Variations in the venous supply of the floor of the oral cavity: Assessment of relative hemorrhage risk during surgery.

There is little anatomical evidence about the venous plexus in the floor of the oral cavity, although venous injury can elicit late postoperative bleeding after oral surgery and it is difficult to identify the exact location of such an injury. The aim of this study was to assess the relative risk for venous injury during surgery. We investigated the course patterns of the venous plexus in the floor of the oral cavity and analyzed their relationships to those of the arteries using 23 human cadavers (41 halves) in the anatomy course at Niigata University during 2016-2018. The venous plexus in the floor of the oral cavity comprised the perforating submental vein, the vena comitans of the hypoglossal nerve, the vena comitans of the submandibular duct, the vena comitans of the lingual nerve, the sublingual vein, and the deep lingual vein. Individual variations of this plexus include duplications or absences of some veins. There is a high incidence of a submental branch running above the mylohyoid or perforating submental artery in the sublingual fossa among individuals with the perforating submental vein piercing the mylohyoid muscle, whereas the sublingual artery has a high incidence there when there is no perforating submental vein. The course patterns of arteries in the floor of the oral cavity can be predicted by estimating the course patterns of the submental veins. The course patterns of the submental veins or veins associated with the nerves and submandibular duct need to be carefully considered during surgery.

Radiological approach for the newly incorporated T staging factor, depth of invasion (DOI), of the oral tongue cancer in the 8th edition of American Joint Committee on Cancer (AJCC) staging manual: assessment of the necessity for elective neck dissection.

The 8th edition of American Joint Committee on Cancer's (AJCC) Cancer Staging Manual was modified by incorporating depth of invasion (DOI) in the T categorization of oral cavity cancer. This is because DOI is strongly associated with cervical lymph node metastasis, which is the most important negative prognostic factor of oral cavity cancer. This major change in the AJCC Cancer Staging Manual caused re-staging of T category in several cases. Although, the DOI on MRI and CT (radiological DOI; r-DOI) strongly correlated with pathological DOI (p-DOI), it is often 2-3 mm larger than p-DOI. Due to this variance, estimation of p-DOI based on r-DOI may not be accurate. However, when a lesion is undetectable on MRI, p-DOI was often smaller than 4 mm. On the other hand, when MRI depicts lesions with styloglossus and hyoglossus muscle invasion, p-DOI was always larger than 4 mm. These correlations between MRI findings and p-DOI are important when assessing the need for elective neck dissection, as the National Comprehensive Cancer Network (NCCN) recommends elective neck dissection in cases with DOI greater than 4 mm.

Risk of Myocardial Infarction and Ischemic Stroke after Dental Treatments.

The association between invasive dental treatments (IDTs) and a short-term risk of myocardial infarction (MI) and ischemic stroke (IS) remains controversial. Bacterial dissemination from the oral cavity and systemic inflammation linked to IDT can induce a state of acute vascular dysfunction. The aim of study is to investigate the relation of IDTs to MI and IS by using case-only study designs to analyze data from a large Taiwanese cohort. A nationwide population-based study was undertaken by using the case-crossover and self-controlled case series design to analyze the Taiwanese National Health Care Claim database. Conditional logistic regression model and conditional Poisson regression model were used to estimate the risks of MI/IS. In addition, we used burn patients as negative controls to explore the potential effect of residual confounding. In total, 123,819 MI patients and 327,179 IS patients in the case-crossover design and 117,655 MI patients and 298,757 IS patients were included in the self-controlled case series design. Results from both study designs showed that the risk of MI within the first 24 wk after IDT was not significantly different from or close to unity except for a modest risk during the first week for patients without other comorbidities (odds ratios [95% confidence intervals] of 1.31 [1.08-1.58] and 1.15 [1.01-1.31] for 3 d and 7 d, respectively). We also observed no association between IDTs and IS, or the risk ratio was close to unity. IDTs did not appear to be associated with a transient risk of MI and IS in the Taiwanese population, with consistent findings from both case-only study designs. However, we cannot exclude that dental infections and diseases may yield a long-term risk of MI and IS.

Tactile recovery assessment with shortened Semmes-Weinstein monofilaments in patients with buccinator myomucosal flap oral cavity reconstructions.

BACKGROUND: The sensitive restoration is a primary aim of oral reconstructive surgery. The Semmes-Weinstein monofilament test is the "Gold Standard" to assess the threshold of tactile sensitivity on the skin but its use in the oral cavity is limited due to the size of the tools. We adopted half-cut Semmes-Weinstein monofilaments to evaluate the threshold of tactile sensitivity in oral reconstructions with buccinator myomucosal flaps. MATERIALS AND METHODS: Monofilaments were half-cut and recalibrated. Fifty-seven oral reconstructions were considered at 4-year minimum follow-up. Test was conducted both on the reconstructive flap and on the non-operated contralateral side. RESULTS: All of the considered flaps (100%) showed a recovery of tactile sensitivity. The overall average tactile threshold value assessed on this sample was 0.76 ± 1.58 g/mm2 overall. CONCLUSIONS: Shortened monofilaments allow easily assessment of tactile sensitivity in all the oral cavity areas, even in operated patients which often present lockjaw or microstomia.

Assessment of Fibula Flap Skin Perfusion in Patients Undergoing Oromandibular Reconstruction: Comparison of Clinical Findings, Fluorescein, and Indocyanine Green Angiography.

IMPORTANCE: Complications of partial flap necrosis contribute substantially to morbidity in patients who undergo head and neck reconstructive surgery. OBJECTIVE: To assess the usefulness of clinical findings, intraoperative fluorescein angiography, and intraoperative indocyanine green angiography (ICGA) for evaluation of flap skin paddle perfusion in patients undergoing oromandibular reconstruction who are at high risk of partial skin paddle necrosis. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review from May 21, 1996, to May 27, 2015, at a tertiary care academic medical center. Participants were 73 patients who underwent reconstruction of through-and-through defects of the mucosa, mandible, and skin using fibula free flaps that contained large bilobed skin paddles. MAIN OUTCOMES AND MEASURES: The rates of partial skin paddle necrosis and revision reconstructive surgery. RESULTS: The rates of partial flap necrosis were 8% (n = 2) among 25 patients in whom the skin paddle was trimmed based on ICGA and 33% (n = 16) among 48 patients in whom the skin paddle was trimmed according to clinical findings (P = .02). The rates of revision reconstructive surgery were 20% (5 of 25) when flap skin paddles were trimmed using ICGA and 42% (20 of 48) when trimmed per clinical findings (P = .06). CONCLUSIONS AND RELEVANCE: The use of ICGA may reduce the risk of partial skin flap necrosis in free flaps used in patients undergoing head and neck reconstruction who are at high risk of developing flap necrosis. Indocyanine green angiography imaging should be considered in any flap in which skin paddle viability is uncertain based on clinical findings and in patients in whom the skin paddle extends beyond the primary and adjacent angiosomes. LEVEL OF EVIDENCE: 3.

Assessment of upper airway obstruction by measuring peak oral and nasal inspiratory flow.

OBJECTIVE: We wanted to access upper airway obstruction in patients undergoing tonsillectomy by measuring peak oral and nasal inspiratory airflow. METHODS: We recruited study participants from a cohort of patients on the waiting list for tonsillectomy, with or without adenoidectomy, at University Hospital of Wales, Cardiff, UK. Fifty patients enrolled on phase I of the study and underwent pre-operative measurement of the rate of peak oral and nasal inspiratory flow; 25 of these patients returned after one month for phase II of the study and underwent post-operative measurement of the rate of both peak oral and nasal inspiratory flow. RESULTS: Of the 25 participants who completed phase II of the study, 17 (68 per cent) showed an increase in post-operative peak oral inspiratory flow rate by an average of 45 per cent, while 18 (72 per cent) showed an increase in post-operative peak nasal inspiratory flow rate by an average of 22 per cent. CONCLUSION: Both peak oral and nasal inspiratory flow rate measurements may be useful measures of oral and nasal obstruction. Further larger studies are needed to develop these measurements as screening and efficacy measures for adenotonsillectomy to relieve upper airway obstruction.

Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps.

Reconstructive surgery of the head and neck region has undergone tremendous advancement over the past three decades, and the success rate of free tissue transfers has risen to greater than 95%. It must always be considered that not all patients are ideal candidates for free flap reconstruction, and also that not every defect strictly requires a free flap transfer to achieve good functional results. At our institution, free flap reconstruction is first choice, although we use pedicled alternative flaps for most weak patients suffering from severe comorbidities, and for pretreated patients presenting a second primary or a recurrent cancer. From July 2006 to May 2010, 54 consecutive patients underwent soft tissue reconstruction of oral cavity and oropharyngeal defects. We divided the cohort in three groups: Group 1 (G1): 16 patients in good general conditions that received free radial forearm flap reconstruction; Group 2 (G2): 18 high-risk patients that received a reconstruction with infrahyoid flap; Group 3 (G3): 20 patients that received temporal flap (10 cases) or pectoral flap (10 cases) reconstruction. We must highlight that pedicled alternative flaps were used in elderly, unfavourable and weak patients, where usually the medical costs tend to rise rather than decrease. We compared the healthcare costs of the three groups, calculating real costs in each group from review of medical records and operating room registers, and calculating the corresponding DRG system reimbursement. For real costs, we found a statistically significant difference among groups: in G1 the average total cost per patient was € 22,924, in G2 it was € 18,037 and in G3 was € 19,872 (p = 0.043). The amount of the refund, based on the DRG system, was € 7,650 per patient, independently of the type of surgery. Our analysis shows that the use of alternative non-microvascular techniques, in high-risk patients, is functionally and oncologically sound, and can even produce a cost savings. In particular, the infrahyoid flap (G2) ensures excellent functional results, accompanied by the best economic savings in the worst group of patients. Our data reflect a large disconnection between the DRG system and actual treatment costs.

[Cost effectiveness of a free forearm flap in reconstruction of the oral cavity and pharynx--the donor site complications]. / Cena uzyskania wolnego plata przedramienia w rekonstrukcjach w obrebie jamy ustnej i gardla--powiklania miejsca donorowego.

PURPOSE: Evaluation of the donor site efficiency in patients after reconstructive surgery with use of free forearm flap. All patients were treated for oral cavity and larynx cancer. MATERIALS AND METHODS: a group of 21 patients (16 men and 5 women) treated in 2007-2011. The retrospective analysis was conducted on the anamnesis, operating protocols, physical examination and a questionnaire, there was completed by patients during a routine ENT follow up examination. The PRWE (Patient Rated Wrist Evaluation) subjective questionnaire was used to estimate the rate of pain severity and wrist mobility. RESULTS: In 59% of patients the wrist was healed primary, in 36% of patients by granulation. In all patients the wound was healed satisfactory in follow up examination, but 60% of patients revealed extensive scars formation. 62% of patients showed no local pain at rest, while in 38% of them worsening of symptoms was noticed--average 0.5/10 (median 1.0). Pain was more intense in patients who did basic motor activity of hands approximately 1/10 and lifting weights averaging 2.1/10. Dysfunction of the wrist was at the level of the average value of 4.2/50. CONCLUSIONS: Surgical reconstruction with a use of the free forearm flap is associated with the formation of extensive wrist scars. The risk of local complications is low while preserving the qualification protocol, postoperative care and proper surgical management. Reconstructive surgery based on the free forearm flaps gives satisfactory functional results of the donor site. However, it requires surgical experience and practical knowledge of anatomy.

Three-dimensional CT angiography for the diagnosis and assessment of arteriovenous malformations in the oral and maxillofacial region.

OBJECTIVE: The purpose of this study was to evaluate the diagnostic performance of three-dimensional computed tomography angiography (3D-CTA) for arteriovenous malformations (AVMs) in the oral and maxillofacial region. MATERIALS AND METHODS: Sixty four-slice spiral CT angiography of oral or maxillofacial region was performed in 8 patients with surgically proven arteriovenous malformations. The morphologic features, size, location, boundary, and feeding and draining vessels of lesions were reviewed. RESULTS: AVMs in 5 patients were located in the soft tissues and 3 were in the mandible. CTA of all cases showed tangles of disorganized vessels with well-defined borders. The feeding and draining vessels were enlarged and tortuous. Four patients had bone involvement. CONCLUSION: Sixty four-slice spiral CTA can accurately demonstrate the morphological characteristics of AVMs.

Transoral robotic surgery: does the ends justify the means?

PURPOSE OF REVIEW: Head and neck surgical science has developed dramatically during the past 20 years with a major focus on organ preservation surgery. Among these organ preserving surgeries are the selective neck dissections, supracricoid partial laryngectomies, transoral laser surgeries, and now a newcomer, transoral robotic surgery utilizing the da Vinci surgical system. Transoral robotic surgery is in its infancy, but, indeed, there have been some questions raised about the role of these innovative robotic surgical techniques. RECENT FINDINGS: This article will review, point by point, the questions that have been raised concerning the feasibility; safety and efficacy; teachability; and cost effectiveness of transoral robotic surgery. SUMMARY: Although the present literature reports early findings, without long-term oncologic outcomes, the results are consistently encouraging. Training programs have already yielded successes. Indeed, multiple institutions have shown that transoral robotic surgery programs can be successfully established yielding excellent clinical outcomes. In addition, early studies of swallowing function following transoral robotic surgery show swallowing outcomes that are superior to some of the reported chemoradiation results for equivalent lesions.

Objective assessment of speech after surgical treatment for oral cancer: experience from 196 selected cases.

In 1992, a personal computer-based workstation for speech-digitized analysis was developed in conjunction with Canniesburn Hospital and Edinburgh University to measure all dispersion in speech after surgery for oral cancer. The voices of 196 patients with tumor of the oral cavity were recorded preoperatively and postoperatively. Surgical resection was carefully mapped out on standard diagrams of the oral cavity. Patients' recordings were assessed for conversational understandability by two referees. Patients also self-scored their speech using the Functional Intraoral Glasgow Scale self-questionnaire. Many patients had similar if not identical resections; therefore, 12 homogeneous groups were identified. Functional outcome for speech was correlated with the site and size of resected tissue and with the reconstruction modalities. The original association of an objective, computer-based tool and two subjective assessment tools proved to be the most suitable investigation method for speech. The general pattern was for consistently better speech quality with smaller excisions. The reconstruction modalities did not seem to influence the overall speech quality, as it was related mainly to the extent of surgical demolition. The authors present a detailed correlation between site and size of excision and functional outcome using color multiple-view diagrams for immediate appreciation. Positive and negative prognostic factors were identified in surgery for oral cancer.

Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer.

OBJECTIVE: To compare the cost and functional results of free and pedicled soft tissue reconstruction after posterior oral cavity and oropharyngeal extirpation. DESIGN: Retrospective study of 53 consecutive patients undergoing extirpation with primary soft tissue reconstruction from January 1, 1991, to December 31, 1995. Median follow-up was 298 days. SETTING: Academic tertiary care medical center. INTERVENTION: Twenty-four patients underwent reconstruction with a pedicled pectoralis major myocutaneous flap (PMMF); 29 patients, with a fasciocutaneous free flap (FF) (27 radial forearm, 1 lateral arm, and 1 scapular). MAIN OUTCOME MEASURES: Direct (inpatient hospital resources used and monetary costs) and intangible (post-operative complications and function) costs. RESULTS: Operative time was longer for FF reconstructions (P = .003), but both patient groups had similar intensive care unit and hospital stays. Treatment cost for FF reconstructions was $41,122, compared with $37,160 for PMMF reconstructions (P = .003). This difference was due to increased professional fees for FF reconstruction (P < .001) which was offset by intangible cost differences. The PMMF group tended toward an increased rate of flap-related complications, compared with the FF group. At last follow-up, 4 patients in the FF group (15%) and 3 in the PMMF group (15%) had their tracheotomy. In contrast, 17 (85%) patients in the PMMF group and 11 (39%) patients in the FF group required enteral tube feedings (P = .002). Also, 18 (64%) patients in the FF group were eating at least a soft diet compared with 6 (30%) patients in the PMMF group (P = .02). CONCLUSIONS: Comparison of direct costs reveals only a modest difference in reconstruction costs that is outweighed by the intangible costs of PMMF reconstruction. The functional benefits of FF reconstruction appear to justify its slight increased expense and its use rather than PMMF reconstruction after extirpation in the posterior oral cavity and oropharynx.

Economic analysis and its application to oral and maxillofacial surgery.

PURPOSE: Recent clinical publications have increasingly emphasized comparison of cost with benefits in such areas such as drug therapies, surgical procedures, and prophylaxis regimes within certain populations. In the past, cost analysis was based principally on the comparative market price of new treatment compared with standard therapy. Benefits were assessed solely in terms of objective clinical and imaging improvement. Now, issues such as quality of life, early return to occupation, and subjective symptoms of pain and discomfort caused by a treatment are also being critically evaluated. Addressing these latter issues, however, is often complicated and expensive. This article reviews some terms and principles of cost analysis, cost effectiveness, and cost-benefit analysis. Examples are given of recent attempts to quantify costs and benefits for individuals, hospitals, health organizations, and society as a whole. Guidelines are suggested concerning how these studies can be applied to oral and maxillofacial surgery.

The clinically negative neck in patients with early oral cavity carcinoma: a decision-analysis approach to management.

Despite improvements in both diagnostic and therapeutic techniques in recent decades, the prognosis for oral cavity squamous cell carcinoma has not improved. Patients presenting with overt regional metastases necessarily undergo therapeutic intervention directed to both the primary site and the neck. However, controversy persists regarding the best management for patients without clinical evidence of nodal disease. Would these patients best be managed with elective treatment of the neck, with no neck treatment unless overt nodal metastases are detected, or would some diagnostic test be beneficial in determining which patients are at highest risk of having occult nodal disease and, therefore, most likely to benefit from elective treatment? We performed a decision analysis to address this question. Baseline probability assumptions were made based on the evidence available in the literature for the parameters of interest. A decision tree was constructed and analyzed. In the final analysis, two options, elective functional neck dissection for all patients and a supraomohyoid neck dissection, were equally beneficial and were significantly better than the remaining options tested. Either of these surgical treatment strategies shifted the survival distribution curve significantly to the right.

Need and demand for dental treatment. A comparison between an evaluation based on an epidemiologic study of 35-, 50-, and 65-year-olds and performed dental treatment of matched age groups.

The aim of this study was to compare the results of the level of treatment need as judged from a sample drawn from the general population aged 35, 50, and 65 years with treatments performed in 1992 and 1993 of patients of matched ages. Both the sample and the patients lived in Västerbotten in the northern part of Sweden. In all three age groups there was a significantly higher frequency of restorative treatment performed than the professionally assessed need in the epidemiologic sample. In all ages examined, treatment aimed at rehabilitation of temporomandibular disorders was performed statistically significantly (p < 0.001) less frequently than the evaluated need in the population. A similar result was found for dentures among 65-year-olds. The results may reflect dental care paradigms favoring operations on single teeth rather than treatments aimed at functional rehabilitation on a broader sense.

Service mix in general dental practices employing and not employing dental hygienists.

Service mix studies conducted in Australia have indicated a low provision of periodontal services. The service mix in Australian general dental practices employing dental hygienists has not been studied. This study compares the service mix between 18 practices employing hygienists and 29 practices not employing hygienists in Adelaide. Practices employing hygienists tended to be larger group practices, with younger dentists seeing a younger set of patients. Practices employing dental hygienists provided a mean of 97.9 services to 57.2 patients over 2 days, significantly higher than the mean of 68.8 procedures to 39.1 patients in practices not employing dental hygienists. Comparing the % of procedures provided in treatment categories as a ratio of total procedures, practices employing dental hygienists provided significantly more periodontal procedures and less oral surgery, prosthetic and restorative procedures. Periodontally-related services accounted for an average of 37.7% of procedures in practices employing dental hygienists compared with 18.9% in practices not employing dental hygienists (p < 0.05). Periodontal and preventive treatment of 50.7% of patients in practices employing hygienists was delegated to a hygienist, and the level of delegation of periodontally-related procedures was 77.2%. Over 90% of procedures performed by hygienists were periodontally-related, with the removal of subgingival calculus accounting for 57.7% of all procedures provided by dental hygienists. In conclusion, practices employing hygienists had a more periodontally-orientated service mix, with hygienists acting to complement the services of dentists in the provision of periodontal services, rather than as a substitute for the dentist.

Oral cavity reconstruction: an objective assessment of function.

The prime objective of oral cavity reconstruction is restoration of function, which must be carefully studied while evaluating the success of any reconstructive endeavour. We devised a unique comprehensive test series for the purpose that is suitable for use in routine follow-ups, and capable of providing objective documentation. Functional assessment included evaluation of general health, food intake, oral competence, mastication, speech, swallowing, tongue mobility, and shoulder-neck function. Fifty patients who had surgery were analyzed and their functional scores compared with those of 10 normal volunteers. The extent of mandibular resection and the magnitude of soft tissue excision significantly affected overall scores of function. Oral competence, as reflected by the water holding test (WHT), was uniformly impaired in the 50 patients, and in dentate individuals, the quality of bolus provided good correlation with all other functional scores. Among reconstructive modalities employed here, the bi-paddled pectoralis major flap produced the best overall scores.

Dental claims in the Swedish Patient Insurance Scheme.

The Swedish Patient Insurance Scheme covers treatment injuries and guarantees the replacement of failed removable prostheses for 1 year and fixed prostheses for 2 years after fitting. In this paper, 573 dental cases are analysed for a 3-month period in 1986, during which crowns and bridges formed the vast majority of failed treatments that were reported.