Sentinel lymph node biopsy versus observation in high-risk cutaneous squamous cell carcinoma in immunosuppressed and immunocompetent patients: An inverse probability of treatment weighting study.

BACKGROUND: The survival benefit of sentinel lymph node biopsy (SLNB) in immunocompetent and immunosuppressed patients with high-risk cutaneous squamous cell carcinoma (cSCC) has not been established. OBJECTIVE: To determine whether SLNB improves disease-specific survival (DSS) in high-risk cSCC. Secondary objectives were to analyse disease-free survival, nodal recurrence-free survival and overall survival (OS). METHODS: Multicentre, retrospective, observational cohort study comparing survival outcomes in immunosuppressed and immunocompetent patients treated with SLNB or watchful waiting. Inverse probability of treatment weighting was used to adjust for possible confounding effects. RESULTS: We studied 638 tumours in immunocompetent patients (SLNB n = 42, observation n = 596) and 173 tumours in immunosuppressed patients (SLNB n = 28, observation n = 145). Overall, SLNB was positive in 15.7% of tumours. SLNB was associated with a reduced risk of nodal recurrence (NR) (hazard ratio [HR], 0.05 [95% CI, 0.01-0.43]; p = 0.006), disease specific mortality (HR, 0.17 [95% CI, 0.04-0.72]; p = 0.016) and all-cause mortality (HR, 0.33 [95% CI, 0.15-0.71]; p = 0.004) only in immunocompetent patients. CONCLUSIONS: SLNB was associated with improvements in NR, DSS and OS in immunocompetent but not in immunosuppressed patients with high-risk cSCC.

Clinical utility of contact heat evoked potentials (CHEPs) in a case of mentalis nerve lesion.

OBJECTIVE: Nociceptive evoked potentials are still infrequently used in electrodiagnostic studies of single patients. We report a case in which the results of contact heat evoked potentials (CHEPs) provided unique information for the diagnosis. METHODS: After biopsy for a local cementoma, a 21-year-old woman presented with neuropathic pain in the distribution of her left mentalis nerve. A CT scan showed a well circumscribed lesion near the mentalis nerve groove. We examined brainstem reflexes and evoked potentials conveyed through the mentalis nerve. RESULTS: Blink reflex responses recorded from the orbicularis oculi, jaw jerk and masseteric silent period recorded from the masseter muscles and long latency evoked potentials recorded from Cz to electrical stimulation of the mentalis nerve were all within normal values, with no differences between sides. However, CHEPs, recorded from Cz to thermoalgesic stimulation of the left mentalis area were decreased to approximately 1/3 their size in comparison to stimulation to the unaffected side. CONCLUSION: While the patient reported symptoms and had neuroimaging signs of mentalis neuropathy, the sole electrophysiological abnormality identified was that of CHEPs, which specifically test small, unmyelinated fibers. SIGNIFICANCE: Nociceptive evoked potentials can provide unique information on damage of small nerve fibers in specific cases.

Immediately loaded zygomatic implants vs conventional dental implants in augmented atrophic maxillae: 1-year post-loading results from a multicentre randomised controlled trial.

PURPOSE: To compare the clinical outcome of immediately loaded cross-arch maxillary prostheses supported by zygomatic implants vs conventional implants placed in augmented bone. MATERIALS AND METHODS: In total, 71 edentulous patients with severely atrophic maxillas without sufficient bone volumes for placing dental implants, or when it was possible to place only two implants in the anterior area (minimal diameter 3.5 mm and length of 8 mm) and less than 4 mm of bone height subantrally, were randomised according to a parallel group design to receive zygomatic implants (35 patients) to be loaded immediately vs grafting with a xenograft, followed after 6 months of graft consolidation by placement of six to eight conventional dental implants submerged for 4 months (36 patients). For immediate loading, zygomatic implants had to be inserted with an insertion torque superior to 40 Ncm. Screw-retained metal reinforced acrylic provisional prostheses were provided, to be replaced by definitive Procera Implant Bridge Titanium prostheses (Nobel Biocare, Göteborg, Sweden), with ceramic or acrylic veneer materials 4 months after initial loading. Outcome measures were: prosthesis, implant and augmentation failures, any complications, quality of life (OHIP-14), patients' number of days with total or partial impaired activity, time to function and number of dental visits, assessed by independent assessors. Patients were followed up to 1 year after loading. RESULTS: No augmentation procedure failed. Five patients dropped out from the augmentation group. Six prostheses could not be delivered or failed in the augmentation group vs one prosthesis in the zygomatic group, the difference being statistically significant (difference in proportions = -16.5%; P = 0.045; 95% CI: -0.34 to -0.01). Eight patients lost 35 implants in the augmentation group vs two patients who lost four zygomatic implants, the difference being statistically significant (difference in proportions = -20.1%; P = 0.037; 95% CI: -0.38 to -0.02). A total of 14 augmented patients were affected by 22 complications, vs 28 zygomatic patients (40 complications), the difference being statistically significant (difference in proportions = 34.8%; P = 0.005; 95% CI: 0.12 to 0.54). The 1-year OHIP-14 score was 3.93 ± 5.86 for augmented patients and 3.97 ± 4.32 for zygomatic patients with no statistically significant differences between groups (mean difference = 0.04; 95% CI: -2.56 to 2.65; P = 0.747). Both groups had significantly improved OHIP-14 scores from before rehabilitation (P < 0.001 for both augmented and zygomatic patients). On average, the number of days of total infirmity was 7.42 ± 3.17 for the augmented group and 7.17 ± 1.96 for the zygomatic group, the difference not being statistically significant (mean difference = -0.25; 95% CI: -1.52 to 1.02; P = 0.692). The number of days of partial infirmity were on average 14.24 ± 4.64 for the augmented group and 12.17 ± 3.82 for the zygomatic group, the difference being statistically significant (mean difference = -2.07; 95% CI: -4.12 to -0.02; P = 0.048). The mean number of days that needed to have a functional prosthesis was 444.32 ± 207.86 for augmented patients and 1.34 ± 2.27 for zygomatic patients, the difference being statistically significant (mean difference = -442.98; 95% CI: -513.10 to -372.86; P < 0.001). The average number of dental visits was 19.72 ± 12.22 for augmented patients and 15.12 ± 5.76 for zygomatic patients, the difference not being statistically significant (mean difference = -4.61; 95% CI: -9.31 to 0.92; P = 0.055). CONCLUSIONS: Preliminary 1-year post-loading data suggest that immediately loaded zygomatic implants were associated with statistically significantly fewer prosthetic failures (one vs six patients), implant failures (two vs eight patients) and time needed to functional loading (1.3 days vs 444.3 days) when compared to augmentation procedures and conventionally loaded dental implants. Even if more complications were reported for zygomatic implants, they proved to be a better rehabilitation modality for severely atrophic maxillae. Long-term data are absolutely needed to confirm or dispute these preliminary results.

Immediately loaded zygomatic implants vs conventional dental implants in augmented atrophic maxillae: 4 months post-loading results from a multicentre randomised controlled trial.

PURPOSE: To compare the clinical outcome of immediately loaded cross-arch maxillary prostheses supported by zygomatic implants vs conventional implants placed in augmented bone. MATERIALS AND METHODS: A total of 71 edentulous patients with severely atrophic maxillas, who did not have sufficient bone volume to place dental implants or when it was possible to place only two implants in the front area (minimal diameter 3.5 mm and length of 8 mm) and less than 4.0 mm of bone height subantrally, were randomised according to a parallel group design. They (35 patients) received zygomatic implants to be loaded immediately vs grafting with a xenograft, followed, after 6 months of graft consolidation, by the placement of six to eight conventional dental implants, submerged for 4 months (36 patients). To be loaded immediately, zygomatic implants had to be inserted with an insertion torque superior to 40 Ncm. Screw-retained, metal-reinforced, acrylic provisional prostheses were provided to be replaced by definitive Procera Implant Bridge Titanium prostheses (Nobel Biocare, Göteborg, Sweden) with ceramic or acrylic veneer materials 4 months after initial loading. Outcome measures were: prosthesis, implant and augmentation failures, any complications, quality of life (OHIP-14), the number of days that patients experienced total or partial impaired activity, time to function, and number of dental visits, assessed by independent assessors. Patients were followed up to 4 months after loading. RESULTS: No augmentation procedure failed. Three patients dropped out from the augmentation group. Six prostheses could not be delivered or failed in the augmentation group vs one prosthesis in the zygomatic group, the difference being statistically significant (difference in proportions = 15.32%; P = 0.04; 95% CI: 0.23 to 31.7). Eight patients lost 35 implants in the augmentation group vs three implants in one patient from the zygomatic group, the difference being statistically significant (difference in proportions = 21.38%; P = 0.001; 95% CI: 3.53 to 39.61). In total, 14 augmented patients were affected by 20 complications vs 26 zygomatic patients (35 complications), the difference being statistically significant (difference in proportions = 31.87%; P = 0.008; 95% CI: 6.48 to 53.37). The OHIP-14 score was 3.68 ± 5.41 for augmented patients and 4.97 ± 5.79 for zygomatic patients, with no statistically significant differences between groups (mean difference = 1.29; 95%CI -1.60 to 4.18; P = 0.439). Both groups had significantly improved OHIP-14 scores from before rehabilitation (P < 0.001 for both augmented and zygomatic patients). The number of days of total infirmity was, on average, 7.42 ± 3.17 for the augmented group and 7.17 ± 1.96 for the zygomatic group, the difference not being statistically significant (mean difference = -0.25; 95% CI: -1.52 to 1.02; P = 0.692). Days of partial infirmity were on average 14.24 ± 4.64 for the augmented group and 12.17 ± 3.82 for the zygomatic group, the difference being statistically significant (mean difference = -2.07; 95% CI: -4.12 to -0.02; P = 0.048). The mean number of days to have a functional prosthesis was 444.32 ± 207.86 for augmented patients and 1.34 ± 2.27 for zygomatic patients, the difference being statistically significant (mean difference = -442.9; 95% CI: -513.10 to -372.86; P < 0.001). The average number of dental visits was 16.79 ± 10.88 for augmented patients and 12.58 ± 5.21 for zygomatic patients, the difference not being statistically significant (mean difference = -4.21; 95% CI -8.48 to 0.06; P = 0.053). CONCLUSIONS: Preliminary 4-months post-loading data suggest zygomatic implants were associated with statistically significantly less prosthetic (one vs six patients) and implant failures (one patient lost three implants versus 35 implants in eight patients) as well as time needed to functional loading (1.3 days vs 444.3 days) when compared with augmentation procedures and conventionally loaded dental implants. Even if more complications were reported for zygomatic implants, which were solved spontaneously or could be handled, zygomatic implants proved to be a better rehabilitation modality for severely atrophic maxillae. Long-term data are essential to confirm or dispute these preliminary results. Conflict of interest statement: This study was originally supported by Nobel Biocare, the manufacturer of the implants, and the provisional and definitive prosthetic components used in this study, which were provided free for the patients. However, before any results were known, Nobel Biocare withdrew the financial support and recruitment had to be stopped. Tecnoss (Giaveno, Torino, Italy) kindly donated the bone substitutes and the membranes, whereas Global D (Brignais, France) donated the osteosynthesis screws. Data property belonged to the authors and by no means did the manufacturers interfere with the publication of the results.

Surgical Repositioning of the Premaxilla Using a Minimally Invasive Endonasal Approach.

OBJECTIVE: The aim of this study was to evaluate a technique for the surgical repositioning of the premaxilla using a minimally invasive endonasal approach. DESIGN: Retrospective review of clinical records. SETTING: Tertiary care, University Hospital, pediatric maxillofacial surgery unit. PATIENTS: Twenty-one patients (12 boys and 9 girls), ages ranging from 6 to 21 years, with BCLP+A and premaxillary malposition (PM). INTERVENTIONS: Surgical repositioning of the premaxilla (SRP) using a minimally invasive endonasal approach, from November 2007 to November 2015. MAIN OUTCOME MEASURES: Achieving maxillary arch alignment and premaxillary stability was defined as treatment success. Intraoperative and postoperative complications were also recorded. RESULTS: In all cases (100%), the treatment was successful either at first surgery or after reoperation. Two patients (9.5%) were reoperated-one due to premaxillary instability and one due to PM relapse. There were no perioperative complications. CONCLUSIONS: SRP using a minimally invasive endonasal approach is a safe and effective technique that levels and aligns the maxillary arch in preparation for SABG, which minimizes the risk of wound infection and premaxillary vascular compromise. The endonasal approach improves tissue quality of the mucoperiosteal flaps when performing the SABG procedure. Further prospective studies are needed to elucidate the best protocols and techniques for the management of PM in patients with BCLP+ A.

SPECT-CT and intraoperative portable gamma-camera detection protocol for sentinel lymph node biopsy in oral cavity squamous cell carcinoma.

OBJECTIVE: The aim of this study was to evaluate a multimodality approach to sentinel lymph node biopsy (SLNB) detection with lymphoscintigraphy and single-photon emission computed tomography (SPECT)/computed tomography (CT). When combined with intraoperative imaging by a portable gamma camera (PGC), improved SLNB accuracy and detection rate may result. MATERIAL AND METHODS: A total of 42 patients selected for SLNB in node-negative T1 and T2 oral squamous cell carcinoma were retrospectively analyzed. The detection protocol consisted of preoperative lymphoscintigraphy and SPECT/CT performed the day before surgery. Intraoperative sentinel lymph node (SLN) detection was done with the aid of a PGC in association with hand-held gamma probe. RESULTS: All SLN detected in the preoperative study could be harvested except for one case. A total of 131 SLN were resected. This number was higher than the SLN depicted on lymphoscintigraphy (119 SLNs) and SPECT/CT (123 SLNs). Sublingual SLNs were observed in two cases (4.76%). These SLNs were detected by SPECT/CT but not by lymphoscintigraphy. Five (3.8%) additional SLNs not previously visualized on lymphoscintigraphy or on SPECT/CT were detected intraoperatively with the aid of the PGC. Positive SLNs were detected in eight cases (19%). Micrometastases were detected in five cases (62%) and macrometastases in three cases (38%). CONCLUSION: The SLNB detection protocol described contributes to more accurate study and detection.

Traumatic pseudoaneurysm of the superficial temporal artery: case report and review of the literature.

Pseudoaneurysm of the superficial temporal artery is an uncommon complication of a blunt trauma. It usually presents as a pulsating mass in the frontotemporal area a few weeks after the injury. Doppler ultrasonography, angiography, or computed tomographic angiography can aid or confirm the diagnosis. The treatment of choice is the surgical resection of the pseudoaneurysm and ligation of the vessels. We report a case of a pseudoaneurysm of the frontal branch of the superficial temporal artery and review the literature.