Immediate dental rehabilitation in fibula free flaps for malignancy: Is it feasible?

BACKGROUND: Fibula free flap reconstruction has revolutionized maxillofacial reconstruction. While immediate dental rehabilitation with dental implants and teeth has shown benefits, it remains uncommon, especially for patients with malignancy. METHODS: A retrospective cohort study at a single institution explored immediate dental rehabilitation in fibula flaps for patients with malignant disease. Thirteen patients with malignancies that underwent immediate fibula free flap reconstruction with dental implants and dental prosthesis were included with a minimum of 3-month follow-up. RESULTS: Forty eight implants replaced 90 teeth in 13 patients. All implants were integrated at 3 months, with an overall success rate of 87.5%. Two patients experienced delayed (>3 months postoperatively) implant loss due to osteoradionecrosis and infection. Peri-mucositis occurred in three patients which resolved with treatment. Skin paddles were used in 11 patients and radiation therapy was not delayed for any patient. CONCLUSION: With proper patient selection, diagnosis of malignancy and the need for osteocutaneous flap reconstruction does not exclude the ability to place immediate implants and deliver an immediate dental prosthesis in head and neck reconstruction.

The utility of cone-beam computed tomography and multislice computed tomography scan for the evaluation of invasion versus erosion by mandibular squamous cell carcinoma as viewed on medical PACS.

Introduction: The degree of bone involvement in mandibular squamous cell carcinoma has a significant impact on surgical planning. The purpose of this study was to determine the utility of cone-beam computed tomography (CBCT) for the evaluation of invasion by mandibular squamous cell carcinoma. Methods: A retrospective review was conducted to identify subjects treated for oral squamous cell carcinoma (OSCC). All subjects had OSCC adjacent or fixed to the mandible, received preoperative CBCT and multislice computed tomography scan (MSCT), and had resection specimens that included bone. Results: Twenty-one subjects met the inclusion criteria. The sensitivity of CBCT was 100% (95% CI 0.75-1), the specificity was 75% (95% CI 0.35-0.97), the positive predictive value was 87% (95% CI 0.66-0.98), and the calculated test accuracy was 91%. The sensitivity of MSCT was 92% (95% CI 0.64-1), the specificity was 100% (95% CI 0.63-1), and the calculated test accuracy was 95%. Discussion: CBCT provides meaningful data that may be useful in identifying bony involvement in patients with mandibular squamous cell carcinoma. The utility in delineating erosion versus invasion is limited.

Immediate Teeth in Fibulas Versus Standard Fibula Free Flap: A Comparison of Donor Surgical Site Infections.

BACKGROUND: Immediate placement of dental implants with dental restoration at the leg donor site requires implant components and prosthetic materials that are not packaged sterile. PURPOSE: This study aimed to determine if there was a difference in donor surgical site infection between patients that received a fibula free flap with dental implants and immediate teeth (ITFFF: immediate teeth fibula free flap) before flap transfer to the defect site when compared to standard fibula free flaps (SFFFs) without dental implant placement. STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study was designed and implemented. The study population was composed of patients who underwent free fibula flap transfer for the treatment of benign or malignant conditions of the head and neck from 2015 to 2022. Patients who received immediate dental implants without teeth were excluded, since those implants are sterile and buried under soft tissue. PREDICTOR VARIABLE: The surgical treatment with either ITFFF or SFFF was treated as the primary predictor variable. MAIN OUTCOME VARIABLE: The primary outcome variable was postoperative donor surgical site infection. COVARIATES: There were 12 covariate variables including age, sex, diabetes diagnosis, immunosuppression/prior chemotherapy treatment, body mass index, smoking status, pack year history, pathology treated, technique for fibula donor site closure, skin paddle harvest, skin paddle area (cm2), and negative pressure wound therapy. ANALYSES: For the effect of the covariates on the primary predictor variable, χ2 analyses and t-tests were used. The effect of the primary predictor variable on the primary outcome was evaluated using χ2 analysis. A P value of < 0.05 was considered statistically significant. RESULTS: There were 37 patients in the ITFFF group and 47 in the SFFF group. The donor site infection rate for the entire study population was 2.38%. In the ITFFF group, there was 1 donor surgical site infection (2.70%), and in the SFFF group there was also 1 donor surgical site infection (2.13%). There was no significant difference in donor surgical site infection between the groups (P = .86). CONCLUSION AND RELEVANCE: This study found no difference in donor surgical site infection rates between patients who received ITFFF versus SFFF. The overall donor surgical site infection rate following fibula free flap is low.

Individualized implants using point-of-care printed models in the treatment of orbital blowout fractures.

OBJECTIVE: This case series aims to highlight the digital workflow used by our institution to treat orbital fractures by creating individualized implants using point-of-care, 3-dimensional (3D) printed models. STUDY DESIGN: The study population comprised consecutive patients who presented to John Peter Smith Hospital with isolated orbital floor and/or medial wall fractures from October 2020 to December 2020. Patients treated within 14 days of their initial injury and with 3 months postoperative follow-up were included. Bilateral orbit fractures were excluded because an intact contralateral orbit is needed for 3D modeling. RESULTS: A total of 7 consecutive patients were included. The orbital floor was involved in 6 of the fractures, whereas 1 fracture involved the medial wall. All patients with preoperative diplopia, enophthalmos, or both had resolution by the 3-month postoperative follow-up appointment. Postoperatively, there were no complications in all patients included. CONCLUSIONS: The point-of-care digital workflow presented allows for the efficient production of individualized orbital implants. This method may produce a midface model in hours that can be used to pre-mold an orbital implant to the mirrored, unaffected orbit.

Does the use of a "wrap" in three-dimensional surgical planning influence the bony margin status of benign and malignant neoplasms of the oral, head, and neck region? An initial investigation.

PURPOSE: Three-dimensional surgical planning (3-DSP) is becoming commonplace in the management of benign and malignant disease for oral and maxillofacial surgery practice within the last decade. Surgeons utilize a virtual "wrap" to preoperatively delineate and define maxillofacial tumor resection margins. The investigators hypothesized that the use of a wrap is a predictable method to obtain negative bony margins. METHODS: The investigators implemented a retrospective chart review. The sample was composed of patients over the age of 18 treated at John Peter Smith Health Network and Parkland/UT Southwestern Medical Center who obtained 3-DSP for the pathology of the head and neck, involving the bone, with a virtual wrap utilized for bony margins. The proportion of cases was calculated, descriptive statistics were reported, and binomial exact calculation was performed for confidence intervals. The primary variable analyzed was bony margin status on final histopathology, involved or uninvolved, based on the pathology report. RESULTS: The sample was composed of 39 cases, one of which was excluded due to aborting the preplanned 3-DSP. Of the 38 included cases, one had involved bony margin on final histopathology (2.6%; 95% confidence limits, 0.1%, 13.8%). There were 16 malignant cases (42%) and 22 benign cases (58%). When stratified by pathology, 1 out of the 16 malignant cases (6.3%; 95% confidence interval, 0.2%, 30%) and 0 out of the 22 benign cases (95% confidence interval, 0%, 15.4%) had an involved bony margin on final histopathology. CONCLUSION: The results of this preliminary study suggest three-dimensional surgical planning with wrap margins is a predictable method to obtain negative bony margins in benign and malignant disease of the maxillofacial complex. Further studies will focus on compiling prospective data to solidify the accuracy and predictability of using a wrap to obtain negative bony margins.

Etramp5 as a useful serological marker in children to assess the immediate effects of mass drug campaigns for malaria.

INTRODUCTION: Serological methods provide useful metrics to estimate age-specific period prevalence in settings of low malaria transmission; however, evidence on the use of seropositivity as an endpoint remains scarce in studies to evaluate combinations of malaria control measures, especially in children. This study aims to evaluate the immediate effects of a targeted mass drug administration campaign (tMDA) in Haiti by using serological markers. METHODS: The tMDA was implemented in September-October 2018 using sulfadoxine-pyrimethamine and single low-dose primaquine. A natural quasi-experimental study was designed, using a pretest and posttest in a cohort of 754 randomly selected school children, among which 23% reported having received tMDA. Five antigens were selected as outcomes (MSP1-19, AMA-1, Etramp5 antigen 1, HSP40, and GLURP-R0). Posttest was conducted 2-6 weeks after the intervention. RESULTS: At baseline, there was no statistical difference in seroprevalence between the groups of children that were or were not exposed during the posttest. A lower seroprevalence was observed for markers informative of recent exposure (Etramp5 antigen 1, HSP40, and GLURP-R0). Exposure to tMDA was significantly associated with a 50% reduction in the odds of seropositivity for Etramp5 antigen 1 and a 21% reduction in the odds of seropositivity for MSP119. CONCLUSION: Serological markers can be used to evaluate the effects of interventions against malaria on the risk of infection in settings of low transmission. Antibody responses against Etramp5 antigen 1 in Haitian children were reduced in the 2-6 weeks following a tMDA campaign, confirming its usefulness as a short-term marker in child populations.

Management of Salivary Gland Injury.

Although a rare sequala of soft tissue injury, salivary gland trauma may result in significant morbidity. Salivary gland injury can involve the major as well as the minor glands. Because of the proximity of adjacent vital structures, a thorough history and physical examination are mandatory during patient evaluation. Trauma to the major salivary glands may involve the parenchyma, duct, or neural injury. Treatment requires adherence to primary principles of soft tissue management. Ductal and neural injury should be repaired primarily. Sialocele and fistula are potential complications of repaired and unrepaired salivary gland injury.

Immediate Teeth in Fibulas: Expanded Clinical Applications and Surgical Technique.

PURPOSE: The placement of immediate implants and teeth during jaw reconstruction using a fibula free flap has increased in recent years. Modifications of traditional fibula reconstructive techniques are needed to maximize success. This technique has not been described in patients requiring simultaneous soft tissue reconstruction. Our patient cohort includes cases with malignant pathology and those requiring skin paddles.  With digital workflows and point-of-care 3D printing, surgery is no longer delayed weeks for prosthesis fabrication. The purpose of this case series is to demonstrate a single institution's experience with expanded clinical applications and surgical techniques that enable predictable outcomes for immediate teeth in fibula flaps. MATERIALS AND METHODS: Ninety-five implants were placed in 22 patients undergoing fibula reconstruction of the jaw with immediate implants and an immediate dental prosthesis. Skin paddles were used in 10 patients while 12 patients had native mucosa. Six patients were treated for malignancies and underwent postoperative radiation. Implant success and complications were compared between implants with skin paddles and implants with native mucosa. RESULTS: Of 95 implants, 92 implants integrated for a 97% integration rate. All 13 radiated implants in 4 patients integrated. All 36 implants adjacent to skin paddles in 10 patients integrated. Seven implants were lost in a delayed fashion 9 to 15 months postoperatively resulting in a 93% overall implant success rate. Of the 22 patients, diagnoses were benign pathology for 11 patients, malignant pathology for 6 patients, gunshot wounds for 3 patients, and osteoradionecrosis for 2 patients. CONCLUSION: Immediate placement of dental prostheses on immediate implants during fibula reconstruction of the jaws can be performed with a high rate of predictability. This technique can be expanded to select patients needing skin paddles. Modifications of traditional fibula reconstructive techniques are helpful to minimize soft tissue and prosthetic challenges.

Immediate Teeth in Fibulas: Planning and Digital Workflow With Point-of-Care 3D Printing.

PURPOSE: Point-of-care 3-dimensional (3D) printing has become more common in recent years because many hospitals have created 3D printing laboratories. Traditional techniques to fabricate an immediate dental prosthesis for fibula and implant reconstructions have involved outsourcing to dental laboratories. This results in delays, making it suitable only for benign disease. In the present report, we have demonstrated a technique for in-house creation of a 3D printed dental prosthesis for placement of implants at free fibula maxillofacial reconstruction. Our digital method has reduced costs and shortened the interval to surgery compared with traditional laboratory techniques. MATERIALS AND METHODS: Twelve patients underwent free fibula reconstruction of the mandible or maxilla with immediate implants and immediate teeth. A dental implant-retained restoration was created before surgery for immediate placement at fibula reconstruction. For the first 5 patients, the prosthesis was fabricated by a dental laboratory after virtual surgical planning. For the next 7 patients, the prosthesis was designed by the surgeon and 3D printed via the in-house laboratory. Four of these in-house cases were performed for malignant disease with skin paddles. RESULTS: All 12 patients received an immediate implant-retained fixed prosthesis at fibula reconstruction. The time required to generate the in-house 3D printed prostheses was significantly shorter than that required to create the dental laboratory-fabricated prostheses. The costs were also less with the 3D printed prostheses compared with the dental laboratory-fabricated prostheses. CONCLUSIONS: The digital workflow we have presented eliminates the delay in creating a dental laboratory-fabricated provisional dental prosthesis for fibula and implant reconstruction. This allows for immediate dental restoration for patients with malignant disease previously considered unsuitable owing to the inherent delay required using an offsite dental laboratory. A decrease in cost to create in-house 3D printed prostheses was noted compared with the prostheses fabricated by a dental laboratory. Case selection is critical to predict the soft tissue needs for composite defects.

Role of Free Tissue Transfer in Facial Trauma.

For large composite traumatic defects of the head and neck, free tissue transfer presents a reconstructive allowing for the reconstitution of both form and function. Furthermore, the ability to provide bulk, soft, and hard tissue, as well as immediate dental rehabilitation, makes free tissue transfer an efficient and attractive option for head and neck reconstruction. Herein, we discuss the utility of free tissue transfer in facial trauma, its problems, complications, and controversies.

Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

Spindle cell and pleomorphic lipomas (SC/PLs) are a rare form of lipomatous tumors. They typically occur as a slow-growing localized mass in the subcutaneous fatty tissue of the posterior neck, back, and shoulders. This benign variant represents less than 1.5% of all lipomas and is relatively uncommon in the head and neck area. A manifestation in the larynx is even rarer. Unlike other anatomic locations, laryngeal lipomas can pose life-threatening symptoms secondary to acute obstruction of the upper aerodigestive tract. This report presents a case of a large SC/PL of the larynx associated with hoarseness, dysphagia, globus sensation, and neck fullness. The tumor was successfully removed through an anterior transcervical approach with infrahyoid myotomy. The authors review the literature concerning head and neck adipocytic tumors with spindle cells and discuss the difficulties in distinguishing SC/PLs from liposarcomas. To the best of the authors' knowledge, this is the first case to be reported in the oral and maxillofacial surgery literature.

Preoperative Vascular Interventions to Improve Donor Leg Perfusion: A Report of Two Fibula Free Flaps Used in Head and Neck Reconstruction.

PURPOSE: For reconstruction of head and neck defects, the fibula free flap is the first choice at many institutions. The main contraindication for fibula harvest is the lack of 3-vessel runoff, which leads to postoperative vascular compromise of the lower extremity. Atherosclerosis is the most common disease, which can limit the use of this donor site. In general, vascular interventions, which include angioplasty, atherectomy, and stenting, have been used to fix arterial supplies using endovascular methods. The purpose of this study was to report on the outcome of a preliminary cohort of patients after vascular interventions to re-establish vessel patency to allow safe use of the free fibula free flap in head and neck reconstruction. MATERIALS AND METHODS: A single-institution retrospective case review using electronic medical records was designed. The study population was composed of patients who underwent a fibula free flap procedure for head and neck reconstruction from 2015 through 2017. Inclusion criteria were patients who underwent conventional angiography and required vascular interventions. There were no specific exclusion criteria. The primary outcome of interest was vascular compromise of the donor site. Additional variables of interest included success of reconstruction and perioperative donor or recipient site complications. RESULTS: Two patients who underwent preoperative vascular interventions of the superficial femoral artery and posterior tibial artery were identified. The mean age was 65 years, and these patients underwent resection and reconstruction for mandibular carcinoma. For these patients, fibula flaps were harvested from the left lower extremity and included skin paddles. The fibula flaps survived and the donor feet maintained adequate perfusion. One patient had poor take of the split-thickness skin graft. No long-term functional deficit was noted. CONCLUSIONS: Vascular interventions could be a safe method to re-establish vascular flow and 3-vessel runoff for select patients initially unable to undergo fibula free flap harvest.

Intrapartum and neonatal mortality among low-risk women in midwife-led versus obstetrician-led care in the Amsterdam region of the Netherlands: a propensity score matched study.

OBJECTIVE: To compare intrapartum and neonatal mortality in low-risk term women starting labour in midwife-led versus obstetrician-led care. STUDY DESIGN: We performed a propensity score matched study using data from our national perinatal register, completed with data from medical files. We studied women without major risk factors with singleton pregnancies who gave birth at term between 2005 and 2008 in the Amsterdam region of the Netherlands. Major risk factors comprised non-vertex position of the fetus, previous Caesarean birth, hypertension, (gestational) diabetes mellitus, post-term pregnancy (≥42 weeks), prolonged rupture of membranes (>24 hours), vaginal bleeding in the second half of pregnancy or induced labour. Groups were devided by midwife-led versus obstetrician-led care at the onset of labour. The primary outcome was intrapartum and neonatal (<28 days) mortality. Secondary outcomes included obstetric interventions, 5 min Apgar scores<7 and neonatal intensive care admittance for >24 hours. RESULTS: We studied 57 396 women. Perinatal mortality occurred in 30 of 46 764 (0.64‰) women in midwife-led care and in 2 of 10 632 (0.19‰) women in obstetrician-led care (OR 3.4, 95% CI 0.82 to 14.3). A propensity score matched analysis in a 1:1 ratio with 10 632 women per group revealed an OR for perinatal mortality of 4.0 (95% CI 0.85 to 18.9). CONCLUSION: Among low-risk women, midwife-led care at the onset of labour was associated with a statistically non-significant higher mortality rate.

Comparison of the Le Fort I maxillary osteotomy with the sublabial transnasal and endonasal approaches to the sphenoid sinus and sella: a cadaveric study.

PURPOSE: The purpose of this study is to compare the access afforded by the Le Fort I osteotomy with the more traditional sublabial and endonasal approaches to the pituitary fossa. PATIENTS AND METHODS: Five fresh cadaveric heads were obtained for this study. Endonasal, sublabial, and Le Fort I osteotomy approaches to the pituitary fossa were performed on each specimen. Retractors were placed in the surgical field to simulate the intraoperative speculum position for each approach. Fluoroscopic images were obtained in 2 views. For each specimen, all images for a given approach were digitally superimposed to compare the magnitude of exposure obtained by each approach. Angular measurements were then compared among the 3 approaches. RESULTS: In the axial plane the degree of lateral exposure with the Le Fort I approach ranged from 15 degrees to 35 degrees, with a mean of 22.6 degrees. By comparison, minimal or no lateral movement of the speculum was possible with the sublabial and endonasal approaches. In the sagittal plane the degree of vertical exposure with the Le Fort I approach ranged from 13 degrees to 22 degrees, with a mean of 17 degrees. The sublabial approach provided 6 degrees to 17 degrees of vertical exposure, with a mean of 11.4 degrees. Minimal or no vertical movement of the speculum was possible with the endonasal approach. CONCLUSIONS: The Le Fort I osteotomy is a valuable midline approach for pituitary lesions that require broad exposure. Access in both the axial and sagittal planes is greater than with traditional trans-septal approaches.

Prenatal diagnosis of fetal intracranial hemorrhage at 25 weeks of gestation.

OBJECTIVE: To determine whether magnetic resonance imaging (MRI) can give further information for the prenatal diagnosis of intracranial hemorrhage, when ultrasound (US) is not conclusive. METHODS: We report on a fetus in the 26th week of gestation with a grade-III hemorrhage in the right cerebral hemisphere, which was suspected on US examination and specified by MRI examination in a patient with pre-eclampsia. RESULTS: Doppler measurement of the umbilical artery, which showed the absence of end diastolic velocity, was indicative of placental insufficiency. The MRI specified the findings found by US examination and confirmed the poor outcome of the fetus. Labor was induced by prostaglandins in the 27th week of gestation. Postmortem examination showed a female fetus with a grade-III intracranial hemorrhage in the center of the right hemisphere with a diameter of 4 cm. A hemorrhage was also found in the subarachnoid space and in the occipital region of the left hemisphere. CONCLUSION: We suggest that fetuses at high risk of developing hypoxia should be sonographically evaluated and MRI should be considered when intracranial echogenicities are seen.