had a significant difference in risk of cervical lymph node metastasis. Conclusions. I-US is useful for preoperatively assessing the invasive depth of tongue carcinoma. Furthermore, observations from I-US and invasive depth of the tumor allowed presumptive diagnosis with regard to cervical lymph node metastasis.