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Massive Osteolysis of the Mandible: Report of a Case. Arimatsu T, Yong RC, Uneoka M, et al: J Jpn Stomatol Sot 32: 183, 1983

Massive osteolysis is a rare idiopathic lesion that has also been reported as phantom bone disease, disap- pearing bone disease, acute spontaneous resorption of bone, and progressive atrophy of bone. This paper de- scribes a case occurring in the mandible and surveys the literature, which showed 11 similar cases. The patient was a 45-year-old woman with extensive bone resorption of both mandibular angles. The lesions were completely asymptomatic and were fortuitously found on a pan- oramic radiograph. No abnormalities were noted in the other bones. In the 11 cases reviewed, the lesions were usually asymptomatic, but pain in the mandible, mostly resulting from pathologic fracture, was the chief com- plaint in six patients. The site of involvement was con- fined to the mandible alone in five cases, whereas in the remaining cases, osteolysis was noted in more than two other bones, including the maxilla in six cases. The os- teolysis had progressed to such an extent that the entire or unilateral half of the mandible had disappeared in six cases and the mandibular body and/or angle had been partially lost in the other cases. Although the site of pre- dilection could not be determined, the ramus and the mid- line area of the mandible seemed to be less frequently affected. Radiographically, the lesions were quite vari- able, with localized or diffuse radiolucencies that were not always diagnostic. The causes may include vascular abnormalities, trauma, nerve disturbance, and so forth, but the definite cause is still obscure.-TAM10 NAKAJIMA

Reprint requests to Department of Dental Radiology, School of Dentistry, Kyushu University 3-l-1, Maidashi, Higashi-Ku. Fu- kuoka City 812. Japan.

The Incidence and Management of Osteoradionecrosis of the Jaws Following Head and Neck Radiotherapy. Coffin F: Br J Radio1 56:851, 1983

This paper reports 22 cases of osteoradionecrosis of the jaws that required resection following radiotherapy out of 2,853 cases of head and neck tumors. Each patient received radiation doses capable of causing osteoradi- onecrosis between January 1, 1970, and December 31, 1981, at the Royal Marsden Hospital, London. Data on radiation dose, location of original lesion, and precipi- tating factors for the pathogenesis of the osteoradione- crosis are presented.

All but one of the 22 cases of osteoradionecrosis in- volved the mandible; the lone case of maxillary osteora- dionecrosis involved the entire bony palate. The impor- tance of immaculate oral hygiene and strict avoidance of surgical intervention, except in the case of unstable pathologic fractures and appearance of chronic fistulas from the mouth to skin recalcitrant to antibiotic therapy, is emphasized. In the event of extractions or infection, tetracycline was the antibiotic of choice in doses of 250 mg four times a day for seven days prior to extraction, reduced to 250 mg three times a day for 14 days, and continued twice a day as long as the wound or infection persisted.

The incidence of osteoradionecrosis in the 22 cases was categorized into patterns: surgery before irradiation (9 patients), surgery during irradiation (1 patient), surgery after irradiation (8 patients), and irradiation alone (4 pa-

tients). The recorded incidence of osteoradionecrosis was low. These factors were worthy of consideration in the irradiated patients: (1) the dose of radiation needed for a cure, (2) period of time between surgery and beginning of radiation therapy, (3) strict avoidance of surgery to the jaws after radiotherapy and three months previously if possible, (4) avoidance of the bone in biopsy of a sus- pected recurrence, (5) once a radial course of radiation therapy has been accomplished, design of any surgery to the jaw bones to remove all irradiated bone involved, and (6) obsessional dental health.-N. RAY LEE

Reprint requests to Dr. Coffin: 53 New Cavendish St., London. W 1, England.

Day-stay Oral Surgery. Vickens P, Goss AN: Aust Dent J 28:135, 1983

Most free-standing surgicenters or day-stay ambulatory anesthesia care facilities have similar criteria for treat- ment. Six hundred ninety-four patients were operated on for various dental surgical and restorative procedures in a one-year period. Their ages ranged from 2 to 73 years. Young healthy patients did not have any preoperative physical examination. The majority of patients (53%) were between the ages of 16 and 25 years.

Endotracheal intubation was the most common airway management technique used. Approximately 89 of 694 patients (13%) were scheduled for a planned admission after surgery. An additional six patients were admitted because of surgical or traumatic complications that were not associated with anesthetic management. Generally, overnight admission of the patient was designated for any procedure requiring more than 60 minutes. No patients discharged from the day-stay visit needed to be read- mitted because of anesthetic or surgical complications.- ROBERT L. CAMPBELL

Reprint requests to Dr. Vickens: Department of Oral Pathology and Oral Surgery, University of Adelaide, Adelaide, SA 5000, Australia.

The Favorable Effect of Early Parenteral Feeding on Survival in Head-injured Patients. Rapp BP, et al: J Neurosurg 58:906, 1983

Profound catabolism in the patient with head injury and a correlation between the severity of brain damage and energy requirements have been confirmed in previous studies. In this prospective study, the effects of early total parenteral nutrition (TPN) were compared with those of the traditionally delayed standard enteral nutrition (SEN). Thirty-eight patients were randomized to receive TPN (20 patients) or SEN (18 patients). There was no significant difference in the severity of head injury be- tween the two groups as measured by the Glasgow Coma Scale. TPN was begun within 48 hours of admission, whereas the SEN feedings were based on digestive ca- pability when bowel sounds were present and gastric re- sidual volume was less than 100 mg/hour. Eight of the 18 SEN patients died within 18 days of injury, whereas no patient in the TPN group died within this period. Five of the eight deaths in the SEN group were attributed to or associated with sepsis. The TPN patients also had a more positive nitrogen balance, a higher serum albumin level, and higher total lymphocyte count than the SEN patients. The authors concluded that the improved nutritional state

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of the TPN patients may lead to a greater immunologic response to infection, resulting in decreased suscepti- bility to sepsis.-STEVEN B. ARAC;ON

Reprint requests to Dr. Young: Divison of Neurosurgery, Uni- versity of Kentucky Medical Center, 800 Rose St. MS107, Lex- ington, KY 40536.

Steroid-induced Fractures and Bone Loss in Patients with Asthma. Adinoff AD. Hollister JR: N Engl J Med 3091265, 1983

This study examined the relationship between the ad- ministration of supraphysiologic doses of corticosteroids and the occurrence of osteoporosis and pathologic frac- tures in asthmatic adults. The retrospective study in- cluded 128 asthmatic patients receiving long-term (daily or alternate-day adrenal corticosteroids for at least one year) and compared them with a prospective study group of 54 other asthmatic patients of similar age who did not require long-term corticosteroid therapy. Fourteen pa- tients (11%) of 128 long-term steroid therapy patients had a total of 58 documented fractures. No fractures occurred in the 54 patients who used steroids intermittently. Ver- tebral compression was most common, although rib frac- tures associated with coughing were frequently seen. All patients with fractures had received daily doses of pred- nisone (or an equivalent steroid) of at least 15 mg (mean 30 mg) for al least three years (mean eight years) before the first fracture. Measurements of bone density by photon absorptiometry demonstrated that only patients who required long-term steroid treatment had diminished values. These patients had normal cortical bone mass but significantly reduced values at the distal radial site. Tra- becular mass values were significantly lower in the long- term-use patients than in either normal controls or the intermittent-use group. The retrospective review showed an association between corticosteroid use and fractures of vertebrae and ribs. In the prospective study, the treat- ment with corticosteroids and not the illness (asthma) itself was the critical determinant in decreasing bone mass in patients receiving long-term corticosteroid therapy. The diminished trabecular bone mass in the forearm in patients receiving long-term treatment was consistent with the tendency to fracture in vertebrae and ribs, which are primarily trabecular bone. The role of physical activity as a possible factor in bone-mineral loss was uncertain. The study was unable to correlate the se- lective loss of trabecular mass with either the duration or the dose of cOrtiCOSterOidS.-ROBERT C. HOBBS

Reprint requests to Dr. Hollister: 3800 E. Colfax Ave., Denver. co 80206.

Free Autogenous Graft Coverage of Vital Retained Roots. Lambert PM, Skerl RF, Campana HN: J Prosthet Dent 50:611, 1983

Intentional preservation of vital roots submucosally has been advocated as a means of preventing or retarding alveolar atrophy. Presently employed surgical techniques result in loss of vestibular depth and attached mucosa, as wide subperiosteal reflection is used to achieve primary closure. Free autogenous grafts offer one possible solu- tion to this problem. Previous attempts at mucosal grafting over retained roots were performed directly over cortical bone and failed. The authors report a study in

dogs in which free grafts (palatal and skin) were placed over retained roots, and a tissue bed was created by su- praperiosteal dissection. The grafts were successful and the roots remained submerged. Histologic examination revealed continued viability of the pulp tissue in the roots and cemental bridging in some cases. The authors con- clude that free autogenous grafting over a properly pre- pared recipient bed and vital roots can be successfully employed.--RlCHARD L. FIESE

Reprint requests to Dr. Lambert: Veterans Administration Med- ical Center, 4100 West Third St., Dayton, OH 45428.

Influence of the Vertical Dimension in the Treatment of Myofascial Pain-dysfunction Syndrome. Manns A, Mir- alles R, Santanden H. et al: J Prosthet Dent 505’00, 1983

Seventy-five patients who received diagnoses of my- ofascial pain-dysfunction syndrome were treated .wifh maxillary splints having anterior bite planes of varying thicknesses. Criteria for the diagnosis of MPD were ( 1) preauricular pain. (2) tenderness to palpatation of the muscles of mastication, (3) limitation on opening or de- viation on opening, (4) clicking or popping, (5) bruxing or clenching.

Three treatment groups of 25 patients each were estab- lished randomly. Group 1 received bite planes with 1 mm of opening. Groups II and III received bite planes based on the amount of activity in the masseter muscle as re- corded by an electromyogram (EMG). Group II patients received appliances with openings equal to half the dis- tance between the vertical dimension of occlusion (VDO) and the point of least activity by EMG. The average opening was 4.42 mm. Group III received appliances with openings equal to the point of least muscular acfivity (8.15 mm).

Treatment consisted of wearing the appliances for three hours during the day and nocturnally for three weeks. The conditions of all patients were evaluated at one day, three days, one week, two weeks, and three weeks. Eval- uation consisted of subjective responses to a question- naire and objective response as recorded by an examiner. All three treatment groups improved significantly by the end of the treatment period. Improvement in Groups II and III were faster and greater than in Group I.

The authors conclude that bite planes that open the jaws beyond rest position do not necessarily induce reflex muscular contraction. The authors also conclude that maximum benefit is gained from splints that stretch the muscles of mastication to a point near the length of least activity as recorded by electromyography. Other possible explanations of the results of their study are not ex- plored.-R. L. F~ESE

Reprint requests to Dr. Manns: University of Chile, Faculty of Medicine, Casilla 137-D Correo Central, Santiago, Chile.

Proliferative Myositis of the Masseter Muscle. Orlowski W, Freedman PD, Lowerman H: Cancer 52:904, 1983

This article is a case report of a 62-year-old woman with proliferative myositis (PM) of the masseter muscle. Proliferative myositis is very rare, only 41 cases having been described in the literature to date, but it is important to differentiate it clinically and histologically from more ominous pathologic conditions. Clinically, the patient had pain and difficulty in opening of the mouth. The growth