A National Assessment of Racial and Ethnic Disparities in Cleft Lip Repair

PURPOSE

This study examined the impact of patient race/ethnicity on the likelihood of experiencing delays to surgery, post-operative surgical complications, and prolonged hospital length of stay (LOS) following primary cleft lip (CL) repair.

METHODS

Patients who underwent CL repair were identified in the 2006-2012 Kids' Inpatient Database. Primary outcomes were defined as treatment after 6-months-old, presence of any surgical complication, LOS >1 day, and total hospital charges. Multivariable analyses were performed to adjust for sociodemographic and clinical characteristics that might account for differences in outcomes.

RESULTS

There were 5927 eligible patients with cleft lip: 3724 White, 279 Black, 1316 Hispanic, 277 Asian/Pacific-Islander, and 331 other race/ethnicity. Across all outcomes, there were significant unadjusted differences (p<0.001) by race/ethnicity, with White children having the lowest odds of delayed surgery, complications, and prolonged LOS, and the lowest charges. Multivariable analyses suggested that differences in baseline health status may account for much of this disparity in combination with factors such as income, insurance type, and location. Even after adjusting for co-variates, significantly increased odds of delayed surgery and higher charges remained for Hispanic and Asian/PI patients.

CONCLUSION

There are significant differences in the odds of delays, complications, prolonged hospital stays, and total charges among CL patients of different race/ethnicity. Advocacy efforts to ameliorate disparity in early infant health may subsequently improve equity in cleft outcomes.

Gender Differences Among Head and Neck Microvascular Reconstructive Surgeons

OBJECTIVE

To determine whether gender differences exist in the training history, practice patterns, and home lives of surgeons who perform microvascular reconstruction of the head and neck.

STUDY DESIGN

Cross-sectional survey.

SETTING

Medical facilities that employ surgeons who practice head and neck microvascular reconstruction in the United States.

METHODS

A survey was created using the Research Electronic Data Capture Framework and was distributed via email to microvascular reconstructive surgeons. Descriptive statistics were performed using Stata software.

RESULTS

No significant differences were found in training or current practice patterns between microvascular surgeons who identify as men versus those who identify as women. Women had fewer children (p = .020) and were more likely to be childless (p = .002). Whereas men were more likely to report a spouse/partner as primary caretaker, women were more likely to hire a professional caretaker or cite themselves as a primary caretaker (p < .001). Women were more likely to have finished residency (p = .015) and fellowship (p = .014) more recently and to practice in the Southeast (p = .006). Of the microvascular surgeons who reported practice setting switches, men more commonly changed positions for career advancement, whereas women were more likely to switch due to burnout (p = .002).

CONCLUSION

This study found no gender-based differences in training or practice patterns. However, significant differences were identified in childbearing, family structure, geographic practice location, and motives for switching practice.

TMJ Ankylosis Following Mandibular Distraction Osteogenesis: Management With Simultaneous Midface External Distraction and Bilateral Temporomandibular Joint Replacement

Early mandibular distraction osteogenesis (MDO) can decrease upper airway and feeding complications in pediatric patients with micrognathia; however, temporomandibular joint (TMJ) complications like TMJ ankylosis (TMJA) may occur. TMJA can disturb pediatric patients' function and craniofacial growth, resulting in significant physical and psychosocial consequences. Additional surgical procedures may also be required, increasing the burden of care on patients and their families. CMF surgeons must discuss the potential complications of early MDO surgery with families as well as potential solutions should these problems occur. This report presents the case of a 17-year-old male with a severe craniofacial anomaly with features of Treacher-Collins syndrome (TCS) and a surgical history of tracheostomy, cleft palate repair, mandibular reconstruction with harvested costochondral grafts, and MDO with resultant bilateral TMJA and limited mouth opening. The patient Was treated with bilateral custom alloplastic TMJ replacements and simultaneous maxillary DO using a Rigid External Distraction (RED) device.

Extent of Extranodal Extension in Oral Cavity Squamous Cell Carcinoma is Not Independently Associated With Overall or Disease-Free Survival at a 2.0-mm Threshold

PURPOSE

The presence of extranodal extension (ENE) conveys a poor prognosis in oral cavity squamous cell carcinoma (OSCC); however, there is no consensus regarding whether the histopathologic extent of ENE (e-ENE) may be a more discriminating prognostic indicator. The purpose of this study was to assess the impact of minor ENE (<2.0 mm) versus major ENE (≥ 2.0 mm) on overall survival (OS) and disease-free survival (DFS) in OSCC.

MATERIALS AND METHODS

A single-institution, retrospective cohort study was designed using an electronic medical record review. Inclusion criteria included patients with OSCC and cervical node metastasis. All subjects were treated between the years 2009 and 2017 in the Michigan Medicine Department of Oral and Maxillofacial Surgery (Ann Arbor, Michigan). The primary predictor variable was e-ENE, measured as the maximum distance of tumor invasion into extranodal tissue from the outer aspect of the nodal capsule. Primary outcome variables were OS and DFS. Other covariates included demographic data, tumor staging, and histopathologic data. Descriptive statistics were performed. Kaplan-Meier survival plots for OS and DFS were performed. The data were mined for an alternative threshold at which e-ENE may impact survival using Cox proportional hazards models.

RESULTS

One hundred sixty eight subjects were included (91 ENE-negative, 48 minor ENE, and 29 major ENE). Most subjects were male (62%) and the mean age was 62.9 years. Mean follow-up time was 2.97 +/- 2.76 years. There was no statistically significant difference in OS or DFS between minor and major ENE. Five-year OS for minor ENE was 30.4% versus 20.7% for major ENE (P = .28). Five-year DFS for minor ENE was 26.7% versus 18.1% for major ENE (P = .30). Five-year OS and DFS was worse for subjects with ENE-positive disease versus ENE-negative disease (OS: 26.9% vs 63.1%, hazard ratio [HR]: 2.70, 95% confidence interval [CI]: [1.77, 4.10], P < .001; DFS: 23.7% vs 59.7%, HR = 2.55, 95% CI [1.71, 3.79], P < .001). At an alternative threshold of 0.9 mm e-ENE, there was greater DFS in subjects with e-ENE 0.1-0.9 mm versus e-ENE > 0.9 (40.6% vs 18.9%, respectively) (HR = 0.49, 95% CI [0.24, 0.99], P = .047).

CONCLUSION

There was no independent association between survival and e-ENE at a 2.0-mm threshold.

Clinical Practice Trends and Postoperative Outcomes in Primary Cleft Rhinoplasty

PURPOSE

Optimal correction of the cleft nasal deformity remains challenging. The purpose of this study was to examine the practice patterns and postoperative course of patients undergoing cleft lip repair with rhinoplasty compared to those who have primary lip repair without rhinoplasty.

METHODS AND MATERIALS

A retrospective cohort study was conducted based on the Kids' Inpatient Database. Data were collected from January 2000 to December 2011 and included infants aged 12 months and younger who underwent cleft lip repair. The predictor variable was the addition of rhinoplasty at primary cleft lip repair. Primary outcome variables included hospital setting, year, and admission cost, while secondary outcome variables included length of stay and postoperative complication rate. Independent t-tests and chi-squared tests were performed. Continuous variables were analyzed by multiple linear regression models.

RESULTS

The study sample included 4559 infants with 1422 (31.2%) who underwent primary cleft rhinoplasty. Over time, there was a significant increase in the proportion of cleft lip repairs accompanied by a rhinoplasty (p < .01). A greater proportion of patients with unilateral cleft lips received simultaneous rhinoplasty with their lip repairs (33.8 vs 26.0%, p < .01). This cohort had a significantly shorter length of stay (1.6 vs 2.8 days, p < .01) when compared to children that underwent cleft lip repair alone.

CONCLUSIONS

Performing primary cleft rhinoplasty is becoming more common among cleft surgeons. Considering comparable costs and complication rates, a rhinoplasty should be considered during the surgical treatment planning of patients with cleft nasal deformities.

Polymeric scaffolds for dental pulp tissue engineering: A review

OBJECTIVES

The purpose of this review is to describe recent developments in pulp tissue engineering using scaffolds and/or stem cells. It is crucial to understand how this approach can revitalize damaged dentin-pulp tissue. Widespread scaffold materials, both natural and synthetic, and their fabrication methods, and stem-progenitor cells with the potential of pulp regeneration will be discussed.

DATA AND SOURCES

A review of literature was conducted through online databases, including MEDLINE by using the PubMed search engine, Scopus, and the Cochrane Library.

STUDY SELECTION

Studies were selected based on relevance, with a preference given to recent research, particularly from the past decade.

CONCLUSIONS

The use of biomaterial scaffolds and stem cells can be safe and potent for the regeneration of pulp tissue and re-establishment of tooth vitality. Natural and synthetic polymers have distinct advantages and limitations and in vitro and in vivo testing have produced positive results for cell attachment, proliferation, and angiogenesis. The type of biomaterial used for scaffold fabrication also facilitates stem cell differentiation into odontoblasts and the resulting biochemistry of tissue repair for each polymer and cell type was discussed. Multiple methods of scaffold design exist for pulp tissue engineering, which demonstrates the variability in tissue engineering applications in endodontics. This review explains the potential of evidence-based tissue engineering strategies and outcomes in pulp regeneration.

Evaluating the July Effect in Oral and Maxillofacial Surgery: Part II-Orthognathic Surgery

PURPOSE

The purpose of this study was to determine if there is an increased postoperative complication rate in orthognathic surgery during the first academic quarter (Q1) (July to September).

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was accessed to identify cases with Current Procedural Terminology codes pertaining to orthognathic procedures from 2008 to 2017. Procedures were separated into 2 groups based on time in the academic year: Q1 (July to September) versus remaining quarters (RQ). The inclusion criteria were Current Procedural Terminology codes representing operations resulting in movement of the dentate portion of the jaws and age of 18 years or older. Patient demographic characteristics and perioperative complications were compared between the groups. Descriptive statistics, Fisher exact tests, and χ² tests were executed.

RESULTS

The Q1 cohort included 877 cases, and the RQ cohort included 2,062 cases. The average age of patients was 47.0 ± 19.5 years in Q1 versus 47.2 ± 19.4 years in RQ. The most frequent complications were blood transfusion (11.97% in Q1 vs 12.57% in RQ, P = .64), reoperation (8.67% in Q1 vs 8.84% in RQ, P = .87), and combined superficial and deep-space infection (5.02% in Q1 vs 5.76% in RQ, P = .51). Medical complications involving other organ systems were rare (<1%). Analyses showed no significance between complication rate and time of year.

CONCLUSIONS

The results of this study indicate that there is no association between time of year and complication rates after orthognathic surgery. Additional investigations could be useful in shining light on this topic as it pertains to the training of future surgeons.

Standing on the Shoulders of Giants: Dental Students Seek Academically Productive Mentors

PURPOSE

The purpose of this study was to determine whether a strong statistical correlation exists between the involvement of trainee groups and the academic productivity of the senior author.

MATERIALS AND METHODS

A retrospective cohort study of publications in the Journal of Oral and Maxillofacial Surgery from 2002 to 2016 was designed and implemented. The primary predictor variables were the presence of a trainee (dental student or oral and maxillofacial surgery [OMS] resident), year of publication, and study design and topic. The outcome variable was the Hirsch index (h-index) of the senior author. Author affiliations were queried using ScienceDirect, and the Scopus database was used to identify the h-index of the senior author from each publication spanning the previous 15 years. Descriptive statistics and t tests were performed to determine significance.

RESULTS

Of the 6,398 articles published in the Journal of Oral and Maxillofacial Surgery from January 2002 to December 2016, 1,341 (21.0%) met the inclusion criteria. The mean h-index of senior authors of articles with trainees or OMS residents was not significantly different from the mean h-index of senior authors without trainees (P = .50) or OMS residents (P = .37), whereas the mean h-index of senior authors working with dental students was significantly greater than the h-index of those not working with dental students (P < .01). Dental student mentors had a mean h-index that was below the sample mean from 2002 to 2007 but rose above the sample mean from 2010 to 2016. Trainees were more likely to work with academically productive mentors in orthognathic surgery (P < .01), temporomandibular joint (P < .05), retrospective cohort (P < .05), and innovative technique (P < .05) studies but less likely in randomized controlled trials (P < .05).

CONCLUSIONS

Dental students seek more academically productive mentors to a greater degree. More studies should be conducted to elucidate the attributes of the ideal mentor in academic OMS and to determine whether differences in mentorship exist between domestic and foreign OMS programs.

Fixation Points in the Treatment of Traumatic Zygomaticomaxillary Complex Fractures: A Systematic Review and Meta-Analysis

PURPOSE

Controversy remains regarding the optimal degree of anatomic exposure, reduction, and fixation required during open reduction and internal fixation of zygomaticomaxillary complex (ZMC) fractures. We critically examined the reported data to compare the patient outcomes after various degrees of ZMC reduction and internal fixation.

MATERIALS AND METHODS

A systematic review and meta-analysis were designed to test the null hypothesis of no difference in outcomes between different degrees of fixation of ZMC fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Of 1213 screened studies, 13 met the inclusion criteria. Fracture instability at 3 months was greater with 2-point fixation (61.1%) than with 3-point fixation (10.6%; relative risk, 2.5, 95% confidence interval [CI], 1.4 to 3.3). Less vertical orbital dystopia was seen with 3-point fixation than with 2-point fixation (mean difference, 0.9 mm; 95% CI, 0.6 to 1.3 mm). The incidence of infection and malar asymmetry did not differ between the groups. The quality of evidence was very low to low.

CONCLUSIONS

The reported data were limited by low quality, retrospective studies. However, the meta-analysis of randomized control trial data suggested a superiority of 3 points of exposure and fixation regarding fracture stability. When 2 points appear to provide stable fixation, the potential benefits of a third point should be weighed against the cost, operative time, and exposure/periosteal stripping on a case-by-case basis.

Trainee Contribution Is Not Associated With Citation Frequency: A Retrospective Study

PURPOSE

Publication citation frequency is a measure of scientific influence. The purpose of this study was to measure the association between trainee involvement in publications and citation frequency.

MATERIALS AND METHODS

A retrospective cohort study of the Journal of Oral and Maxillofacial Surgery from January to December 2010 was conducted. For each included publication, the study topic and design were recorded. The primary predictor variable was trainee involvement (yes or no). For the purpose of our study, the term "trainee" encompassed dental students, graduate (non-dental) students, oral and maxillofacial surgery residents, and non-oral and maxillofacial surgery residents, as indicated by author affiliations listed in each article. The outcome variable was the number of citations accumulated between 2010 and 2017. Descriptive statistics were computed. Analyses of variance were performed to compare citation distribution among study types and designs. Student t tests and χ² tests were performed.

RESULTS

The sample consisted of 111 publications, of which 85 (76.6%) had at least 1 trainee author. Among all publications, the mean number of citations was significantly different across study designs (P = .03), with case reports earning the lowest number of citations on average (mean, 14.9 citations). Trainee publications had significantly different distributions of study topics (P = .02) and designs (P < .01). Among publications with a trainee author, the most common topic was pathology (37%) and the most common study design was a case report (45%). Despite the higher proportion of case reports, the mean number of citations between trainee (mean, 30.4 citations) and non-trainee (mean, 30.5 citations) publications was not significantly different (P = .99).

CONCLUSIONS

Including trainees does not alter the citation frequency of the articles published in the Journal of Oral and Maxillofacial Surgery. This finding is encouraging to both academic surgeons and their trainees, as a higher volume of students and residents can be engaged in research while preserving the influence of the published works.

Advancements in craniofacial prosthesis fabrication: A narrative review of holistic treatment

The treatment of craniofacial anomalies has been challenging as a result of technological shortcomings that could not provide a consistent protocol to perfectly restore patient-specific anatomy. In the past, wax-up and impression-based maneuvers were implemented to achieve this clinical end. However, with the advent of computer-aided design and computer-aided manufacturing (CAD/CAM) technology, a rapid and cost-effective workflow in prosthetic rehabilitation has taken the place of the outdated procedures. Because the use of implants is so profound in different facets of restorative dentistry, their placement for craniofacial prosthesis retention has also been widely popular and advantageous in a variety of clinical settings. This review aims to effectively describe the well-rounded and interdisciplinary practice of craniofacial prosthesis fabrication and retention by outlining fabrication, osseointegrated implant placement for prosthesis retention, a myriad of clinical examples in the craniofacial complex, and a glimpse of the future of bioengineering principles to restore bioactivity and physiology to the previously defected tissue.

Evaluation of the in vitro biodegradation and biological behavior of poly(lactic-co-glycolic acid)/nano-fluorhydroxyapatite composite microsphere-sintered scaffold for bone tissue engineering

The objective of this research was to study the degradation and biological characteristics of the three-dimensional porous composite scaffold made of poly(lactic- co-glycolic acid)/nano-fluorhydroxyapatite microsphere using sintering method for potential bone tissue engineering. Our previous experimental results demonstrated that poly(lactic- co-glycolic acid)/nano-fluorhydroxyapatite composite scaffold with a ratio of 4:1 sintered at 90ºC for 2 h has the greatest mechanical properties and a proper pore structure for bone repair applications. The weight loss percentage of both poly(lactic- co-glycolic acid)/nano-fluorhydroxyapatite and poly(lactic- co-glycolic acid) scaffolds demonstrated a monotonic trend with increasing degradation time, that is, the incorporation of nano-fluorhydroxyapatite into polymeric scaffold could lead to weight loss in comparison with that of pure poly(lactic- co-glycolic acid). The pH change for composite scaffolds showed that there was a slight decrease until 2 weeks after immersion in simulated body fluid, followed by a significant increase in the pH of simulated body fluid without a scaffold at the end of immersion time. The mechanical properties of composite scaffold were higher than that of poly(lactic- co-glycolic acid) scaffold at total time of incubation in simulated body fluid; however, it should be noted that the incorporation of nano-fluorhydroxyapatite into composite scaffold leads to decline in the relatively significant mechanical strength and modulus during hydrolytic degradation. In addition, MTT assay and alkaline phosphatase activity results defined that a general trend of increasing cell viability was seen for poly(lactic- co-glycolic acid)/nano-fluorhydroxyapatite scaffold sintered by time when compared to control group. Eventually, experimental results exhibited poly(lactic- co-glycolic acid)/nano-fluorhydroxyapatite microsphere-sintered scaffold is a promising scaffold for bone repair.

Evaluation of glycated albumin (GA) and GA/HbA1c ratio for diagnosis of diabetes and glycemic control: A comprehensive review

Diabetes Mellitus (DM) is a group of metabolic diseases characterized by chronic high blood glucose concentrations (hyperglycemia). When it is left untreated or improperly managed, it can lead to acute complications including diabetic ketoacidosis and non-ketotic hyperosmolar coma. In addition, possible long-term complications include impotence, nerve damage, stroke, chronic kidney failure, cardiovascular disease, foot ulcers, and retinopathy. Historically, universal methods to measure glycemic control for the diagnosis of diabetes included fasting plasma glucose level (FPG), 2-h plasma glucose (2HP), and random plasma glucose. However, these measurements did not provide information about glycemic control over a long period of time. To address this problem, there has been a switch in the past decade to diagnosing diabetes and its severity through measurement of blood glycated proteins such as Hemoglobin A1c (HbA1c) and glycated albumin (GA). Diagnosis and evaluation of diabetes using glycated proteins has many advantages including high accuracy of glycemic control over a period of time. Currently, common laboratory methods used to measure glycated proteins are high-performance liquid chromatography (HPLC), immunoassay, and electrophoresis. HbA1c is one of the most important diagnostic factors for diabetes. However, some reports indicate that HbA1c is not a suitable marker to determine glycemic control in all diabetic patients. GA, which is not influenced by changes in the lifespan of erythrocytes, is thought to be a good alternative indicator of glycemic control in diabetic patients. Here, we review the literature that has investigated the suitability of HbA1c, GA and GA:HbA1c as indicators of long-term glycemic control and demonstrate the importance of selecting the appropriate glycated protein based on the patient's health status in order to provide useful and modern point-of-care monitoring and treatment.