Immediate Implants in Fibulas: Does the Implant to Fibula Osteotomy Distance Impact Early Implant Failure?

BACKGROUND: When placing dental implants in the free fibula flap, the osteotomy cut edge poses a unique challenge in that an optimal distance has not yet been established. PURPOSE: The study aimed to measure the association between implant-to-fibula osteotomy edge distance and early implant failure in patients who received free fibula flap reconstruction with immediate implants. STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study was designed and implemented. The study population was composed of patients who underwent free fibula flap transfer with immediate dental implant placement for the treatment of benign or malignant conditions of the head and neck from 2015 to 2022 at John Peter Smith Hospital. Subjects were excluded if the implant was in the middle of the free flap bordered by adjacent implants, was >10 mm from the osteotomy edge, or had insertional torque values of ≤30 Ncm. PREDICTOR VARIABLE: Primary predictor variable was the implant distance in millimeters from the fibula osteotomy edge. MAIN OUTCOME VARIABLE: Primary outcome variable was early implant failure, defined as implant exfoliation noted by the patient or failure due to implant movement or pain necessitating explantation within 6 months of placement. COVARIATES: The covariates were age, sex, diabetes diagnosis, American Society of Anesthesiologists classification, smoking status, history of head and neck radiation, pathology treated, and if postoperative radiation treatment was received. ANALYSES: A generalized estimating equations model was used to assess the relation between the primary predictor and outcome. A P value of <.05 was considered statistically significant. RESULTS: The sample was composed of 48 subjects who had 130 implants placed, with early failures occurring in 5 implants (3.9%) in 3 subjects. The mean age of the sample was 49 years (standard deviation [SD] 20) and 29 (60%) were male. The mean implant distances for early failures and nonfailures were 3.5 mm (SD 1.04) and 4.3 mm (SD 1.5), respectively. There was a statistically significant relation between implant distance and early implant failure (P = .005, odds ratio 0.6, 95% confidence interval 0.39 to 0.85). CONCLUSION AND RELEVANCE: This study found that shorter distances between the implant and the edge of the fibula osteotomy are associated with early implant failure.

Evaluation of postoperative peri-implant reactive tissues following implant supported prosthetic rehabilitation in fibula free flaps.

OBJECTIVES: The purpose of this study was to measure the frequency of peri-implant reactive tissue development in a cohort of patients following immediate implant supported prosthetic rehabilitation in fibula free flaps at our institution and to document 2 cases of management based on our institution's experience. STUDY DESIGN: To address this question of study design, a case series was performed from October 2014 to May 2022. We included patients that underwent a fibula free flap reconstruction of the mandible or maxilla with immediate implant placement and dental prostheses fabrication. Forty-four patients met the inclusion criteria, and, among the participants, a total of 26 male patients (59%) and 18 female patients (41%) were evaluated, with 185 implants placed all together. RESULTS: Twenty patients (45%) were treated for benign pathology, 12 with malignant pathology (27%), 5 with trauma (11%), and 7 with osteoradionecrosis (16%). Postoperative peri-implant reactive tissues were seen to develop at 39 of the implant sites (21%). CONCLUSION: Reactive tissues were found to be a common complication in patients treated with fibular free flap reconstructions involving implant rehabilitation. Our institution noted that local excision of such reactive tissues, in addition to silver nitrate cauterization and topical steroid application, may provide reasonable success in dealing with these occurrences. (Oral Surg Oral Med Oral Pathol Oral Radiol YEAR;VOL:page range).

Are More Medically Complex Patients Who Undergo Complex Septorhinoplasty at an Increased Risk for Surgical Site Infection?

BACKGROUND: Prophylactic antibiotics are routinely prescribed by surgeons for their patients who undergo septorhinoplasty. However, the literature to support this remains controversial, especially in complex cases, those that require grafts, revision cases, extended surgical time, and an American Society of Anesthesiologists (ASA) value greater than or equal to 3. PURPOSE: The study purpose was to evaluate for a potential association between increased anesthetic complexity and the risk for surgical site infection (SSI) following complex septorhinoplasty. STUDY DESIGN, SETTING, SAMPLE: Retrospective cohort study of patients who underwent a complex septorhinoplasty between 2005 and 2022 at the Dallas Veterans Affairs Medical Center. Patients were excluded if they did receive a septorhinoplasty, did not follow up, or had insufficient records. INDEPENDENT VARIABLE: All patients were assigned an ASA value prior to surgery, with an ASA value of 3 serving as this study's independent variable. MAIN OUTCOME VARIABLE: The main outcome variable of interest was the development of a postoperative SSI, defined as findings consistent with cellulitis, purulence, or fistula development necessitating antibiotic treatment. COVARIATES: The demographic covariates included patient age and sex. Clinical covariates included diabetes status, history of nasal trauma or surgery, and smoking status. The operative covariates were surgical duration, perioperative antibiotic, intraoperative complication, and type of cartilage graft used. ANALYSES: χ2 Analysis and t-tests were used for calculations, with P values < .05 being considered significant. RESULTS: A total of 182 patients were included in this study, 81 (45%) with an ASA ≤2 and 101 (55%) with an ASA of 3. A patient's age (P < .01), male sex (P < .01), and a diagnosis of diabetes (P < .01) were associated with an ASA value of 3. In total, there were 6 (3.3%) SSIs, with 2 (1%) occurring in those with an ASA of 3. An ASA value of 3 (P = .27, relative risk of .40) was not shown to be associated with an increased risk of SSI. CONCLUSION AND RELEVANCE: Our results suggest that an ASA of 3 is not significant with regard to postoperative infection in patients who undergo a complex nasal septorhinoplasty, and prophylactic postoperative antibiotics are not warranted.

The effect of free flap surgery for oral cancer on laryngeal grade and intubation difficulty.

OBJECTIVE: The purpose of this study was to evaluate the change in laryngeal grade and intubation difficulty at subsequent surgery in patients with prior free flap reconstruction for oral cancer. STUDY DESIGN: This retrospective case series included patients with a diagnosis of oral cancer who underwent free flap reconstruction (FFR) (S1) followed by a subsequent surgery (S2) which required intubation. The primary predictor variable was FFR. The primary outcome variable was the change in laryngeal grade, based on the classification of Cormack and Lehane, after FFR. Secondary outcomes were intubation difficulty and number of intubation attempts. RESULTS: Thirty-three patients were included in the study. At S1, the average laryngeal grade was 1.1. There were 5 difficult intubations. The average time to S2 was 19 months. At S2, average laryngeal grade was 1.4. There were 17 difficult intubations. Analysis showed a significant association between FFR and a more obstructed view of the glottis at S2 (P = .007; 95% CI 0.101-0.808). FFR increased the odds of having >1 intubation attempt nearly 7-fold (OR 6.74; 95% CI 1.35-33.75), and the odds of a difficult intubation nearly 6-fold (OR 5.95; 95% CI 1.84-19.19) at S2, both of which were significant (P = .011 and P = .002, respectively) CONCLUSIONS: This investigation found an association between FFR for patients with oral cancer and a higher laryngeal grade - that is, a more obstructed view of the glottis - at subsequent surgery, in addition to increased intubation difficulty and greater number of intubation attempts.

Valence ambiguity dynamically shapes striatal dopamine heterogeneity.

Adaptive decision making relies on dynamic updating of learned associations where environmental cues come to predict positive and negatively valenced stimuli, such as food or threat. Flexible cue-guided behaviors depend on a network of brain systems, including dopamine signaling in the striatum, which is critical for learning and maintenance of conditioned behaviors. Critically, it remains unclear how dopamine signaling encodes multi-valent, dynamic learning contexts, where positive and negative associations must be rapidly disambiguated. To understand this, we employed a Pavlovian discrimination paradigm, where cues predicting positive and negative outcomes were intermingled during conditioning sessions, and their meaning was serially reversed across training. We found that rats readily distinguished these cues, and updated their behavior rapidly upon valence reversal. Using fiber photometry, we recorded dopamine signaling in three major striatal subregions -,the dorsolateral striatum (DLS), the nucleus accumbens core, and the nucleus accumbens medial shell - and found heterogeneous responses to positive and negative conditioned cues and their predicted outcomes. Valence ambiguity introduced by cue reversal reshaped striatal dopamine on different timelines: nucleus accumbens core and shell signals updated more readily than those in the DLS. Together, these results suggest that striatal dopamine flexibly encodes multi-valent learning contexts, and these signals are dynamically modulated by changing contingencies to resolve ambiguity about the meaning of environmental cues.

The utility of cone-beam computed tomography and multislice computed tomography scan for the evaluation of invasion versus erosion by mandibular squamous cell carcinoma as viewed on medical PACS.

Introduction: The degree of bone involvement in mandibular squamous cell carcinoma has a significant impact on surgical planning. The purpose of this study was to determine the utility of cone-beam computed tomography (CBCT) for the evaluation of invasion by mandibular squamous cell carcinoma. Methods: A retrospective review was conducted to identify subjects treated for oral squamous cell carcinoma (OSCC). All subjects had OSCC adjacent or fixed to the mandible, received preoperative CBCT and multislice computed tomography scan (MSCT), and had resection specimens that included bone. Results: Twenty-one subjects met the inclusion criteria. The sensitivity of CBCT was 100% (95% CI 0.75-1), the specificity was 75% (95% CI 0.35-0.97), the positive predictive value was 87% (95% CI 0.66-0.98), and the calculated test accuracy was 91%. The sensitivity of MSCT was 92% (95% CI 0.64-1), the specificity was 100% (95% CI 0.63-1), and the calculated test accuracy was 95%. Discussion: CBCT provides meaningful data that may be useful in identifying bony involvement in patients with mandibular squamous cell carcinoma. The utility in delineating erosion versus invasion is limited.

Microbial keratitis in Southern Malawi: a microbiological pilot study.

OBJECTIVE: Microbial keratitis (MK) is a significant cause of blindness in sub-Saharan Africa. We investigated the feasibility of using a novel corneal impression membrane (CIM) for obtaining and processing samples by culture, PCR and whole-genome sequencing (WGS) in patients presenting with suspected MK in Malawi. METHODS AND ANALYSIS: Samples were collected from patients presenting with suspected MK using a 12 mm diameter polytetrafluoroethylene CIM disc. Samples were processed using culture and PCR for Acanthamoeba, herpes simplex virus type 1 (HSV-1) and the bacterial 16S rRNA gene. Minimum inhibitory concentrations of isolates to eight antimicrobials were measured using susceptibility strips. WGS was used to characterise Staphylococcus aureus isolates. RESULTS: 71 eyes of 71 patients were included. The overall CIM isolation rate was 81.7% (58 positive samples from 71 participants). 69 (81.2%) of isolates were Gram-positive cocci. Coagulase-negative Staphylococcus 31.8% and Streptococcus species 14.1% were the most isolated bacteria. Seven (9.9%) participants were positive for HSV-1. Fungi and Acanthamoeba were not detected. Moxifloxacin and chloramphenicol offered the best coverage for both Gram-positive and Gram-negative isolates when susceptibility was determined using known antimicrobial first quartile concentrations and European Committee on Antimicrobial Susceptibility Testing breakpoints, respectively. WGS identified known virulence genes associated with S. aureus keratitis. CONCLUSIONS: In a resource-poor setting, a CIM can be used to safely sample the cornea in patients presenting with suspected MK, enabling identification of causative microorganisms by culture and PCR. Although the microbiological spectrum found was limited to the dry season, these preliminary results could be used to guide empirical treatment.

Immediate Teeth in Fibulas Versus Standard Fibula Free Flap: A Comparison of Donor Surgical Site Infections.

BACKGROUND: Immediate placement of dental implants with dental restoration at the leg donor site requires implant components and prosthetic materials that are not packaged sterile. PURPOSE: This study aimed to determine if there was a difference in donor surgical site infection between patients that received a fibula free flap with dental implants and immediate teeth (ITFFF: immediate teeth fibula free flap) before flap transfer to the defect site when compared to standard fibula free flaps (SFFFs) without dental implant placement. STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study was designed and implemented. The study population was composed of patients who underwent free fibula flap transfer for the treatment of benign or malignant conditions of the head and neck from 2015 to 2022. Patients who received immediate dental implants without teeth were excluded, since those implants are sterile and buried under soft tissue. PREDICTOR VARIABLE: The surgical treatment with either ITFFF or SFFF was treated as the primary predictor variable. MAIN OUTCOME VARIABLE: The primary outcome variable was postoperative donor surgical site infection. COVARIATES: There were 12 covariate variables including age, sex, diabetes diagnosis, immunosuppression/prior chemotherapy treatment, body mass index, smoking status, pack year history, pathology treated, technique for fibula donor site closure, skin paddle harvest, skin paddle area (cm2), and negative pressure wound therapy. ANALYSES: For the effect of the covariates on the primary predictor variable, χ2 analyses and t-tests were used. The effect of the primary predictor variable on the primary outcome was evaluated using χ2 analysis. A P value of < 0.05 was considered statistically significant. RESULTS: There were 37 patients in the ITFFF group and 47 in the SFFF group. The donor site infection rate for the entire study population was 2.38%. In the ITFFF group, there was 1 donor surgical site infection (2.70%), and in the SFFF group there was also 1 donor surgical site infection (2.13%). There was no significant difference in donor surgical site infection between the groups (P = .86). CONCLUSION AND RELEVANCE: This study found no difference in donor surgical site infection rates between patients who received ITFFF versus SFFF. The overall donor surgical site infection rate following fibula free flap is low.

Are higher odontogenic infection severity scores associated with difficult intubations?

PURPOSE: This study aimed to determine if there is a relation between odontogenic infection severity score (OISS) and difficult intubation at the time of surgical treatment for severe odontogenic infections (SOI). A secondary goal of this study was to determine the utility of OISS as a predictor of difficult intubations. METHODS: This retrospective cohort study was composed of consecutive patients admitted and surgically treated in the operating room (OR) for SOIs. Patients with an OISS ≥ 5 were designated as Group 1 and < 5 Group 2. RESULTS: There was a statistically significant difference in difficult intubations between the two groups (p = 0.018). Patients with an OISS ≥ 5 were nearly four times more likely to be difficult intubations compared to patients with an OISS < 5 (OR 3.70, 95% CI 1.19-11.45). When OISS ≥ 5 was used to predict difficult intubation, the sensitivity was 69%, the specificity was 63%, the positive predictive value was 23%, and the negative predictive value was 93%. CONCLUSION: OISS ≥ 5 was associated with a higher prevalence of difficult intubations compared to an OISS < 5. OISS may provide clinically relevant data that can be used with established risk factors, laboratory values, and clinical judgment.

The effect of mandibular advancement for mandibular deficiency dentofacial deformities on laryngeal grade and intubation difficulty: a preliminary study.

OBJECTIVE: The purpose of this study was to evaluate mandibular advancement for cases of mandibular deficiency with changes in vocal cord grade and intubation difficulty at subsequent surgery requiring intubation. STUDY DESIGN: This retrospective case series included patients with a diagnosis of mandibular deficiency (Class II skeletal dentofacial deformity) who underwent mandibular advancement surgery (T1) followed by a subsequent surgery (T2) which required intubation. The primary predictor variable was mandibular advancement. The primary outcome variable was the change in laryngeal grade-Cormack and Lehane-after mandibular advancement. A secondary outcome was intubation difficulty after mandibular advancement. RESULTS: Eight patients were included in the study. At T1, the average laryngeal grade was 1.6. There was 1 difficult intubation. The average time to T2 was 9 months. At T2, all patients were intubated on their first attempt, and all had a Cormack-Lehane Grade I view of the vocal cords. There were no difficult intubations at T2. Analysis showed a significant association between mandibular advancement and laryngeal grade at T2 (P = .03; 95% CI 0.07-1.13). CONCLUSIONS: This preliminary investigation found an association between mandibular advancement for cases of mandibular and improved laryngeal grade at subsequent intubation without any difficult intubations.

Individualized implants using point-of-care printed models in the treatment of orbital blowout fractures.

OBJECTIVE: This case series aims to highlight the digital workflow used by our institution to treat orbital fractures by creating individualized implants using point-of-care, 3-dimensional (3D) printed models. STUDY DESIGN: The study population comprised consecutive patients who presented to John Peter Smith Hospital with isolated orbital floor and/or medial wall fractures from October 2020 to December 2020. Patients treated within 14 days of their initial injury and with 3 months postoperative follow-up were included. Bilateral orbit fractures were excluded because an intact contralateral orbit is needed for 3D modeling. RESULTS: A total of 7 consecutive patients were included. The orbital floor was involved in 6 of the fractures, whereas 1 fracture involved the medial wall. All patients with preoperative diplopia, enophthalmos, or both had resolution by the 3-month postoperative follow-up appointment. Postoperatively, there were no complications in all patients included. CONCLUSIONS: The point-of-care digital workflow presented allows for the efficient production of individualized orbital implants. This method may produce a midface model in hours that can be used to pre-mold an orbital implant to the mirrored, unaffected orbit.

Is Presurgical Pain Intensity Related to Postoperative Recurrence of Post-Traumatic Trigeminal Neuropathic Pain?

PURPOSE: Post-traumatic trigeminal neuropathic pain (PTTNp) is a challenging condition to treat, and equally as challenging is the identification of surgical outcome variables to guide treatment. The study purpose was to determine if preoperative pain intensity was related to postoperative recurrence of PTTNp. MATERIALS AND METHODS: This retrospective cohort study assessed subjects at a single institution with preoperative PTTNp of either the lingual or inferior alveolar nerves who underwent elective microneurosurgery. Two cohorts were established as follows: No PTTNp at 6 months (group 1); presence of PTTNp at 6 months (group 2). The primary predictor variable was the preoperative visual analog scale (VAS) score. The primary outcome variable was PTTNp (recurrence or no recurrence at 6 months). The demographic and injury characteristics of the groups were compared to assess whether they were similar using Wilcoxon rank analysis. Two-tailed Student's t-test was performed to analyze the difference in preoperative mean VAS scores. Multivariate multiple linear regression models were used to determine the association between the covariates on the outcomes of the primary predictor variable and the primary outcome variable. A P value of <.05 was considered statistically significant. RESULTS: Forty-eight patients were included in the final analysis. There were 20 patients with no pain at 6 months and 28 with recurrence at 6 months following surgery. There was a significant difference in mean preoperative pain intensity between the two groups (P value .04). The mean preoperative VAS score in group 1 was 6.31 (standard deviation, 2.65), while the mean preoperative VAS score in group 2 was 7.75 (standard deviation, 1.95). Regression analysis showed that one covariate, the type of nerve injured, explained some variability of preoperative VAS score, but by only 16% (P value .005). Regression analysis also showed that two covariates, Sunderland classification and time to surgery, explained some of the variability of PTTNp at 6 months, by approximately 30% (P value .001). CONCLUSION: This study showed that presurgical pain intensity level was related to postoperative recurrence in the surgical treatment of PTTNp. In patients with recurrence, the preoperative pain intensity was higher. Other factors, including time interval from injury to surgery, were also related to recurrence.

Antimicrobial resistance in topical treatments for microbial keratitis: protocol for a systematic review and meta-analysis.

INTRODUCTION: There is evidence for increased resistance against the antimicrobials used to treat keratitis. This review aims to provide global and regional prevalence estimates of antimicrobial resistance in corneal isolates and the range of minimum inhibitory concentrations (MIC) with their associated resistance breakpoints. METHODS AND ANALYSIS: We report this protocol following Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols guidelines. We will conduct an electronic bibliographic search in MEDLINE, EMBASE, Web of Science and the Cochrane Library. Eligible studies will report in any language data for the resistance or MIC for antimicrobials against bacterial, fungal or amoebic organisms isolated from suspected microbial keratitis. Studies that only report on viral keratitis will not be included. There will be no time restrictions on the date of publication. Screening for eligible studies, assessment of risk of bias and data extraction will be conducted by two reviewers independently, using predefined inclusion criteria and prepiloted data extraction forms. We will resolve disagreements between the reviewers by discussion and, if required, a third (senior) reviewer will arbitrate. We will assess the risk of bias using a tool validated in prevalence studies. The certainty of the evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation approach. Pooled proportion estimates will be calculated using a random-effects model. Heterogeneity will be assessed using the I2 statistic. We will explore differences between Global Burden of Disease regions and temporal trends. ETHICS APPROVAL AND DISSEMINATION: Ethics approval is not required as this is a protocol for a systematic review of published data. The findings of this review will be published in an open-access, peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42023331126.

How Does Changing the Time to Surgery Affect the Recurrence of Post-Traumatic Trigeminal Neuropathic Pain.

PURPOSE: The recurrence of post-traumatic trigeminal neuropathic pain (PTTNp) following peripheral microneurosurgery continues to be poorly understood. The objective of this study was to determine if the time from injury to surgery of the trigeminal nerve in patients with PTTNp affected the recurrence of PTTNp following surgery. PATIENTS AND METHODS: A retrospective cohort of patients with PTTNp prior to trigeminal nerve surgery at a single institute was analyzed for the presence or absence of PTTNp at 6 months postsurgery. The primary predictor was the time from injury to surgical treatment and the primary outcome was the presence or absence of PTTNp using subjective and objective neurosensory testing at 6 months. Four groups were predefined to evaluate the effect of time to surgery: Group 1 (0 to 100 days), Group 2 (101 to 200 days), Group 3 (201 to 300 days), and Group 4 (> 300 days). Repeated measures analysis of variance was used to assess differences in the presence or absence of PTTNp among groups. If a statistical difference was found, a post hoc Tukey-Kramer test was performed. RESULTS: Sixty of 63 eligible patients met inclusion and exclusion criteria with end points at 6 months. The weighted mean PTTNp score in Group 1 was 1.6 ± 0.32, Group 2 was 1.61 ± 0.18, Group 3 was 1.3 ± 0.29, and Group 4 was 1 ± 0.0. There was a statistically significant difference in the primary outcome among the groups based on time from injury to repair (P = .0002). The between-group differences were significant for Group 1 and 3 and 4 and between Group 2 and 3 and 4 (P < .01). Within the 4 cohorts, the percentage of patients with PTTNp before surgery with no neuropathic pain at the 6-month follow-up was 41.6%. However, between the 4 cohorts, when the time to surgery was 200 days or less, the percentage of patients with PTTNp before surgery with no neuropathic pain at the 6-month follow-up was more than 60%. CONCLUSIONS: Time from injury to surgery appears to have an effect on the recurrence of PTTNp. Best outcomes are associated with operative interventions within 200 days of the injury.

Complications of Severe Odontogenic Infections: A Review.

Severe odontogenic infections are routinely treated with little associated morbidity and mortality. Improvements in surgical techniques, antibiotic treatments, and imaging modalities have made associated complications exceedingly rare. A number of complications have been described in the literature including airway obstruction, descending necrotizing mediastinitis, orbital abscess, septic cavernous sinus thrombosis, cerebral abscess, sepsis, necrotizing fasciitis, and Lemierre's syndrome. The purpose of this article is to discuss the pathophysiology of severe odontogenic infections and the risk factors associated with the development of complications. Given the morbidity and mortality of these conditions, it is important to review the clinical features of each and the diagnostic tools that aid in early recognition.