Fellowship Training in Oral and Maxillofacial Surgery: Opportunities and Outcomes.

The pursuit of fellowship training stems from one's desire to master a focused area of surgery. Successful applicants tend to have published articles and participated in other scholarly activities. They commonly have a mentor within the subspecialty of their interest. Selection of the program is generally based on the breadth of experience available followed by faculty reputation and location. Advantages to the successful fellowship graduate include the experience and confidence to provide specialized and efficient care to patients. Enhancements to an academic department with a fellowship program include mentorship for residents and guidance toward fellowship, as well as an increased level of scholarly activity.

Brush swab as a noninvasive surrogate for tissue biopsies in epigenomic profiling of oral cancer.

BACKGROUND: Oral squamous cell carcinoma (OSCC) has poor survival rates. There is a pressing need to develop more precise risk assessment methods to tailor clinical treatment. Epigenome-wide association studies in OSCC have not produced a viable biomarker. These studies have relied on methylation array platforms, which are limited in their ability to profile the methylome. In this study, we use MethylCap-Seq (MC-Seq), a comprehensive methylation quantification technique, and brush swab samples, to develop a noninvasive, readily translatable approach to profile the methylome in OSCC patients. METHODS: Three OSCC patients underwent collection of cancer and contralateral normal tissue and brush swab biopsies, totaling 4 samples for each patient. Epigenome-wide DNA methylation quantification was performed using the SureSelectXT Methyl-Seq platform. DNA quality and methylation site resolution were compared between brush swab and tissue samples. Correlation and methylation value difference were determined for brush swabs vs. tissues for each respective patient and site (i.e., cancer or normal). Correlations were calculated between cancer and normal tissues and brush swab samples for each patient to determine the robustness of DNA methylation marks using brush swabs in clinical biomarker studies. RESULTS: There were no significant differences in DNA yield between tissue and brush swab samples. Mapping efficiency exceeded 90% across all samples, with no differences between tissue and brush swabs. The average number of CpG sites with at least 10x depth of coverage was 2,716,674 for brush swabs and 2,903,261 for tissues. Matched tissue and brush swabs had excellent correlation (r = 0.913 for cancer samples and r = 0.951 for normal samples). The methylation profile of the top 1000 CpGs was significantly different between cancer and normal samples (mean p-value = 0.00021) but not different between tissues and brush swabs (mean p-value = 0.11). CONCLUSIONS: Our results demonstrate that MC-Seq is an efficient platform for epigenome profiling in cancer biomarker studies, with broader methylome coverage than array-based platforms. Brush swab biopsy provides adequate DNA yield for MC-Seq, and taken together, our findings set the stage for development of a non-invasive methylome quantification technique for oral cancer with high translational potential.

Virtual Surgical Planning in Oral and Maxillofacial Surgery.

Virtual surgical planning provides the ability to visualize the patient anatomy and pathologic condition, establish pertinent reference points, and simulate osteotomies and reconstruction design in advance of the surgery. Virtual surgical planning is also an ideal environment for improved communication between the patient and the surgical team.

Preparation of the Neck for Advanced Flap Reconstruction.

Microvascular free tissue transfer has revolutionized the reconstruction of complex maxillofacial defects. These cases often necessitate a 2-teamed approach, with an ablative surgeon at the head and a reconstructive surgeon at a distant site for flap harvest. Careful attention to recipient vessel identification and preservation establishes the foundation for successful reconstruction. This article describes the surgical landmarks of the frequently utilized arteries and veins, vessel handling techniques, and general principles for the preparation of free tissue transfer recipient sites in head and neck reconstruction.

Single-Unit 3D-Printed Titanium Reconstruction Plate for Maxillary Reconstruction: The Evolution of Surgical Reconstruction for Maxillary Defects-A Case Report and Review of Current Techniques.

The complex 3-dimensional anatomy of the facial skeleton creates a unique challenge for surgical reconstruction. Even more difficult is the precise reconstruction of the maxilla owing to its lack of solid bony support after large resections. Virtual surgical planning (VSP) technology has many applications in head and neck surgery, such as preoperative planning, fabrication of cutting guides and stereolithographic models, and fabrication of custom implants. We present the case of a patient who had undergone surgical resection of a mucoepidermoid carcinoma of the maxilla and immediate reconstruction with a vascularized free fibula flap using VSP. Using a custom 3-dimensional, titanium printed plate, which corresponded precisely with the surgical defect, the maxilla and midface were reconstructed to ideal dimensions with no unplanned surgical manipulation and a shorter overall operating time. We have described the technique and reviewed the pertinent reported data.

The Use of Acellular Urinary Bladder Matrix as Coverage for Fasciocutaneous Free Flap Donor Sites: An Alternative to Traditional Grafting Procedures.

PURPOSE: The purpose of this review is to 1) evaluate our early experience with urinary bladder matrix as a dressing for the management of complex wounds subsequent to fasciocutaneous or osteocutaneous vascularized tissue harvests, 2) assess coverage of exposed tendons and the duration of granulation and epithelial coverage, and 3) assess esthetic and functional outcomes compared with traditional means for the management of vascularized tissue harvest sites. PATIENTS AND METHODS: This prospective study consisted of 8 consecutive patients in whom a substantial cutaneous component was harvested as part of a vascularized tissue reconstruction, which did not permit for primary closure (n = 7) or had skin graft failure (exposed tendon) that required additional treatment (n = 1). RESULTS: Functional and esthetic outcomes were comparable to those of traditional methods of donor site closure as determined by clinical evaluation and subjective assessment by the patient. In all patients, no additional grafting was required to achieve full coverage. Irregularities of the wound achieved a level plane with granulation tissue an average of 3 to 4 weeks after surgery, followed by an additional 5 to 8 weeks for epithelialization. Wound care was minimal and included twice-daily wet-to-dry dressings. It was noted that complete wound healing was delayed in the urinary bladder matrix group, which required more attention during wound care when compared with published data. Advantages included facilitation of a robust granulation layer that leveled wound irregularities and avoidance of an additional skin graft site. CONCLUSIONS: The use of urinary bladder matrix is a viable option for the rehabilitation of donor sites of vascularized tissue that include skin. Benefits include the avoidance of an additional skin graft donor site, facilitation of epithelialization over exposed tendons, leveling of the donor site texture, and an equivalent esthetic result compared with current practices for wound coverage. The success of this technique may be limited by the cost of materials and the protracted course for wound epithelialization.

Resection of an ameloblastoma in a pediatric patient and immediate reconstruction using a combination of tissue engineering and costochondral rib graft: A case report.

BACKGROUND AND OVERVIEW: Ameloblastoma is an odontogenic tumor predominantly occurring in patients who are in their 20s and 30s. Approximately 10% to 15% of ameloblastomas occur in patients younger than 18 years. Although it is a benign tumor, an ameloblastoma can have a devastating effect on children both physically and emotionally. The aim of this case report is to demonstrate how tissue engineering and surgical techniques can minimize morbidity and recovery time after extirpation and immediate reconstruction of a mandibular ameloblastoma. CASE DESCRIPTION: An 11-year-old girl was referred for surgical evaluation of a lesion found on a routine dental radiograph. Resection of a mandibular unicystic ameloblastoma resulted, including immediate reconstruction using a costochondral rib graft, allogeneic bone, bone marrow aspirate concentrate, and recombinant human morphogenetic protein-2. One year postoperatively, the patient had no evidence of recurrence as well as excellent mandibular bone height and width with good facial form. The patient has returned to her daily life without any disabilities or disfigurement. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Dentists are typically the first health care providers to discover oral pathology in patients. The coordination of care by the dental care providers and the oral and maxillofacial specialist was key to the successful outcome for this patient. With biotechnology and surgical techniques, the dental surgeon can extirpate an ameloblastoma and reconstruct the mandible defect to the ideal shape and size with minimal morbidity and recovery time.

Immediate Transoral Allogeneic Bone Grafting for Large Mandibular Defects. Less Morbidity, More Bone. A Paradigm in Benign Tumor Mandibular Reconstruction?

PURPOSE: Reconstruction of hard tissue continuity defects caused by ablative tumor surgery has been traditionally reconstructed with autogenous bone grafts or microvascular free flaps. Although results have been predictable from these 2 methods of reconstruction, the morbidity associated with bone harvest is quite serious for the patient. Predictable results have been obtained with using a combination of 100% cadaver bone, bone marrow aspirate concentrate (BMAC), and recombinant human bone morphogenic protein in immediate reconstruction for benign tumor extirpations through the extraoral approach. In light of these successful outcomes, the same combination was evaluated with an intraoral approach. This study evaluated the success of immediate mandibular reconstruction through the intraoral approach without any autogenous bone harvesting. PATIENTS AND METHODS: The aim of this retrospective study was to share the authors' experience with the use of 100% allogeneic bone in combination with bone morphogenic protein and BMAC through the transoral approach for immediate reconstruction of continuity defects that resulted from benign tumor surgery. A retrospective chart review was performed of all patients undergoing bone graft reconstruction at the University of Texas Health Sciences Center at Houston (UTHealth) Department of Oral and Maxillofacial Surgery from December 2014 through January 2016. Inclusion criteria were biopsy-proven benign tumors, American Society of Anesthesiologists I or II health status, and adequate intraoral soft tissue for primary closure determined during initial consultation. RESULTS: Five patients who underwent this procedure at the UTHealth Department of Oral and Maxillofacial Surgery from December 2014 through January 2016 are presented. The success rate was 100%. All patients showed excellent bone quality clinically and radiographically for endosseous dental implant placement. With the transoral approach and no autogenous bone harvesting, the average operating time was 3.4 hours and the hospital stay was 2.4 days. CONCLUSIONS: Composite allogeneic tissue engineering is an effective and predictable technique for immediate reconstruction of continuity defects from ablative benign tumor surgery. Overall, there was no donor site morbidity, the intraoperative time was shorter, there were fewer admission days, and total costs overall were lower compared with traditional methods.

A technique for the treatment of oral-antral fistulas resulting from medication-related osteonecrosis of the maxilla: the combined buccal fat pad flap and radical sinusotomy.

OBJECTIVE: Bisphosphonates and monoclonal antibodies directed at osteoclastic function are frequently used to treat postmenopausal and corticosteroid-induced osteoporosis. They are also used in the treatment of certain metastatic malignancies. However, osteonecrosis of the jaw has been reported after intravenous, subcutaneous, or oral use of these agents. More than 12 million Americans and another 20 million worldwide are thought to be taking a bisphosphonate. Exposed bone with oral-antral fistulas has been known to occur increasingly as a specific presentation of what is now termed medication-related osteonecrosis of the jaws (MRONJ) with a specific International Classification of Diseases, 10th revision (ICD-10) code. Oral-antral communications caused by bisphosphonate concomitant with secondary sinusitis represent a unique treatment challenge for the oral and maxillofacial surgeon. The purpose of this article is to demonstrate a simple but effective technique to treat oral-antral communications caused by MRONJ. STUDY DESIGN: With the review and approval of the University of Miami Internal Review Board, we identified 23 patients who had undergone this surgical procedure. RESULTS: We report a 100% resolution of osteonecrosis of the jaw (ONJ) and sinusitis with repneumatization. CONCLUSIONS: The buccal fat pad and radical sinustomy can be used as an effective and predictable technique for the resolution of oral-antral fistulas caused by MRONJ.

Reconstruction of Temporal Hollowing Defect With Anterior-Lateral Thigh Free Flap Following Resection of Recurrent Ameloblastoma of the Infratemporal Fossa and Right Mandible (a Case Report).

Recurrent invasive ameloblastoma of the infratemporal fossa is an uncommonly encountered phenomenon in the practice of oral and maxillofacial surgery and presents many surgical challenges for the practitioner. This case report describes a patient who underwent previous resection of a mandibular ameloblastoma with multiple recurrences. The patient was diagnosed with a recurrent ameloblastoma of the infratemporal fossa that was subsequently resected and reconstructed using an anterolateral thigh (ALT) free tissue transfer. There are few reported cases of recurrent ameloblastomas in the infratemporal fossa and none that describe surgical resection and reconstruction of such a lesion. Owing to the uniqueness of the surgical defect, an ALT flap was used to correct the temporal hollowing. There have been multiple reported cases of reconstruction of temporal hollowing defects using autogenous fat or allograft; however, none have described the use of a de-epithelialized ALT microvascular reconstruction of a temporal hollowing defect. This case report describes a unique clinical situation of surgical resection and reconstruction that resulted in a satisfactory outcome for the patient.

Use of Botox (OnabotulinumtoxinA) for the Treatment of Parotid Sialocele and Fistula After Extirpation of Buccal Squamous Cell Carcinoma With Immediate Reconstruction Using Microvascular Free Flap: A Report of 3 Cases.

PURPOSE: Buccal squamous cell carcinoma is an aggressive form of oral carcinoma with a high recurrence rate. Injury to the parotid duct is often unavoidable when surgically treating buccal squamous cell carcinoma because of the intimate anatomic relation among the buccal mucosa, Stensen duct, and parotid gland. It is often difficult to achieve negative margins and preserve the integrity of the parotid duct. Sialocele formation is a frequent and untoward complication owing to extravasation of saliva into the surgical defect, which delays healing, creates fistulas, and produces painful facial swelling. Currently, no consensus exists regarding the management of a parotid sialocele. Multiple investigators have described different modalities of treatment, such as repeated percutaneous needle aspiration, pressure dressings, antisialagogue therapy, radiotherapy, botulinum toxin, and surgical techniques, including duct repair, diversion, ligation, drain placement, and parotidectomy. MATERIALS AND METHODS: With approval from the institutional review board of the University of Texas Health Sciences Center at Houston, 3 cases of parotid sialocele and nonhealing fistulas successfully treated with Botox (onabotulinumtoxinA) after tumor extirpation, neck dissection, and reconstruction with a microvascular free flap are presented. RESULTS: At the University of Texas Health Sciences Center at Houston, the radiation oncologist prefers not to start adjunctive radiation treatment with a nonhealing wound or a drain in the field of radiation. Ideally, a standard timing of adjuvant radiotherapy is 6 to 8 weeks after surgery and 60 cGy should be completed before 7 months. CONCLUSIONS: With the use of Botox, the nonhealing wound resolved and the drain was removed at least 2 weeks before the initiation of adjunctive radiotherapy, thus minimizing the delay in adjuvant treatment.

Adenoid cystic carcinoma of the minor salivary glands: a retrospective series of 29 cases and review of the literature.

OBJECTIVE: Approximately 78% of minor salivary gland tumors are malignant, of which adenoid cystic carcinoma (ACC) represents 15% in our series. ACC is an uncommon tumor characterized by slow growth and a high potential for recurrence. This series of 29 consecutive patients examines clincopathologic features, management, and survival outcomes. MATERIALS AND METHODS: This study is a retrospective chart review of 29 patients with ACC of the minor salivary glands in a period of 23 years (1989 and 2012). RESULTS: The mean age was 61.2 years (16-89 years), with no gender predilection. The majority occurred in the palate/maxilla (66%) and initial presentation was stage IV. Mean follow-up was 42.6 months. Recurrence rate was 10% local, 14% distant over the observation period. CONCLUSIONS: The palate/maxilla is the preferred location for occurrence, and initial presentation at stage IV is common. Postoperative radiation remains a common strategy to prevent local recurrence in lesions with adverse features.

Oral surgery in patients undergoing chemoradiation therapy.

Oral health care in patients undergoing chemotherapy and/or radiation therapy can be complex. Care delivered by a multidisciplinary approach is timely and streamlines the allocation of resources to provide prompt care and to attain favorable outcomes. A hospital dentist, oral and maxillofacial surgeon, and a maxillofacial prosthodontist must be involved early to prevent avoidable oral complications. Prevention and thorough preparation are vital before the start of chemotherapy and radiation therapy. Oral complications must be addressed immediately and, even with the best management, can cause delays and interruption in treatment, with serious consequences for the outcome and prognosis.

Evaluation and staging of the neck in patients with malignant disease.

This article presents an overview of the evaluation and staging of the neck in the context of malignant disease. The current tumor-nodes-metastasis (TNM) nodal classification is reviewed followed by a brief discussion of the common malignant processes encountered in the head and neck and their associated risk factors for cervical metastasis. Common imaging modalities, such as ultrasound, magnetic resonance imaging, Computed tomography, and positron emission tomography, for the investigation of the neck are also summarized.

Parotid lymphoma: a review of clinical presentation and management.

Lymphoma of the parotid gland is a relatively rare occurrence among head and neck tumors. Presentation is indistinguishable from other swellings of the parotid gland; therefore, it is important to consider lymphoma in the differential diagnosis when examining parotid swellings. Parotid lymphomas are most likely to be B-cell non-Hodgkin lymphoma of 1 of 3 types, which include follicular, marginal zone, and diffuse large B cell, although other histologic patterns have been described. We present a review of 3 patients with parotid lymphoma who presented to the University of Maryland Medical Center's Department of Oral and Maxillofacial Surgery with facial swelling. Two patients were diagnosed with follicular lymphoma, whereas the third was diagnosed with marginal zone lymphoma.

Robotic surgery: a new approach to tumors of the tongue base, oropharynx, and hypopharynx.

Oropharyngeal cancer was traditionally treated with en bloc resection of the tumor via lip-split mandibulotomy approach, often with adjuvant radiation and chemotherapy. In the 1990s, organ-sparing definitive chemoradiation therapy without surgery became the standard of care for oropharyngeal squamous cell carcinoma. Although organ-sparing treatment provided acceptable locoregional disease control with preservation of anatomic organs adjacent to the tumors and less disfiguration from lack of surgical incisions, it often resulted in significant deficits in speech and swallowing. This article reviews a current organ-and-function preserving approach to oropharyngeal carcinoma using the surgical robot.

Resection and immediate reconstruction of a pediatric vascular malformation in the mandible: case report.

Arteriovenous malformations (AVMs) within the mandible are rare and potentially life-threatening conditions that can pose a therapeutic dilemma. We present the case of a child with significant spontaneous gingival bleeding, radiographic evidence of a space-occupying lesion of the mandible, and delayed diagnosis and treatment because of parental reluctance to accept invasive treatment. Imaging studies and intravascular embolization with coils limited, but did not stop blood flow to this lesion. Resection of the mandible was the definitive treatment. The AVM was removed from the resected segment and the bone was replaced as a free graft, thereby avoiding a second site morbidity. Two years after surgery the replaced segment was well consolidated with moderate vertical resorption-remodeling.

Cavernous sinus thrombosis secondary to fracture of posterior maxillary sinus wall. Case report.

The presentation of cavernous sinus thrombosis can be ominous and, in many cases, lead to death or serious morbidity. Infections from the face can tract via a valveless venous system in a retrograde manner to the cavernous sinus. A case of cavernous sinus thrombosis secondary to a non-operable posterior maxillary sinus wall fracture is reported. This case is of interest because the inciting factor was a fracture in the posterior maxillary wall that created a tract from which bacteria traveled to the pterygoid plexus and, ultimately, to the cavernous sinus. Although cavernous sinus thrombosis is uncommon, we present this case to remind medical and dental professionals of the potential complications of infection and trauma to the face, especially in immunocompromised patients.