The TSAR-osteotomy, a total subapical and ramus osteotomy: A technical note.

There are several treatment options to treat a class II dentofacial deformity with a pronounced chin. A total subapical osteotomy is one of these options. This type of osteotomy was refined to total subapical and ramus (TSAR) osteotomy. In this technical note, a detailed and schematic presentation of the TSAR osteotomy is presented step by step. The surgical approach to the TSAR osteotomy is divided into three parts. The first part consists of the horizontal osteotomy at the level of the ramus, the second part approaches the corticotomy to release and protect the mental nerve and the third part consists of connecting the horizontal ramus osteotomy and the local corticotomy around the mental nerve. In this third part, it is important that the inferior alveolar nerve (IAN) is actively sought and protected.

Stair-stepped mandibulotomy: Clinical indication, surgery program design, and operation points.

For radical treatment of malignancies in the posterior region of the oral cavity and oropharynx, surgical exposure of the tumor by mandibulotomy is often required. Midline or paramedian vertical mandibulotomies are commonly performed in clinical practice, but these can damage the suprahyoid musculature and genioglossus, and weaken the swallowing and speech function of patients. Stair-stepped mandibulotomy is a new procedure, developed on the principles of functional surgery, that preserves the structure and function of the mandible whilst providing a clear field and avoiding damage to critical muscle attachments. Stair-stepped mandibulotomy is suitable for patients whose primary tumor is located in the middle and posterior part of the tongue or oropharynx, especially if the lesion involves extrinsic tongue muscles. In this case report, we draw on 2 cases of typical patients in our center to elaborate the surgery program design, operation points, advantages and disadvantages of stair-stepped mandibulotomy.

Early and Late Complications of Mandibulectomy Free Flap Reconstruction: Does the Selective Use of Soft Tissue Only Flaps Reduce Complications?

PURPOSE: This study aims to evaluate the factors most associated with early and late complications following microvascular free tissue transfer (MVFTT) after mandibulectomy. METHODS: A retrospective review of patients undergoing MVFTT after segmental mandibulectomy from September 2016 to February 2021 was performed across a single academic institution. Surgical variables were collected, including the location of the resultant mandibular defect (anterior vs posterior) and flap type (osseous or non-osseous). The primary outcome variables included postoperative complications (early, <90 days; and late, >90 days) and the patients' functional status (return to oral intake). Descriptive statistics, chi-square test, Fischer's exact test, and 2-sample t tests were used to analyze differences among variables. RESULTS: We analyzed a cohort of 114 consecutive patients with mandibular defects, comprising 57 anterior and 57 posterior defects. Bony free flaps with hardware were used to reconstruct 98% of anterior defects compared to 58% of posterior defects (P < .001). All soft tissue only flaps did not utilize any hardware during the reconstruction. Anterior defects demonstrated more late complications requiring additional surgery (30% vs 9%, P = .04). A secondary analysis of posterior mandibular reconstructions compared soft tissue only flaps and bony free flaps with hardware and showed equivalent rates of early (12% vs 13%, P > .99) and late (9% vs 8%, P > .99) complications requiring additional surgery while demonstrating a similar return to full oral competence (55% vs 46%, P = .52) and recovery of a 100% oral diet (67% vs 54%, P = .53). CONCLUSION: Osseous free tissue transfer for segmental mandibular defects remains the gold standard in reconstruction. In our patient cohort, anterior mandibular defects are associated with greater late (>90 day) complications requiring additional surgery. Comparable outcomes may be achieved with soft tissue only versus osseous free flap reconstruction of posterior mandibular defects.

Mandibular Body Osteotomy Combined with Sagittal Split Ramus Osteotomy for the Treatment of Severe Skeletal Class â ¢ Malocclusion with Ankylosed Teeth.

This study presents a combination of 2 different surgery procedures performed on the mandible as part of the treatment aiming to improve the facial profile and occlusal function of patients with severe skeletal class Ⅲ malocclusion and bilateral edentulous gaps. The teeth next to the edentulous gaps were found to be ankylosed. Mandibular setback by bilateral sagittal split ramus osteotomies and mandibular body osteotomies, combined with Le Fort Ⅰ level maxillary advancement were performed, since the chief complaint of the patient was a concave profile. As a result, the skeletal class Ⅲ malocclusion had been corrected, a satisfying facial profile had been achieved, and no apparent adverse effect was found. Thus, it has been proved that the combination of sagittal split ramus osteotomy and mandibular body osteotomy is available for correcting skeletal class Ⅲ malocclusion.

Double Chin Concerns after En Bloc Mandibular U-Shaped Osteotomy: Submental-Cervical Soft Tissue Changes and Anterior Belly of Digastric Muscle Assessment.

OBJECTIVE: To assess submental-cervical soft tissue changes after en bloc mandibular U-shaped osteotomy and examine alterations in the anterior belly of digastric muscle (ABDM). METHODS: A retrospective study analyzed 20 patients who underwent en bloc mandibular U-shaped osteotomy from 2018 to 2023. Preoperative (Tp) and long-term follow-up (Tf) CT data were collected for analysis, measuring mandibular volume, soft tissue thickness at menton (Mes) and cervicale (C), and ABDM parameters (length, cross-sectional area (CSA), volume, distance from centroid point to the mandibular margin). Correlation analyses were performed to investigate the connection between soft tissue thickness changes, ABDM changes, and mandibular osteotomy volume. RESULTS: Long-term follow-up revealed a significant increase in soft tissue thickness at the Mes and C points after U-shaped mandibular osteotomy, especially at the C point. The adaptive length of ABDM decreased, CSA increased, and volume decreased, but the ABDM centroid point shifted downward relative to the mandibular margin, indicating drooping protrusion. The increment of soft tissue thickness was moderately positively correlated with the amount of osteotomy, and the decrement of ABDM length and volume were slightly positively correlated with the amount of osteotomy. CONCLUSION: The degree of soft tissue relaxation after U-shaped osteotomy is related to the extent of osteotomy. Notably, the protrusion of ABDM relative to the mandibular margin affects submental-cervical contour aesthetics. Prior to U-shaped osteotomy, it is crucial to assess the soft tissue condition of the patient's lower face, and the individualized design of the osteotomy volume should be carried out cautiously and safely. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Aesthetic Enhancement of the Gonial Angle and Inferior Mandibular Border in the Chinese Population.

BACKGROUND: The current absence of a standardized mandibular body osteotomy design poses challenges in surgical planning. Traditional approaches may not suit patients with wider anterior mandibles, potentially resulting in unsatisfactory outcomes. Addressing this issue requires a rational design that combines mandibular angle and body osteotomies for improved clinical practice. OBJECTIVES: In this retrospective cohort study we aimed to analyze mandibular computed tomography (CT) data with digital methods. The goal was to establish an integrated osteotomy design for both mandibular angle and body procedures and classify prevalent mandibular types in the Chinese Han population for surgical guidance. METHODS: Included were 89 patients who underwent mandibular angle osteotomy without genioplasty between 2016 and 2022 at Peking University Third Hospital. Mimics 21.0 software facilitated CT data reconstruction and osteotomy planning. Postoperative effects were assessed through imaging, complications, and surveys, leading to mandibular type classification. RESULTS: Mandibular angles were categorized by 3 types, based on osteotomy range. Type I involved mandibular body osteotomy only, type II mandibular angle osteotomy only, and type III both mandibular angle and body osteotomies. Distribution within the cohort was 2.25%, 8.99%, and 88.76% for types I, II, and III respectively. Patient satisfaction was high, with minor and major complications at 47.19% and 1.12% by Clavien-Dindo classification. CONCLUSIONS: Utilizing Mimics software, we established an integrated osteotomy design and categorized mandibular types. Findings offer valuable guidance for mandibular angle surgery and contribute to understanding of Asian mandibular morphology.

Alloplastic reconstruction of the mandible after subtotal mandibulectomy for medication-related osteonecrosis of the jaw: An update of the method.

BACKGROUND: Reconstruction of continuity defects following osteonecrosis in multimorbid patients is challenging. In all cases of the predescribed palliative treatment method for alloplastic mandible reconstruction, plate fractures were detected in follow-up. We hypothesized that a modification could avoid these fractures, leading to stable long-term results. METHODS: This retrospective study compares the original method with a modification using single, laser-sintered CAD-CAM plates instead of manually bent miniplates. The predescribed shuttering technique was used to reconstruct the mandible in its original shape with bone cement. RESULTS: Uneventful wound healing was observed in 86% of the cases after modification of the method. No implant or plate fracture occurred. CONCLUSIONS: The presented method should be considered as a treatment option for mandible reconstruction in elderly, multimorbid patients in palliative situations. The results of this study suggest that the modification of the method leads to significantly improved long-term stability. Donor site morbidity is avoided with this method of palliative surgery.

Redefining Mandibular Sub-units: The "ABC" Classification and Surgical Strategies for Lower Face Contouring.

BACKGROUND: In east Asia, lower face contouring surgeries including reduction mandibuloplasty and genioplasty are the most popular aesthetic craniofacial surgeries. Conventional selection of surgical strategies mainly relied on the visual judgment of the mandibular angle, without overall assessment of the mandibular sub-units. Furthermore, only a few studies offered quantitative assessment of the mandibular shape. METHODS: From 2010 to 2021, 1241 patients diagnosed with square faces and received customized lower face contouring surgeries by the senior author were reviewed and analyzed to propose an "ABC" classification system for facilitating surgical planning. RESULTS: Among them, 998 (80.42%) received bilateral mandible reshaping, 155 (12.49%) underwent bilateral mandible reshaping combined with genioplasty, and 88 (7.09%) received asymmetric mandible reshaping. A modified classification system composed of three critical parameters (height, morphology/thickness, divergence) in three aesthetic zones (mandibular angle, mandibular body, chin) was proposed based on quantitative summarization of the CT database and the senior author's 12-year experience. The way to facilitate surgical planning with this classification was demonstrated. CONCLUSIONS: This modified classification system ushered a decision-making process that prioritized several critical measurements and proposed an operative planning form. Meanwhile, it can also be cooperated into the three-dimensional virtual surgical plan. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Straight-segment mandibulectomy: a reproducible porcine mandibular critical-size defect model.

Porcine mandibular defect models are commonly used for the preclinical evaluation of reconstruction techniques. Existing studies vary in technique, complexity, and postoperative outcomes. The procedures are complex and often described without sufficient detail. We describe in detail a simple and reproducible method for creating a critical-size mandibular defect in a porcine model. Seven hemimandibular critical size defects were created in five male Yorkshire-Landrace pigs, three with unilateral defects and two with bilateral defects. A transverse incision was made over the mandibular body. Periosteum was incised and elevated to expose the mandibular body and a critical-size defect of 30 × 20 mm created using an oscillating saw. The implant was inserted and fixed with a titanium reconstruction plate and bicortical locking screws, and the wound closed in layers with resorbable sutures. Intraoral contamination was avoided. Dentition was retained and the mental nerve and its branches preserved. The marginal mandibular nerve was not encountered during dissection. All pigs retained normal masticatory function, and there were no cases of infection, wound breakdown, haematoma, salivary leak, or implant-related complications. The procedure can be performed bilaterally on both hemimandibles without affecting load-bearing function. All pigs survived until the end point of three months. Postoperative computed tomographic scans and histology showed new bone formation, and a three-point bend test showed the restoration of biomechanical strength. Straight-segment mandibulectomy is a simple and reproducible method for the creation of critical-size mandibular defects in a porcine model, simulating a load-bearing situation.

Surgical cutting guide and single plate fixation for intraoral vertical ramus osteotomy.

With the advancement of digital technology over the last few decades, the use of virtual surgical planning and fabrication of surgical guides have tremendously improved the outcomes of various maxillofacial surgical procedures. The intraoral vertical ramus osteotomy (IVRO) is an orthognathic surgical procedure largely employed for mandibular setback in correcting dentofacial deformities. This study describes the design and application of a surgical cutting guide for IVRO. The guide can also be used to facilitate the placement of miniplate fixation. The initial experience at the authors' centre suggests that the guide has allowed the osteotomy to be performed with increased precision and confidence. Furthermore, the use of miniplate fixation decreased the period of maxillomandibular fixation. However, a larger series is required to evaluate the utility of this system more thoroughly.

Impact of Mandibular Angle Osteotomy Using a Geometric Mathematical Design on the Aesthetic Osteotomy Line: A Retrospective Observational Study.

BACKGROUND: Mandibular angle osteotomy (MAO) is a frequently described technique in Eastern females. The success hinges on the precise positioning of the osteotomy line. The geometric mathematical method is viable. Therefore, we explored the impact of mandibular angle osteotomy using aesthetic standards and printed digital osteotomy templates (DOTs) on the aesthetic osteotomy line. METHODS: This retrospective observational study included female patients with prominent mandibular angle (PMA) who underwent MAO at our hospital between January 2020 and March 2021. Thirty-three female patients were included, 22 in the DOTs group using new DOTs, and 11 in the traditional group using traditional free-hand techniques. RESULTS: Regarding the width of the excised bone, the postoperative deviation from the preoperative plan was not significant in the DOTs group (0.5 ± 0.3 mm, P > 0.05), while the deviation was significant for the traditional group (2.5 ± 1.2 mm, P<0.05). The preparation time was longer in the DOTs group than in the traditional group (82 ± 11 vs. 53±4 min, P < 0.001). The osteotomy time and the operation time were shorter in the DOTs group than in the traditional group (osteotomy: 54 ± 5 vs. 73 ± 6 min; preparation: 124 ± 10 vs. 169 ± 13 min; both P < 0.001). The Likert (4.0 ± 0.5 vs. 1.0 ± 0.6, P = 0.006) and FACE-Q scores (17.5 ± 1.7 vs. 15.6 ± 1.3, P = 0.029) were higher in the DOTs group. CONCLUSIONS: The new method of positioning the new aesthetic osteotomy line based on geometric analysis might provide a possible osteotomy method that strongly suggests effectiveness, safety, individualization, and accuracy, with a shorter operation and higher patient satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Posterior Mandibular Segmental Split Osteotomy: A Novel Technique for Edentulous Space Reconstruction in Patients With Skeletal Class III Malocclusion.

ABSTRACT: This study presents an innovative surgery that successfully improved the facial profile and occlusal function of a patient with a skeletal Class III malocclusion and posterior hypodontia. The patient had chief complaints of missing teeth and a protrudedjaw. A novel 1-stage surgery referred to as posterior mandibular segmental split osteotomy combined with Le Fort i osteotomy and BSSRO was used because the patient wanted to save time and was worried about periodontal complications associated with other treatment methods. As a result, a satisfying facial profile and a Class I occlusion with a normal position of the posterior dentoalveolar segment of the mandible were achieved with no adverse effects. Thus, posterior mandibular segmental split osteotomy can be considered an effective treatment for skeletal Class III malocclusion with posterior hypodontia.

Application of Segmented Template in Three-Dimensionally Guided Mandibular Angle Osteotomy.

BACKGROUND: The procedure of mandibular angle osteotomy (MAO) via an intraoral approach is challenging and experience-dependent due to the limited field of view and inadequate operational space. Uncertainty about the osteotomy line and plane can lead to severe complications. A three-dimensional printed guidance template based on a computer-assisted preoperative simulation is a potential solution to this problem. The current study aims to retrospectively investigate the feasibility and accuracy of using a custom-made segmented template to guide the osteotomy plane during the procedure. METHODS: Sixty patients who had segmented template-guided MAO were included in the study. Preoperative simulation using the custom-designed template and postoperative computed tomography were collected and parameters, including mandibular angle, gonion distance, and the mandibular plane angle were measured. A paired t tests and intraclass correlation coefficients (ICCs) were used to evaluate the efficacy, accuracy, and symmetry of the results. All complications were reviewed. RESULTS: The patients had a significantly larger mandibular angle and narrower gonion distance postoperatively. Preoperative simulations and postoperative outcomes were compared; ICCs were larger than 95% indicating significant agreement. Bilateral postoperative comparisons of the mandible also demonstrated excellent agreement (ICC > 95%). Numbness in the chin area was the most frequent complication but all recovered by 3 months postoperatively. CONCLUSIONS: The custom-made template can guide the osteotomy plane during the MAO procedure and achieve favorable accuracy and symmetry. Direct contact of the saw with the guidance template not only facilitates control of the osteotomy line but also the oblique angle of the osteotomy plane. This methodology may be a feasible and effective tool for mandibular contouring.

Expanded Transoral Microvascular Mandibular Reconstruction: A Scar-Free Approach.

PURPOSE: We present our experience with transoral segmental mandibulectomy, in conjunction with vascularized osseous mandibular reconstruction, utilizing an intraoral anastomosis and free of extraoral incisions. Virtual surgical planning and intraoperative navigation were used to help achieve this minimally invasive and scar-free approach. METHODS: A retrospective study was performed on 9 patients who underwent transoral segmental mandibulectomy followed by vascularized osseous reconstruction using an intraoral anastomosis between January 2018 and October 2018. The anastomotic recipient vessels were the facial artery and vein. The outcome variable was defined as the flap survival. Postoperative panoramic radiographs and computed tomography images were obtained for assessment of the neo-mandible. In addition, we performed a cadaver dissection to highlight relevant anatomic details of the facial artery and vein. RESULTS: Successful transoral segmental mandibulectomy was achieved in 9 patients, with an intraoral anastomosis successfully achieved in 8 patients. In one patient, an extraoral anastomosis was required because of challenging facial vein anatomy. Both recipient and donor sites healed uneventfully with a 100% successful rate of flap survival. In all cases, a well-positioned neo-mandible with good occlusion was demonstrated on postoperative imaging and examination. A symmetric facial appearance with no restrictions in mouth opening was also achieved in each case. In our cadaver dissection, we describe the anatomical course of the facial artery and vein. An average angle of 30° between these vessels is identified. CONCLUSIONS: Transoral segmental mandibulectomy combined with intraoral microvascular mandibular reconstruction is a surgically achievable technique with the benefit of being scar free.

Assessment of an Artificial Intelligence Mandibular Osteotomy Design System: A Retrospective Study.

BACKGROUND: In this study, an AI osteotomy software was developed to design the presurgical plan of mandibular angle osteotomy, which is followed by the comparison between the software-designed presurgical plan and the traditional manual presurgical plan, thus assessing the practicability of applying the AI osteotomy software in clinical practices. METHODS: (1) Develop an AI osteotomy software: design an algorithm based on convolutional neural networks capable of learning feature point and processing clustering segmentation; then, select 2296 cases of successful 3D mandibular angle osteotomy presurgical plans, followed by using those 2296 cases to train the deep learning algorithm; (2) compare the osteotomy presurgical plan of AI osteotomy software and that of manual: first step: randomly selecting 80 cases of typical female head 3D CTs, and designing those 80 cases by means of AI osteotomy software designing (group A) and manually designing (group B), respectively; second step: comparing several indexes of group A and those of group B, including the efficiency index (time from input original CT data to osteotomy presurgical plan output), the safety index (the minimum distance from the osteotomy plane to the mandibular canal), the symmetry indexes (bilateral difference of mandibular angle, mandibular ramus height and mandibular valgus angle) and aesthetic indexes (width ratio between middle and lower faces (M/L), mandibular angle and mandibular valgus angle). RESULTS: The efficiency index: the design time of group A is 1.768 ± 0.768 min and that of group B is 26.108 ± 1.137 min, with P = 0.000; the safety index: The minimum distances from the osteotomy plane to the mandibular canal are 3.908 ± 0.361mm and 3.651 ± 0.437mm, p = 0.117 in groups A and B, respectively; The symmetry indexes: Bilateral differences of mandibular angle are 1.824 ± 1.834° and 1.567 ± 1.059° in groups A and B, respectively, with P = 0.278; bilateral differences of mandibular ramus height are 2.083 ± 1.263 and 2.965 ± 1.433, respectively, with P = 0.119 in groups A and B; Aesthetic indexes: M/L in groups A and B is 1.364 ± 0.074 and 1.371 ± 0.067, respectively, with P = 0.793; mandibular angles in groups A and B are 127.724 ± 5.800° and 127.242 ± 5.545°, respectively, with P = 0.681; Valgus angles in groups A and B are 11.474 ± 5.380 and 9.743 ± 4.620, respectively, with P = 0.273. CONCLUSIONS: With high efficiency, as well as safety, symmetry and aesthetics equivalent to those of a manual design, the AI osteotomy software designing can be used as an alternative method for manual osteotomy designing. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Reduction Mandibuloplasty Along with Partial Masseter Muscle Resection: Masseter Muscle Response and Bone Regeneration.

OBJECTIVE: To compare the masseter muscle changes and bone regeneration between reduction mandibuloplasty along with partial masseter muscle resection and reduction mandibuloplasty alone. METHODS: Forty-seven patients who complained of prominent mandibular angle and hypertrophy masseter muscles (MMH) were divided into group 1 treated with reduction mandibuloplasty along with partial masseter muscle resection, and group 2 treated with reduction mandibuloplasty alone. Pre-5 days and long-term postoperative computed tomography data were collected, and the masseter muscle volume, hemi-mandible volume, and unilateral lower face width were measured. Patient satisfaction and complication were also evaluated. RESULTS: At long-term follow-up, group 1 showed a greater decrease in masseter volume (p < 0.001), and lower face width (p < 0.001), and less bone regeneration (p < 0.001) than group 2. Furthermore, patients in group 1 had higher satisfaction with the surgical outcome (p < 0.05). CONCLUSION: Reduction mandibuloplasty along with partial masseter muscle resection can achieve a slender frontal appearance and significantly decrease bone generation. For patients with MMH, reduction mandibuloplasty along with partial masseter muscle resection is an effective and predictable lower face reshaping surgery. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Rare clear cell odontogenic carcinoma associated with impacted tooth in a young patient: case report and literature review.

Clear cell odontogenic carcinoma (CCOC) is a rare malignant odontogenic tumor. It is characterized by showing, on histopathological examination, clusters of vacuolated and clear tumor cells with epithelial differentiation surrounded by fibrocollagenous stroma and fibroblasts. The present study presents a rare clinical case of mandibular CCOC associated with an impacted tooth in a 26-year-old woman surgically treated with mandibulectomy and reconstruction with iliac crest bone graft. The patient has been followed up for 22 months without signs of recurrence. A search for case report/case series was carried out in the PUBMED database, as well as in the references of relevant previously published literature reviews. Ninety-six publications were identified, totaling 136 distinct cases reported. Female sex was the most affected (63.1%) with 63.3% of cases occurring in patients in the fifth, sixth, or seventh decades of life. The mandible was more affected than the maxilla (74.2%). Association of CCOC with impacted teeth was found in 2.4% of cases, thus rendering it a rare occurrence. The present case report corroborates the results of the survey regarding sex and anatomical location of the tumor; however, it contradicts the findings regarding age predilection. The case described is the fourth known occurrence of tooth impaction associated with the tumor and the first in a female. In conclusion, CCOC should be considered, as well as other malignancies, as a possible diagnosis of maxillary or mandibular intraosseous lesions even in unusual circumstances such as in association with impacted teeth and in young patients.

Association of Plate Contouring With Hardware Complications Following Mandibular Reconstruction.

OBJECTIVES/HYPOTHESIS: Despite considerable effort being dedicated to contouring reconstruction plates, there remains limited evidence demonstrating an association between contour and reconstructive outcomes. We sought to evaluate whether optimizing mandibular reconstruction plate contouring is associated with reduced postoperative hardware complications. STUDY DESIGN: Retrospective cohort study. METHODS: A cohort study was performed with adult patients (age ≥18 years) who underwent mandibulectomy and osseous free flap reconstruction following oncologic ablation at the University Health Network in Toronto, Canada, between January 1, 2003 and December 31, 2014. Patients with computed tomography scans performed within 1 year of reconstruction were included. Computer-based three-dimensional models were generated and used to calculate the mean plate-to-bone gap (mm). The primary outcome was plate exposure. Secondary outcome included a composite of plate exposure or intraoral dehiscence. Logistic regression models were fitted for each outcome accounting for other patient and surgical characteristics associated with the primary outcome. RESULTS: Ninety-four patients met inclusion criteria, with a mean age of 60.4 (standard deviation [SD] 14.9). The mean follow-up time was 31.4 months (range 3-94). Reconstruction was performed with fibular (57%) and scapular free flaps (43%). In the multivariable model, small mean plate-to-bone gap (<1 mm) was independently associated with 86% reduced odds of plate exposure (odds ratio [OR] 0.12; 95% confidence interval [CI] 0.02-0.55). Mean plate-to-bone gap less than 1 mm was also independently associated with reduced odds of developing a composite of plate exposure or intraoral dehiscence (OR, 0.29; 95%CI, 0.11-0.75). CONCLUSION: Optimizing plate contouring during mandibular reconstruction may decrease the development of postoperative hardware complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:61-66, 2022.

Acesso cirúrgico ao segmento cervical distal da artéria carótida interna e à bifurcação carotídea alta - revisão integrativa da literatura e proposta de protocolo / Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation - integrative literature review and protocol proposal

Resumo Diversas manobras já foram descritas para o acesso ao segmento distal cervical da artéria carótida interna ou à bifurcação carotídea alta; entretanto, há divergências na sistematização dessas técnicas. O objetivo deste estudo é revisar as técnicas descritas e propor um protocolo prático que auxilie na seleção da técnica mais adequada para cada caso. Para isso, foi realizada uma busca nas bases de dados PubMed Central, Biblioteca Virtual em Saúde e SciELO por artigos sobre o tema, em língua inglesa ou portuguesa, publicados entre os anos de 1980 e 2021. Entre as manobras descritas, parece razoável que as duas etapas iniciais sejam a abordagem ao músculo esternocleidomastóideo, seguida pela secção/retração do ventre posterior do músculo digástrico. Caso necessário, a subluxação mandibular temporária unilateral é um recurso adicional e preferível à divisão do aparato estiloide, devido ao menor potencial de morbidade. Exposições ainda mais amplas podem ser obtidas com as osteotomias mandibulares.

Abstract Several different maneuvers have been described for obtaining access to the distal cervical segment of the internal carotid artery or to a high carotid bifurcation. However there are different approaches to systematization of these techniques. The objective of this study is to review the techniques described and propose a practical protocol to support selection of the most appropriate technique for each case. The review is based on the results of database searches on PubMed Central, the Virtual Health Library (BVSalud), and SciELO for articles on the subject published in English or Portuguese from 1980 to 2021. Among the different maneuvers described, it appears reasonable that the first two steps should be to obtain access at the sternocleidomastoid muscle, followed by section or retraction of the digastric muscle posterior belly. If needed, temporary unilateral mandibular subluxation is an additional resource that is preferable to division of the styloid apparatus process, because of its lesser potential for morbidity. Even wider exposure can be obtained using mandibular osteotomies.