Int. J. Oral Maxillofac. Surg.

2000; 29: 72–73 Copyright C Munksgaard 2000

Printed in Denmark . All rights reserved

ISSN 0901-5027

Letter to the Editor

Unusual periosteal reaction caused by an
accidentally displaced dental root
Dear Editor,
A 50-year-old Japanese man presented
with swelling of the right body of the
mandible. Oral examination revealed a
bony hard swelling on the buccal side
Fig. 1. Radiograph showing a round, thin
bone rim and a displaced dental root.
of the mandibular body at the right the course of many years. Signs and
lower molar region, from which the first symptoms of inflammation developed
and second molars had been extracted about 30 years after dental root dis-
by a dentist when the patient was 20 placement. This case indicates that dis-
years old. A radiograph revealed an el- placed teeth and dental fragments can
lipsoid radiolucent lesion with a thin act as foreign bodies and cause in-
bone rim. The lesion was attached to flammation, irrespective of the time
the mandibular body, and there was no since displacement.
evidence of bone resorption. A radio- S I,
paque lesion with a smooth margin, M O,
suspected to be a dental root, was T M
found in the radiolucent lesion (Fig. 1).
The clinical diagnosis was a chronic
subperiosteal granuloma with new bone Address:
formation, caused by a displaced dental Seiji Iida1,
root. Extirpation and osteoplasty were Masayuki Ozaki2,
performed with the patient under infil- Tokuzo Matsuya1
1
tration anesthesia. The granulomatous First Department of Oral and Maxillo-
tissue was covered by a thin layer of facial Surgery
bone posteriorly and inferiorly, and was Osaka University Faculty of Dentistry
easily ablated from the periosteum. The 1–8, Yamadaoka
extirpated specimen was a granulo- Suita City
matous ellipsoid lesion. Its lumen was Osaka, 565-0871
filled with puriform fluid and contained Japan
a resorbed dental root. Histopatholog- Tel: π81 6 6879 2936
ically, the wall of this cystic lesion con- Fax: π81 6 6876 5298
2
sisted of fibrous and granulation tissue Department of Dental and Oral
with no epithelial lining. The hard mass Surgery
was confirmed to be a dental root. The Daiwa Bank Medical Center
postoperative course was uneventful. 2-2-1, Bingo-machi Chuo-ku
In our patient, a displaced dental Osaka 541-0051
root caused a periosteal reaction over Japan

Letter to the Editor and Reply Letter

Dear Editor,
The effect of suction drainage on micro-
vascular anastomosis.
We read with interest the article by
C et al.1 on suction systems for
microvascular anastomosis in a rat
model. We have reservations, however,
with respect to the authors’ con-
clusions. The procedure in this model is
not routinely used in microvascular free
flap surgery, as the vessels remained in
their anatomical position surrounded
by their normal structures. In microvas-
cular surgery for free flap reconstruc-
tion in the head and neck, the vessels

Fig. 1. Suction drain sucking up the venous pedicle of a radial free flap (arrow) with conse-
quent venous obstruction and flap compromise.
are placed in an unnatural position, and
therefore are much more likely to be
sucked over to the position of the drain
(Fig. 1). For their study to be of value
in answering this controversial ques-
tion, the authors would need to have
carried out a free flap procedure that
resulted in total disruption of the posi-
tion of both the vein and the artery.
During microvascular anastomosis
both an artery and a vein are anastom-
osed. The vein is considerably more de-
formable than the artery and more
prone to cause flap compromise2. As it
stands, there is very little likelihood that
a drain sutured into position would
trouble this simple anastomosis. It is
our opinion that the method used is in-
adequate to conclude that suction
drainage does not have any detrimental
effect on a healing microvascular anas-
tomosis for free flap surgery.
The use of suction drains for free flaps
requires the drain to be anchored to
avoid sucking in the anastomosis (Fig.
1). This means that the placement is not
ideal for maximal drainage. In addition,
a full ‘‘suck down’’ of the skin into
thedefect can distort the anastomosis,
with the result that compromised suc-
tion drainage is accepted, making hae-
matoma development more likely.
Between 1992 and 1997, we carried out
350 free flap reconstructions and used
closed active vacuum drains in these
cases. Haematoma requiring return to
theatre occurred in 29 cases (8.2%). In 11
cases (37.9%) the haematoma was as-
sociated with vascular compromise of
the free flap. Anchoring the pedicle or
the drain away from each other did not
eliminate this complication. In April
1997, we abandoned the use of suction
drains in favour of an open, passive, cor-
rugated drain system. A recent sub-
sequent audit demonstrated that we have
not returned to theatre for haematoma
in over 100 cases of free flap repair. This
audit indicates that pressure drainage
systems reduce the chance of haema-
toma formation and possible resulting
flap compromise. Further clinical re-
search is required to resolve this contro-
versy, rather than animal studies which
often fail to simulate the human clinical
situation.
A J. S
J C. D
J S. B
73
References
1. C BH, Y JH, L WJ. A study of
the effect of suction drainage on micro-
vascular anastomosis. Int J Oral Maxillo-
fac Surg 1999: 28: 67–9.
2. D JC, B JS, V ED,
M JP. Analysis of surgical inter-
vention in 60 cases of free flap compro-
mise in head and neck reconstruction. J
Craniomaxillofac Surg 1998: 26 (Suppl
1): 39.
Address:
Regional Maxillofacial Unit
University Hospital Aintree
Longmoor Lane
Liverpool L9 7AL
UK
Dear Editor,
I thank Drs. Sidebottom, Devine and
Brown for showing interest in our
paper. Their opinion is quite interest-
ing. Initially we had similar concerns.
As a result of the study presented, how-
ever, we are presently using suction
drainage and it has not increased graft
loss.
At the moment we are reviewing our
data and are preparing a manuscript
entitled ‘‘A clinical study of the effect
of suction drainage on microvascular
anastomosis’’. We hope to be able to
eliminate the concerns of our col-
leagues.
B-H C
Address:
Byuang-Ho Choi
Dept. of Oral and Maxillofacial Surgery
Wonju Christian Hospital
Yonsei University
162 Ilsan-dong, Wonju
Kangwon-Do
South Korea