The Use of Urinary Bladder Matrix for Reconstructing Avulsed Traumatic Soft Tissue Injuries to the Maxillofacial Region.

INTRODUCTION: The purpose of the study was to provide an overview of our initial experience utilizing urinary bladder matrix (UBM) for reconstructing avulsed injuries resulting from trauma. MATERIALS AND METHODS: This retrospective case series evaluated patients presented with avulsed soft tissue injuries to the head and neck who underwent reconstruction with UBM. Patients were treated by Oral and Maxillofacial Surgery Service in Louisiana State University Health Sciences Center (Baton Rouge, LA). Descriptive variables were collected. Descriptive statistics were calculated. RESULTS: Eight patients (mean age 55.8 y) met our inclusion criteria. Wounds were located in the scalp (n=2, 25%), mandible (n=2, 25%), upper eyelid (n=1, 12.5%), cheek (n=1, 12.5%), nose (n=1, 12.5%), or neck (n=1, 12.5%). The depth of the wound extended from the skin to the subcutaneous tissue (n=1, 12.5%), muscle (n=2, 25%), bone (n=3, 37.5%), and/or cartilage (n=1, 12.5%). The mean wound diameter was 47.9 cm 2 (range 17-85 cm 2 ). Wounds were classified as acute (n=6, 75%) or chronic wounds (n=2, 25%). At 6 months, all patients had achieved complete healing with no need for additional surgical procedures (n=8, 100%) with a mean healing time of 36.5 days (range 14-90 d). CONCLUSION: Urinary bladder matrix minimize donor-side morbidity, eliminates contraction, and offers a wide range of product sizes to cover a wide range of maxillofacial soft tissue defects in a single-stage manner.

The Incidence of COVID-19 Patients in Oral and Maxillofacial Surgery.

PURPOSE: The SARS-CoV-2 global pandemic has resulted in widespread changes to healthcare practices across the United States. The purpose of this study is to examine the incidence of COVID-19 patients in the oral-maxillofacial surgery setting in order to help guide perioperative protocols during the pandemic. METHODS: In this retrospective cohort study, predictor variables (presence of preoperative symptoms on presentation, patient age, patient gender, patient race, hospital location, and presence of statewide stay-at-home orders) were examined with outcome variables (SARS-CoV-2 test results) over 10 months between March 2020 and December 2020 for patients undergoing surgical procedures in the operating room by the following Oral-Maxillofacial Surgery Departments: - Louisiana State University Health Sciences Center (Baton Rouge, LA) - University of Illinois at Chicago (Chicago, IL) - University of Texas Health Science Center at Houston (Houston, TX) Data analysis included Fisher exact tests to compare categorical variables across COVID test groups and Wilcoxon rank sum tests to compare continuous covariates. Two-sample tests of proportions were used to compare observed COVID-19 positivity rates to other study results. RESULTS: Out of 684 patients in 3 institutions, 17 patients (2.5%, 95% CI = 1.5 to 4.0%) tested positive for COVID-19 over a 10 month interval (March 1, 2020- December 31, 2020). The majority of patients that tested positive were asymptomatic in the preoperative setting (P-value = .09). They were significantly more likely to be African-American (P-value = .015) and less likely to have a stay-at-home order present at the time of surgery (P-value = .033). Age, gender, and hospital location did not play a statistically significant role. CONCLUSION: Our results demonstrate a 2.5% incidence of COVID-19 infection in the total population of patients undergoing scheduled oral-maxillofacial surgeries in 3 major healthcare systems across the United States. This data may help inform perioperative protocols and infection control measures during the COVID-19 pandemic.

Use of Vascularized Myo-Osseous Fibula Free Flap to Reconstruct a Hemimandibular Defect With a Concomitant Skull Defect Arising From Stock Condylar Prosthesis Displacement Into the Middle Cranial Fossa.

Functional reconstruction of the temporomandibular joint (TMJ) is a controversial topic among oral and maxillofacial surgeons; this controversy becomes more complicated when one dives into the dilemma of the ideal reconstructive modality. TMJ defects might result from various etiologies, such as blunt or penetrating traumatic injuries, advanced degenerative joint disease, or various pathologic conditions, including benign and malignant conditions, that might arise from the TMJ or adjacent tissues. Reconstruction of the TMJ is vital because of its essential function in mastication, articulation, speech, and facial esthetics and symmetry. In the pediatric population, the TMJ acts as a growth center. TMJ reconstructive surgery might be influenced by various factors that can steer the surgeon toward adopting a specific reconstructive modality. These factors can be classified into preoperative factors that include the overall general health of the patient, expectations, and socioeconomic status that might be an obstacle in using custom-made solutions. The surgeon's experience, level of comfort, and training are crucial influencing factors. TMJ reconstructive options consist of autogenous grafts or alloplastic options. Autogenous grafts encompass 2 broad subcategories. The first is the vascularized option, and a good example is the vascularized fibula free flap. The second subcategory includes nonvascularized grafts, such as costochondral grafts and sternoclavicular grafts. Alloplastic grafts include various TMJ stock joints or custom-made patient-specific prostheses and stock condylar prostheses. The goals of TMJ reconstruction are to establish a pain-free normal range of mouth opening, stable occlusion, and absence of facial deformity. Complication rates in TMJ surgery are low and include surgical infection, nerve injury, failure or fracture of the prosthesis, or injury to adjacent structures. This report presents a case of a stock condylar prosthesis displaced into the middle cranial fossa, which was managed with a 2-stage approach of removing the displaced prosthesis and then reconstruction with a fibula vascularized free flap and a simultaneous contralateral sagittal split osteotomy.

The Use of Virtual Surgical-Guided Osteoplasty for Maxillofacial Brown Tumors.

A 28-year-old African American female with end-stage renal disease on dialysis secondary to preeclampsia presented to the office as a referral for large multifocal tumors of maxilla and mandible. Surgical pathology and laboratory findings were supportive of secondary hyperparathyroidism leading to multifocal brown tumors. She underwent osteoplasty after using virtual surgical planning to create stereolithic models to visualize the tumor and fabricate cutting guides to minimize the risk of injury to adjacent nerves and teeth. Brown tumors can be resistant to medical management with unreliable regression in size. With the advent of customized surgical guides, more precise and judicious surgery can be performed on these types of tumors safely.

Pedicle Orientation in Free-Flap Microvascular Maxillofacial Reconstruction.

Oncologic and traumatic defects of the maxilla can pose a challenge to patients, reconstructive surgeons, and maxillofacial prosthodontists in an attempt to provide satisfactory treatment. Oral-nasal and oral-antral fistulas are frequently treated with soft tissue flaps, osteocutaneous flaps, or a maxillofacial obturator. The free fibula microvascular osteocutaneous flap has proved the workhorse of these maxillary and mandibular reconstructions. The success of microvascular reconstruction often hinges on flap viability in the immediate postoperative period. With most flap failures attributed to vascular compromise resulting from clot formation and venous congestion, uncompressed, and nontortuous pedicle positioning demands surgical attention. Although the use of the free fibula flap in maxillary reconstruction is a well-described and predictable procedure, the specifics of the flap inset with respect to pedicle positioning and technique within the maxilla and neck have not been clearly detailed in the available studies. In the present technique note, we have provided our surgical description for pedicle positioning and anatomic alterations in an attempt to improve microvascular anastomosis flap success.

Use of Virtual Surgical Planning for Simultaneous Maxillofacial Osteotomies and Custom Polyetheretherketone Implant in Secondary Orbito-Frontal Reconstruction: Importance of Restoring Orbital Volume.

Correction of orbito-frontal defects involves a multitude of surgical challenges, and requires careful and detailed planning. In the trauma setting, one must be prepared to deal with injuries to adjacent structures and be able to incorporate their repair into the surgical plan to maximize the functional and esthetic reconstruction for the benefit of the patient. Victims who have sustained trauma of the cranial complex in combination with mid-facial trauma, particularly involving the orbit, present a difficult scenario, especially when future ocular prosthetic rehabilitation is a concern. The authors present a patient of virtual surgical planning-guided planning of mid-facial osteotomies and custom implant creation for the secondary reconstruction of a patient who sustained extensive orbito-frontal trauma, requiring not only cranial vault recontouring, but also reconstruction of the mid-facial and orbital complex to accommodate an ocular prosthesis that would demonstrate proper anatomical relationships to maximize esthetics and function.

Inaugural Survey on Practice Patterns of Orbital Floor Fractures for American Oral and Maxillofacial Surgeons.

PURPOSE: In recent years, several studies have reported on practitioners' preferences for the treatment of orbital floor fractures, showing widely varying practice patterns. The purpose of the present study was to identify the practice patterns among oral and maxillofacial surgeons involved in the management of orbital floor fractures in the United States and compare them with the available published data. MATERIALS AND METHODS: An anonymous survey was created and electronically mailed to surgeons. We also reviewed the published data on orbital floor fractures using a PubMed and MEDLINE search. The responses to the survey were analyzed using descriptive statistics. RESULTS: The factors that had the greatest influence on the surgeon's decision to operate were a defect size > 2 cm2, enophthalmos, entrapment, and persistent diplopia. The most common surgical approach reported was a preseptal transconjunctival approach (32.0%), followed by the subciliary (27.9%) and postseptal transconjunctival (26.2%) approaches. The most commonly reported implant for orbital reconstruction was titanium (65.4%), followed by Medpor (43.7%) and composite Medpor and titanium (26.4%). The review of the published data showed a consensus among many of the operative indications mentioned, including a large defect size, enophthalmos, clinical entrapment, and persistent diplopia. CONCLUSIONS: Oral and maxillofacial surgeons in the United States have a wide range of practice habits in the management of orbital floor fractures. Although the quality of the available evidence is poor, it supports a consistent approach to the management of orbital floor fractures in terms of the indications and surgical approach. The choice of reconstructive material and timing of repair remain more controversial. A clear need exists for improvement in the available data to help guide and set standards of care for the specialties managing orbital floor fractures.

A Detailed Analysis of Mandibular Angle Fractures: Epidemiology, Patterns, Treatments, and Outcomes.

PURPOSE: The purpose was to analyze mandibular angle fractures by examining epidemiologic trends and mechanisms of injury and to determine whether a statistically meaningful relation existed between certain treatment modalities and patient outcomes. MATERIALS AND METHODS: A retrospective chart analysis was performed, and data were limited to 1 operator. Treatment variables were methods of fixation, postoperative intermaxillary fixation (IMF), and retention versus extraction of teeth in the line of fracture. Outcomes were rates of postoperative infection, fracture healing, and overall patient comfort. Analysis was performed using the Fisher exact test, Wald test, and χ(2) test, with a P value less than .05 considered significant. RESULTS: One hundred three patients were included in this study. The mean age was 30.4 years, most patients were men, and most injuries occurred during physical altercations and on the left side of the face. The most common concomitant fracture was of the contralateral parasymphysis. A statistically meaningful relation was noted between methods of fixation and healing and overall patient comfort, with the Champy technique and reconstruction plate being associated with the highest rates of bony union and patient comfort. No statistically relevant correlation was found between methods of fixation and rates of infection. There was no statistically relevant link for extraction versus retention of healthy teeth in the line of fracture or use of IMF with patient comfort, postoperative infection, or fracture healing. CONCLUSION: Although the Champy technique and reconstruction plates were associated with better postoperative outcomes, such as patient comfort and fracture healing, these should not be used interchangeably. IMF and extraction versus retention of teeth in the line of fracture did not influence any of the outcomes.

Quality of life assessment in patients after mandibular resection and free fibula flap reconstruction.

PURPOSE: The aim of the present study was to assess patients' quality of life (QOL) after mandibular resection and reconstruction with the free fibula flap (FFF). MATERIALS AND METHODS: We performed a retrospective study of all patients who underwent segmental mandibular resection and FFF reconstruction at the Division of Oral and Maxillofacial Surgery, McGill University Health Center. The patients were contacted and asked to complete a QOL assessment at least 1 year after surgery. The patients' photographs were taken and evaluated for the esthetic outcomes after surgery by 2 dental health professionals using a visual analog scale and compared with the patients' self-evaluations. A descriptive analysis was used for data analysis. RESULTS: Seventeen patients underwent segmental mandibular resection and reconstruction with a FFF, and 11 completed the QOL questionnaire. Two patients were deceased at the start of the study, 1 refused to complete the QOL questionnaire, and 3 had developed disease recurrence and were not asked to complete the QOL questionnaire. Of the 11 patients who completed the QOL assessment, 8 rated their overall QOL as outstanding, very good, or good and 3 reported it to be fair. No significant correlation was found between the patients' self-reported esthetic evaluation and the third-party evaluations. CONCLUSIONS: Most patients who underwent mandibular resection and FFF reconstruction reported satisfaction with their overall QOL. We did not find a correlation between the patients' perceived esthetic outcome and the dental healthcare professionals' assessment.

Evolving trends in the management of orbital floor fractures.

BACKGROUND: The management of orbital floor fractures is diverse and continues to evolve. The purpose of the current study was to provide an updated summary of the literature, with a focus on interspecialty differences, and contrast that with current treatment strategies of actively practicing plastic surgeons. METHODS: A survey was conducted of surgeons who currently manage orbital floor fractures. The results are summarized and compared with a 10-year literature review (2002-2012) of surgical approaches, indications and timing of surgery, and implant selection in various surgical disciplines. Inclusion criteria included studies in English language with 10 or more patients. RESULTS: The survey response rate was 56%, of which 86 surgeons were identified to currently manage orbit fractures. A third of participants reported they are less likely to operate on these fractures relative to earlier in their career. Six factors were found to have the greatest influence on surgeon's operative decision: enophthalmos, hypophthalmos, positive forced duction, defect size, motility restriction, and persistent diplopia. The most common preferred approach to the orbit is midlid/infraorbital (45%) followed by transconjunctival (31%) and subciliary (24%). Medpor and titanium are the most preferred implants (83%) compared with autologous bone (5%). CONCLUSIONS: Significant interdisciplinary and intradisciplinary differences in the management of orbital fractures exist. The most significant trends are the growing popularity of alloplastic versus autogenous materials for orbital floor reconstruction and the fact that one-third of surgeons are more likely to opt for a nonoperative (conservative) approach compared with earlier in their careers.

Reticular Myxoid Odontogenic Neoplasm with Novel STRN::ALK Fusion: Report of 2 Cases in 3-Year-Old Males.

Odontogenic tumors represent a collection of entities ranging from hamartomas to destructive benign and malignant neoplasms. Occasionally, pathologists encounter gnathic lesions which clearly exhibit an odontogenic origin but do not fit within the confines of established diagnoses. Here, we describe two such odontogenic tumors, both affecting 3-year-old males. Each case presented as a destructive, radiolucent mandibular lesion composed of mesenchymal cells, some with unique multi-lobed nuclei, frequently arranged in a reticular pattern and supported by a myxoid stroma with focal laminations. Production of odontogenic hard tissues was also seen. Because of their unique microscopic features, both cases were investigated by next-generation sequencing and found to harbor the same STRN::ALK oncogene fusion. To our knowledge, these cases represent the first report of an odontogenic tumor with a STRN::ALK gene rearrangement. We propose the possibility that this neoplasm could be separate from other known odontogenic tumors. Both patients were treated with surgical resection and reconstruction. The prognosis of patients with this entity is currently uncertain but shall become more apparent over time as more cases are identified and followed.

Human Tooth Crack Image Analysis with Multiple Deep Learning Approaches.

Tooth cracks, one of the most common dental diseases, can result in the tooth falling apart without prompt treatment; dentists also have difficulty locating cracks, even with X-ray imaging. Indocyanine green (ICG) assisted near-infrared fluorescence (NIRF) dental imaging technique can solve this problem due to the deep penetration of NIR light and the excellent fluorescence characteristics of ICG. This study extracted 593 human cracked tooth images and 601 non-cracked tooth images from NIR imaging videos. Multiple imaging analysis methods such as classification, object detection, and super-resolution were applied to the dataset for cracked image analysis. Our results showed that machine learning methods could help analyze tooth crack efficiently: the tooth images with cracks and without cracks could be well classified with the pre-trained residual network and squeezenet1_1 models, with a classification accuracy of 88.2% and 94.25%, respectively; the single shot multi-box detector (SSD) was able to recognize cracks, even if the input image was at a different size from the original cracked image; the super-resolution (SR) model, SR-generative adversarial network demonstrated enhanced resolution of crack images using high-resolution concrete crack images as the training dataset. Overall, deep learning model-assisted human crack analysis improves crack identification; the combination of our NIR dental imaging system and deep learning models has the potential to assist dentists in crack diagnosis.

Mouthwash as a non-invasive method of indocyanine green delivery for near-infrared fluorescence dental imaging.

SIGNIFICANCE: X-ray imaging serves as the mainstream imaging in dentistry, but it involves risk of ionizing radiation. AIM: This study presents the feasibility of indocyanine green-assisted near-infrared fluorescence (ICG-NIRF) dental imaging with 785-nm NIR laser in the first (ICG-NIRF-I: 700 to 1000 nm) and second (ICG-NIRF-II: 1000 to 1700 nm) NIR wavelengths. APPROACH: Sprague Dawley rats with different postnatal days were used as animal models. ICG, as a fluorescence agent, was delivered to dental structures by subcutaneous injection (SC) and oral administration (OA). RESULTS: For SC method, erupted and unerupted molars could be observed from ICG-NIRF images at a short imaging time (<1 min). ICG-NIRF-II could achieve a better image contrast in unerupted molars at 24 h after ICG injection. The OA could serve as a non-invasive method for ICG delivery; it could also cause the glow-in-dark effect in unerupted molars. For erupted molars, OA can be considered as mouthwash and exhibits outstanding performance for delivery of ICG dye; erupted molar structures could be observed at a short imaging time (<1 min) and low ICG dose (0.05 mg / kg). CONCLUSIONS: Overall, ICG-NIRF with mouthwash could perform in-vivo dental imaging in two NIR wavelengths at a short time and low ICG dose.

Detection and analysis of enamel cracks by ICG-NIR fluorescence dental imaging.

Cracked teeth are the third most common cause of tooth loss, but there is no reliable imaging tool for the diagnosis of cracks. Here, we demonstrate the feasibility of indocyanine green near-infrared fluorescence (ICG-NIRF) dental imaging for the detection of enamel cracks and enamel-dentin cracks in vitro in the first (ICG-NIRF-I, 700-950 nm) and second (ICG-NIRF-II, 950-1700 nm) imaging windows with transmission excitation light, and compared ICG-NIRF with conventional NIR illumination-II (NIRi-II) and X-ray imaging. Dentin cracks were detected by CT scan, while most enamel cracks, undetectable under X-ray imaging, were clearly visible in NIR images. We found that ICG-NIRF-II detected cracks more effectively than NIRi-II, and that light orientation is an important factor for crack detection: an angled exposure obtained better image contrast of cracks than parallel exposure, as it created a shadow under the crack. Crack depth could be evaluated from the crack shadow in ICG-NIRF and NIRi-II images; from this shadow we could determine crack depth and discriminate enamel-dentin cracks from craze lines. Cracks could be observed clearly from ICG-NIRF images with 1-min ICG tooth immersion, although longer ICG immersion produced images with greater contrast. Overall, our data show that ICG-NIRF dental imaging is a useful tool for diagnosing cracked teeth at an early stage.

Modified fibula free flap harvesting technique for prevention of heterotopic pedicle ossification.

BACKGROUND: Pedicle ossification is thought to arise from the residual perieosteum left along the pedicle during the fibula free flap (FFF) harvesting. Pedicle ossification in head and neck reconstruction can cause trismus, pain on mastication/turning the neck, or neck swelling. METHODS: Two patients reported in this article developed severe trismus within 6 months after mandibular reconstruction with FFF. CT scans revealed ossification along the vascular pedicle interfering with mouth opening. Both patients underwent surgical debridement of the heterotopic bone. RESULTS: Surgical debridement of the heterotopic bone led to the resolution of trismus in both patients with pedicle ossification. CONCLUSIONS: Pedicle ossification is a complication of FFF that can be effectively managed by removal of heterotopic bone. However, it is best prevented at the time of initial surgery. In this article, a new modified FFF harvesting technique is introduced to prevent pedicle ossification and reduce the ischemia time.

Indocyanine green-assisted dental imaging in the first and second near-infrared windows as compared with X-ray imaging.

Indocyanine green (ICG) has been widely used in medical imaging, such as in retinal angiography. Here, we describe a pilot ex vivo study of ICG-assisted near-infrared fluorescence (NIRF) dental imaging in the first (700-950 nm for ICG-NIRF-I) and second (1000-1700 nm for ICG-NIRF-II) NIR windows using human extracted teeth; our study is compared with the traditional prevalent X-ray imaging and NIR II illumination (NIRi-II, 1310 nm) without ICG enhancement. The results show that ICG fluorescence has much better imaging contrast in both windows compared with NIRi-II (by quantitatively comparing NIR intensity of the critical neighboring structures, such as enamel and dentin). Cracked teeth, notoriously hard to diagnose by dental X-ray and computed tomography, were clearly profiled in NIRF dental imaging. An insidious occlusal caries, missing in X-ray imaging, became a bright dot that was readily observed in ICG-NIRF-I images. For dental decay, NIRF imaging with ICG enhancement could clearly delineate the decay boundary. NIRF in both windows distinguished interproximal and occlusal superficial caries. Overall, ICG-assisted NIRF dental imaging has unique advantages in identifying cracked teeth and insidious caries. The two NIR imaging windows used in our study might one day serve as noninvasive and nonionizing-radiation methods for the diagnosis of critical dental diseases in situ.

Tissue Engineering for Vertical Ridge Reconstruction.

This article provides an overview of basic tissue engineering principles as they are applied to vertical ridge defects and reconstructive techniques for these types of deficiencies. Presented are multiple clinical cases ranging from office-based dentoalveolar procedures to the more complex reconstruction of postresection mandibular defects. Several different types of regenerative tissue constructs are presented; either used alone or in combination with traditional reconstructive techniques and procedures, such as maxillary sinus augmentation, Le Fort I osteotomy, and microvascular free tissue transfer. The goal is to also familiarize the reconstructive surgeon to potential future strategies in vertical alveolar ridge augmentation.

Broken dental needle retrieval using a surgical navigation system: a case report and literature review.

This paper reports a case of fractured needle retrieval in the pterygomandibular space using the Medtronic surgical navigation system. Current literature on needle fracture and retrieval in the oral cavity was also reviewed. A literature search was conducted in the following databases: PubMed, MDConsult, The Cochrane Library, and Google. A variety of keywords were used, including "needle fracture," "broken dental needle," "needle injuries in dentistry," "foreign body retrieval," and "dental needle retrieval." Articles published after 1980 were reviewed. Seventeen articles that involved broken dental needle retrieval were selected.