Prognostic Involvement of Lymph Node Density in Oral Squamous Cell Carcinoma. A New Predictive Model.

PURPOSE: Lymph node density (LND) has been reported to be a significant predictor of survival in oral squamous cell carcinoma (OSCC). The aim of this study was to analyze LND as a prognostic factor in OSCC and create a predictive model that determines the probability of death in these patients. METHODS: A retrospective cohort study was carried out with a cohort of patients who underwent cervical dissection and primary resection of OSCC between 1980 and 2020. The primary predictor variable in this study was LND, which is defined as the number of positive lymph nodes divided by the total number of lymph nodes removed. The cutoff values for prediction of disease-specific survival (DSS) were calculated by receiver operating characteristic curve analysis, which determined the best cutoff value was 0.07. Patients were divided into binary subgroups (low and high risk) using the best cutoff value of LND. The outcome variable was DSS, defined as the duration from the date of diagnosis to death due to OSCC and not due to other causes or secondary tumors. Other variables were type of neck dissection, postsurgical treatment, surgical margin, pathological T category stage, pathological N category (pN) stage, extranodal extension, perineural invasion, bone invasion, and presence of recurrence. A predictive model (score) was generated by selecting variables using a log-rank test and by using the Cox proportional-hazards regression (multivariate analysis). RESULTS: The sample consisted of 368 patients, 252 (68.5%) male and 116 (31.5%) female patients, with a mean age of 60.3 years. According to the LND cutoff value, there were 289 patients with a low LND (≤0.07) and 79 with a high LND (>0.07). The univariate analysis showed LND as a significant predictor of DSS at 5 years (67.1% in LND ≤ 0.07 vs 32.9% in LND > 0.07; P < .001). The Cox multivariate analysis identified LND (hazard ratio [HR] = 27.2; 95% confidence interval [CI], 3.18-231; P = .002), recurrence (HR = 4.45; 95% CI, 2.3-8.4; P < .001), and type of treatment (HR = 0.52; 95% CI, 0.34-0.81; P < .001) as independent predictive factors for DSS. In the predictive model, the presence of recurrence was the most important factor with 8 points, whereas LND >0.07 contributed only 1 point; however, the 2 categories resulting from this limit were statistically significant. CONCLUSIONS: Our study demonstrates that LND is an additional prognostic factor in patients with a pN+ disease. In addition, our predictive model could be useful in the therapeutic algorithm of OSCC patients, as it can predict the probability of death in these patients.

Is There a Relationship Between Age, Personal Factors or Surgical Findings, and Outcome After Temporomandibular Joint Arthroscopy?

PURPOSE: The variables involved in prognosis after treatment of internal derangement (ID) of the temporomandibular joint (TMJ) are unclear. The purpose of this study was to estimate the frequency and identify which factors are associated with treatment success (or failure) among patients with ID managed with arthroscopy. MATERIAL AND METHODS: A retrospective cohort study was carried out of patients undergoing TMJ arthroscopy over a 9-year-period. The predictor variable was composed of a set of demographic, clinical, and operative findings, including, as primary variable, the patient's age. The primary outcome variable was based on the American Association of Oral and Maxillofacial Surgery (AAOMS) criteria of pain (measured by visual analogue scale (VAS)) and maximal interincisal opening (MIO) defined as VAS ≤ 3 and MIO greater 35 mm and grouped as success or failure. The improvement in pain and functional values were compared with the age by using the Pearson correlation coefficient, whereas categorical variables were tested using chi-squared analysis, and mean values were compared with Student t-test or ANOVA. Subsequently, a logistic regression model was used, and the odds ratios (OR) of the evaluated comparisons were calculated. RESULTS: A total of 212 patients were included in this study. In terms of arthroscopic findings, the presence of severe chondromalacia, adhesions or disc perforation (P < .001), was related with older patients. However, there was no statistically significant correlation between age and the postoperative improvement referred to pain or MIO. According to the AAOMS criteria, the procedure was successful in 54.24% of the cases. Two factors were related with a favorable outcome in the adjusted regression analysis: a higher presurgical MIO (OR 0.91, P < .001) and the presence of adhesions (OR 0.41, P = .003). CONCLUSION: Age has no influence on the outcome after arthroscopy. A higher presurgical MIO and the presence of adhesions provide, in the long-term, a favorable prognosis.

Arthroscopic Management of Synovial Chondromatosis of the Temporomandibular Joint. Case Series and Systematic Review.

AIM: Synovial chondromatosis (SC) is a benign condition that is characterized by the formation of cartilaginous nodules within the synovial tissue of a joint that may detach and form loose bodies inside the articular space. The purpose of this study is to evaluate the use of surgical arthroscopy for the treatment of SC of the temporomandibular joint (TMJ). MATERIALS AND METHODS: A series of six patients treated with arthroscopy (one patient requiring an open arthrotomy due to the size of the loose bodies) in our centre between 1997 and 2016 is presented and results are discussed. A systematic review of the literature of patients with SC treated with arthroscopy or arthroscopy-assisted open arthrotomy is also carried out. RESULTS: Pain, which was the main symptom in our patients, and maximum mouth opening both improved significantly after surgical treatment. Three of the patients were diagnosed with primary SC, and the other 3 had a previous diagnosis of internal derangement. None of the patients showed signs of relapse during the follow-up period. CONCLUSIONS: Surgical arthroscopy is a minimally invasive procedure that allows the extraction of loose bodies and even partial synovectomy of the affected membrane with good results and without recurrence of the disease. This technique can be useful in cases of SC with loose bodies measuring less than 3 mm or without extra-articular extension.

Pathological mandibular fracture: A severe complication of periimplantitis.

Nowadays, dental implant treatment is a very common option for patients even in medical compromised conditons. Some complications related to them have been described. Periimplantitis (PI) is one of the biggest concerns complications of these kind of treatments, probably has a multifactorial aethiology. Usually the consequences of PI are the loss of the implants and prostheses, expenses of money and time for dentists and patients. Very often PI implies the necesity of repeating the treatment . Pathological mandibular fracture due to PI is a severe but infrequent complication after dental implant treatment, especially after PI. In this study we present three cases of mandibular pathologic fractures among patients with different medical and dental records but similar management: two of them had been treated years ago of oral squamous cell carcinoma with surgery and radiotherapy, the other patient received oral bisphosphonates for osteoporosis some years after implantation. We analized the causes, consequences and posible prevention of these fractures as well as the special features of this kind of mandibular fractures and the different existing treatments. Key words:Periimplantitis, pathological mandibular fracture, mandibular atrophy, bicortical implants.

Time to loading and locoregional control in perioperative high-dose-rate brachytherapy: The tumor bed effect revisited.

PURPOSE: To determine whether the time to loading (TTL) affects locoregional control. METHODS AND MATERIALS: Locoregional control status was determined in 301 patients enrolled in several perioperative high-dose-rate brachytherapy (PHDRB) prospective studies conducted at the University of Navarre. The impact of the time elapsed from catheter implantation to the first PHDRB treatment (TTL) was analyzed. Patients treated with PHDRB alone (n = 113), mainly because of prior irradiation, received 32 Gy in eight twice-a-day treatments or 40 Gy in 10 twice-a-day treatments for negative or close/positive margins, respectively. Patients treated with PHDRB + external beam radiation therapy (EBRT) (n = 188) received 16 Gy in four twice-a-day treatments or 24 Gy in six twice-a-day treatments for negative or close/positive margins followed by 45 Gy of EBRT in 25 treatments. RESULTS: After a median followup of 6.5 years (range, 2-13.6+), 113 patients have failed (37.5%), 65 in the PHDRB-alone group (57.5%) and 48 in the combined PHDRB + EBRT group (25.5%). Patients who started PHDRB before Postoperative Day 5 had a 10-year locoregional control rate of 66.7% and patients who started PHDRB on Postoperative Day 5 or longer had a 10-year locoregional control rate of 51.8% (p = 0.009). Subgroup analysis detected that this difference was only observed in the recurrent cases treated with PHDRB alone (Subset 2; n = 99; p = 0.004). No correlation could be detected between locoregional control rate and TTL in the other patient subsets although a trend toward a decreased locoregional control rate after a longer TTL was observed when they were grouped together (p = 0.089). CONCLUSIONS: Patients should start PHDRB as soon as possible to maximize locoregional control especially in those recurrent cases treated with PHDRB alone. The time effect in other disease scenarios is less clear.

Volume of high-dose regions and likelihood of locoregional control after perioperative high-dose-rate brachytherapy: do hotter implants work better?

PURPOSE: To determine whether perioperative high-dose-rate brachytherapy (PHDRB) implants with larger high-dose regions produce increased locoregional control. METHODS AND MATERIALS: Patients (n=166) enrolled in several PHDRB prospective studies conducted at the University of Navarre were analyzed. The PHDRB was given to total doses of 16Gy/4 b.i.d. or 24Gy/6 b.i.d. treatments for negative or close/positive margins along with 45Gy/25 Rx of external beam radiation therapy. The histogram-based generalized equivalent uniform dose (EUD) formulism was used to quantify and standardize the dose-volume histogram into 2-Gy equivalents. The region of interest analyzed included: tissue volume encompassed by the prescription isodose of 4Gy (TV100). Routine dose reporting parameters such as physical dose and single-point 2-Gy equivalent dose were used for reference. RESULTS: After a median followup of 7.4 years (range, 3-12+), 50 patients have failed, and 116 remain controlled at last followup. Overall, EUD was not different in the patients who failed compared with controls (89.1Gy vs. 86.5Gy; p=not significant). When patients were stratified by risk using the University of Navarre Predictive Model, very high-risk patients (i.e., tumors ≥3cm resected with close <1mm/positive margins) had an improved locoregional control with higher EUD values (p=0.028). This effect was not observed in low-, intermediate-, and high-risk University of Navarre Predictive Model categories. CONCLUSIONS: In very high-risk patients, enlarged high-dose regions can produce a dose-response effect. Routine dose reporting methods such as physical dose and single-point 2-Gy equivalent dose may not show this effect, but it can be revealed by histogram-based EUD assessment.

Zygomatic distraction osteogenesis for correction of midfacial support after hemimaxillectomy: experience and technical considerations.

PURPOSE: The maxilla is the functional and esthetic keystone of the midface, and large maxillary defects remain a challenge for reconstructive surgery. Different regional and microvascularized flaps have been used to restore the hemimaxilla. Distraction osteogenesis offers an alternative to complex flaps, with less donor-site morbidity. This method is also preferable as a secondary reconstruction in cases of serious bone defects where other flaps have failed. PATIENTS AND METHODS: Four patients with maxillary defects after oncologic ablation presented at a mean follow-up period of 36 months (standard deviation, 18 mo). In these patients, transport distraction osteogenesis of the zygoma was used to restore the bony support of the low maxilla. RESULTS: After a latency period of 15 days, distraction began at a rate of 0.5 mm/day. A 2-step distraction, by changing the direction of the zygomatic device, was carried out in 3 cases. After a consolidation period of 4 to 6 months for each distraction, the devices were removed and the bone edges were joined together with an autogenous bone graft (anterior iliac crest and calvaria). A good quality of bone was observed in the distracted gap, which allowed for postoperative dental implant placement and prosthetic rehabilitation. CONCLUSION: In patients with large maxillary defects in which the remaining bone is insufficient and in patients in whom other reconstructive methods have failed, zygomatic distraction is an excellent option to restore the low projection of the maxilla. Bone transport was found to be a stable reconstructive method that allowed for the restoration of function and esthetics in oncologic patients.

Vertical distraction osteogenesis of a free vascularized fibula flap in a reconstructed hemimandible for mandibular reconstruction and optimization of the implant prosthetic rehabilitation. Report of a case.

Free vascularized fibular flap is considered the treatment of choice in mandibular reconstruction for extensive bone defects (over 6 centimeters) resulting from trauma, infections or tumor resections. But, when the reconstruction involves a dentate mandible, the fibula has the limit as it does not offer sufficient bone height to restore the alveolar arch up to the occlusal plane. Therefore, the deficiency in bone height makes implant placement impractical. We report a case of vertical distraction osteogenesis of a free vascularized fibula flap used to reconstruct a hemimandible after resection of an odontogenic myxoma, for optimization of the implant prosthetic rehabilitation. The distraction device was applied intraorally. After 10 days of latency period, distraction protocol was performed at a distraction rate of 0.5 mm per day. A consolidation period of 3 months followed. Afterwards the distraction device was removed and 3 osseointegrated dental implants were placed in the distracted area. As a result, the vertical discrepancy between the fibula and the native hemimandible was corrected. The amount of vertical height achieved after distraction was 17 milimeters. The increase of vertical bone height was stable and enabled placement of dental implants without any complications. In conclusion, we consider that vertical distraction osteogenesis of free vascularized flaps is a reliable technique that optimizes implant positioning for ideal prosthetic rehabilitation, after mandibular reconstruction following tumor surgery.

A 12-year retrospective analytic study of the implant survival rate in 177 consecutive maxillary sinus augmentation procedures.

PURPOSE: This retrospective study sought to demonstrate the outcome of maxillary sinus elevation surgery in a series of 177 procedures performed over 12 years and to determine the existence of variables that could independently predict implant survival. MATERIALS AND METHODS: A retrospective descriptive and analytic study of a series of maxillary sinus elevation procedures performed between 1996 and 2007 was undertaken. The sample was composed of patients with severe atrophy of the posterior maxilla who had been rehabilitated with osseointegrated implants placed in grafted maxillary sinuses. Several features of the patients (smoking habit, presence of comorbidities, and previous oral carcinoma) and of the surgical procedure (grafting material, associated procedures, associated materials, simultaneous/delayed implant placement, and complications) related to implant survival or failure were monitored during the follow-up period. Implant survival and the existence of variables that could predict implant survival independently were analyzed statistically. RESULTS: One hundred seventy-seven sinus augmentation procedures were performed in 119 consecutive patients (mean age 50.02 years; SD 11.5). Of the 272 implants placed in sinus-augmented regions, 19 were lost. The mean follow-up period was 60.7 months (SD 36.5). The overall cumulative implant survival rate was 93% after 5 years. The multivariate analysis showed that the presence of complications related to the sinus augmentation procedure (membrane perforation and sinusitis) and peri-implantitis were factors in predicting implant failure. CONCLUSIONS: On the basis of this retrospective analysis, it might be concluded that sinus augmentation is a very versatile procedure. Its efficacy and predictability in terms of implant survival rate is extremely high and independent of the graft material, surgical technique, associated comorbidities, smoking habits, and timing of implant placement. Complications such as membrane perforation, sinusitis, and peri-implantitis appeared to influence implant failure.

Transport osteogenesis in the maxillofacial skeleton: outcomes of a versatile reconstruction method following tumor ablation.

OBJECTIVES: To report our clinical experience using bifocal distraction osteogenesis (BDO) with internal devices to treat patients having bony defects of the maxillofacial skeleton following tumor ablation and to focus on outcomes of dental implant placement in patients having maxillomandibular segmental defects. DESIGN: Retrospective case series. SETTING: Academic research. PATIENTS: Patients were selected according to the following inclusion criteria: a bony defect in the maxillofacial skeleton, moderate soft-tissue defect, local or general conditions that preclude more aggressive surgery, and adequate patient compliance. Types of BDO included horizontal mandibular or maxillar alveolar, bilateral alveolar, vertical mandibular or maxillar, ramus and body, mandibular angle, symphysis, the 2-step procedure, temporalis muscle flap reconstruction, vascularized free-fibular flap reconstruction, radial forearm free-flap reconstruction, and pectoralis muscle flap reconstruction. MAIN OUTCOME MEASURES: The latency period was 10 days, after which distraction was initiated at a rate of 0.5 mm/d. The distraction period continued until the transport disk reached the distal stump. The consolidation period ranged from 8 to 48 weeks. Seven patients required additional bone grafting to complete union with the residual bone. RESULTS: Twenty-eight patients having bony defects of the maxillofacial skeleton underwent BDO. The mean (SD) bony defect length was 47.0 (20.1) mm. The mean (SD) distracted bone lengthening was 36.5 (20.0) mm, with a mean (SD) consolidation period of 16.4 (8.0) weeks. The bony defect involved the hemimandibular body in 12 patients, with greater involvement of the body and symphysis in 4 patients and of the bilateral mandibular body in 2 patients. Complications after BDO included the following: discomfort in 8 patients, complete intraoral exposure and infection in 3 patients, partial cutaneous exposure in 1 patient, premature consolidation in 1 patient, and temporomandibular joint ankylosis in 1 patient. Overall, BDO for reconstruction of bony defects was successful in 22 patients and failed in 6 patients. At the end of the follow-up period, 11 patients had undergone endosseous dental implant placement. CONCLUSIONS: Bifocal distraction osteogenesis potentially benefits patients with bony defects following tumor ablation at various locations in the maxillofacial skeleton. Sufficient bone is gained to allow dental implant placement, an important functional outcome.

Horizontal alveolar transport osteogenesis (HATO) in case of marginal mandibular resection or inferior maxillectomy.

We report two new techniques for the reconstruction of maxillary and mandibular defects: horizontal alveolar transport osteogenesis and the miniplate-guided transport osteogenesis.

Bifocal transport osteogenesis for the reconstruction of adult calvarial defects: a new surgical technique.

Calvarial defects are common problems in craniofacial surgery. They may be explained by surgical interventions, infectious processes, cranial trauma or congenital anomalies. Calvarial defects are particularly challenging because they do not heal spontaneously in humans older than 24 months. The feasibility of using bifocal transport distraction osteogenesis to repair calvarial defects has been successfully evaluated in numerous experimental models. To our knowledge, it has not been used for the reconstruction of human skull defects. We report the first case of human calvarial defect healed by transport distraction osteogenesis.

Reconstruction of oromandibular defects by vascularized free flaps: the radial forearm free flap and fibular free flap as major donor sites.

PURPOSE: Since the advent of the modern microvascular techniques, the radial forearm free flap (RFFF) and the vascularized fibular free flap (VFFF) have become reliable methods for reconstructing oromandibular defects. The purpose of this study is to evaluate our experience with the use of both free flaps in the reconstruction of oral cavity defects after tumoral ablation. PATIENTS AND METHODS: Over a 9-year period, 103 consecutive patients were treated in our department for the reconstruction of oral defects after tumor ablation by means of microvascularized free flaps. A total of 55 patients underwent reconstruction using RFFFs; 42 patients underwent reconstruction using VFFFs with or without skin paddles. Patients were treated for benign (n = 15) and malignant (n = 82) entities. All but 7 patients received donor site covering with abdominal full-thickness skin grafts. RESULTS: Of the 55 patients who received RFFFs, 5 (9.09%) developed necrosis at the end of the postsurgical period, and 7 patients developed complications of the donor site. Of the 42 patients who received VFFFs, an overall flap survival rate of 92.85% was achieved, and complications at the donor site occurred in 5 patients. For both free flaps, anesthesia time lasted from 6 to 15 hours (mean, 9.57 hours), whereas the mean flap ischemic time was 82.86 minutes. CONCLUSIONS: Our results reveal that the RFFF is a reliable method for reconstructing a wide range of oral cavity defects with an acceptably low morbidity rate. It provides adequate bulk and pliability, enabling the reconstruction of a wide variety of locations within the oral cavity. The VFFF allows good reconstruction of composite mandibular defects and provides adequate support for dental implants.

Bilateral mental nerve neuropathy as the sole presenting symptom of Burkitt's Lymphoma.

There are several pathologies that may cause alteration of the lower lip sensation, therefore a differential diagnosis is needed. Among these pathologies, we have focused on intrabone growing tumours such as Burkitt's Lymphoma. Burkitt's Lymphoma is a malignant tumour of B-Cell lymphocyte origin, classified as a Non-Hodgkin's Lymphoma. Three clinical subtypes are described: endemic, sporadic and HIV associated. It is characterized by very fast growing, undifferentiated lymphocytes and bone marrow infiltration. A high incidence of Burkitt's Lymphoma has been reported in African children. It is known to have a good response to radiotherapy and chemotherapy treatment. This report describes the case of a 29 year-old Spanish man diagnosed with Burkitt's Lymphoma, in which his first and only symptom was bilateral anaesthesia of the lower lip. We have also described the clinical evolution, steps for diagnosis and treatment.

Local recurrences and second primary tumors from squamous cell carcinoma of the oral cavity: a retrospective analytic study of 500 patients.

BACKGROUND: The purpose of this study was to evaluate the incidence of local recurrences (LRs) and second primary tumors (SPTs) from squamous cell carcinoma (SCC) of the oral cavity primarily treated with surgery and to further study their relationship with several primary tumor clinical and pathological features. METHODS: Five hundred of 522 patients with SCC of the oral cavity primarily treated with surgery were retrospectively analyzed for the appearance of LRs and SPTs within the oral cavity. All patients with SPTs fulfilled the Warren & Gates criteria. Several clinical features were analyzed. Histological study included TNM classification, tumor size, tumor thickness, surgical margins, perineural infiltration, peritumoral inflammation, and bone involvement. In the univariant analysis, the possible association between different clinical and pathological features and the presence of LRs or SPTs was analyzed by means of the chi-square test for categorical data and the Student's t test for parametric data. The appearance of LRs and SPTs was also studied by binary logistic regression as time-dependant phenomena, in the univariant analysis. Logistic regression was also used for the multivariant analysis between the selected variables. The Kaplan-Meier method was used to estimate the probability of SPT- or LR-free survival. RESULTS: The mean duration of the follow-up period was 52.27 +/- 49.52 months. At the end of this time, 53.82% of the patients were alive without evidence of disease, whereas 31.48% had specifically died of disease. Twenty-eight (5.6%) patients developed an SPT within the oral cavity, whereas 95 (19%) patients developed an LR during the whole follow-up period. The 5-year disease-specific survival rate for the whole series was 67.2%, in contrast to 34.9% in the group of patients with SPT and/or LR. In relation to the univariant analysis, T classification, TNM staging, pT classification, surgical margins, bone involvement, and postoperative radiotherapy (RT) were found to be predictive for LR. In relation to the multivariant analysis, only postoperative RT and bone involvement were predictive for the development of LR. CONCLUSION: The identification of preoperative and postoperative clinical and pathological features that prelude a higher risk for the appearance of LRs and/or SPTs may be of potential interest in determining which patients should benefit of a closer regular follow-up. When considering together the whole clinical and pathological features, only postoperative RT and bone involvement were predictive for the development of LRs. Because of the poor survival rate of the affected patients, we strongly recommend aggressive surgical treatment following the appearance of an SPT or LR.

Le Fort I osteotomy, bilateral sinus lift, and inlay bone-grafting for reconstruction in the severely atrophic maxilla: a new vision of the sandwich technique, using bone scrapers and piezosurgery.

Severe atrophy of the edentulous maxilla and progressive pneumatisation of the maxillary sinus can compromise the insertion of dental implants. In this context, ideal implant positioning is limited by inadequate height, width, and quality of the bone. Le Fort I osteotomy and interpositional bone graft is an excellent treatment concept for the dental rehabilitation of patients with atrophied maxilla and reversed intermaxillary relationship. In this report, we indicate the transcendent aspect of elevation and preservation of maxillary sinus and nasal mucosa, modifying the sandwich technique by the useful of bone scrapers and piezosurgery. The procedure is described including a 1-stage approach using cortico-cancellous bone blocks through which implants are placed. In the extremely atrophied alveolar process of the maxilla, this technique provides the desired gain of bone, allows for the ideal placement of dental implants, and improves any discrepancy between the upper and lower arches.

Solitary cystic lymph neck node metastasis of occult thyroid papillary carcinoma.

The appearance of a solitary lateral cervical cystic mass as the only initial presenting symptom of occult thyroid carcinoma is uncommon. Its presence is often misdiagnosed due to the more frequent branchial cyst in young people. Although oronasopharyngeal squamous cell carcinoma has been reported as the main cause of lymph neck node metastasis, thyroid papillary carcinoma may be responsible for solitary cervical cystic masses as the initial manifestation of the disease. This situation has been rarely reported, although solid masses are much more frequent. In most of these cases all such lesions may initially be considered as metastatic foci from a primary thyroid lesion. However, an alternative explanation by means of which ectopic thyroid tissue is associated with a branchial cyst has to be considered, especially if no primary tumour is observed in the histological examination of the thyroid gland. We present a rare case of solitary cystic lymph node metastasis of occult papillary carcinoma of the thyroid. We also discuss possible etiology for thyroid papillary carcinoma in lateral neck cysts.

Vascularized free fibular flap for the reconstruction of mandibular defects: clinical experience in 42 cases.

OBJECTIVE: Since the advent of modern microvascular techniques, the fibula has become a reliable method for the reconstruction of partial or total mandibular defects. The purpose of this study is to evaluate our experience with the use of the vascularized free fibular flap for the reconstruction of mandibular defects following surgical resection. PATIENTS AND METHODS: During a 5-year period, 102 consecutive patients were treated in our department for reconstruction of oral and maxillofacial defects, using microvascularized free flaps. Forty-two patients were reconstructed by means of the free vascularized fibular flap with or without a skin paddle. Patients underwent resection for benign (n = 15) and malignant (n = 27) entities. Fourteen patients received preoperative radiotherapy and only 1 patient received preoperative chemotherapy. The donor site was closed primarily in 7 cases, whereas an abdominal full-thickness skin graft was used in 35 cases. RESULTS: Thirty-eight patients were treated by means of an osteocutaneous flap, whereas only 4 developed an osseous flap. Five patients developed complications related to the vascular anastomosis and needed a second surgical look. One patient died in the immediate postoperative period. The skin island flap was completely viable in 37 cases (88%). Considering bone survival as the main objective, an overall flap survival rate of 92.85% was achieved in the whole series. Endosseous dental implants were placed in 11 patients with adequate outcome. In 5 of these cases the double-barrel technique was performed. CONCLUSION: Our results reveal that the vascularized free fibular flap is a reliable method for reconstructing mandibular defects with an acceptable low morbidity rate. The use of the osteocutaneous flap provides good reconstruction of composite mandibular defects. It constitutes an adequate support for dental implants.

Contralateral lymph neck node metastasis of squamous cell carcinoma of the oral cavity: a retrospective analytic study in 315 patients.

PURPOSE: In relation to primary squamous cell carcinoma (SCC) of the oral cavity, many clinical and histopathologic factors have been reported to be predictive for lymph neck node relapse. However, few large studies concerning the association between clinical-histopathologic features and the development of contralateral lymph neck node relapse (CLNR) after surgical resection of primary SCC of the oral cavity are available. The purpose of this study was to analyze those factors related to the appearance of contralateral lymph neck node relapse in patients with SCC of the oral cavity primarily treated by means of surgery. PATIENTS AND METHODS: This study was based on a series of 315 consecutive patients with primary SCC of the oral cavity treated between June 1979 and December 1999. All patients were treated primarily by means of surgery with or without adjuvant radiotherapy. The following data were analyzed for each patient: age, gender, habits, time to diagnosis, performance status, tumor clinical features, histologic grade, TNM staging, type of neck dissection, survival outcome, and functional/esthetic results at the end of the follow-up period. Histologic study included the pTNM classification, tumor size, surgical margins, extracapsular spread of lymph neck node metastasis, perineural infiltration, peritumoral inflammation, and bone involvement. RESULTS: Eighty-three patients eventually died of the disease (26.34%). A total of 177 patients were alive with no evidence of recurrence at the end of the study. The mean disease-specific survival rate was 147 +/- 6 months. Twenty-nine (9.1%) patients developed ipsilateral lymph neck node relapse (ILNR), whereas 18 (5.69%) patients developed CLNR. The mean period of time from surgery to the appearance of CLNR was 12.52 months (range, 3 to 49 months). Eighteen of 29 patients with ILNR finally died of the disease. Seven of 18 patients with CLNR died of the disease. Several clinical-pathologic features were predictive for CLNR in SCC of the oral cavity, such as the time to diagnosis, TNM staging, positive ipsilateral clinical N status, histopathologic differentiation, surgical margins of primary tumor resection, type of neck dissection, and perineural infiltration. CONCLUSION: Delay in diagnosis 12 or more months is associated with increased CLNR. Clinical and pathologic factors predictive for CLNR are TNM tumor staging IV, histopathologic poor-differentiation of the primary tumor, surgical margins less than 1 cm around the primary tumor, performance of isolated ipsilateral modified type III radical neck dissection, and perineural tumor involvement. Presence of ipsilateral neck metastasis at the time of diagnosis is associated with an augmented incidence of CLNR in SCC of the oral cavity.