Patient-specific Implants Improve Volumetric Surgical Accuracy Compared to Stock Reconstruction Plates in Modern Pardigm Virtual Surgical Planning of Fibular Free Flaps for Head and Neck Reconstruction.

BACKGROUND: Virtual surgical planning (VSP) for composite microvascular free flaps has become standard of care for oncologic head and neck reconstruction. Controversy remains as to the use of three-dimensional (3D)-printed titanium patient-specific implants (PSIs) versus hand-bent stock reconstruction plates. Proponents of PSIs cite improved surgical accuracy, reduced operative times, and improved clinical outcomes. Detractors purport increased cost associated with PSIs and presumed equivalent accuracy with less expensive stock plates. PURPOSE: The study purpose was to measure and compare the 3D-volumetric accuracy of PSI versus stock reconstruction plates among subjects undergoing VSP-guided mandibular fibular free flap reconstruction. STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study of subjects undergoing VSP-guided fibular free flap reconstructions at Mayo Clinic between 2016 and 2023 was performed. Subjects were excluded for non-VSP guidance, midfacial reconstruction, nonfibular free flaps, and lack of requisite study variables. PREDICTOR VARIABLE: The primary predictor was the type of reconstruction plate utilized (PSI vs stock plate). MAIN OUTCOME VARIABLE: The main outcome was volumetric surgical accuracy of the final reconstruction compared to the preoperative surgical plan by root mean square error (RMSE) calculation. Lower RMSE values indicated a higher surgical accuracy. COVARIATES: Covariates included age, sex, race, smoking status, American Society of Anesthesiologists Physical Status Classification System, Charlson Comorbidity Index, preoperative diagnosis, and number of fibular segments. ANALYSES: Differences in surgical accuracy were assessed between preoperative and postoperative segmented scans using volumetric overlays from which RMSE values were calculated. Univariate and multivariate modeling of plate type to RMSE calculation was performed. Statistical significance set to P < .05. RESULTS: Total of 130 subjects were identified, 105 PSI and 25 stock plates. Calculated mean RMSE in millimeters (mm) for stock plates was 1.46 (standard deviation: 0.33) and 1.15 (standard deviation: 0.36) for PSIs. Univariate modeling demonstrated a statistically significant difference in RMSE of 0.31 (95% confidence interval: 0.16-0.47) (P < .001) equating to a 21.2% (P < .001) improved volumetric surgical accuracy for PSIs. The association of improved volumetric accuracy with PSIs has been maintained in all multivariate models controlling for confounding. CONCLUSION AND RELEVANCE: In modern era VSP-guided head and neck fibular free flap reconstruction, patient-specific 3D-printed titanium implants confer a statistically significant improvement in volumetric surgical accuracy over stock reconstruction plates.

The use of artificial intelligence to detect voided medication orders in oral and maxillofacial surgery inpatients.

OBJECTIVE: The aim of this study is to determine if supervised machine learning algorithms can accurately predict voided computerized physician order entry in oral and maxillofacial surgery inpatients. METHODS: Data from Electronic Medical Record included patient demographics, comorbidities, procedures, vital signs, laboratory values, and medication orders were retrospectively collected. Predictor variables included patient demographics, comorbidities, procedures, vital signs, and laboratory values. Outcome of interest is if a medication order was voided or not. Data was cleaned and processed using Microsoft Excel and Python v3.12. Gradient Boosted Decision Trees, Random Forest, K-Nearest Neighbor, and Naïve Bayes were trained, validated, and tested for accuracy of the prediction of voided medication orders. RESULTS: 37,493 medication orders from 1,204 patient admissions over 5 years were used for this study. 3,892 (10.4%) medication orders were voided. Gradient Boosted Decision Trees, Random Forest, K-Nearest Neighbor, and Naïve Bayes had an Area Under the Receiver Operating Curve of 0.802 with 95% CI [0.787, 0.825], 0.746 with 95% CI [0.722, 0.765], 0.685 with 95% CI [0.667, 0.699], and 0.505 with 95% CI [0.489, 0.539], respectively. Area Under the Precision Recall Curve was 0.684 with 95% CI [0.679, 0.702], 0.647 with 95% CI [0.638, 0.664], 0.429 with 95% CI [0.417, 0.434], and 0.551 with 95% CI [0.551, 0.552], respectively. CONCLUSION: Gradient Boosted Decision Trees was the best performing model of the supervised machine learning algorithms with satisfactory outcomes in the test cohort for predicting voided Computerized Physician Order Entry in Oral and Maxillofacial Surgery inpatients.

Does Alcohol Use Influence Hospitalization Outcomes in Adults Suffering Craniomaxillofacial Fractures From Street Fighting?

Study Design: This retrospective cohort study utilized the National Inpatient Sample (NIS) database for the years 2016-2018. Incidences of street fighting were identified using the corresponding ICD-10 codes. Objective: To determine whether alcohol use (measured by blood alcohol content (BAC)) in patients sustaining maxillofacial trauma from hand-to-hand fighting influence hospitalization outcomes. Methods: The primary predictor variable was BAC stratified into six categories of increasing magnitude. The primary outcome variable was mean length of hospital stay (days). The secondary outcome variable was total hospital charges (US dollars). Results: Our final sample consisted of 3038 craniomaxillofacial fractures. Each additional year in age added +$545 in hospital charges (P < .01). Non-elective admissions added $14 210 in hospital charges (P < .05). Patients admitted in 2018 experienced approximately $7537 more in hospital charges (P < .01). Le Fort fractures (+$61 921; P < .01), mandible fractures (+$13 227, P < .01), and skull base fractures (+$22 170; P < .05) were all independently associated with increased hospital charges. Skull base fractures added +7.6 days to the hospital stay (P < .01) and each additional year in patient age added +.1 days to the length of the hospital stay (P < .01). Conclusions: BAC levels did not increase length of stay or hospitalization charges. Le Fort fractures, mandible fractures, and skull base fracture each independently increased hospital charges. This reflects the necessary care (ie, ICU) and treatment (ie, ORIF) of such fractures. Older adults and elderly patients are associated with increased length of stay and hospital charges-they are likely to struggle in navigating the healthcare system and face socioeconomic barriers to discharge.

Assessing reviews of academic oral and maxillofacial surgeons within the US on Healthgrades.

PURPOSE: The purpose of the following study was to explore the patient feedback on academic oral and maxillofacial surgeons (OMSs) practicing in the United States (US) using the physician rating website (PRW) Healthgrades.com. METHODS: We conducted a retrospective cohort study on academic OMSs in the US using data from Healthgrades.com. Predictor variables included OMS characteristics or rating characteristics. The primary outcome variable was overall rating. Linear regression was used to determine independent predictors of overall rating. RESULTS: The final study sample consisted of 309 academic OMSs (mean age, 56.4 years; males, 86.4%). Age group was significantly associated with overall rating (p = 0.034). Dual-degree OMSs had a higher mean overall rating than single-degree OMSs (4.26 vs. 3.98, p = 0.012). The number of ratings was also significantly associated with overall rating (p = 0.019). Upon controlling for all other variables, merely age group was independently associated with overall rating. Specifically, OMSs aged 41-55 years were associated with a higher overall rating (+0.96, p = 0.022) relative to OMSs aged >70 years. CONCLUSIONS: The OPRs on Healthgrades.com for academic OMSs within the US are generally positive. Age was the only independent predictor for overall rating - younger OMSs (aged 41-55 years) were independently associated with a higher overall rating relative to older OMSs (aged >70 years). The new generation of younger OMSs is likely to be aware of PRWs and their implications in the growing world of online exposure.

Motorcycle Accidents are the Strongest Risk Factor for Panfacial Fractures Among Pediatric Patients.

Study Design: A retrospective cohort study was conducted using the Kids' Inpatient Database from 2000 to 2014. Subjects were included if they were 18 years and younger and suffered any type of facial fracture. Objective: The purpose this study was to determine the risk factors for incurring panfacial fractures among the pediatric population. Methods: The primary predictor variables were a set of heterogenous variables that included patient characteristics, injury characteristics, hospitalization outcomes. The primary outcome variable was panfacial fracture. Logistic regression was used to determine the independent risk factors for panfacial fractures. Results: Relative to infants and toddlers, teenagers were nearly three times more likely to sustain panfacial fractures (P < .01). Relative to no chronic conditions, patients with one or more chronic conditions were more likely to incur panfacial fractures. Motorcycle accidents were over three times more likely (P < .01) to result in panfacial fractures while car accidents were over two times more likely (P < .01) to result in panfacial fractures. Falls were less likely (OR, .39; P < .01) to result in panfacial fractures. Conclusions: Motor vehicle accidents was a major risk factor for panfacial fractures. Teenagers are also found to have an increased risk for panfacial fractures relative to infants and toddlers. Each additional chronic condition was a significant risk factor for suffering panfacial fractures relative to not having any chronic condition at all. In contrast, falls independently decreased the risk of incurring a panfacial fractures. Special attention should be given to safety precautions when occupying a motor vehicle.

Association of hyperparathyroidism and benign fibro-osseous jaw tumors: a 25-year retrospective study at Mayo Clinic.

PURPOSE: The purpose of this study is to evaluate the association between hyperparathyroidism (PHPT), parathyroid hormone levels, and calcium levels in patients diagnosed with benign fibro-osseous lesions such as fibrous dysplasia (FD), ossifying fibroma (OF), central giant cell granulomas (GCG). METHODS: This is a retrospective, single-center study from a sample of patients who underwent surgical treatment of FD, OF, and GCG at Mayo Clinic between 1996 and 2021. Patient demographics, history of PHPT, histopathological diagnosis, and relevant laboratory values such as parathyroid hormone (PTH), serum calcium, vitamin D, and alkaline phosphatase were collected. RESULTS: Of the patients diagnosed with FD (n = 64), OF (n = 24), and GCG (n = 5), a diagnosis of PHPT was found in 2 patients (3.1%), 1 patient (4.2%), and 0 patients (0%), respectively. Elevated PTH levels (>65 pg/mL) were observed in 3 patients (4.7%) with FD, 1 patient (4.2%) with OF, and 1 patient (20%) with GCG. Mean (standard deviation) calcium levels were 9.3 (0.6) mg/dL in the FD group, 9.4 (0.5) mg/dL in the OF group, and 9.3 (0.6) mg/dL in the GCG group. Patients with fibro-osseous jaw tumors including FD, OF, and GCG may have increased risk of PHPT compared to the general population. CONCLUSION: Patients with benign jaw tumors including FD, OF, and GCG may have increased risk of PHPT compared to the general population. Surgeons treating these benign tumors need to be cognizant of these findings, obtain appropriate laboratory studies, and incorporate multidisciplinary care including endocrinologists, endocrine surgeons, and maxillofacial surgeons.

What explains very poor Yelp reviews of oral and maxillofacial surgeons in private practice?

OBJECTIVE: Websites that maintain online physician ratings, such as Yelp.com, have been growing in popularity throughout the United States. The purpose of this study was to determine which factors increase the risk for very poor reviews (1 out of 5 stars) on Yelp.com for oral and maxillofacial surgeons (OMSs) in private practice. STUDY DESIGN: A retrospective cohort study was conducted using data on OMSs from Yelp.com. Predictor variables included clinician characteristics, practice characteristics, and review characteristics. The primary outcome variable was a very poor review. Logistic regression was used to determine risk factors for a very poor review. RESULTS: The final sample consisted of 3802 reviews. Relative to male clinicians, female clinicians were 2.7 times (P < .01) more likely to receive a very poor review. Clinicians who completed residency during the 1970s were over 4.5 times (P < .01) more likely to receive a very poor review relative to clinicians who completed residency during the 2010s. Relative to clinical reviews, nonclinical reviews were more likely (odds ratio = 2.6, P < .01) to be very poor and clinical and nonclinical reviews were less likely (odds ration = 0.5, P < .01) to be very poor. CONCLUSIONS: Nonclinical reviews were more likely to be very poor relative to clinical reviews. Several clinician factors, including female sex and completing OMS residency during the 1970s, were risk factors for receiving a very poor review.

What is the Incidence of Oral Cancer Recurrence in Patients Reconstructed With a Microvascular Free Flap, Endosseous Implants, and an Oral Prosthesis and How Does the Timing of Implant Placement Influence Recurrence?

PURPOSE: In patients with malignant oral disease, there is concern that immediate implant placement at the time of ablative and microvascular free flap surgery can contribute to tumor recurrence or delay the diagnosis of recurrence. The purpose of this study is to 1) estimate the incidence of recurrence in patients with malignant disease treated with immediate microvascular free flap reconstruction, endosseous implants, and an oral prosthesis, 2) measure and compare the timing of implant placement, immediate versus delayed, and the time to complete oral rehabilitation, and 3) measure the association between the timing of implant placement and tumor recurrence. MATERIALS AND METHODS: This is a retrospective cohort study utilizing medical record analysis involving patients with malignant oral cancer undergoing tumor resection and immediate microvascular reconstruction from 1996 to 2019 at the Mayo Clinic, Rochester, MN by the Division of Oral and Maxillofacial Surgery. Additional inclusion criteria comprised of immediate or delayed endosseous implant placement, the fabrication of an oral prosthesis, and a minimum of 2-year follow-up. Data on patient demographics, tumor characteristics, timing of implant placement and prosthesis loading, type of prosthesis, tumor recurrence, or second primary tumor events were analyzed. RESULTS: Thirty-three patients with a mean follow-up of 6.4 years were included. Twenty-four patients (72.7%) were diagnosed with squamous cell carcinoma with 3 patients experiencing tumor recurrence. Fifteen patients had immediate implant placement while 18 patients had delayed implant placement. The mean number of days to prosthetic loading of the implants was 680.4 days and 330.1 days for the delayed implant group and immediate implant group, respectively, which was statistically significant (P = .004). The timing of implant placement and the event of a recurrence were not statistically significant (P = .075). CONCLUSION: The incidence of recurrence in patients with malignant oral cancer treated with microvascular reconstruction, endosseous implants, and an oral prosthesis was 12.5% with one recurrence occurring beneath the oral prosthesis. Delayed implant placement resulted in a statistically significant delay in the completion of oral rehabilitation compared to immediate implant placement. There was no difference in the incidence of recurrence in the immediate implant group compared to the delayed implant group.

Surgical and prosthetic rehabilitation of siblings with Witkop tooth and nail syndrome using zygomatic implants: a familial case series of 3 patients with up to 15-year follow-up.

Witkop tooth and nail syndrome is a rare, autosomal dominant type of ectodermal dysplasia that can have significant effects on dentition, including hypoplastic and malformed dentition and significantly atrophic maxillas. Endosseous implants have become one possible solution to replace missing teeth, although their use in areas where bone is sparse becomes challenging. Due to the severe atrophy of the maxillary alveolus, extensive preprosthetic surgeries including orthognathic surgery, extensive bone grafting, and sinus floor augmentations have been recommended prior to placement of endosseous dental implants. Although this treatment has shown favorable outcomes, it requires multiple surgical procedures, contributing to a prolonged treatment course and increased morbidity. An alternative treatment of atrophic maxillas in patients with ectodermal dysplasia includes the use of zygomatic implants. This familial case series discusses 3 siblings, all previously diagnosed with Witkop Syndrome, who underwent comprehensive preprosthetic surgery and prosthetic rehabilitation using zygomatic implants with a follow-up period up to 15 years.

Risk factors for increased length of hospital stay among young pediatric patients who suffer facial fractures.

BACKGROUND/AIM: It is not known whether the mechanism of facial trauma influences the associated length of hospitalization. The aim of this study was to determine whether the mechanism of injury influenced the length of hospital stay (LOS) among pediatric patients who sustained facial fractures. MATERIALS AND METHODS: This retrospective cohort study was completed using the Kids' Inpatient Database (KID). The primary predictor variable was the mechanism of injury. The primary outcome variable was LOS. Linear regression was used to determine independent predictors of increased/decreased length of stay. A p-value of less than .05 was considered statistically significant. RESULTS: The final sample consisted of 2865 subjects aged 12 years or younger who had suffered facial fractures. The most common mechanism of injury was motor vehicle accidents (MVA) (58.6%). Facial fractures due to MVA added 1.20 days (95% CI, 0.02, 2.38; p < .05) when compared to those due to a fall. CONCLUSIONS: MVA significantly prolonged the LOS among young pediatric patients who sustained facial fractures, reflecting the exceptional amount of force involved. Having a chronic condition was also a significant factor for longer LOS. Four or more fractures also led to a longer LOS.

Accuracy and Precision of the Computed Tomographic Angiography Perforator Localization Technique for Virtual Surgical Planning of Composite Osteocutaneous Fibular Free Flaps in Head and Neck Reconstruction.

BACKGROUND: Virtual surgical planning (VSP), computer aided design/computer aided modeling, and 3-dimensional printing technology have been shown to improve surgical accuracy and efficiency in head and neck reconstruction. However, persisting criticism of the technology is that it does not adequately address the soft tissue-related aspects of reconstructive surgery. Prior publication on the computed tomographic angiography (CTA) perforator localization technique has demonstrated how soft tissue planning can be incorporated directly into existing VSP workflows. PURPOSE: The aim of this study is to prospectively assess the accuracy, precision, negative predictive value (NPV), and positive predictive value (PPV) of the CTA perforator localization technique for VSP of osteocutaneous fibular free flaps. MATERIALS AND METHODS: A prospective observational study in a consecutive cohort of subjects undergoing VSP of osteocutaneous fibular free flaps at Mayo Clinic between 2018 and 2020 was completed. All cutaneous perforators from the peroneal system of the selected donor leg were identified preoperatively through a previously reported CTA tracing method and registered into the VSP. Perforators were classified as primary or secondary based on whether the perforators were targeted for use in the final reconstructive plan. Perforator measurements obtained from the VSP were cross-referenced with intraoperatively obtained measurements of actual perforator locations to calculate accuracy, precision, NPV, PPV, sensitivity, and specificity of the CTA localization technique. RESULTS: Sixty consecutive subjects were enrolled in the study. A total of 141 perforators were identified preoperatively on CTA and 145 perforators were identified on operative exposure. One perforator identified on preoperative CTA was not identified on surgical exposure (false positive perforator). Six perforators were identified on operative exposure alone without recognition on preoperative CTA (false negative perforators). The accuracy of CTA perforator identification was 96.52%. Median precision of perforator localization was 0.3 cm (standard deviation 0.40) between CTA and operatively identified locations. PPV of the technique was 99.29% and NPV was 90.00%. CONCLUSION: The CTA localization technique for identifying and incorporating cutaneous perforator locations into VSP of osteocutaneous fibular free flaps is a reliable, accurate, and precise technique to employ in the modern paradigm of guided surgery for head and neck reconstruction.

Education Solutions to the Medical-Dental Divide.

Arbitrarily cordoning off the mouth from the rest of the body is the educational approach that, since 1840, has been responsible for the medical-dental schism that persists today, preventing oral health's integration with overall health. This divide has also thwarted oral disease prevention initiatives, access to services, and health equity. This article offers an educational plan for reunifying medicine and dentistry, which involves interprofessional education, dual degree training, integrating oral health into medical education, and integrated residency training.

Teledentistry in the management of a non-Hodgkin's lymphoma manifesting as a gingival swelling: A case report.

Oral cavity lymphomas constitute only 3% of all lymphomas in the general population but are the third most common oral malignancy. A 67-year-old female with a history of osteoporosis, Graves' disease and non-Hodgkin's lymphoma was referred to the Department of Dental Specialties with a chief complaint of persistent soft tissue swelling facial to the maxillary incisors of possible non-odontogenic origin. To expedite care, the patient was first seen via teledentistry and subsequently appointed for an in-person evaluation and treatment. Examination revealed 1-3 mm probing depths and a firm, non-tender, non-fluctuant mass in the facial soft tissues approximating teeth nos. 7-10. Biopsy of the affected area was performed. A diagnosis of recurrent follicle center cell lymphoma, a form of non-Hodgkin's lymphoma, was rendered. The patient was subsequently referred to the Oncology and Hematology team, followed for 6 weeks and remained symptom-free. This case underlies the importance of teledentistry to expedite care and manage patient expectations. Additionally, it also underscores the importance of microscopic examination of tissue samples from oral lesions that appear non-odontogenic in nature and reinforces the role of dentistry in uncovering the oral-systemic link.

Hypervascular mucoepidermoid caricinoma of the palate.

Salivary mucoepidermoid carcinoma is the most common malignant salivary gland tumor. Low or intermediate grade tumors are slow-growing and can be mistaken for benign lesions on both physical exam and imaging studies. We present a case of hypervascular mucoepidermoid carcinoma of the hard palate that was initially thought to represent a benign vascular lesion. To our knowledge, only two prior cases of hypervascular mucoepidermoid carcinoma have been previously reported. This is the first case showing the MRI features of this tumor and its temporal evolution on CT over several years. Our patient ultimately underwent angiographic tumor embolization so that her lesion could be safely biopsied without significant bleeding risk. We present this as a potential diagnostic pitfall and explain how the treatment for hypervascular mucoepidermoid carcinoma varies compared to conventional tumors.

The Medial Femoral Condyle Free Flap for Reconstruction of Recalcitrant Defects in the Head and Neck.

BACKGROUND: Small recalcitrant defects of the mandible and maxilla may be secondary to tumor, trauma, infection, and congenital origin. Vascularized bone grafting has been shown to effectively manage these defects; however, donor sites are limited. The vascularized medial femoral condyle (MFC) provides adequate cortical cancellous bone with the option of a skin island, consistent anatomy, and minimal donor site morbidity. This article outlines the use of the MFC flap for maxillomandibular reconstruction. METHODS: A retrospective chart review of patients who required segmental maxillomandibular reconstruction with the MFC flap was conducted. A total of 9 patients (5 men and 5 women) with an average age of 45.3 years were identified. The etiology of the defects, flap sizes, and postoperative outcomes were recorded. RESULTS: Three patients had osteoradionecrosis of the neomandible after irradiation of the free fibula reconstruction, 3 patients had defects after cancer extirpation (1 mandible, 2 maxillary), 1 patient had a maxillary defect from trauma, and 2 patients had a residual cleft palate defect. All defects failed initial treatment with nonvascularized bone grafts. The average dimensions of the MFC flaps were 1.2 × 2.5 × 4 cm. Two of 9 flaps included a skin island. Eight flaps survived completely, but 1 patient suffered from flap failure requiring debridement and resulted in an oroantral fistula. Four patients received endosseous dental implants. Average time to union was 6.7 months, and average time to implant was 6.75 months. The average follow-up time was 24.9 months. CONCLUSIONS: The MFC flap is useful in the reconstruction of small segmental maxillomandibular defects and for the salvage of a neomandible after osteoradionecrosis. The MFC flap provides a reliable platform for endosseous dental implants and serves as an alternative source of vascularized bone reconstruction in the head and neck.

Safety of Outpatient Procedural Sedation Administered by Oral and Maxillofacial Surgeons: The Mayo Clinic Experience in 17,634 Sedations (2004 to 2019).

PURPOSE: The safety of the team anesthesia model routinely used by the specialty of oral and maxillofacial surgery has recently been called into question. The purpose of this article is to measure the frequency of adverse anesthetic events related to ambulatory surgical procedures performed under intravenous (IV) sedation by the Division of Oral and Maxillofacial Surgery at the Mayo Clinic during a 15-year period using the team anesthesia model. MATERIALS AND METHODS: A retrospective cohort study was designed, and a sample of subjects identified undergoing IV sedation at Mayo Clinic from 2004 to 2019. The primary outcome variable of interest was the presence of anesthetic-related adverse events (AEs) consistent with the World Society of Intravenous Anesthesia International Sedation Task Force's intervention-based definitions of adverse anesthetic events. Additional covariates included patient age, gender, American Society of Anesthesiologists (ASA) score, type of surgical procedure performed, and the type/dosage of medications administered periprocedurally. Univariate logistic regression analysis was used to assess for associations between AEs and covariates. RESULTS: The study identified 17,634 sedations administered to 16,609 unique subjects. In 17,634 sedations, 16 (0.1%) AEs and no subject deaths (0%) were identified. There were no statistically significant associations between AEs and age (hazard ratio [HR], 0.4; 95% confidence interval [95% CI], 0.2 to 1.3; P = .13); gender (HR, 0.9; 95% CI, 0.3 to 2.5; P = .87); ASA 2 classification (HR, 1.6; 95% CI, 0.6 to 4.5; P = .33); ASA 3 classification (HR, 1.3; 95% CI, 0.1 to 22.0; P = .86), or types of IV sedation medications administered during the procedure: fentanyl (HR, 0.4; 95% CI, 0.02 to 6.3; P = .5); midazolam (HR, 1.0; 95% CI, 0.2 to 4.3; P = .98); propofol (HR, 1.0; 95% CI, 0.3 to 3.5; P = .99); or ketamine (HR, 1.0; 95% CI, 0.1 to 7.3; P = .97). CONCLUSIONS: The frequency of AEs (0.1%) and 0% mortality rate reported in this study demonstrate that the anesthesia team model used by oral and maxillofacial surgeons compares favorably to standardized intervention-based adverse anesthetic event outcomes reported by other nonanesthesiology specialties routinely performing outpatient procedural sedation.

Microvascular Reconstruction of Total Maxillary Avascular Necrosis as a Complication of Routine Orthognathic Surgery.

Severe complications and morbidity after orthognathic surgery are infrequently encountered and even more infrequently reported considering the extent to which this procedure is performed by surgeons within the specialty of maxillofacial surgery. Avascular necrosis of the maxilla after Le Fort I osteotomy is perhaps the most dreaded outcome of orthognathic surgery. However, it accounts for an extremely small subset of overall surgical complications. The reported risk factors associated with avascular maxillary necrosis include segmental osteotomies, vertical posterior impactions, large transverse expansions, anterior advancements exceeding 9 to 10 mm, an improper surgical technique, excessive soft tissue degloving of the maxilla, intraoperative hemorrhage, perforation or laceration of the palatal soft tissue pedicle, previous maxillary or palatal surgery, and other medical comorbidities. Although anecdotal cases of total maxillary necrosis after orthognathic surgery have been alluded to within the specialty as a whole, to the best of our knowledge, no previous studies have reported total maxillary necrosis occurring after routine orthognathic surgery. We have presented a truly unique case of total maxillary avascular necrosis that occurred after standard 1-piece Le Fort I osteotomy in a patient without medical or surgical risk factors for the complication either known preoperatively or identified postoperatively. The resultant maxillary defect from total avascular necrosis was comprehensively treated with surgical debridement of the nonviable maxilla, osteocutaneous fibular free flap reconstruction, staged endosseous implant reconstruction of the neomaxilla, and comprehensive prosthodontic rehabilitation.