Recurrent Ameloblastoma Involving Fibula Neo-mandible: Management with Digital Planning and Reconstruction Using a Contralateral Free Fibula Flap.

Ameloblastoma is a locally aggressive tumor that most commonly arises in the mandible. It has a high rate of recurrence if inadequately excised. We report a case of a patient who developed recurrence of his ameloblastoma in his fibula flap mandibular reconstruction despite clear resection margins 23 years after resection. This is the first reported case of recurrent ameloblastoma in a neo-mandible reconstruction in the setting of negative margins. We discuss its surgical management using digital planning and reconstruction using a contralateral free fibula flap. Ameloblastoma is a locally aggressive entity that requires complete excision. Recurrence can even occur in the reconstruction, which can present a challenge to manage. Consideration should be given to repeat excision and second osseous flap reconstruction.

Postoperative radiotherapy for patients with oral squamous cell carcinoma with intermediate risk of recurrence: A case match study.

BACKGROUND: The purpose of this study was to determine the effect of postoperative radiotherapy (PORT) on recurrence and survival in patients with oral squamous cell carcinoma (OSCC) of intermediate recurrence risk. METHODS: Intermediate risk patients, defined as pT1, pT2, pN0, or pN1 with at least one adverse pathological feature (eg, lymphovascular/perineural invasion), were identified from the head and neck databases of the Liverpool Head and Neck Cancer Unit and the Sydney Head and Neck Cancer Institute. Patients who received surgery and PORT were case matched with patients treated by surgery alone based on pN, pT, margins, and pathological features. RESULTS: Ninety patients were matched into 45 pairs. There was significant improvement (P = .039) in locoregional control with PORT (84%) compared with surgery alone (60%), which was concentrated in the pN1 subgroup (P = .036), but not the pN0 subgroup (P = .331). CONCLUSION: PORT significantly improves locoregional control for intermediate risk OSCC.

Tailored approach to oromandibular reconstruction in patients with compromised lower limb vessels.

BACKGROUND: The purpose of this study was to compare outcomes for segmental reconstruction of the mandible between patients who underwent reconstruction with a fibula flap (group 1), and those with an alternative osseous free flap in which the fibula flap was unsuitable either for defect reasons (group 2) or in which the fibula flap could not safely be harvested because of compromised leg vessels (group 3). METHODS: One hundred fifty-two patients who underwent osseous free flap reconstruction of a mandibular segmental defect between January 2008 and June 2014 were identified from operating records. Outcomes between groups was compared. RESULTS: The flap success rate was 97% and the late recipient-site complication rate was 19%. There was no difference in flap success or complication rates between groups. CONCLUSION: Bony reconstruction of the mandible can be achieved with no compromise in flap success even where preoperative vascular studies or the nature of the defect deem the fibula unsuitable. © 2017 Wiley Periodicals, Inc. Head Neck 39: 916-920, 2017.

Influence of surgical margins on local recurrence in T1/T2 oral squamous cell carcinoma.

BACKGROUND: The purpose of this study was to explore the significance of resection margin status on local recurrence and survival for early (T1/T2) oral cancer and to determine if the significance of the resection margin varies with the biological aggression of the tumor as determined by pN status. METHODS: The influence of resection margin size and local recurrence for 295 patients with pT1/T2 oral cavity squamous cell carcinomas (SCCs) treated by primary surgery, including neck dissection, between 1998 and 2010 was analyzed. RESULTS: Overall, there was a trend toward increased local recurrence with close or involved margins. When stratified according to nodal status, there was no relationship between margin size and local recurrence for the pN0 group. CONCLUSION: The size of the resection margin does not seem to influence local control in stage I/II oral cancer. With future advances in preoperative neck staging, this data may help plan personalized therapy in head and neck cancer.

De-escalation of surgery for early oral cancer--is it oncologically safe?

This study is a review of practice for patients with T1 or T2 squamous cell carcinoma (SCC) of the anterior tongue and floor of the mouth who presented to the regional maxillofacial unit in Liverpool between 1992 and 2007. We examined trends in management and analysed their effects on resection margins, recurrence, and survival. The Liverpool head and neck oncology database was used to identify patients, and to retrieve their clinical, surgical, and pathological data. When data were missing the case notes and pathology records were reviewed. Follow up was taken to January 2011. A total of 382 patients were included. Despite more conservative treatment with closer resection margins (27% in 1992-1995 and 60% in 2004-2007), fewer free flaps (79% in 1992-1995 and 38% in 2004-2007), and less adjuvant radiotherapy (37% in 1992-1995 and 22% in 2004-2007), there has been no significant increase in local recurrence (14% in 1992-1996 and 8% in 2004-2007), and overall survival has not been adversely affected. This is most striking when T1 tumours are considered in isolation with a consistent trend towards fewer clear margins (95% in 1992-1995 and 28% in 2004-2007) and fewer free flaps (53% in 1992-1995 and 11% in 2004-2007). The case mix was similar over the study period. These data support a more conservative approach to the management of early oral cancer.

Superior border plating technique in the management of isolated mandibular angle fractures: a retrospective study of 50 consecutive patients.

PURPOSE: To determine the complication rate for patients presenting with isolated mandibular angle fractures treated by open reduction and internal fixation using a single superior border miniplate technique. PATIENTS AND METHODS: This is a retrospective study of consecutive patients with isolated mandibular angle fractures treated using a specific protocol at a Regional Oral and Maxillofacial Department between January 1998 and December 2004. Patient demographics, fracture etiology, length of hospital stay, removal of third molar, and postoperative complications were recorded. Preoperative and postoperative inferior alveolar nerve function was recorded. Objective sensory testing and patient interviews were conducted to determine the incidence of postoperative sensory deficit. RESULTS: The study population included 50 patients presenting with isolated mandibular angle fractures, 6 patients (12%) experienced complications requiring bone plate removal. These complications were minor and occurred after fracture healing as follows: 4 patients (8%) experienced superficial soft tissue infection associated with the bone plate, treated with oral antibiotics, 1 patient (2%) experienced bone plate exposure, and a further patient (2%) presented with a fractured bone plate. All 6 patients (12%) were treated by bone plate removal under general anesthesia as elective day case surgery. Thirty-nine (78%) patients had long-term sensory follow-up, mean 37 months (2 to 84 months). Permanent inferior alveolar sensory deficit (>12 months) was present in 4 (8%). Five of 26 (19%) patients with normal postinjury/preoperative sensory function had a postoperative sensory deficit. All patients in this group reported recovery of normal sensation within 6 months. CONCLUSIONS: The results of this study suggest that the complication rates associated with the treatment of isolated mandibular angle fractures using a superior border plating technique, in this patient population, is relatively low (12%). The complications were all minor in nature. There was a permanent (>12 months) inferior alveolar sensory deficit in 4 (8%) patients.

Anatomical study of factors contributing to zygomatic complex fracture instability in human cadavers.

BACKGROUND: Stable reduction of fractures of the zygomatic complex is essential to avoid long-term aesthetic, sensory, and ocular consequences. Delayed collapse or relapse after reduction of fractures of the zygomatic complex is attributed to muscle forces, when there has been no additional trauma. A number of studies have identified the masseter muscle as a contributor, but none has described the role of the temporalis muscle. METHODS: The origins of the temporalis muscle were examined in six cadaveric dissections. The temporal and zygomatic regions were exposed through a temporoparietal flap. Bone cuts were made above and below the frontozygomatic suture in the lateral orbital margin. The lateral orbital margin was then fractured and reflected laterally on its periosteum so that muscle attachments could be seen clearly. RESULTS: In all six dissections, the authors found that the temporalis muscle took origin not only from the floor of the temporal fossa and temporalis fascia but also from the lateral margin of the orbit and the frontal process of the zygomatic bone as far down as the body of the zygoma. CONCLUSIONS: The authors postulate that the functional forces exerted by this muscle on the zygomatic complex cause postoperative distraction at the frontozygomatic suture. The authors' findings provide further anatomical evidence to support internal fixation of all fractures of the zygomatic complex, even those that are considered clinically stable, if permanent flattening of the cheekbone is to be avoided.

Case report--odontogenic keratocysts: enucleation, bone grafting and implant placement: an early return to function.

The odontogenic keratocyst (OKC) is a developmental odontogenic cyst accounting for approximately 3%-17% of cysts of the jaws. This is an uncommon lesion both clinically and pathologically because of the unusual growth pattern and high tendency for recurrence. The recommended surgical management of the lesion varies from marsupialisation to en bloc resection. In the treatment of a large mandibular OKC, enucleation and immediate bone grafting maintains mandibular integrity, reduces the risk of pathological fracture permits restoration of function with implant-supported prostheses. We recommend the following protocol in the management of large mandibular OKC: 1. Biopsy of the lesion. 2. CT scans in axial and coronal planes. 3. Enucleation of the cyst and removal of the associated teeth. 4. The excision of the overlying mucosa. 5. Immediate mandibular reconstruction with a corticocancellous iliac crest bone graft. 6. Placement of endosseous implants four months following bone grafting. 7. Reconstruction of the dentition six months following implant placement.

Osteomyelitis of the maxilla secondary to osteopetrosis: report of a case.

Osteomyelitis of the maxilla is extremely rare. When it occurs, there is invariably an underlying predisposing condition. We describe a 28-year-old woman whose presentation with osteomyelitis of the maxilla led to a diagnosis of generalized osteopetrosis.