The Inferior Alveolar Nerve: To Graft or Not to Graft in Ablative Mandibular Resection?

PURPOSE

To determine contemporary surgical decision-making processes regarding the use of a nerve graft with ablative mandibular resection and to identify utilization barriers among head and neck surgeons.

MATERIALS AND METHODS

An online electronic survey that queried practice patterns and subjective opinions regarding inferior alveolar nerve (IAN) grafting at the time of mandibular resection was distributed to head and neck surgeons and oral and maxillofacial surgery residency program directors (N = 249) by use of REDCap.

RESULTS

The response rate was 37%. Only 10.6% of respondents perform IAN reconstruction "always" (60% "usually" or "sometimes" and 28.8% "rarely" or "never") with ablative benign mandibular resection, whereas only 1.1% perform IAN grafting always (10-20% usually or sometimes and 89% rarely or never) with ablative malignant mandibular resection. Among the 93 participants, the most important utilization barriers were lack of evidence for improving quality of life, potential impact of radiation on nerve healing, and lack of efficacy for restoration of neurosensory function.

CONCLUSIONS

Despite evidence-based literature showing the efficacy of immediate IAN grafting with ablative benign mandibular resection, most head and neck surgeons do not perform this procedure routinely in patients with benign or malignant mandibular pathology. Future research should focus not only on the achievement of functional sensory recovery but also on the impact of IAN grafting on improved quality-of-life indicators in both benign and malignant mandibular disease, with and without adjunctive chemoradiation therapy.

Is There an Association Between Comprehensive Basic Science Examination Score and Acceptance into an Oral and Maxillofacial Surgery Residency Program?

Sparse data exist regarding the association between applicants' Comprehensive Basic Science Examination (CBSE) scores and acceptance into an oral and maxillofacial surgery (OMFS) residency program. The aims of this study were to assess the association between applicants' CBSE scores and acceptance into one OMFS residency program; to determine the association between other applicant-related variables and acceptance into the program; and to identify the mean CBSE score of accepted applicants by their dental schools' American Association of Oral and Maxillofacial Surgeons (AAOMS) district. For this retrospective data analysis conducted in 2017, the study sample consisted of applicants to the University of Illinois at Chicago OMFS residency program for the application cycles of 2013-14, 2014-15, and 2015-16. The primary predictor variable was CBSE score. The primary outcome variable was acceptance to the program. A total of 477 applicants were in the sample. In the multivariate analysis, CBSE score was found to be significantly associated with an increased chance of acceptance into the program (OR=1.11, 95% CI: 1.08, 1.15; p<0.001). Other variables associated with acceptance, though to a non-significant degree, were age (p=0.01), dental school grade point average (GPA) (p=0.01), and number of externships completed prior to application (p=0.02). These findings may be useful for both applicants and program directors.

Does Low-Level Laser Therapy Affect Recovery of Lingual and Inferior Alveolar Nerve Injuries?

PURPOSE

Iatrogenic damage to the inferior alveolar nerve (IAN) and lingual nerve (LN) may occur during routine oral and maxillofacial surgery procedures. The primary aim of this study was to determine, using a prospective, double-blind, randomized controlled clinical trial, whether the proportion of nerve-injured patients with postoperative neurosensory improvement over a 3-month period differed significantly between a control group and a low-level laser therapy (LLLT) group.

PATIENTS AND METHODS

The study sample consisted of 35 patients with iatrogenic nerve injury due to third molar odontectomy, dental implant placement, or local anesthetic injection. The investigators used a randomized, double-blind laser delivery system to administer either placebo or LLLT to patients who met the inclusion criteria. The outcome variable of neurosensory improvement was defined as a minimum 1-unit increase from baseline in visual analog scale rating and was based on standard objective clinical neurosensory testing. Study variables included the affected nerve (IAN or LN) and time from injury to treatment (3 to 12 months or >12 months). Univariate statistical analysis (χ² test) was performed to determine significance between the groups.

RESULTS

Neurosensory improvement was observed in 46.7% of the LLLT patients, who showed at least a 1-unit improvement at 3 months, compared with 38.5% improvement for controls (P = .66), regardless of the specific nerve involved (IAN or LN). In addition, no observed difference was noted between the study groups based on time from injury to treatment.

CONCLUSIONS

This study failed to provide sufficient evidence to conclude that a difference in neurosensory improvement exists between the LLLT and placebo groups with IAN or LN injuries. However, this study is unique in the prospective double-blind study design and comprehensive neurosensory testing protocols. There is a continued need for further clinical studies on LLLT in oral and maxillofacial surgery nerve injuries.

Laser-Assisted Indocyanine Green Imaging for Assessment of Perioperative Maxillary Perfusion During Le Fort I Osteotomy: A Pilot Study

PURPOSE

To determine the changes in maxillary perfusion during different stages of Le Fort I osteotomies as measured by laser-assisted indocyanine green imaging (LAICGI) and to determine whether various clinical factors affect maxillary vascular perfusion.

MATERIALS AND METHODS

The medical records of those who had undergone Le Fort I osteotomy with LAICGI at the University of Illinois from 2016 to 2017 were reviewed retrospectively. The maxillary perfusion levels using LAICGI were measured before induction, after induction, after down fracture, after segmentalization (for segmental osteotomies), and after wound closure. The effects of clinical variables, including gender, race, American Society of Anesthesiologists physical status, type of Le Fort I osteotomy, intraoperative status of the descending palatine vessels, maxillary movements (anteroposterior, vertical, transverse), and hemodynamic data (mean arterial blood pressure, heart rate), were analyzed.

RESULTS

Compared with the preoperative baseline values, the indocyanine green (ICG) levels decreased after down fracture and mobilization, segmentalization, and wound closure; no statistically significant differences were found among these 3 points. Segmentalization did not affect the ICG levels compared with the nonsegmentalized cases. Male gender and the amount of maxillary impaction were significantly associated statistically with decreased ICG levels, although the difference was not clinically significant.

CONCLUSIONS

Compared with the baseline levels, maxillary perfusion, as measured by LAICGI, decreased from down fracture to wound closure. Segmentalization did not appear to influence maxillary perfusion, although male gender and impaction were associated with decreased perfusion. Because of its safety and convenience, LAICGI shows promise as a method of assessing maxillary perfusion in future largescale prospective studies linking perioperative perfusion to the occurrence of aseptic necrosis.

Senior Oral and Maxillofacial Surgery Resident Confidence in Performing Invasive Temporomandibular Joint Procedures

PURPOSE

The purpose of this study was to evaluate the level of confidence that senior-level oral and maxillofacial surgery (OMS) residents have in the management of temporomandibular joint (TMJ) disorders, determine their exposure to various invasive TMJ procedures during training, and assess their confidence in performing those procedures on completion of residency.

MATERIALS AND METHODS

A questionnaire was designed, and a link to a University of Illinois at Chicago Qualtrics Survey platform (Qualtrics, Provo, UT) was e-mailed to all program directors at Commission on Dental Accreditation-accredited OMS training programs in the United States. The program directors were asked to forward the 20-multiple-choice question anonymous survey to their senior-level residents for completion. The survey included the program's demographic characteristics, resident's confidence in assessing and managing patients with temporomandibular disorders (TMDs), resident's experience performing various invasive TMJ procedures, and whether the resident believed he or she had received sufficient education and clinical experience in the management of TMJ disorders. The data were collected and summarized by use of a standard spreadsheet analysis, as well as appropriate descriptive and analytical statistical tests.

RESULTS

The response rate was 28.0%. Of the 56 respondents, 52 (92.9%) reported having received instruction in nonsurgical management of TMDs. All respondents confirmed that invasive TMJ procedures were performed in their program. The most commonly performed procedure was TMJ arthrocentesis (mean rating, 3.11), followed by open TMJ surgery (mean rating, 2.82). The least-performed invasive surgical procedure was autogenous total TMJ replacement surgery (mean rating, 1.39). Eighty percent of residents reported being comfortable managing the TMD patient. The only procedure with which the respondents were highly confident was TMJ arthrocentesis (mean rating, 3.89).

CONCLUSIONS

This study suggests that confidence levels in the management of the TMD patient are related directly to the invasive TMJ procedure experience obtained during residency. This finding may have implications on the practice patterns of OMS surgeons as it relates to access to care for the TMD patient.

Does Receiving a Blood Transfusion Predict for Length of Stay in Children Undergoing Cranial Vault Remodeling for Craniosynostosis? Outcomes Using the Pediatric National Surgical Quality Improvement Program Dataset

PURPOSE

Recent interventions have aimed at reducing the need for blood transfusions in the perioperative period in patients with craniosynostosis undergoing cranial vault remodeling. However, little is known regarding whether the receipt of a blood transfusion influences the length of hospital stay. The purpose of this study was to assess whether the receipt of a blood transfusion in patients undergoing cranial vault remodeling is associated with an increased length of stay.

MATERIALS AND METHODS

To address the research purposes, we designed a retrospective cohort study using the 2014 Pediatric National Surgical Quality Improvement Program (NSQIP Peds) dataset. The primary predictor variable was whether patients received a blood transfusion during cranial vault remodeling. The primary outcome variable was length of hospital stay after the operation. The association between the receipt of blood transfusions and length of stay was assessed using the Student t test. The association between other covariates and the outcome variable was assessed using linear regression, analysis of variance, and the Tukey test for post hoc pair-wise comparisons.

RESULTS

The sample was composed of 756 patients who underwent cranial vault remodeling: 503 who received blood transfusions and 253 who did not. The primary predictor variable of blood transfusion was associated with an increased length of stay (4.1 days vs 3.0 days, P = .03). Other covariates associated with an increased length of stay included race, American Society of Anesthesiologists status, premature birth, presence of a congenital malformation, and number of sutures involved in craniosynostosis.

CONCLUSIONS

The receipt of a blood transfusion in the perioperative period in patients with craniosynostosis undergoing cranial vault remodeling was associated with an increased length of stay.