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Suhaym O, Moles L, Callahan N. Cutting guides in mandibular tumor ablation: Are we as accurate as we think? Saudi Dent J 2024; 36:340-346. [PMID: 38420006 PMCID: PMC10897611 DOI: 10.1016/j.sdentj.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 03/02/2024] Open
Abstract
Purpose Tumor margin status is critical in local tumor recurrence and is a significant prognostic factor in head and neck cancer survival. With the introduction of computer-assisted surgical planning, one of the main challenges is the accurate positioning of the surgical cutting guide but there is limited evidence of the accuracy of the 3D cutting guides in mimicking virtually planned osteotomy. This study evaluates the accuracy of osteotomy lines produced by 3D-printed cutting guides and assesses the overall accuracy of mandibular reconstruction. Material and Methods The pre and postoperative 3D models were aligned using an automated surface registration feature based on the iterative closest point algorithm. The differences in osteotomy line deviation, linear and angle measurements, and 3D volume quantification of the pre and post models were measured. Results We included 14 patients (8 men and 6 women with ages ranging from 13 to 75 years) with a segmental mandibular resection who met all of the inclusion criteria. The smallest defect size was 4.4 cm, the largest defect was 12.2 cm, and the average was 7.30 cm +/- 2.80 cm. The average deviation between virtually planned osteotomy and actual surgical osteotomy was 1.52 +/-1.02 mm. No covariates were associated with increased inaccuracy of the 3D-printed cutting guides. Conclusion The finding of this study suggests that virtual surgical planning is an unambiguous paradigm shift in the predictability of the surgical plan and achievement of the reconstruction goals. The 3D-printed cutting guides are a very accurate and reliable tool in translating virtual ablation plans to an actual surgical resection margin.
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Affiliation(s)
- Omar Suhaym
- Maxillofacial Surgery and Diagnostic Sciences, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center (KAIMRC), Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Ar Rimayah, 14611 Riyadh, Saudi Arabia
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2
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Rao D, Weyh A, Bunnell A, Hernandez M. The Role of Imaging in Mandibular Reconstruction with Microvascular Surgery. Oral Maxillofac Surg Clin North Am 2023:S1042-3699(23)00002-X. [PMID: 37032176 DOI: 10.1016/j.coms.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Imaging plays a critical role in the diagnosis, staging, and management of segmental mandibular defects. Imaging allows mandibular defects to be classified which aids in microvascular free flap reconstruction. This review serves to complement the surgeon's clinical experience with image-based examples of mandibular pathology, defect classification systems, reconstruction options, treatment complications, and Virtual Surgical Planning.
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Affiliation(s)
- Dinesh Rao
- Department of Radiology, University of Florida, College of Medicine, 655 West 8th Street, Jacksonville, FL 32209, USA.
| | - Ashleigh Weyh
- Department of Oral and Maxillofacial Surgery, University of Florida, College of Medicine, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Anthony Bunnell
- Department of Oral and Maxillofacial Surgery, University of Florida, College of Medicine, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Mauricio Hernandez
- Department of Radiology, University of Florida, College of Medicine, 655 West 8th Street, Jacksonville, FL 32209, USA
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3
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Taney K, Smith MM, Cummings NP, Lozano AJ. Risk Factors for Failure of Hard Palate Mucoperiosteal Flap Repair of Acquired Oronasal Communication in Dogs: A Pilot Study. Front Vet Sci 2021; 8:762842. [PMID: 34805341 PMCID: PMC8595595 DOI: 10.3389/fvets.2021.762842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/11/2021] [Indexed: 11/22/2022] Open
Abstract
The objective of this retrospective pilot study was to describe potential risk factors for failure of hard palate mucoperiosteal flaps (HPF) transposed for closure of oronasal communication. Dogs (n = 28) with acquired oronasal communication defects were included in the study population. Functional success of an HPF was determined by visual inspection at the last examination and lack of clinical signs. Risk factors for HPF failure including age, sex, body weight, presence of neoplasia at the time of surgery, presence of neoplasia after surgery due to incomplete or narrow margins, use of CO2 laser, previous surgeries in the same location, HPF blood supply, size of the HPF as a percentage of the total area of the hard palate mucoperiosteum, and distance traveled by the apex of the HPF were evaluated using descriptive statistics and unadjusted logistic regression modeling. Seven out of 28 (25%) hard palate flap procedures resulted in persistent oronasal communication and were considered failures. Body weight (Median: 17 vs. 25 kg, OR = 0.94, 80% CI = 0.90, 0.99), presence of neoplasia at the time of surgery (86 vs. 57%, OR = 4.50, 80% CI = 1.01, 20.06), HPF area (Median: 0.49 vs. 0.41, OR = 84.40, 80% CI = 1.66, 4,298) and apex travel distance (Median: 2.06 vs. 0.67, OR = 5.15, 80% CI = 2.14, 12.38) were associated with flap failure. Within this sample, the presence of neoplasia at the time of initial surgery, increasing the area of the HPF, and distance traveled by the HPF apex were associated with a greater odds of HPF failure. Further studies with larger sample sizes are needed to confirm repeatability of these results. HPFs remain a viable surgical option for closure of oronasal communication. Careful surgical planning, strict adherence to surgical principles, and awareness of anatomical limitations can increase the likelihood of success.
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Affiliation(s)
- Kendall Taney
- Center for Veterinary Dentistry and Oral Surgery, Gaithersburg, MD, United States
| | - Mark M Smith
- Center for Veterinary Dentistry and Oral Surgery, Gaithersburg, MD, United States
| | | | - Alicia J Lozano
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA, United States
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Hennocq Q, Khonsari RH, Vacher C, Nicol P. Twelve-year experience in mandibular reconstruction using osteo-muscular dorsal scapular pedicled flaps. J Plast Reconstr Aesthet Surg 2021; 74:259-267. [DOI: 10.1016/j.bjps.2020.08.124] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/06/2020] [Accepted: 08/14/2020] [Indexed: 11/30/2022]
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Heterotopic Ossification of the Vascular Pedicle after Maxillofacial Reconstructive Surgery Using Fibular Free Flap: Introducing New Classification and Retrospective Analysis. J Clin Med 2020; 10:jcm10010109. [PMID: 33396904 PMCID: PMC7794830 DOI: 10.3390/jcm10010109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/18/2020] [Accepted: 12/27/2020] [Indexed: 01/08/2023] Open
Abstract
Heterotopic ossification (HO) is one of the described phenomena after maxillofacial reconstructive surgery using fibular free flap (FFF) at the reception-site. The aim of this study was to determine the radiological incidence and form of HO along the fibular vascular pedicle as well as the rate of clinical symptoms if present. CT-scans of 102 patients who underwent jaw reconstructive surgery by using FFF from January 2005 to December 2019 were evaluated concerning the presence of HO. Subsequently, the patient files were evaluated to identify the cases with clinical signs and complications related to the presence of HO. A radiological classification of four different HO types was developed. Out of 102 patients, 29 (28.43%) presented radiological findings of HO. Clinical symptoms were recorded in 10 cases (9.8%) (dysphagia (n = 5), trismus (n = 3), bony masses (n = 2)) and from these only five (4.9%) needed surgical removal of calcified structures. HO occurs significantly in younger patients (mean 52.3 year). In maxillary reconstructions, HO was radiologically visible six months earlier than after mandibular reconstruction. Furthermore, HO is observed after every third maxilla and every fourth mandible reconstruction. This study developed for the first time a classification of four distinct HO patterns. HO types 1 and 2 were mostly observed after mandible reconstruction and type 4 predominantly after maxilla reconstruction.
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Saraiya HA. Wide Excision with Immediate Reconstruction of the Mandible Using Free Fibular Flap in Ameloblastoma of the Mandible-A Need of Time: Our Experience of 37 Cases. Indian J Plast Surg 2020; 53:363-370. [PMID: 33402766 PMCID: PMC7775221 DOI: 10.1055/s-0040-1719198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background
Ameloblastoma is a benign yet locally aggressive odontogenic tumor of the jaw with high recurrence rates. Despite many studies, the search is still on for the treatment approach which can render the acceptable recurrence rates with good functional and esthetic results.
Methods
In this prospective study, we operated on 37 patients of mandibular ameloblastoma between 2009 and 2018. Two patients were treated with curettage and chemical sterilization of the cavity. Resection of a tumor with a 2-cm margin was performed in the rest of 35 patients. The mandibular defect was primarily reconstructed with the microvascular free fibular flap in 29 patients.
Results
The follow-up ranged from 6 months to 7.7 years with a mean of 5.1 years. A tumor recurred within a year in all two patients (100%) treated with curettage. Out of 35 radical excisions, only one patient (2.85%) developed recurrence 3 years after the disease-free interval. Good mouth opening, intelligible speech, satisfactory lower jaw shape, and facial profiles were achieved in all 29 patients who were treated with primary free fibular flap.
Conclusion
We prefer wide excision with 2-cm margins on each side of a tumor with the primary reconstruction of the mandible in all cases of mandibular ameloblastoma. The free fibular microvascular flap is our treatment of choice as all defects of the mandible can be reconstructed with the free fibular flap. Wide excision is the key to prevent a recurrence.
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Affiliation(s)
- Hemant A Saraiya
- Saraiya Plastic Surgery and Burns Hospital, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
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Attia S, Diefenbach J, Schmermund D, Böttger S, Pons-Kühnemann J, Scheibelhut C, Heiss C, Howaldt HP. Donor-Site Morbidity after Fibula Transplantation in Head and Neck Tumor Patients: A Split-Leg Retrospective Study with Focus on Leg Stability and Quality of Life. Cancers (Basel) 2020; 12:E2217. [PMID: 32784461 PMCID: PMC7465780 DOI: 10.3390/cancers12082217] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 12/21/2022] Open
Abstract
The free fibula flap has been one of the most important microvascular grafts for orofacial reconstruction for more than 30 years. The complication rates at the donor-site reported in literature are considered to be low, but the published data vary greatly in some cases. In particular, restrictions in the stability and balance of the involved leg and their effects on the quality of life have been described very inconsistently to date. Therefore, this study mainly focuses on the stability and balance of the affected leg in a split-leg design. Between December 2014 and January 2018, out of 119 subjects who underwent mainly jaw ablative tumor surgery and reconstruction using a fibula flap, 68 subjects were examined for donor site morbidity. Besides reporting general types of complications, two specific test procedures were used. The Star Excursion Balance Test (SEBT) as a practical test for ankle function and the Foot and Ankle Disability Index (FADI) as a questionnaire in order to assess quality of life, depending on the lower leg function. SEBT revealed an average of 55.3 cm with the operated leg as the supporting leg, which corresponds to 95.5% of 57.9 cm achieved with the healthy leg as the supporting leg. An average FADI score of 89.4% was recorded. SEBT and FADI seem to be suitable methods of examination for subjects post fibular transplantation and pointed out minimal limitations of the involved legs in comparison to the unaffected legs. These limitations were clinically not relevant and they had minor influence on the subjects' quality of life and their daily activities.
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Affiliation(s)
- Sameh Attia
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
| | - Jonas Diefenbach
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
| | - Daniel Schmermund
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
| | - Sebastian Böttger
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
| | - Jörn Pons-Kühnemann
- Institute for Medical Informatics, Medical Statistics, Faculty of Medicine, Justus-Liebig University Giessen, Rudolf-Buchheim Str. 6, 35392 Giessen, Germany; (J.P.-K.); (C.S.)
| | - Christine Scheibelhut
- Institute for Medical Informatics, Medical Statistics, Faculty of Medicine, Justus-Liebig University Giessen, Rudolf-Buchheim Str. 6, 35392 Giessen, Germany; (J.P.-K.); (C.S.)
| | - Christian Heiss
- Department of Trauma, Hand and Reconstructive Surgery, Justus-Liebig University Giessen, Rudolf-Buchheim- Str. 7, 35392 Giessen, Germany;
| | - Hans-Peter Howaldt
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
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Considerations for Mandibular Reconstruction in the Pediatric Patient Following Resection of Malignant Tumors. J Craniofac Surg 2019; 30:e163-e168. [PMID: 30614992 DOI: 10.1097/scs.0000000000005098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We recently achieved favorable results in 3 pediatric patients with mandibular osteosarcomas that were treated at our hospital, including with immediate reconstructive surgery performed after tumor resection. Based on a literature review and practical investigation, we discuss the considerations for mandibular reconstruction after malignant lesions are removed from the mandible in children. Mandibular reconstruction for pediatric patients requires an understanding of the changes in bone and soft-tissue architecture due to growth and development at both the donor and recipient sites. Immediate mandibular reconstruction with a free flap can be considered a reasonable option even for young children who require extensive mandibular surgery. However, the variables affecting decisions about treatment planning vary between the different conditions in individual patients, and moreover, these cases are not common in the pediatric population. Therefore, long-term follow-up treatment and further investigations are required for the optimized diagnosis, treatment, and prognosis of pediatric mandibular malignancies.
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Awad ME, Altman A, Elrefai R, Shipman P, Looney S, Elsalanty M. The use of vascularized fibula flap in mandibular reconstruction; A comprehensive systematic review and meta-analysis of the observational studies. J Craniomaxillofac Surg 2019; 47:629-641. [PMID: 30782453 DOI: 10.1016/j.jcms.2019.01.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/11/2018] [Accepted: 01/25/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Vascularized fibular flaps are considered the gold standard for the reconstruction of segmental defects in the mandible. This review compares the complication and success rates of these techniques between primary and secondary reconstruction, as well as between lateral and antero-lateral defects. TYPE OF STUDIES REVIEWED A systematic review and meta-analysis were conducted according to PRISMA protocol and the Cochrane Handbook for Systematic Reviews of Interventions. The authors performed an independent comprehensive search using PubMed, Ovid MEDLINE, Web of Science, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and COS Conference Papers Index according to established inclusion and exclusion criteria. The methodological index for nonrandomized studies (MINORS) was used to assess the quality of the included studies. Meta-analysis was conducted to compare the type of reconstruction and location of the defect. RESULTS Seventy-eight studies, involving 2461 patients, were eligible. 83.7% of the included patient received primary reconstruction with vascularized fibular flap. The overall flap success rate was 93%. There was improvement in MINORS quality score over time with positive correlation with the publication year (r = 0.5549, P < 0.0001, CI 0.3693 to 0.6979). Meta-analysis indicated no significant association in flap success between primary and secondary reconstruction, or lateral and antero-lateral defects. CONCLUSION Based on the available studies, this review found no evidence of difference in success or complication rates between primary and secondary reconstruction or between lateral and anterolateral defects. High-quality clinical studies are required to analyze the outcome of these techniques, especially regarding the impact of chemotherapy, radiation therapy, implant-supported dental prostheses, and preoperative planning, on the outcome of reconstruction.
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Affiliation(s)
- Mohamed E Awad
- Oral Biology Department, Dental College of Georgia, Augusta University, Augusta, GA, USA
| | - Amara Altman
- Dental College of Georgia, Augusta University, Augusta, GA, USA
| | | | - Peter Shipman
- Robert B. Greenblatt M.D. Library, Augusta University, Augusta, GA, USA
| | - Stephen Looney
- Department of Biostatistics, Augusta University, Augusta, GA, USA
| | - Mohammed Elsalanty
- Oral Biology Department, Dental College of Georgia, Augusta University, Augusta, GA, USA.
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Smits RWH, Ten Hove I, Dronkers EAC, Bakker Schut TC, Mast H, Baatenburg de Jong RJ, Wolvius EB, Puppels GJ, Koljenović S. Evaluation of bone resection margins of segmental mandibulectomy for oral squamous cell carcinoma. Int J Oral Maxillofac Surg 2018; 47:959-964. [PMID: 29605084 DOI: 10.1016/j.ijom.2018.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 01/15/2018] [Accepted: 03/09/2018] [Indexed: 12/01/2022]
Abstract
Resection margins are frequently studied in patients with oral squamous cell carcinoma and are accepted as a constant prognostic factor. While most evidence is based on soft tissue margins, reported data for bone resection margins are scarce. The aim of this retrospective study was to evaluate and determine the utility of surgical margins in bone resections for oral cavity squamous cell carcinoma (OCSCC). The status of bone resection margins and their impact on survival was investigated in patients who had undergone segmental mandibulectomy for OCSCC. Medical records were retrieved for the years 2000-2012; 127 patients were identified and included in the study. Tumour-positive bone resection margins were found in 21% of the patients. The 5-year overall survival was significantly lower in this group (P<0.005). Therefore, there is a need for intraoperative feedback on the status of bone resection margins to enable immediate additional resection where necessary. Although the lack of intraoperative methods for the evaluation of bone tissue has been addressed by many authors, there is still no reliable method for widespread use. Future research should focus on an objective, accurate, and rapid method of intraoperative assessment for the entire bone resection margin to optimize patient outcomes.
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Affiliation(s)
- R W H Smits
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands; Centre for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ivo Ten Hove
- Centre for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands; Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - E A C Dronkers
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - T C Bakker Schut
- Centre for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - H Mast
- Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - R J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - E B Wolvius
- Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - G J Puppels
- Centre for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - S Koljenović
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
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Barroso EM, Ten Hove I, Bakker Schut TC, Mast H, van Lanschot CGF, Smits RWH, Caspers PJ, Verdijk R, Noordhoek Hegt V, Baatenburg de Jong RJ, Wolvius EB, Puppels GJ, Koljenović S. Raman spectroscopy for assessment of bone resection margins in mandibulectomy for oral cavity squamous cell carcinoma. Eur J Cancer 2018; 92:77-87. [PMID: 29428867 DOI: 10.1016/j.ejca.2018.01.068] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 12/22/2017] [Accepted: 01/07/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the potential of Raman spectroscopy for detection of oral cavity squamous cell carcinoma (OCSCC) in bone resection surfaces during mandibulectomy. MATERIALS & METHODS Raman mapping experiments were performed on fresh mandible resection specimens from patients treated with mandibulectomy for OCSCC. A tumour detection algorithm was created based on water concentration and the high-wavenumber range (2800 cm-1-3050 cm-1) of the Raman spectra. RESULTS Twenty-six ex vivo Raman mapping experiments were performed on 26 fresh mandible resection specimens obtained from 22 patients. The algorithm was applied on an independent test set and showed an accuracy of 95%, a sensitivity of 95%, and a specificity of 87%. CONCLUSION These results form the basis for further development of a Raman spectroscopy tool as an objective method for intraoperative assessment of bone resection margins.
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Affiliation(s)
- Elisa M Barroso
- Department of Oral and Maxillofacial Surgery, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Ivo Ten Hove
- Department of Oral and Maxillofacial Surgery, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Tom C Bakker Schut
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - Hetty Mast
- Department of Oral and Maxillofacial Surgery, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Cornelia G F van Lanschot
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Roeland W H Smits
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Peter J Caspers
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Rob Verdijk
- Department of Pathology, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Vincent Noordhoek Hegt
- Department of Pathology, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Robert J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Eppo B Wolvius
- Department of Oral and Maxillofacial Surgery, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Gerwin J Puppels
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Senada Koljenović
- Department of Pathology, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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Abstract
Ablative surgery of mandible often necessitates combined reconstruction of the mandible and the temporomandibular joint. Fibula-free flaps with gap arthroplasty or osseochondral grafts are common procedures in the authors' practice. In search for a better reconstructive option free fibula flap is used together with a metatarsal bone flap for the vascular reconstruction of the mandibular body and the condyle at the same time. The 2 osseous-free flaps have been fused and used as a combined flow through double-free flap. The literature has been reviewed for other reconstructive options, but no alternatives providing autologous reconstruction of both the mandible and the condyle with vascular tissue have been found. This is a preliminary report of this new technique which the authors humbly think is very promising.
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13
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Free Hand Perforator Concept in Osteocutaneous Free Fibula Flap Through Posterior Approach. J Craniofac Surg 2017; 28:559-563. [DOI: 10.1097/scs.0000000000003342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Kumar BP, Venkatesh V, Kumar KAJ, Yadav BY, Mohan SR. Mandibular Reconstruction: Overview. J Maxillofac Oral Surg 2016; 15:425-441. [PMID: 27833334 PMCID: PMC5083680 DOI: 10.1007/s12663-015-0766-5] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 02/28/2015] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Mandibular reconstruction has changed significantly over the years and continues to evolve with the introduction of newer technologies and techniques. PURPOSE This article reviews the history of oromandibular reconstruction, biomechanics of mandible, summarizes the reconstruction options available for mandible with defect classification, goals in reconstruction, the various donor sites, current reconstructive options, dental rehabilitation and persistent associated problems. SUMMARY Oromandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes with the use of autogenous bone grafts and current reconstructive options. The ideal reconstruction would provide a solid arch to articulate with the upper jaw, restoring swallowing speech, mastication, and esthetics. Autogenous vascularized bone grafts in combination with microsurgical techniques have revolutionized mandibular reconstruction in oral cancer surgery. Current trends in mandibular reconstruction aim to achieve reestablishment of a viable mandible of proper form and maxillary mandibular relationship while decreasing the need for invasive autogenous graft procurement. However the optimal reconstruction of mandibular defects is still controversial in regards to reconstructive options which include the donor site selection, timing of surgery and method of reconstruction.
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Affiliation(s)
- Batchu Pavan Kumar
- Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda, 508254 Andhra Pradesh India
| | - V. Venkatesh
- Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda, 508254 Andhra Pradesh India
| | - K. A. Jeevan Kumar
- Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda, 508254 Andhra Pradesh India
| | - B. Yashwanth Yadav
- Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda, 508254 Andhra Pradesh India
| | - S. Ram Mohan
- Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda, 508254 Andhra Pradesh India
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Can the inferior alveolar nerve be used as a marker in frozen section for free margin control after segmental mandibulectomy in tumour ablation? Int J Oral Maxillofac Surg 2016; 45:1366-1371. [PMID: 27453212 DOI: 10.1016/j.ijom.2016.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 02/09/2016] [Accepted: 06/24/2016] [Indexed: 11/23/2022]
Abstract
This study critically assessed the possibility of tumour spread along the inferior alveolar nerve (IAN) and its sensitivity as an intraoperative marker for clear bony margin control in frozen section during segmental mandibulectomy. Fifteen patients with oral squamous cell carcinoma (OSCC) involving the mandible and requiring a segmental mandibulectomy were included in this prospective trial. The ends of the IAN were analyzed using quick section analysis and the results compared with those of the definite pathological report. Nerve tissue could be identified in 25 of the 27 specimens collected. No specimen revealed tumour invasion. All histological diagnoses were finally confirmed. Three positive bony margins with microscopic carcinoma infiltrates were found, whereas corresponding nerve tissue did not confirm tumour invasion. This study supports the assumption that the pattern of tumour invasion is rarely primarily along the IAN in OSCC involving the mandible. Quick section analysis of the nerve tissue alone is therefore not a valid marker for intraoperative bony margin control. However, it can be used as an additional intraoperative diagnostic tool combined with other methods in rare cases of primary tumour spread along the IAN. A review of current knowledge regarding bony margin control published in the literature is provided.
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Nieberler M, Häußler P, Kesting MR, Kolk A, Deppe H, Weirich G, Wolff KD. Clinical Impact of Intraoperative Cytological Assessment of Bone Resection Margins in Patients with Head and Neck Carcinoma. Ann Surg Oncol 2016; 23:3579-3586. [DOI: 10.1245/s10434-016-5208-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Indexed: 11/18/2022]
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17
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Sagittal split osteotomy on the previously reconstructed mandible with fibula free flap. J Craniofac Surg 2015; 25:1833-5. [PMID: 25203580 DOI: 10.1097/scs.0000000000001058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The fibula free flap offers several advantages in mandibular reconstruction, including an optimal length and bone quality for dental implantation; therefore, the use of this flap has become a method of choice for mandibular reconstruction. Although the development of computer-assisted surgical planning has increased the accuracy of mandibular reconstruction, some unexpected outcomes still occur in clinical settings. The patient in this report underwent mandibular reconstruction with the fibula free flap because of mandibular resection resulting from an ameloblastoma. However, unexpected movement of the grafted fibula bone had been observed, and we could not achieve a proper occlusal relationship even with implant-supported prosthesis. To resolve this problem, we corrected the position of previously grafted fibula and implants by using orthognathic surgery: sagittal split osteotomy on body and angle area and vertical osteotomy on the mandibular symphysis. After the orthognathic surgery at the previously reconstructed mandible with fibula free flap, a favorable and stable occlusal relationship could be achieved. The result demonstrated that the sagittal split osteotomy at the previous fibula free flap site can be successfully carried out to establish the proper occlusion.
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Evaluation of plate-related complications and efficacy in fibula free flap mandibular reconstruction. J Craniofac Surg 2015; 25:397-9. [PMID: 24561366 DOI: 10.1097/scs.0000000000000656] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIM The objective of this study was to evaluate the incidence of plate-related complications after vascularized bony reconstruction of the mandible, comparing the plate type used. PATIENTS AND METHODS Between 2004 and December 2012, a total of 41 free osteocutaneous fibula flaps have been used in an equal number of patients for reconstruction of the mandible, at the Division of Maxillofacial surgery, San Giovanni Battista Hospital, University of Turin. Malignant pathology was the most common indication for segmental mandibulectomy.Patient outcomes were retrospectively evaluated with special attention to plate complications such as plate fracture, exposure, infection, and bony nonunion.The types of reconstruction plates used were mandible plates 2.0, locking plates 2.0, miniplates (<2.0), and locking 2.4 plates. RESULTS Mandible plates 2.0 were used in 14 patients, locking plates 2.0 in 12 patients, and locking 2.4 plates in 4 patients. The most commonly used plates were miniplates, which were used in 86 patients.A total of 5 plate complications occurred after 41 procedures in an equal number of patients.Two complications occurred in patients receiving 2.0 mandible plates (2/14). One complication occurred in patients receiving 2.0 locking plates (1/12). Two complications occurred in patients receiving miniplates (2/86). CONCLUSIONS In our experience, miniplates are not associated to a high rate of complications comparing to other plates. The advantage of these plates and the low rate of complications make them our first choice for mandibular reconstructions.
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To Computer-Aided Design and Manufacturing or Not to Computer-Aided Design and Manufacturing? Free Fibula Flap With Computer-Aided Technique for Mandibular Reconstruction. J Craniofac Surg 2015; 26:e206-9. [DOI: 10.1097/scs.0000000000001431] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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20
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Nieberler M, Häusler P, Drecoll E, Stoeckelhuber M, Deppe H, Hölzle F, Kolk A, Wolff KD, Kesting MR, Weirich G. Evaluation of intraoperative cytological assessment of bone resection margins in patients with oral squamous cell carcinoma. Cancer Cytopathol 2014; 122:646-56. [PMID: 24753505 DOI: 10.1002/cncy.21428] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 03/16/2014] [Accepted: 03/17/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Frozen sections are routinely applied to control for adequate resection margins. In cases in which carcinoma infiltrates bone, the intraoperative microscopic assessment of bone margins remains challenging due to technical difficulties to section native bone. The objective of the current study was to evaluate an intraoperative cytological approach to control bone resection margins in patients with bone-infiltrating oral squamous cell carcinomas. METHODS A total of 174 cytological preparations obtained from bone margins of bone-infiltrating oral squamous cell carcinomas (28 patients) were assessed intraoperatively and compared with the corresponding histological findings. In a validation cohort (45 patients) the intraoperative cytological assessment of bone resection margins (ICAB) (104 margins) was evaluated as a diagnostic tool for routine clinical application. RESULTS In the first patient cohort, the ICAB revealed 95.3% sensitivity and 96% specificity. The results provided an accuracy of 95.7% with a significant correlation noted between cytological and histological results (κ, 0.91; P < .001), and a positive predictive value and negative predictive value of 93.8% and 96.9%, respectively. In the validation cohort, ICAB revealed 80% sensitivity and 98.9% specificity with 98% accuracy. There was a significant correlation found between cytological and histological results (κ, 0.91; P < .001), providing a positive predictive value and negative predictive value of 80% and 98%, respectively. ICAB could predict final resection status at bone margins with 80% sensitivity and 97.5% specificity. A significant correlation was found between the cytological and histological resection status at bone margins (κ, 0,75; P < .001). CONCLUSIONS ICAB could supplement intraoperative frozen sections of soft tissue margins as a standard procedure to control for adequate resection at bone margins.
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Affiliation(s)
- Markus Nieberler
- Department of Oral and Maxillofacial Surgery, Rechts der Isar Hospital, Technical University Munich, Munich, Germany
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21
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Harnessing the Potential of the Free Fibula Osteoseptocutaneous Flap in Mandible Reconstruction. Plast Reconstr Surg 2010; 125:305-314. [DOI: 10.1097/prs.0b013e3181c2bb9d] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Schrag C, Chang YM, Tsai CY, Wei FC. Complete rehabilitation of the mandible following segmental resection. J Surg Oncol 2006; 94:538-45. [PMID: 17061277 DOI: 10.1002/jso.20491] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Segmental resection of the mandible leads to significant patient morbidity. Loss of mandibular support to the teeth, tongue and lip causes dysfunctional mastication, swallowing, speech, airway protection and oral competence. Patients also suffer disfigurement following segmental mandibulectomy because the mandible is an important aesthetic landmark. The degrees to which dysfunction and disfigurement occur depend both on the location of the mandibular segment removed and the amount of surrounding soft tissue excised. Between January 1985 and December 2004, 780 fibula osteoseptocutaneous flaps have been used for head and neck reconstruction at the Chang Gung Memorial Hospital, Taiwan. The fibula flap has proven to be the bony flap of choice because it has a lengthy bicortical segment of bone available, a reasonably long vascular pedicle, large diameter vessels, good bone quality, and is easily contoured with multiple osteotomies. The flap can be harvested while ablation is being performed. In addition, a reliable, mobile, thin skin component can always be included to address the soft tissue reconstructive requirements. A chimeric design employing a portion of the soleus muscle can provide further reconstructive options. Ideally complete rehabilitation of the mandible involves placement of titanium osseointegrated implants, which allow dental restoration. Primary placement of implants is preferred in patients without cancer. Selection of candidates to receive osseointegrated implants is paramount. The temporomandibular joint remains a challenge to reconstruct adequately.
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Affiliation(s)
- Christiaan Schrag
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
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23
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Brown J, Chatterjee R, Lowe D, Lewis-Jones H, Rogers S, Vaughan D. A new guide to mandibular resection for oral squamous cell carcinoma based on the Cawood and Howell classification of the mandible. Int J Oral Maxillofac Surg 2005; 34:834-9. [PMID: 15919180 DOI: 10.1016/j.ijom.2005.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2004] [Revised: 04/10/2005] [Accepted: 04/14/2005] [Indexed: 01/18/2023]
Abstract
A new guide for mandibular resection in the management of oral squamous cell carcinoma based on the Cawood and Howell classification of the jaws is suggested. This was a retrospective review of case records and pre-operative orthopantomograms (OPG), bone scintigraphy and magnetic resonance imaging (MRI). The classification of the mandible was based on the residual bone height as measured in the molar region of the OPG to be equivalent to the Cawood and Howell classification of the mandible (Class I-II dentate or immediate post-extraction), Class III-IV >20mm well-rounded or knife-edge ridge, and Class V-VI <20mm (flat or depressed ridge form). Of the 77 patients, 58% (22/38) of Class I-II, 43% (9/23) of Class III-IV and 6% (1/16) of Class V-VI were treated with a marginal (rim) resection of the mandible. The predictability of the pre-operative investigations was more accurate in the edentulous mandible (Class III-VI). A simple guide is suggested for mandibular resection taking into account the pre-operative investigations, the estimation of invasion clinically, and the Cawood and Howell classification of ridge resorption.
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Affiliation(s)
- J Brown
- Regional Maxillofacial Unit, University Hospital Aintree, Lower Lane, Liverpool L9 7AL, UK.
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24
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Kolb F, Julieron M. Chirurgie réparatrice en cancérologie ORL : principales méthodes et indications. Cancer Radiother 2005; 9:16-30. [PMID: 15804616 DOI: 10.1016/j.canrad.2005.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2005] [Indexed: 10/25/2022]
Abstract
Oncologic cervicofacial surgery and plastic surgery have had a common evolution over the last 50 years where progress erasing from one was beneficial to the other one. We review here the historical evolution of these specialties and present the state of the art of plastic surgery in the field of cervicofacial oncology.
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Affiliation(s)
- F Kolb
- Département de cancérologie cervicofaciale, institut Gustave-Roussy, 39, rue Camille-Desmoulins, 94895 Villejuif, France.
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25
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Abstract
There is little evidence that the tumor enters the mandible preferentially through the occlusal surface, the periodontal membrane, or named foramina. Tumor enters the mandible at the point of contact, which is often at the junction of the attached and reflected mucosa, which lies below the crest of the ridge in all but grossly resorbed mandibles. Angulation of the bone cut in rim or marginal resection of the mandible is advised. The erosive pattern of disease is associated with shallow mandibular invasion and smaller tumors in the soft tissue. This finding supports the principle of marginal resection in such cases. There is little evidence to support the principle that the tumor spreads preferentially along the inferior alveolar nerve or the bone marrow. The inclusion of the neurovascular bundle in marginal resections of the mandible is not necessary. Preoperative assessment should include plain radiography combined with a sensitive scan (bone scintigraphy, single photon emission computerized tomography, or MRI) and inspection of the bone surface after periosteal stripping at the time of the resection.
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Affiliation(s)
- James Brown
- Regional Maxillofacial Unit, University Hospital Aintree, Liverpool L9 7AL, UK.
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26
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Baker A, McMahon J, Parmar S. Immediate reconstruction of continuity defects of the mandible after tumor surgery. J Oral Maxillofac Surg 2001; 59:1333-9. [PMID: 11688038 DOI: 10.1053/joms.2001.27825] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- A Baker
- Derbyshire Royal Infirmary, Derby, England.
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27
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Acton CH, Layt C, Gwynne R, Cooke R, Seaton D. Investigative modalities of mandibular invasion by squamous cell carcinoma. Laryngoscope 2000; 110:2050-5. [PMID: 11129019 DOI: 10.1097/00005537-200012000-00014] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES/HYPOTHESIS To compare preoperative investigations with histological findings in squamous cell carcinoma (SCC) of the oral mucosa that abuts the mandible. Both clinical and radiological examinations fail to predict accurately invasion of the mandible by intraoral SCC. STUDY DESIGN This two-part, prospective study is of a consecutive series of patients whose first malignancy of the upper aerodigestive tract abutted the lingual surface of the mandible. METHODS AR patients presented to the Queensland Radium Institute Head and Neck Clinic between 1993 and 1997 with a biopsy-proven SCC that abutted the mandible. These tumors were investigated clinically, radiologically, and histologically. Sensitivity, specificity, and predictive values were calculated for various approaches. In the second part of the study, single photon emission computed tomography (SPECT) bone scans were included. Quantification ratios of bone scans compared the average counting statistics in visually identified mandibular abnormal uptake with normal cervical spine and jaw. RESULTS Sixty-seven patients were followed for 55 months and assessed with orthopantomogram (OPG), computed tomography (CT) scans, and, in the second part of the study, SPECT bone scans. Thirty-six tumors showed histological evidence of bony invasion. Bony involvement was suggested by OPG in 36 and confirmed histologically in 27 patients. CT scans showed evidence of bone invasion in 22 cases, with 18 of these histologically confirmed. Technetium 99m methylene diphosphonate (MDP) bone scans with planar imaging and SPECT were performed in 24 patients, and histological appearance was suitable for analysis in 14. Three patients with tumor (cervical spine ratios greater than 1.5 predicting malignant involvement) had this confirmed histologically. CONCLUSIONS The first part of the study confirms our hypothesis that currently used investigations, as well as clinical assessment, fail to predict accurately invasion of the mandible by intraoral SCC. The second part suggests that SPECT scanning with high quantification ratios is promising in the prediction of tumor involvement.
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Affiliation(s)
- C H Acton
- Department of Paediatrics and Child Health, Royal Brisbane Hospital, Queensland, Australia
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28
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Lydaki E, Bolonaki I, Stiakaki E, Kambourakis A, Cordeiro PB, Meyers PA, Delides G, Hatzimanolis P, Kalmanti M. Immediate free flap mandibular reconstruction in osteosarcoma of the mandible in childhood. Pediatr Hematol Oncol 2000; 17:335-40. [PMID: 10845233 DOI: 10.1080/088800100276334] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Mandibular osteogenic sarcoma (OS) is a very rare entity in childhood. Adequate surgical rejection with a wide margin of normal tissue is the mainstay of treatment of this site, while the role of adjuvant chemotherapy remains uncertain. A case is presented of a 15 1/2-year-old male with a huge OS of the mandible. The boy underwent surgical resection of the mandible with immediate fibula free flap reconstruction and is alive and free of disease 6 1/2 years following unitial diagnosis. This case suggests that immediate bone reconstitution with vascularized grafts have good functional and morphological results for osteosarcoma of the lower jaw.
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Affiliation(s)
- E Lydaki
- Department of Pediatric Hematology/Oncology, University Hospital of Heraklion, Crete, Greece
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29
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Abstract
PURPOSE Efforts to conserve the mandible in resection for oral cancer tend to bring the resection margin progressively closer to the tumor front. This study of the manner of mandibular invasion by carcinoma of the lower alveolus provides added information regarding the behavior of the cancer within the bone. MATERIALS AND METHODS Twenty-four resected specimens of squamous carcinoma of the lower alveolus were studied with x-rays and step-serial whole-organ histological sections. RESULTS In 19 of the 21 specimens showing bone invasion, the spread was in the form of a broad front. Insinuation of tumor beyond the tumor front was extensive in 9 of 13 tumors showing deep mandibular invasion. Horizontal subcortical spread took place in 5 of 18 specimens for a distance of up to 1 cm. Perineural spread along the inferior alveolar nerve was found in 4 of 13 specimens in which the tumor extended to the canal; tumor spread along the canal, without neural involvement, was never seen. Preoperative orthopantomogram correctly estimated the extent of mandibular invasion in 16 of 24 patients. CONCLUSIONS The tumor front of mandibular invasion by carcinoma of the lower alveolus is usually broad. In the absence of deep invasion, which is defined by invasion reaching the alveolar canal, there is little or no insinuation of cancer cells beyond the tumor front, and no spread along the alveolar canal. Marginal mandibulectomy can be applied more widely, taking a margin of 1 cm in all directions.
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Affiliation(s)
- K H Lam
- Department of Surgery, Queen Mary Hospital, the University of Hong Kong, Hong Kong
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30
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Demirkan F, Wei FC, Chen HC, Chen IH, Liao CT. Oromandibular reconstruction using a third free flap in sequence in recurrent carcinoma. BRITISH JOURNAL OF PLASTIC SURGERY 1999; 52:429-33. [PMID: 10673916 DOI: 10.1054/bjps.1999.3173] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Successful results of a second microsurgical reconstructive attempt have been reported previously in recurrent oral carcinoma. However, the feasibility of a third free flap following a third excision has remained to be determined. Six oral carcinoma patients with multiple recurrences, surgical excisions and free flap reconstructions on three separate occasions are presented. Resections had a curative intent in all cases in the first and second ablations and in four of the six cases in the third one. Five radial forearm flaps and one double free flap were used for the first reconstruction. During the second reconstruction two radial forearm, two fibula osteoseptocutaneous, one double free flap and one rectus femoris flap were used to reconstruct the larger defects resulting from excision of the recurrent tumours. However, no vascularised bone transfers were performed following the third excision and soft tissue free flap plus plate option was used for segmental mandibular defects. There was one partial flap loss among 21 free flaps performed. Three patients died within an average of 8 months following the third reconstruction while the others remained alive, surviving an average of 6 months. In conclusion, a third free tissue transfer for reconstruction in multiply recurrent oral carcinoma was found to be feasible, safe and effective. The use of free flaps contributed to the prevention of complications in these difficult cases and enabled the patients to spend the remaining days of their lives outside hospital.
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Affiliation(s)
- F Demirkan
- Department of Plastic and Reconstructive Surgery, Chang Gung University, Taipei, Taiwan
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31
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Schwartz MH, Drew SJ, Sachs SA. Osseous Reconstruction Following Treatment of Head and Neck Tumors. Oral Maxillofac Surg Clin North Am 1997. [DOI: 10.1016/s1042-3699(20)30961-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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32
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Ord RA, Aisner S. Accuracy of frozen sections in assessing margins in oral cancer resection. J Oral Maxillofac Surg 1997; 55:663-9; discussion 669-71. [PMID: 9216496 DOI: 10.1016/s0278-2391(97)90570-x] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE This study examined the accuracy of frozen section diagnosis of tissue samples from surgical margins compared with the final histologic diagnosis of the same tissue. The total resection specimen was also examined to see whether frozen sections were helpful in predicting negative margins for the entire cancer. The nature of positive and negative margins and their implications for the surgeon are discussed. PATIENTS AND METHODS The records of 49 consecutive patients with previously untreated squamous carcinoma of the mouth were reviewed. All frozen and permanent sections were evaluated by one pathologist. Margins involved by carcinoma, carcinoma in situ, dysplasia, or with carcinoma within 5 mm were defined as positive. Histologic findings were compared with the patient's clinical course to define the relationship between positive margins and local recurrence. Patients were followed for 17 to 45 months or until death. RESULTS Three hundred four of 307 frozen sections showed concordance with the permanent section of the same tissue sample (two false negative and one false positive), an accuracy rate of 99%. When the final margins of the resected surgical specimen were compared with the frozen section diagnoses, ten patients had positive final margins. In three patients, these were diagnosed by frozen section. Seven patients had final margins that were positive when the surgical resection specimen was examined but were not diagnosed by frozen section. A greater local recurrence note was found in patients with invasive carcinoma at the margin, dysplastic margins, and margins within 5 mm of the cancer. CONCLUSIONS Although frozen sections are extremely accurate, they are not as reliable in eliminating positive margins in the final specimen as the surgeon might hope.
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Affiliation(s)
- R A Ord
- Department of Oral and Maxillofacial Surgery, University of Maryland, Baltimore 21201-1586, USA
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33
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Ord RA, Sarmadi M, Papadimitrou J. A comparison of segmental and marginal bony resection for oral squamous cell carcinoma involving the mandible. J Oral Maxillofac Surg 1997; 55:470-7; discussion 477-8. [PMID: 9146516 DOI: 10.1016/s0278-2391(97)90693-5] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE This study reviews the accuracy of preopertive diagnosis of mandibular invasion by oral squamous cell carcinoma and assesses the role of marginal resection of the mandible in its treatment. PATIENTS AND METHODS A retrospective study of a 5-year cohort of 46 patients who underwent mandibular resection for previously untreated oral squamous cell carcinoma was done. Data evaluated included age; sex; site and stage of cancer; preoperative clinical, panoramic, and computed tomography (CT) evaluations; and histologic findings on the resection specimen. The type of mandibular resection (segmental vs marginal) and treatment outcome also were compared. RESULTS Clinical examination, panoramic radiographs, and CT scans were 78.5% to 82.6% accurate in diagnosing mandibular invasion by squamous carcinoma. Clinical examination and panoramic radiographs are more sensitive than CT scans (86.6% vs 53%), but CT scans were more specific (92.5% vs 80%). The mandible was involved in 65% of patients with segmental resection and 7.6% of patients who had a marginal resection. Nineteen percent of the patients in the marginal resection group died of their oral cancer, two of five patients with local recurrence. Ten percent of patients in the segmental resection group died of oral cancer; no local recurrences were seen. CONCLUSION There is no completely accurate method of diagnosing bony invasion of the mandible by oral squamous cell carcinoma. A combination of clinical examination, plain radiographs, and computed tomography (CT) scans may improve the diagnosis. Marginal resection is best reserved for cancers close to the bone with no invasion, minimal cortical invasion, or with early "arrosive" invasion. It is best in the symphysis region. Careful case selection will allow a favorable oncologic outcome with preservation of the mandibular contour.
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Affiliation(s)
- R A Ord
- Department of Oral and Maxillofacial Surgery, University of Maryland at Baltimore, USA
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34
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Reychler H, Iriarte Ortabe J, Pecheur A, Brogniez V. Mandibular reconstruction with a free vascularized fibula flap and osseointegrated implants: a report of four cases. J Oral Maxillofac Surg 1996; 54:1464-9. [PMID: 8957129 DOI: 10.1016/s0278-2391(96)90267-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- H Reychler
- Saint-Luc University Hospital, Catholic University of Louvain-en-Woluwe, Brussels, Belgium
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35
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Abstract
Of the various oral carcinoma subsites, the carcinomas related to the mandibular region (alveolar ridge, floor of mouth, lower retromolar area, lower buccal sulcus) are among those with the highest rate of recurrences. Neoplastic invasion of the mandible is one of the factors promoting the recurrences. Determining the presence and extent of bony involvement is therefore critical in the management of patients. The surgeon has several methods to aid in the determination of margins of invasion: radiology, gross clinical inspection, and intraoperative frozen section. Each has its deficiences and in the end, it is a combination of the methods, tempered by clinical judgment, that produces the best results.
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Affiliation(s)
- K R Cleary
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, USA
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36
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Affiliation(s)
- D D Lydiatt
- Department of Otolaryngology-Head and Neck Surgical Oncology, University of Nebraska Medical Center, Omaha 68198-1225, USA
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37
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Abstract
We reviewed the records of 27 patients who underwent primary mandibular reconstruction with AO plates to investigate the outcome and complications of this procedure. Immediate soft-tissue flap coverage was required in 26 patients. Early complications were seen in 44% of the patients, with the highest incidence after irradiation (P = 0.02). Late complications were mostly related to tumor recurrence (12). Late complications not associated with recurrence were persistent pain (2), minor infections (3), plate exposure (3), and plate fracture (1). Good to excellent cosmetic results were obtained in all but 1 patient. Full mastication was not possible for any of our patients, and therefore function was not fully restored. Speech and deglutition were mostly influenced by the amount of soft-tissue resection. Mean follow-up was 20 months (range 3 to 52). At last evaluation, 12 patients were alive and free of disease, and 15 were dead of disease or other causes. Our results show that primary mandibular reconstruction with rigid plates is a safe, effective, and reliable technique to restore mandibular continuity and cosmesis. For lateral defects, this method is a viable alternative to free vascularized osseocutaneous flaps.
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Affiliation(s)
- P Lavertu
- Department of Otolaryngology, Cleveland Clinic Foundation, Ohio 44195
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