Submental Flap Versus Radial Forearm Free Flap for the Reconstruction of Medium Size Soft Tissue Defect in the Oral Cavity.

The aim of this work is to compare the functional and esthetic outcome of the submental flap and radial forearm free flap for the reconstruction of medium-sized soft tissue defect in the oral cavity. Patients diagnosed with squamous cell carcinoma of the oral cavity and reconstructed with a submental flap or radial forearm free flap between 2015 and 2020 were reviewed and analyzed. Tumor site, complication at the donor site, complication at the recipient site, duration of the hospital stay, local or cervical recurrence, and esthetic results were also analyzed to compare the difference in outcomes between the two groups. Submental flap represents a safe and useful reconstructive recourse for head and neck reconstructive surgeons when it is correctly indicated. Lower rate of complication at the donor site, better esthetic result, and a shorter hospital stay represent the strengths of this flap when it is not necessary to perform compartment surgery. However, more studies are needed with a larger number of patients.

Controversies in the treatment of early-stage oral squamous cell carcinoma.

The treatment of early-stage oral squamous cell carcinoma (OSCC) is still a controversial issue. Thanks to the 8th edition of TNM by AJCC there is a better distinction between the stages of OSCC. However, Stages I and II still share the same treatment protocol, even if the prognosis is radically different. A retrospective study has been conducted including 70 previously untreated patients with Stage I or II OSCC, treated with tumorectomy and selective neck dissection. The study focuses on the link between pT1/2 and various other factors, particularly histological grading, vascular and perineural invasion, local and cervical recurrence, surgical margins and overall survival. These data reveal significant differences between pT1 and pT2 in histological grade, perineural invasion, cervical recurrence, surgical margins, and overall survival, emphasizing the necessity of different treatment protocols for T1 and T2 OSCC. Distinct strategies should be proposed to treat Stage I and II OSCC, with Stage II patients possibly benefitting from more aggressive treatments: following these data, a wait-and-see strategy should only be considered in Stage I, while certain treatments at the cervical level - such as prophylactic neck dissection and sentinel node biopsy - should always be considered for Stage II tumors.

What is the real prognostic value of close margins in oral oncology?

AIM: The surgical margin is usually considered an important prognostic factor in oral oncology. However, the real value of a close surgical margin and its relationship with survival is still unclear. Thus, the present report sought to identify the relationship between close surgical margins and overall 3-year survival, whilst also analyzing the association between such margins and recurrence. MATERIALS AND METHODS: The medical records of 200 patients affected by oral squamous cell carcinoma were retrospectively reviewed. The patients were divided into three groups: positive margin (0-2 mm), close margin (2-5 mm), and negative margin (>5 mm). The relationship between surgical margins and overall survival and recurrence rate was analyzed. RESULTS: Surgical margins and reoperation were found to have no significant association with overall survival (P > 0.05). Overall survival was 63% in our sample. Specifically, this was 50%, 64.7% and 66.2% in patients with positive, close and free margins, respectively. Perineural invasion, pN, and locoregional or cervical recurrences were the factors most directly related to overall survival. DISCUSSION: The results of this study indicate that surgical margins are not directly related to overall survival and other factors might significantly influence patient outcomes. Advanced T stage, node involvement, perineural invasion, and ECS are strongly linked with patient survival (P < 0.05). These findings should be carefully evaluated in patients with close surgical margins. Our results indicate that an aggressive adjuvant treatment of patients with close surgical margins could help in obtaining a similar pattern of overall survival with patients with negative margins.

Intraoperative cytological examination of bone medullary. A useful technique to predict the extension of bone invasion in segmental mandibulectomy.

AIM: The main of the present report is to evaluate the utility of intraoperative cytological analysis of medullary bone to predict the extension of bone infiltration in segmental mandibulectomy. MATERIALS AND METHOD: Between the years 2016 and 2018, a total of 17 previously untreated patients with squamous cell carcinoma of the oral cavity underwent a segmental mandibular resection and intraoperative cytological analysis of the bone medullary at Virgen de las Nieves University Hospital (HUVN). The results of the intraoperative cytological analysis were compared with the result of the postoperative histopathological examination and sensitivity, specificity, positive predictive value, and negative predictive value of the test were calculated. RESULTS: Cytological analysis was positive in three patients and the bone resection was consequently extended. All the extensions of these bone margins were clean following the postoperative histological examination. However, two other patients previously classified as clean with intraoperative cytological analysis of bone medullary presented infiltration of bone margins postoperatively. The protocol demonstrated a high negative predictive value (85,7%). The positive predictive value, sensitivity, and specificity were 33,3%, 33,3%, and 85,7% respectively. CONCLUSION: Intraoperative cytological analysis of bone medullary could represent an easy, fast, reliable and inexpensive method to reduce the rate of r1 surgeries attributable to the infiltration of the bone margin. This may have a positive impact on overall survival without increasing the duration and the iatrogenicity of surgery.

Unfavorable outcomes in microsurgery: possibilities for improvement.

The main aim of the present report is to describe our learning curve in microsurgery and how we solved the problems that frequently occur during the first phases of this learning curve. We analyzed the medical records of 69 patients that underwent head and neck reconstruction with free flaps in our department. The patients were divided into two groups. Group 1 included the patients reconstructed between January 2011 and June 2017, whilst Group 2 included those reconstructed between July 2017 and August 2018. A χ2 test was used to compare the differences between the two groups in terms of flap failure (failure and partial failure) and eventual clinical errors. The p value was set at 0.05. Flap failure and clinical errors were most frequently observed in Group 1 (p < 0.05). Greater awareness of the need for proper functioning of the anastomosis during surgery, along with more exhaustive postoperative monitoring might explain the lower number of failures and signs of vascular compromise observed in Group 2. A number of variables may influence flap survival. Postoperative care, head position, kinking, body temperature, blood pressure and the ability to recognize the sign of vascular compromise all play a fundamental role following surgery. However, microsurgery is not just a routine type of surgery, and a properly trained team with several types of professionals must be adequately prepared to obtain acceptable results.

Behavior of Buccal Mucosal Squamous Cell Carcinoma: A Retrospective Study of 53 Carcinomas of This Anatomical Region.

The main aim of the present report is to study the pattern of distribution of cervical metastasis in buccal mucosa cancer and to discuss the various therapeutic options available. Fifty-three patients with squamous cell carcinoma of the buccal mucosa treated with tumorectomy and selective neck dissection were included in the study. We also studied the relationship between specific pathological features and overall survival. Level Ib was the most affected level, followed by level IIa. T stage, N stage, N involvement tumor thickness, extracapsular spread (ECS), and vascular invasion were associated with poorer outcomes regarding overall survival ( p < 0.001). Carcinoma of the buccal mucosa should be treated aggressively from the early stages. A large tumorectomy of the primary tumor is required to reduce the number of local recurrences. Moreover, we recommend performing a supraomohyoid neck dissection even in cT1N0 if there is a suspicion that the tumor thickness may be greater than 0.4 cm. The high risk of local recurrence obliges protection of the neck from a future cervical recurrence even in T1 small tumors. This could reduce the risk of cervical involvement during the follow-up and improve overall survival rates.

Behavior of squamous cell carcinoma of the floor of the mouth. Is supraomohyoid neck dissection sufficiently safe to manage clinically N0 patients?

AIM: The main aim of the present report is to study the behavior of SCC of the floor of the mouth. MATERIALS AND METHOD: A retrospective analysis was conducted using the records of patients diagnosed with squamous cell carcinoma of the floor of the mouth between 2000 and 2012 in the HUVN. Ninety-three patients with squamous cell carcinoma of the floor of the mouth treated with tumourectomy and selective neck dissection were included in the study. The pattern of distribution of cervical metastases and numerous histological features such as T-stage, N stage, surgical margins, tumor thickness, ECS (extracapsular spread) and vascular invasion were analyzed. RESULTS: Level I was the most affected level, followed by Level II. T stage, tumor thickness, and surgical margins showed a strong relationship with the risk of developing a local or cervical failure at follow-up. Overall survival was 52.7%. T stage, tumor thickness, N stage, recurrence, extracapsular spread, and vascular invasion were also associated with a poor prognosis. CONCLUSIONS: SCC of the floor of the mouth is an aggressive disease even at early stages. Due to the low rate of positive nodes observed at level IV and V in clinically N0 patients, supraomohyoid neck dissection might be considered sufficiently safe in this group.

Is a "watch and wait strategy" safe to manage clinically N0 squamous cell carcinoma of the upper jaw?

PURPOSE: The main aim of the present study is to analyze the behavior of squamous cell carcinoma (SCC) of maxillary gingiva, alveolus, and hard palate and to determine the utility of selective neck dissection in clinically N0 patients at early stages. MATERIAL AND METHOD: Twenty-nine previously untreated patients with SCC of maxillary gingiva, alveolus, and hard palate were diagnosed and treated with at least a tumorectomy and selective neck dissection at HUVN and included in the study. RESULTS: A total of 34.4% of patients (10/29) showed nodal involvement at postoperative histopathologic exam. Several pathologic features such as N involvement, N stage, T stage, and locoregional failure all have a negative impact on overall survival. DISCUSSION: SCC of maxillary gingiva, alveolus, and hard palate shows an aggressive behavior that is comparable with other oral cavity cancers. A more aggressive treatment is thus required for improving locoregional control and overall survival. Supraomohyoid neck dissection may be useful in cT2N0M0.

Endovascular treatment of an intraosseous arteriovenous malformation of the mandible in a child. A case Report.

The modern application of interventional radiology techniques is revolutionizing the treatment of the vascular malformations of the head and neck. In fact, the morbidity related with the surgical extirpation of the malformation might be drastically reduced with the use of an endovascular approach. The present report describes the case of a 11 years old male affected by a large intraosseous arteriovenous malformation of the mandible. The coil embolization of the main drainage vein caused the spontaneous regression of the lesion and avoided a mutilating surgery and severe psychological sequels. A multidisciplinary approach of these case is mandatory. A careful clinical and radiological study of the patient is essential for a proper management. The choice of the treatment should be based on the location and extension of the malformation, age of the patient, experience with endovascular techniques and clinic. Key words:Endovacualr approach, intraosseous arteriovenous malformation, head and neck, child.

Distribution of cervical metastasis in tongue cancer: Are occult metastases predictable? A retrospective study of 117 oral tongue carcinomas.

PURPOSE: The aims of this study were to evaluate the pattern of distribution of cervical metastasis in tongue cancer and to analyze the various therapeutic options available. Moreover, numerous histological features were analyzed to assess the impact of each factor on overall survival. MATERIALS AND METHODS: A retrospective analysis was conducted using the records of patients diagnosed with oral tongue cancer between 2004 and 2010 in the Virgen de las Nieves University Hospital (HUVN). A total of 117 patients with squamous cell carcinoma of the tongue treated with glossectomy and selective neck dissection were included in the study. The pattern of distribution of cervical metastases and numerous histological features such as T-stage, N stage, surgical margins, tumor thickness, extracapsular spread (ECS) and vascular invasion were analyzed. RESULTS: Level IIA was the most affected, followed by level III. The rate of skip metastasis was 7,4%. T and N stage, tumor thickness, ECS, surgical margins and nerve and vascular invasion were associated with poorer outcomes in terms of overall survival (p < 0,001). CONCLUSION: Cervical nodal involvement represents the major prognostic factor in tongue cancer. A total of 51,2% of N+ patients presented T1 and T2 tumors in this series. We recommend performing neck dissection at the early stages in clinically N0 patients when a tumor thickness >0,4 cm is suspected. Level IV should be included in the neck dissection of clinically N0 tongue cancer.

Juxtacortical Mandibular Chondrosarcoma during pregnancy: A case report.

Chondrosarcoma is one of the most common malignant bone tumors in adults. It use to affect upper arm, pelvis and thigh bone. A wide surgical extirpation represent the gold standard to treat this disorder. In fact, radiotherapy and chemotherapy are no useful. Interestingly, chondrosarcoma is rare in head and neck (HNCS) and extremely uncommon during pregnancy. Thus, there is a lack of evidence about the proper treatment in these cases. A wide surgical extirpation is also considered the most effective procedure in HNCS. There are no consistent evidences about the he role of radiation and chemotherapy. In view of that, the present study describes a case of juxtacortical mandibular chondrosarcoma affecting a 28-year-old pregnant woman. After a multidisciplinary analysis of the case, we decided to treat the patient with a wide surgical resection and and immediately reconstruction. Key words:Mandibular chondrosarcoma, pregnancy, surgical extirpation, radiotherapy, chemoteraphy.

Cherubism. A case report.

Cherubism is a rare disorder with autosomal dominant inheritance. It is classified as a benign fibro-osseous lesions and may involve either facial bone. Its typical dentofacial deformities are caused by mutations in the SH3BP2 gene. The protein encoded by SH3BP2 had a significant role in the regulation of osteoblasts and osteoclasts. Accordingly with the radiological findings, differential diagnoses includes fibrous dysplasia, giant cell granuloma, osteosarcoma, juvenile ossifying fibroma, fibrous osteoma, odontogenic cyst and hyperparathyroidism. The aim of the present report is twofold. First, we examine the importance of the proper management of these cases. Second, we describe this rare syndrome with the goal of proposing suitable treatments.

Psycho-social impact of orthogathic sugery.

BACKGROUND: Orthognathic surgery is a branch of maxillofacial surgery. It carries out the treatment of the facial skeleton asymmetries and deformities. The patients who ask for this surgery are often young people who usually refer symptoms related to dental malocclusion, difficulty eating and temporo-mandibular pain. These physical symptoms are often accompanied by psychological symptoms triggered by their physical appearance such as low self-esteem, self-confidence and negativism about their social and emotional future. MATERIAL AND METHODS: Patients with skeletal malformation of facial bones, consisting in Class II, III, open bite and asymmetries, underwent to orthognathic surgery in our center agreed to participate voluntarily in this study. They answered a questionnaire regarding several psychosocial variables. RESULTS: Orthognathic surgery helps to improve patient's psychosocial well-being. CONCLUSIONS: Patients with dentofacial deformitiesexperience physical and psychological, oftentimes underestimated by society. A combination of orthodontic treatment and reconstructive surgery is often a necessity to restore function and psychosocial well-being. Key words:Orthogathic surgery, psychosocial consequences, mood, emotions, sense of power, motivation, satisfaction, social changes, satisfaction.

Posttraumatic carotid-cavernous fistula: Pathogenetic mechanisms, diagnostic management and proper treatment. A case report.

UNLABELLED: Carotid-cavernous fistulas are an uncommon diseases characterized by abnormal communications between arteries and veins located in the cavernous sinus. According with Barrow´s classification they could be divided in two groups: direct and indirect. The typical symptoms showed by theses pathologies are: pulsating exophthalmos and orbital blow. The present study describes a case of direct posttraumatic carotid-cavernous fistula in a 26 years old man. Furthermore, we present the images that we used to make the diagnosis. In this light, we decided to treat this case with endovascular approach after considering several therapeutic options. The aim of the present report is twofold. First, we examine the importance of the proper management of the direct posttraumatic carotid-cavernous fistula. Second, we describe this rare syndrome with the goal of proposing suitable treatments. KEY WORDS: Carotid cavernous fistulas, pulsating exophthalmos, orbital blow, endovascular approach, Barrow´s classification.

Long-term outcome of dental implants after maxillary augmentation with and without bone grafting.

BACKGROUND: This study aims to evaluate the technique of sinus bone reformation, which consists of elevating the sinus membrane and placement the implant without bone graft, compared with the widely-used technique involving raising the maxillary sinus and grafting, using animal hydroxyapatite as the filler, while simultaneously fixing the implants. MATERIAL AND METHODS: This is a retrospective study on two groups of patients who underwent elevation of the sinus membrane and simultaneous placement of the implant. The grafting technique was applied to one group, while the other had no graft. An alveolar ridge height of 4 to 7 mm was necessary. Radiological control was undertaken at 6 months and one year post-prosthetic loading. In each group 38 implants were placed. RESULTS: No significant behavioural differences were observed in the implants according to the Albrektsson success criteria. Implant failure was observed in 2 implants from the bone grafting group (success rate 93%) and in 1 implant from the reformation group (success rate 97%). In this group, bone formation was observed on both sides of each implant, the bone gain was measured using image management software (2.7±0.9mm mesial and 2.6±0.9mm distal). There was no correlation between mesial and distal bone gain and implant's length. CONCLUSIONS: The results indicate that bone reformation is a valid technique in cases involving atrophy of the posterior maxilla. Primary stability, maintenance of space by the implant, and the formation of a blood clot are crucial in this technique in order to achieve bone formation around the implant. It is an alternative to the conventional technique of sinus lift with filling material, and has several advantages over this procedure, including a lower infection risk, as it does not involve a biomaterial, reduced cost, a simpler technique, and better acceptance by the patient.

Immediate Implants Placed in Fresh Sockets Associated with Periapical Pathology: A Split-Mouth Design and Survival Evaluation after 1-Year Follow-Up.

PURPOSE: To compare the immediate implant success rates between sites with chronic apical lesions and healthy sites in the same patients 1 year postdelayed loading. MATERIALS AND METHODS: One hundred sixty-eight immediate implants were placed in sixty patients at upper incisor, canine, and premolar sites. A split-mouth design was used, placing a minimum of two implants, one in a fresh socket associated with chronic periapical disease, the average lesion size was larger than 4 mm and less than 8 mm (test group), and the other(s) in a healthy fresh socket (control group). Implant survival rate at 1 year postloading delayed was compared between the groups. RESULTS: The implant survival rate was 98.2% for the total sample (n = 168); out of the three implants lost, two were from the test group, and one was from the control group (in the same patient as one of the former). Among the surviving implants, five were also considered failures due to excessive bone loss (n = 3) and also because of the recurrence of the periapical lesions (n = 2). Survival rates were significantly lower in the test than control sites at 12 months postloading. CONCLUSIONS: Implant survival rates were significantly lower after the immediate implantation in postextraction sockets associated with chronic periapical disease (90.8%) than in healthy postextraction sockets (98.1%).

Oral and general health-related quality of life in patients treated for oral cancer compared to control group.

BACKGROUND: Health-related quality of life (HRQoL) is gaining importance as a valuable outcome measure in oral cancer area. The aim of this study was to assess the general and oral HRQoL of oral and oropharyngeal cancer patients 6 or more months after treatment and compare them with a population free from this disease. METHODS: A cross-sectional study was carried out with patients treated for oral cancer at least 6 months post-treatment and a gender and age group matched control group. HRQoL was measured with the 12-Item Short Form Health Survey (SF-12); oral HRQoL (OHRQoL) was evaluated using the Oral Health Impact Profile (OHIP-14) and the Oral Impacts on Daily Performances (OIDP). Multivariable regression models assessed the association between the outcomes (SF-12, OHIP-14 and OIDP) and the exposure (patients versus controls), adjusting for sex, age, social class, functional tooth units and presence of illness. RESULTS: For patients (n = 142) and controls (n = 142), 64.1% were males. The mean age was 65.2 (standard deviation (sd): 12.9) years in patients and 67.5 (sd: 13.7) years in controls. Patients had worse SF-12 Physical Component Summary scores than controls even in fully the adjusted model [ß-coefficient = -0.11 (95% CI: -5.12-(-0.16)]. The differences in SF-12 Mental Component Summary were not statistically significant. Regarding OHRQoL patients had 11.63 (95% CI: 6.77-20.01) higher odds for the OHIP-14 and 21.26 (95% CI: 11.54-39.13) higher odds for OIDP of being in a worse category of OHRQoL compared to controls in the fully adjusted model. CONCLUSION: At least 6 months after treatment, oral cancer patients had worse OHRQoL, worse physical HRQoL and similar psychological HRQoL than the general population.

Oral health-related quality of life and malnutrition in patients treated for oral cancer.

PURPOSE: This study examined whether oral health-related quality of life (OHRQoL) is associated with nutritional status in patients treated for oral cancer. METHODS: A cross-sectional study was carried out on with patients treated for oral cancer at least 6 months after treatment. OHRQoL was measured using two questionnaires: Oral Impacts on Daily Performances (OIDP) and Oral Health Impact Profile (OHIP-14); malnutrition risk was assessed through the Mini Nutritional Assessment (MNA). Multivariable regression models assessed the association between the outcomes (OIDP and OHIP-14) and the exposure (MNA), adjusting for sex, age, clinical stage, social class, date of treatment completion, and functional tooth units. RESULTS: The final simple included 133 patients, 22.6 % of which were malnourished or at risk of malnutrition. More than 95 % of patients reported a negative impact on the OHRQoL for both measures used. Patients with malnutrition or risk of malnutrition had significantly worse OHRQoL than those with no malnutrition, even after adjusting for clinical and socioeconomic data (ß-coefficient = 8.37 (95 % confidence interval (CI) 1.42-15.32) with the OIDP and ß-coefficient = 2.08 (95 % CI 0.70-3.46) with the OHIP-14). CONCLUSION: Being malnourished or at risk of malnutrition is an important longer-term determinant of worse OHRQoL among patients treated for oral cancer.

Selective use of postoperative neck radiotherapy in oral cavity and oropharynx cancer: a prospective clinical study.

BACKGROUND: In cervical postoperative radiotherapy, the target volume is usually the same as the extension of the previous dissection. We evaluated a protocol of selective irradiation according to the risk estimated for each dissected lymph node level. METHODS: Eighty patients with oral/oropharyngeal cancer were included in this prospective clinical study between 2005 and 2008. Patients underwent surgery of the primary tumor and cervical dissection, with identification of positive nodal levels, followed by selective postoperative radiotherapy. Three types of selective nodal clinical target volume (CTV) were defined: CTV0, CTV1, and CTV2, with a subclinical disease risk of <10%, 10-25%, and 25% and a prescribed radiation dose of <35 Gy, 50 Gy, and 66-70 Gy, respectively. The localization of node failure was categorized as field, marginal, or outside the irradiated field. RESULTS: A consistent pattern of cervical infiltration was observed in 97% of positive dissections. Lymph node failure occurred within a high-risk irradiated area (CTV1-CTV2) in 12 patients, marginal area (CTV1/CTVO) in 1 patient, and non-irradiated low-risk area (CTV0) in 2 patients. The volume of selective lymph node irradiation was below the standard radiation volume in 33 patients (mean of 118.6 cc per patient). This decrease in irradiated volume was associated with greater treatment compliance and reduced secondary toxicity. The three-year actuarial nodal control rate was 80%. CONCLUSION: This selective postoperative neck irradiation protocol was associated with a similar failure pattern to that observed after standard neck irradiation and achieved a significant reduction in target volume and secondary toxicity.