Biomechanical Evaluation of a New Fixation Method for Stabilization of Sagittal Split Ramus Osteotomy After Mandibular Advancement

Study Design: Biomechanical in vitro study. Mandibular advancement after sagittal split ramus osteotomy (SSRO) is a common procedure in orthognathic surgery. Several fixation methods are used for stabilization of SSRO. Objective: The aim of this study was to compare a new fixation method (gridplate) with more contemporary applied methods of fixation. Material and Methods: In this study, 50 polyurethane hemimandibles with a prefabricated SSRO were used as specimens. All hemimandibles were advanced by 8 mm and divided into 5 groups with different fixation methods: (A) one 4-hole miniplate with 4 monocortical screws; (B) two 4-hole miniplates with 8 monocortical screws; (C) one 4-hole miniplate with 4 monocortical screws and 1 bicortical screw in the retromolar area (hybrid method); (D) 3 bicortical screws in an inverted-L pattern; and (E) one 8-hole gridplate with 8 monocortical screws. Loads in newtons were recorded at displacements of the mandibular incisive edge at 1 mm, 3 mm and 5 mm. Results: Fixation with 3 bicortical screws and the gridplate presented the most stability, followed by two 4-hole miniplates. Fixation with the hybrid method or the single miniplate showed the least stability. Conclusion: According to the results of this study, the 8-hole gridplate design appears a sufficient fixation method regarding stabilization of SSRO with larger mandibular advancement.

The Use of a CAD/CAM Surgical Obturator Without Impressions to Restore a Maxillectomy Defect

Immediate obturation of the patient undergoing maxillectomy who is not undergoing formal autologous reconstruction is important for immediate form and function of the patient. Exophytic tumors, that are large in dimension can make pre-operative obturator formation challenging. Traditional methods of obturator fabrication involve a physical or digital impression. Preoperative virtual surgical planning for tumor resection and reconstruction using free tissue transfer has become a mainstay in head and neck reconstruction. We describe a variation of this for a patient unable to undergo free tissue transfer where the authors used preoperative virtual surgical planning and CAD/CAM technologies to perform tumor resection, and fabricated an obturator based on the CT imaging alone.

Reconstruction of a Combined Frontal Bone and Orbital Roof Defect With Associated Meningoencephalocele Using 3D Modeling and 3D Navigation

Introduction: Orbital roof fractures are uncommon and normally associated with high energy trauma in which multiple other injuries are present. Most can be managed non-operatively with close observation. However, in a small proportion the defect is such that it permits the development of a meningoencephalocele, which can cause exophthalmos, a reduction in visual acuity and pain, all of which are unlikely to improve without surgical treatment. In light of their scarcity and the potential of serious risks with surgery that includes meningitis and visual disturbance (or even loss), thorough planning is required so that the meningoencephalocele can be reduced safely and the orbital roof adequately reconstructed. Methods: We report a case of a patient with a frontal bone defect, orbital roof fracture and associated meningoencephalocele that presented years after being involved in a road traffic accident in another country, who complained of a significant headache and orbital pain. The use of 3D modeling to help plan the surgery, and intraoperative 3D navigation to help negotiate the anterior skull base are described along with the reconstruction of the frontal bone and orbital roof using titanium mesh contoured on the 3D model. Conclusions: Although conservative management of orbital roof fractures predominates; those that are symptomatic, have associated neurologic symptoms or pose a risk to the eyesight warrant a surgical approach. The methods of repair, which center around separating the intracranial and intraorbital contents, are described in the context of this patient and previous cases, and a treatment algorithm is proposed.

Suprafascial Free Flaps: Classification and Comprehensive Review of the Literature

Study Design: Suprafascial free flaps have become common place in reconstructive surgery units. Nomenclature related to these flaps has not been uniform throughout the scientific literature, especially in regard to planes of dissection. This study is designed as a comprehensive review of the literature. Objectives: Our study highlights which flaps are used most frequently, their main indications, their survival rate, and how they have evolved in the last few decades as innovations have been introduced. Methods: A review of the literature was performed using keywords and Medical Subject Headings search terms. PubMed, Embase, and Cochrane Library were searched using the appropriate search terms. Data collected from each study included flap type, dissection plane, preoperative planning, area of reconstruction, as well as complications, donor-site morbidity and survival rate. Results: Seven hundred and fifty-five studies were found based on the search criteria. After full-text screening for inclusion and exclusion criteria 34 studies were included. A total of 1332 patients were comprised in these studies. The most common types of flaps used were superficial circumflex iliac perforator flap (SCIP), anterolateral thigh flap (ALT), and radial forearm flap. The most common areas of reconstruction were head & neck and limbs. There was no significant difference in survival rates between flaps that were raised in different planes of dissection. Conclusions: Based on the author’s review of the literature, suprafascial flaps are reliable, they have low donor site morbidity, and there is a wide selection available for harvest. The use of new technologies for preoperative planning, such as CT-Angiography and UHF ultrasound, have contributed to have more predictable results. We propose a standardized classification for these flaps, in order to create a uniform nomenclature for future reference.

Management of Basal Cell Adenoma of Accessory Parotid Gland Through Transoral Approach: Report of a Rare Case With Review

Diagnosis of mid-cheek mass has always been a diagnostic dilemma for clinicians. The incidence of the accessory parotid gland (APG) has been well documented in the literature. However, a diverse spectrum of pathologies can arise from this accessory parotid tissue. Basal cell adenoma is a rare benign tumor that predominantly affects the parotid gland. Its occurrence in the accessory parotid gland has been documented in 9 cases till date. Surgical approaches for the management of such APG lesions have been in debate. This report documents a case of Basal Cell Adenoma arising in accessory parotid tissue in a 55-year-old woman who was treated by transoral excision. This paper also reviews previously documented cases of all APG lesions and attempts to elucidate the rationale for selecting an appropriate surgical approach.

TMJ Replacement Following Pseudoarthrosis of Condylar Neck Fracture With Dislocation of the Condylar Neck Within the Infra-Temporal Fossa

Study Design: Case Report Objective: To present a patient with long-standing TMJ dislocation and pseudoarthrosis in the temporal bone treated with orthognathic surgery and unilateral joint replacement. Method: The patient, a 52-year-old female, came to our department to treat facial asymmetry and oral rehabilitation. The patient reported early facial trauma at 7 years old showing partial edentoulism, dental occlusion class III and a 19 mm mandibular midline deviation. Cone beam computed tomography showed the left TMJ in long-standing dislocation into the fossa temporalis, creating a new articular fossa in the temporal bone and adaptation of the hard and soft tissue. Results: Orthognathic surgery and TMJ replacement using a patient-specific implant and dental rehabilitation were planned; surgery was performed with no complications, and the 1-year follow-up showed that this treatment was a good option for long-standing TMJ dislocation. Conclusion: The long-term TMJ dislocation can be successfully treated by TMJ replacement using a patient-specific implant to obtain facial balance and oral function and avoid relapse.

Oral Kaposi’s Sarcoma: A Case Report and Literature Review on Treatment Management

Background: Kaposi’s sarcoma is a common malignancy in HIV patients. Oral manifestation of AIDS-associated Kaposi’s sarcoma occurs in up to 65% of HIV/AIDS patients and is a poor prognostic factor. We report the case of a patient with a progressive bulky manifestation of oral Kaposi’s sarcoma. Case Presentation: A 48-year-old male presented with dysphagia due to progressive indolent swelling of the palate. Intraoral inspection revealed an uneven, partially ulcerated, livid mass, approximately 5 cm in diameter, extending antero-posteriorly from the superior vestibulum to the soft palate and across the hard palate, thereby overgrowing remaining teeth and the alveolar arch. Serological testing revealed an HIV infection, and further tests showed HHV8-positivity. The patient underwent surgical debulking of the oral lesions and, following complete remission, received full mouth reconstruction with an implant-supported prosthesis. Conclusions: Understanding the relation of HIV and HHV8-infection in terms of disease onset and clinical presentation is important to increase awareness of oral Kaposi’s sarcoma and ensure subsequent appropriate management of affected patients. Clinical staging represents the most important factor for choosing the optimal treatment. The introduction of combined antiretroviral therapy has proven to be efficient in curing oral Kaposi’s sarcoma, while several additional locoregional treatment options, including debulking surgery, may be necessary for symptom relief or to improve cosmesis. Radiotherapy should be applied restrictively due to potentially severe toxic mucosal reactions, whereas additional chemotherapy must be considered in severe cases that present with widespread disseminated disease. A multidisciplinary approach to the treatment of functionally and aesthetically impairing oral Kaposi’s sarcoma is highly recommended.

Evaluating an International Facial Trauma Course for Surgeons: Did We Make a Difference?

Study Design: Retrospective data analysis study. Objective: Attending continuing professional development (CPD) and continuing medical education (CME) activities is a necessity for practicing surgeons in most parts of the world. To enhance best practices in conducting CME/CPD, objective evaluation of these events is crucial. This article aims to evaluate one such international standardized CPD course conducted for facial surgeons across the globe. The Management of Facial Trauma course was developed by an international planning committee of experienced surgeons and has been implemented in all regions of the world. Method: This 2-day course is delivered using a combination of short lectures, small group discussions, and practical hands-on activities. Data collected from pre- and post-course evaluations of 86 Management of Facial Trauma courses conducted worldwide from 2017-2019 were collated and analyzed. Results: Participant demographics and experience levels varied slightly across the regions. Evaluation of the course effectiveness revealed overall high ratings for educational impact, content usefulness, and faculty performance. Conclusion: Our results indicated that this standardized course met the audience needs and enabled participants to plan changes in clinical practice. In addition, it confirmed that the course was relevant across different specialties and across different cultures and countries.

Acute Airway Compromise After Isolated Mandibular Subcondyle Fracture in a Patient With a Hemi-Mandible: A Case Report

Evaluation of the airway is the first step in any trauma protocol, and this is particularly important in instances of facial trauma. While airway compromise is not uncommon in blunt or penetrating facial trauma, it is rarely a significant concern in instances of an isolated mandibular fracture. We report a rare case of immediate airway compromise in an elderly, edentulous female who sustained an isolated mandibular subcondyle fracture, complicated by her history of a remote hemimandibulectomy for management of her oral cancer. Initial airway management was performed conservatively with prone or lateral positioning under continuous pulse oximetry monitoring in the intensive care unit, followed promptly by open anatomic reduction and internal fixation of the fracture under more optimal operative conditions. After stabilizing the subcondylar fracture, the patient followed a mechanical soft/no-chew diet for 6 weeks until the fracture was healed. She has experienced no airway concerns since her surgery. This case report stresses the importance of a comprehensive evaluation of the airway in facial trauma patients with altered baseline anatomy, as well as highlights the considerations for emergent surgical airway versus immediate or delayed surgical fracture fixation.