[Reconstruction after facial trauma with dento-alveolar injury]. / Reconstructie na aangezichtstrauma met dentoalveolair letsel.

While abroad, a healthy 36-year-old woman slammed head-on into a rock wall at high speed, resulting in significant facial trauma. The initial trauma care and first aid took place abroad. In the Netherlands, the woman was referred to the Department of Oral and Maxillofacial Surgery (OMFS) for reconstruction of her face and alveolar processes, gingiva and dentition. In view of the seriousness of the injuries, a 3D treatment plan was drawn up in a multidisciplinary collaboration with an OMF surgeon, an implantologist, dentist and dental technician. By making a digital setup of both the top and bottom front in advance, it was possible to work predictably. The first step consisted of bone augmentation by means of an iliac crest graft to reconstruct the major bone defects of the superior and inferior alveolar processes. Implants were then placed in the upper and lower jaws in the ideal position for the suprastructure by means of drill jigs. Within 10 months after the trauma, the implant bridges could be placed on individual zirconia frameworks to optimally restore oral function and aesthetics, completing the reconstruction.

Salvage Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) for T4b Esophageal Cancer After Definitive Chemoradiotherapy.

BACKGROUND: Patients  with esophageal cancer  that invades adjacent structures (cT4b) are precluded from surgery and usually treated with definitive chemoradiotherapy (dCRT). dCRT might result in sufficient downstaging to enable a radical resection, possibly improving survival. This study aimed to assess the perioperative and oncologic outcomes of a salvage robot-assisted minimally invasive esophagectomy (RAMIE) in patients with cT4b esophageal cancer after dCRT. METHODS: Between June 2012 and November 2019, patients who underwent a RAMIE with a gastric conduit reconstruction after completion of dCRT for cT4b esophageal carcinoma were identified from a prospectively maintained surgical database at the University Medical Center Utrecht. RESULTS: In total, 24 patients with a histopathologically confirmed T4b adenocarcinoma or squamous cell carcinoma of the esophagus were included. The adjacent organs involved were the tracheobronchial tree (67%), aorta (21%) or both (13%). No conversions or major intraoperative complications were observed. A radical resection was achieved in 22 patients (92%), and a pathologic complete response was observed in 13 (54%) patients. Postoperative grade 2 or higher complications occurred in 20 patients (83%). The disease-free survival at 24 months was 68% for the patients in whom a radical resection was achieved. CONCLUSION: In patients with cT4b esophageal cancer treated with dCRT followed by a salvage RAMIE, a radical resection rate of 92% was achieved, with acceptable complications and promising survival rates. These results demonstrate the feasibility of a curative surgical treatment for patients with initially irresectable esophageal cancer but underscore the importance of a proper preoperative patient selection.

[A surprising cause of a neck fistula]. / Een verrassende oorzaak van een halsfistel.

A 24-year-old woman presented with trismus, which had left her unable to open her mouth beyond 1 centimetre. It proved to be a pericoronitis with lingual swelling in the region of tooth 38. The trismus disappeared after removal of the 38. After a week, however, a submandibular swelling occurred. From this, an orocutaneous neck fistula developed from which a hay stalk was removed. In retrospect, the hay stalk ended up under the operculum of tooth 38 after eating meat cooked in hay, the stalk next made its way to the neck.

[Factors contributing to a delay in the diagnostic process in oral cancer]. / Factoren die bijdragen aan het delay in het diagnostisch proces van een mondholtetumor.

In patients with a new squamous cell carcinoma in the oral cavity, factors were investigated that determine the time interval between the occurrence of the first symptoms, the diagnosis and the start of treatment. Status research was conducted on 87 patients who were diagnosed in 2017 at the department of Oral and Maxillofacial Surgery at the Radboud university medical centre (Radboudumc), Nijmegen, the Netherlands. Patients were asked about the length of time between the appearance of the first symptoms and their visit to the dentist or general practioner. Especially patients who were not registered with a dentist waited on average 2 months longer, the most important reasons being that they thought it would solve itself and treatment anxiety. It was concluded that in the case of a squamous cell carcinoma, patients who are not registered with a dentist, are more often toothless and present later with a larger tumour than patients registered with a dentist. Training on recognising the first symptoms of squamous cell carcinomas in the oral cavity should be intensified among dentists and also general practitioners, dental hygienists and dental prosthetic technicians.

Diagnostic performance of MRI for assessment of response to neoadjuvant chemoradiotherapy in oesophageal cancer.

BACKGROUND: Patients with a pathological complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) for oesophageal cancer may benefit from non-surgical management. The aim of this study was to determine the diagnostic performance of visual response assessment of the primary tumour after nCRT on T2-weighted (T2W) and diffusion-weighted (DW) MRI. METHODS: Patients with locally advanced oesophageal cancer who underwent T2W- and DW-MRI (1·5 T) before and after nCRT in two hospitals, between July 2013 and September 2017, were included in this prospective study. Three radiologists evaluated T2W images retrospectively using a five-point score for the assessment of residual tumour in a blinded manner and immediately rescored after adding DW-MRI. Histopathology of the resection specimen was used as the reference standard; ypT0 represented a pCR. Sensitivity, specificity, area under the receiver operating characteristic (ROC) curve (AUC) and interobserver agreement were calculated. RESULTS: Twelve of 51 patients (24 per cent) had a pCR. The sensitivity and specificity of T2W-MRI for detection of residual tumour ranged from 90 to 100 and 8 to 25 per cent respectively. Respective values for T2W + DW-MRI were 90-97 and 42-50 per cent. AUCs for the three readers were 0·65, 0·66 and 0·68 on T2W-MRI, and 0·71, 0·70 and 0·70 on T2W + DW-MRI (P = 0·441, P = 0·611 and P = 0·828 for readers 1, 2 and 3 respectively). The κ value for interobserver agreement improved from 0·24-0·55 on T2W-MRI to 0·55-0·71 with DW-MRI. CONCLUSION: Preoperative assessment of residual tumour on MRI after nCRT for oesophageal cancer is feasible with high sensitivity, reflecting a low chance of missing residual tumour. However, the specificity was low; this results in overstaging of complete responders as having residual tumour and, consequently, overtreatment.

[Antibiotic prophylaxis and (pre-)dental implant surgery]. / AB-profylaxe en (pre)implantologische chirurgie.

Recent literature indicates that in a healthy patient, who has sufficient bone volume to allow implant placement, it is justified to refrain from prophylactic administration of antibiotics. The patient should, however, rinse with chlorhexidine digluconate 1 day prior to treatment and at least 1 week postoperatively. In the case of an immune-compromised patient, a single antibiotic gift is indicated 1 hour before the procedure (2 grams of amoxicillin orally or 2 grams of cefazoline intravenously). In the case of a healthy patient, antibiotic (AB) prophylaxis is also indicated if autologous bone, a bone filler or membranes are applied. Although AB prophylaxis is not necessary when harvesting extraoral bone grafts, it is indicated because the harvested bone is applied intraorally in the same treatment session. The question whether postoperative administration of antibiotics is still needed remains open.

Preoperative image-guided identification of response to neoadjuvant chemoradiotherapy in esophageal cancer (PRIDE): a multicenter observational study.

BACKGROUND: Nearly one third of patients undergoing neoadjuvant chemoradiotherapy (nCRT) for locally advanced esophageal cancer have a pathologic complete response (pCR) of the primary tumor upon histopathological evaluation of the resection specimen. The primary aim of this study is to develop a model that predicts the probability of pCR to nCRT in esophageal cancer, based on diffusion-weighted magnetic resonance imaging (DW-MRI), dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG PET-CT). Accurate response prediction could lead to a patient-tailored approach with omission of surgery in the future in case of predicted pCR or additional neoadjuvant treatment in case of non-pCR. METHODS: The PRIDE study is a prospective, single arm, observational multicenter study designed to develop a multimodal prediction model for histopathological response to nCRT for esophageal cancer. A total of 200 patients with locally advanced esophageal cancer - of which at least 130 patients with adenocarcinoma and at least 61 patients with squamous cell carcinoma - scheduled to receive nCRT followed by esophagectomy will be included. The primary modalities to be incorporated in the prediction model are quantitative parameters derived from MRI and 18F-FDG PET-CT scans, which will be acquired at fixed intervals before, during and after nCRT. Secondary modalities include blood samples for analysis of the presence of circulating tumor DNA (ctDNA) at 3 time-points (before, during and after nCRT), and an endoscopy with (random) bite-on-bite biopsies of the primary tumor site and other suspected lesions in the esophagus as well as an endoscopic ultrasonography (EUS) with fine needle aspiration of suspected lymph nodes after finishing nCRT. The main study endpoint is the performance of the model for pCR prediction. Secondary endpoints include progression-free and overall survival. DISCUSSION: If the multimodal PRIDE concept provides high predictive performance for pCR, the results of this study will play an important role in accurate identification of esophageal cancer patients with a pCR to nCRT. These patients might benefit from a patient-tailored approach with omission of surgery in the future. Vice versa, patients with non-pCR might benefit from additional neoadjuvant treatment, or ineffective therapy could be stopped. TRIAL REGISTRATION: The article reports on a health care intervention on human participants and was prospectively registered on March 22, 2018 under ClinicalTrials.gov Identifier: NCT03474341 .

The peri-esophageal connective tissue layers and related compartments: visualization by histology and magnetic resonance imaging.

An organized layer of connective tissue coursing from aorta to esophagus was recently discovered in the mediastinum. The relations with other peri-esophageal fascias have not been described and it is unclear whether this layer can be visualized by non-invasive imaging. This study aimed to provide a comprehensive description of the peri-esophageal fascias and determine whether the connective tissue layer between aorta and esophagus can be visualized by magnetic resonance imaging (MRI). First, T2-weighted MRI scanning of the thoracic region of a human cadaver was performed, followed by histological examination of transverse sections of the peri-esophageal tissue between the thyroid gland and the diaphragm. Secondly, pretreatment motion-triggered MRI scans were prospectively obtained from 34 patients with esophageal cancer and independently assessed by two radiologists for the presence and location of the connective tissue layer coursing from aorta to esophagus. A layer of connective tissue coursing from the anterior aspect of the descending aorta to the left lateral aspect of the esophagus, with a thin extension coursing to the right pleural reflection, was visualized ex vivo in the cadaver on MR images, macroscopic tissue sections, and after histologic staining, as well as on in vivo MR images. The layer connecting esophagus and aorta was named 'aorto-esophageal ligament' and the layer connecting aorta to the right pleural reflection 'aorto-pleural ligament'. These connective tissue layers divides the posterior mediastinum in an anterior compartment containing the esophagus, (carinal) lymph nodes and vagus nerve, and a posterior compartment, containing the azygos vein, thoracic duct and occasionally lymph nodes. The anterior compartment was named 'peri-esophageal compartment' and the posterior compartment 'para-aortic compartment'. The connective tissue layers superior to the aortic arch and at the diaphragm corresponded with the currently available anatomic descriptions. This study confirms the existence of the previously described connective tissue layer coursing from aorta to esophagus, challenging the long-standing paradigm that no such structure exists. A comprehensive, detailed description of the peri-esophageal fascias is provided and, furthermore, it is shown that the connective tissue layer coursing from aorta to esophagus can be visualized in vivo by MRI.

Postoperative socket irrigation with drinking tap water reduces the risk of inflammatory complications following surgical removal of third molars: a multicenter randomized trial.

OBJECTIVES: The primary aim of the present study was to evaluate the effectiveness of postoperative irrigation of the socket with drinking tap water on inflammatory complications following lower third molar removal. MATERIAL AND METHODS: A multicenter randomized controlled trial was carried out from June 2013 to June 2014. In one arm of the study, patients were instructed to irrigate the tooth socket and surgical site with a Monoject® Curved 412 Tip Syringe (Tyco/healthcare-Kendall, Mansfield, MA, USA) with tap water. In a second arm of the study, the standard postoperative instructions did not include irrigation instructions. The incidences of alveolar osteitis and wound infection were recorded for each group and analyzed by the Fisher's exact test. RESULTS: A total of 280 patients with 333 mandibular third molars were analyzed. According to the intention-to-treat (ITT) analysis, inflammatory complications occurred in 18 cases in the Monoject® group (11.4 %) compared to 34 cases (19.1 %) in the control group (p = 0.04). These complications were associated with significant worse outcomes regarding quality of life, pain, and trismus and caused significantly more missed days of work or study. Female gender, age >26, bone removal, deep impacted third molars, less experienced surgeons, and a high amount of debris at the surgical site were also identified as risk factors for developing inflammatory complications following lower third molar removal. CONCLUSION: Irrigation of the surgical site with drinking tap water using a curved syringe following removal of third molars is effective in reducing the risk of inflammatory complications. CLINICAL RELEVANCE: Water is a very accessible, cost-effective irrigant without side effects and the results from this study have proven that it can be used to reduce the risk of inflammatory complications and associated morbidity following lower third molar removal.

[Implant-supported 3D-printed bridge in the edentulous maxilla]. / Implantaatgedragen 3D-geprinte brug in de edentate bovenkaak.

A healthy 72-year-old man presented with retention problems concerning the dentures in his maxilla. On account of extreme resorption, placement of implants without prior bone augmentation was not an option. The proposal was to use autologous bone harvested from the iliac crest. After a healing period of 4 months, a cone beam computed tomography scan was made, following which the virtual implant planning of 6 implants was carried out. With the help of a template supported by osteosynthesis screws, which had already been inserted during the augmentation procedure, the plan was applied to the patient. The precision of the fit between the planning and the actual placement of the implants has become so high that it was decided to place a 3D-printed dental bridge immediately following implant placement. The treatment trajectory and the costs can thus be significantly reduced whilst the patient gets to enjoy the implant-supported dentures sooner.

Health-related quality of life after pancreatic resection for malignancy.

BACKGROUND: Health-related quality of life (QoL) is of major importance in pancreatic cancer, owing to the limited life expectation. The aim of this prospective longitudinal study was to describe QoL in patients undergoing resection for pancreatic or periampullary malignancy. METHODS: QoL was measured on a scale of 0-100 in patients who underwent pancreatic resection for malignancy or premalignancy at the University Medical Centre Utrecht before resection, and 1, 3, 6 and 12 months after surgery. Measures consisted of the RAND-36, the European Organization for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30) and the EORTC pancreatic cancer-specific module (QLQ-PAN26). RESULTS: Between March 2012 and November 2013, 68 consecutive patients with a malignancy (59 patients) or premalignancy (9) were included. Physical role restriction, social and emotional domains showed a significant and clinically relevant deterioration directly after operation in 53 per cent (RAND-36, P < 0.001), 63 and 78 per cent (QLQ-C30 and RAND-36 respectively, P < 0.001) and 37 per cent (RAND-36, P < 0.001) of patients respectively. Most domains demonstrated recovery to preoperative values or better at 3 months, except for physical functioning. Emotional functioning at 3, 6 and 12 months was better than at baseline (P < 0.001). Symptom scores revealed a deterioration in vitality, pain (P = 0.002), fatigue (P < 0.001), appetite loss (P < 0.001), altered bowel habit (P = 0.001) and side-effects (P < 0.001) after 1 month. After 3 months, only side-effects were worse than preoperative values (P < 0.001). CONCLUSION: QoL after pancreatic resection for malignant and premalignant tumours decreased considerably in the early postoperative phase. Full recovery of QoL took up to 6 months after the operation.

A systematic review on the long-term success of calcium phosphate plasma-spray-coated dental implants.

The objectives of the current review were (1) to systematically appraise, and (2) to evaluate long-term success data of calcium phosphate (CaP) plasma-spray-coated dental implants in clinical trials with at least 5 years of follow-up. To describe the long-term efficacy of functional implants, the outcome variables were (a) percentage annual complication rate (ACR) and (b) cumulative success rate (CSR), as presented in the selected articles. The electronic search yielded 645 titles. On the basis of the inclusion criteria, 8 studies were finally included. The percentage of implants in function after the first year was estimated to be 98.4 % in the maxilla and 99.2 % in the mandible. The estimates of the weighted mean ACR-percentage increased over the years up to 2.6 (SE 0.7) during the fifth year of function for the maxilla and to 9.4 (SE 8.4) for the mandible in the tenth year of function. After 10 years, the mean percentage of successful implants was estimated to be 71.1 % in the maxilla and 72.2 % in the mandible. The estimates seem to confirm the proposed, long-term progressive bone loss pattern of CaP-ceramic-coated dental implants. Within the limits of this meta-analytic approach to the literature, we conclude that: (1) published long-term success data for calcium phosphate plasma-spray-coated dental implants are limited, (2) comparison of the data is difficult due to differences in success criteria among the studies, and (3) long-term CSRs demonstrate very weak evidence for progressive complications around calcium phosphate plasma-spray-coated dental implants.

[Implant positioned buccally of the alveolar process; a complication]. / Implantaat buccaal van de botlamel geplaatst; een complicatie.

Because of a blue discolouration of her mucosa a 58-year-old patient visited her new dentist. Her medical history revealed that several months before an implant in the region of dental element 22 had been installed. When palpating the alveolar region, a painless hard swelling was felt. As a malposition of the implant was suspected, it was decided to have a cone beam computed tomography-scan made. The sagittal scan revealed that apically the implant in the region of dental element 22 was not embedded in the jawbone. Following the placement of an implant, it is always necessary to verify that the implant procedure has been carried out successfully; palpating the implant bed is always required.

Imaging of oesophageal cancer with FDG-PET/CT and MRI.

Integrated 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) PET/CT and magnetic resonance imaging (MRI) with functional features of diffusion-weighted imaging (DWI) are advancing imaging technologies that have current and future potential to overcome important limitations of conventional staging methods in the management of patients with oesophageal cancer. PET/CT has emerged as an important part of the standard work-up of patients with oesophageal cancer. Besides its important ability to detect unsuspected metastatic disease, PET/CT may be useful in the assessment of treatment response, radiation treatment planning, and detection of recurrent disease. In addition, high-resolution T2-weighted MRI and DWI have potential complementary roles. Recent improvements in MRI protocols and techniques have resulted in better imaging quality with the potential to bring improvement in staging, radiation treatment planning, and the assessment of treatment response. Optimal use and understanding of PET/CT and MRI in oesophageal cancer will contribute to the impact of these advancing technologies in tailoring treatment to the individual patient and achieving best possible outcomes. In this article, we graphically outline the current and potential future roles of PET/CT and MRI in the multidisciplinary management of oesophageal cancer.

[The extra value of training dental students in surgical skills]. / Evaluatie van het Chirurgisch Profiel binnen de 6-jarige opleiding in Nijmegen.

In 2010, the revised 3-year master's programme was introduced in the Netherlands, which meant that the full programme of dental education was extended to 6 years. In Nijmegen, this was structured to include a set of profile programmes, next to the existing curriculum. Three profiles were chosen, one of which was the Surgical Profile. The aim of this programme was that the more complex procedures and the treatment of medically compromised patients would be carried out by those students in the 6-year educational programme who participated in the Surgical Profile. The experiences of students following this profile were evaluated by means of a questionnaire. In a second questionnaire, distributed 1 year after the students had graduated, respondents were asked whether they were still making use of the skills that they had been taught. The conclusion was that the training of master's students in dental surgery results in a high degree of satisfaction. The study revealed moreover that 93% of the students who completed the Surgical Profile put the skills they had been taught to use during the first year as dentists and even wanted to build on that knowledge by means of relevant post-graduate courses.

[Immediate front implant placements 2. Objective and subjective aesthetic treatment results]. / Immediaat geplaatste fronttandimplantaten 2. Objectief en subjectief esthetisch behandelresultaat.

In this study, the aesthetic outcome of treatment was analysed after immediate implant placement in 16 patients. During implant installation the gap between the implant and the buccal plate was filled with a bone substitute. Only single tooth replacements were included; the final crowns were placed 3-6 months after implant installation, all with individual manufactured abutments with an emerging profile and platform switching. Postoperative aesthetics were analysed based on clinical photographs and satisfactionquestionnaires. The objectively attained White Esthetic Score and Pink Esthetic Score with an average value of 8.4 and 11.8 respectively, scored high, as was also observed for patient's satisfaction on both treatment and outcome (an average of 8.7). It may be concluded that flapless immediate implant placement together with the application of a bone substitute into the buccal gap in combination with a final crown with emerging profile results in objective and subjective good aesthetics and high patient satisfaction.

[Immediately placed front tooth implants 1. Analysis with cone beam computed tomography after remodelling of the buccal plate]. / Immediaat geplaatste fronttandimplantaten 1. Analyse met conebeamcomputertomografie naar remodellering van de buccale botlamel.

In the period 1 January 2008 to 1 January 2012, an implant was installed in 186 patients immediately after the removal of a maxillary incisor. Subsequent to the placement of the implant, the 2 mm gap between implant and buccal plate was filled with a bone substitute. In the case of 16 patients, in addition to a preoperative and immediately postoperative cone beam computer tomogram, a late-postoperative cone beam computer tomogram was also produced.Immediately post-operative, the buccal plate thickness increased by 1.5 mmfrom 0.9 mm to 2.4 mm. During the evaluation period of 1 to 4 years a reduction took place resulting in a final buccal plate thickness of 1.8 mm on average. Surprisingly, the buccal plate bone height increased by 1.6 mm, to an average of 1.2 mm above the implant shoulder. It was crucial in this case that the implant was placed in such a way that a gap of a minimum of 2.0 mm was created between the original buccal plate and the implant, and that this gap was filled with a bone substitute.

[Implant placement in the aesthetic zone: the socket-shield-technique]. / Implanteren in de esthetische zone: de socket-shieldtechniek.

Following the extraction of an incisor in the maxilla, resorption of the -alveolar bone always occurs, especially on the buccal side. This often indicates that in the buccocervical area, insufficient bone is present to cover the dental implant. One treatment option is to carry out a bone transplant on the buccal side prior to or during the placement of the implant. An alternative way of supporting the buccocervical gingival is to leave the buccal part of the radixin situ, the so-called socket-shield technique. The results of this treatment for 16 consecutive patients were evaluated and revealed that the socket-shield technique produces good treatment results.

[Incisors with a mind of their own]. / Eigenwijze incisieven?

A 43-year-old man, known to have hypodontia, was bothered by his over-erupted central incisors. After the placement of implants and the accompanying crown- and bridgework, the central incisors appear to be increasingly over-erupted. The history shows that this phenomenon has already been seen in the past. Three mechanisms can be responsible for the over-eruption, specifically: continuous facial growth, over-eruption of both central incisors in the maxilla as a consequence of agenesis of opposing dentition and relapse of the orthodontic treatment as a result of the fact that orthodontic retention is not readily possible. After the central incisors were first cut in such a way that an acceptable incisal line has again been formed, the single-unit fixed dental prostheses on the front elements were replaced with porcelain ones.

[Lack of retention of the upper denture: is placement of 2 palatal implants the solution?]. / Retentieproblemen van de bovenprothese: is het plaatsen van 2 palatinale implantaten de oplossing?

A 72-year-old man, edentulous in the maxilla for 20 years, presented himself at his dentist in 2006 with complaints concerning retention of his upper denture. The placement of implants was only possible if bone augmentation was undertaken; this was definitively rejected by the man. As an alternative, Muchor anchors were placed, but these did not provide an adequate solution to the retention problem. In the end, 2 palatal implants were placed, with magnetic anchoring. One year later, the man was very satisfied with this solution.