Risk Factors for Infection Recurrence After Surgical Resection of Advanced Stage Osteonecrosis of the Mandible.

BACKGROUND: Advanced stage osteoradionecrosis (ORN) and medication-related osteonecrosis of the jaw (MRONJ) are challenging disease entities requiring multimodal therapy including surgical resection. However, risk factors associated with infection recurrence are poorly understood. PURPOSE: The purpose of this study was to identify risk factors associated with infection recurrence following resection of advanced stage ORN or MRONJ of the mandible. STUDY DESIGN, SETTING, SAMPLE: This was a retrospective cohort study including patients who underwent segmental mandibulectomy for management of ORN or MRONJ between 2016 and 2021 at the authors' institution. Subjects who did not have margin viability data were excluded. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: The primary predictor variable was viability of resection margins on histopathologic analysis (viable or nonviable). Secondarily, other risk factors categorized as demographic (age, sex, race), medical (comorbidities), and perioperative (reconstructive modality, antibiotic duration, microbiological growth) were evaluated. MAIN OUTCOME VARIABLE: The primary outcome variable was time to infection recurrence defined as time from surgical resection to clinical diagnosis of a fistula tract, abscess, or persistent inflammatory symptoms necessitating surgical intervention. COVARIATES: Not applicable. ANALYSES: Descriptive and bivariate statistics were used to identify associations between risk factors and time to infection recurrence. A significance level of P ≤ .05 was considered significant. RESULTS: The cohort consisted of 57 subjects with a mean age of 63.3 ± 10.0 years (71.9% Male, 75.4% White) treated for ORN (47.4%) or MRONJ (52.6%). A total of 19/57 (33%) subjects developed a recurrence of infection with 1 and 2 year survival of 75.8 and 66.2%, respectively. Nonviable resection margins were associated with earlier time to infection recurrence (P ≤ .001, hazard ratio (HR) = 11.9, 95% confidence interval (CI) = 3.84 to 36.7) as was younger age (P = .005, HR = 0.921, 95% CI = 0.869 to 0.976) and atypical pathogen growth on culture (P = .002, HR = 8.58, 95% CI = 2.24 to 32.8). CONCLUSIONS AND RELEVANCE: Histopathologic margin viability was associated with earlier time to infection recurrence following resection of advanced stage ORN or MRONJ of the mandible. Additional studies are needed to identify interventions that may improve outcomes in this demographic.

Evaluation of Accessibility and Content of Oral and Maxillofacial Surgery Fellowship Program Websites.

PURPOSE: Opportunities for graduating oral and maxillofacial surgery residents to pursue fellowship training are expanding. However, there is a paucity of information in the literature for prospective applicants in our specialty. The purpose of this study was to evaluate the accessibility and content of oral and maxillofacial surgery fellowship program websites (FPWs). METHODS: The authors designed a cross-sectional study including oral and maxillofacial surgery fellowship programs in North America listed on 4 major websites: 1) The American Association of Oral and Maxillofacial Surgeons, 2) The American Academy of Craniomaxillofacial Surgeons Match, 3) The American Dental Association, and 4) The American Academy of Cosmetic Surgery. The existence and accessibility of stand-alone FPWs from these listings were assessed. Content scores were generated based on the presence or absence of 23 content variables related to program characteristics, fellow recruitment, and fellow education on listings and available webpages. Descriptive and bivariate statistics were used to evaluate the relationship between predictor variables and content scores. RESULTS: A total of 44 fellowship programs were included. Of these fellowships, 26 (59.1%) had a stand-alone FPW. The mean content score was 10.8 ± 4.82 out of a maximum of 23. Content scores were significantly greater for head and neck oncology fellowships (P ≤ .001), programs with a stand-alone FPW (P ≤ .001), and Commission on Dental Accreditation-accredited programs (P = .046). Programs with a stand-alone FPW had content scores 1.87 times greater than those without and was the predictor variable with the greatest mean difference between groups. There was no significant difference in content scores with respect to geographic region. CONCLUSIONS: Oral and maxillofacial surgery FPWs demonstrate deficiencies in content areas relevant to prospective applicants. Optimizing the content of FPWs may represent an opportunity to better inform and recruit graduating residents into fellowship programs.

Treatment of cT1N0M0 tongue cancer: outcome and prognostic parameters.

PURPOSE: The objective of the present study was to summarize the treatment and outcomes of cT1N0M0 tongue cancer for which the management is less defined. MATERIALS AND METHODS: A total of 65 consecutive cases of cT1 tongue cancer were retrospectively reviewed. The Fisher exact, χ(2), and Wilcoxon tests were used to statistically analyze the data. RESULTS: The tumor depth had a significant relation to the presence of neck metastasis (P < .05). A 3-mm cutoff point provided better predictive value, with a sensitivity of 92.9% and specificity of 43.1%. The biopsy depth combined with palpation was accurate in determining the tumor depth preoperatively in 87.7%. On multivariate analysis, only the tumor site (ventral tongue) and the presence of erythroleukoplakia had any significant relation to disease-free survival (P = .010). CONCLUSIONS: Elective neck dissection should be considered for patients with cT1N0 oral tongue squamous carcinoma with a biopsy depth of 3 mm or greater. The biopsy depth, combined with the clinical examination findings, is a useful method to help determine the tumor depth preoperatively.

Is hardware colonization associated with latent hardware complications and removal in maxillomandibular free flap reconstruction?

BACKGROUND: The relationship between hardware colonization, latent hardware complications, and hardware removal remains unclear following osteocutaneous free flap reconstruction of the jaws. METHODS: Retrospective cohort study of all patients undergoing free flap reconstruction of the maxilla or mandible from 2016 to 2021. RESULTS: A total of 240 subjects were included. Hardware colonization was associated with latent hardware complication in bivariate (p ≤ 0.001) and multivariate analysis (p ≤ 0.001). Time to latent hardware complication was 6.87 months earlier in colonized subjects (p ≤ 0.001). Of the 35 subjects undergoing hardware removal, 25 initiated but failed conservative therapy, and resolution of symptoms was achieved in 24 subjects after one operative intervention and 33 subjects after repeat intervention if indicated. CONCLUSIONS: Hardware colonization increases the risk and onset of latent hardware complication. Prompt hardware removal may improve outcomes by leading to faster resolution of symptoms without the burden and cost of conservative therapies.

Venous anastomoses using microvascular coupler in free flap head and neck reconstruction.

PURPOSE: This study is a retrospective review of the experience using the venous coupler for head and neck reconstruction over a 3-year period at the University of Maryland Medical Center, Department of Oral and Maxillofacial Surgery. MATERIALS AND METHODS: One hundred seventy-eight consecutive cases of microvascular free flaps between May 2007 and September 2010 were retrospectively reviewed. Data were collected by demographic information, flap type, recipient vessels, method of anastomosis, coupler size, coupler orientation, complications associated with coupler, and reconstruction results. Fisher exact test was used for statistical analysis. RESULTS: There were 294 anastomotic coupler devices used in 173 flaps, with hand-sewn venous anastomoses performed in 5 patients. The overall flap success rate was 94.9% (169/178). Success rate among cases in which the coupler was used was 95.4% (8/173). Total coupler venous thrombosis rate was 4.0% (7/173), with a statistically significant difference (P < .05) in reference to the number of venous anastomoses performed: 58 cases had a single vein anastomosed, 5 cases developed thrombosis; while the 115 flaps with 2 venous anastomoses, only 2 cases had thrombosis. CONCLUSIONS: The microvascular coupler is reliable for venous anastomosis in free flap head and neck reconstruction; dual-vein anastomoses appear to have better results than single-vein anastomoses. Flow coupler has a promising utility in monitoring buried flaps and flaps that are difficult to observe. The microvascular coupler deserves to be more commonly used in free flap head and neck reconstruction.

Is the prevention of condylar sag with maxillomandibular fixation the key to functional reconstruction of a mandibular disarticulation resection?

OBJECTIVE: The aim of this study was to evaluate the long-term outcomes of the use of the free fibula flap for reconstruction with mandibular disarticulation resections. STUDY DESIGN: A retrospective chart cohort review was performed in patients reconstructed with a fibula free flap for a mandibular disarticulation resection at an academic tertiary care institution over a 5-year period. RESULTS: Twenty-four patients were included in the study. Fourteen patients were treated for benign pathology, and 10 cases were malignant. Average follow-up was 20 months. Virtual surgical planning/3-dimensional models were used in all cases. Maxillomandibular fixation (MMF) with surgical wires was used in 65% (n = 13/20) of the dentate patients. Average maximum interincisal opening was 28.2 mm in patients receiving radiation and 38.7 mm in the nonradiated group (P = .01). No patient developed joint ankylosis. Neocondyle position was an average of 11.7 mm from condylar fossa, radiographically. Seventeen of the dentate patients (85%) had reproducible class I occlusion. Occlusion was superior in patients placed into MMF compared with those with elastics or no MMF (P = .06) and independent of the position of the neocondyle (P = .19). CONCLUSIONS: The vascularized fibula flap can be used to provide functional reconstruction of the mandibular condyle defect. The use of at least 2 weeks of MMF maintains an adequate occlusion irrespective of the fibula-glenoid fossa position. The neocondyle does not need to directly abut the articular disc or fossa for adequate functional outcomes.

Ghost Cell Odontogenic Carcinoma Arising in a Previous Calcifying Odontogenic Cyst: A Case Report and Review of Literature.

Ghost cell odontogenic carcinoma (GCOC) is a rare malignant tumor of odontogenic origin, with only about 50 cases reported in the English literature so far. Histologically, it is characterized by ghost cells, dentinoid deposits, high grade malignant cellular features, and areas of necrosis and invasion. Having common histological features with other odontogenic ghost cell lesions (OGCL) like calcifying odontogenic cyst (COC) and dentinogenic ghost cell tumors, it is crucial to recognize GCOC malignant features, as it can be destructive and invasive, sometimes showing distant metastases and high recurrence rate. For this reason, it may entail more aggressive surgical approach and multimodal therapeutic regimen. Here we present a case report of GCOC arising in a previous COC, treated with surgical excision that showed persistence and recurrence after two years. The clinical and histological features of this rare occurrence are presented, in addition to the surgical approach, and a summary of literature review of OGCL.

Can extraoral suction units minimize droplet spatter during a simulated dental procedure?

BACKGROUND: Aerosol and droplet production is inherent to dentistry. Potential for COVID-19 spread through aerosols and droplets characterizes dentistry as having a high risk of experiencing viral transmission, with necessity for aerosol and droplet mitigation. METHODS: Simulations of restorative treatment were completed on a dental manikin with a high-speed handpiece and high-volume evacuation suction. Variable experimental conditions with use of an extraoral vacuum suction at different distances from the simulated patient's mouth and different vacuum settings were tested to evaluate extraoral suction ability for droplet reduction. RESULTS: Using the extraoral suction unit during dental procedure simulations reduced droplet spatter at the dentist's eye level, as well as the level of the simulated patient's mouth. When the extraoral suction unit was used at level 10 and 4 inches from the simulated patient's mouth, less spatter was detected. CONCLUSIONS: Extraoral suction units are an effective method of reducing droplet spatter during operative dental procedures and can be useful in helping reduce risk of experiencing COVID-19 spread during dental procedures. PRACTICAL IMPLICATIONS: During the pandemic, dentistry and its aerosol-generating procedures were placed on hold. The process to getting back to patient care is multifactorial, including personal protective equipment, patient screening, and mitigating aerosol spread.

The deep circumflex iliac artery free flap in maxillofacial reconstruction: a comparative institutional analysis.

PURPOSE: The aim of the present study was to perform a comparative analysis of the utility, outcomes, and complications of DCIA (deep circumflex iliac artery) flap for the reconstruction of maxillofacial defects between two institutions that continue to use the DCIA flap as a reconstructive resource. MATERIALS AND METHODS: This retrospective analysis included a total of 68 patients (mean age 51.1 years) at the University Hospital of Parma, Parma, Italy, and the University of Maryland, Baltimore, USA, between January 2010 and April 2019. RESULTS: No statistical differences were found in relation to the site of reconstruction (p = 0.09), bone graft quantity (p = 0.93), rehabilitation with dental implants (p = 0.464), length of hospitalization (p = 0.086), BMI (0.677), swallow function (p = 0.419), medical comorbidities (p = 0.933), pre-existing radiation (p = 0.691), adjuvant treatment (p = 0.298), ECOG-PS pre-and post-surgery (p = 0.329; p = 0.545), and flap failure: one partial failure observed (p = 0.412) and donor site morbidities (p = 0.742). A noted trend to increased risk of hernia without the use of a primary mesh repair was observed (p = 0.059). CONCLUSION: The DCIA free flap represents a useful and reliable reconstructive flap for maxillofacial reconstruction. Reconstructive microvascular surgeons should be proficiently trained in this flap technique for its consideration as a first-line option in maxillofacial reconstruction.

Nonodontogenic Tumors of the Jaws.

Nonodontogenic tumors of the jaws are common in the pediatric population, accounting for approximately 70% of pediatric jaw tumors. This article focuses on the clinical characteristics and management of the benign nonodontogenic tumors (nonaggressive and aggressive) of the jaws most commonly encountered in children.