Kevin L. Rieck

Practice-based clinical evaluation of ceramic single crowns after at least five years.

STATEMENT OF PROBLEM Long-term practice-based clinical evaluations of various contemporary ceramic crown restorations from multiple practitioners are limited. PURPOSE The aims of this study were to evaluate the clinical performance of ceramic single crowns and to identify factors that influence their clinical performance. MATERIAL AND METHODS Ceramic single crowns that had been placed at the Mayo Clinic and in function since 2005 were identified and included in the study. The restorations were examined clinically, radiographically, and with photographs. Modified United States Public Health Services criteria were used for the clinical evaluation. The ceramic systems evaluated were bilayer and monolayer. RESULTS Fifty-nine patients (41 women, 18 men) with 226 single teeth and implants restored with single ceramic crowns were identified. The mean duration from insertion date to study examination date was 6.1 years. Thirteen restorations (6%) were replaced at a mean 3.3 years after insertion date (range, 0.1-6.1 years). Estimated replacement-free survival rates (95% confidence interval [CI]; number of teeth/implants still at risk) at 5 years after insertion date were 95.1% (95% CI, 92.2-98.1; 153) and at 10 years were 92.8% (95% CI, 89.1-96.8; 8). The most common reason for replacement was fracture to the core of posterior layered ceramic crowns. The most commonly used luting agent was resin-modified ionomer cement. Most restorations exhibited clinically acceptable marginal integrity, shade, no caries recurrence, and no periapical pathology. CONCLUSIONS The clinical performance of ceramic single crowns at 5 and 10 years supports their application in all areas of the mouth. With the majority of fractures to the core occurring early in the lifetime of layered ceramic posterior crowns, consideration of other monolithic ceramic systems for posterior crowns is advised.

Evaluation for Clinical Predictors of Positive Temporal Artery Biopsy in Giant Cell Arteritis

PURPOSE To examine the clinical predictors of a positive temporal artery biopsy (TAB) among patients suspected of having giant cell arteritis. PATIENTS AND METHODS We conducted a retrospective study of all consecutive patients who underwent TAB by a single surgeon (K.L.R.) at the Department of Oral Maxillofacial Surgery from April 30, 2002, to June 29, 2006. The medical records were reviewed for the clinical symptoms, laboratory findings, biopsy results, and final diagnosis. The variables of interest as predictors of positive biopsy findings were analyzed using logistic regression analysis. RESULTS During the study period, 82 patients underwent TAB. Histologic evidence of arteritis was present in 22 patients (26.8%). Two (2.4%) were diagnosed with giant cell arteritis clinically but had negative TAB findings. The patients presenting with weight loss or jaw claudication were more likely to have a positive TAB finding (odds ratio 4.50, 95% confidence interval 1.45 to 13.93; and odds ratio 3.71, 95% confidence interval 1.28 to 10.76, respectively). No laboratory findings were predictive of a positive TAB finding. Prednisone use before TAB also was not associated with a decreased likelihood of a positive finding. CONCLUSIONS Patients suspected of having giant cell arteritis were more likely to have a positive TAB finding if they presented with weight loss or jaw claudication. In the present series, corticosteroid therapy before biopsy did not affect the rate of positive TAB findings.

Lower Extremity Compartment Syndrome Associated With Hypotensive General Anesthesia for Orthognathic Surgery: A Case Report and Review of the Disease

d p i t t h s d ompartment syndrome (CS) is a process that occurs hen pressure increases within closed, inelastic musulofascial compartments. A vicious cycle begins as eperfusion follows ischemia, leading to edema. dema in a fixed space can result in pressures elevatng above capillary pressure; arterial inflow and veous outflow are thus diminished. This process is rogressive, with worsening ischemia, further presure increase, halted outflow, and eventually, when he metabolic demands of the tissue are no longer et, rhabdomyolysis and necrosis. This rapidly progressive complication is especially evastating to the muscles and nerves of the lower xtremity involved with ambulation. Several etiologies or CS have been described in the literature. These nclude trauma, exercise, drug abuse, peripheral vascuar disease, snake bites, obesity, vasocompressive mediation, muscular physique, anesthesia-induced hypotenion, long-duration surgeries, and surgical positioning long-term compression and pedal dorsiflexion). Although trauma is the most common cause of CS, ong-duration surgeries in lithotomy position are recgnized causes of CS. There are very few reports on

Comparative analysis of fracture characteristics of the developing mandible: The Mayo Clinic experience

OBJECTIVE To review and compare the epidemiology and treatment of mandibular fractures in subgroups of a pediatric population. METHODS We conducted a retrospective review of pediatric patients (age, ≤18 years) with mandibular fractures treated at our institution from January 1996 through November 2011. RESULTS We identified 122 patients (93 [76%] male) with 216 mandibular fractures. The prevalent mechanisms of injury were motor vehicle accidents (n=52 [43%]), sports injuries (n=24 [20%]), and assault (n=13 [11%]). The most common fracture sites were subcondylar, parasymphyseal, angle, and body. Two patients (2%) were treated conservatively by observation only, 67 (55%) underwent maxillomandibular fixation alone, 41 (34%) underwent maxillomandibular fixation with plate fixation, and 7 (5.7%) underwent plate fixation only. The average duration of maxillomandibular fixation was 26 days (range, 7-49 days). Complications occurred in 11 patients (9.0%) over a mean follow-up of 92 days (range, 21-702 days). Fifty patients (41.0%) had comorbid conditions or a history of mental illness at the time of injury, including attention deficit hyperactivity disorder (n=11 [9%]), mental disorders other than attention deficit hyperactivity disorder (n=23 [19%]), and asthma (n=17 [14%]). Twenty-six patients (21%) had a history of substance use, the most common being tobacco (n=18 [15%]), alcohol (n=13 [11%]), and marijuana (n=11 [9%]). CONCLUSIONS Treatment approach and outcomes were affected by age and fracture characteristics. In addition, a marked proportion of this cohort had preexisting mental disorders and history of substance use, which may have implications on treatment approach.

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.

Rehabilitation of medically complex ectodermal dysplasia with novel surgical and prosthodontic protocols

The functional and aesthetic needs of a 17-year-old patient afflicted with ectodermal dysplasia, chronic long-term immunosuppression, cleft palate, velopharyngeal insufficiency, hypernasality, maxillary hypoplasia, and oligodontia were met with a multidisciplinary team approach. Predictable functional and aesthetic outcomes were obtained with a combination of injection augmentation of the soft palate and nasopharynx and rigid fixation maxillary external distraction with immediate placement and immediate load protocols. No biological or prosthetic complications were noted after definitive rehabilitation with a mandibular implant-retained fixed prosthesis and a maxillary implant-retained detachable prosthesis.

Virtual surgical planning for treatment of severe mandibular retrognathia with collapsed occlusion using contemporary surgical and prosthodontic protocols.

PURPOSE To meet functional and esthetic needs in an older adult for treatment of complex skeletal and dentoalveolar deformities using contemporary surgical and prosthodontic protocols. METHODS An older adult with dentoalveolar complex and skeletal deformity (mandibular retrognathia) was treated by a combination of virtual planning and current surgical and prosthodontic protocols. Treatment planning steps and sequencing are presented. RESULTS Skeletal, soft tissue, and dental harmonies were attained without biological or mechanical complications. Definitive oral rehabilitation was completed with a maxillary complete denture and a mandibular metal ceramic fixed implant-retained prosthesis. CONCLUSIONS A surgical and prosthodontic team approach in combination with technologic advances can predictably optimize esthetic and functional outcomes for patients with complex skeletal and dentoalveolar deformities.

Intra-Arch Elastics Technique: A Novel Method for Controlling the Abutment/Soft Tissue Interface During Implant Reconstruction of the Orofacial Region

In the past 30 years, composite microvascular free tissue transfer has become a popular and highly successful option for the reconstruction of defects in the head and neck region. However, inherent shortcomings exist with free tissue transfer in that the imported tissue often fails to adequately replicate the characteristics of the native tissues. This can lead to difficulties when attempting reconstruction from a surgical and prosthetic standpoint. Endosseous implants are often required to adequately retain prostheses, and management of the peri-implant soft tissues represents a critical challenge for the oral and maxillofacial surgeon. This report describes a novel technique for controlling the implant-abutment-soft tissue interface and the advantages of this technique as it pertains to orofacial reconstruction.

Novel Oncologic, Surgical, and Prosthetic Treatment of High-Grade Surface Osteosarcoma, Osteoblastic Mandible Type

An accurate diagnosis of osteosarcoma of the jaws (OS) is determined by proper documentation and interpretation of clinical symptoms, radiologic findings, meticulous histologic survey, and a characteristic growth pattern. The characteristics of high-grade OS include a chief complaint of swelling/pain, a ‘‘fluffy’’ radiologic appearance with or without corticomedullary involvement, osteoblasts as the predominant cell type on histologic examination, and a highly aggressive growth pattern arising from the periosteal tissue. OSs of the mandible and maxilla are collectively known as gnathic osteosarcomas (GOSs) and usually exhibit long-standing pain or swelling. Emphasis on multidisciplinary oncologic, surgical, and prosthetic treatment planning of GOSs improves the treatment outcome and long-term prognosis. The treatment of GOSs, especially in the mandible, requires careful consideration of adjacent bone, soft tissue, surrounding perioral musculature, teeth, interocclusal relationships, and facial aesthetics. Integration of oncologic therapy is of predictive value in the treatment of GOSs. Neoadjuvant chemotherapy assesses the responsiveness of the tumor to chemotherapy and minimizes the potential for the presence of distant micrometastasis. The benefits of adjuvant and neoadjuvant chemotherapy protocols have continued to be evaluated, with a reported local recurrence risk of 1.1% to 13.5%. It has been reported