Novel In-House Design for Fibula Cutting Guide With Detachable Connecting Arm for Head and Neck Reconstruction.

The use of in-house 3D planning and manufacture has become more common in high-volume head and neck reconstructive centers worldwide. Various fibula cutting guides have been designed to allow for accurate and predictable head and neck reconstruction. In this paper, we describe the design, manufacture, and operative technique for use of a novel fibula cutting guide with detachable connecting arms. This straightforward design produces a guide that is less bulky, provides better access for safe osteotomies, and is versatile and adjustable to minimize bone removal between segments.

Nationwide randomised trial evaluating elective neck dissection for early stage oral cancer (SEND study) with meta-analysis and concurrent real-world cohort.

BACKGROUND: Guidelines remain unclear over whether patients with early stage oral cancer without overt neck disease benefit from upfront elective neck dissection (END), particularly those with the smallest tumours. METHODS: We conducted a randomised trial of patients with stage T1/T2 N0 disease, who had their mouth tumour resected either with or without END. Data were also collected from a concurrent cohort of patients who had their preferred surgery. Endpoints included overall survival (OS) and disease-free survival (DFS). We conducted a meta-analysis of all six randomised trials. RESULTS: Two hundred fifty randomised and 346 observational cohort patients were studied (27 hospitals). Occult neck disease was found in 19.1% (T1) and 34.7% (T2) patients respectively. Five-year intention-to-treat hazard ratios (HR) were: OS HR = 0.71 (p = 0.18), and DFS HR = 0.66 (p = 0.04). Corresponding per-protocol results were: OS HR = 0.59 (p = 0.054), and DFS HR = 0.56 (p = 0.007). END was effective for small tumours. END patients experienced more facial/neck nerve damage; QoL was largely unaffected. The observational cohort supported the randomised findings. The meta-analysis produced HR OS 0.64 and DFS 0.54 (p < 0.001). CONCLUSION: SEND and the cumulative evidence show that within a generalisable setting oral cancer patients who have an upfront END have a lower risk of death/recurrence, even with small tumours. CLINICAL TRIAL REGISTRATION: NIHR UK Clinical Research Network database ID number: UKCRN 2069 (registered on 17/02/2006), ISCRTN number: 65018995, ClinicalTrials.gov Identifier: NCT00571883.

Admission patterns and outcomes of patients admitted to critical care in the UK with surgically treated facial infection: an analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database.

Facial infections are common and can occasionally be severe. A small number of patients may develop severe sepsis or airway compromise requiring critical care admission. We examined a national intensive care database to assess patterns of admission and outcomes for patients in this cohort. An analysis was performed of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme database. Data were extracted on case mix and outcomes for patients coded as 'mandible, facial bones, dental, and salivary infection' admitted to critical care between 2010 and 2019. Data included admission numbers, demographics, comorbidities, physiology scores, and outcomes including length of stay and mortality. There were 2820 admissions for patients with facial infections from 212 CCUs over the ten-year period. Admissions increased from 194 in 2010 to 368 in 2019. These admissions accounted for 0.16% of overall admissions in 2010 and 0.21% in 2019, a statistically significant increase in the rate of admissions, p < 0.001. The median age of patients was 48 years and 62.7% were male. Sepsis was present in 77.6% of patients. The median length of stay in critical care was 49 hours (IQR 23.2, 100.3 hours). The median total hospital stay was 7 days (IQR 4, 16 days). The rate of admissions to CCUs for facial infection remains low overall but has significantly increased over the last decade. With increasing demand for this resource ongoing monitoring of utilisation is important.

Rehabilitation post maxillary and mandibular reconstruction: Current status and future approaches.

Rehabilitation post reconstruction in head and neck cancer surgery is a vital component to improving quality of life. In this paper we discuss the current approaches to reconstruction of the maxilla and mandible and how they pertain to rehabilitation. There is a detailed discussion of dental rehabilitative challenges with different composite flaps and ways to solve those challenges. We conclude with a discussion about future approaches to reconstruction and how they will impact on improving rehabilitative outcomes and ultimately improve the quality of life of our patients.

Outcomes of implant-based oral rehabilitation in head and neck oncology patients-a retrospective evaluation of a large, single regional service cohort.

BACKGROUND: The study reports on implant survival outcomes in head and neck cancer patients who received implant-based oral rehabilitation in a regional service centre. METHODS: A retrospective analysis of implant survival outcomes in patients treated in a regional service from 2012 to 2017 was performed. The primary outcome measure was implant survival. The secondary outcome measure was to assess the effect of covariates associated with implant failure including bone type, radiotherapy, chemotherapy, gender and surgical implant complications. Kaplan-Meier survival curves were applied to compare differences in the survival rates of groups of variables. Cox proportional hazards models were applied to identify covariates associated with implant failure. p value was set at 0.05. RESULTS: The sample was composed of 167 head and neck cancer patients who had 779 dental implants placed. Implant survival estimates were calculated: 3 years, 95.7% [95%CI 94.3-97.2%] and 5 years, 95.5% [95%CI 93.9-97.0%], with a median follow-up of 38 months. Gender (p = 0.09), radiotherapy (p = 0.16) and chemotherapy (p = 0.17) did not significantly influence implant survival, whereas implant failure was higher in transported (reconstructed) bone sites in comparison with native bone (p < 0.01). CONCLUSION: The result of this study suggests that overall implant survival as part of the routine oral rehabilitation is high in this patient cohort; however, implant failure was found to be statistically higher for implant placed into transported bone in comparison to native bone.

HOPON (Hyperbaric Oxygen for the Prevention of Osteoradionecrosis): A Randomized Controlled Trial of Hyperbaric Oxygen to Prevent Osteoradionecrosis of the Irradiated Mandible After Dentoalveolar Surgery.

PURPOSE: Hyperbaric oxygen (HBO) has been advocated in the prevention and treatment of osteoradionecrosis (ORN) of the jaw after head and neck radiation therapy, but supporting evidence is weak. The aim of this randomized trial was to establish the benefit of HBO in the prevention of ORN after high-risk surgical procedures to the irradiated mandible. METHODS AND MATERIALS: HOPON was a randomized, controlled, phase 3 trial. Participants who required dental extractions or implant placement in the mandible with prior radiation therapy >50 Gy were recruited. Eligible patients were randomly assigned 1:1 to receive or not receive HBO. All patients received chlorhexidine mouthwash and antibiotics. For patients in the HBO arm, oxygen was administered in 30 daily dives at 100% oxygen to a pressure of 2.4 atmospheres absolute for 80 to 90 minutes. The primary outcome measure was the diagnosis of ORN 6 months after surgery, as determined by a blinded central review of clinical photographs and radiographs. The secondary endpoints included grade of ORN, ORN at other time points, acute symptoms, pain, and quality of life. RESULTS: A total of 144 patients were randomized, and data from 100 patients were analyzed for the primary endpoint. The incidence of ORN at 6 months was 6.4% and 5.7% for the HBO and control groups, respectively (odds ratio, 1.13; 95% confidence interval, 0.14-8.92; P = 1). Patients in the hyperbaric arm had fewer acute symptoms but no significant differences in late pain or quality of life. Dropout was higher in the HBO arm, but the baseline characteristics of the groups that completed the trial were comparable between the 2 arms. CONCLUSIONS: The low incidence of ORN makes recommending HBO for dental extractions or implant placement in the irradiated mandible unnecessary. These findings are in contrast with a recently published Cochrane review and previous trials reporting rates of ORN (non-HBO) of 14% to 30% and challenge a long-established standard of care.

Free Bone Grafts for Mandibular Reconstruction in Patients Who Have Not Received Radiotherapy: The 6-cm Rule-Myth or Reality?

Bony reconstruction of the mandible after surgical resection results in improved rehabilitation and aesthetics. Composite tissue transfer has transformed reconstruction, particularly in patients who have received radiotherapy. However, there is morbidity related to free tissue transfer. Free nonvascularized bone grafts have much lower morbidity. Surgeons believe that free bone grafts greater than 6.0 cm are prone to failure. The aims of this study was to assess whether bone grafts greater than 6.0 cm in length have a high risk of failure. A retrospective study was performed on all patients who had free bone grafts greater than 6.0 cm in length at Birmingham, UK, and Florida, the United States. None of the patients received radiotherapy. A total of 14 patients had undergone bone grafts for mandibular defects greater than 6.0 cm in length; 13 of the bone grafts were successful. Of these 13, none were infected and there was radiographic evidence of bony union. Some of the patients have been dentally rehabilitated with implants. Contrary to much of the literature and many surgeons belief, our study has shown that long mandibular defects (>6.0 cm) are not a contraindication to the use of free bone grafts. Key principles to achieve success are discussed in this article.