Kevin Arce

Evaluation of Clinical Outcomes of Osseointegrated Dental Implantation of Fibula Free Flaps for Mandibular Reconstruction

IMPORTANCE Dental implantation has been used for oral rehabilitation to improve cosmesis and function. OBJECTIVE We aim to evaluate the clinical outcomes and success rates of primary and secondary dental implant placement in vascularized fibula bone grafts used for segmental mandibulectomy defects. DESIGN, SETTING, AND PARTICIPANTS A retrospective review was performed between November 2005 and July 2014 on all patients undergoing both fibula free tissue reconstruction of mandibular defects and endosseous dental implantation at an academic tertiary care referral hospital. INTERVENTIONS Either primary (n = 20) or secondary (n = 26) dental implantation of the fibula was performed. MAIN OUTCOMES AND MEASURES Timing of implantation, location of implants, history of tobacco, alcohol, and radiation, reason for mandibulectomy, and outcomes related to these parameters. RESULTS Forty-six patients (31 males, 15 females; mean age, 58.0 years) underwent dental implantation to the fibula graft. A total of 227 implants were placed, with a mean of 5 implants per patient (range, 2-7). Of these, 44 were placed into native mandible and 183 into fibula flap. Twenty patients underwent primary implantation and received 96 implants, while 26 patients underwent secondary implantation and received 131 implants. There were no flap failures and 22 implant-related complications in 16 patients (implant failure, n = 10; granulation or soft-tissue overgrowth, n = 6; exposed bone around implant, n = 6). An implant failure occurred in 10 patients (22%) resulting in removal of 15 implants. Nine of these patients underwent successful dental rehabilitation, 5 without further implantation, and 4 with replaced implants. One patient was not rehabilitated secondary to failed implantation. Therefore, there was a 93% overall implant survival rate (n = 212) and 98% overall implant-supported prosthesis success rate (n = 45) at a mean follow-up of 22 months. There was no difference in implant survival between primary (94%) (n = 90) and secondary (93%) (n = 122) implantation. Neither a history of preimplant or postimplant radiation exposure nor the diagnosis of osteoradionecrosis affected implant survival. CONCLUSIONS AND RELEVANCE Osseointegrated dental implantation is a relatively safe procedure with few complications. Vascularized fibula grafts are a suitable method of mandibular reconstruction and are amenable to successful primary and secondary endosseous implantation. LEVEL OF EVIDENCE 4.

Dental Extraction in the Thrombocytopenic Patient Is Safe and Complications Are Easily Managed

PURPOSE To characterize bleeding risk and management of bleeding in thrombocytopenic patients undergoing dental extraction. MATERIALS AND METHODS This retrospective cohort study included 68 patients with hematologic disease and concomitant thrombocytopenia undergoing dental extractions. The inclusion criterion was a platelet count of 100,000/μL or less at the time of consultation or extraction. Patients using anticoagulation therapy were excluded from the study. Predictors measured were age, gender, platelet count, platelet transfusion before or during surgery, local hemostatic measurements at the time of surgery (absorbable hemostat or antifibrinolytic rinse), number of teeth extracted, diagnosis, and extraction type. The primary outcome was postoperative bleeding requiring intervention. A secondary outcome was surgical site infection. Descriptive and bivariate statistics were computed and the P value was set at .05. No logistic regression was used based on the distribution of outcomes. RESULTS Sixty-eight patients underwent extraction of 200 teeth. Five (7.4%) had postoperative bleeding that was always controlled with routine intervention. Mean platelet count was 44,647/μL. Bleeding was more frequent with lower platelet levels (P = .048). Thirty-two patients received platelet transfusion and 26 received local measures. Platelet transfusion and local hemostatic measures had no effect on bleeding outcomes. CONCLUSION Surgical and routine extractions are safe procedures in patients with thrombocytopenia, and postoperative bleeding is typically well handled with simple local measures. The benefits of pre- or intraoperative platelet transfusion are unclear in this population. Likewise, the benefit of prophylactic local hemostatic measures is unclear and should be based on the surgeons discretion and experience.

Mandibular alveolar reconstruction using three-dimensional planning.

Purpose of reviewResection of malignant disease often results in full-thickness segmental defects of the mandible and loss of dentition. Ideal rehabilitation of the patient requires replacement of the missing segment with vascularized bone that will receive dental implants, and allow osseointegrated prosthetic rehabilitation and restoration of dentition and proper occlusion. Inexact contouring of the bony reconstruction can result in both cosmetic and functional defects that can diminish the future quality of life of the patient. This review summarizes recent advances in preoperative planning and intraoperative techniques that can maximize the success of proper alveolar reconstruction and dental restoration of the patient suffering a segmental maxillary or mandibular defect. Recent findingsPreoperative modeling can be achieved with computer software that utilizes patient imaging. From this imaging, anticipated surgical defects can be planned, models can be generated, and intraoperative templates can be produced. These can be used to improve reconstructive plate bending, relative positioning of bone to opposing jaw, contouring of the reconstructive bone, and even placement of osseointegrated implants in a single operative setting. SummaryIn patients with complex mandibular defects, the use of computer-assisted three-dimensional planning and modeling can result in time-saving and improved outcomes during maxillary and mandibular reconstruction.

Impact of Intraoperative Fluid Administration on Length of Postoperative Hospital Stay Following Orthognathic Surgery

PURPOSE The purpose of this study was to evaluate whether the volume of intraoperative fluids administered to patients during routine orthognathic surgery is associated with increased length of hospital stay for postoperative convalescence. MATERIALS AND METHODS A retrospective cohort study design was used to identify 168 patients undergoing routine orthognathic surgery at Mayo Clinic from 2010 through 2014. The primary predictor variable was total volume of intravenous fluids administered during orthognathic surgery. The primary outcome variable was the length of hospital stay in hours as measured from the completion of the procedure to patient dismissal from the hospital. Additional covariates were collected including patient demographic data, preoperative American Society of Anesthesiologists (ASA) score, type of intravenous fluid administered, complexity of surgical procedure, and duration of anesthesia. RESULTS On univariate analysis, total fluid was significantly associated with increased length of stay (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.42 to 2.33; P < .001). After adjustment for surgical complexity and duration of anesthesia on multivariable regression analysis, the association of fluid level with length of hospital stay was no longer statistically significant (OR, 0.86; 95% CI, 0.61 to 1.22; P = .39). Duration of anesthesia remained the only covariate that was significantly associated with increased length of hospital stay in the multivariable regression model (OR, 2.21; 95% CI, 1.56 to 3.13; P < .001). CONCLUSIONS Among surgical complexity, duration of anesthesia, and total volume of intraoperative intravenous fluids administered for routine orthognathic surgery, the duration of anesthesia has the strongest predictive value for patients requiring prolonged hospital stay for postoperative convalescence.

Development of stable peri-implant soft tissue and mentolabial sulcus depth with an implant-retained soft tissue conformer after osteocutaneous flap reconstruction.

Excessive soft tissue bulk, movement, chronic inflammation, and hypertrophy in periimplant areas pose challenges for long-term management of peri-implant soft tissues surrounding osteocutaneous flap reconstructions. A case history report is presented on the predictable establishment of stable peri-implant soft tissue and improved mentolabial sulcus depth in a patient treated for high-grade osteosarcoma of the mandible. Following surgical resection, reconstruction with osteocutaneous fibula free flap, and endosseous implant placement, a combined surgical and prosthetic approach was used through a lip switch vestibuloplasty and an implant-retained soft tissue conformer.

Whole-Arch Single-Stage Free Flap Reconstruction and Rehabilitation of the Mandible: A Case Report and Technical Considerations on a New Technique.

The purpose of this report is to describe the techniques used in the reconstruction of a complete angle-to-angle mandibular defect in the absence of any remaining mandibular teeth. Because no remaining dental or occlusal landmarks remain in such a case, additional challenges must be considered.

Pediatric Odontogenic Cysts of the Jaws

Odontogenic cysts represent a common form of pathology of the jaws, and the natural history, clinicopathologic findings, and appropriate management strategies are important to the oral and maxillofacial surgeon. Odontogenic cysts in the pediatric populations are important pathologic entities given their potential impact on the growth and development of the maxillofacial complex. Inappropriate management strategies can severely affect the form and function of the growing child. Categorizing pediatric odontogenic cysts into inflammatory or developmental causes provides a convenient way of conceptualizing these various entities and helps facilitate the appropriate diagnosis and the subsequent management.

Impact of Perioperative Fluid Administration on Postoperative Morbidity and Length of Hospital Stay Following Maxillomandibular Advancement for Obstructive Sleep Apnea

PURPOSE The purpose of this study was to evaluate whether the volume of perioperative fluids administered to patients undergoing maxillomandibular advancement (MMA) for treatment of obstructive sleep apnea (OSA) is associated with an increased incidence of postoperative complications and prolonged length of hospital stay. MATERIALS AND METHODS A retrospective cohort study design was implemented and patients undergoing MMA for OSA at the Mayo Clinic were identified from 2001 through 2014. The primary predictor variable was the total volume of intravenous fluids administered during MMA. The primary outcome variable was length of hospital stay in hours. Secondary outcome variables included the presence of complications incurred during postoperative hospitalization. Additional covariates abstracted included basic demographic data, preoperative body mass index, preoperative apnea-hypopnea index, preoperative Charlson comorbidity index, preoperative American Society of Anesthesiologists score, type of intravenous fluid administered, surgical complexity score, duration of anesthesia, duration of surgery, and the use of planned intensive care unit admission. Univariate and multivariable models were developed to assess associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables. RESULTS Eighty-eight patients undergoing MMA for OSA were identified. Total fluid volume was significantly associated with increased length of stay (odds ratio [OR] = 1.34, 95% confidence interval [CI], 1.05-1.71; P = .020) in univariate analysis. Total fluid volume did not remain significantly associated with increased length of hospital stay in stepwise multivariable modeling. Total fluid volume was significantly associated with the presence of postoperative complications (OR = 1.69; 95% CI, 1.08-2.63; P = .021) in univariate logistic regression. CONCLUSION Fluid administration was not found to be significantly associated with increased length of hospital stay after MMA for OSA. Increased fluid administration might be associated with the presence of postoperative complications after MMA; however, future large multicenter studies will be required to more comprehensively assess this association.

Dental extraction in the neutropenic patient.

PURPOSE To identify risks of dental extraction in patients with mild, moderate, and severe neutropenia. MATERIALS AND METHODS The authors undertook an observational study of 116 patients diagnosed with neutropenia and undergoing dental extractions in the Mayo Clinic Division of Oral and Maxillofacial Surgery. Absolute neutrophil count (ANC) was no higher than 1,500/μL. Predictors were ANC, age, diagnosis, number of teeth removed, type and location of extraction, length of antibiotic use, presence and type of bacteremia at the time of consultation or extraction, reason for consultation, indication for extraction, and use of any granulocyte colony-stimulating factor (GCSF). Primary outcomes were total complications, surgical site infections, delayed healing, and prolonged postoperative pain. Descriptive and bivariate analyses were undertaken, with statistical significance set at a P value less than or equal to .05. RESULTS One hundred sixteen patients underwent extraction while neutropenic. The overall complication rate was 8.6% (n=10). All were minor complications requiring simple interventions, if any. Complications were delayed healing, surgical site infection, and prolonged postoperative pain. Delayed healing was not associated with ANC. GCSF and related medications did not appear to affect outcomes in these patients. CONCLUSION The results of this preliminary study suggest that extraction of teeth in patients at all stages of neutropenia can be conducted safely. Complications of extraction were few and should be easily controlled. Further studies are required to clarify and stratify risk for future patients.

Orthognathic Surgery in Patients With Congenital Myopathies and Congenital Muscular Dystrophies: Case Series and Review of the Literature

PURPOSE This case series examined preoperative findings and the surgical, anesthetic, and postoperative management of 6 patients with congenital myopathies (CMs) and congenital muscular dystrophies (CMDs) treated at a tertiary medical institution with orthognathic surgery over 15 years to describe pertinent considerations for performing orthognathic surgery in these complex patients. MATERIALS AND METHODS According to the institutional review board-approved protocol, chart records were reviewed for all orthognathic surgical patients with a clinical, genetic, or muscle biopsy-proved diagnosis of CM or CMD. RESULTS Six patients (5 male, 1 female) qualified, and they were treated by 4 surgeons in the division of oral and maxillofacial surgery from 1992 through 2007. Average age was 19.5 years at the time of orthognathic surgery. Five patients had Class III malocclusions and 1 patient had Class II malocclusion. All 6 patients had apertognathia with lip incompetence. Nasoendotracheal intubation with a difficulty of 0/3 (0=easiest, 3=most difficult) was performed in all cases. Routine induction and maintenance anesthetics, including halogenated agents and nondepolarizing muscle relaxants, were administered without malignant hyperthermia. All 6 patients underwent Le Fort level osteotomies; 4 also had mandibular setback surgery with or without balancing mandibular inferior border osteotomies. Five patients required planned intensive care unit care postoperatively (average, 18.4 days; range, 4 to 65 days). Postoperative respiratory complications resulting in major blood oxygen desaturations occurred in 5 patients; 4 of these patients required reintubation during emergency code response. Five patients required extended postoperative intubation (average, 4.2 days; range, 3 to 6 days) and ventilatory support. Average hospital length of stay was 21.8 days (range, 6 to 75 days). Average postoperative follow-up interval was 29.8 weeks (range, 6 to 128 weeks). CONCLUSIONS Patients with CMs or CMDs often have characteristic dentofacial malocclusions that contribute to functional problems with feeding and drooling and psychosocial problems. Orthognathic surgery, usually bimaxillary, can be judiciously considered in these patients; these procedures typically require multidisciplinary pre- and postoperative evaluation and care over lengthy hospital stays with a high risk of respiratory complications that bear consideration in treatment planning.