Microstructured beta-tricalcium phosphate for alveolar cleft repair: a two-centre study.

The current standard of care in alveolar cleft repair is timing the procedure in the mixed dentition stage and making use of autologous bone to restore the maxillary defect. Using a synthetic bone substitute bypasses the risk of donor site morbidity and reduces the operation time. In this study, the outcome of alveolar cleft repair using microporous beta-tricalcium phosphate (ß-TCP) was investigated in patients with unilateral cleft lip and palate. Twenty patients were enrolled prospectively in this study, divided between two centres. Continuity of the alveolar process, recurrence of oronasal fistulas, and eruption of teeth into the repaired cleft were evaluated at 1year postoperative. Also, cone beam computed tomography scans were analyzed using a volume-based semi-automatic segmentation protocol. No adverse events were reported. The mean residual bone volume in the repaired cleft at 1year postoperative was 65%. There was no recurrence of oronasal fistula. Furthermore, 90% of the teeth adjacent to the cleft erupted spontaneously and all patients showed a continuous alveolar process. Secondary alveolar grafting using microporous ß-TCP can safely be used in the clinical situation. Residual calcified tissue, canine eruption, and complication rates at the recipient site are comparable to those with autologous grafts.

Intratumoral injection of radioactive holmium ( 166 Ho) microspheres for treatment of oral squamous cell carcinoma in cats.

BACKGROUND & AIMS: A "microbrachytherapy" was developed as treatment option for inoperable tumours by direct intratumoral injection of radioactive holmium-166 ( 166 Ho) microspheres (MS). 166 Ho emits ß-radiation which potentially enables a high, ablative, radioactive-absorbed dose on the tumour tissue while sparing surrounding tissues. MATERIALS & METHODS: Safety and efficacy of 166 Ho microbrachytherapy were evaluated in a prospective cohort study of 13 cats with inoperable oral squamous cell carcinoma without evidence of distant metastasis. RESULTS: Local response rate was 55%, including complete response or partial response (downstaging) enabling subsequent marginal resection. Median survival time was 113 days overall, and 296 days for patients with local response. Side effects were minimal. Tumour volume was a significant predictor of response. DISCUSSION: Response rate may be further improved by optimizing the intratumoral spatial distribution of 166 Ho MS. CONCLUSION: 166 Ho microbrachytherapy has potential as a minimally invasive, single procedure radio-ablation treatment of unresectable tumours with minimal morbidity.

Long-term mid-facial growth of patients with a unilateral complete cleft of lip, alveolus and palate treated by two-stage palatoplasty: cephalometric analysis.

OBJECTIVES: The aim of this study is to evaluate long-term facial growth in adults previously treated for an isolated unilateral complete cleft lip, alveolus and palate by two-stage palatoplasty. MATERIALS AND METHODS: Unilateral cleft lip and palate (UCLP) patients of 17 years and older treated by two-stage palatoplasty were invited for long-term follow-up. During follow-up, lateral cephalograms were obtained (n = 52). Medical history was acquired from their medical files. Outcome was compared to previously published normal values and the Eurocleft study. RESULTS: Soft and hard palate closure were performed at the age of 8 (SD 5.9) months and 3 (SD 2.2) years, respectively. The mean maxillary and mandibular angle (SNA, SNB) were 74.9° (SD 4.2) and 75.8° (SD 3.8). Maxillary and maxillomandibular relationships (SNA, ANB) were comparable to all Eurocleft Centres, except for Centre D. We observed a significantly steeper upper interincisor angle compared to the Eurocleft Centres. CONCLUSIONS: This study describes the long-term craniofacial morphology in adults treated for a UCLP with hard palate closure at a mean age of 3 years. The mean maxillary angle SNA and mandibular angle SNPg were comparable to previous studies both applying early and delayed hard palate closure. The observed upper incisor proclination is likely caused by orthodontic overcorrection in response to the unfavourable jaw relationships. No clear growth benefit of this protocol could be demonstrated. CLINICAL RELEVANCE: The present study shows the long-term craniofacial morphology of UCLP adults after the Utrecht treatment protocol which includes two-stage palate closure.

Management of the premaxilla in the treatment of bilateral cleft of lip and palate: what can the literature tell us?

OBJECTIVE: In the treatment of bilateral cleft lip and palate (BCLP) patients, there is discussion about the management of the position of the premaxilla. This literature analysis summarises the literature on managing this condition. MATERIALS AND METHODS: A PubMed, Embase and Cochrane Library search was conducted resulting in 4465 articles which were screened on title and abstract. RESULTS: Seventy-one articles were available in full text, 16 of which were included in this literature analysis. We searched on keywords timing and technique, complications, growth of the maxilla and results after bone grafting the alveolar process. This literature analysis has shown that there are various ways to correct the position of the premaxilla. These can be divided into primary, early, late secondary and tertiary intervention before the age of 8 years, between the ages of 8 and 12 years and older than 12 years. Correction is done with surgery, orthodontics or a combination, with or without bone grafting. CONCLUSIONS: An osteotomy of the premaxilla in combination with secondary alveolar bone grafting appears to be the most successful technique. Combining early secondary alveolar bone grafting with osteotomy creates more room to ensure a watertight closure of the nasal mucosa resulting in fewer postoperative complications. Before surgery, the orthodontist should try to optimise the position of the premaxilla for its surgical correction prior to bone grafting. CLINICAL RELEVANCE: The treatment of BCLP patients is still based on experience and expert opinions. This literature analysis tries to give a summery on how to handle the protruded and displaced premaxilla.

The Co-Expression of Kallikrein 5 and Kallikrein 7 Associates with Poor Survival in Non-HPV Oral Squamous-Cell Carcinoma.

OBJECTIVE: Oral squamous-cell carcinoma (OSCC) still has a poor prognosis. Lymph node metastasis (LNM) is a major determinant of treatment decisions and prognosis. Serine protease inhibitor Kazal-type 5 (SPINK5) is the inhibitor of kallikrein 5 (KLK5) and KLK7. SPINK5, KLK5 and KLK7 are three of the genes of a recently validated LNM-predicting gene expression profile in OSCC. This study evaluates their clinicopathological role and value as biomarkers in OSCC. METHODS: Eighty-three patients with primary OSCC, treated surgically between 1996 and 2000, were included. Gene expression data were acquired from a previously reported study. Human papillomavirus (HPV) status was determined by an algorithm for HPV-16. Protein expression for KLK5, KLK7 and SPINK5 was semi-quantitatively determined in all 83 tumours by immunohistochemistry. All expression data were correlated with clinicopathological parameters. RESULTS: Concurrent loss of KLK5 and KLK7 correlates with worse disease-specific and overall survival (DSS and OS). Multivariate analysis proved that co-expression is an independent prognostic factor for DSS (p = 0.029) and OS (p = 0.001). CONCLUSION: This report demonstrates that concurrent loss of KLK5 and KLK7 associates with a poor clinical outcome in OSCC and could therefore serve as prognostic marker in this disease.

Predictive factors for premature loss of Martin 2.7 mandibular reconstruction plates.

Mandibular reconstruction with a plate, with or without a vascularised free (bone) flap, is commonly used to treat patients with a segmental mandibular defect. Common complications are loosening of the osteosynthesis screws, malposition, intraoral or extraoral exposure, or infection. To define prognostic factors for premature loss of such plates and improve future planning, we designed a retrospective study of all patients operated on between 2005 and 2011 for reconstruction of a mandibular segmental defect with a reconstruction plate with or without a free vascularised (bone) flap. Prognostic factors collected from medical records were the patient's age, sex, and American Society of Anesthesiologists (ASA) grade; treatment with radiotherapy; whether they had diabetes or smoked; the site of the mandibular defect; whether there was a dental occlusion; the number of screws used on each side, and the use of a free vascularised (bone) flap; and whether the diagnosis was of oral cancer, benign tumour, or trauma. One hundred patients were included, 79 with oral cancer, 19 with benign tumours, and 2 with trauma. In 20 patients the Martin 2.7 reconstruction plate failed. Diabetes and smoking were significant prognostic factors for premature loss of the reconstruction plate with a hazard ratio of 2.95 (95% CI 1.068-8.172), p value=0.04, for diabetes, and 2.42 (95% CI 1.006-5.824), p value=0.05, for smoking. Smokers and diabetic patients have a higher risk of failure after mandibular reconstruction with a 2.7 reconstruction plate.

Long-term effect of a nurse-led psychosocial intervention on health-related quality of life in patients with head and neck cancer: a randomised controlled trial.

BACKGROUND: Head and neck cancer (HNC) patients are prone to have a poor health-related quality of life after cancer treatment. This study investigated the effect of the nurse counselling and after intervention (NUCAI) on the health-related quality of life and depressive symptoms of HNC patients between 12 and 24 months after cancer treatment. METHODS: Two hundred and five HNC patients were randomly allocated to NUCAI (N=103) or usual care (N=102). The 12-month nurse-led NUCAI is problem-focused and patient-driven and aims to help HNC patients manage with the physical, psychological and social consequences of their disease and its treatment. Health-related quality of life was evaluated with the EORTC QLQ-C30 and QLQ H&N35. Depressive symptoms were evaluated with the CES-D. RESULTS: At 12 months the intervention group showed a significant (P<0.05) improvement in emotional and physical functioning, pain, swallowing, social contact, mouth opening and depressive symptoms. At 18 months, global quality of life, role and emotional functioning, pain, swallowing, mouth opening and depressive symptoms were significantly better in the intervention group than in the control group, and at 24 months emotional functioning and fatigue were significantly better in the intervention group. CONCLUSION: The NUCAI effectively improved several domains of health-related quality of life and depressive symptoms in HNC patients and would seem a promising intervention for implementation in daily clinical practice.

[The Great War 1914-1918 and oral and maxillofacial surgery]. / De Grote Oorlog 1914-1918 en de mondziekten, kaak- en aangezichtschirurgie.

One hundred years ago the Great War, also known as the first world war, started. Historians consider the attack on the Austrian Archduke Franz Ferdinand on June 18, 1914 as the cause of the catastrophe. The initial war of movement turned into a 'Sitz Krieg', trench warfare. Many hundreds of thousands of military casualties were treated for a wide variety of facial wounds that resulted from the conflict. The origin of the specialisation oralmaxillofacial surgery is considered to be a consequence of these treatments. Several treatments dating from the first world war are still in use, such as the application of the 'dental splint' in fracture treatment, intra-oral transposition flaps for sealing small injuries and bone transplants from the iliac crest to restore defects of the jaw. In the Netherlands, which was neutral, experiences from the Great War were retained by the appointment in 1919 of a Lecturer in Oral Diagnosis and Oral Surgery at the University of Utrecht.

Augmented mandibular bone structurally adapts to functional loading.

Long-term changes in trabecular bone structure during the 10 years following onlay grafting with simultaneous mandibular implant placement were studied. Extraoral radiographs of both mandibular sides in eight patients were taken regularly. Bone structure was analysed using a custom-written image analysis program. Parameters studied were trabecular area and perimeter and marrow cavity area and perimeter. After skeletonisation of the trabecular network, the number of end points and branching points, skeleton length, and branch angle were determined. The observed structural changes agree with the development of a more complex and more delicate or fine osseous structure. The bone shows more trabecular branching. All changes are most pronounced in the graft spongiosa, but are also found in the graft cortex and in the original mandible. The mean trabecular branch angle becomes more horizontal. The applied technique can be used to analyse long-term changes in the architecture of bone grafts. Changes found in the graft architecture correspond to changes expected after functional adaptation to loading.

A lower border augmentation technique to allow implant placement after a bilateral mandibular fracture as a complication of vertical distraction osteogenesis: a case report.

As with other techniques, vertical distraction osteogenesis (VDO) can also induce complications. The case of a patient with a residual alveolar ridge in the symphyseal area of 8 mm is presented. After performing VDO, the patient returned at 1-day postoperatively complaining of pain and dislocation of the distractor device, due to a fracture of the lower mandibular segment on the right side. After removal of the distractor device and application of osteosynthesis plates, the patient returned 2 weeks later due to a second fracture of the lower segment, yet on the left side. After removing the osteosynthesis material, stabilization of the mandible was achieved with an acrylic splint, which was fixated with peri-mandibular wiring. Finally, reconstruction was accomplished by lower border onlay grafting, limited to the symphyseal area, in preparation for implant insertion. Ultimately, after a healing period of 5 months, two endosseous implants were installed. The patient's function has remained satisfactory for 3 years. Reinforcement of the extreme resorbed edentulous mandible after fracture healing by lower border bone augmentation can be a reliable method to allow implant installation in a second stage.

Interforaminal implant placement in oral cancer patients: during ablative surgery or delayed? A 5-year retrospective study.

In a retrospective study, two mandibular prosthetic rehabilitation strategies supported by implants in oral cancer patients were evaluated: implants placed in the non-resected edentulous symphyseal area during ablative surgery (DAS implants); or at a later stage (postponed (P) implants). Medical files of patients from two head-neck oncology groups from 2000 to 2005 were screened for study inclusion. DAS protocol was used in one group and P protocol in the other. After a 5 year follow-up of 261 edentulous patients with oral cancer in the second group, P implants were placed in 27 patients to support an overdenture. Of the 249 edentulous patients in the first group, 82 patients were given an implant supported overdenture using the DAS implant protocol. Regarding implant loss, no statistically significant differences were seen between the DAS and P implants. In the DAS group, more patients benefited from an implant-supported lower overdenture (39 versus 11%, respectively), and they received their overdenture on average 20.0 months sooner (sd=11.01, p<0.001) after ablative surgery. 17.1% of DAS implants and 4.6% of P implants were never loaded due to tumour and patient related factors including unfavourable implant soft tissue, tumour recurrence near the implant, or radiotherapy induced trismus.

The use of intra-osseous versus extra-osseous distraction devices in atrophic mandibles.

To allow for implant placement in severe atrophic edentulous mandibles, distraction osteogenesis can be used to gain sufficient bone height. The efficacy of extra-osseous and intra-osseous devices is evaluated. In this retrospective study, 45 patients treated with an extra-osseous device (EOD) were compared with 43 patients treated with an intra-osseous device (IOD). From a statistical point of view, both patient groups were comparable for age and sex ratio. The IOD group gained more bone height (9.8 mm) than the EOD group (6.0mm). A significantly higher degree of backward tilting of the device was observed in the EOD group (12.1°), compared with the IOD group (3.0°). There were also significantly more fractures of the basal bone segment and sensory disturbances of the chin area in the EOD group than in the IOD group. The IOD group scored significantly better on bone height gained, backward tilting of the device, occurrence of fractures, and postoperative sensory disturbances. Despite the fact that the mean preoperative bone height for the IOD group was substantially higher (18.6mm) than for the EOD group (11.9 mm), it may be concluded that for augmentation procedures of the edentulous mandible, the IOD is more favourable.

The influence of a Le Fort I impaction and advancement osteotomy on smile using a modified alar cinch suture and V-Y closure: a prospective study.

A previous report from the authors' department showed that a modified alar cinch suture combined with a muco-musculo-periosteal V-Y closure (mACVY) improves nasolabial mobility. To test if the improvements were equal to the range of nasolabial mobility in non-dysgnathic persons, a prospective study was carried out in 56 patients: 31 with mACVY, 25 with simple closing sutures (SCS) and 18 non-operated, angle class I volunteers. Standardized full facial frontal photographs, taken immediately preoperatively and 18 months postoperatively were used. The landmarks, alare, crista philtri and cheilion were analysed. The test has a standard deviation of 0.9 mm. Intra-group changes, paired t-test, and inter-group differences, unpaired t-test (p<0.05) were statistically analysed. The results show significant preoperative differences in nasolabial mobility compared with the control group, for both groups. Postoperative mobility improved in both groups, but significantly with mACVY with horizontal movement of cheilion and alare, and the vertical movement of crista philtri and less so for the vertical movement of crista philtri with SCS. Postoperative inter-group differences in mobility were small and significant for SCS vs the control group. It can be concluded that using mACVY improves orofacial movement to the level of normal class I volunteers.

A gene expression profile for non-smoking and non-drinking patients with head and neck cancer.

OBJECTIVE: A small subset of patients with head and neck squamous cell carcinoma are non-smoking and non-drinking and have distinct clinical characteristics. We aimed to identify a possible different genetic profile for these patients when compared with their smoking and drinking counterparts. MATERIALS AND METHODS: The gene expression data previously detected from primary tumors located in the oral cavity and oropharynx, using DNA microarray was analyzed for their differential expression between non-smoking and non-drinking patients (n = 15) and smoking and drinking patients (n = 89). Student's T-test (P < 0.05) and 10-fold cross-validation procedure (100 times repeated) were performed to determine differentially expressed genes. RESULTS: Non-smoking and non-drinking patients were older, mostly female and had oral cavity-localized tumors, whereas smoking and drinking patients were younger male patients with 81% oral cavity and 19% oropharynx tumors. A set of 49 differentially expressed genes were detected. Among others, seven genes related to interferon-γ were upregulated and two genes linked to NFKB pathway were downregulated. CONCLUSIONS: Differentially expressed genes in non-smoking and non-drinking patients possibly indicate the presence of a different cellular response to carcinogenic events in these patients. Further studies are warranted to validate this gene set and explore possible therapeutic implications to improve prognosis for these patients.

Tongue function in patients treated for malignancies in tongue and/or floor of mouth; a one year prospective study.

Progress in (reconstructive) surgery and radiotherapy tends to improve survival and reduce oral functional deficits. Despite the growing sophistication of cancer treatment, patients still report deterioration in tongue function. Sensory function, mobility, and force of the tongue were determined in 45 patients with a carcinoma of tongue and/or floor of mouth. Measurements were performed before surgery, shortly after surgery, shortly after radiotherapy, 6, and 12 months after surgery. Surgery had a negative impact on tongue sensory function and mobility. Post-surgery radiotherapy did not further deteriorate sensory function, mobility, or force of the tongue. Patients in the surgery-radiotherapy group (SRG) had significantly worse tongue sensory function and mobility than patients in the surgery group (SG), probably caused by more advanced tumour stage and more extensive reconstructions and related scar tissue. The tongue force in patients in both groups significantly increased in the first 6 months after surgery, but this increase disappeared in the next 6 months. The authors conclude that surgery had a significant negative influence on tongue function, especially in the group of patients treated with radiotherapy. No further deterioration of tongue function was observed after post-surgical radiotherapy within the first year after surgery.

Extra-oral implants: insertion per- or post-ablation?

Although the benefit of extra-oral implants in the reconstruction of maxillofacial oncological defects is undisputable, some relevant issues need to be clarified. The purpose of this retrospective study was to evaluate the relationship between implants placed during ablation (DA-implants) and after ablation (AA-implants) of the tumor with respect to implant survival. In total, 103 implants were assessed: 44 nasal implants (17 patients) and 59 orbital implants (18 patients). All patients received their implant-retained maxillofacial epithesis between 1997 and 2010, with a mean follow-up of 35 months (range 8-156 months). The survival rate of DA-implants was 90.0% for the orbital region and 93.5% for the nasal region. The survival rate of the AA-implants for the orbital and the nasal region was 82.8% and 61.5%, respectively. This study shows a significant higher survival rate of extra-oral implants placed during ablative surgery compared to implants in a later stage (p=0.044), thereby stressing the importance of installing extra-oral implants during the ablative surgical session.

Human Papillomavirus and Oropharyngeal Squamous Cell Carcinoma: A Case-Control Study regarding Tobacco and Alcohol Consumption.

We aimed to determine the role of HPV in the pathogenesis and outcome of oropharyngeal squamous cell carcinoma (OSCC) in lifelong nonsmoking and nondrinking patients. A case-case analysis was performed to compare the presence of HPV-DNA in tumor cells of 16 nonsmoking and nondrinking with 16 matched smoking and drinking patients (matching criteria: age at incidence, gender, tumor sublocation, tumor stage). HPV was detected using 2 PCR tests, FISH analysis, and p16(INK4A) immunostaining. Nonsmoking and nondrinking patients had more HPV-positive tumors than smoking and drinking patients (n = 12; 75% versus n = 2; 13%; P < 0.001). All HPV-positive tumors showed p16(INK4A) overexpression, and 1 HPV-negative tumor had p16(INK4A) overexpression, (P < 0.001). Overall survival and disease-specific survival were higher for HPV-positive compared to HPV-negative cases (P = 0.027, P = 0.039, resp.). In conclusion, HPV is strongly associated with OSCC of nonsmoking and nondrinking patients. Specific diagnostic and therapeutic actions should be considered for these patients to achieve a better prognosis.

[Diagnosis and classification of headache and temporomandibular disorders, a new opportunity]. / Diagnose en classificatie van hoofdpijn en temporomandibulaire disfunctie, een nieuwe kans.

Patients with orofacial pains are generally treated by physicians. A small number of patients are treated for pain in the temporomandibular joint, the masticatory and the neck muscles, by dentists and orofacial surgeons. Among half of the patients being treated in neurological headache clinics, the temporomandibular joint and the masticatory muscles are the source of the pain. In order to achieve better research and a classification, the International Headache Society, consisting largely of neurologists, developed a classification system. A comparable development occurred among oral health specialists. Employing these 2 methods with the same patients leads to different diagnoses and treatments. Both the International Classification of Headache Disorders II and the Research Diagnostic Criteria for Temporomandibular Disorders are being revised. This creates the opportunity to establish a single classification for these orofacial pains, preferably within the new International Classification of Headache Disorders.

Effect on the contour of bone and soft tissue one year after harvesting chin bone for alveolar cleft repair.

In this study the authors evaluate and quantify the residual bony defect in the mandibular symphysis and its effect on the soft tissue contour a minimum of 1 year after harvesting chin bone. 59 ASA I cleft lip and palate patients, aged 8-19 years were included. In all patients an autologous bone graft from the mandibular symphysis was harvested for transplantation to the alveolar cleft. Lateral cephalograms were used to measure the donor site defects, and the effects on the soft tissue contour. An evident residual defect was measured at the donor site 1 year after harvesting chin bone. A significant relation was seen between age at time of surgery and size of the defect 1 year postoperatively. In older patients a larger defect remained. Using the current surgical technique of harvesting chin bone, complete bony repair of the defect was not achieved. This study shows postoperatively persisting defects that comprise on average 14% of the original peroperative defects. A significant increase in soft tissue thickness was seen at the mandibular symphysis at a minimum of 1 year postoperatively. These changes in the soft tissue chin contour 1 year after harvesting bone are similar to normal growth changes.

Spontaneous regression of advanced merkel-cell-like small cell carcinoma of the parotid gland.

Small cell carcinomas of the salivary gland are rare. We present a case of spontaneous regression of an advanced merkel-cell-like small cell carcinoma of the parotid gland.