Implications of the composite free flap harvest site on quality of life after head and neck surgery: a prospective series.

Quality of life (QOL) has become a primary determinant of the treatment outcome. There is a poor evidence base regarding the QOL implications of free flap harvest from the various different osseous composite donor sites. This prospective study assessed the impact of free flap harvest on QOL and compared QOL morbidity between fibula, scapula, and iliac crest (deep circumflex iliac artery; DCIA) donor sites in head and neck reconstructive surgery. This was a single-site prospective cohort clinical research study. Fifty-nine patients were recruited between 2017 and 2021; 30 underwent fibula flap reconstructive surgery, 17 scapula flap, and 12 DCIA flap. The patients were assessed using the University of Washington Quality of Life Questionnaire version 4 (UW-QOL v4) preoperatively and again at >12 months postoperatively. The results showed no significant change in the mean global QOL score postoperatively when compared to the preoperative baseline in any of the donor site groups. However, the mean postoperative scores for the appearance domain were significantly lower than the preoperative scores in all of the donor site groups. In addition, fibula flap patients had significantly reduced physical activity and recreation QOL domain scores postoperatively when compared to the preoperative scores.

Meningoencephalitis following Le Fort I osteotomy: a case report.

Le Fort I osteotomies, although they are common procedures, carry a degree of risk of injury to the surrounding structures. Skull base fractures and cerebrospinal fluid rhinorrhoea are amongst the most serious on the list of complications. This is the first reported case of meningoencephalitis post Le Fort I osteotomy, shedding some light on its identification, causes, and management.

What should every dental health professional know about electronic cigarettes?

Electronic cigarettes (E-cigarettes) have become increasingly popular around the world. Currently, dental professionals' knowledge and attitudes are varied with many clinicians unclear regarding the impact of E-cigarette products on the oral and general health of their patients. With developing social and health-related challenges, advice of dental and medical associations and other regulatory bodies on E-cigarette use is changing. Growing evidence demonstrating the risks of E-cigarette usage has prompted a review of legislation in the United Kingdom (UK), United States of America (USA), Australia and Canada to include the sale and availability of E-cigarettes, particularly those containing nicotine. Further consideration within the scientific and public health community is being given to assessing demographic usage patterns particularly uptake by non-smokers and adolescents, efficacy as a cessation tool, the impact of vapour on bystanders and direct injuries via explosions as well as emerging lung injuries. This article aims to provide a summary of the most up to date evidence relating to E-cigarette use, the latest position of dental associations and the oral health implications of E-cigarettes compared to conventional smoking. The article also aims to collate this information in order to provide dental clinicians with guidance on how to advise patients, specifically in answering common questions posed regarding E-cigarette use.

Dealing with vascular anomalies during radial forearm free flap harvest: report of two cases and review of the literature.

Radial forearm free flap reconstruction for head and neck cancer is very common, and it is widely considered a workhorse flap. Although this flap has a relatively reliable anatomy, surgeons need to be aware of possible anatomical variations and how to deal with them. This paper presents the cases of two patients who underwent oral reconstruction, in whom anomalies of the radial artery were identified while raising a radial forearm free flap. Case 1 demonstrates the dominant branch of the radial artery joining the common interosseous artery approximately 9 cm from the first wrist crease. Case 2 demonstrates abnormal distal branching of the radial artery approximately 4 cm from the first wrist crease. Reconstruction with the flap was successful in both cases. A literature review of reported anomalies of the radial artery is presented, and how to deal with such vascular anomalies is discussed.

Is there a role for pentoxifylline and tocopherol in the management of advanced osteoradionecrosis of the jaws with pathological fractures? Case reports and review of the literature.

Osteoradionecrosis (ORN) is an infrequent but serious complication of radiotherapy, especially in the head and neck region. It is a slowly progressive condition, with management in the early stages focused on symptom control, and surgery usually reserved for advanced ORN. However, established ORN is difficult to treat. The role of hyperbaric oxygen therapy has recently been contested. The use of pentoxifylline in the management of ORN was first described by Delanian in 2004, but its benefits have not been replicated in other studies. In cases of advanced ORN with pathological fractures, many centres still advocate surgical resection and reconstruction. However, in this group of patients who often have multiple medical comorbidities, many of whom have previously undergone significant surgery, a resective plan is not always ideal. This paper presents two successful cases of bony union after the use of pentoxifylline and tocopherol to manage grade III ORN of the mandible. Both patients had pathological fractures and orocutaneous fistulas and were deemed unsuitable for surgery. The possible reasons for the success of pentoxifylline and tocopherol are discussed, and a review of the current literature evidence of similar cases is presented. Pentoxifylline and tocopherol should be considered for the management of advanced ORN where surgical management is not appropriate.

Arthrocentesis in the management of internal derangement of the temporomandibular joint.

BACKGROUND: Temporomandibular disorders (TMD) cover a wide spectrum of disorder; myalgic, arthralgic and psychogenic. The procedure of TMJ arthrocentesis has a role in managing patients with arthralgic pain and limitation if they fail to respond to non-surgical therapy. METHOD: The patient records of a single private specialist OMS were searched over the 9-year period of 2006-2014 to identify patients who had arthrocentesis as part of their multidisciplinary management. The detailed demographic, diagnosis, pre and post arthrocentesis procedure were identified and put on a database. Appropriate statistics were performed. RESULTS: Seventy-six patients had 115 arthrocentesis procedures performed in the study period. Fifty of 76 had improvement in their pain and 16 of 41 had an increased jaw opening of more than 10 mm. There were no complications or morbidity. Analysis of patient variables generally showed no correlations. CONCLUSIONS: Temporomandibular joint arthrocentesis has a role in the multidisciplinary, multimodality treatment of arthralgic TMD.

Can radiological examination of mandibular bone invasion accurately predict the need for mandibular resection in oral squamous cell carcinoma?

Bone invasion by oral squamous cell carcinoma necessitates jaw resection, with preoperative imaging ideally able to guide the resection. A retrospective review of 109 patients with oral squamous cell carcinoma who underwent mandibular resection was performed. Eighty-three had preoperative computed tomography (CT) imaging and 72 underwent magnetic resonance imaging (MRI). The presence of bone invasion on imaging was compared to histopathology. Bone invasion was detected in 44 of 109 resection specimens (40.4%) and was identified on CT in 31 of 83 cases (37.4%) and on MRI in 35 of 72 cases (48.6%). The sensitivity and specificity of CT for detecting bone invasion was 69.0% and 79.6%, respectively, while for MRI was 87.1% and 80.5%, respectively. Histological detection of bone invasion was associated with greater disease-specific mortality (P=0.002), as was MRI detection of bone invasion (P=0.027). CT detection was not significant (P=0.240). Negative prediction of bone invasion was 95% accurate for both modalities in clinically non-invaded mandibles. Survival was reduced in patients who underwent marginal mandibular resection when bone invasion was detected histologically (33.3% vs. 70.5%, P=0.277) and with CT, although this was not statistically significant. More data are required to determine whether more aggressive resection is warranted when bone invasion is detected preoperatively.

Assessing an oral surgery specific protocol for patients on direct oral anticoagulants: a retrospective controlled cohort study.

Chronic therapy with the new direct oral anticoagulants (DOACs) poses new challenges for dental practitioners assessing the risk versus benefit of cessation versus non-cessation of anticoagulant therapy for dentoalveolar procedures. A retrospective controlled cohort study was designed to evaluate a non-cessation protocol for patients taking DOACs in the setting of dental extractions. A records review covering the period 1 January 2016 to 31 December 2016 identified 43 patients on DOAC therapy; 53 dentoalveolar procedures were performed under local anaesthesia, of which 15 included varying degrees of peri-procedural cessation. A control group of 50 patients on uninterrupted warfarin therapy undergoing 59 dentoalveolar procedures was identified. The incidence, severity, and timing of bleeding events were recorded for each group. Four (10.5%) minor bleeding events were recorded in the non-cessation DOAC group and nine (15.3%) minor bleeding events in the warfarin group. No bleeding events were recorded in the DOAC cessation group. Comparison of the incidence of bleeding events between the non-cessation DOAC group and the warfarin group showed no statistically significant difference (odds ratio 0.65, P=0.56). Within the limitations of this study, dental extractions in the context of continuing DOAC therapy can be performed safely provided extra local haemostatic measures are applied.

Long-term outcomes of craniofacial implants for the restoration of facial defects.

The aim of this study was to evaluate the long-term survival of craniofacial implants and prostheses and to identify factors associated with failure in a cohort of patients. A 25-year retrospective analysis was conducted at Royal Melbourne Hospital. Data included demographic characteristics, age, site and cause of the deformity, and number and survival of implants. Odds ratios were calculated and event-to-time Kaplan-Meier analyses performed. One hundred and ten patients were included (341 implants); their mean age was 46.2 years. The overall implant survival rate was 79.5% (mean follow-up 10.6 years). Temporal implants had the highest success rate (97.0%), followed by nasal implants (87.5%) and orbital implants (63.3%); differences were statistically significant (P<0.0001 and P=0.033, respectively). Kaplan-Meier analyses to determine long-term implant and prosthesis survival found temporal implants had the highest prosthetic (P<0.0001) and implant survival (P<0.0001). Patients with congenital deformities demonstrated the highest success rate. Radiotherapy was found to increase the risk of implant failure (P=0.02). Craniofacial implant-retained prostheses are a reliable and effective option for the restoration of facial defects, with good long-term success rates. Orbital implants and those placed post oncological surgery have a higher failure rate.

Diagnostic dilemma between medication-related osteonecrosis and oral squamous cell carcinoma in a mandibular lytic lesion.

Osteolytic lesions of the mandible are common, and there are two important differential diagnoses that must be considered: medication-related osteonecrosis of the jaws (MRONJ) and squamous cell carcinoma (SCC). In patients with a history of taking antiresorptive medication as well as risk factors for neoplasia it can be difficult to differentiate between the two. We describe two cases in both of which a mandibular osteolytic lesion was inadequately identified as either MRONJ or SCC because of confusing clinical and histopathological features. We also reviewed relevant publications to identify similar cases. Here we discuss our clinical dilemma when faced with two different conditions that present with similar clinical and histopathological features.

High-flow paediatric mandibular arteriovenous malformations: case reports and a review of current management.

High-flow vascular malformations in the paediatric population are potentially life-threatening and are challenging to treat. This paper describes the management of three cases of mandibular arteriovenous malformations and reviews the contemporary management options for these serious lesions.

Surgical anatomy of the spinal accessory nerve: review of the literature and case report of a rare anatomical variant.

OBJECTIVE: To evaluate the prevalence of variations in the anatomical route of the spinal accessory nerve from the base of the skull to the point where it enters the trapezius muscle. A case report is used to demonstrate an example of a rare but clinically important anatomical variant of this nerve. METHODS: An independent review of the literature using Medline, PubMed and Q Read databases was performed using combinations of terms including 'spinal accessory nerve', 'anatomy', 'surgical anatomy', 'anatomical variant', 'cranial nerve XI' and 'shoulder syndrome'. RESULTS: Our report demonstrates marked variation in spinal accessory nerve anatomy. At the point of crossing over the internal jugular vein, the spinal accessory nerve passes most commonly laterally (anterior) to the internal jugular vein. The reported incidence of this lateral relationship varies from 67 to 96 per cent. The nerve can also pierce the internal jugular vein, as demonstrated in our case study, with incidence ranging from 0.48 to 3.3 per cent. CONCLUSION: Anatomical variations of the spinal accessory nerve are not uncommon, and it is important for the surgeon to be aware of such variations when undertaking surgery in both the anterior and posterior triangles of the neck.

Mandibular distraction osteogenesis for the management of upper airway obstruction in children with micrognathia: a systematic review.

Mandibular distraction osteogenesis (MDO) is increasingly used for neonates and infants with upper airway obstruction secondary to micrognathia. This systematic review was conducted to determine the effectiveness of MDO in the treatment of airway obstruction. The databases searched included PubMed, Embase, Scopus, and grey literature sources. The inclusion criteria were applied to identify studies in children with clinical evidence of micrognathia/Pierre Robin sequence (PRS) who had failed conservative treatments, including both syndromic and non-syndromic patients. Overall 66 studies were included in this review. Primary MDO for the relief of upper airway obstruction was found to be successful at preventing tracheostomy in 95% of cases. Syndromic patients were found to have a four times greater odds of failure compared to those with isolated PRS. The most common causes of failure were previously undiagnosed lower airway obstruction, central apnoea, undiagnosed neurological abnormalities, and the presence of additional cardiovascular co-morbidities. MDO was less effective (81% success rate) at facilitating decannulation of tracheostomy-dependent children (P<0.0001). Failure in these patients was most commonly due to severe preoperative gastro-oesophageal reflux disease, swallowing dysfunction, and tracheostomy-related complications. The failure rate was higher when MDO was performed at an age of ≥24 months. More studies are needed to evaluate the long-term implications of MDO on facial development and long-term complications.

Protocol in managing oral surgical patients taking dabigatran.

New anticoagulants are being introduced into the market. These drugs are orally administered, have predictable pharmacokinetics and dose response, do not require monitoring and have an acceptable safety profile when used appropriately, and so avoid many of the disadvantages and possible complications of warfarin and heparin. Dabigatran is the most widely used, and has been approved by the Therapeutic Goods Administration. The use of dabigatran will likely increase in the coming years, and so it is important for dentists to be aware of its mechanism of action, the possible complications, and how to reverse the bleeding if it occurs. This review discusses dabigatran and reports on our experience of five cases, and provides practical clinical advice on how to manage patients on dabigatran who require dental treatment, particularly extractions.

The incidence of mandibular third molar impactions in different skeletal face types.

BACKGROUND: The cause of mandibular third molar impaction is said to be due to inadequate space between the distal of the second mandibular molar and the anterior border of the ascending ramus of the mandible. The amount of space is determined primarily by facial growth. This study aimed to assess whether different patterns of facial growth lead to a different incidence of mandibular third molar impaction. It was hypothesized that those with predominantly horizontal (brachyfacial) would have lower incidence of mandibular third molar impaction compared with those with a predominantly vertical growth pattern (dolichofacial). METHODS: Ninety-eight dental records were sourced from the records of orthodontic patients in the Royal Dental Hospital of Melbourne and all lateral cephalometric radiographs and orthopantomograms were assessed. The degree of impaction was determined by the Pell and Gregory system, and the facial type categorized by the facial axis angle. RESULTS: The overall rate of mandibular third molar impaction was 58.76 per cent. Those with a facial axis angle >93 (brachyfacials) demonstrated an almost two times lower incidence of mandibular third molar impaction as compared to subjects with a facial axis angle <87 (dolichofacials). CONCLUSIONS: Within the limitations of the study, it was concluded that the greater horizontal facial growth pattern of brachyfacial subjects over dolichofacial subjects provides increased space for full eruption of the mandibular third molars.