Custom CAD/CAM Peek Implants for Complex Orbitocranial Reconstruction: Our Experience with 15 Patients.

Bone defects within the cranio-orbital complex present unique challenges in terms of surgical planning and reconstruction. This article presents a novel approach using PEEK material and advanced surgical technologies to address these challenges. A retrospective analysis of 15 patients who underwent craniofacial reconstruction using patient-specific polyetheretherketone (PEEK) implants between 2016 and 2021 was carried out. Comprehensive preoperative planning was performed, utilizing advanced imaging techniques and specialized software for virtual surgical planning. Patient-specific PEEK PSIs were designed and manufactured based on the preoperative plan. Intraoperative navigation was used to guide the surgical procedure, enabling precise osteotomy and optimal implant placement. This article describes the step-by-step process and the tools utilized in each phase. The etiologies were as follows: meningioma in seven cases, benign lesions in five cases, malignant tumors in two cases, and trauma sequelae in one case. In all cases, 3D-printed PEEK implants were utilized to achieve precise reconstruction. No major complications were described. In one case, an implant replacement was needed with successful outcomes. Our study demonstrates the feasibility and effectiveness of using PEEK patient-specific implants for personalized craniofacial reconstruction. The combination of advanced imaging, virtual planning, and CAD-CAM technology contributes to improved surgical outcomes in terms of oncologic margin control, functional restoration, and aesthetic results.

Navigation-guided resection of locally advanced midface malignancies. Does it improve the safety of oncologic resection?

INTRODUCTION: Treatment of malignant midface tumors is a surgical challenge with an increased difficulty to obtain free surgical margins. The computer assisted surgery (CAS) and intraoperative navigation (ION) can be very helpful in complex midface resections. The main objective of this paper is to evaluate if the ION could improve the rate of free surgical margins in locally advanced midface malignancies. MATERIALS AND METHODS: A retrospective cohort study was performed including 40 patients with a locally advanced malignant midface tumor (T4a/b) surgically treated from September 2016 to September 2022. Patients were divided in two groups, a control group included 20 patients operated on without ION and the study group included 20 patients treated with Navigation assisted surgery. A systematic analysis was performed comparing surgical margins in both groups. RESULTS: Squamous cell carcinoma was the most common histological type. Oral cavity was the most common primary location. Overall, considering each specimen as an hexahedrium, 240 surgical margins were analyzed. 15 out of 120 margins analyzed in the navigation group (12.5 %) were positive while 30 out of 120 margins analyzed in control group (25 %) were affected (p 0.013). Concerning margin location, the ION group showed less involvement of the upper surface of specimen than in control group (p 0.048). CONCLUSION: Navigation Assisted Surgery seems to improve the rate of free surgical margins in patients with locally advanced midface malignancies, specially concerning involvement of the superior margin. Further studies are recommended to corroborate these results and its potential influence in survival rates.

Custom made cutting guides and osteosynthesis plates versus CAD/CAM occlusal splints in positioning and fixation of the maxilla in orthognathic surgery: A prospective randomized study.

The aim of this study is to compare the accuracy of maxilla positioning in orthognathic surgery with the use of custom-made devices (cutting guides and patient-fitted osteosynthesis plates) comparing to CAD/CAM splints. A prospective randomized study was performed. Patients with dentofacial deformities undergoing orthognathic surgery were compared, using customized guides (experimental group) vs. CAD/CAM surgical splints (control group) for the repositioning of the upper maxilla. Preoperative and postoperative CT scans were used to compare positioning and fixation of the maxilla in the three planes of space. A total of 30 patients were included in the study (15 patients in each study group). The mean error obtained with customized guides was 0.8 mm (range 0.1-1.9) in the anterior-posterior axis, 0.4 mm (range 0-1.4) in the vertical axis and 0.2 mm (range 0-1.1) in the horizontal axis. There were statistically significant differences in the anterior-posterior and vertical axes in favour of the customized implants, whereas there were no differences in the horizontal plane. Furthermore, there was a mean reduction of the operative time of 36.5 min in the experimental group. Within the limitations of the study it seems that patient specific surgical guides should be preferred when accuracy of repositioning of the maxilla and saving operative time are the priority.

Resultados de la asistencia compartida con medicina interna en un servicio de cirugía oral y maxilofacial / Results of comanagement with internal medicine in oral and maxillofacial surgery department

ANTECEDENTES Y OBJETIVO: La edad de los pacientes ingresados para tratamiento por los servicios de cirugía oral y maxilofacial (COMF) es progresivamente más alta, con la comorbilidad asociada que eso conlleva, y supone un incremento sustancial de las interconsultas a los servicios de medicina interna (MI), que no alcanzan la efectividad requerida. Una alternativa para mejorar la atención a los pacientes es la colaboración entre ambos servicios mediante la asistencia compartida (AC). El objetivo de este artículo es estudiar la repercusión y el efecto del empleo de la AC en los pacientes de COMF. MÉTODOS: Estudio observacional retrospectivo de los pacientes ≥ 16 años ingresados desde el 12 de marzo de 2017 hasta el 12 de marzo de 2019 en COMF, con AC con MI desde el 12 de marzo de 2018. Las variables analizadas son edad, sexo, tipo de ingreso, si fue intervenido quirúrgicamente, peso administrativo asociado a GRD, número total de diagnósticos al alta, índice de comorbilidad de Charlson (ICh), exitus, reingresos urgentes y estancia hospitalaria. RESULTADOS: Los pacientes con AC fueron de menor edad (2,8 años, intervalo de confianza del 95 % [IC 95 %] 0,1 a 5,6), pero con mayor número de diagnósticos (0,8; IC 95 % 0,4 a 1,2) y una tendencia a mayor ICh (0,3; IC 95 % -0,1 a 0,6) y peso administrativo (0,04; IC 95 % -0,03 a 0,1). Al ajustar, observamos que la AC redujo el 22,7 % la estancia en CMF, 1 día (IC 95 % -1,8 a -0,3), el 40 % los reingresos urgentes y el 50 % la mortalidad, ambos no significativos. El descenso de la estancia supone una disminución de costes de, como mínimo, 231.816,7 €. CONCLUSIONES: La edad de los enfermos ingresados para tratamiento por los servicios de cirugía oral y maxilofacial es cada vez más alta, que se asocia con una mayor comorbilidad. El empleo de la asistencia compartida con medicina interna en el manejo de los pacientes ingresados en cirugía oral y maxilofacial se asocia a una disminución de la estancia y los costes, en línea con lo observado en otros servicios quirúrgicos

BACKGROUND AND OBJECTIVE: The age of patients admitted for treatment by Oral and Maxillofacial Surgery (OMFS) services is progressively higher, with the associated comorbidity that this entails, and supposes a substantial increase in referrals to the Internal Medicine (IM) services, which do not reach the required effectiveness. An alternative to improve patient care is collaboration between both services through shared care (SC). The objective of this article is to study the repercussion and effect of the use of shared care in Oral and Maxillofacial patients. METHODS: Retrospective observational study of patients aged ≥ 16 years admitted from 3/12/2017 to 3/12/2019 at OMFS, with SC with IM from 3/12/2018. The variables analyzed are age, sex, type of admission, whether the patient underwent surgery, administrative weight associated with DRG, total number of diagnoses at discharge, Charlson's comorbidity index (HCI), death, urgent readmissions and hospital stay. RESULTS: Patients with AC were younger (2.8 years, 95 % confidence interval [95 % CI] 0.1 to 5.6), but with a greater number of diagnoses (0.8, 95 % CI 0.4 to 1.2) and a trend towards higher CIh (0.3; 95 % CI -0.1 to 0.6) and administrative weight (0.04; 95 % CI -0.03 to 0.1 ). When adjusting, we observed that CA reduced the stay in the CMF by 22.7 %, 1 day (CI 95 % -1.8 to -0.3), 40 % the urgent readmissions and 50 % the mortality, both not significant. The decrease in the stay implies a reduction in costs of, at least, € 231,816.7. CONCLUSIONS: The age of patients admitted for treatment by Oral and Maxillofacial Surgery services is increasingly higher, which is associated with greater comorbidity. The use of shared care with Internal Medicine in the management of patients admitted to Oral and Maxillofacial Surgery is associated with a decrease in stay and costs, in line with what was observed in other surgical services

Transmandibular Approach in Head and Neck Oncological Surgery.

Objective: To evaluate the advantages and disadvantages of the transmandibular approach to the posterior area of the maxilla, oropharyngeal region and the hypopharynx in head and neck surgery. Methods: A series of 42 patients who underwent a lip-split mandibulotomy procedure to access malignant tumours affecting deep areas of the head and neck region between 2008 and 2018 in the Department of Oral and Maxillofacial Surgery at the Ramón y Cajal University Hospital (Madrid, Spain) were retrospectively reviewed. The diagnosis and operations data of the patients were collected and analysed. Results: Using the transmandibular approach, 42 patients were operated on to access malignant tumours located in the oropharynx (n = 23, 54.76%) including the posterior third of the tongue, tonsil and soft palate, retromolar trygone (n = 9, 21.43%), floor of the mouth (n = 3, 7.14%), skull base (n = 2, 4.76%), superior maxilla (n = 3, 7.14%) and deep lobe of the parotid gland (n = 2, 4.76%). Primary reconstruction was carried out in all cases. The most used flap reconstruction method was the forearm fasciocutaneous flap in 48.71% of cases, followed by the anterolateral thigh flap in 20.51% of cases. The remaining cases were treated with other methods. The most frequent complication was surgical wound infection. Conclusion: The transmandibular approach is a good alternative to provide access for the removal of complex tumours affecting the oropharyngeal region. This approach facilitates direct visualisation of the lesion and bleeding control, allowing tumour resection with wide margins and making primary reconstruction easier. Although further progress in the transoral robotic approach could be a good option in selected cases, given the current state of knowledge, the transmandibular approach is a good option to access tumours affecting deep areas of the oral cavity and oropharynx.

Infecciones cervicofaciales graves. Nuestra experiencia en el Hospital Universitario Ramón y Cajal de Madrid / Severe cervicofacial infections. Our experience in Ramón y Cajal University Hospital, Madrid

INTRODUCCIÓN: Las infecciones cervicofaciales constituyen un motivo de consulta muy frecuente en los servicios de Urgencias de nuestro país, siendo con frecuencia causa de gran morbilidad y de importantes complicaciones, incluyendo el compromiso de la vía aérea. Por todo ello, un diagnóstico y tratamiento precoces son de vital importancia. El objetivo principal es realizar un estudio observacional retrospectivo sobre los pacientes diagnosticados de infección cervicofacial grave en nuestro centro, analizando múltiples variables demográficas, el tratamiento administrado, la duración del ingreso y las complicaciones observadas. MATERIAL Y MÉTODOS: Estudio observacional descriptivo retrospectivo sobre una muestra de 47 pacientes diagnosticados de infección cervicofacial grave en nuestro centro entre abril de 2016 y marzo de 2018. Se recogen y analizan múltiples variables: sexo, etiología, clínica asociada, aislamiento microbiológico, tratamiento, comorbilidades, duración de ingreso y complicaciones asociadas. RESULTADOS: El 51 % de la muestra fueron pacientes menores de 50 años sin comorbilidades asociadas. Las comorbilidades más frecuentes fueron los hábitos tóxicos (tabaco y alcohol), hipertensión arterial y diabetes. Respecto a la etiología, el 91 % fueron odontogénicas, siendo los cordales inferiores las piezas dentales afectadas con mayor frecuencia (79,06 %). La clínica característica de presentación fue la tríada de tumefacción facial, dolor y trismus (hasta el 60 %). El espacio cervicofacial afectado con mayor frecuencia fue el submandibular (56 %). El aislamiento microbiológico mostró que la mayoría fueron infecciones polimicrobianas mixtas (18 de 38 aislamientos) con predominio de los grupos Streptococo y Prevotella. Las complicaciones encontradas fueron: dos pacientes con obstrucción de vía aérea superior que precisaron traqueostomía previa intubación, un hematoma postquirúrgico, tres reintervenciones por mala evolución clínica y un paciente con mediastinitis. CONCLUSIONES: De los resultados obtenidos podemos concluir que la etiología odontogénica es la más frecuente, siendo el espacio submandibular el más afectado. En el Hospital Ramón y Cajal de Madrid, la mayoría de las infecciones cervicofaciales graves son mixtas con microrganismos aislados aerobios y anaerobios. El tratamiento combinado con cirugía y antibioterapia intravenosa fue de elección. Amoxicilina-Clavulánico fue el antibiótico más utilizado. Las complicaciones evolutivas graves son poco frecuentes con un tratamiento adecuado

INTRODUCTION: Cervical infections are a very common reason for consultation in the emergency services of our country. However, in certain cases, these infections are a cause of a great morbidity and important complications, including the compromise of the upper airway. For all these reasons, early diagnosis and treatment are of a great importance. The main objective is to perform a retrospective study of patients diagnosed with severe cervicofacial infection in our department, analyzing multiple demographic variables, treatment administered, time of hospitalization and complications observed. MATERIAL AND METHODS: Retrospective descriptive observational study based on a sample of 47 patients diagnosed with severe cervicofacial infection in our center between April 2016 and March 2018. Multiple variables were collected, among which are: sex, etiology, associated symptoms, microbiological isolation, treatment established, comorbidities, time of hospital admission and complications. RESULTS: 51 % of the sample were patients under 50 years of age without comorbidities. The most frequent comorbidities were toxic habits (tobacco and alcohol), hypertension and diabetes. Regarding the etiology, 91 % were odontogenic, being the third inferior molars the most frequently affected (79.06 %). The characteristic clinical presentation was the triad of facial swelling, pain and trismus (up to 60 %). The most frequently affected cervicofacial space was the submandibular space (56 %). The microbiological isolation showed that the majority were mixed polymicrobial infections (18 of 38 isolates) with predominance of the Streptococcus and Prevotella groups. The complications that we found were: two upper airway obstructions, a cervical bleeding, three reinterventions for a bad clinical evolution and a patient with mediastinitis. CONCLUSIONS: We can conclude that odontogenic etiology is the most frequent in severe cervicofacial infections, with the submandibular space being the most affected. Most of severe cervicofacial infections in Ramón y Cajal Hospital were polymicrobial and mixed infections. The combined treatment with surgery and intravenous antibiotic therapy was the therapeutic option chosen for all patients. Amoxicillin-Clavulanic was the most used broad-spectrum antibiotic. Complications are uncommon with an adequate treatment