Outcomes of osseointegrated implants in patients with benign and malignant pathologies of the head and neck: a 10-year single-centre study.

The surgical management of head and neck pathologies involving the maxilla and mandible results in significant functional and aesthetic deficits, and ultimately reduced quality of life. Composite free flaps used for reconstruction address many of these deficits and create a foundation for the use of osseointegrated implants to support prosthetic replacement of the dentition. There are few comparative studies examining outcomes of implants in native and reconstructed bone in head and neck cancer patients. The aim of this retrospective cohort study was to compare survival rates and the effects of risk factors between implants placed in native and reconstructed bone. The Kaplan-Meier method estimated cumulative 1- and 5-year implant survival rates of 99.5% and 95% for native bone and 96% and 88% for reconstructed bone. Multivariate Cox regression found an increased risk of implant failure in reconstructed bone (hazard ratio (HR) 9.9, 95% confidence interval (CI) 3.4-29.7, P<0.001). Subgroup analysis of the cohorts found an increased risk of failure in the reconstructed group associated with radiotherapy (HR 6.4, 95% CI 1.8-22.3, P=0.004), current smoking (HR 23.2, 95% CI 2.7-198.6, P=0.004), and previous smoking (HR 9.0, 95% CI 1.1-71.9, P=0.038). There was no effect in the native bone group. Implants placed into reconstructed bone had higher rates of failure, and smoking status and radiotherapy increased the risk of implant failure.

A pilot study for presence of circulating tumour cells in adenoid cystic carcinoma.

Adenoid cystic carcinoma (ACC) is a rare salivary gland neoplasm with a poor long-term prognosis due to multiple recurrences and distant metastatic spread. Circulating tumour cells (CTCs) are tumour cells shed from a primary, recurrent, or metastatic cancer that are detectable in the blood or lymphatics. There is no literature to date confirming the presence of CTCs in ACC. The aim of this study was to determine whether CTCs are detectable in ACC. Blood samples were collected from eight patients with histologically confirmed ACC. The TNM stage of the tumour was recorded, as well as any prior treatment. CTCs were isolated by spiral microfluidics and detected by immunofluorescence staining. Three of the eight patients recruited (32.5%) had staining consistent with the presence of CTCs. Of these three patients with detectable CTCs, one had confirmed pulmonary metastasis, one had suspected pulmonary metastasis and was awaiting confirmation, and one had local recurrence confirmed on re-resection. One patient with known isolated pulmonary metastasis had previously undergone a lung metastasectomy and did not have CTCs detected. CTCs are detectable in ACC. In this small patient sample, CTCs were found to be present in those patients with recurrent local disease and known distant metastatic disease. CTCs in ACC should be investigated further for their potential use as an adjunct in staging, prognosis, and the detection of recurrence.

Pregnancy and childbirth after an iliac crest free flap.

We report two successful pregnancies and vaginal deliveries by patients who had previously had deep circumflex iliac artery free flaps that had been harvested for reconstruction in the head and neck.

Patient compliance and mandible fractures: a prospective study.

Fractures of the facial skeleton place a burden on healthcare systems at the individual and population level. It is suggested that a high proportion of such patients are non-compliant with various aspects of their care. It stands to reason that non-compliance would contribute to adverse outcomes and increased costs in general. The intent of this study was two-fold: to determine factors associated with poor compliance in the studied population of 215 patients with 359 mandible fractures, and to determine whether poor compliance is associated with an increased incidence of treatment complications. Being male, an illicit drug user, non-employed, and living furthest from care were the factors associated with non-compliance in the studied population. Compliance with soft diet, mouthwash, oral antibiotics, cigarette cessation, and review appointment attendance was 74%, 96%, 96%, 16%, and 58%, respectively. Global compliance scores of low, medium, and high were assigned to 27%, 59%, and 14% of participants, respectively. None of the individual postoperative compliance variables was found to be significantly associated with outcomes of treatment at the 5% level. Borderline associations were found. Globally non-compliant patients were significantly more likely to experience wound dehiscence. The utility of the current postoperative regimen should be further elicited.

A prospective study examining the effects of treatment timing in the management of mandible fractures.

The ideal timing for treatment of mandible fractures has not been well established. The objective of this study was to analyse the effects of treatment timing in the surgical management of mandible fractures. A prospective evaluation of 215 continuous patients with a total of 359 mandible fractures was undertaken. Nine outcome variables were analysed in relation to treatment delay by logistic regression modelling: wound dehiscence, hardware exposure, local postoperative infection, malocclusion, trismus, nerve damage, fracture non-union, return to theatre, and radiographic outcome. Nineteen additional variables were included in the analysis to adjust for potential confounding. Delay was measured in days and ranged from 0 to 41days, with a mean delay of 4.6days. The incidence of wound dehiscence, hardware exposure, local postoperative infection, trismus, nerve damage, fracture non-union and return to theatre was 6%, 4%, 11%, 8.5%, 47%, 2% and 8%, respectively. Objective malocclusion and poor radiographic outcomes were evident in 13% and 4.5% of cases, respectively. No statistically significant association was found between treatment delay and treatment outcomes. The findings of this study suggest it may be safe to delay the definitive treatment of mandible fractures. Treatment delay may allow for improved resource distribution and prioritization of more time-dependent interventions.

Reconstruction of major defects of the jaws.

Prosthetic replacements in the 19th and early 20th century were superseded by pedicled flaps and obturators. These have subsequently been superseded by free tissue transfer which currently is the mainstay of reconstructive jaw surgery. Although malignant and benign processes of the jaws are the predominant cause of segmental defects, a significant proportion still occurs due to trauma, or even iatrogenic causes such as radiotherapy. The varied aetiologies demand a nuanced approach to reconstruction and although the techniques remain similar the timing can be quite different. The maxilla and the mandible are both amenable to composite reconstruction with bone. The fibula, iliac crest, scapula, distal radius and medial femoral condyle are the most commonly utilised donor sites for vascularised reconstruction. Each has strengths and weaknesses and the requirements of the defect, and patient preference should outweigh surgeon preference. Osseointegrated implants allow reliable rehabilitation of the dentition by anchoring facial prostheses. Their integration into composite flaps is highly reliable although soft tissue management can be challenging. Virtual surgical planning and 3D printing have already impacted on the surgical workflow and improved the reliability and accuracy of results. If this technology can be applied to tissue typing and human tissue (instead of just plastic and metal) a fully prefabricated and vascularised jaw without donor site morbidity would be the ultimate aim.

Total temporomandibular joint replacement prostheses: a systematic review and bias-adjusted meta-analysis.

The aim of the present study was to determine which prosthesis has resulted in the best outcomes after total temporomandibular joint replacement (TMJR). A comprehensive electronic search was undertaken in September 2015. Inclusion criteria encompassed studies that described one of the three current TMJR systems and that had pre- and postoperative data on at least two of the following TMJR indications: pain, diet, function, and maximum inter-incisal opening (MIO). Sixteen papers were included in the systematic review, reporting 10 retrospective studies and six prospective studies (no randomized controlled or case-controlled trials). A total 312 patients with 505 TMJ Concepts prostheses, 728 patients with 1048 Biomet prostheses, and 125 patients with 196 Nexus prostheses were included in the analysis. There was no real difference between the various TMJR systems in terms of pain or diet scores. Function scores improved with the TMJ Concepts, but this was the only prosthesis for which data were available. Biomet prostheses appeared to have a greater increase in MIO mean gain compared to TMJ Concepts and Nexus prostheses; however this was heavily biased by one study. Without this study, there was no real difference in MIO. It is concluded that the prostheses are similar, but most data are available for the TMJ Concepts prosthesis, with results being favourable.

A multi-outcome analysis of the effects of treatment timing in the management of zygomatic fractures.

The aim of this study was to analyze the effects of surgical treatment delay in the management of zygomatic fractures. A retrospective case series of 99 patients was undertaken. Four outcome measures were analyzed in relation to delay: facial symmetry, facial scarring, trismus, and radiographic outcome. Five additional variables were subsequently analyzed: operation, diagnosis, primary operator, regular alcohol use, and regular cigarette use. Statistically significant associations were found between delay and facial scarring, and delay and radiographic outcome. For each additional delay of a day, the odds of facial scarring being present, compared to absent, decreased by 13% (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.76-0.98). For regular cigarette users, for each additional day of delay there was a 306-fold increased risk of having a radiographic outcome of major deviation from premorbid compared to equivalent to premorbid (OR 306.38, 95% CI 2.08-45,161.49). For non-regular cigarette users/non-users, for each additional day of delay there was a 1.5-fold increased risk of having a radiographic outcome of major deviation from premorbid compared to equivalent to premorbid (OR 1.50, 95% CI 1.08-2.09). These findings correlate with commonly held beliefs and anecdotal evidence. Despite the limitations, this study allows for an evidence-based approach to the timing of treatment of zygomatic fractures.

The relative survival of composite free flaps in head and neck reconstruction.

Various composite free flaps are available for reconstruction of bony head and neck defects. The aim of this study was to compare the relative success of four different bony free flaps. One hundred and seventy-three microvascular composite free flap reconstructions for bony defects of the head and neck region, performed over the period April 2008 to April 2015, were reviewed retrospectively. The type of free flap, indication for free flap reconstruction, age at harvesting of the free flap, use of pre- or postoperative radiotherapy, and free flap failure were examined. For the 173 reconstructions performed, 84 fibula free flaps, 43 iliac crest free flaps, 32 scapula free flaps, and 14 osteocutaneous radial forearm free flaps were harvested. The mean age at time of harvesting was 40.7 years for the iliac crest, 57.3 years for the fibula, 64.3 years for the scapula, and 73.9 years for the osteocutaneous radial forearm free flap. No complete free flap failure was documented, nor was there any failure of bony segments. Three fibula flap skin paddles did not survive. No returns to theatre for salvage were required. This study showed no difference in the survival rates of these four types of composite free flap.

Coping with an altered mouth and perceived supportive care needs following head and neck cancer treatment.

PURPOSE: Oral health is essential to general health and well-being and is severely impacted by head and neck cancer (HNC) and its treatment. This study aimed to describe how people who have been treated for HNC cope with altered oral health and function and to identify their supportive care needs. METHODS: A qualitative, descriptive approach was used. Data was collected from individual interviews with six participants 6 months after treatment. Data analysis was performed by qualitative content analysis involving inductive and directed approaches. Directed content analysis was guided by the Stress, Appraisal and Coping Model. RESULTS: Three themes describing changed oral health were identified from the data: dimensions of eating, maintaining oral health after treatment and adapting to the chronic side effects of treatment. A strong use of problem-focussed coping was described, in addition to the importance of peer support in adapting to the psychosocial outcomes of treatment. Support needs identified related to increased access to specialist dental oncology services post treatment, information needs and a need for more psychological support. CONCLUSION: The study findings describe the experience of a sample of people who have received treatment for HNC. Due to a demographically homogenous sample and the strong use of positive coping strategies, the results presented may not describe the experience of the wider HNC population; however, these results provide insight into factors that may influence positive coping.

The effect of treatment timing on the management of facial fractures: a systematic review.

The ideal timing for treatment of facial fractures has not been well established. The objective of this systematic review was to examine the effects of treatment delay on outcome in the management of facial fractures. The PubMed database was used to search for relevant English-language articles published between 1979 and 2013. Cross-referencing identified additional studies. There were no selection restrictions for study type. The first author, using pre-defined data fields, extracted information independently. Studies were assessed by study type, evidence level, sample size, data collected, outcome variables, control of confounding variables, and findings. Thirty studies were identified. Inconsistency was identified with data collected, outcome variables, and findings. Of the 30 studies identified, 28 were case series, thereby providing a low level of evidence overall. The majority of case series were retrospective and sample sizes were predominantly small. Control of confounding variables was poor. Eighteen studies found no statistically significant relationship between treatment delay and treatment outcome. Nine studies found a statistically significant relationship between treatment delay and worse treatment outcomes. There were three studies with conflicting results. With the current body of evidence, definitive conclusions cannot be drawn on the timing of treatment for facial fractures.

Platelet rich plasma for the prevention of osteoradionecrosis. A double blinded randomized cross over controlled trial.

Osteoradionecrosis of the jaws is a complication of radiotherapy and controversy remains about the management of teeth in the field of radiotherapy. Platelet rich plasma has been advocated in multiple surgical sites, both bone and soft tissue, to promote healing and reduce complications. A randomized double blinded controlled trial was performed on patients receiving bilateral radiotherapy that affected the mandible who required pre treatment dental extractions. One side received platelet rich plasma and the other acted as a control. Twenty-two patients were recruited over 12 months and over a 5-year period following treatment three developed osteoradionecrosis (14%). Platelet rich plasma failed to show any benefit in the prevention of osteoradionecrosis. Nor was there any benefit in pain scores or mucosal healing on sides that were treated with platelet rich plasma. Platelet rich plasma fails to show a benefit in the prevention of osteoradionecrosis. The rate of osteoradionecrosis is high compared to other published series and the prophylactic removal of molar teeth should be questioned as a preventative measure.

Comparison of treatment modalities in burning mouth syndrome.

BACKGROUND: Burning mouth syndrome (BMS) is characterized by a spontaneous burning pain in the oral mucosa without known organic cause or standardized treatment. The aims of this study were to assess and compare the efficacy of clonazepam and diazepam in relieving the symptoms associated with BMS and evaluate for which patients this treatment might be effective by correlating treatment efficacy with underlying psychological status. METHODS: The medical records of BMS patients attending an oral medicine private practice (1999-2004) were reviewed. The patients were then contacted and asked to complete a short questionnaire regarding their response to diazepam/clonazepam drug therapies. A second group of patients attending the above clinic (n = 30) were asked to fill out a hospital anxiety and depression assessment form in an attempt to correlate treatment success with underlying psychological status. RESULTS: A total of 71.4 per cent of patients treated with clonazepam had partial or complete resolution of their oral symptoms, while 55.1 per cent of patients treated with diazepam had improvement of their oral symptoms. There was no correlation between underlying anxiety or depression and efficacy of benzodiazepine medication. CONCLUSIONS: A greater percentage of patients taking clonazepam reported either partial or complete relief of symptoms compared to diazepam. However, the differences were not statistically significant. There was no correlation found between underlying psychopathology and treatment success with benzodiazepines.

Treatment delays in paediatric dento-alveolar trauma at a tertiary referral hospital.

BACKGROUND: Paediatric dento-alveolar trauma is a common event. Delays in treatment can have adverse effects on long term outcomes and the aim of this study was to quantify the treatment delays in paediatric dento-alveolar trauma in a tertiary referral hospital. METHODS: All cases of paediatric dento-alveolar trauma over a two year period from July 2000 to June 2002 were identified and the charts were reviewed retrospectively. All children presenting to the emergency department with dento-alveolar trauma within 48 hours of injury during the time period were included. RESULTS: Forty-three patients were identified. The average age was 5.51 years, though there was a bias towards one and two year olds. Males were injured 1.5 times more frequently than females. There was an average delay of 9.6 hours between injury and treatment for all patients. Transit time from outside practitioners to hospital and waiting times in hospital made up the greatest delays. Children injured an average of 2.37 teeth and only 14 per cent were uncomplicated crown fractures. CONCLUSIONS: Children who present to children's hospitals for treatment of dento-alveolar trauma have more severe injuries than those treated elsewhere. They have large but potentially reducible delays between injury and treatment.

Oral and maxillofacial surgical considerations for a case of Hutchinson-Gilford progeria.

Hutchinson-Guilford progeria is a rare genetic condition showing the stigmata of accelerated ageing combined with severe growth retardation. Patients with this condition show a classical facies and clinical features with an average age of death of 13, usually due to atherosclerotic changes. Craniofacial and dental manifestations include mandibular and maxillary hypoplasia, both vertically and horizontally. Delayed and abnormal tooth eruption and morphology are commonly present. The long-term medical prognosis and eruption potential of individual teeth is important when considering treatment. In addition to this, surgical planning and surgical technique must be modified by the abnormal facial morphology, dermal inelasticity, potential anaesthetic difficulties, and ongoing deterioration in the medical condition. These factors mandate early and definitive intervention for oral surgical conditions. We report the case of a 13-year-old male treated for pericoronitis and oral pain relating to delayed eruption of first permanent molars.