Immediate Implants in Fibulas: Does the Implant to Fibula Osteotomy Distance Impact Early Implant Failure?

BACKGROUND: When placing dental implants in the free fibula flap, the osteotomy cut edge poses a unique challenge in that an optimal distance has not yet been established. PURPOSE: The study aimed to measure the association between implant-to-fibula osteotomy edge distance and early implant failure in patients who received free fibula flap reconstruction with immediate implants. STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study was designed and implemented. The study population was composed of patients who underwent free fibula flap transfer with immediate dental implant placement for the treatment of benign or malignant conditions of the head and neck from 2015 to 2022 at John Peter Smith Hospital. Subjects were excluded if the implant was in the middle of the free flap bordered by adjacent implants, was >10 mm from the osteotomy edge, or had insertional torque values of ≤30 Ncm. PREDICTOR VARIABLE: Primary predictor variable was the implant distance in millimeters from the fibula osteotomy edge. MAIN OUTCOME VARIABLE: Primary outcome variable was early implant failure, defined as implant exfoliation noted by the patient or failure due to implant movement or pain necessitating explantation within 6 months of placement. COVARIATES: The covariates were age, sex, diabetes diagnosis, American Society of Anesthesiologists classification, smoking status, history of head and neck radiation, pathology treated, and if postoperative radiation treatment was received. ANALYSES: A generalized estimating equations model was used to assess the relation between the primary predictor and outcome. A P value of <.05 was considered statistically significant. RESULTS: The sample was composed of 48 subjects who had 130 implants placed, with early failures occurring in 5 implants (3.9%) in 3 subjects. The mean age of the sample was 49 years (standard deviation [SD] 20) and 29 (60%) were male. The mean implant distances for early failures and nonfailures were 3.5 mm (SD 1.04) and 4.3 mm (SD 1.5), respectively. There was a statistically significant relation between implant distance and early implant failure (P = .005, odds ratio 0.6, 95% confidence interval 0.39 to 0.85). CONCLUSION AND RELEVANCE: This study found that shorter distances between the implant and the edge of the fibula osteotomy are associated with early implant failure.

Are More Medically Complex Patients Who Undergo Complex Septorhinoplasty at an Increased Risk for Surgical Site Infection?

BACKGROUND: Prophylactic antibiotics are routinely prescribed by surgeons for their patients who undergo septorhinoplasty. However, the literature to support this remains controversial, especially in complex cases, those that require grafts, revision cases, extended surgical time, and an American Society of Anesthesiologists (ASA) value greater than or equal to 3. PURPOSE: The study purpose was to evaluate for a potential association between increased anesthetic complexity and the risk for surgical site infection (SSI) following complex septorhinoplasty. STUDY DESIGN, SETTING, SAMPLE: Retrospective cohort study of patients who underwent a complex septorhinoplasty between 2005 and 2022 at the Dallas Veterans Affairs Medical Center. Patients were excluded if they did receive a septorhinoplasty, did not follow up, or had insufficient records. INDEPENDENT VARIABLE: All patients were assigned an ASA value prior to surgery, with an ASA value of 3 serving as this study's independent variable. MAIN OUTCOME VARIABLE: The main outcome variable of interest was the development of a postoperative SSI, defined as findings consistent with cellulitis, purulence, or fistula development necessitating antibiotic treatment. COVARIATES: The demographic covariates included patient age and sex. Clinical covariates included diabetes status, history of nasal trauma or surgery, and smoking status. The operative covariates were surgical duration, perioperative antibiotic, intraoperative complication, and type of cartilage graft used. ANALYSES: χ2 Analysis and t-tests were used for calculations, with P values < .05 being considered significant. RESULTS: A total of 182 patients were included in this study, 81 (45%) with an ASA ≤2 and 101 (55%) with an ASA of 3. A patient's age (P < .01), male sex (P < .01), and a diagnosis of diabetes (P < .01) were associated with an ASA value of 3. In total, there were 6 (3.3%) SSIs, with 2 (1%) occurring in those with an ASA of 3. An ASA value of 3 (P = .27, relative risk of .40) was not shown to be associated with an increased risk of SSI. CONCLUSION AND RELEVANCE: Our results suggest that an ASA of 3 is not significant with regard to postoperative infection in patients who undergo a complex nasal septorhinoplasty, and prophylactic postoperative antibiotics are not warranted.

The Cost of Surgically Treated Severe Odontogenic Infections: A Retrospective Study Using Severity Scores.

PURPOSE: Hospital treatment of odontogenic infections can be costly, and often these infections present with varying degrees of severity that can be quantified with odontogenic infection severity scores (OISSs). The purposes of this study were (1) to measure the association between OISSs and hospital bills and (2) to identify risk factors associated with OISSs. METHODS: This retrospective cohort study assessed subjects from January 1, 2016, to December 31, 2020, with severe odontogenic infections treated in the operating room and admitted to the University of Texas Southwestern Medical Center/Parkland Memorial Hospital for >1 hospital day. OISSs were assigned based on the risk to the airway and vital structures. OISSs ≥ 5 were designated group A and < OISSs 5 group B. The primary predictor variable was OISSs, and the primary outcome variable was the mean billed cost of the stay. Analysis to identify associated variables for OISS ≥ 5 was also conducted. Secondary predictor variables were age, gender, smoking status, HIV diagnosis, diabetes mellitus diagnosis, blood glucose at admission, and white blood cell count (WBC) at admission. The secondary outcome variable was OISS. Comparisons between Group A and Group B were conducted using t-tests. Analysis to identify associated variables for OISS ≥ 5 was conducted using univariate and multivariate analysis. Values of P < .05 were considered statistically significant. RESULTS: There were 144 subjects that met inclusion criteria. There were 65 subjects in Group A and 69 in Group B. Group A had a significantly larger mean billed cost of stay (95% CI 8937.7 to 48,225.74; P = .001). Analysis of secondary predictor variables revealed that male sex (OR 2.07; 95% CI 1.06 to 4.07; P = .03), blood glucose ≥ 100 at presentation (OR 3.05; 95% CI 1.46 to 6.38; P = .002), and WBC of > 11,000/mL at presentation (OR 3.17; 95% CI 1.44 to 6.98; P = .003) resulted in an increased likelihood of OISS ≥ 5. CONCLUSIONS: Patients with OISSs ≥ 5 have higher mean billed costs when compared to patients with OISSs < 5. Male sex, blood glucose ≥ 100, and WBC >11,000/mL at presentation is associated with increased likelihood of OISS >5.

Low Insertional Torque and Early Dental Implant Failure.

PURPOSE: There is lack of uniformity regarding the ideal insertional torque with which dental implants need to be placed. The purpose of this retrospective analysis is to compare the incidence of early dental implant failures with an insertional torque less than 30 N-cm to implants placed with an insertional torque 30 N-cm or greater. METHODS: A retrospective cohort study was conducted to evaluate dental implants placed between 2015 and 2016 at the Veterans Affairs North Texas Health Care System in Dallas. The primary predictor variable was dental implant insertional torque, measured at the time of implant placement as either greater than or equal to 30 N-cm or less than 30 N-cm. The primary outcome variable was early implant failure, defined as implant exfoliation noted by the patient or failure due to implant movement or pain necessitating explantation before prosthesis loading. The study conducted a time-to-event analysis to examine a group difference in time to implant failure between insertional torque group greater than or equal to 30 N-cm and less than 30 N-cm using Kaplan-Meir curves and a frailty model. The time to follow-up was censored at 6 months. RESULTS: One hundred three patients had 214 implants placed, with early failures occurring in 14 implants (6.5%). Implants placed with an insertional torque less than 30 N-cm were nearly 14 times more likely to have an early failure compared to implants placed with an insertional torque 30 N-cm or greater (hazard ratio = 13.909; 95% confidence interval, 1.835 to 105.416), which was statistically significant (P = .0108). CONCLUSIONS: The results of this retrospective cohort study suggest that insertional torque values less than 30 N-cm are associated with early dental implant failures. Future, prospective studies will be performed to further elucidate the association between insertional torque and early dental implant failure.

Hygiene Recall in Diabetic and Nondiabetic Patients: A Periodic Prognostic Factor in the Protection Against Peri-Implantitis?

PURPOSE: Diabetes mellitus is associated with an increased risk of poor outcomes with dental implant placement. This study aims to identify if frequency of hygiene visits is a protective factor for the development of peri-implantitis in diabetic patients. METHODS: A retrospective cohort design was conducted on patients presenting for dental implant placement at the Philadelphia Veterans Affairs (VA) Medical Center from 2006 to 2012. The primary predictor variable was hygiene frequency, recorded as either infrequent, annual (7-12 month recall), or biannual (≤6-month recall). The number of months between implant placement and the presence of peri-implantitis was the primary outcome (time-to-peri-implantitis) variable, which was assessed on a subject level and adjusted for clustered, correlated multiple implants on the same subject. Additional variables were greater than or equal to 60 years of age, male gender, smokers, short implant length, diabetes, uncontrolled diabetes, and removable prostheses. Descriptive, univariate, and Cox proportional hazards regression statistics were computed to measure associations with peri-implantitis with P ≤ .05 used to define statistical significance. RESULTS: The study sample was composed of 286 patients. In total, 748 implants were placed. Subjects greater than or equal to 60 years of age were 2 times more likely to develop peri-implantitis (hazards ratio (HR) = 2.015, 95% Cl (0.985-4.119), P = .0549). Subjects receiving implant-supported removable prostheses were 2.3 times more likely to develop peri-implantitis (HR = 2.315, 95% CI (1.006-5.327), P = .0485). With each hygiene visit, patients' risk of developing peri-implantitis decreased 20% (HR = 0.805, 95% Cl (0.394-1.647), P = .5528). In addition, diabetic patients were 49% more likely to develop peri-implantitis (HR = 1.491, 95% CI (0.758-2.936), P = .2475) than nondiabetic patients. CONCLUSIONS: Diabetic patients may be at increased risk for the development of peri-implantitis and an increased frequency of hygiene visits may reduce peri-implant diseases.

Is Alcohol Consumption Associated With Protection Against Peri-Implantitis? A Retrospective Cohort Analysis.

PURPOSE: Recent studies have pointed to the effects of social factors on the health of dental implants. We investigated whether varying levels of alcohol consumption will influence the health of dental implants and associated peri-implant inflammation. PATIENTS AND METHODS: A retrospective cohort study was performed to evaluate implants placed from 2006 to 2012 at the Philadelphia Veteran's Affairs Medical Center. Alcohol consumption was gathered from the health maintenance records within 3 months of implant placement and served as the predictor variable. Analysis was performed at follow-up visits for the presence of the outcome variable, peri-implantitis, which was assessed at an implant level. A multivariable generalized estimating equation logistic regression model was constructed, and a Wald test was used to analyze the statistical significance of each parameter. The results were interpreted as an odds ratio estimate, including the 95% confidence interval. Descriptive statistics were used to compute and analyze the data, with P < .05 used to define statistical significance. RESULTS: Demographically, our cohort consisted mainly of male patients (92%), with an average age of 60 years at implant placement. The mean interval to peri-implantitis was 30 ± 25 months. Peri-implantitis occurred most frequently within 2 years of implant placement. The incidence of peri-implantitis was greatest among heavy alcohol consumers (42%) and lowest among mild and moderate consumers (12 and 6%, respectively). Compared with no consumption, mild alcohol consumption was associated with a 47% decrease in peri-implantitis (P < .0223) and moderate consumption was associated with a 75% decrease (P < .0250). Heavy consumption was associated with a nearly threefold increase in peri-implantitis (P < .0001). CONCLUSIONS: The results from our retrospective cohort analysis revealed that mild to moderate alcohol consumption is associated with a lower rate of peri-implantitis. However, heavy consumption was associated with an increase in the incidence of peri-implantitis among patients with dental implants.

Trainee Contribution Is Not Associated With Citation Frequency: A Retrospective Study.

PURPOSE: Publication citation frequency is a measure of scientific influence. The purpose of this study was to measure the association between trainee involvement in publications and citation frequency. MATERIALS AND METHODS: A retrospective cohort study of the Journal of Oral and Maxillofacial Surgery from January to December 2010 was conducted. For each included publication, the study topic and design were recorded. The primary predictor variable was trainee involvement (yes or no). For the purpose of our study, the term "trainee" encompassed dental students, graduate (non-dental) students, oral and maxillofacial surgery residents, and non-oral and maxillofacial surgery residents, as indicated by author affiliations listed in each article. The outcome variable was the number of citations accumulated between 2010 and 2017. Descriptive statistics were computed. Analyses of variance were performed to compare citation distribution among study types and designs. Student t tests and χ2 tests were performed. RESULTS: The sample consisted of 111 publications, of which 85 (76.6%) had at least 1 trainee author. Among all publications, the mean number of citations was significantly different across study designs (P = .03), with case reports earning the lowest number of citations on average (mean, 14.9 citations). Trainee publications had significantly different distributions of study topics (P = .02) and designs (P < .01). Among publications with a trainee author, the most common topic was pathology (37%) and the most common study design was a case report (45%). Despite the higher proportion of case reports, the mean number of citations between trainee (mean, 30.4 citations) and non-trainee (mean, 30.5 citations) publications was not significantly different (P = .99). CONCLUSIONS: Including trainees does not alter the citation frequency of the articles published in the Journal of Oral and Maxillofacial Surgery. This finding is encouraging to both academic surgeons and their trainees, as a higher volume of students and residents can be engaged in research while preserving the influence of the published works.

Are higher odontogenic infection severity scores associated with difficult intubations?

PURPOSE: This study aimed to determine if there is a relation between odontogenic infection severity score (OISS) and difficult intubation at the time of surgical treatment for severe odontogenic infections (SOI). A secondary goal of this study was to determine the utility of OISS as a predictor of difficult intubations. METHODS: This retrospective cohort study was composed of consecutive patients admitted and surgically treated in the operating room (OR) for SOIs. Patients with an OISS ≥ 5 were designated as Group 1 and < 5 Group 2. RESULTS: There was a statistically significant difference in difficult intubations between the two groups (p = 0.018). Patients with an OISS ≥ 5 were nearly four times more likely to be difficult intubations compared to patients with an OISS < 5 (OR 3.70, 95% CI 1.19-11.45). When OISS ≥ 5 was used to predict difficult intubation, the sensitivity was 69%, the specificity was 63%, the positive predictive value was 23%, and the negative predictive value was 93%. CONCLUSION: OISS ≥ 5 was associated with a higher prevalence of difficult intubations compared to an OISS < 5. OISS may provide clinically relevant data that can be used with established risk factors, laboratory values, and clinical judgment.

The effect of mandibular advancement for mandibular deficiency dentofacial deformities on laryngeal grade and intubation difficulty: a preliminary study.

OBJECTIVE: The purpose of this study was to evaluate mandibular advancement for cases of mandibular deficiency with changes in vocal cord grade and intubation difficulty at subsequent surgery requiring intubation. STUDY DESIGN: This retrospective case series included patients with a diagnosis of mandibular deficiency (Class II skeletal dentofacial deformity) who underwent mandibular advancement surgery (T1) followed by a subsequent surgery (T2) which required intubation. The primary predictor variable was mandibular advancement. The primary outcome variable was the change in laryngeal grade-Cormack and Lehane-after mandibular advancement. A secondary outcome was intubation difficulty after mandibular advancement. RESULTS: Eight patients were included in the study. At T1, the average laryngeal grade was 1.6. There was 1 difficult intubation. The average time to T2 was 9 months. At T2, all patients were intubated on their first attempt, and all had a Cormack-Lehane Grade I view of the vocal cords. There were no difficult intubations at T2. Analysis showed a significant association between mandibular advancement and laryngeal grade at T2 (P = .03; 95% CI 0.07-1.13). CONCLUSIONS: This preliminary investigation found an association between mandibular advancement for cases of mandibular and improved laryngeal grade at subsequent intubation without any difficult intubations.

Does implant placement using a minimally invasive technique increase early failures among trainees at an academic center?

PURPOSE: This study aims to identify whether dental implants placed using a flapless technique have a higher early failure rate, defined as failure within 6 months of placement, compared to implants placed with flap elevation when a surgical guide is not used. METHODS: A retrospective cohort study was conducted to evaluate implants placed with either flapless (FL) or mucoperiosteal flap (MF) surgery between 2006 and 2012 at the Philadelphia VA Medical Center (PVAMC). Implant status after FL or MF surgery was assessed using dental encounter and radiographs at subsequent follow-up appointments to assess for early implant failures within 6 months of implant placement. RESULTS: The FL technique was used to place 89 implants in 38 subjects, while the MF technique was used to place 381 implants in 139 subjects. Early failure occurred in 37 implants, of which 13 occurred in the FL group and 24 occurred in the MF group. FL surgery was found to be associated with a 265% increase in early implant failure (OR 2.653; 95% CL 1.287-5.469) and was statistically significant (p = 0.0064). Residents were over 200% more likely to have an early implant failure when using the FL technique (OR 2.314; 95% CL 1.112-4.816), CONCLUSIONS: Analysis revealed flapless implant placement was associated with higher early implant failure rates. In addition, early failures were more likely to occur when residents placed an implant using the flapless technique. While FL surgery can result in long-term success, it is a more technique-sensitive approach that requires greater clinical skill and stricter case selection to perform.

Assessment of pro re nata inpatient opioid consumption following surgical treatment of severe odontogenic infections.

OBJECTIVE: The purpose of this study was to analyze the pro re nata (PRN) opioid consumption of patients with severe odontogenic infections following operating room incision and drainage using odontogenic infection severity scores (SS). STUDY DESIGN: This retrospective study reviewed consecutive charts of patients admitted for severe odontogenic infections from January 2016 to December 2020. Postoperative opioid doses were tabulated. Severity scores (SSs) were assigned based on the risk to the airway and vital structures. Patients with SS ≥5 were designated as group A and patients with SS <5 as group B. The primary predictor variable was SS, and the primary outcome variable was amount of milligram morphine equivalent consumed. RESULTS: A total of 93 patients met the inclusion criteria. Group A included 40 patients, and group B included 53 patients. No statistically significant difference was found between the 2 groups in age, hospital duration, and American Society of Anesthesiologists classification. Group A consumed a significantly greater amount of PRN postoperative inpatient opioid medications (P = .02). CONCLUSIONS: Patients with odontogenic infection SS ≥5 consumed more postoperative PRN opioid analgesic medications. Given that odontogenic infections are largely preventable, it is imperative to prevent progression of odontogenic infections to limit patient exposure to opioid medication.

Are proton pump inhibitors associated with implant failure and peri-implantitis?

OBJECTIVE: Proton pump inhibitors (PPIs) may be linked to implant failure by affecting bone metabolism and osseointegration. This study evaluated how PPIs influence long-term implant failure and peri-implantitis in PPI users and nonusers. STUDY DESIGN: This was a retrospective cohort study of patients treated at the Philadelphia Veterans Affairs Medical Center between 2006 and 2013. The primary predictor variable was PPI use. Outcome variables were long-term implant failure and the presence of peri-implantitis. Data gathered included demographic characteristics, medical comorbidities, implant location, and dimensions. Multivariate regression models measured independent factor associations. The final study cohort contained 933 implants placed in 284 patients. A total of 323 (32.6%) implants were placed in patients with ongoing PPI use. PPI users were less likely to smoke (22.1% vs 31.9%; P < .01) and use illicit drugs (5.0% vs 9.7%; P = .01) and more likely to have undergone prior bone grafting (18.3% vs 12.9%; P = .03). RESULTS: PPI use lost significance after controlling for confounding factors and was not an independent predictor of implant failure (odds ratio [OR], 0.801; 95% confidence interval [CI], 0.56-1.15; P = .24) or peri-implantitis (OR, 0.801; 95% CI, 0.56-1.15; P = .24). CONCLUSIONS: Our study found no independent associations between PPI use and implant failure or peri-implantitis. Contrary to published literature, PPIs may not influence implant health.

Does alcohol consumption protect against late dental implant failures?

PURPOSE: Social factors have been implicated in the development of peri-implant pathologies, including implant failure. This study aims to investigate whether alcohol consumption affects late dental implant failures. METHODS: A retrospective cohort study evaluated implants placed between 2006 and 2012 at the Philadelphia Veterans Affairs Medical Center. The primary predictor variable was alcohol consumption, measured as nonconsumption and mild, moderate, and heavy consumption. The primary outcome variable was late dental implant failure. Univariate, bivariate, and multivariate statistics were applied, with P < .05 used to define statistical significance. RESULTS: Our cohort consisted of 103 patients and 295 implants with a 5-year minimum follow-up. Most patients were male (93%) with an average age of 60 at the time of implant placement. Late implant failure was associated with 30 implants. Compared to nonconsumption, mild consumption was associated with a 75% decrease in late implant failure (P = .0494), moderate consumption was associated with a 60% decrease (P = .3826), and heavy consumption was associated with a 200% increase (P < .1782). Compared to mild consumption, heavy consumption was associated with an 847% increase in late failure (P = .0135). CONCLUSIONS: Results from this retrospective cohort analysis suggest that mild alcohol consumption is associated with a decrease in late dental implant failures.

Identification and description of mobile dental programs--a brief communication.

OBJECTIVES: The purpose of this study was to identify and describe mobile dental programs in California. METHODS: The programs were identified by Internet searches, county health officers, local dental society directors, mobile program directors, and others. A cross-sectional survey was mailed to program directors if their programs provide clinical dental services beyond screening and education. RESULTS: In California, 33 programs were identified; survey response rate was 70 percent. The populations most likely to be served were those with low-income (100 percent), elementary (77 percent) and preschool (68 percent) children, non-English speakers (64 percent), and the Medicaid-eligible (64 percent). At least half of the programs were providing services in designated Dental Health Professional Shortage Areas. Most program directors indicated that if their program was discontinued, it would be "very difficult" (61 percent) or "difficult" (35 percent) for the target populations to get dental services. CONCLUSIONS: Mobile dental programs are a highly variable, but important, strategy for bringing dental care to many underserved populations.