Rates of Occult Invasive Disease in Patients With Biopsy-Proven Oral Cavity Squamous Cell Carcinoma in Situ.

Importance: The likelihood that an oral cavity lesion harbors occult invasive disease after biopsy demonstrating carcinoma in situ (CIS) is unknown. While de-escalated treatment strategies may be appealing in the setting of CIS, knowing whether occult invasive disease may be present and its association with survival outcomes would lead to more informed management decisions. Objective: To evaluate rate of occult invasive disease and clinical outcomes in patients with oral cavity CIS. Design, Setting, and Participants: This was a retrospective population-based cohort study using the National Cancer Database and included adults with biopsy-proven oral cavity CIS as the first diagnosis of cancer between 2004 and 2020. Data were analyzed from October 10, 2022, to June 25, 2023. Exposures: Surgical resection vs no surgery. Main Outcomes and Measures: Analyses calculated the rate of occult invasive disease identified on resection of a biopsy-proven CIS lesion. Univariate and multivariate logistic regression with odds ratios and 95% CIs were used to identify significant demographic and clinical characteristics associated with risk of occult invasion (age, year of diagnosis, sex, race and ethnicity, oral cavity subsite, and comorbidity status). Kaplan-Meier curves for overall survival (OS) were calculated for both unresected and resected cohorts (stratified by presence of occult invasive disease). Results: A total of 1856 patients with oral cavity CIS were identified, with 122 who did not undergo surgery (median [range] age, 65 [26-90] years; 48 female individuals [39.3%] and 74 male individuals [60.7%]) and 1458 who underwent surgical resection and had documented pathology (median [range] age, 62 [21-90] years; 490 female individuals [33.6%] and 968 male individuals [66.4%]). Of the 1580 patients overall, 52 (3.3%) were Black; 39 (2.5%), Hispanic; 1365 (86.4%), White; and 124 (7.8%), other, not specified. Among those who proceeded with surgery with documented pathology, 408 patients (28.0%) were found to have occult invasive disease. Higher-risk features were present in 45 patients (11.0%) for final margin positivity, 16 patients (3.9%) for lymphovascular invasion, 13 patients (3.2%) for high-grade invasive disease, and 14 patients (3.4%) for nodal involvement. For those patients with occult disease, staging according to the American Joint Committee on Cancer's AJCC Cancer Staging Manual, eighth edition, was pT1 in 341 patients (83.6%), pT2 in 41 (10.0%), and pT3 or pT4 disease in 26 (6.4%). Factors associated with greater odds of occult invasive disease at resection were female sex, Black race, and alveolar ridge, vestibule, and retromolar subsite. With median 66-month follow-up, 5-year OS was 85.9% in patients who proceeded with surgical resection vs 59.7% in patients who did not undergo surgery (difference, 26.2%; 95% CI, 19.0%-33.4%). Conclusions and Relevance: This cohort study assessed the risk of concurrent occult invasion with biopsy-proven CIS of the oral cavity, demonstrating that 28.0% had invasive disease at resection. Reassuringly, even in the setting of occult invasion, high-risk disease features were rare, and 5-year OS was nearly 80% with resection. The findings support the practice of definitive resection if feasible following biopsy demonstrating oral cavity CIS.

Carcinosarcoma of the parotid gland: a case report and review of the literature.

BACKGROUND: Carcinosarcoma of the parotid gland is an extremely rare malignancy comprising of 0.04-0.16% of all salivary gland tumors. This is the first case of an adenoid cystic carcinoma with chondrosarcoma to the best of our knowledge. They consist of distinct carcinomatous and sarcomatous components and may arise de novo or from a preexisting pleomorphic adenoma. CASE PRESENTATION: Herein we present a case of an 80-year-old white female who presented with progressively increasing left facial swelling over 6 weeks. Magnetic Resonance Imagining revealed a mass (3.4 cm) in the parotid gland with a predominant cystic/necrotic component. The cytology was atypical (Milan3) and a total parotidectomy and selective lymph node dissection was done. The resection showed extensive necrosis with high grade sarcomatous (chondrosarcoma) areas. The epithelial component was adenoid cystic carcinoma with perineural invasion. The patient is currently undergoing radiotherapy of the tumor bed and skull base due to propensity of perineural invasion of the adenoid cystic component. The most common carcinomas in carcinosarcomas of salivary glands are adenocarcinoma and squamous cell carcinoma. CONCLUSION: Carcinosarcoma is a high-grade aggressive lesion with a poor prognosis and should be treated aggressively. More studies are needed to understand the origin of these tumors.

Osteoradionecrosis versus Cancer Recurrence: An Unresolved Clinical Dilemma.

INTRODUCTION: Osteoradionecrosis is a rare and debilitating risk of definitive chemoradiotherapy for head and neck squamous cell carcinoma. It is difficult to distinguish between osteoradionecrosis and recurrent or progressive disease, as clinical and radiologic features may be similar. Our aim was to compare the clinical presentation and radiologic features of osteonecrosis with those of recurrent or progressive cancer. METHODS: We conducted a single-center case series of 19 patients with head and neck squamous cell carcinoma diagnosed between 2011 and 2019 who subsequently developed clinical and/or radiological suspicion of osteoradionecrosis. The population was a referred sample from head and neck cancer physicians at Northwell Health Cancer Institute. Clinician notes and imaging reports were reviewed to assign a final diagnosis of either cancer, osteonecrosis, or indeterminate. RESULTS: No differences were found in the clinical presentation or radiologic features between groups. Median time between treatment and development of symptoms was longer in patients with a final diagnosis of osteoradionecrosis than recurrent or progressive disease (5 vs. 3 months), but this difference was not statistically significant. Radiation dose and type were not associated with diagnosis. Mean standard uptake value maximums on positron emission tomography/computed tomography were significantly higher in the cancer group (median 14.8 vs. 9.1, p < 0.0152). At 1 year after first suspicion of osteoradionecrosis, 100% of osteoradionecrosis patients were alive, versus 28.6% of cancer patients. DISCUSSION/CONCLUSION: There is significant overlap in clinical and radiologic features of osteoradionecrosis and cancer. Standard uptake maximums may be helpful in predicting diagnosis. Occurrence of symptoms within 6 months of completing chemoradiotherapy should raise the concern for malignancy.

Oropharyngeal tumor cells induce COX-2 expression in peripheral blood monocytes by secretion of IL-1α.

Oropharyngeal squamous cell cancer (OPC) accounts for 3% of all cancers and greater than 1.5% of all cancer deaths in the United States, with marked treatment-associated morbidity in survivors. More than 80% of OPC is caused by HPV16. Tumors induced by HPV have been linked to impaired immune functions, with most studies focused on the local tumor microenvironment. Fewer studies have characterized the effects of these tumors on systemic responses in OPC, especially innate responses that drive subsequent adaptive responses, potentially creating feed-back loops favorable to the tumor. Here we report that elevated plasma levels of PGE2 are expressed in half of patients with OPC secondary to overexpression of COX-2 by peripheral blood monocytes, and this expression is driven by IL-1α secreted by the tumors. Monocytes from patients are much more sensitive to the stimulation than monocytes from controls, suggesting the possibility of enhanced immune-modulating feed-back loops. Furthermore, control monocytes pre-exposed to PGE2 overexpress COX-2 in response to IL-1α, simulating responses made by monocytes from some OPC patients. Disrupting the PGE2/IL-1α feed-back loop can have potential impact on targeted medical therapies.

Immunoglobulin G4-Associated Cholangitis: Two Case Reports and Clinical Use of Classic and Emerging International Diagnostic Criteria.

Immunoglobulin G4-related disease is a multisystem disorder with unique gastrointestinal tract manifestations, often simulating neoplasms and other inflammatory conditions. Appropriate clinical suspicion and application of internationally validated criteria can assist in making the proper diagnosis. This article describes two cases of patients presenting with biliary tract manifestations simulating lymphoproliferative disease and adenocarcinoma, respectively. Clinical, radiological, and histopathological findings ultimately led to the correct diagnosis, and revealed useful nuances for detection of future cases. Application of specific criteria, such as the classic Japan Biliary Association clinical diagnostic criteria published in 2012 and revised in 2020 as well as the 2019 American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) classification criteria, has limitations but provides important warnings to be considered in the diagnostic journey of these challenging cases.

Sentinel Lymph Node Biopsy Versus Elective Node Dissection in Stage cT1-2N0 Oral Cavity Cancer.

OBJECTIVE: To compare overall survival (OS) and disease-free survival (DFS) between sentinel lymph node biopsy (SNB) and elective neck dissection (END) in the surgical management of cT1-2N0 oral cavity squamous cell carcinoma (OCSCC). METHODS: English full-text articles were searched in PubMed and Embase on May 9, 2021. Articles had to compare SNB with END in cT1-T2N0 OCSCC patients; report hazard ratios (HRs), Kaplan-Meier curves, or P-values with total number of events for survival outcomes; be from a clinical trial, cohort, or case-control study. Two reviewers reviewed articles and a third settled disagreements. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Risk of Bias in Non-randomized Studies of Interventions tool and revised Cochrane risk-of-bias tool for randomized trials were used. The generic inverse variance method with a random-effect model was used for meta-analysis. RESULTS: Ten studies, five retrospective, three prospective, and two randomized controlled trials, were included (total number of patients [n] = 10,498, END n = 9102, SNB n = 1396). No significant differences were found in OS (HR = 0.92; 95% confidence interval [CI]: 0.65-1.31) or DFS (HR = 0.70; 95% CI: 0.41-1.20). Heterogeneity was not detected in pooled OS analysis (P = .18; I2  = 30%), but was in pooled DFS analysis (P = .003; I2  = 66%). CONCLUSIONS: No statistically significant differences in OS or DFS were observed between SNB and END in cT1-2N0 OCSCC, suggesting that SNB might be an alternative to END in the management of early-stage, clinically node-negative OCSCC. Laryngoscope, 132:989-998, 2022.

A Mobile Patient-Facing App for Tracking Patient-Reported Outcomes in Head and Neck Cancer Survivors: Single-Arm Feasibility Study.

BACKGROUND: Patients with head and neck cancer (HNC) frequently experience disease-related symptoms and treatment adverse effects that impact their overall quality of life. Cancer-specific mobile health apps for patient-related outcomes allow patients to communicate with their clinicians and proactively track their symptoms, which have been shown to improve clinical management and disease outcomes. OBJECTIVE: The purpose of this study was to evaluate the feasibility of LogPAL, a novel iPhone-based mobile health app designed to help HNC survivors track and manage their posttreatment symptoms. METHODS: Patients who completed curative treatment for HNC in the preceding 24 months were recruited from 2 clinical sites within a single institution. Upon enrollment, participants completed a brief sociodemographic survey, downloaded the app onto their iPhone devices, and were asked to complete a series of biweekly questionnaires (based on the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events) via the app for an 8-week study period. The primary feasibility endpoints included retention (retaining >80% of the enrolled participants for the duration of the study period), adherence (>50% of the participants completing 100% of the questionnaires over the study period), and usability (a mean system usability scale [SUS] score >68). Additional postintervention questions were collected to assess perceived usefulness, acceptance, and overall satisfaction. RESULTS: Between January and October 2019, 38 participants were enrolled in the study. Three participants dropped out, and 3 were classified as nonusers. The remaining 32 (87%) were eligible for analysis. Their mean age was 57.8 (SD 12.3) years (range 24-77 years, 81% [26/32] male). Overall, 375 of 512 (73.2%) questionnaires were completed, with 17 (53%) of the 32 participants adherent. Participant-reported usability was acceptable; the mean SUS score was 71.9 (95% CI 64.3-79.5) with high satisfaction of LogPAL usefulness and likelihood to recommend to other cancer survivors. CONCLUSIONS: This single-arm prospective pilot study showed that LogPAL is a feasible, regularly used, accepted app for HNC survivors, justifying a full-scale pilot. Based on the findings from this study, future iterations will aim to improve usability and test intervention efficacy.

Stereotactic body radiotherapy as primary treatment for elderly and medically inoperable patients with head and neck cancer.

BACKGROUND: Patients with head and neck cancer (HNC) who are not candidates for definitive treatment represent an increasing challenge, with limited data to guide management. Conventional local therapies such as surgery and chemoradiation can significantly impact quality of life (QoL). There has been limited data published using stereotactic body radiotherapy (SBRT) as primary treatment in previously unirradiated patients. We hypothesize that SBRT provides high rates of control while limiting toxicity. METHODS: A total of 66 medically unfit previously unirradiated patients with HNC were treated with SBRT, consisting of 35-40 Gy to gross tumor volume and 30 Gy to clinical target volume in five fractions. RESULTS: Median age was 80 years. Local control (LC) and overall survival (OS) at 1 year were 73% and 64%. Two patients experienced grade 3 toxicity. CONCLUSION: SBRT shows acceptable outcomes with relatively low toxicity in previously unirradiated patients with HNC who are medically unfit for conventional treatment. SBRT may provide an aggressive local therapy with high rates of LC and OS while maintaining QoL.

BRAZILIAN CONSENSUS ON INCIDENTAL GALLBLADDER CARCINOMA.

BACKGROUND: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. AIM: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. METHODS: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. RESULTS: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. CONCLUSIONS: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

Preoperative imaging characteristics predict poor survival and inadequate resection for left-sided pancreatic adenocarcinoma: a multi-institutional analysis.

BACKGROUND: Optimal treatment of pancreatic ductal adenocarcinoma of the neck, body and tail (PDAC-NBT) necessitates R0 surgical resection. Preoperative radiographic identification of patients likely to achieve successful oncologic resection remains difficult. This study seeks to identify preoperative imaging characteristics predictive of non-R0 resections or impaired survival for PDAC-NBT. METHODS: Patients at five high-volume centers who underwent resection for PDAC-NBT were retrospectively analyzed. The most immediate preoperative cross-sectional scan was assessed along with outcome measures of overall survival and margin status. RESULTS: 330 patients were treated between 2001 and 2016. Margin status included 247 R0 (78.2%), 67 R1 (21.2%), and 2 R2 (0.6%). A non-R0 resection predicted worse survival (p = 0.0002). On preoperative imaging, patients with tumors greater than 20 mm, tumor attenuation greater than 70 Hounsfield units, or who demonstrated pancreatic atrophy and/or calcifications also had worse survival (p = 0.010, p = 0.036, p = 0.025 respectively). Patients with tumors interfacing with the splenic artery or vein or extending posteriorly achieved fewer R0 resections (p = 0.0006, p = 0.0004, p = 0.001, respectively). CONCLUSION: Preoperative cross-sectional imaging can identify tumor characteristics associated with poor survival and non-R0 resection. Further investigation is needed to identify the appropriate surgical and treatment modifications necessary to clinically benefit this subset of patients.

Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) has proven advantages over its open counterpart and is becoming more frequently performed around the world. It still remains a difficult operation due to the retroperitoneal location of the pancreas and limited experience and training with the procedure. In addition, complications such as bleeding or postoperative pancreatic fistula (POPF) remain a problem. A standardized approach to LDP with stepwise graded compression technique for pancreatic transection has been utilized at a single center, and we sought to describe the technique and determine the outcomes. METHODS: A review of all patients undergoing LDP by a clockwise approach including the graded compression technique from August 1, 2008 to December 31, 2017 was performed. An external audit was performed by the Dutch Pancreatic Cancer Group. RESULTS: Overall, 260 patients with a mean age and a BMI of 62.3 and 28, respectively, underwent LDP using this technique. Mean operative time and blood loss were 183 min and 248 mL, respectively,. Hand-assisted method and conversion to open were both 5%. Major morbidity and mortality were 9.2% and 0.4%, respectively,. POPF was noted in 8.1%. The technical steps include (1) mobilization of the splenic flexure of the colon and exposure of the pancreas, (2) dissection along the inferior edge of the pancreas and choosing the site for pancreatic division, (3) pancreatic parenchymal division using a progressive stepwise compression technique with staple line reinforcement, (4) ligation of the splenic vein and artery, (5) dissection along the superior edge of the pancreas and residual posterior attachments, and (6) mobilization of the spleen and specimen removal. CONCLUSION: LDP with a clockwise approach for dissection, combined with the progressive stepwise compression technique for pancreatic transection, resulted in excellent outcomes including a very low POPF rate.

Brazilian consensus on incidental gallbladder carcinoma / Consenso brasileiro de carcinoma incidental de vesícula biliar

ABSTRACT Background: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. Aim: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. Methods: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. Results: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. Conclusions: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

RESUMO Racional: Carcinoma incidental da vesícula biliar é definido como uma neoplasia descoberta por exame histológico após colecistectomia videolaparoscópica. É potencialmente uma doença curável. Entretanto algumas questões relacionadas ao seu manuseio permanecem controversas e uma estratégia definida está associada com melhor prognóstico. Objetivo: Desenvolver o primeiro consenso baseado em evidências para o manuseio de pacientes com carcinoma incidental da vesícula biliar no Brasil. Métodos: Dezesseis questões foram selecionadas e para responder as questões e 36 membros das sociedades brasileiras e internacionais foram incluídos. As recomendações foram baseadas em evidências da literatura atual. Um relatório final foi enviado para os membros do painel para avaliação de concordância. Resultados: Avaliação intraoperatória da peça cirúrgica, uso de bolsas para retirar a peça cirúrgica e exame histopatológico de rotina, foram recomendados. Avaliação pré-operatória completa é necessária e deve ser realizada assim que o estadiamento final esteja disponível. Avaliação da margem do ducto cístico e biópsia de rotina do linfonodo 16b1 são recomendadas. Quimioterapia deve ser considerada e quimioradioterapia indicada se a margem cirúrgica microscópica seja positiva. Os portais devem ser ressecados excepcionalmente. O estadiamento laparoscópico antes da operação é recomendado, mas o tratamento radical por abordagem minimamente invasiva deve ser realizado apenas em centros especializados em cirurgia hepatopancreatobiliar minimamente invasiva. A extensão da ressecção hepática é aceitável até que seja alcançada a ressecção R0. A linfadenectomia padrão é indicada para tumores iguais ou superiores a T2, mas a ressecção da via biliar não é recomendada de rotina. Conclusões: Recomendações seguras foram preparadas para carcinoma incidental da vesícula biliar, destacando os mais frequentes tópicos do trabalho diário do cirurgião do aparelho digestivo e hepatopancreatobiliar.

Laparoscopic Duodenojejunostomy for the SMA Syndrome.

OBJECTIVE: The Superior Mesenteric Artery Syndrome (SMAS) was first described by Rokitansky in 1842. Clinical symptoms include postprandial pain, nausea, vomiting and weight loss. Duodenojejunostomy is the treatment of choice for patients with SMAS. We now present a case of a young female with SMAS who successfully underwent laparoscopic duodenojejunostomy. INDICATIONS: The first line treatment for SMAS is medical management, which includes infusion therapy, bowel rest, parenteral nutrition and a nasojejunal feeding tube inserted into the jejunum past the obstruction. If medical therapy fails, surgery is recommended. PROCEDURE: A symptomatic patient with body mass index (BMI) of 19.4 kg/m2 underwent laparoscopic duodenojejunostomy. The patient tolerated the procedure well. The post-operative period was uneventful and the patient was discharged after three days. On six month follow up, the patient had gained weight and her symptoms were completely resolved. CONCLUSION: SMAS is still a poorly recognised pathology. A high index of suspicion should be given for patients with unclear causes of postprandial nausea, vomiting and abdominal pain, especially in young females. A laparoscopic approach seems to be safe and effective for patients with SMAS.

Retraction notice to: Sensitization of squamous cell carcinoma to cisplatin induced killing by natural agents.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor in Chief. An investigation by Wayne State University identified a discrepancy between the data reported in Figures 5 and the original collected data. The investigation committee concluded that this undermined the scientific basis of the publication, that no credible replacement data were available, and advised that the publication should be retracted.

Pretreatment computed tomographic gross tumor volume as predictor of persistence of tracheostomy and percutaneous endoscopic gastrostomy tube in patients undergoing larynx preservation.

BACKGROUND: Although larynx preservation affords patients improvements in laryngectomy-free survival, little has been reported regarding the functional outcomes after larynx preservation. The purpose of this study was to report the predictive value of pretreatment CT-gross tumor volume (GTV) for persistence of tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube in larynx preservation patients. METHODS: Each patient had a CT scan before initiation of therapy and the GTV was contoured. RESULTS: Using recursive partitioning analysis (RPA), threshold GTVs of 27.16 cc and 12 cc were identified for association of time with tracheostomy and PEG tube, respectively. Median (95% confidence interval [CI]) times above and below these thresholds were 1.84 (1.06-not reached [NR]) and 0.75 (0.63-1.26) years, respectively (p = .03) for time with tracheostomy and 1.75 (1.34-NR) and 0.84 (0.46-NR) years, respectively (p = 0.10) for time with PEG tube. CONCLUSION: This study demonstrates that pretreatment CT-GTV is predictive of an approximately 2.5-fold and approximately 2-fold, respectively, increase in time with tracheostomy and PEG tube. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1458, 2016.

Jornada Participativa do SUS / Participative Journey of the Unified Health System (SUS)

A Jornada Participativa do SUS de Santo André é um projeto intersetorial, criado em 2015, que reuniu diversas iniciativas para aprimorar o planejamento e desempenho das eleições dos 56 Conselhos Locais de Saúde (CLS). Esse projeto realizou uma avaliação minuciosa das eleições de 2013, identificando as dificuldades e falhas do seu percurso. Esse processo de análise envolveu uma avaliação da conjuntura política do país, que tem gerado um progressivo desinteresse e descrédito da população nas instituições e nos partidos políticos, o que contribuiu para o esvaziamento dos Conselhos Locais. A Gestão Participativa em Santo André é um método de governo que requer constante avaliação e ousadia para escutar e dialogar com os diversos setores no acompanhamento e transparência da gestão.

Stability of midface fracture repair using absorbable plate and screw system pilot holes drilled and pin placement at angles other than 90°.

IMPORTANCE: Conventional plating systems use titanium plates for fixation of fractures, with benefits of strength and biocompatibility. However, titanium plates require that screws be placed at a 90° angle to the pilot holes. In the midface, this becomes extremely difficult. Today, a variety of craniomaxillofacial osteosynthesis systems are available, including resorbable plating systems. Specifically, the KLS Martin Sonic Weld system ultrasonically fuses the plate and the head of the pin when placed and will fill the pilot hole grooves completely even at less than 90° angles, which provides a tremendous advantage in midface fracture repair. OBJECTIVE: To determine if the KLS Martin Sonic Weld system provides plate-screw construct stability in human heads even when placed at acute angles at the midface buttresses. DESIGN, SETTING, AND SPECIMENS: Twenty cadaveric head specimens with the mandible removed were prepared by creating osteotomies in the midface buttresses bilaterally. Specimens were defleshed and placed in a 2-part testing rig to hold and position the head for testing in a standard material testing system. Testing was performed at the Wayne State University Bioengineering test laboratories, Detroit, Michigan, using an Instron device and high-speed camera. Specimens were plated on one side of the midface using the KLS Martin Sonic Weld system with pilot holes and pins placed at 90° angles. On the contralateral side, the buttresses were plated with the KLS Martin Sonic Weld system at 60°, 45°, and 30° angles. Data were collected using the TDAS data acquisition system and were compared with matched pairs within each specimen. MAIN OUTCOMES AND MEASURES: Ultrasonically vibrated pins placed into absorbable mini-plates at less than 90° angles with the KLS Martin Sonic Weld system were compared with the same amount of stress as the system placed at a 90° angle before demonstrating plate-screw construct failure. RESULTS Fifty-seven paired tests were collected, with 114 total tests. Twenty failures were due to bone breakage, and 94 fixations failed as a result of the plate-screw construct breaking. Fractures fixated with the ultrasonic absorbable plating system placed with screws at all tested angles failed at similar loads to our control plates with pins placed at 90° angles. These results lend the surgeon to successfully reduce fractures in the midface fragments in difficult-to-reach areas and possibly cut down on operative time while improving the chance of achieving a long-lasting adequate reduction. CONCLUSIONS AND RELEVANCE: Although there is a measured difference in the laboratory, no clinical difference is observed because the maximum force is not usually encountered. Overall, the clinical scenario indicates absorbable plates to be a viable option in less accessible areas. LEVEL OF EVIDENCE: NA.

Pilar sobre implante em zircônia: relato de caso clínico / Zirconia implant abutment: a case report

A Odontologia Estética trouxe para a realidade do consultório odontológico atual a mimetização das nuances de cor, texturas e características ópticas para reabilitações realizadas em porcelana. Para que este fato ocorra, é necessário que uma boa parte das características estruturais de um dente natural seja reproduzida. O esmalte dental é reproduzido com sucesso satisfatório através da utilização de técnicas inovadoras e porcelanas de qualidade avançada. A dentina também deve ser reproduzida, e para que isso seja possível em reabilitações sobre implantes surgiu a possibilidade de serem confeccionados pilares em porcelana pura do tipo zircônia. São pilares instituídos com a proposta de oferecer resistência mecânica satisfatória à sustentação de coroas sobre implantes, além da condição estética. Desta forma, descreveu-se o caso clínico que visou a utilização de um implante imediato ativado imediatamente com a utilização de um provisório sobre o implante posicionado na região do dente 22 de uma paciente de 33 anos. Como o objetivo principal do caso foi atingir excelência em estética, optou-se pela utilização de um pilar de zircônia (CONEXÃO@) sobre o implante colocado. Verificou-se, além de benefícios estéticos, saúde gengival na área implantada, pois a zircônia possui biocompatibilidade e filia aos tecidos vivos quando comparada a pilares sobre implantes confeccionados em metal. O caso clínico vem sendo acompanhado com proservação de 7 anos. Conclui-se que a opção da utilização dos novos pilares em zircônia traz para os casos de reabilitação sobre implantes uma resolução mais interessante para os anseios estéticos e funcionais dos pacientes da atualidade.

Esthetic Dentistry has brought the reality of current dental mimicking the nuances of color,texture and optical properties for renovations carried out in porcelain. So that this does occur, it is necessary for a good part of the structural characteristics of a natural tooth to be played. The enamel is successfully reproduced satisfactorily by the use of innovative techniques and advanced quality porcelain. Dentin also be reproduced, and for this to be possible in rehabilitation on implants arose the possibility of pillars made of porcelain-type pure zirconia. Pillars are set up with the proposal to provide satisfactory mechanical strength to the support of crowns on implants in addition to the aesthetic condition. Thus, described the case history which endorsed the use of an implant immediately activated immediately by using a duty on the implant positioned in the region of tooth 22, a patient of 33 years. As the main objective of the case was achieved excellence in aesthetics, it was decided to use a pillar of zirconia (CONEXÃO SISTEMA DE PRÓTESE@) on the implant placed. It was found, and aesthetic benefits, gingival health in the area because the implanted zirconia has biocompatibility and affiliated to the living tissue quite satisfactory when compared to pillars on implants ma de of metal, and it was proved with preservation of 7 years. We conclude that the option of using new pillars in zirconia brings to the cases of rehabilitation on implants a resolution much more interesting for the aesthetic and functional desires of patients.

Próteses parciais removíveis como solução de caso com perda de dimensão vertical de oclusão: relato de caso clínico / Removable partial dentures as a solution for a case with loss of occlusal vertical dimension: case report

A perda dos dentes pode acarretar inúmeros problemas ao indivíduo, influenciando em suas condições gerais e sistêmicas. Acompanhada da perda dos dentes, muitas vezes ocorre a diminuição da dimensão vertical de oclusão, e, em casos extremos, o colapso oclusal. Um novo plano oclusal e o restabelecimento de uma dimensão vertical mais próxima do ideal podem ser realizados através do uso de próteses parciais removíveis corretamente indicadas e bem planejadas. Assim, com um trata- mento bastante convencional e conservador, tido por muitos profissionais como uma possibilidade obsoleta, pode-se chegar a um resultado funcionalmente e esteticamente satisfatório. No presente caso clínico, em que o paciente apresentava prótese parcial fixa provisória anterior insatisfatória e diminuição da dimensão vertical de oclusão devido a desgaste pela oclusão apenas na bateria ante- rior, com extrusão de dentes superiores e forte resistência a procedimentos cirúrgicos, foi realizada a confecção de próteses parciais removíveis superior e inferior, de forma a resgatar a dimensão vertical ideal do paciente, em sua relação cêntrica, e estabelecendo um plano oclusal mais favorável. Aliado a instalação das próteses, realizou-se restaurações nos dentes anteriores inferiores a fim de pro- porcionar overbite, overjet e guia de desoclusão corretos. Conclui-se que casos menos extensos em que é possível a restauração dos dentes anteriores de forma direta, e restabelecimento da dimensão vertical de oclusão com os dentes artificiais posteriores como suporte, utilizando-se das técnicas corretamente, as PPRs se configuram como ótima opção de tratamento.

The loss of teeth can cause many problems for the individual, acting on their general and systemíc conditions. Accompanied by loss of teeth often occurs a decrease in occlusal vertical dimension and, in extreme cases, occlusal collapse. A new occlusal plane and the restoration of a vertical dimension closest to the ideal can be achieved through the use of removable partial dentures properly displayed and well planned. So with a conventional and conservative treatment, regarded by many professionals as an obsolete possibility, vou can get a result functionally and es- thetically satisfactory.ln this case study, in which the patient had anterior unsatisfactory provisory fixed partial denture and decreased occlusal vertical dimension due to the occlusion only wear on the front battery, with extrusion of upper teeth and strong resistance to surgical procedures, upper and lower removable partial dentures were made, in order to rescue the ideal vertical dimension of the patient, in his centric relation, establishing a more favorable occlusal plane. Allied prosthesis installation, lower incisives were reconstructed with direct resin restorations in order to be pos- sible to get correct overjet, overbite and anterior guide desocclusion. It is concluded that in less extensive cases where it is possible the restoration of anterior teeth in a direct way, and restoration of vertical dimension of occlusion with posterior artificial teeth for support, using the techniques correctly, the PPRs are configured as a great option of treatment.