Competing interests

None declared.
Ethical approval
Not required.
References
1. Aoki T, Naito H, Ota Y, Shiiki K.
Myositis ossicans traumatica of the mas-
ticatory muscles: review of the literature
and report of a case. J Oral Maxillofac
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ELG. Myositis ossicans traumatica of
the masticatory musculature: a case report
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Surg 2002: 60: 10721076.
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cans: medial pterygoid musclea case
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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.
Email: omfsvat@hotmail.com
doi:10.1016/j.ijom.2010.10.024
Case Report
Trauma
Transmucosal xation of the
fractured edentulous mandible
G. A. Wood, D. F. Campbell, L. E. Greene: Transmucosal xation of the fractured
edentulous mandible. Int. J. Oral Maxillofac. Surg. 2011; 40: 549552. # 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 xation is a new strategy for the treatment of edentulous
mandibular fractures using external xation principles within the oral cavity. The
component parts of this technique are not new. External xation, 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 xation technique. The rst eight patients treated with this
technique have achieved bony union, they have no long-term sensory decit and all
patients were able to eat a soft diet with minimal discomfort the day after surgery.
The rst ve of eight patients on long-term review showed bony union conrmed
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 ossicans traumatica of the medial pterygoid 549
Treatment of the edentulous fractured
mandible presents special difculties
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 xation. Patients are
often elderly
9
with acute and chronic co-
morbidities frequently complicating man-
agement and adding to anaesthetic risks
5
.
The specic problems of edentulous man-
dibular fractures relate to the remaining
mandibular bone height. The difculty of
achieving bony union is well known. Frac-
tures amenable to mini-plate xation 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
benet of bi-cortical xation 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 sufcient with xation through one
cortical plate as STOELINGA et al. described
in the xation of mandibular osteo-
tomies
10
. Bi-cortical xation would
increase the rmness of xation and can
be achieved with this technique.
The aim of this study was to establish
whether rigid xation could be achieved
transmucosally using existing locking
plates and establishedexternal xationcon-
cepts. The rst eight cases are reported.
Materials and method
Patients with an edentulous fractured
mandible that required xation were
selected. If they were unt 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 xed (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
xation, as this would have increased the
risk of non-union. Bony union was con-
rmed 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 xed.
Transmucosal xation 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 xation 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 specic 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 conrm satisfactory
reduction. At review, following xation
removal, patients were assessed for mobi-
lity or pain at the fracture site. If patients
remained symptom free 2 weeks after xa-
tion removal they were discharged. The
rst three patients returned for follow-up
and radiography to conrm bony union.
Results
All patients were able to eat a soft break-
fast on the rst postoperative day,
seemed untroubled by the procedure
and did not complain of any signicant
pain.
After xation 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
rst 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 rst eight patients (Table 1), one
had a dense unilateral sensory decit in the
distribution of the mental nerve following
bilateral fracture xation, but this had
resolved by the time xation 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 signicant 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 xation for
similar fractures and followed this up with
a retrospective questionnaire to determine
the signicant morbidities associated with
conventional techniques. All had sensory
decits 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 xation 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 xation of two patients trea-
ted under local anaesthesia because of med-
ical co-morbidities rendering themunt 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 rst 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 decit following surgery Temporary (2 months)
Postoperative infection Nil
Transmucosal xation 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
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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
Email: 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 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: 552555. # 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 ne needle biopsy showed macrovesicular steatosis with a
slight chronic portal inammatory inltrate and signs of siderosis. Iron metabolism
was slightly altered. Genetic tests showed a heterozygotic mutation for hereditary
552 Wood et al.