Sat Parmar

Recent advances in reconstructive oral and maxillofacial surgery.

Reconstruction within the head and neck is challenging. Defects can be anatomically complex and may already be compromised by scarring, inflammation, and infection. Tissue grafts and vascularised flaps (either pedicled or free) bring healthy tissue to a compromised wound for optimal healing and are the current gold standard for the repair of such defects, but disadvantages are their limited availability, the difficulty of shaping the flap to fit the defect and, most importantly, donor site morbidity. The importance of function and aesthetics has driven advances in the accuracy of surgical techniques. We discuss current advances in reconstruction within oral and maxillofacial surgery. Developments in navigation, three-dimensional imaging, stereolithographic models, and the use of custom-made implants can aid and improve the accuracy of existing reconstructive methods. Robotic surgery, which does not modify existing techniques of reconstruction, allows access, resection of tumours, and reconstruction with conventional free flap techniques in the oropharynx without the need for mandibulotomy. Tissue engineering and distraction osteogenesis avoid the need for autologous tissue transfer and can therefore be seen as more conservative methods of reconstruction. Recently, facial allotransplantation has allowed whole anatomical facial units to be replaced with the possibility of sensory recovery and reanimation being completed in a single procedure. However, patients who have facial allotransplants are subject to life-long immunosuppression so this method of reconstruction should be limited to selected cases.

Use of a titanium cutting guide to assist with raising and inset of a DCIA free flap

Reconstructing maxillary defects can be challenging. In particular, Class 3 and 4 defects require careful planning. Bone for reconstruction must be placed in the correct three dimensional (3D) position in order to achieve a good cosmetic and functional result. Correct size and positioning of the harvested bone also enables placement of dental implants and allows rehabilitation. We describe the use of a Deep Circumflex Iliac Artery Flap (DCIA) cutting guide to aid safe harvest and positioning of the correct quality and quantity of bone. We illustrate the benefits of using a guide based upon stereolithographic planning models of the pelvis by presenting 4 cases where planning to this level has been used. Our experiences clearly demonstrate the potential benefits that preformed cutting guides may have on outcomes when reconstructing complex maxillary defects. In particular, we note a reduction in operative time and improved functional and aesthetic results. The use of such a guide has not previously been described.

Does Extraction or Retention of the Wisdom Tooth at the Time of Surgery for Open Reduction and Internal Fixation of the Mandible Alter the Patient Outcome

Whether to extract or retain wisdom teeth present in a fracture line is a controversial topic. This study reviewed the records of all patients who had mandibular wisdom teeth at the time of the injury, and had an open reduction and internal fixation procedure between January 2009 and January 2012. The cohort of patients who concomitantly had their wisdom tooth extracted at the time of fixation had a greater complication rate (24.3%) compared with patients who did not (14.9%). This suggests that if third molars in the line of a fracture have caries, are fractured, show signs of pericoronitis, are periodontally involved, or are interfering with the occlusion are extracted at the time of fixation, this will increase the incidence of complications.

Free Bone Grafts for Mandibular Reconstruction in Patients Who Have Not Received Radiotherapy: The 6-cm Rule—Myth or Reality?

Bony reconstruction of the mandible after surgical resection results in improved rehabilitation and aesthetics. Composite tissue transfer has transformed reconstruction, particularly in patients who have received radiotherapy. However, there is morbidity related to free tissue transfer. Free nonvascularized bone grafts have much lower morbidity. Surgeons believe that free bone grafts greater than 6.0 cm are prone to failure. The aims of this study was to assess whether bone grafts greater than 6.0 cm in length have a high risk of failure. A retrospective study was performed on all patients who had free bone grafts greater than 6.0 cm in length at Birmingham, UK, and Florida, the United States. None of the patients received radiotherapy. A total of 14 patients had undergone bone grafts for mandibular defects greater than 6.0 cm in length; 13 of the bone grafts were successful. Of these 13, none were infected and there was radiographic evidence of bony union. Some of the patients have been dentally rehabilitated with implants. Contrary to much of the literature and many surgeons belief, our study has shown that long mandibular defects (>6.0 cm) are not a contraindication to the use of free bone grafts. Key principles to achieve success are discussed in this article.

A Review of the Use of Resorbable Plateing Systems in Cranio-Maxillofacial Surgery

Resorbable materials have been used for many different procedures in cranio-maxillofacial surgery. However, they have had varying rates of success. The use of resorbable for oncological reconstruction is a relatively new area, compared with paediatric trauma and orthognathic surgery.

Hyperglobus, do not forget the sinister.

Hyperglobus is an elevation of the ocular globe with the majority of the orbit remaining intact. We present a case of hyperglobus caused by a metastatic mass from a prostate carcinoma. There are no other reported cases in the literature.