Immediate dental rehabilitation in fibula free flaps for malignancy: Is it feasible?

BACKGROUND: Fibula free flap reconstruction has revolutionized maxillofacial reconstruction. While immediate dental rehabilitation with dental implants and teeth has shown benefits, it remains uncommon, especially for patients with malignancy. METHODS: A retrospective cohort study at a single institution explored immediate dental rehabilitation in fibula flaps for patients with malignant disease. Thirteen patients with malignancies that underwent immediate fibula free flap reconstruction with dental implants and dental prosthesis were included with a minimum of 3-month follow-up. RESULTS: Forty eight implants replaced 90 teeth in 13 patients. All implants were integrated at 3 months, with an overall success rate of 87.5%. Two patients experienced delayed (>3 months postoperatively) implant loss due to osteoradionecrosis and infection. Peri-mucositis occurred in three patients which resolved with treatment. Skin paddles were used in 11 patients and radiation therapy was not delayed for any patient. CONCLUSION: With proper patient selection, diagnosis of malignancy and the need for osteocutaneous flap reconstruction does not exclude the ability to place immediate implants and deliver an immediate dental prosthesis in head and neck reconstruction.

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.

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.

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.

Peripheral intraosseous carcinoma arising from a recurrent odontogenic keratocyst.

Primary intraosseous carcinoma (PIOC) is a distinct clinical and genomic pathology that should be considered when treating aggressive odontogenic cysts refractory to standard treatments. Odontogenic cysts have a very low chance of malignant transformation, with most studies citing an incidence of <0.05%. The pathogenesis of PIOC is multifactorial, with chronic inflammation-induced carcinogenesis being the most cited theory. Early detection is imperative to enhance the patient's prognosis, with the 5-year overall survival rate of PIOC being 38%. This paper presents a case of PIOC and reviews data on its epidemiology, diagnosis, presentation, and treatment.

Does the use of a "wrap" in three-dimensional surgical planning influence the bony margin status of benign and malignant neoplasms of the oral, head, and neck region? An initial investigation.

PURPOSE: Three-dimensional surgical planning (3-DSP) is becoming commonplace in the management of benign and malignant disease for oral and maxillofacial surgery practice within the last decade. Surgeons utilize a virtual "wrap" to preoperatively delineate and define maxillofacial tumor resection margins. The investigators hypothesized that the use of a wrap is a predictable method to obtain negative bony margins. METHODS: The investigators implemented a retrospective chart review. The sample was composed of patients over the age of 18 treated at John Peter Smith Health Network and Parkland/UT Southwestern Medical Center who obtained 3-DSP for the pathology of the head and neck, involving the bone, with a virtual wrap utilized for bony margins. The proportion of cases was calculated, descriptive statistics were reported, and binomial exact calculation was performed for confidence intervals. The primary variable analyzed was bony margin status on final histopathology, involved or uninvolved, based on the pathology report. RESULTS: The sample was composed of 39 cases, one of which was excluded due to aborting the preplanned 3-DSP. Of the 38 included cases, one had involved bony margin on final histopathology (2.6%; 95% confidence limits, 0.1%, 13.8%). There were 16 malignant cases (42%) and 22 benign cases (58%). When stratified by pathology, 1 out of the 16 malignant cases (6.3%; 95% confidence interval, 0.2%, 30%) and 0 out of the 22 benign cases (95% confidence interval, 0%, 15.4%) had an involved bony margin on final histopathology. CONCLUSION: The results of this preliminary study suggest three-dimensional surgical planning with wrap margins is a predictable method to obtain negative bony margins in benign and malignant disease of the maxillofacial complex. Further studies will focus on compiling prospective data to solidify the accuracy and predictability of using a wrap to obtain negative bony margins.

Jaw in a Day: Immediate Dental Rehabilitation during Fibula Reconstruction of the Mandible.

Reconstructing mandibular defects presents challenges to dental rehabilitation related to altered bone and soft tissue anatomy. Dental implants are the most reliable method to restore the lost dentition. Immediate dental implants have been placed for many years but with unacceptably low rates of dental/prosthetic success. Current virtual technology allows placement of both fibulas and guided implants in restoratively driven positions that also allow immediate dental rehabilitation. Inexpensive three-dimensional printing platforms can create provisional dental prostheses placed at the time of surgery. This article reviews our digital and surgical workflow to create an immediate dental prosthesis to predictably restore the dentition during major jaw reconstruction with fibula free flaps.

Management of Salivary Gland Injury.

Although a rare sequala of soft tissue injury, salivary gland trauma may result in significant morbidity. Salivary gland injury can involve the major as well as the minor glands. Because of the proximity of adjacent vital structures, a thorough history and physical examination are mandatory during patient evaluation. Trauma to the major salivary glands may involve the parenchyma, duct, or neural injury. Treatment requires adherence to primary principles of soft tissue management. Ductal and neural injury should be repaired primarily. Sialocele and fistula are potential complications of repaired and unrepaired salivary gland injury.

Immediate Teeth in Fibulas: Expanded Clinical Applications and Surgical Technique.

PURPOSE: The placement of immediate implants and teeth during jaw reconstruction using a fibula free flap has increased in recent years. Modifications of traditional fibula reconstructive techniques are needed to maximize success. This technique has not been described in patients requiring simultaneous soft tissue reconstruction. Our patient cohort includes cases with malignant pathology and those requiring skin paddles.  With digital workflows and point-of-care 3D printing, surgery is no longer delayed weeks for prosthesis fabrication. The purpose of this case series is to demonstrate a single institution's experience with expanded clinical applications and surgical techniques that enable predictable outcomes for immediate teeth in fibula flaps. MATERIALS AND METHODS: Ninety-five implants were placed in 22 patients undergoing fibula reconstruction of the jaw with immediate implants and an immediate dental prosthesis. Skin paddles were used in 10 patients while 12 patients had native mucosa. Six patients were treated for malignancies and underwent postoperative radiation. Implant success and complications were compared between implants with skin paddles and implants with native mucosa. RESULTS: Of 95 implants, 92 implants integrated for a 97% integration rate. All 13 radiated implants in 4 patients integrated. All 36 implants adjacent to skin paddles in 10 patients integrated. Seven implants were lost in a delayed fashion 9 to 15 months postoperatively resulting in a 93% overall implant success rate. Of the 22 patients, diagnoses were benign pathology for 11 patients, malignant pathology for 6 patients, gunshot wounds for 3 patients, and osteoradionecrosis for 2 patients. CONCLUSION: Immediate placement of dental prostheses on immediate implants during fibula reconstruction of the jaws can be performed with a high rate of predictability. This technique can be expanded to select patients needing skin paddles. Modifications of traditional fibula reconstructive techniques are helpful to minimize soft tissue and prosthetic challenges.

Considerations in Free Flap Reconstruction of the Midface.

Midface reconstruction has been a consistent challenge for reconstructive surgeons even with the significant advances in technology and technique achieved over the recent years. A meticulous preoperative assessment of the patient is required to properly assess the defect or anticipated defect, determine proper reconstructive surgical plan, and discuss expected functional and aesthetic outcomes with the patient. For years we have employed local flaps, regional flaps, obturators, alloplastic implants, free flaps, or a combination of the previously mentioned techniques to address complex midface reconstruction. Free flap reconstruction in the midface requires special considerations for the pedicle, flap selection, and flap design to ensure an optimal outcome. The introduction of virtual surgical planning for reconstruction has enhanced patient outcomes to include advances in immediate dental rehabilitation at the time of free flap surgery. Postoperative considerations including quality of life, functional and aesthetic outcomes, and management of complications will also be discussed.

Palatomaxillary Obturation and Facial Prosthetics in Head and Neck Reconstruction.

Rehabilitation of head and neck defects following trauma, oncologic resection, or congenital malformation is a challenging task. Not only is the restoration of three-dimensional form necessary for acceptable cosmesis, but simultaneous restoration of functional speech and swallow is also essential for optimal reconstruction outcomes. While advances in free tissue transfer have allowed surgical reconstruction of head and neck defects once considered inoperable and associated with poor quality of life, not all patients are ideal surgical candidates. As such, nonsurgical solutions to both functional and cosmetic restoration remain a necessary alternative option. Facial prostheses and palatomaxillary obturators have evolved with increasingly biocompatible materials as well as retention systems to address significant defects that challenge the limits of surgical reconstruction.

Immediate Teeth in Fibulas: Planning and Digital Workflow With Point-of-Care 3D Printing.

PURPOSE: Point-of-care 3-dimensional (3D) printing has become more common in recent years because many hospitals have created 3D printing laboratories. Traditional techniques to fabricate an immediate dental prosthesis for fibula and implant reconstructions have involved outsourcing to dental laboratories. This results in delays, making it suitable only for benign disease. In the present report, we have demonstrated a technique for in-house creation of a 3D printed dental prosthesis for placement of implants at free fibula maxillofacial reconstruction. Our digital method has reduced costs and shortened the interval to surgery compared with traditional laboratory techniques. MATERIALS AND METHODS: Twelve patients underwent free fibula reconstruction of the mandible or maxilla with immediate implants and immediate teeth. A dental implant-retained restoration was created before surgery for immediate placement at fibula reconstruction. For the first 5 patients, the prosthesis was fabricated by a dental laboratory after virtual surgical planning. For the next 7 patients, the prosthesis was designed by the surgeon and 3D printed via the in-house laboratory. Four of these in-house cases were performed for malignant disease with skin paddles. RESULTS: All 12 patients received an immediate implant-retained fixed prosthesis at fibula reconstruction. The time required to generate the in-house 3D printed prostheses was significantly shorter than that required to create the dental laboratory-fabricated prostheses. The costs were also less with the 3D printed prostheses compared with the dental laboratory-fabricated prostheses. CONCLUSIONS: The digital workflow we have presented eliminates the delay in creating a dental laboratory-fabricated provisional dental prosthesis for fibula and implant reconstruction. This allows for immediate dental restoration for patients with malignant disease previously considered unsuitable owing to the inherent delay required using an offsite dental laboratory. A decrease in cost to create in-house 3D printed prostheses was noted compared with the prostheses fabricated by a dental laboratory. Case selection is critical to predict the soft tissue needs for composite defects.

Experience With "Jaw in a Day" Technique.

The "Jaw in a Day" (JIAD) technique, first described by Levine and colleagues, establishes immediate functional occlusion through a single-stage maxillomandibular reconstruction with concurrent implant placement and provisional prosthesis delivery. In this study, the authors describe 2 cases exemplifying the reconstructive principles of JIAD. One patient underwent mandibular reconstruction with the JIAD technique and another patient underwent JIAD with an optimized rapid sequence computer-aided design and computer-aided manufacturing (CAD-CAM) for composite maxillomandibular reconstruction. Immediate implant-borne prosthesis was fixated and all implants osseointegrated into the neomandible. Although the authors' patient outcomes are consistent with the literature, the published reports of JIAD remain limited, and further studies are required to assess the long-term functional and aesthetic outcomes as well as cost-effectiveness of this approach.

Spindle Cell Sarcoma of the Maxilla: A Rare Entity, Case Report, and Review of the Literature.

Spindle cell sarcoma (SCS) is a malignancy, with the most recent Surveillance, Epidemiology, and End Results (SEER) data citing a total of 250 reported cases occurring in the head and neck. Of these cases, none originated in the maxillofacial hard tissue. To the best of our knowledge, only 2 cases of primary osseous SCS of the maxillofacial region have been reported. These cases were not accounted for in the SEER data. The diagnosis of SCS requires its differentiation from other sarcomas and spindle cell neoplasms. Therefore, a comprehensive review to reinforce its inclusion in oral and maxillofacial surgeons' differential diagnosis for osseous neoplastic pathology is desired. In the present case report, we have described a maxillary SCS in a patient with an initial diagnosis of a spindle cell lesion of uncertain biologic behavior. We reviewed the data for SCS, including the epidemiologic data, diagnostic challenges, clinical and radiographic presentations, prognostic indicators, and treatment.

Role of Free Tissue Transfer in Facial Trauma.

For large composite traumatic defects of the head and neck, free tissue transfer presents a reconstructive allowing for the reconstitution of both form and function. Furthermore, the ability to provide bulk, soft, and hard tissue, as well as immediate dental rehabilitation, makes free tissue transfer an efficient and attractive option for head and neck reconstruction. Herein, we discuss the utility of free tissue transfer in facial trauma, its problems, complications, and controversies.

Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

Spindle cell and pleomorphic lipomas (SC/PLs) are a rare form of lipomatous tumors. They typically occur as a slow-growing localized mass in the subcutaneous fatty tissue of the posterior neck, back, and shoulders. This benign variant represents less than 1.5% of all lipomas and is relatively uncommon in the head and neck area. A manifestation in the larynx is even rarer. Unlike other anatomic locations, laryngeal lipomas can pose life-threatening symptoms secondary to acute obstruction of the upper aerodigestive tract. This report presents a case of a large SC/PL of the larynx associated with hoarseness, dysphagia, globus sensation, and neck fullness. The tumor was successfully removed through an anterior transcervical approach with infrahyoid myotomy. The authors review the literature concerning head and neck adipocytic tumors with spindle cells and discuss the difficulties in distinguishing SC/PLs from liposarcomas. To the best of the authors' knowledge, this is the first case to be reported in the oral and maxillofacial surgery literature.