Graeme Warrack: oral surgeon and war hero.

This paper describes the heroic efforts of Graeme Warrack, an oral surgeon, to save as many lives as possible during the battles around Arnhem in 1944. As the chief medical officer (CMO) of the medical section of the 1st British Airborne Division, he and his staff took care of many casualties, both on the battlefield and at the emergency hospital in Apeldoorn, north of Arnhem. He escaped from the hospital when all the patients were to be transported to prisoner of war (POW) camps in Germany, and was hidden by a Dutch family. Finally, with the help of the Dutch resistance movement, he was successfully ferried over the big rivers into liberated country.

Onlay bone grafts from iliac crest: a retrospective analysis.

This study was performed to address the outcomes of patients treated with onlay grafts from the iliac crest to augment the deficient jaw. The results of 173 consecutive patients who underwent bone grafting prior to implant surgery are presented. The grafts were taken from the anterior iliac crest to repair alveolar bone deficiencies that were too large to be corrected using intraoral bone grafts. Three months postoperatively, 869 implants were placed into 190 onlay grafts (167 grafts in the maxilla, 23 in the mandible). The follow-up ranged from 3 months to 23 years post implantation. All patients received a fixed prosthesis. Parameters examined included healing of the donor site and bone grafts, implant survival, peri-implant condition, and donor site morbidity. The overall survival rate for all implants was calculated to be 95%±2.7% according to Kaplan-Meier analysis. The implant survival rate compares favourably with those reported in studies using intraoral and extraoral bone.

Ten years of experience with the anterior maxillary and mandibular osteoplasty (class IV ridges): a retrospective analysis of implant survival rates.

The anterior maxillary osteoplasty restores adequate bone to the edentulous Class IV ridge prior to placement of endosseous implants. The aim of this retrospective study was to compare the long-term survival of implants placed into the particulate bone of an anterior alveolar osteoplasty to those placed into a 'block' onlay bone graft. Of 85 patients with Class IV 'knife-edge' alveolar ridges, 50 received interpositional particulate bone via an alveolar osteoplasty and 35 received an onlay cortico-cancellous graft. A total of 386 implants were placed as a secondary procedure and followed postoperatively (mean 6 years; 39 failures). There was improved cumulative survival of implants placed into the particulate bone of an osteoplasty compared to the block bone of an onlay graft. Implants supporting a fixed superstructure had a longer cumulative survival than those supporting a removable appliance. There was no statistical difference between implants placed into male and female bone, or between those in edentulous and partially dentate jaws. Within a partially dentate jaw there was a statistically significant increase in cumulative survival for implants within osteoplasty inlay bone compared to onlay bone grafts. Anterior osteoplasty is the surgical treatment of choice for augmentation of the resorbed Class IV alveolar ridge prior to placement of osseo-integrated implants.

What is the quality of the evidence base for pre-implant surgery of the atrophic jaw?

This review aimed to evaluate the level of evidence for bone augmentation preimplant surgery for atrophic jaws in studies which measure outcome. Medline, Embase, Cochrane library and online journal searches were performed with a defined search strategy and the abstracts screened against selection criteria. The resultant papers were sorted by study design using the Cochrane study design algorithm, analysed for clinical/statistical homogeneity and graded with the Oxford Centre of Evidence-based Medicine levels of evidence. The initial online Medline search yielded 1194 results and the Embase search yielded 490 results. Using the selection criteria, 10 studies were identified. Additionally, 5 articles were identified from bibliography and online searches, giving a total of 15 studies for grading. All 15 studies were graded as level 4 evidence. No meta-analysis of outcomes was possible with the low level of evidence and degree of heterogeneity found. The best grade of recommendation that can be made for a particular preimplant surgical bone augmentation procedure, from these level 4 studies, is Grade C. Benchmarking studies by assessing quality of evidence can be helpful to inform future study designs with respect to reporting study outcomes with a higher level of evidence.

The further development and validation of the Liverpool Oral Rehabilitation Questionnaire: a cross-sectional survey of patients attending for oral rehabilitation and general dental practice.

BACKGROUND: Since the first version of the Liverpool Oral Rehabilitation Questionnaire (LORQ) was first published in 2004, the questionnaire has been modified to include more detail on chewing and appearance, and also details of denture, dental and implant status. AIM: The aim of this study is to report the ongoing development and validation of the LORQ version3. METHODS: A postal survey of the LORQv3 and OHIP-14 questionnaires was performed in April 2004 of 164 patients who had attended the oral rehabilitation clinic from February 2000. In addition The LORQv3 was administered to 349 patients attending six General Dental Practices, based in Liverpool, attending for routine care. RESULTS: Patients attending GDP scored appreciably better on most items in the LORQv3. The questionnaire discriminated between cancer and non-cancer oral rehabilitation patients in items such as swallowing, chewing, trismus, drooling and food clearance. There was no significant difference between rehabilitation groups for any of the seven OHIP-14 domains. The LORQv3 demonstrated good criterion validity when compared to the OHIP-14 with social items in the LORQv3 correlating well with items of the OHIP-14. Conversely various LORQv3 items did not have strong correlates within the OHIP-14 thus endorsing the additional items in the LORQv3.

Trends in head and neck microvascular reconstructive surgery in Liverpool (1992-2001).

Microvascular reconstructive techniques in head and neck surgery are well established, but we are now entering an era of modification exemplified by perforator and free style free flaps. We present a review of the database introduced into the unit in 1992 over a 10-year period, during which time 977 patients with malignant disease were operated on and 620 defects were reconstructed with free flaps. There were 358 radial forearm flaps, 78 composite radial forearm flaps, 84 iliac crest flaps, 43 fibular flaps, 24 from the scapula, 26 from the latissimus dorsi, 4 from the rectus abdominis, and 3 from the lateral arm. The main changes over this time have been the use of more bulky flaps for larger resections of the tongue and the preference for iliac crest flaps over those from the fibula and forearm for composite reconstructions. Improving reliability of tissue transfer remains an important aim, and further development of reliable objective methods of monitoring of flaps is required.

Survey of oral rehabilitation in a consecutive series of 130 patients treated by primary resection for oral and oropharyngeal squamous cell carcinoma.

The purpose of this study was to investigate the use of oral rehabilitation in a group of patients who had primary resection of oral and oropharyngeal squamous cell carcinoma. Of 132 consecutive patients operated on for previously untreated disease between January 1995 and June 1997, 130 were recruited. The University of Washington Quality of Life questionnaire was completed on the day before operation at 6 and 12 months, and at last review. A larger similar dataset was used to predict survival. Twenty-eight patients (22%) were seen by the oral rehabilitation team. The median (IQR) time from operation to start of treatment was 12 months (6-21). The median (IQR) time from beginning to end of rehabilitation was 14 months (5-49). Patients with larger tumours (P=0.06) and patients who were edentulous with dentures in the maxilla (P=0.07) were most likely to be seen for oral rehabilitation.

Salivary gland scintigraphy--a suitable substitute for sialography?

By comparing 27 patients who had both scintigraphy and sialography in the assessment of salivary gland disease, scintigraphy has been shown to correlate well with abnormal sialograms. It is suggested that scintigraphy could become the initial screening procedure in the assessment of salivary gland disease. A normal scintiscan is unlikely to miss significant pathology (as demonstrated by sialography), but sialography must always be performed if there is a suspicion of duct obstruction on scintigraphy. Patients suspected of focal salivary gland pathology such as tumour have not been investigated. The series documents the findings in patients who presented with facial pain, swelling or xerostomia suggesting sialadenitis, duct occlusion or Sjögren's syndrome.

Monitoring of Tübingen endosseous dental implants by glycosaminoglycans analysis of gingival crevicular fluid.

Glycosaminoglycans (GAG) in gingival crevicular fluid (GCF) samples were determined by cellulose acetate electrophoresis and densitometric scanning. Two GAG bands, hyaluronic acid and chondroitin-4-sulphate (C4S), were detected in GCF from implants, similar to the profile from teeth. High GCF volumes and GAG contents, notably C4S, may reflect postoperative alveolar bone responses, particularly resorption, at different stages of healing and function of successful implants. They may also indicate adverse tissue changes in failing implants. A comparison of crowned implants and matched teeth suggests that the periodontal ligament contributes to the GCF GAG profile. This may be a useful laboratory method of monitoring implants to detect adverse tissue responses at an early stage.

Oral rehabilitation with implant-retained prostheses following ablative surgery and reconstruction with free flaps.

Ablative surgery of the oral tissues may result in significant facial deformity, poor oral function, and psychologic detriment. Immediate surgical reconstruction with vascularized free flaps has become increasingly popular, but the oral rehabilitation of these patients with conventional dental prostheses is usually unsuccessful. The results and clinical experiences of treating a group of 17 patients with ablative surgery, immediate reconstruction with free flaps, and restoration with mandibular implant-retained prostheses are presented after follow-up periods of 6 months to 7 years. Most patients expressed a high degree of satisfaction with their prostheses. General principles and guidelines for the provision of this effective treatment modality are discussed.

The functional case for miniplates in maxillofacial surgery.

A review is presented of the application of miniplates in maxillofacial surgery, with an emphasis on maxillofacial trauma. The advantages are highlighted, particularly in relation to functional considerations, including jaw function, weight loss, and pulmonary function. Miniplates are considered to be the best treatment for patients with maxillofacial fractures.

Reconstructive preprosthetic surgery. I. Anatomical considerations.

When considering preprosthetic surgery of the edentulous jaws, it is important that the clinician fully understands the anatomical consequences of reduction of the residual ridges. Based on a classification of the edentulous jaws, changes in the relationship of the jaws to each other, in muscle relations and function, in the oral mucosa and in facial morphology have been measured relative to the stage of resorption of the edentulous jaws.

Oral rehabilitation with endosteal implants and free flaps.

Current management of oral cancer following tumour resection includes reconstruction of the surgical defect with free vascularized flaps and rehabilitation of orofacial form and function with the aid of endosteal implants. The choice of flap for reconstruction influences the use of implants, and further hard- and soft-tissue surgery is frequently required to enhance the success of oral rehabilitation.

Anterior maxillary osteoplasty to broaden the narrow maxillary ridge.

The application of endosseous implants has extended the range of options and effectiveness of reconstructive preprosthetic surgery. Placement of endosseous implants in the edentulous maxilla is often restricted due to lack of available bone. Exposure of the underlying anterior maxillary bone frequently reveals a ridge form which is adequate in height but too narrow to accommodate endosseous implants. A horseshoe type osteotomy extending from the ridge crest into the floor of nose has been developed which allows advancement of the outer cortex to restore lost facial form and placement of an interpositional bone graft and endosseous implants to restore lost function.

A classification of the edentulous jaws.

A classification of the edentulous jaws has been developed based on a randomised cross-sectional study from a sample of 300 dried skulls. It was noted that whilst the shape of the basalar process of the mandible and maxilla remains relatively stable, changes in shape of the alveolar process is highly significant in both the vertical and horizontal axes. In general, the changes of shape of the alveolar process follows a predictable pattern. Such a classification serves to simplify description of the residual ridge and thereby assist communication between clinicians; aid selection of the appropriate surgical prosthodontic technique; offer an objective baseline from which to evaluate and compare different treatment methods; and help in deciding on interceptive techniques to preserve the alveolar process. An awareness of the pattern of resorption that takes place in various parts of the edentulous jaws, enables clinicians to anticipate and avert future problems.

Effect of intermaxillary fixation on pulmonary function.

A study to measure the pulmonary effects of intermaxillary fixation (IMF) demonstrated that this technique produces a significant degree of airway obstruction. This may be dangerous to patients with limited respiratory reserve due to chronic obstructive airways disease. The impairment of pulmonary function can be assessed pre-operatively and should be estimated in high risk patients. Alternative management of stabilization of jaw fractures that avoid IMF should be considered in such patients.

Reconstruction of the severely resorbed (Class VI) maxilla. A two-step procedure.

The medium-term results of 12 patients that underwent reconstruction of the severely resorbed maxilla are reported. The method described entails a two-step procedure including Le Fort I osteotomy and grafting of the floor of the sinus and nose with particulate bone and hydroxyapatite (HA). The implants were placed in a second procedure. A 5% failure rate was noted in those patients that were grafted with particulate bone mixed with HA.

Endosseous implants in the irradiated composite radial forearm free flap.

This paper describes the application of endosseous titanium implants that have been inserted into the vascularized bone of the radial forearm composite flap, used for mandibular reconstruction. The technique described allows full orofacial rehabilitation to be achieved, following ablative surgery and adjuvant radiotherapy.

Changes in facial form relative to progressive atrophy of the edentulous jaws.

The surgical and prosthodontic rehabilitation of the edentulous patient aims to restore oral function and facial form. Planning treatment requires an understanding of the effect of progressive jaw atrophy, and the concomitant effect on the soft tissues of the face. This study examined 179 Caucasians at different stages of jaw atrophy according to the Cawood and Howell classification; various standard anthropological measurements of the face, according to Farkas, were also taken. We have demonstrated that changes in the soft tissues are related to the degree of underlying jaw atrophy. This has important implications when planning surgical and prosthodontic rehabilitation of the edentulous patient. Early stages of jaw atrophy (Class II, III & IV) result in the collapse of the circumoral musculature causing a narrowing of the mouth, loss of lip support, inversion of the lips and contraction of the cheeks. Late changes of jaw atrophy (Class V & VI) result in changes in vertical facial proportion causing a decrease in lower facial height and an increase in chin prominence. These late skeletal changes accentuate the earlier soft tissue facial effects.

Mandibular reconstruction and rehabilitation in childhood.

The management of a case of osteosarcoma of the mandible in an 7-year-old girl is presented. A variety of reconstructive techniques were used following surgical ablation of the tumour, including the use of a revascularised free bone flap and osseointegrated endosseous implants.