The Alberta Reconstructive Technique: An Occlusion-Driven and Digitally Based Jaw Reconstruction.

OBJECTIVES/HYPOTHESIS: The free flap reconstructive protocols of the jaws have been refined over the years and presently are based on bone-driven approaches that generally use the lower border of the mandible or the anterior surface of the maxilla as the templates for reconstruction because these contours are deemed important to the eventual cosmetic outcomes of patients. The ultimate goal of functional jaw reconstruction, however, is the reconstruction of the dental occlusion and oral rehabilitation. The purpose of the present study was to evaluate the Alberta reconstructive technique (ART), which is a new approach of occlusion-driven jaw reconstruction with digitally planned immediate osseointegrated implant installation. STUDY DESIGN: Prospective cohort study. METHODS: This research study considers the ART's safety, effectiveness, accuracy, timeliness of reconstruction, aesthetic appeal, and cost-effectiveness in comparison with the standard bone-driven and delayed osseointegrated implant installation (BDD) protocol. RESULTS: The ART procedures were as safe and more effective at achieving full occlusal reconstruction and oral rehabilitation. The ART cohort of patients achieved oral rehabilitation in 21.4 month as compared to 73.1 months for the BDD cohort. There were no differences in the aesthetic appeal the two groups. The ART cost an average of $22,004 less than BDD and we calculated the quality adjusted life years gain to be between 2.14 and 4.04 in favour of ART. CONCLUSIONS: The ART is a good option for patients with jaw defects. It provides a safe, effective, accurate, aesthetic, and cost-effective reconstruction that restores form and function in a timely manner. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:S1-S14, 2019.

Three-dimensional morphological changes of the temporomandibular joint and functional effects after mandibulotomy.

BACKGROUND: The midline and paramedian mandibulotomy are surgical procedures that divide the mandibular bone into two halves and disconnects the condylar heads of the TMJ from each other. This study aimed to prospectively evaluate the temporomandibular joint (TMJ) functional and morphological changes after mandibulotomy using a reconstructed 3D models of the TMJ. METHODS: Sixteen adult patients diagnosed with oral and oropharyngeal tumors with planned surgical mandibulotomy (test group, 9 patients) or transoral (control group, seven patients) treatments were included in the study. MRI and CBCT images were obtained immediately preceeding surgery and 6-8 weeks after surgery. Using the MRI-CBCT registered images, TMJ tissues were segmented at the two occasions by the same operator and 3D models were reconstructed for morphological assessment. Changes across time were measured using the volume overlap and Hausdorff distance of the disc and condyle 3D models. Disc-condyle relationship was measured using point-based and color map analysis. To assess the early functional changes, the Jaw function limitation scale (JFLS) and the maximum mouth opening were measured. Two-sample Hotelling T2 t-test was performed to determine the significance of the morphological and clinical outcomes' differences between the two groups. RESULTS: The two-sample Hotelling T2 t-test showed significant differences (T2 (df1,df2) = 0.97 (5,26), p <0.01) between the mean values of all outcomes among the 2 groups. The change in disc displacement was significantly different between the two groups (p <0.05). However, the condylar displacement was not significantly different between the two groups (p =0.3). The average of the JFLS score was five times larger after mandibulotomy, and was 2 times larger after transoral surgery (p < 0.01). Patients showed decrease in the average of the maximum interincisal mouth opening by 11 mm after mandibulotomy, and by 5.4 mm after transoral surgery. CONCLUSION: The quantitative assessment of the TMJ showed minimal changes of the condylar position and variable degrees of articular disc displacement associated with the paramedian split mandibulotomy. As well, limited jaw functions and vertical mouth opening were noticed more in the mandibultomy group compared to the transoral group in 6- weeks after surgery.

Bone impacted fibular free flap: a novel technique to increase bone density for dental implantation in osseous reconstruction.

BACKGROUND: Fibular free flap (FFF) bone has thick cortical bone surrounding a fatty marrow. The cortex has sufficient density for dental implantation, but the marrow limits bone stock. A novel technique was devised to increase bone density: the bone-impacted fibular free flap (BIFFF). The purpose of this study was to: (1) describe the BIFFF technique; (2) evaluate the bone density of BIFFF; and (3) evaluate the stability/success of implants placed in BIFFFs. METHODS: Patients undergoing maxillary/mandibular reconstruction with FFFs were prospectively enrolled from 1998 to 2008. Two cohorts were compared: BIFFF and nonmodified FFF. The main outcome was bone density as seen on CT scans. Primary dental implant stability was determined via Periotest. RESULTS: Thirty-eight patients were included in this study. BIFFFs achieved higher bone density versus unmodified FFFs (p < .05). Greater primary dental implant stability occurred in BIFFFs (p < .05). One hundred percent of BIFFF and 59% of nonmodified FFF implants were successful at 1 year. CONCLUSION: BIFFF increases reconstructed bone density, initial dental implant stability, and 1-year implant success.

MRI findings of radiation-induced changes of masticatory muscles: a systematic review.

BACKGROUND: Radiotherapy to the head and neck regions can result in serious consequences to the temporomandibular joint (TMJ) and chewing muscles. Magnetic resonance imaging (MRI) demonstrates soft-tissue alterations after radiotherapy, such as morphology and signal intensity. OBJECTIVE: The purpose of this review is to critically and systematically analyse the available evidence regarding the masticatory muscles alterations, as demonstrated on MRI, after radiotherapy for head and neck cancer. DATA SOURCES: Electronic search of MEDLINE, EMBASE, EBM reviews and Scopus. INCLUSION CRITERIA: Reports of any study design investigating radiation-induced changes in masticatory muscles after radiotherapy in patients with head and neck cancer were included. RESULTS AND SYNTHESIS METHODS: An electronic database search resulted in 162 papers. Sixteen papers were initially selected as potentially relevant studies; however, only four papers satisfied all inclusion criteria. The included papers focused on the MRI appearance of masticatory muscles following radiotherapy protocol. Two papers reported outcome based on retrospective clinical and imaging records, whereas the remaining two papers were case reports. Irradiated muscles frequently show diffuse increase in T2 signal and post-gadolinium enhancement post-irradiation. Also, muscle size changes were reported based on subjective comparison with the contralateral side. The quality of all included papers was considered poor with high risk of bias. CONCLUSION: There is no evidence that MRI interpretations indicate specific radiation-induced changes in masticatory muscles. There is a clear need for a cohort study comparing patients with pre- and post-radiotherapy MRI.

Capturing patient benefits of treatment.

Findings from the Academy of Osseointegration State of the Science on Implant Dentistry Conference clearly demonstrate that data are lacking regarding both quality of design and adequate outcome measures (standardization, validity, and relevance to patient) to support an evidence-based systematic evaluation of implant efficacy. Despite the dearth of controlled trials and the variability in defining implant survival/success, the preponderance of evidence is viewed as lending support for consideration of dental implant therapy as a safe and predictable alternative to conventional restorations for many applications. However, this minimal conclusion undermines the best intentions of the dental profession, which is striving to substantiate to the patient, third-party providers, and the government the relative benefits and risks of various prosthetic treatment alternatives. The conclusions of multiple consensus conferences have repeatedly stressed that additional research with good strength of evidence following a broad spectrum of outcomes is vital to extend the breadth of conclusions regarding dental implant treatment efficacy. However, without a set of consensus-based core outcome measures addressing pertinent clinical and patient-centered factors, future expensive, time-consuming, and technically complex clinical studies may suffer the same critical flaws seen in the current body of research. It may be possible and useful to establish a core set of well-defined, discriminatory, and feasible outcome measures for common utilization and a hierarchy of additional recommended outcome measures for specific benefit categories. Such a standardized group of outcome measures would be likely to significantly enhance the potential for future research. In addition, with the formation of consensus guidelines, there would be an opportunity for scientific journals to promote the quality of implant dentistry research by suggesting the inclusion of these core outcome measures in studies submitted for publication.

Swallowing function in patients with base of tongue cancers treated with primary surgery and reconstructed with a modified radial forearm free flap.

OBJECTIVE: To report swallowing outcomes and biomechanical properties of the base of the tongue (BOT) and the posterior pharyngeal wall (PPW) in patients who undergo surgical reconstruction with the beavertail modification of radial forearm free flap after primary resection of BOT cancer. DESIGN: Prospective cohort study with a 1-year minimum follow-up performed between October 1, 2001, and August 31, 2005. SETTING: Tertiary care facility. PATIENTS: Patients diagnosed as having primary carcinoma of the BOT were treated with primary surgical resection and reconstruction followed by radiotherapy. Inclusion criteria were collection of videofluoroscopic swallowing study (VFSS) data before and 1 year after surgery. Forty-one patients were treated during a 5-year period, and 20 were included in the final analysis. INTERVENTIONS: Reconstruction of BOT defects with the beavertail modification of radial forearm free flap followed by postoperative radiation. MAIN OUTCOME MEASURES: Aspiration score, pharyngeal residue score, and biomechanical analysis of BOT and PPW mobility were performed using images from VFSSs. Both the BOT and PPW positions were measured from 2 static bony landmarks. RESULTS: Of the 20 patients in the final analysis, 19 (95%) were able to swallow safely at 1 year. Mobility of the BOT after surgery was reduced in all postoperative VFSS data. Anteroposterior dimension or bulk of the BOT was preserved. No significant difference was found in PPW mobility. CONCLUSIONS: The beavertail modification of the radial forearm free flap is a good reconstructive option after BOT cancer extirpation. The procedure preserves the bulk of the BOT after cancer treatment and maintains adequate BOT-PPW apposition. This allows structures such as the pharyngeal, oral, and suprahyoid musculature to contract and generate the necessary force to propel the food bolus through the oropharynx, resulting in a safe swallow.

An improved impact technique for monitoring percutaneous implant integrity.

PURPOSE: The purpose of this study was to investigate the validity of the current Periotest system when measuring implant systems and to present a new system to monitor implant interface integrity. MATERIALS AND METHODS: The new system records an impact accelerometer signal and utilizes software for data analysis to determine the resonance frequency of an implant-abutment system. The new system uses the handpiece from the Periotest to acquire an impact signal but makes no use of the rest of the device. Tests were completed to determine the repeatability of the new system along with the effects clinical variables such as abutment torque, angulation of the handpiece, striking height, and distance handpiece is held from the abutment have on the measurement results. Accuracy of the current Periotest method as well as the new system was independently evaluated through the use of an abutment with a strain gauge attached. RESULTS: The new system for impact testing is shown to have greater accuracy than that of the Periotest device. Additionally, the effects of handpiece distance from abutment and torque (when above 15 Ncm) were found to be negligible while angulation of the handpiece and striking height affected the resonance frequency of the new system. CONCLUSION: The results of the in vitro testing indicate that greater resolution and accuracy can be achieved from an impact test that utilizes a clinical measurement protocol and independent analysis of the impact accelerometer signal.

Social perception of speech in individuals with oropharyngeal reconstruction.

Oral cancer affects approximately 5% of the Canadian population every year. One option for treatment of oropharyngeal cancer includes resection of the diseased tissue with primary reconstruction of the defect using a microvascular free flap, followed by post-operative adjuvant radiation therapy. The aim of reconstructive surgery is to maintain functional speech and swallowing. While the literature provides support for the maintenance of speech intelligibility following reconstructive procedures, certain aspects of resonance may be altered when the palatal structures are involved. Little is known about the effect of such alterations on the perception of speakers who have been treated with microvascular free flap reconstruction. Social perception is a process in which we infer attributes of others, with the speech signal playing an integral part in attribution. The purpose of this study was to explore the social perceptions formed about speakers both before and after surgery for oropharyngeal cancer. The results of this study revealed that positive perceptions of speakers significantly diminished as a result of surgery and negative perceptions increased. Certain variables, such as degree of resection of the soft palate and base of tongue, and sex of the speaker, had influence on the results. This research suggests that intelligibility measurements of speech, although useful, do not provide a complete indication of the social impact of reconstructive surgery on patients with oropharyngeal resections.

Nasopharyngoscopy in palatopharyngeal prosthetic rehabilitation: A preliminary report.

PURPOSE: Prosthetic rehabilitation of speech disorders related to palatopharyngeal dysfunction is accomplished through separation of the oral and nasal cavities. The ability to achieve this separation is challenged when the disorder or defect involves the soft palate. Prosthetic rehabilitation of soft palate disorders and defects has traditionally relied on functional contouring of a prosthesis using functionally adapted impression materials. However, there are limitations to this process, particularly in its inability to visualize function as it relates to the prosthesis in a 3-dimensional space. The aim of this study was to address this limitation by describing outcomes related to the use of nasopharyngoscopy (NPS) for visualization of the velopharyngeal port during assessment and treatment of palatopharyngeal dysfunction. MATERIALS AND METHODS: A retrospective analysis of speech data was conducted for 5 patients who were assessed before treatment, after prosthetic intervention using conventional functional impression techniques, and after prosthetic intervention using NPS. Nasalance and velopharyngeal orifice area outcome measurements were collected for each patient at clinically predetermined intervals. Perceptual assessment of speech samples was performed as well. RESULTS: Improvements in speech function were observed for all patients after treatment with a prosthesis designed via a conventional functional impression technique; however, no patient showed normal values for nasalance or velopharyngeal orifice area. With the use of NPS to adjust the wax impression-derived prosthesis, both nasalance and velopharyngeal orifice area measurements for all patients were within normal limits. Similarly, perceptual judgment of speech found that normal resonance balance was obtained after use of NPS. CONCLUSION: The addition of NPS into prosthetic treatment for palatopharyngeal disorders shows promise for improved speech results.

Submandibular gland transfer for prevention of xerostomia after radiation therapy: swallowing outcomes.

OBJECTIVE: To assess swallowing outcomes in patients with oropharyngeal carcinoma in relation to the Seikaly-Jha procedure for submandibular gland transfer (SJP). The SJP has recently been described as beneficial in the prevention of xerostomia induced by radiation therapy in patients with head and neck cancer. DESIGN: Inception cohort. SETTING: University-affiliated primary care center. PATIENTS: A phase 2 clinical trial was conducted from February 1, 1999, through February 28, 2002, to evaluate SJP in patients with head and neck cancer. During that period, a consecutive sample of 51 patients who underwent surgical resection and reconstruction with a radial forearm free flap for oropharyngeal carcinoma were referred for functional assessment of swallowing after completion of adjuvant radiation therapy. At 6 months after surgery, swallowing assessments for 24 patients were available. INTERVENTION: The cohort of 24 patients included 13 who had preservation of 1 submandibular gland (SJP group) and 11 who did not (control group). MAIN OUTCOME MEASURES: Quantitative and qualitative aspects of swallowing were obtained to determine whether patients in the SJP group performed more optimally than those in the control group. RESULTS: Baseline and stimulated salivary flow rates were significantly different between groups. Patients in the SJP group were able to move the bolus through the oral cavity and into the pharynx faster than those in the control group. In addition, patients in the SJP group swallowed less often per bolus than patients in the control group. The complete swallowing sequence was twice as long in controls. CONCLUSIONS: The SJP for submandibular gland transfer appears to be beneficial in promoting more time-efficient swallowing behaviors. This efficiency has implications for the overall well-being and nutritional status of patients with head and neck cancer.

Consensus statements on the BAHA system: where do we stand at present?

After more than 25 years of clinical experience, the BAHA (bone-anchored hearing aid) system is a well-established treatment for hearing-impaired patients with conductive or mixed hearing loss. Owing to its success, the use of the BAHA system has spread and the indications for application have gradually become broader. New indications, as well as clinical applications, were discussed during scientific roundtable meetings in 2004 by experts in the field, and the outcomes of these discussions are presented in the form of statements. The issues that were discussed concerned BAHA surgery, the fitting range of the BAHA system, the BAHA system compared to conventional devices, bilateral application, the BAHA system in children, the BAHA system in patients with single-sided deafness, and, finally, the BAHA system in patients with unilateral conductive hearing loss.

Long-term outcomes of submandibular gland transfer for prevention of postradiation xerostomia.

BACKGROUND: Xerostomia is a permanent and devastating sequela of head and neck irradiation, and its numerous consequences affect most aspects of the patient's life. A new method of preserving and protecting a single submandibular gland from radiation damage through the Seikaly-Jha procedure (SJP) has recently been described. OBJECTIVE: To report the long-term outcomes of the SJP. DESIGN: Inception cohort. Patients The trial was conducted between February 1, 1999, and February 1, 2002. All patients were followed up through the head and neck cancer clinic at the Cross Cancer Institute. All data were collected by a dedicated research nurse. Salivary function was evaluated at regular intervals with salivary flow studies and questionnaires. RESULTS: Ninety-six patients were enrolled in the study, and 38 had a minimum of 2 years' follow-up. The cohort of 38 patients was composed of 2 groups: 26 patients had preservation of one submandibular gland through the SJP, while the remaining 12 did not. Salivary flow was preserved in the SJP group, in which 83% of patients reported normal amounts of saliva 2 years after radiotherapy, compared with none in the SJP group. There were no disease recurrences on the side of the transferred gland or in the submental space. There were no surgical complications attributed to the transfer procedure. CONCLUSIONS: The SJP prevented xerostomia in 83% of the study patients. The approach appears to be oncologically sound and safe.

Maxillary obturators: the relationship between patient satisfaction and speech outcome.

BACKGROUND: Patient satisfaction with a maxillary obturator has been studied in relation to extent of surgical defect, sociodemographic characteristics, scores on mental health inventories, and psychosocial adjustment to illness scales. However, review of the literature reveals limited study of the relationship between patient satisfaction with an obturator and clinical speech outcome measures. The purpose of this study is to relate patient satisfaction scores obtained by questionnaire with those obtained by means of clinical speech measurements. METHODS: Acoustical, aeromechanical, and perceptual measurements of speech were collected for 20 patients after receiving a definitive obturator. Patient satisfaction with their obturator was later measured with the Obturator Functioning Scale (OFS). RESULTS: Results reveal that poorer aeromechanical speech results were associated with patient-reported avoidance of social events, whereas lower speech intelligibility outcomes were related to overall poorer perception of speech function on the OFS. Several background patient characteristics were significantly related to several responses on the OFS and to the aeromechanical assessment outcomes. CONCLUSIONS: Results from instrumental assessments of speech seem to be informative regarding not only speech outcome but also a patient's satisfaction with the obturator. Consideration of background patient characteristics is important when interpreting both clinically obtained and patient-perceived outcomes.

Functional outcomes after primary oropharyngeal cancer resection and reconstruction with the radial forearm free flap.

OBJECTIVE: To report prospectively collected aeromechanical, acoustical, and perceptual speech outcomes, as well as preliminary swallowing data, in patients having reconstruction with radial forearm free flaps after primary resection for oropharyngeal cancer. STUDY DESIGN: Prospective cohort study. METHODS: Acoustical, aeromechanical, and perceptual speech data and swallowing data were gathered at three evaluation times (preoperatively and before and after radiation therapy) for patients treated for oropharyngeal cancer by means of primary resection and reconstruction with a radial forearm free flap. Degree of involvement of the soft palate and base of tongue, along with reconstructive techniques, were entered as between-group factors in the analysis. RESULTS: There were no significant differences in speech intelligibility between the patient groups based on the degree of palate and tongue resected. However, patients with resections of half or more than half of the soft palate had significantly higher nasalance values and larger velopharyngeal orifice areas than individuals who had less than half of the soft palate resected. Significant within-subject differences were revealed across evaluation times for the dependent variables nasalance, velopharyngeal orifice area, and word intelligibility. Ninety-four percent of the patients were able to resume a normal or soft diet. There was a 6% incidence of aspiration in 128 swallows that were analyzed. The amount of base of tongue resected did not significantly affect any of the speech or swallowing parameters. CONCLUSIONS: Radial forearm free flaps are a good reconstructive option after oropharyngeal cancer extirpation. Our acoustic and aeromechanical results indicated that issues related to quality of the speech signal require further study for resections of half or more than half of the soft palate.

Speech outcomes in patients rehabilitated with maxillary obturator prostheses after maxillectomy: a prospective study.

PURPOSE: Speech outcome measurements are valuable in guiding treatment and determining the effectiveness of rehabilitation with a maxillary obturator prosthesis in individuals with palatal resection. Although speech outcome data exist in the literature for such patients, relatively few reports have used clinical tools designed to measure the acoustic, physiologic, and perceptual bases of speech. This investigation reports these measures for individuals rehabilitated with a maxillary obturator. MATERIALS AND METHODS: Speech measurements were collected prospectively at three clinical visit times (preoperative, postresection without an obturator, and with a definitive obturator) for 12 patients assigned to three groups based on the extent of their resection (< half the hard palate, > or = half the hard palate, hard and soft palates). Acoustic data were obtained with the Nasometer, aeromechanical data were collected with the PERCI-SARS, and perceptual ratings of speech intelligibility were obtained through listener analysis. RESULTS: Significant differences existed among the three treatments for all dependent variables and revealed that speech without an obturator is significantly different from the preoperative state, while speech with an obturator does not differ significantly from preoperative function. Individuals with soft palate involvement exhibited significantly poorer nasalance values than individuals with involvement of the hard palate only. CONCLUSION: Rehabilitation with a maxillary obturator is successful in restoring preoperative speech function. Rehabilitation of individuals with involvement of the soft palate may be more challenging.