A preliminary analysis of patient reported outcomes following posterolateral mandible reconstruction: The role of flap type.

BACKGROUND: The choice of tissue type for free flap reconstruction of posterolateral mandible resections is dependent on patient and defect characteristics. We compared clinical and patient-reported outcomes following reconstruction of these defects with a soft tissue or bony free flap. METHODS: A retrospective review was performed on patients who underwent posterolateral segmental mandibulectomy with immediate free flap reconstruction at MSKCC from 2006 to 2021. Outcomes of interest were patient-reported outcome measures (PROMs) assessed by FACE-Q surveys and complications at the flap recipient site. RESULTS: Ninety patients received a bony flap and 24 patients received a soft tissue flap. Patients reconstructed with soft tissue flaps had greater rates of composite soft tissue defects (p < 0.0001), condyle resection (p = 0.001), and peripheral vascular disease (p = 0.035). Complication rates were similar between the cohorts (p > 0.05). Bony flaps scored higher on multiple FACE-Q scales: Facial Appearance (p = 0.023) Eating/Drinking (p = 0.029), Smiling (p = 0.012), Speaking (p < 0.001), Swallowing (p = 0.012), Smiling Distress (p = 0.037), and Speaking Distress (p = 0.001). CONCLUSION: Reconstruction of posterolateral mandibular defects has a similar complication profile when utilizing a bony or soft tissue free flap. Bony flaps may perform better with respect to PROMs. Reconstructive surgeons should consider using bony flap reconstruction to achieve higher patient satisfaction and quality of life.

Does the use of intraoperative frozen section of bone marrow from the cut end of the mandible help assess the adequacy of bone margins following mandibulectomy for oral cancer?

BACKGROUND: The adequacy of the cut end of the mandible following a segmental mandibulectomy done for oral cancer intraoperatively is at times assessed using a frozen section (FS) of the bone marrow (BM) at the cut ends. The study aimed to assess its utility to guide the intraoperative decision on the adequacy of bony margins. MATERIALS AND METHODS: All patients with oral squamous cell carcinoma (OSCC) who underwent segmental mandibulectomy from January 2012 to December 2021 at our institute and for whom intraoperative FS of BM was utilized were included. We analyzed the sensitivity, specificity, and positive and negative predictive value (PPV, NPV) of this in predicting positive bone margins. RESULTS: A total of 457 patients were included in the study. The majority of the cases were per premium cases (n = 372, 81.4%). The median age of the cohort was 52 years (range: 22-80 years). Most patients had T4 disease (n = 406, 88.8%). On FS, BM was positive in only 18 patients (3.9%) for whom the bone margin was revised. BM biopsy report in the final histopathology was positive in 12 patients (2.2%). The sensitivity, specificity PPV, and NPV were 52.3%, 98.65%, 64.7%, and 97.7% respectively. No factors predicting BM positivity on FS could be identified in this cohort. CONCLUSIONS: The BM FS was positive in only a small percentage of patients, and it helped in reducing the bone margin positivity rate from 3.9% to 2.2% only. Hence the intraoperative BM FS seems to have limited utility as seen from our study.

Performance of cone-beam computed tomography (CBCT) in comparison to conventional computed tomography (CT) and magnetic resonance imaging (MRI) for the detection of bone invasion in oral squamous cell cancer (OSCC): a prospective study.

BACKGROUND: Oral squamous carcinoma (OSCC) is often diagnosed at late stages and bone erosion or invasion of the jawbone is frequently present. Computed tomography (CT) and magnetic resonance imaging (MRI) are known to have high diagnostic sensitivities, specificities, and accuracies in detecting these bone affections in patients suffering from OSCC. To date, the existing data regarding the impact of cone-beam computed tomography (CBCT) have been weak. Therefore, this study aimed to investigate whether CBCT is a suitable tool to detect bone erosion or invasion in patients with OSCC. METHODS: We investigated in a prospective trial the impact of CBCT in the diagnosis of bone erosion or invasion in patients with OSCC who underwent surgery. Every participant received a CBCT, CT, and MRI scan during staging. Imaging modalities were evaluated by two specialists in oral and maxillofacial surgery (CBCT) and two specialists in radiology (CT and MRI) in a blinded way, to determine whether a bone affection was present or not. Reporting used the following 3-point system: no bony destruction ("0"), cortical bone erosion ("1"), or medullary bone invasion ("2"). Histological examination or a follow-up served to calculate the sensitivities, specificities, and accuracies of the imaging modalities. RESULTS: Our results revealed high diagnostic sensitivities (95.6%, 84.4%, and 88.9%), specificities (87.0%, 91.7%, and 91.7%), and accuracies (89.5%, 89.5%, and 90.8%) for CBCT, CT, and MRI. A pairwise comparison found no statistical difference between CBCT, CT, and MRI. CONCLUSION: Our data support the routine use of CBCT in the diagnosis of bone erosion and invasion in patients with OSCC as diagnostic accuracy is equal to CT and MRI, the procedure is cost-effective, and it can be performed during initial contact with the patient.

[Application of double-layer soft tissue suture closure technique in the surgical treatment of patients with mandible medication-related osteonecrosis of the jaw of early and medium stages].

OBJECTIVE: To investigate the clinical application effect of double-layer soft tissue (DLST) suture closure technique in patients with mandible medication-related osteonecrosis of the jaw (MRONJ) of early and medium stages resulted in application of anti-bone-resorptive drugs. METHODS: Early to medium stage mandible MRONJ patients who underwent surgical treatment in the fourth ward of Peking University School and Hospital of Stomatology from October 2021 to September 2022 were included. Clinical information of the patients were collected, including primary disease, concomitant disease, medication regimen (drug type, duration of medication), MRONJ stage, clinical symptoms, imaging manifestations, etc. During surgery, after using marginal mandibulae resection to remove the necrotic bone, the wound was closed using DLST closure technique. Regular post-operative follow-up was performed to evaluate the therapeutic effect and complications of the DLST technique, the pain score and functional status of the patiens were evaluated. RESULTS: This study totally included 13 patients, 12 women and 1 man, aged (66.69±13.14) years. Seven patients had osteoporosis, 2 had lung cancer, 3 had breast cancer and 1 had prostate cancer among their primary diseases; 7 had no concomitant diseases, 2 had diabetes mellitus, 2 had cardiovascular disease and 1 had dry syndrome. Intravenous zoledronic acid were used in 9 patients, the average duration was (37.7±20.0) months, and other drugs, such as letrozole tablets were taken in 7 patients at the same time; Denosumab injection was used in 3 patients for an average of (10.3±11.9) months; Alendronate sodium tablets were taken in 5 patients for an average of (55.20±27.20) months, and prednisone acetate tablets or acarbose tablets were taken to varying degrees in 2 patients. The average post-operative follow-up was 11.9 months (9 to 17 months), and all the 13 patients were cured without complications, such as pus overflow and so forth. The pre-operative score of Karnofsky performance status (KPS) in the patients was 68.46±14.05, and the post-operative score was 82.31±15.36, and the difference was statistically significant (P < 0.05). The pre-operative score of visual analogue scale (VAS) in the patients was 5.77±0.73 and the post-operative score was 0.38±0.51, and the difference had statistical significance (P < 0.001). CONCLUSION: The double-layer soft tissue suture closure technique can achieve good clinical results in patients with MRONJ of the mandible using anti-bone-resorptive drugs alone, and can provide clinical treatment ideas for MRONJ patients with more complicated drug use.

A novel simulation module for segmental mandibulectomy and mandible reconstruction using 3D models.

INTRODUCTION: Mandibular resection and reconstruction are common but complex procedures in head and neck surgery. Resection with adequate margins is critical to the success of the procedure but technical training is restricted to real case experience. Here we describe our experience in the development and evaluation of a mandibular resection and reconstruction simulation module. METHODS: 3D printed (3DP) models of a mandible with a pathologic lesion were developed from imaging data from a patient with an ameloblastoma. During an educational conference, otolaryngology trainees participated in a simulation in which they reviewed a CT scan of the pathologic mandible and then planned their osteotomies before and after handling a 3DP model demonstrating the lesion. The adequacy of the osteotomy margins was assessed and components of the simulation were rated by participants with pre- and post-training surveys. RESULTS: 52 participants met criteria. After reviewing the CT scan, 34 participants (65.3 %) proposed osteotomies clear of the lesion. This proportion improved to 48 (92.3 %, p = 0.001) after handling the 3D model. Among those with initially adequate margins (n = 33), 45.5 % decreased their margins closer to the ideal, 27.2 % made no revision, 21.2 % widened their margins. 92 % of participants found the simulation beneficial for surgical planning and technical training. After the exercise, the majority of participants had increased confidence in conceptualizing the boundaries of the lesion (69.2 %) and their abilities to ablate (76.5 %). CONCLUSIONS: The structured mandibulectomy simulation using 3DP models was useful in the development of trainee experience in segmental mandible resection. LAY SUMMARY: This study presents the first mandibulectomy simulation module for trainees with the use of 3DP models. The use of a 3DP model was also shown to improve the quality of surgical training.

Clinical outcomes of teeth adjacent to the site of mandibulotomy or mandibulectomy in patients with head and neck cancer: results from a multidisciplinary mono-institutional head and neck tumor board.

INTRODUCTION: The aim of this case series was to evaluate the necrosis of teeth adjacent to the site of mandibulotomy or mandibulectomy in a cohort of patients suffering from head and neck cancers. METHODS: Fourteen patients who underwent segmental mandibulectomy or paramedian mandibulotomy for oral, oropharynx or major salivary gland cancer and a total of 23 teeth were included in this case series. Twelve patients underwent adjuvant head and neck radiotherapy. Cold sensitivity pulp testing and/or electric pulp testing were performed on teeth at the margin of mandibulectomy and on teeth adjacent to mandibulotomy after surgery. A "positive" response was considered the healthy state, and "negative" was considered the diseased state of the tooth. RESULTS: The 10 patients who underwent mandibulotomy had 12 teeth with a negative response. The 4 patients treated by mandibulectomy had two positive and three negative responses to cold and electric pulp tests. Fifteen out of 23 teeth (65.2%) showed a negative response to sensitivity testing. CONCLUSIONS: Tooth necrosis seems to be a common event after mandibulectomy and mandibulotomy. CLINICAL RELEVANCE: To avoid post-surgery complications, performing root canal therapy before surgery on the teeth adjacent to the surgical site could be an appropriate strategy.

Quality of life after segmental mandibulectomy and free flap for mandibular osteonecrosis: Systematic review.

OBJECTIVE: Review QOL outcomes among patients undergoing segmental mandibulectomy and bony free flap reconstruction for ONJ. DATA SOURCES: PubMed was searched for MeSH terms "Quality of life," "Osteonecrosis," "Osteoradionecrosis," "Bisphosphonate-associated osteonecrosis of the jaw," "Free tissue flaps," and "Mandibular reconstruction." REVIEW METHODS: English language studies with QOL outcomes data for patients undergoing free flap reconstruction for advanced ONJ were included. 197 records were initially screened; 18 full texts assessed; 10 full texts included. PRISMA guidelines were followed. RESULTS: Ten studies were included in this systematic review: six retrospective, three retrospective with comparison groups, and one prospective. In studies with comparison groups, ONJ patients have worse self-reported QOL than the general population as well as head and neck cancer patients without ONJ. Nearly all patients with QOL measurements (220/235 patients) had ONJ from prior radiation. Segmental mandibulectomy and bony free flap improved overall QOL in over half of patients, as well as pain associated with ONJ in 70-75 % of patients. Surgery did not improve long-term effects of radiation such as chewing, swallowing, and salivary production. Donor site morbidity rarely affects QOL. CONCLUSIONS: Osteonecrosis of the jaw (ONJ) worsens quality-of-life, and advanced disease often requires segmental mandibulectomy and bony free flap reconstruction. Patients and surgeons may expect improvement in some, but not all, domains of patient-reported QOL by the use of segmental mandibulectomy and reconstruction for advanced ONJ.

Resolution of Excessive Interocclusal Restoration Space Post-Mandibulectomy Using a Two-Layer Retrievable Fixed Implant-Supported Prosthesis: A Case Report.

Patients treated with segmental mandibulectomy often require complicated rehabilitation. Maintenance of mandibular continuity and provision of adequate soft and hard tissue volumes are two key factors required for good clinical outcomes. Moreover, excessive interocclusal restoration space is a common problem in these patients. This case report describes the process of prosthetic rehabilitation from extensive surgical excision to final rehabilitation by using a creative two-layer fixed implant prosthesis in a 70-year-old patient with oral squamous cell carcinoma.

Prosthetic Management of Severe Mandibular Deviation in a Hemi-Mandibulectomy Patient Following Osteoradionecrosis.

Rehabilitation of a patient after hemi-mandibulectomy without reconstruction represents a prosthodontic challenge. Indeed, mandibular deviation and decreased occlusal contacts are a common presentation post-surgery. This paper reports on a patient who presented with these challenges and where chronic osteoradionecrosis has resulted in significant mandibular deviation. A maxillary cobalt chrome mandibular deviation device, designed with palatal bite plane and constructed using 3D printing methods, resulted in a successful outcome. The authors aim to show how restorative management of similar patients can be successful using a modern approach.

Locoregional recurrence rate and disease-specific survival following marginal vs segmental resection for oral squamous cell carcinoma with mandibular bone invasion.

BACKGROUND AND OBJECTIVES: To determine locoregional recurrence rate (LRR) and disease-specific survival (DSS) following marginal vs segmental mandibulectomy. METHODS: Included were 210 patients, who had marginal or segmental mandibulectomy between 2000 and 2017. Marginal resection was performed when complete removal of the tumor was deemed feasible on the condition that at least 1 cm bone height of the inferior border of the mandible could be preserved. Segmental resection was performed in case less than 1 cm bone height of the mandible would remain. Clinical and histopathological data were collected from medical records. LRR and DSS were computed using Kaplan-Meier analysis. Cox-regression analysis was used to identify risk factors for LRR and DSS. RESULTS: A total of 59 marginal and 151 segmental resections had been performed. There was no significant difference in 3- and 5-year LRR (P = .904) and no significant difference in 3- and 5-year DSS (P = .362) between the marginal and segmental resection group. Cox-regression analysis showed a trend for surgical margin less than equal to 1 mm, to affect LRR (P = .05) and surgical margin less than equal 1 mm, perineural invasion and lymph node metastasis to affect DSS (P < .05). CONCLUSIONS: There was no difference in outcome between the two types of mandibulectomy.

Modified facelift approach for posterior segmental mandibulectomy: a blend of oncology and cosmesis.

BACKGROUND: The approach to the mandible for segmental resection in malignant pathologies entails a lip-split, angle-split or visor flap incision with extension of the incision into the neck for performing neck dissection. The modified facelift approach with robot-assisted neck dissection can be used to achieve oncologically safe resections with good cosmesis. METHODS: Three patients meeting the inclusion criteria underwent the procedure at the Robotic facility of HCG Cancer Centre, Bangalore. RESULTS: The patients were analyzed on the basis of bone defect length, the margin status of primary, functional and aesthetic outcomes. One patient had wound dehiscence and needed secondary suturing. At 6 months, patients were satisfied with the aesthetic outcomes and functional results CONCLUSION: Modified facelift approach is a feasible procedure ensuring better cosmesis without compromising oncological outcomes.

Preradiation tooth extraction and jaw osteoradionecrosis: Nationwide population-based retrospective study in Taiwan.

OBJECTIVE: Radiotherapy (RT) for head and neck cancer (HNC) within 7 days of tooth extraction is contraindicated because it may increase the risk of osteoradionecrosis of the jaw (ORNJ). However, delayed RT could compromise survival in patients with HNC. By using a national healthcare database, we reviewed the contraindications and analysed other risk factors for ORNJ. DESIGN: A retrospective cohort study. SETTING: By using Taiwan's National Health Insurance Research Database, 5,062 HNC patients with at least one tooth extraction 1-21 days before the first RT day (index day) and without any extractions during or after RT from 2000 to 2013 were included. The patients were divided into two groups according to the time of tooth extraction before the index day: 1-7 days and 8-21 days. PARTICIPANTS: Taiwanese patients with head and neck cancer. MAIN OUTCOMES MEASURE: Univariate and multivariate Cox proportional hazard regression models were used to evaluate the risk factors of ORNJ. RESULTS: The overall incidence of ORNJ in the included patients was 1.03% (mean follow-up duration, 4.07 ± 3.01 years; range, 1.00-13.99 years). Tooth extraction within 7 days before RT was not associated with increased ORNJ risk (hazard ratio [HR] =0.734; P = .312). Significant risk factors for ORNJ included oral cancer (adjusted HR = 3.961), tumour excision surgery within 3 months before RT (adjusted HR = 3.488) and mandibulectomy within 3 months before RT (adjusted HR = 5.985; all P < .001). CONCLUSION: In a mean follow-up of 4 years, tooth extraction within 7 days before RT for HNC treatment did not increase the ORNJ risk compared with tooth extraction 7-21 days before RT.

Management of an Imminent Pathological Fracture of a Fibular Neomandible Via a Minimally Invasive Approach-A Case Report.

Fibular free flap reconstruction remains the workhorse of postmandibulectomy reconstruction. Dental implantation to support a dental prosthesis is a sought-after outcome when the area of resection involves tooth-bearing zones. Chronic perisoft tissue pedicle hyperplasia with secondary infection leading to gradual bone loss is a simple complication to manage in the general population, but it becomes a serious issue in the fibula mandibular reconstruction patient in that it can lead to pathological fracture of the fibula. A case of a patient with a near fracture of his fibula mandibular reconstruction, and its management via a minimally invasive approach is presented.

Anchored guided rehabilitation.

The loss of mandibular continuity leads to difficulty in swallowing, problems in mastication, altered mandibular movement, impaired speech articulation, and cosmetic disfigurement. Rehabilitation of such patients becomes more challenging in the case of complete edentulous maxillary and mandibular arches due to a lack of support and anchorage. This case report describes prosthetic rehabilitation of completely edentulous arches with segmental mandibulectomy. Hence, the anchorage was provided with the help of osseointegrated implants in both the maxillary and mandibular arches. Deviation of the mandible toward the unresected side during mastication and other functions was corrected using a palatal ramp. An attempt was made for prosthetic rehabilitation of mandibulectomy defect which required a multidisciplinary approach and which fulfilled the patient's requirement of mastication.

Oncologic outcome of marginal mandibulectomy in squamous cell carcinoma of the lower gingiva.

BACKGROUND: There is a large amount of controversy about the best management of the mandible in oral squamous cell carcinoma (SCC), mainly owing to the inability to acquire accurate bone invasion status. Therefore, our goal was to analyse the oncologic safety in patients undergoing marginal mandibulectomy (MM) for cT1-2 N0 SCC of the lower gingiva. METHODS: Patients undergoing MM for untreated cT1-2 N0 SCC of the lower gingiva were retrospectively enrolled. The main endpoints of interest were locoregional control (LRC) and disease-specific survival (DSS). RESULTS: A total of 142 patients were included in the analysis, and a pathologic positive node was noted in 27 patients. Cortical invasion was reported in 23 patients, and medullary invasion was reported in 9 patients. The 5-year LRC and DSS rates were 85 and 88%, respectively. Patients with bone invasion had a significantly higher risk for recurrence than patients without bone invasion. However, the DSS was similar in patients with versus without bone invasion. Patients with a high neutrophil lymphocyte ratio had a higher risk for worse prognosis. CONCLUSIONS: The oncologic outcome in patients undergoing MM for cT1-2 N0 SCC of the lower gingiva was favourable; bone invasion was not uncommon, but it significantly decreased the prognosis in patients undergoing MM.

Long-term health-related quality of life after mandibular resection and reconstruction.

PURPOSE: To compare short- and long-term quality of life (QOL) scores in patients undergoing mandibular resection and reconstruction. MATERIALS AND METHODS: All the patients who underwent resection and reconstruction of the mandible between 2000 and 2015 at a large tertiary center were retrospectively reviewed. Their QOL was measured by the University of Washington QOL questionnaire. Between 12 and 189 months (median 83.5 months) had elapsed since the end of treatment. The QOL of the short-term (< 5 years) and long-term (> 5 years) follow-up groups was compared and analyzed. RESULTS: Fifty-eight patients completed the questionnaire. The scores for physical function, emotional function, activity, recreation, and taste domains were significantly higher for the long-term follow-up group. The activity and pain domains posed a significant problem for significantly more patients in the short-term follow-up group. CONCLUSION: Comparison of the short- and long-term QOL scores of patients undergoing mandibular resection and reconstruction revealed that the scores for the latter were significantly higher in several domains. This finding might be indicative of a cumulative effect of time on patients' QOL, even many years post-treatment.

Partial mandibulectomy without bony reconstruction in patients with oropharyngeal or mouth cancer.

AIM OF THE STUDY: Resection of tumours of the oral cavity has significant consequences relating to function and aesthetic properties. Advancements in surgical techniques and microvascular surgery have enabled reconstructive outcomes to reach those of pre-surgery levels with good functional and aesthetic results. However, reconstructive options are not without complications. MATERIAL AND METHODS: We report the outcome of 23 patients with large tumours of the oral cavity or floor of the mouth, who underwent resection of the tumour and parts of the mandible without bony reconstruction. The patient population consisted of 19 oropharyngeal carcinomas and four floor of the mouth cancers, all of which had stage cT4 (six female and 17 male patients), and with an average patient age of 59.8 years. The pre- and postoperative ability to open the mouth, level of pain while masticating, mastication function pre and post-surgery, and the aesthetic outcome post-surgery were measured. RESULTS: The results obtained were deemed pleasantly acceptable by the patients, from aesthetic, functional, and analgesic points of view. DISCUSSION: A thorough preoperative work up is required and discussion with a multidisciplinary team is a necessity. This treatment option is more acceptable to the patient than would be expected and provides a satisfactory functional and aesthetic outcome. Therefore, we believe that partial mandibulectomy without bony reconstruction is an acceptable management option for a carefully selected group of patients who may not be suitable for the extensive surgery involved with bony reconstruction.

Oral rehabilitation following fasciocutaneous free-flap reconstruction: A retrospective study.

AIM: The aim of this study is to retrospectively, observe a consecutive series of patients with segmental mandibulectomy defects reconstructed with fasciocutaneous free flaps and mandibular resection prostheses, and to review treatment concepts for the management of such patients. SETTINGS AND DESIGN: Observational study done at Memorial Sloan Kettering Cancer Center, New York, NY, USA. MATERIALS AND METHODS: Records were reviewed of all patients who had fasciocutaneous free-flap reconstruction and fabrication of mandibular resection prostheses following segmental mandibulectomy between 2000 and 2017 at a tertiary cancer center. Mandibular resection prosthesis fabrication interval data, as well as follow-up interval data, were recorded. STATISTICAL ANALYSIS USED: Descriptive statistics. RESULTS: Twenty-one consecutive patients had mandibular resection prostheses fabricated following segmental mandibulectomy and fasciocutaneous free-flap reconstruction during the study. The median time for mandibular resection prosthesis delivery following surgery was 9 months (range 4-41 months). There was a median of two-follow-up visits (range 0-4) within the first 90 days of mandibular resection prosthesis delivery. CONCLUSIONS: Oral rehabilitation with mandibular resection prosthesis following segmental mandibulectomy and fasciocutaneous free-flap reconstruction is an attainable treatment goal for the oncologic patient. Reviewing the proposed course of care is helpful for patient management.

Identification of predisposing factors for osteonecrosis of the jaw after marginal mandibulectomy in the surgical management of oral squamous cell carcinoma.

BACKGROUND: The aim of this study is to evaluate osteonecrosis of the jaw (ONJ) with the extent of marginal mandibulectomy. METHODS: Between January 2006 and December 2012, 3087 patients undergoing ablative resection were consecutively enrolled. Among them, 345 cases undergoing marginal mandibulectomy were retrospectively reviewed. RESULTS: The occurrence of ONJ was 5.51% and associated with body mass index, overall stage, diabetes, concomitant mandibulotomy, and radiotherapy (P = 0.023, 0.033, 0.009, 0.016, and 0.006, respectively). As for bone parameters based on radiological measurements after marginal mandibulectomy, resected bone height, remaining bone height to original bone height ratio, and resected bone height to original bone height ratio were associated with ONJ. In multivariate logistic analyses, concomitant mandibulotomy, radiotherapy, diabetes, resected bone height of >14.5 mm, resected bone height to original bone height ratio of >49.5%, and remaining bone height to original bone height ratio of <53.5% indicated higher risks for ONJ (adjusted HR: 4.345, 4.152, 4.079, 3.402, 3.541, and 3.211; P = 0.018, 0.013, 0.009, 0.021, 0.018, and 0.043, respectively). CONCLUSIONS: This study demonstrated the predisposing factors and parameters associated with ONJ with marginal mandibulectomy; more caution is necessitated in performing marginal mandibulectomy in patients with multiple risks to prevent ONJ.