Effects of Pre-Operative Risk Factors on Intensive Care Unit Length of Stay (ICU-LOS) in Major Oral and Maxillofacial Cancer Surgery.

OBJECTIVE: This study aimed to investigate the effect of certain pre-operative parameters directly on the post-operative intensive care unit (ICU)-length of stay (LOS), in order to identify at-risk patients that are expected to need prolonged intensive care management post-operatively. MATERIAL AND METHODS: Retrospectively, patients managed in an ICU after undergoing major oral and maxillofacial surgery were analyzed. Inclusion criteria entailed: age 18-90 years, major primary oral cancer surgery including tumor resection, neck dissection and microvascular free flap reconstruction, minimum operation time of 8 h. Exclusion criteria were: benign/borderline tumors, primary radiation, other defect reconstruction than microvascular, treatment at other centers. Separate parameters used within the clinical routine were set in correlation with ICU-LOS, by applying single testing calculations (t-tests, variance analysis, correlation coefficients, effect sizes) and a valid univariate linear regression model. The primary outcome of interest was ICU-LOS. RESULTS: This study included a homogenous cohort of 122 patients. Mean surgery time was 11.4 (±2.2) h, mean ICU-LOS was 3.6 (±2.6) days. Patients with pre-operative renal dysfunction (p < 0.001), peripheral vascular disease-PVD (p = 0.01), increasing heart failure-NYHA stage categories (p = 0.009) and higher-grade categories of post-operative complications (p = 0.023) were identified as at-risk patients for a significantly prolonged post-operative ICU-LOS. CONCLUSIONS: At-risk patients are prone to need a significantly longer ICU-LOS than others. These patients are those with pre-operative severe renal dysfunction, PVD and/or high NYHA stage categories. Confounding parameters that contribute to a prolonged ICU-LOS in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.

Complex Mandibular Reconstruction for Head and Neck Squamous Cell Carcinoma-The Ongoing Challenge in Reconstruction and Rehabilitation.

Large head and neck squamous cell carcinoma (HNSCC) tumors affecting the mandible require a versatile reconstruction to maintain form, function, and quality of life. Large defect reconstruction of soft and hard tissue in the head and neck necessitates, at best, one vascular system including various tissues by large dimensions. The subscapular flap system seems to meet these standards. A retrospective study was conducted focusing on clinical data, including an analysis of the quality of life with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires, (QLQ-C30 and QLQ-H&N43). A total of 154 patients (122 males, 32 females; age range: 31-71 years, mean: 54.5 years) treated at our department from 1983 through to 2019 were included. Of the subscapular system free flaps (SFFs), 147 were based on the angular artery branch of the thoracodorsal pedicle (95.45%), and the remaining seven cases (4.55%) were lateral scapular border flaps. Mean mandible defect length was 7.3 cm. The mean skin paddle dimension was 86.8 cm2. The most common recipient artery was the thyroid superior artery (79.22%). Major postoperative complications occurred in 13 patients (8.44%). This study confirms that SFFs offer excellent soft and hard tissue quality, component independence, a large arc of rotation length, and a large gauge of pedicle, making them the gold standard for the reconstruction of large composite defects of mandibular HNSCC tumors.

Free thoracodorsal, perforator-scapular flap based on the angular artery (TDAP-Scap-aa): Clinical experiences and description of a novel technique for single flap reconstruction of extensive oromandibular defects.

PURPOSE: The reconstruction of oromandibular defects can be challenging, particularly when considerable amounts of bone and soft tissues are lost. In such cases, the use of a single flap may be unsatisfactory and a concomitant free flap is needed. Here we present a chimeric, thoracodorsal perforator-scapular free flap based on the angular artery of the subscapular system (TDAP-Scap-aa) as an alternative technique for single flap reconstruction of extensive oromandibular defects. MATERIALS AND METHODS: The authors studied patients who underwent reconstructions of extensive oromandibular defects with a TDAP-Scap-aa free flap. The operative technique and the clinical experiences are described. Postoperatively, surgical complications were classified with the Clavien-Dindo Classification. RESULTS: Five male patients (59.4 ± 8.8 years) were treated with the TDAP-Scap-aa. Average sizes for harvested hard and soft tissue components, which are both included in the flap and completely independently from each other, were 10.4 ± 1.5 cm of bone length, 2.6 ± 0.3 cm of bone height, 11.6 ± 4.8 cm of skin paddle length and 8.4 ± 1.7 cm of skin paddle width. The overall mean operation time (cut-suture) was 14.6 ± 0.9 h. The postoperative follow-up was 6 months. No complications requiring surgical treatment as well as donor site nerve damages were observed. CONCLUSIONS: In comparison to other double free flaps, the TDAP-Scap-aa offers several advantages such as higher amounts of hard and soft tissues without prolonged operation times, and provides satisfying aesthetic outcomes and little donor site morbidity due to the preservation of muscle and nerve structures. Therefore, the TDAP-Scap-aa constitutes a clinically reliable alternative in extensive oromandibular defect reconstruction.

Clinical experience with a novel structure designed bridging plate system for segmental mandibular reconstruction: The TriLock bridging plate.

The innovative TriLock Bridging Plate System (Medartis AG, Switzerland) was developed to reduce common complications related to conventional mandibular reconstruction plates. The novelties regarding the plating system concern the cross-strut structure in the centerpiece, the bendable side elements and the reduction of the plate's thickness to 2.0 mm 4 different models are available, which cover lateral and central segmental mandibular defects. The plating system has only been introduced at selected maxillofacial units so far and clinical assessment is still lacking. Thus, the aim of the study was to analyze the novel Bridging Plate system in terms of its clinical applicability, rate of trimming and postoperative outcomes in a first investigation over 6 months. The study includes 25 patients with segmental mandibular resection, who underwent reconstruction with TriLock Bridging Plates. According to the assessment parameters, excellent clinical applicability was stated in 48%. The overall trimming rate was found to be 88%. Mostly adaptions to the distal bendable elements of lateral plates were performed. The occurrence of postoperative complications was 16%. Plate fracture occurred in 4%. With reference to the results, the novel plating system represents a viable method for segmental mandibular reconstruction, however, further evaluation is needed, for a more detailed analyzation.

Assessment of tumor margins in head and neck cancer using a 3D-navigation system based on PET/CT image-fusion - A pilot study.

OBJECTIVES: Determination of tumor margins in patients with squamous cell carcinoma of the head and neck (SCCHN) is mostly based on preoperative magnetic resonance imaging (MRI) or computed tomography scans (CT). Local recurrence of disease is often correlated with the presence of positive resection margins after surgical treatment. Positron emission tomography/computed tomography (PET/CT) imaging plays a crucial role in the assessment of patients with SCCHN. The purpose of this study was to determine whether PET/CT could predict tumor extension. METHODS: In 12 patients who underwent surgical treatment of primary SCCHN (Stage III-IV) F18-FDG PET/CT image-fusion was performed on a 3D navigation-system based workstation. Image-guided needle biopsies were obtained from four different, color-coded metabolic areas within the tumor. The histopathological findings were correlated with findings on corresponding PET/CT scans. RESULTS: 81.3% of biopsies from the central area were positive. Specimens taken from the outer metabolic zone were positive in 66.7% of the patients. The highest incidence of positive biopsies was found in the zone adjacent to the outermost area. There was a statistically significant difference in positive tumor histopathology when comparing the various metabolic zones (p = 0.03). CONCLUSION: Exact determination of tumor is an important research topic, although results remain controversial. The results of this study suggest that in some cases PET scans may overestimate tumor extension.

Osteosynthesis using cannulated headless Herbert screws in mandibular angle fracture treatment: A new approach?

INTRODUCTION: Fractures of the mandibular angle are a common type of facial skull fracture. Although operative treatment includes a wide range of fixation techniques, a definite gold standard method has yet to be established. Headless, cannulated Herbert screws, often used in many forms of minimally invasive trauma surgery, provide functional and stable fracture fixation. MATERIALS AND METHODS: In a prospective, double-randomised, controlled, parallel-group - designed, in vitro trial, the biomechanical behaviour of the Herbert bone screw system was compared to that of a conventional locking plate system in 40 mandibular angle fractures of human mandible cadaver phantoms. RESULTS: The mean stress values were 250 (±68.0) N in the plate subgroup and 200 (±61.0) N in the screw subgroup. The respective mean strain values were 7.90 (±2.7) mm and 6.90 (±2.2) mm, and the respective mean stiffness were values 1.10 (±0.61) N/m and 0.78 (±0.40) N/m. The differences in the results obtained using the two treatments were not significant (p = 0.55). CONCLUSIONS: The biomechanical behaviour of the two fixation systems within the tested loads did not significantly differ with respect to postoperative parameters clinically relevant in osteosynthesis. Both systems met the mandibular angle assessment criterion, which is considered to be sufficient for clinical use. The results indicate the potential clinical utility of these two systems, and recommend further testing.

Intermuscular pterygoid-temporal abscess following inferior alveolar nerve block anesthesia-A computer tomography based navigated surgical intervention: Case report and review.

Inferior alveolar nerve block (IANB) anesthesia is a common local anesthetic procedure. Although IANB anesthesia is known for its safety, complications can still occur. Today immediately or delayed occurring disorders following IANB anesthesia and their treatment are well-recognized. We present a case of a patient who developed a symptomatic abscess in the pterygoid region as a result of several inferior alveolar nerve injections. Clinical symptoms included diffuse pain, reduced mouth opening and jaw's hypomobility and were persistent under a first step conservative treatment. Since image-based navigated interventions have gained in importance and are used for various procedures a navigated surgical intervention was initiated as a second step therapy. Thus precise, atraumatic surgical intervention was performed by an optical tracking system in a difficult anatomical region. A symptomatic abscess was treated by a computed tomography-based navigated surgical intervention at our department. Advantages and disadvantages of this treatment strategy are evaluated.

Minimal invasive biopsy of intraconal expansion by PET/CT/MRI image-guided navigation: a new method.

UNLABELLED: Intraorbital tumours are often undetected for a long period and may lead to compression of the optic nerve and loss of vision. Although CT, MRI's and ultrasound can help in determining the probable diagnosis, most orbital tumours are only diagnosed by surgical biopsy. In intraconal lesions this may prove especially difficult as the expansions are situated next to sensitive anatomical structures (eye bulb, optic nerve). In search of a minimally invasive access to the intraconal region, we describe a method of a three-dimensional, image-guided biopsy of orbital tumours using a combined technique of hardware fusion between (18)F-FDG Positron Emission Tomography ((18)F-FDG PET), magnetic resonance imaging (MRI) and Computed Tomography (CT). METHOD AND MATERIAL: We present 6 patients with a total of 7 intraorbital lesions, all of them suffering from diplopia and/or exophthalmos. There were 3 female and 3 male patients. The patients age ranged from 20 to 75 years. One of the patients showed beginning loss of vision. Another of the patients had lesions in both orbits. The decision to obtain image-guided needle biopsies for treatment planning was discussed and decided at an interdisciplinary board comprising other sub-specialities (ophthalmology, neurosurgery, maxillofacial surgery, ENT, plastic surgery). All patients underwent 3D imaging preoperatively ((18)F-FDG PET/CT or (18)F-FDG PET/CT plus MRI). Data was transferred to 3D navigation system. Access to the lesions was planned preoperatively on a workstation monitor. Biopsy-needles were then calibrated intraoperatively and all patients underwent three-dimensional image-guided needle biopsies under general anaesthesia. RESULTS: 7 biopsies were performed. The histologic subtype was idiopathic orbital inflammation in 2 lesions, lymphoma in 2, Merkel cell carcinoma in 1, hamartoma in 1 and 1 malignant melanoma. The different pathologies were subsequently treated in consideration of the actual state of the art. In cases where surgical removal of the lesion was performed the histological diagnosis was confirmed in all cases. CONCLUSION: There is a wide range of possible treatment modalities for orbital tumours depending on the nature of the lesion. Histological diagnosis is mandatory to select the proper management and operation. The presented method allows minimal-invasive biopsy even in deep intraconal lesions, enabling the surgeon to spare critical anatomical structures. Vascular lesions such as cavernous haemangioma, tumour of the lacrimal gland or dermoid cysts present a contraindication and have to be excluded.

The mandibular symphysis as a starting point for the occlusal-level reconstruction of panfacial fractures with bicondylar fractures and interruption of the maxillary and mandibular arches: report of two cases.

Panfacial fractures represent a challenge, even for experienced maxillofacial surgeons, because all references for reconstructing the facial skeleton are missing. Logical reconstructive sequencing based on a clear understanding of the correlation between projection and the widths and lengths of facial subunits should enable the surgeon to achieve correct realignment of the bony framework of the face and to prevent late deformity and functional impairment. Reconstruction is particularly challenging in patients presenting with concomitant fractures at the Le Fort I level and affecting the palate, condyles, and mandibular symphysis. In cases without bony loss and sufficient dentition, we believe that accurate fixation of the mandibular symphysis can represent the starting point of a reconstructive sequence that allows successful reconstruction at the Le Fort I level. Two patients were treated in our department by reconstruction starting in the occlusal area through repair of the mandibular symphysis. Both patients considered the postoperative facial shape and profile to be satisfactory and comparable to the pre-injury situation.

Transformation of a vascularised iliac crest or scapula bone to a pedicled osteomuscular transplant for reconstruction of distant defects in the head and neck region: a new method of transforming two island flaps to one longer island flap.

OBJECTIVE: Bone defects in the maxillofacial region after ablative surgery require reconstructive surgery, usually using microvascular free flaps. This paper presents a new method of reconstructing extensive defects in patients not suitable for microvascular surgery using prefabrication of a vascularised osteomuscular flap from the scapula or iliac crest bone. METHODS: Three patients who were treated with this new technique are presented. Two patients (one mandibular defect and one defect in the maxillary region) received prefabricated osteomuscular flaps from the iliac crest bone using the latissimus dorsi muscle as a pedicle. One patient also presenting a mandibular defect after tumour surgery received a scapula transplant for reconstruction of the defect using the pectoralis major muscle as pedicle. RESULTS: In all three cases vital bone could be transplanted. The pedicle was strainless in all three cases. Minor bone loss could be seen initially only in one case. The results are stable now and one patient received dental implants for later prosthetic treatment. CONCLUSION: The presented two-step surgery provides an excellent method for reconstruction of bony defects in the maxillofacial region in patients where microvascular surgery is not possible due to reduced state of health or lack of recipient vessels.

The influence of the Tübingen soft palate plate and early cleft closure on the nasopharyngeal airway for the management of airway obstruction in an infant with Pierre Robin sequence: A case report.

INTRODUCTION: A Tübingen palate plate and early cleft closure for successful airway management is described in a newborn with Pierre Robin sequence. PRESENTATION OF CASE: A three-day-old newborn with an acute airway obstruction underwent primary treatment with a Tübingen soft palate plate. DISCUSSION: After stabilization of the airway, the cleft soft palate was closed after three months. CONCLUSION: The Tübingen soft palate plate proved to be a very satisfactory treatment for the infant.

Perforating the polydioxanone sheet: avoiding intraorbital hematoma after open treatment of orbital floor fractures.

The surgical treatment of orbital floor fracture, a common facial injury, is not a risk-free procedure. Complications after orbital surgery can include infection, implant migration, mydriasis, epiphora, persistent diplopia, enophthalmos, infraorbital numbness, retrobulbar hemorrhage, and blindness. Blindness has been ascribed to retrobulbar hematoma in almost 50% of cases. In our experience, blood collection above the polydioxanone sheet after the treatment of orbital floor fracture can be caused by the tight adhesion of the sheet to the bony edges of the fracture. Here, we present a simple procedure to avoid this potentially dangerous complication.

Three dimensional comparative measurement of polyurethane milled skull models based on CT and MRI data sets.

OBJECTIVE: Due to the increase in the number and complexity of surgical procedures, available to craniomaxillofacial surgeons, allied to the rapid progress of technological developments, the use and production of 3D models has become important, especially for planning complex cases. The radiation exposure of additional CT based examinations is always subject to debate, so the feasibility of producing 3D models for surgical planning based on MRI imaging has been raised. MATERIAL AND METHODS: 12 male and 3 female patients (n=15) between 47 and 84 years of age (mean age=65) were selected in a prospective study. Both magnetic resonance and computed tomography data sets of the facial bones were collected. Two milled models per patient were prepared: one based on the MRI scan and one based on the CT scan. The milled models were compared in a coordinative surveying procedure within 7 representative distances using a tentative measurement method. RESULTS: Difference values between CT and MRI based models ranged from 0.1mm to 5.9 mm. On average MRI based models were smaller by 0.381 mm (SD 1.176 mm) than those on CT based. The accuracy of models based on MRI data was similar to those based on CT data. MRI based three dimensional milled models provide precise structure accuracy.

Primary osteomyelitis of the mandibular condyle--a rare case.

Osteomyelitis is an inflammatory process involving cortical and cancellous bone. In the maxillofacial region, the mandible is the most frequently affected bone. In the vast majority, a bacterial focus can be identified as the origin of the disease. Chronic progress of the disease may lead to destruction of mandibular bony structures, resulting in mild or severe loss of function if no adequate treatment is applied. In some cases, the etiology of osteomyelitis remains unclear. Review of literature revealed two cases of necrosis of the mandibular condyle caused by primary osteomyelitis. We report a case of primary osteomyelitis of the mandibular condyle in a 51-year-old woman. Radiography revealed an almost complete destruction of the right mandibular condyle, resulting in malocclusion. The patient was treated with long-term antibiotics. No surgical intervention had been performed. After remission of the symptoms, the malocclusion had been corrected prosthetically. After a 4-year follow up period, the occlusion is stabile and there are no signs of progression of the disease.

SAPHO syndrome with affection of the mandible: diagnosis, treatment, and review of literature.

The synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare syndrome of unknown etiology. Involvement of the mandible is found in almost 10% of cases. In the literature, conservative treatment is recommended most often, because decortication and partial resection are found to be ineffective and of temporary profit. We report a case of SAPHO syndrome in a 44-year-old women with unilateral hyperostosis of the mandible and massive painful swelling of the surrounding soft tissues. Owing to facial disfiguration and pain, resection of the affected bone followed by immediate reconstruction with a microvascular iliac crest flap were performed. The aim of this paper was to present the necessity of surgical intervention in SAPHO syndrome of the mandible in cases of esthetic and functional limitation.

Intraoperative control of resection margins in advanced head and neck cancer using a 3D-navigation system based on PET/CT image fusion.

Local recurrent of disease in advanced carcinomas of the head and neck is strongly correlated with the presence of positive or close resection margins after operative treatment. The purpose of this study is to present a new method of assessing resection margins intraoperatively using image-guided surgery based on positron emission tomography/computed tomography (PET/CT) image fusion. In 6 patients who underwent surgical treatment of head and neck stage for T4a-T4b carcinomas PET/CT image fusion was done on the workstation of a 3D-navigation system. Intraoperative image-guided navigation of the defect following surgical ablation of the tumour was performed in every patient. Intraoperative navigation of the ablative defect showed an unsafe resection margin in 4 patients. In three of these patients additional image-guided resection allowed local control of the tumour to be achieved. In one patient additional resection was not possible due to skull base invasion. The histopathological exam of the four tumour specimens confirmed positive or close resection margins. The current results suggest that intraoperative control of the surgical margins using a 3D-navigation system based on PET/CT image fusion can be a useful tool to assess and improve local control in advanced cancer of the head and neck.

Dentoalveolar changes after surgically assisted maxillary expansion: a three-dimensional evaluation.

OBJECTIVES: Surgically assisted rapid palatal expansion (SARPE) is a common procedure to correct maxillary transverse deficiency of >5 mm in patients with closed midpalatal suture. The aim of this study was to three-dimensionally analyze skeletal and dentoalveolar changes after SARPE. STUDY DESIGN: Eighteen mature patients (mean age 26 years) with a palatal transverse deficiency underwent SARPE. The surgical procedure consisted of a lateral osteotomy combined with an interradicular osteotomy between the roots of the upper central incisors. Measuring points were defined on teeth as well as facial skeleton. Computerized tomography scans were performed preoperatively and immediately after the expansion period. RESULTS: Changes of the dentoalveolar and maxillofacial complex were analyzed. CONCLUSIONS: Bilateral osteotomy combined with a sagittal osteotomy between the roots of the upper central incisors is a safe method of surgically assisted maxillary expansion. The amount of dentoalveolar tipping was smaller than reported in literature. The expansion was mostly achieved by maxillary expansion.

Three-dimensional evaluation of secondary alveolar bone grafting using a 3D- navigation system based on computed tomography: a two-year follow-up.

Secondary bone grafting is widely used in the closure of oronasal fistulas and reconstruction of maxillary defects. It often fails from lack of physiological stress or inadequate covering of the transplanted bone with surrounding tissue. The aim of this study was to assess the exact bone volume after secondary alveolar bone grafting over a period of two years using a navigation system based on computed tomography (CT). We examined 20 patients with complete unilateral cleft lip and palate (UCLP) who had been treated by secondary bone grafting during late mixed dentition. CT scans of the upper jaw were taken immediately preoperatively, and 1 and 2 years postoperatively. The cleft defects and the bony bridges were marked on the monitor. The software of the navigation system created three-dimensional models showing the amount and site of bone resorption. The mean bone loss after one and two years was 51% and 52%, respectively. There was a significant correlation between the size of the cleft and the success of the alveolar bone grafting (p=0.01). When the teeth adjacent to the cleft were missing the amount of bone lost was 95% after the first year. There was also significant bone loss in the buccopalatine direction. Three-dimensional reconstruction of the bony bridges with a navigation system accurately shows the amount of bone within the cleft site. This method is definitely superior to conventional two-dimensional orthopantomography.

The use of a 3D navigation system in the treatment of mandibular angle fractures by minimally invasive insertion of Herbert screws for osteosynthesis.

OBJECTIVE: We present a phantom study evaluating the use of a three-dimensional navigation system in the treatment of mandibular angle fractures with traction screw osteosynthesis. The insertion of the so-called "Herbert bone screw" was tested on phantom models of the mandible. MATERIALS AND METHODS: A total of ten synthetic models of the lower jaw were prepared with navigational markers. After inducing artificial fractures in the mandibular angle region, axial CT scans of the models with 1.5-mm slice thickness were performed. The CT data was then transferred to the workstation of the navigation system (STN-Zeiss Navigation System, Aalen, Germany). The access to the fracture and the drilling depth were planned preoperatively on the computer monitor using the software. After calibration of the drill wire, the cannulated traction screws were inserted under three-dimensionally directed computer navigation. RESULTS: The inferior alveolar nerve of the model was spared in all ten cases. Cortical perforation occurred twice in the ascending lower jaw branch, but secure anchorage of the screw was still possible in every case. CONCLUSION: The navigation system is a helpful visualization tool that can prevent damage to the inferior alveolar nerve and enable secure anchoring of the traction screw centrally in the cortical bone without causing perforation. This computer guided insertion method enables stable fixation of the fracture via minimally invasive surgery. Positioning of a traction screw with additional tools belonging to the screw system (drill wire) is demonstrated.