Contemporary Surgical Management of Craniofacial Fibrous Dysplasia Using Computer-Assisted Surgery and Intraoperative Navigation.

Craniofacial fibrous dysplasia (CFD) is a rare developmental disease of bone, which typically presents as a painless, expansile mass causing deformity of the craniofacial skeleton. In rare circumstances, compression of neurovascular structures may arise, causing symptoms such as pain, visual impairment, and hearing loss. Traditionally, CFD debulking has been performed with "freehand" techniques using preoperative imaging and anthropometric norms to determine the ideal amount of tissue removal. The advent of computer-assisted surgery, computer-aided design, and computer-aided manufacturing (CAD/CAM) has revolutionized the management of CFD. Surgeons can now fabricate patient-specific osteotomy/ostectomy guides, allowing for increased accuracy in bone removal and improved cosmetic outcomes. This series of 3 cases describe our institution's technique using patient-specific ostectomy "depth guides", which allow for maximum removal of fibro-osseous tissue while sparing deep and adjacent critical structures. These techniques can be widely applied to the craniofacial skeleton to assist in the surgical management of CFD.

Aggressive presentation of ameloblastic fibro-odontoma: a clinical-pathological enigma.

Ameloblastic fibro-odontoma (AFO) is a rare, gnathic, benign, mixed odontogenic tumor that commonly presents in the first or second decade of life as a unilocular and rarely multilocular radiolucency with variable amounts of calcified material. Tumor progression is typically indolent, and generally accepted treatment is surgical enucleation and curettage. This case report describes an atypical presentation in a 14-year-old male with a multilocular, aggressive AFO requiring hemimandibulectomy with immediate osseous and dental "Jaw-in-a-Day" reconstruction. This report highlights the debate regarding whether AFO is a true neoplasm or an early-stage hamartoma in the continuum of complex odontoma formation. Regardless of the pathogenesis, maxillofacial surgeons and pathologists should be cognizant of the potential for AFO to develop locally aggressive behavior with considerable morbidity.

Bimaxillary Immediate Prosthetic Rehabilitation Using a Custom Maxillary Subperiosteal Implant and Fibula-Free Flap Mandibular Reconstruction After Tumor Ablation.

Subperiosteal implants (SPIs) using rigid fixation have recently emerged as an acceptable alternative to conventional endosteal implants when there is limited or absent alveolar bone. Modern advances in digital technology and manufacturing have improved the usability and stability of this latest generation of SPIs. Herein, we present the first reported case of a modern patient-specific SPI placed in the United States and, to the authors' knowledge, the first reported case performed in conjunction with a simultaneous free flap reconstruction of the opposing arch, and immediate dental rehabilitation of both arches in the world.

Comparative Benefits of Open versus Closed Reduction of Condylar Fractures: A Systematic Review and Meta-Analysis.

BACKGROUND: Many fractures of the mandibular condylar neck are amenable to both open reduction and internal fixation (ORIF) and closed treatment. Clinical outcomes following these two modalities remains a topic of debate. This systematic review critically appraises the literature to compare them following these treatment options. METHODS: A systematic review and meta-analysis was performed to test the null hypothesis of no difference in clinical outcomes in ORIF versus closed treatment of mandibular condyle fractures. The PubMed, Embase, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried from 1946 to 2020. The quality of evidence was determined using Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS: Of 1507 screened articles, 14 met inclusion criteria. ORIF was favored significantly when evaluating temporomandibular joint pain [relative risk (RR), 0.3; 95% CI, 0.1 to 0.7] (number needed to treat to prevent an outcome in one patient, 3; 95% CI, 2 to 6), laterotrusive movements of the mandible (mean difference, 2.3; 95% CI, 1.7 to 3.0) (standardized mean difference, 0.9; 95% CI, 0.4 to 1.3), and malocclusion (RR, 0.5; 95% CI, 0.4 to 0.7) (number needed to treat to prevent an outcome in one patient, 19; 95% CI, 10 to 200). However, ORIF yielded a higher incidence of postoperative infection (RR, 3.6; 95% CI, 0.9 to 13.8) and must be weighed against the understood risk of facial nerve injury. CONCLUSIONS: Meta-analysis of high-level evidence in randomized controlled trial suggests that ORIF significantly improves functional outcomes, decreases pain, and restores occlusion and jaw symmetry. These long-term benefits must be weighed against the increased risk of postoperative infection and exposure of the facial nerve to potential injury.

Extent of Extranodal Extension in Oral Cavity Squamous Cell Carcinoma is Not Independently Associated With Overall or Disease-Free Survival at a 2.0-mm Threshold.

PURPOSE: The presence of extranodal extension (ENE) conveys a poor prognosis in oral cavity squamous cell carcinoma (OSCC); however, there is no consensus regarding whether the histopathologic extent of ENE (e-ENE) may be a more discriminating prognostic indicator. The purpose of this study was to assess the impact of minor ENE (<2.0 mm) versus major ENE (≥ 2.0 mm) on overall survival (OS) and disease-free survival (DFS) in OSCC. MATERIALS AND METHODS: A single-institution, retrospective cohort study was designed using an electronic medical record review. Inclusion criteria included patients with OSCC and cervical node metastasis. All subjects were treated between the years 2009 and 2017 in the Michigan Medicine Department of Oral and Maxillofacial Surgery (Ann Arbor, Michigan). The primary predictor variable was e-ENE, measured as the maximum distance of tumor invasion into extranodal tissue from the outer aspect of the nodal capsule. Primary outcome variables were OS and DFS. Other covariates included demographic data, tumor staging, and histopathologic data. Descriptive statistics were performed. Kaplan-Meier survival plots for OS and DFS were performed. The data were mined for an alternative threshold at which e-ENE may impact survival using Cox proportional hazards models. RESULTS: One hundred sixty eight subjects were included (91 ENE-negative, 48 minor ENE, and 29 major ENE). Most subjects were male (62%) and the mean age was 62.9 years. Mean follow-up time was 2.97 +/- 2.76 years. There was no statistically significant difference in OS or DFS between minor and major ENE. Five-year OS for minor ENE was 30.4% versus 20.7% for major ENE (P = .28). Five-year DFS for minor ENE was 26.7% versus 18.1% for major ENE (P = .30). Five-year OS and DFS was worse for subjects with ENE-positive disease versus ENE-negative disease (OS: 26.9% vs 63.1%, hazard ratio [HR]: 2.70, 95% confidence interval [CI]: [1.77, 4.10], P < .001; DFS: 23.7% vs 59.7%, HR = 2.55, 95% CI [1.71, 3.79], P < .001). At an alternative threshold of 0.9 mm e-ENE, there was greater DFS in subjects with e-ENE 0.1-0.9 mm versus e-ENE > 0.9 (40.6% vs 18.9%, respectively) (HR = 0.49, 95% CI [0.24, 0.99], P = .047). CONCLUSION: There was no independent association between survival and e-ENE at a 2.0-mm threshold.

Validation of Tabletop Microscopes for Microsurgery Simulation and Training.

PURPOSE: Oral and maxillofacial surgery residency programs are increasingly adopting microsurgery as a core element of training; however, many barriers exist that limit trainees' proficiency. The purpose of this study was to perform a validation of 2 tabletop microscope simulations for their use as a training tool, which could serve as an affordable, alternative method to traditional microsurgery training methods. METHODS: A prospective, single-institution, multidepartmental validation study was performed. Two microscopes (monocular digital [DM] and binocular stereo [SM]) were used to perform anastomoses on simulation vessels including a silastic tube and a chicken thigh femoral artery. A microsurgeon panel was selected from a population of microsurgery faculty and fellows at Michigan Medicine (Ann Arbor, MI) to perform the anastomoses. The surgeons each performed 4 anastomoses, using each microscope with each vessel, and subsequently completed a survey evaluating the simulation. Predictor variables were the microscope and the vessel. Primary outcome variable was readiness for use, which was defined as the simulation's ability to incorporate into a microsurgical training curriculum in its current state. Secondary outcome variables included realism, value, usefulness, relevance, difficulty, and cost. Paired t tests were used to compare responses. Alpha was set to 0.05. RESULTS: Seven microsurgeons performed the simulation from the departments of oral and maxillofacial surgery (n = 5), plastic and reconstructive surgery (n = 1), and otolaryngology (n = 1). For readiness, the SM simulation required either no modification (n = 4) prior to implementation into a microsurgery curriculum or minimal modification (n = 3), compared to the DM simulation which required significant modification (n = 4) or extensive modification and re-evaluation (n = 3) (P = .002). The SM demonstrated a greater mean realism score than the DM for depth perception (5.00 vs 1.57, P < .001), field of view (4.57 vs 3.57, P = .038), lighting (5.00 vs 4.00, P = .038), and clarity (5.00 vs 3.86, P = .030). There was no statistically significant difference between SM and DM in value, usefulness, relevance, difficulty, or cost. CONCLUSIONS: Tabletop microscopes demonstrate considerable promise in the future of microsurgical education. The SM simulation was a realistic simulation that may be ready for use in a microsurgical curriculum. Future studies are required to demonstrate the efficacy of this simulation on microsurgical trainees.

Clinical Practice Trends and Postoperative Outcomes in Primary Cleft Rhinoplasty.

PURPOSE: Optimal correction of the cleft nasal deformity remains challenging. The purpose of this study was to examine the practice patterns and postoperative course of patients undergoing cleft lip repair with rhinoplasty compared to those who have primary lip repair without rhinoplasty. METHODS AND MATERIALS: A retrospective cohort study was conducted based on the Kids' Inpatient Database. Data were collected from January 2000 to December 2011 and included infants aged 12 months and younger who underwent cleft lip repair. The predictor variable was the addition of rhinoplasty at primary cleft lip repair. Primary outcome variables included hospital setting, year, and admission cost, while secondary outcome variables included length of stay and postoperative complication rate. Independent t-tests and chi-squared tests were performed. Continuous variables were analyzed by multiple linear regression models. RESULTS: The study sample included 4559 infants with 1422 (31.2%) who underwent primary cleft rhinoplasty. Over time, there was a significant increase in the proportion of cleft lip repairs accompanied by a rhinoplasty (p < .01). A greater proportion of patients with unilateral cleft lips received simultaneous rhinoplasty with their lip repairs (33.8 vs 26.0%, p < .01). This cohort had a significantly shorter length of stay (1.6 vs 2.8 days, p < .01) when compared to children that underwent cleft lip repair alone. CONCLUSIONS: Performing primary cleft rhinoplasty is becoming more common among cleft surgeons. Considering comparable costs and complication rates, a rhinoplasty should be considered during the surgical treatment planning of patients with cleft nasal deformities.

Maxillomandibular advancement effectively treats obstructive sleep apnea in adolescents at short-term follow-up.

OBJECTIVE: To evaluate the efficacy of maxillomandibular advancement (MMA) surgery for the treatment of malocclusion and obstructive sleep apnea (OSA) in an adolescent population. STUDY DESIGN: A retrospective cohort study was designed using electronic medical record chart review. RESULTS: Fifteen patients aged 20 years or younger (range, 14-20) were included. All patients underwent MMA surgery for the primary correction of malocclusion and secondary treatment of OSA. Mean preoperative apnea-hypopnea index (AHI) was 28.9 ± 16.0 events/h (range, 7.1-54.7), and mean postoperative AHI was 5.7 ± 4.6 events/h (range, 1.5-18.4), reflecting a reduction of 23.2 events/h, an 80.6% reduction (P < .001). Fourteen patients (93.3%) experienced improvement in AHI. Mean minimal posterior airway space increased from 4.6 mm to 8.6 mm (P < .001). Mean posterior airway space at the level of the uvular tip increased from 6.7 mm to 11.5 mm (P < .001). Patients who underwent adjunct genioglossus advancement (GGA) had a mean decrease in AHI of 35.3 events/h (P = .004), which was not significantly different from the decrease in those who did not receive GGA. CONCLUSIONS: MMA surgery with or without GGA is an effective treatment option for adolescents with a malocclusion and an AHI >5.0 events/h. In this population, it is shown to decrease AHI and increase posterior airway space. More research is required to determine the ideal adolescent candidate for MMA surgery.

Squamous Cell Carcinoma of the Tongue in Young Patients: A Case Series and Literature Review.

PURPOSE: The purpose of this study was to describe 3 cases of tongue cancer in patients less than 21 years of age. Secondarily, a literature review was performed to examine disease presentation, risk factors, prognosis, and treatment strategies for young persons with tongue cancer. METHODS: The authors presented 3 cases of childhood tongue cancer between 2009 and 2020 at the University of Michigan Department of Oral and Maxillofacial Surgery (Ann Arbor, MI). An electronic literature review was conducted via PubMed, Embase, Web of Science, and MLibrary. RESULTS: Including the present case series, 64 studies reporting 108 cases were identified. Age at presentation ranged from newborn to 20 years, with a mean age of 14.5 years. The majority of patients were female (52.2%); 68.1% of patients presented with T1 or T2 disease. Nodal metastases were seen in 56.1% of patients. The most commonly identified predisposing factors included Fanconi anemia (13.9%), bone marrow transplant (9.3%), tobacco use (6.5%), and xeroderma pigmentosum (4.6%). Most patients received surgery alone (37.5%), followed by surgery with adjuvant radiation (33.8%); 60.6% underwent neck dissection. Overall survival was 60.3% at 1 year and 43.6% at 5 years. CONCLUSIONS: Oral tongue cancer in the young is a rare disease with poorly understood etiology. There is a need for oncologists and maxillofacial surgeons to collaborate in the study of genetic, social, environmental, and medical risk factors contributing to the disease. All patients should undergo high-throughput genetic sequencing to expand our understanding of the disease process and allow for targeted treatment strategies.

Oral Lichen Planus-Associated Oral Cavity Squamous Cell Carcinoma Is Associated With Improved Survival and Increased Risk of Recurrence.

PURPOSE: We investigated the overall survival (OS), disease-specific survival (DSS), and disease-free survival among patients with oral lichen planus-associated oral cavity squamous cell carcinoma (OLP-OCSCC). The secondary objective was to assess the annual risk of tumor recurrence or second primary tumor (SPT). MATERIALS AND METHODS: A comparative retrospective study was performed of patients with OLP-OCSCC presenting between June 2007 and December 2018 to the Department of Oral and Maxillofacial Surgery, Michigan Medicine (Ann Arbor, MI) and patients with OCSCC in the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database (1973 to 2015). RESULTS: A total of 87 patients with OLP-OCSCC met the inclusion criteria, and 55,165 patients with OCSCC from the SEER database were included. The proportion of women was greater in the OLP group than in the SEER group (56.3 vs 38.0%; P < .001). In the OLP group, 47.1% had no smoking history and 43.7% had no alcohol history. Most patients in the OLP group had presented with stage I disease (46.0%) compared with 31.7% in the SEER group (P = .004). Overall, the OS and DSS were significantly greater in the OLP group than in the SEER group at all points from 1 to 5 years (P ≤ .01). In the OLP group, 46 patients (52.9%) had at least 1 recurrence or SPT. At 10 years, the predicted mean number of recurrences was 1.93 per patient (95% confidence interval, 1.56 to 2.39). CONCLUSIONS: OLP-OCSCC frequently affects women, nonsmokers, and nondrinkers and presents with localized disease at a high frequency. Patients with OLP-OCSCC have increased OS and DSS and a greater risk of tumor recurrence or SPT compared with OCSCC in the general population. Lifelong, frequent surveillance is recommended for patients with OLP-OCSCC owing to the risk of late recurrence. Future studies are needed to understand the pathophysiology of OLP-OCSCC.