Resection margin as a predictor of recurrence at the primary site for T1 and T2 oral cancers. Evaluation of histopathologic variables.

OBJECTIVE: To establish whether histopathologic variables other than the pathologist's statement of complete excision predict recurrence of squamous cell carcinoma at the primary site and therefore indicate local postoperative radiotherapy. DESIGN: Retrospective analysis of clinical data and review of slides of resection specimens. SETTING: Tertiary care, hospital-based clinic. PATIENTS: Eighty-two patients who had complete excision only (histologically based) of a T1 or T2 squamous cell carcinoma of the mobile tongue or floor of the mouth but did not receive any form of immediate postoperative radiotherapy. Twenty-nine patients underwent local resection without treatment of the NO neck; in 53 patients a neck dissection was also performed. METHODS: Evaluation of recurrent tumor above the clavicles until 4 years postoperatively and of second and third primaries. Infiltrative depth was evaluated in 73 cases and spidery spread, perineural spread, and angioinvasion in 70 cases. RESULTS: Of the squamous cell carcinoma, 27% were well differentiated and 73% were moderately differentiated; depth of invasion was 5 mm or more in 57%, a spidery growth pattern was present in 51%, there was perineural spread in 16%, and angioinvasion was found in 3%. Recurrences at the primary site, not linked to histopathologic findings, occurred in 4%; 17% of the patients had second primary tumors in the head and neck region, 15% had neck conversions, and 1% had neck recurrence. CONCLUSIONS: When excision of a small squamous cell carcinoma of the mobile tongue or the floor of the mouth is histologically complete, other histopathologic variables are irrelevant in predicting recurrence at the primary site, and local radiotherapy is not indicated, considering the morbidity and high number of second and third primary tumors to be expected that will require future new treatment.

Premature aging of the face after orthognathic surgery.

Attention is drawn to premature aging of the face after orthognathic surgery. Three examples are given of patients of around 30 years or over in whom maxillary excess was reduced. Suggestions for prevention of this (rare?) complication are made.

The case for postoperative orthodontics in orthognathic surgery.

In patients with orthognathic problems, in whom a combination of surgery and orthodontics is required, it seems to us better to defer orthodontic treatment until after surgery has been completed and a possible relapse tendency has petered out. This conclusion is reached on the basis of arch instability and the incidence of root resorption as reported in the orthodontic literature. The soundness of "permanent retention" after orthodontic therapy is questioned. The author's concepts are illustrated with a few case reports.

Serious circulatory disturbance after Le Fort I osteotomy. A case report.

Severe impairment of the blood supply occurred in a patient who underwent a Le Fort I type osteotomy in which the fragment was displaced in a cranio-dorsal direction. Necrosis with sequestration of the torus palatinus present and some permanent parodontal damage ensued. Alternative procedures and management of developing circulatory impairment during surgery are discussed.

Preserving the pterygoid plates in posterior repositioning of the LeFort I osteotomy.

The pterygoid plates have to be fractured and displaced to allow the maxilla to be repositioned posteriorly in the Le Fort I push-back osteotomy. A technique to reposition the maxilla posteriorly while preserving the pterygoid plates and the greater palatine neurovascular bundle is described. This technique reduces the risk of damaging the internal maxillary artery and the internal jugular vein which can lead to excessive haemorrhage. The disturbance to the Eustachian apparatus is also minimized.

Long-term dental management of cleft patients (Part 1).

This review paper examines the problems associated with the cleft patient and presents a scheme of management. Timing of each procedure is important, with particular emphasis on speech and maxillary development. The role of orthodontics is discussed.

Reconstruction of soft tissues of the chin and lower lip region following excision of a basal cell carcinoma.

A rather unusual case of basal cell carcinoma of the labio-mental fold area is presented where it was possible to preserve the vermilion of the lower lip after wide excision. This made reconstruction with bilateral nasolabial flaps and a platysma myocutaneous flap possible. Thus the sensitivity of the lower lip could be partly preserved, a competent lip seal obtained, microstoma avoided and a good vestibulum reconstructed.

Postoperative contamination of mandibular osteotomy sites with saliva.

Postoperative salivary contamination of surgical wounds around the mandible was found in several types of osteotomy and bone grafting procedure. This problem was investigated by determining the amylase content of wound secretions in redon bottles every 24 h. The implications for antibiotic prophylaxis are discussed.

The influence of flucloxacillin and amoxicillin with clavulanic acid on the aerobic flora of the alimentary tract.

In a randomized study, 42 patients undergoing extensive maxillo-facial surgery (correction of the position of the mandible or maxilla by using autologous bone transplants) received prophylactically ten-day courses of either flucloxacillin or amoxicillin with clavulanic acid. Patients were comparable with regard to age and type of surgery. During the prophylactic treatment the effect of antibiotics used on the microbial flora of the alimentary tract was studied. Patients receiving flucloxacillin showed increased numbers of Klebsiella spp. isolated from the faeces (59% of the patients versus 19% of the patients receiving amoxicillin with clavulanic acid). Patients receiving amoxicillin with clavulanic acid showed higher colonization rates of oropharynx with Enterobacteriaceae than patients receiving flucloxacillin (ten patients versus five patients). 60% of those strains isolated from patients receiving amoxicillin with clavulanic acid were resistant to this combination, as compared to 20% of gram-negative bacilli isolated from patients receiving flucloxacillin. In 50% of patients receiving amoxicillin with clavulanic acid, colonization of the gut with yeast occurred, as compared to 18% of patients receiving flucloxacillin. Only one infection leading to a partial loss of the graft was seen in the group of patients receiving flucloxacillin.

In-rolling the drooping nostril rim in cleft patients.

A technique for in-rolling the nostril rim in cleft patients is described. A broken scar line on the inside of the nostril is produced.

Wound infection after mandibular reconstruction with autogenous graft.

An investigation on the fate of bone grafts in 38 patients, who had been subjected to a partial resection of the mandible for benign and malignant tumours, is presented. Apart from thorough drainage, meticulous suturing and gastric tube feeding, high and prolonged administration of antibiotics was practised to prevent infection. The basic antibiotic coverage in most patients consisted of 4 X 3 grams of flucloxacilline intravenously during ten days. After this period revascularization of a bone graft may be assumed to have progressed to such a degree, that thereafter the graft can "defend itself" against invading micro-organisms, if necessary supported by further lower dosage antibiotic treatment. In 28 patients no complications were encountered. Ten patients showed signs of infection, leading to complete loss of the graft in 3 patients. Incision, drainage, removal of sequestra and further antibiotic treatment resulted in preservation of the major part of the grafts in the other 7 patients. No correlation of infection with type of fixation, extent of soft tissue resection or time at which the reconstruction was done (primary or secondary) was found. The basic difference of maxillo-facial bone grafting as compared to bone grafting in other areas of the body is stressed, massive primary contamination combined with dead space and maybe dehiscence of the oral wound margins being mainly responsible for the relatively unfavourable conditions for grafting in this region.

Treatment of unilateral ankylosis of the temporo-mandibular joint when a class II skeletal relationship exists.

If, in a case of ankylosis of the temporo-mandibular joint, a class II skeletal relationship exists, advancement of the mandible into a class I skeletal relationship should be an integral part of the treatment plan. The advantages are: better aesthetics (especially the appearance of the chin), more efficient action of the suprahyoid muscles (mouth openers), diminished contact of the angle of the jaw with the sterno-cleido-mastoid muscle, increased distance of the lower incisors from the axis of rotation of the mandible (resulting in increased incisal distance at the same rotational angle) and the possibility of correction of the sometimes traumatic occlusion against the palatal mucosa all in the same session. The method advocated in unilateral cases is the insertion of a costo-chondral graft on the affected side and a lengthening osteotomy on the opposite side with fixation into a class I skeletal relationship initially disregarding the incisal relationship.

Timing of palatal closure.

Three articles on the influence of timing of palatal closure on jaw development, ENT condition and speech are subjected to an overall evaluation. A number of questions are formulated, which are still to be answered before a well-founded decision on the timing of palatal surgery can be taken. The evidence presently available made the author conclude that the whole palate should be closed before the age of 18 months, at least if the development of speech has priority over development of the maxilla.

The influence of age at operation for clefts on the development of the jaws.

In this follow-up study of adult cleft patients with a unilateral cheilognathopalatoschisis, the effect on maxillo-mandibular development of the age at which the palatoplasty had been performed was investigated. It was concluded that it makes little difference whether the hard palate is closed at the age of 3 or 6 years.

Hyperbaric oxygen treatment of chronic osteomyelitis of the jaws.

A review of the literature on treatment of chronic osteomyelitis of the jaws shows that hyperbaric oxygen is often recommended as an adjunct in treatment of this disease. Definite criteria to indicate this treatment and to evaluate the results have not been reported. The results of hyperbaric oxygen treatment of chronic osteomyelitis of the jaws in 16 patients are presented. In contrast to the good results reported in the literature, only 7 of our patients could be considered as cured. The reasons for this discrepancy are discussed. Our results, as well as the data from the literature, indicate that a combined antibiotic and surgical approach is the treatment of choice in chronic suppurative osteomyelitis. However, in chronic diffuse sclerosing osteomyelitis and in patients in whom decortication and antibiotic therapy have failed, hyperbaric oxygen treatment in combination with antibiotics and surgery seems to be indicated.