Study protocol of a prospective multicenter study comparing (cost-)effectiveness of a tailored interdisciplinary head and neck rehabilitation program to usual supportive care for patients treated with concomitant chemo- or bioradiotherapy

BACKGROUND

Since 2011, a tailored, interdisciplinary head and neck rehabilitation (IHNR) program, covered by the basic healthcare insurance, is offered to advanced head and neck cancer (HNC) patients in the Netherlands Cancer Institute (NKI). This program is developed to preserve or restore patients' functioning, and to optimize health-related quality of life (HRQoL). It applies an integrated approach to define patients' individual goals and provide rehabilitation care throughout the cancer care continuum. The aim of the current study is to assess the (cost-) effectiveness of the IHNR approach compared to usual supportive care (USC) consisting of monodisciplinary and multidisciplinary care in advanced HNC patients.

METHODS

This multicenter prospective observational study is designed to compare (cost-)effectiveness of the IHNR to USC for advanced HNC patients treated with chemoradiotherapy (CRT) or bioradiotherapy (BRT). The primary outcome is HRQoL represented in the EORTC QLQ-C30 summary score. Functional HRQoL, societal participation, utility values, return to work (RTW), unmet needs (UN), patient satisfaction and clinical outcomes are secondary outcomes, assessed using the EORTC QLQ-H&N35, USER-P, EQ-5D-5 L, and study-specific questionnaires, respectively. Both patient groups (required sample size: 64 per arm) are requested to complete the questionnaires at: diagnosis (baseline; T0), 3 months (T1), 6 months (T2), 9 months (T3) and 12 months (T4) after start of medical treatment. Differences in outcomes between the intervention and control group will be analyzed using mixed effects models, Chi-square test and descriptive statistics. In addition, a cost-effectiveness analysis (CEA) will be performed by means of a Markov decision model. The CEA will be performed using a societal perspective of the Netherlands.

DISCUSSION

This prospective multicenter study will provide evidence on the effectiveness and cost-effectiveness of IHNR compared to USC. RTW and societal participation, included as secondary outcomes, have not been studied sufficiently yet in cancer rehabilitation. Interdisciplinary rehabilitation has not yet been implemented as usual care in all centers, which offers the opportunity to perform a controlled clinical study. If demonstrated to be (cost-)effective, national provision of the program can probably be advised.

TRIAL REGISTRATION

The study has been retrospectively registered in the Netherlands Trial Registry on April 24th 2018 ( NTR7140 ).

Combined Mandibular Guidance Therapy in the Management of a Hemimandibulectomy Patient

This case history report describes two different devices, maxillary ramp prostheses (MRP) and mandibular guide flange prostheses (MGFP), prescribed for managing a hemimandibulectomy patient's deviated mandible. The patient was given muscle reprogramming exercises with coordinated use of both guidance prostheses for 2 months, leading to improvements in both postsurgical mandibular deviation and occlusal equilibration. A successful intercuspal position was eventually accomplished through the use of the combination therapy. MRP and MGFP can be a useful approach to avoid mandibular deviation and compromised function following a partial mandibular resection.

Clinical experience on use of oral EGFR-TKIs as first-line treatment of advanced NSCLC from a tertiary care centre in North India and implications of skin rash

BACKGROUND

Limited data are available from India on treatment outcomes with oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in newly diagnosed non-small cell lung cancer (NSCLC). We studied the demographic profile and treatment outcomes of patients with NSCLC, receiving first-line treatment with oral EGFR-TKIs.

METHODS

Retrospective study of newly diagnosed NSCLC patients treated with oral EGFR-TKIs over a 4-year period at a tertiary care institute in North India.

RESULTS

Of 76 patients studied, females and non-smokers constituted 32.9% and 48.7%, respectively. Majority of patients had adenocarcinoma (59.2%), stage IV (64.5%) disease and Karnofsky performance status ≤ 70 (74.5%). Gefitinib was the most frequently used EGFR-TKI (92.1%). Most common indication for the use of EGFR-TKIs was poor performance status (65.8%). Among assessable patients, disease control and progressive disease were evident in 66% and 34%, respectively. Most common side effects were skin rash (17%) and diarrhoea (10.6%). Patients with and without skin rash differed significantly in relation to objective response to treatment (100% versus 23.1%) and overall survival (median not reached versus 178 days). On multivariate logistic regression analysis, malignant pleural effusion was associated with occurrence of rash (odds ratio = 0.19; 95% confidence interval = 0.04-0.95; p = 0.04).

CONCLUSIONS

Oral EGFR-TKIs appear to be useful for the treatment of clinically selected patients with advanced NSCLC. Occurrence of skin rash was independently associated with treatment response and better survival in the current study.

[Chemoradiotherapy in the combined treatment for laryngopharyngeal cancer]

The study included 62 patients with morphologically verified squamous cell carcinoma of laryngopharynx, stages T2-4N0-2M0. As a result of the treatment complete regression was recorded in 28.1 ± 7.9% of cases, partial regression--in 50.0 ± 8.8% of patients, and stabilization--in 21.9 ± 7.3% of cases. The total efficiency of therapy made up 78.1 ± 7.3%. Chemotherapy complications and radiation injuries did not exceed I-II grade by CTC-NCIC criteria and PTOG/EORTC scale, were easily stopped, did not affect the time periods of further treatment and had no considerable influence on the postoperative period. Conservative surgery was performed in 26% of cases. The total 5-year survival rate made up 65.4 ± 8.4%, relapse-free 5-year survival rate--60.6 ± 8.9%. The efficiency of the vocal function rehabilitation made up 73.9 ± 9.1%. Rehabilitation time was 21 ± 8.2 days.

The Amatsu's tracheoesophageal shunt: analysis of 84 cases

INTRODUCTION

Amatsu's tracheoesophageal shunt can be indicated for vocal rehabilitation in candidates to total laryngectomy. It is performed in the period of the procedure of total laryngectomy and has been indicated due to its technical facility, exemption from the use of voice prosthesis, and lack of additional costs for its maintenance.

OBJECTIVE

To evaluate the results obtained with the Amatsu's tracheoesophageal shunt, along 14 years of experience, in two Brazilian hospitals.

STUDY DESIGN

Clinical retrospective.

MATERIAL AND METHOD

From 1991 to 2005, eighty-four patients were submitted to the Amatsu's tracheoesophageal shunt. Seventy-seven (91.7%) were male and seven (8.3%) female, aged between 30 and 82 years, mean age of 57.5 years, and an average age of 52 years. All patients had squamous cell carcinoma of larynx and/or hypopharynx. Sixty-eight (81.0%) were stage III or IV. They were submitted to total laryngectomy and the Amatsu's tracheoesophageal shunt was performed during the tumor removal surgery. The following variables were analyzed: acquisition of intelligible speech, vocal recovery time after surgery, and the occurrence of specific surgical complications of the shunt (pulmonary aspiration).

RESULTS

Seventy-six patients were evaluated with respect to the effectiveness of the technique. Fifty-three patients (70.0%) presented vocalization by the shunt; in 46 patients (60.5%), the speech was fully intelligible. The time required for restoration of speech was 12-87 postoperative days. Of the 83 patients evaluated in relation to the development of complications, 25 (30.1%) presented aspiration by the shunt during oral ingestion. In 23 patients (27.7%), the aspiration was managed conservatively without complications. Two patients (2.4%) required surgical closure of the shunt due to intractable aspiration.

CONCLUSION

Vocal rehabilitation with the Amatsu's tracheoesophageal shunt is effective in most patients who underwent total laryngectomy. It can be evidenced by the acquisition of intelligible speech in most patients. The aspiration, although often, is not shown to be a limiting complication.

Affiliation to the work market after curative treatment of head-and-neck cancer: a population-based study from the DAHANCA database

OBJECTIVES

Survivors of squamous cell carcinoma of the head and neck (HNSCC) are more severely affected in regard to affiliation to the work market than other cancer survivors. Few studies have investigated associations between socioeconomic and disease-related factors and work market affiliation after curative treatment of HNSCC. We investigated the factors for early retirement pension due to disability and unemployment in patients who had been available for work one year before diagnosis.

METHODS

In a nationwide, population-based cohort study, data on 2436 HNSCC patients treated curatively in 1992-2008 were obtained from the Danish Head and Neck Cancer Group database and linked to Danish administrative population-based registries to obtain demographic and socioeconomic variables. We used multivariate logistic regression models to assess associations between socioeconomic factors (education, income and cohabitating status), cancer-specific variables such as tumour site and stage, comorbidity, early retirement pension and unemployment, with adjustment for age, gender and year of diagnosis.

RESULTS

Short education [odds ratio (OR) 4.8; 95% confidence interval (CI) 2.2-10.4], low income (OR 3.2; 95% CI 1.8-5.8), living alone (OR 3.0; 95% CI 2.1-4.4) and having a Charlson comorbidity index score of 3 or more (OR 5.9; 95% CI 3.1-11) were significantly associated with early retirement overall and in all site groups. For the subgroup of patients who were employed before diagnosis, the risk pattern was similar. Tumour stage was not associated with early retirement or unemployment.

CONCLUSIONS

Cancer-related factors were less strongly associated with early retirement and unemployment than socioeconomic factors and comorbidity. Clinicians treating HNSCC patients should be aware of the socioeconomic factors related to work market affiliation in order to provide more intensive social support or targeted rehabilitation for this patient group.

Patients with oral tumors. Part 1: Prosthetic rehabilitation following tumor resection

The present study reports on the surgical and prosthodontic rehabilitation of 46 patients, 31 male and 15 female, after resection of oral tumors. The treatment was carried out from 2004 to 2007 at the Department of Prosthodontics, University of Bern, with a follow-up time of 3 to 6 years. The average age at diagnosis was 54 years. 76% of all tumors were squamous cell carcinoma, followed by adenocarcinoma. Resection of the tumors including soft and/or hard tissues was performed in all patients. 80% of them additionally underwent radiotherapy and 40% chemotherapy. A full block resection of the mandible was perfomed in 23 patients, and in 10 patients, the tumor resection resulted in an oronasal communication. 29 patients underwent grafting procedures, mostly consisting of a free fibula flap transplant. To enhance the prosthetic treatment outcome and improve the prosthesis stability, a total of 114 implants were placed. However, 14 implants were not loaded because they failed during the healing period or the patient could not complete the final treatment with the prostheses. The survival rate of the implants reached 84.2% after 4 to 5 years. Many patients were only partially dentate before the tumors were detected, and further teeth had to be extracted in the course of the tumor therapy. Altogether, 31 jaws became or remained edentulous. Implants provide stability and may facilitate the adaptation to the denture, but their survival rate was compromised. Mostly, patients were fitted with removable prostheses with obturators in the maxilla and implant-supported complete dentures with bars in the mandible. Although sequelae of tumor resection are similar in many patients, the individual intermaxillary relations, facial morphology and functional capacity vary significantly. Thus, individual management is required for prosthetic rehabilitation.

Management of the maxillary cancer patient--what the general dentist should know

BACKGROUND

Maxillary defects are created following surgical treatment of patients with benign and malignant neoplasms, trauma or congenital defects. The size of these defects influences the degree of debilitation.

CASE DESCRIPTION

This patient lacks the conventional support, stability and retention when fabrication of the prosthesis is planned. The prosthesis that is used to close this palatal defect is called the hollow bulb obturator. CLINICAL OUTCOMES: It improves speech, deglutition, esthetics and function for the patient.

Patients with oral tumors. Part 2: Quality of life after treatment with resection prostheses. Resection prosthetics: evaluation of quality of life

In the present study, the oral health-related quality of life of 18 patients (13 men and 5 women) was evaluated using validated questionnaires as proposed by the European Organization of Research and Treatment of Cancer (EORTC). The patients belonged to a cohort of 48 patients, whose prosthetic treatment was performed during the years 2004-2007. In the course of tumor resection, 12 patients underwent graft surgery and 14 patients radiotherapy. One patient required a nasal epithesis since resection of the nose became necessary. Five patients underwent a full block resection of the mandible, and tumor resection in 3 patients resulted in a large oronasal communication. Prosthetic rehabilitation was performed in all patients, and the follow-up period with regular care covered a minimum of 3 years. Eleven patients received dental implants for better support and retention of the prostheses. In spite of compromised oral conditions, functional restrictions, and some difficulties with the prostheses, the answers to the questionnaire were quite positive. The majority judged their general health as good or even excellent. The subjective perception of the patients may contradict the objective view by the dentist. In fact, the individual patient's history and experience provide a better understanding of the impact of oral tumors on daily life. The overall assessment identified 4 items that were perceived as major problems by all patients: swallowing solid food, dry mouth, limited mouth opening, and appearance. Prosthetic rehabilitation has only a limited influence on such problems.

[Karapandzic flap for reconstruction of extensive defects of the lower lip]

OBJECTIVE

To discuss advantages and disadvantages of Karapandzic flap for reconstruction of extensive defects of the lower lip.

METHODS

Two clinical observations and a review of the literature are presented.

RESULTS

The Karapandzic flap requires only one operating time. The tissue used to reconstruct the lower lip is very close to the resected lip. The functional result is satisfactory, the lips being continent, allowing speech and feeding. The main advantage of this technique is the preservation of the labial sphincter, which is vascularized, mobile and sensitive. The aesthetic result is acceptable. This flap keeps the vermilion, but with rounded commissures that corrects spontaneously. The main disadvantage of this flap is the microstomia, requiring only rarely further surgery.

CONCLUSION

The Karapandzic flap is a good option for reconstruction of extensive defects of the lower lip. It recreates the labial sphincter, while maintaining its vascularization and innervation. Functionality is maintained, with an aesthetically acceptable result despite the presence of residual microstomia proportional to the defect.

Rehabilitation of an extraoral and intraoral defect complicated with microstomia. A study case

A 72-year-old man was referred from the surgery department for rehabilitation following surgical resection of Basaloid carcinoma. The first surgical intervention involved the anterior palatal region and was restored with a simple obturator. Two years later further surgery was undertaken to excise a recurrent tumor in the nose and part of the cheek. This resulted in an exposed nasal cavity and maxillary sinus. In addition, there was a small oral aperture composed of thin tissue that stretched to its maximum due to scar formation. The defect was restored with a full thickness skin flap but it subsequently broke down leaving the midface exposed with limited mouth opening due to tissue contraction and scar formation after the flap operation. The defect was rehabilitated with Co-Cr obturator intraorally and a silicone nose retained to the naso-palatal extension of the obturator by a magnet extraorally. This resulted in practically good retention, placement, and adaptation of the two parts of the prosthesis.

Association between microbial flora and tissue abnormality around dental implants penetrating the skin in reconstructed oral cancer patients

PURPOSE

Patients with skin-penetrating implants sometimes report episodic soft tissue reactions. This pilot clinical trial identified the oral microflora of the peri-implant sulcus of cancer patients with jaw reconstruction and compared sites with and without clinical signs of inflammation.

MATERIALS AND METHODS

Ten patients were selected during routine follow-up of their implant-supported removable prostheses. Eligible patients had at least two intraoral skin-penetrating implants; one showed clinical signs of inflammation with/without symptoms and the other served as a healthy control site. Eight of the 10 patients had undergone osseocutaneous fibula free flap reconstruction and two had received split-thickness skin grafts on the surface of the native mandible. Subjects were assessed on two visits, 30 to 40 days apart. Subgingival microbial samples were obtained and periodontal pocket depths were measured at the test implant abutment. Between visits, patients followed a strict oral hygiene regimen. Radiographic marginal bone loss around implants was measured using cone beam imaging during the second visit. The microflora were identified after isolation and purification of all growing colonies.

RESULTS

The number of different microorganisms ranged from 10 to 21 per site. Among all patients, a total of 47 different microorganisms were identified, but none were considered virulent red-complex periodontal pathogens. By the time of the second visit, after adherence to strict mechanical oral hygiene, the average number of microorganisms per site was reduced through elimination of some species. Almost all subjects had identical microbial species in both sites, but the number of visible colonies was lower at the healthy site.

CONCLUSION

Oral peri-implant epidermal proliferation does not appear to be caused by specific microbial pathogens but is likely related to increased microbial load in the implant sulci. Mechanical oral hygiene improves and maintains healthier peri-implant skin tissues.

Modified technique of resection denture prosthesis fabrication for a patient with segmental mandibulectomy--a case report

The rehabilitation of patients following maxillary & mandibular resection is challenging. A prosthesis supported with dental implants is often the treatment of choice, but implants cannot be used predictably in all clinical situations. A tissue supported post resection denture is usually the most acceptable treatment option left in these situations. This case report describes management of a patient who had undergone segmental mandibulectomy & subsequently rehabilitated with resection denture prosthesis. Conventional treatment planning was modified at various stages of fabrication to improve the quality of the final prosthesis.

A randomized preventive rehabilitation trial in advanced head and neck cancer patients treated with chemoradiotherapy: feasibility, compliance, and short-term effects

The aim of this study was to assess the effect of (preventive) rehabilitation on swallowing and mouth opening after concomitant chemoradiotherapy (CCRT). Forty-nine patients with advanced oral cavity, oropharynx, hypopharynx and larynx, or nasopharynx cancer treated with CCRT were randomized into a standard (S) or an experimental (E) preventive rehabilitation arm. Structured multidimensional assessment (i.e., videofluoroscopy, mouth-opening measurement, structured questionnaires) was performed before and 10 weeks after CCRT. In both S and E arms, feasibility was good (all patients could execute the exercises within a week) and compliance was satisfactory (mean days practiced per week was 4). Nevertheless, mouth opening, oral intake, and weight decreased significantly. Compared to similar CCRT studies at our institute, however, fewer patients were still tube-dependent after CCRT. Furthermore, some functional outcomes seemed less affected than those of studies in the literature that did not incorporate rehabilitation exercises. Patients in the E arm practiced significantly fewer days in total and per week, but they obtained results comparable to the S arm patients. Preventive rehabilitation (regardless of the approach, i.e., experimental or standard) in head and neck cancer patients, despite advanced stage and burdensome treatment, is feasible, and compared with historical controls, it seems helpful in reducing the extent and/or severity of various functional short-term effects of CCRT.

Review of methods used in the reconstruction and rehabilitation of the maxillofacial region

Maxillofacial and dental defects often have detrimental effects on patient health and appearance. A holistic approach of restoring lost dentition along with bone and soft tissue is now the standard treatment of these defects. Recent improvements in reconstructive techniques, especially osseointegration, microvascular free tissue transfer, and improvements in bone engineering, have yielded excellent functional and aesthetic outcomes. This article reviews the literature on these modern reconstructive and rehabilitation techniques.

Multiple retentive means for prosthetic restoration of a large facial defect - a case report

A 70-year-old man who suffered from extensive extra and intraoral defects was rehabilitated with a prosthesis using multiple retaining means. The treatment was performed in two parts: externally involving the construction of an episthesis supported only by the remaining intact boundaries of the defect and retained by mini-dental implants and spectacle frame with a modified ear hook; and intraorally by an acrylic resin obturator to restore the function of the hemi-sectioned hard and soft palate. The episthesis was securely retained with minimal movement and/or dislodgment of the prosthesis during function. Multiple retentive techniques may be used to fix heavy external prostheses as an alternative to conventional implants or biological adhesives.

Rehabilitation: long-term physical and functional changes following treatment

OBJECTIVES

To describe the life altering issues that survivors of a head and neck cancer report post treatment and discuss multidimensional rehabilitation approaches.

DATA SOURCES

Published journal articles, literature reviews, research reports, book chapters.

CONCLUSION

Survivors and their family caregivers encounter many changes during the first 3 months following treatment for head and neck cancer, placing them at risk of multiple adjustment difficulties. Progressive weight loss, loss of energy, strength, muscle endurance and decreased functioning severely compromise healthy adjustment and quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can help patients and family identify survivorship issues to be managed at home. Planning, exploring, coaching, practicing skills with survivors and their family caregivers, providing specific information, and linking them with resources can help them bridge this transition into extended survivorship.

Computerised dental implant rehabilitation planning and execution following mandibular resection: a case report

This paper discusses the merits of Computer Tomography (CT) based dental implant planning in the rehabilitation of patients following oral cancer This case report describes the process of prosthetic work-up, computerised implant planning, surgical treatment and successful prosthetic oral rehabilitation of a patient following segmental mandibulectomy and post-operative radiotherapy for intra-osseous squamous cell carcinoma (SCC).

Management of lateral mandibular discontinuity by maxillary guidance

Balance and symmetry of mandibular function is disturbed by loss of continuity of the mandible, which leads to altered mandibular movements and deviation of the residual fragment, as a consequence of which problems with chewing, swallowing, speech, and aesthetics develop. Methods such as maxillary fixation, and use of mandibular and palatal guidance have been used to reduce or eliminate the mandibular deviation. The aim of this study was to achieve a normal maxillomandibular relation in a patient with mandibular discontinuity. An acceptable maxillomandibular relation was obtained within 3 months with a maxillary guidance ramp prosthesis.

Prosthodontic rehabilitation of oral function in head-neck cancer patients with dental implants placed simultaneously during ablative tumour surgery: an assessment of treatment outcomes and quality of life

The aim of this prospective study was to assess treatment outcome and impact on quality of life of prosthodontic rehabilitation with implant-retained prostheses in head-neck cancer patients. Fifty patients were evaluated by standardized questionnaires and clinical assessment. All received the implants during ablative tumour surgery in native bone in the interforaminal area. About two-thirds of the patients (n=31) needed radiotherapy post-surgery. Both in irradiated and non-irradiated bone two implants were lost 18-24 months after installation. Peri-implant tissues had a healthy appearance. No cases of osteoradionecrosis occurred. In 15 patients no functional implant-retained lower dentures could be made for various reasons. The other 35 patients all functioned well, with an improvement in quality of life. Major improvement was observed in the non-irradiated patients. In the irradiated patients, less improvement in many functional items was observed, while items related to the oral sequelae of radiotherapy did not improve. Similar to the quality-of-life assessments, denture satisfaction was improved and tended to be higher in non-irradiated than irradiated patients. Implant-retained lower dentures can substantially improve the quality of life related to oral functioning and denture satisfaction in head-neck cancer patients. This effect is greater in non-irradiated than irradiated cancer patients.

Quality of life related to oral function in edentulous head and neck cancer patients posttreatment

PURPOSE

Surgical treatment of malignancies in the oral cavity and subsequent radiotherapy often result in an oral condition unfavorable for prosthodontic rehabilitation. This study assessed the quality of life related to oral function in edentulous head and neck cancer patients following oncology treatment of malignancies in the lower region of the oral cavity.

MATERIALS AND METHODS

Patients treated between 1990 and 2000 with surgery and radiotherapy for a squamous cell carcinoma in the oral cavity who were edentulous in the mandible and had been treated with a conventional, non-implant-retained denture received an invitation for a clinical check-up (clinical assessment, questionnaires regarding oral function and quality of life).

RESULTS

Sixty-seven of the 84 patients who fulfilled the inclusion criteria were willing to participate in the study. The mean irradiation dosage that these patients had received in the oral region was 61.8 +/- 5.4 Gy. Half of the patients (n=33) were not very satisfied with their prostheses; they wore their mandibular prostheses at most a few hours per day. It was concluded from the clinical assessment that two thirds of the patients (n 4) could benefit from an implant-retained mandibular denture. Analyses of the questionnaires revealed no significant associations between functional assessments, quality of life, and parameters such as size of the primary tumor, location of the primary tumor, and different treatment regimes. Despite cancer treatment, the patients reported a rather good general quality of life.

CONCLUSIONS

Sequelae resulting from radiotherapy probably dominate oral function and quality of life after oncology treatment. In two thirds of the patients, improvement of oral function and related quality of life would be expected with the use of an implant-retained mandibular denture.

Intraoral hair removal on skin graft using Nd:YAG laser

This case report is a demonstration of the efficacy of laser hair removal on a graft site intraorally. A Polaris Long Pulse Nd:YAG laser was used for the procedures.

The Superiorly Based Platysma Flap for Oral Reconstruction in Conjunction With Neck Dissection: A Case Series

PURPOSE

The purpose of this study was to access the reliability and use of the superiorly based platysma flap for reconstruction of small and medium oral defects.

PATIENTS AND METHODS

This case series consists of 5 patients who were reconstructed with a superiorly based platysma flap for defects of the following oral region: buccal mucosa, floor of the mouth, and lateral gingiva. The flaps were monitored for complications, including skin loss and ischemia in the postoperative period.

RESULTS

Three patients (60%) had some skin sloughing in the recipient site. None of the patients had complications in the donor site.

CONCLUSION

The superiorly based platysma flap can survive after the facial artery has been ligated, which is the normal procedure during neck dissection. If skin sloughing occurs, it is usually inconsequential for intraoral reconstruction because the underlying muscle remains viable and undergoes epithelialization.

Oral rehabilitation with the new SG attachment in a patient treated for oral squamous cell carcinoma

In patients who have undergone surgery and radiotherapy for oral squamous cell carcinoma (OSCC), the posterior oral rehabilitation may prove complex. In addition to the defects produced by surgical ablation of the primary tumor, radiotherapy induces deleterious effects upon the oral tissues. We present the case of a 48-year-old male treated two years before due to OSCC in the retromolar trigone and left lateral wall of the oropharynx. Following study of the case with clinical examination and orthopantomography, a management plan was defined involving rehabilitation of the upper dental arch with fixed ceramometallic prostheses, while in the lower arch we chose a unilateral removable prosthesis adapted to a fixed prosthesis by means of a special and versatile attachment based on a new system that functions as a fixed element but which can be removed or changed at some later date. The present clinical case illustrates this type of prosthodontic solution for the management of oncological patients of this kind.

[Application of the free vascularized lateral upper arm flap in intraoral reconstruction following ablative tumour surgery]

OBJECTIVE

To evaluate the application of the lateral arm free flap (LAFF) in the reconstruction for intraoral defects.

METHODS

Intraoral reconstruction was performed using the LAFF for 10 patients with oral squamous cell carcinoma of the tongue (n = 3), cheek (n = 4), gingiva (n = 1) and oropharynx (n = 2). There were 8 men and 2 women (mean age, 52 years).

RESULTS

Nine LAFF healed uneventfully. One flap was lost on the second postoperative day due to venous insufficiency. The donor defect was closed primarily In all patients. There were no significant complications at the donor site.

CONCLUSIONS

Because of the thin and pliable nature, the lateral upper arm flap can be recommended as a choice for repair of moderate-sized defects of the oral maxillofacial area.

Magnet-retained facial prosthesis combined with an implant-supported edentulous maxillary obturator: a case report

The prosthetic rehabilitation of maxillofacial defects is especially challenging when the patient is edentulous. Although dental implants are used to enhance the retention and stability of both facial and maxillary prostheses, combining facial and maxillary prostheses is extremely difficult. This article describes the prosthetic treatment of an edentulous patient with a large maxillary and facial defect. After placing dental implants in the remaining maxilla, a maxillary obturator prosthesis supported by a milled bar attachment was fabricated. The facial prosthesis was retained by a magnetic attachment to the maxillary obturator prosthesis. As the obturator prosthesis was supported securely by this sturdy attachment, the facial prosthesis was stable during mastication and facial movement. The patient reported improvement in prosthesis retention and stability. Both the masticatory and the speech functions of the patient improved.

How satisfied are head and neck cancer (HNC) patients with the information they receive pre-treatment? Results from the satisfaction with cancer information profile (SCIP)

Recent UK government recommendations state that high quality information must be provided for cancer patients. The objectives of this study were firstly, to explore how satisfied head and neck cancer (HNC) patients were with information provided about their illness and treatment, in order to identify areas of improvement. Secondly, to assess the extent to which satisfaction with information before treatment was predictive of long-term outcomes. Patients completed the satisfaction with information profile (SCIP), the Hospital Anxiety and Depression Scale (HADS) and the SF-12 Health Survey (SF-12v2) before treatment (n=82), 1 month after the end of treatment (n=68) and 6-8 months later (n=50). Patients were generally satisfied with information, however key areas of improvement were identified, such as the provision of information about support groups, where to go for financial advice and the long-term affects of treatment on ability to work, physical functioning and QoL. Satisfaction with information before treatment was predictive of depression and Mental Component Summary scores (HR-QoL) 6-8 months after the end of treatment. This study highlights the need for tailored information provision and the impact on longitudinal outcomes of satisfying patient's needs for information prior to treatment.

Long-Term Results of Free Radial Forearm Flap Used for Oral Reconstruction: Functional and Histological Evaluation

PURPOSE

The aim of this study was to evaluate the radial forearm flap with regard to recovery of sensory function, general performance status, cutaneous blood flow and histological observations.

PATIENTS AND METHODS

Thirty patients (23 male and 7 female) with oral carcinoma underwent immediate reconstruction with radial forearm flap after ablative surgery and returned for evaluation. Interviews were conducted to assess the degree of articulation and mastication.

RESULTS

Sensory function tests suggested the restoration of cutaneous sensibility of the forearm flap. Histological findings indicated mucosa-like changes of flaps about 10 months after reconstruction. The clarity of conversation recovered favorably in most patients. However, the degree of recovery was generally related to the time after surgery.

CONCLUSION

The radial forearm flap is a unique flap with specific characters that allowed for best available functional reconstruction of the oral cavity in terms of restoration of sensation, performance, and histological changes to adapt to the new oral environment.

The early use of a perforator flap of the lateral lower limb in maxillofacial reconstructive surgery

The development of perforator-based flaps led to new donor sites and enlarged the spectrum of recipient vessels using arteries and veins of very small calibres. Although these flaps, which are directly anastomosed at their terminal cutaneous branches, are becoming more and more important for reconstructions in other regions of the body, perforator-based flaps have not played an important role in maxillofacial surgery until now. This study reports the experience with 24 consecutive perforator flaps from the lateral lower limb for intra- and extraoral defect coverage. Septo- or myoseptocutaneous perforators from the peroneal artery served as the flap pedicle having a length of 4-7 cm and diameters of 1-2 mm. Indications were reconstructions of the floor of the mouth (10), soft palate (3), tongue (6), closure of perforating cheek defects (2) and reconstruction of the facial skin (3). Anastomoses were performed to the lingual, facial, temporal or thyroid superior artery. Except for 2 cases, all perforator-based flaps were healed well and the morbidity of the donor site was nearly negligible. According to the early experience in this study, perforator-based flaps from the lateral lower limb may have an indication if recipient vessels available are close to the defect and if very low donor site morbidity is important to the patient.

Reconstruction of perioral defects following resection for oral squamous cell carcinoma

PURPOSE

The aim of this study was to review and describe techniques for the reconstruction of large, complex perioral defects after resection of oral squamous cell carcinoma with emphasis on cosmetic and functional outcome.

PATIENTS AND METHODS

A review of techniques and selected case presentations using different flap designs for the reconstruction of large perioral defects following resection of squamous cell carcinoma was performed. The Bernard and Karapandzic flaps were used for large lower lip defects. A Zisser flap technique was used to reconstruct a large commissure defect.

RESULTS

All reconstructed patients had acceptable functional results and healed without complication. The large lower lip defects were easily closed with the Bernard and Karapandzic flaps. The commissure defect was reconstructed using the Zisser technique. While cosmesis was acceptable in all cases, the commissure was the most difficult region to reconstruct with a favorable appearance. There were no flap failures. The Karapandzic flap led to greater rounding of the commissure area and the composite resection resulted in a lack of lower lip support that was improved with prosthesis. Function was noted to be excellent in the Bernard and Karapandzic flaps, with the patients able to purse lips and blow up balloon-type devices.

CONCLUSION

The Bernard, Karapandzic, and Zisser flaps provide a predictable method to reconstruct large perioral defects following resection for oral cancer. Subsequent fabrication of a prosthesis can aid in lip support for the resected area.

Quality of life and functional evaluation after supracricoid partial laryngectomy with cricohyoidoepiglottopexy in Mexican patients

This study assessed the functional results in patients treated primarily through supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP).

Fifteen patients with a diagnosis of epidermoid carcinoma of the glottis region admitted to the Instituto Nacional de Cancerología (México) between June 2001 and September 2002 were studied. Three patients were at stage I, five at stage II, six at stage III, and one at stage IV. Both cricoarytenoid units were preserved in 12 patients, and only one in three. Each case was assessed through the clinical grading postoperative aspiration (CGPA) scale, the performance status scale for head and neck cancer (PSS-HNC), and the Karnofsky Performance Scale (KPS). Likewise, voice quality of the patients was assessed regarding tone and intensity using the SpeechViewer version 1 (IBM) and data were obtained with the Cool Edit 2000 software.

Twelve patients received phoniatric rehabilitation and three were left without rehabilitation. The average time for decannulation was 12 days and 23 days for removal of the nasogastric catheter. The degree of aspiration was 0 in four patients and one in 11. According to PSS-HNC, the mean for normalcy in the diet was 95 and the mean for those eating in public was 91. Intelligibility reached an average of 90. Karnofsky’s assessment was related to the disease and not to the treatment, as it remained at 100 per cent in most patients and was never below 80 percent. The mean intensity of quality of voice was -18 dB below normal; however, the mean frequency was 243.7 Hz.

SCPL and CHEP allows the preservation of the basic function of the larynx; however, a clear alteration in voice occurs after the procedure, although normal frequency is kept when both arytenoids are preserved. Likewise, preservation of both arytenoids shortens the time needed for cannula and feeding catheter removal. PSS-HNC, Karnofsky, and CGPA assessments demonstrated thatpatients can reach an almost normal bio-psycho-social integration. It is recommended that all patients be subjected to phoniatric rehabilitation.

Buccal mucosal transposition flap for reconstruction of oropharyngeal-oral cavity defects: an analysis of six cases

BACKGROUND

Operation on tumors situated in the posterior part of the oral cavity is a challenging aspect of head and neck surgery. Both the approach and the postablative reconstruction of the remaining defect require special procedures. An arsenal of reconstructive methods are available depending on the size and complexity of the defect. The goal should be to employ the simplest surgical reconstructive method, resulting in the best functional result and allowing for later complex oncotherapy.

OBJECTIVE

To study the outcomes of patients treated using buccal mucosal transposition flaps for reconstruction of posterior oral cavity and oropharyngeal border defects.

STUDY DESIGN

A total of 6 patients with defects of the posterior oral cavity and mesopharynx were treated with buccal mucosal transposition flaps. The patients were followed for up to 24 months.

RESULTS

Defects ranging from 12 to 27 cm 2 were reconstructed with the buccal mucosal transposition flap. One patient developed an orocutaneous fistula and 1 had some trismus requiring a Z-plasty scar reorientation. One patient suffered from nasal regurgitation. Five of the 6 patients lived past 24 months, the time of follow-up of this study.

CONCLUSIONS

The buccal mucosal transposition flap, with its random pattern of circulation, used alone proved to be a safe method to reconstruct soft tissue defects or line exposed hard tissues located in the posterior oral cavity and oropharynx.

Reconstruction of large defects postmandibulectomy for oral cancer using plates and myocutaneous flaps: a long-term follow-up

A series of 28 consecutive cases of mandibular reconstruction by means of reconstructive plates and myocutaneous flaps were reviewed. In all cases mandibular resection was indicated for treatment of squamous cell carcinoma of the oral cavity: 25 pelviglossomandibulectomies (resulting in large defects from the angle of the mandible), 2 Commando operations (resulting in lateral defects) and 1 anterior sectional mandibulectomy (resulting in an anterior defect). Tumour stages were T1-T2 (4 cases) and T3-T4 (24 cases). Success was defined as plate maintenance 6 months' postoperatively/postradiotherapy. The overall success rate was 32.2%. Lateral-centre-lateral (L-C-L) defects had 32% success, L (lateral) defects had 50% success and in the single case of a C (centre) defect, the plate was not maintained. Stainless steel reconstruction plates showed a similar success rate as titanium plates (30% versus 34%). In cases not submitted to radiotherapy there were more maintained plates than in cases that received radiotherapy (45.5% versus 23.6%). Reconstruction plates are not effective in bridging large defects of the resected mandible. Only in selected cases that are not eligible for microvascular free flaps should plates and myocutaneous flaps be considered as an option for mandibular reconstruction.

Socioeconomic Effects of and Risk Factors for Disability in Long-term Survivors of Head and Neck Cancer

OBJECTIVE

To evaluate the socioeconomic effect of and risk factors for work-related disability due to head and neck cancer and its treatment.

DESIGN

Cross-sectional analysis of a consecutive series of patients.

SETTING

Tertiary cancer center hospital.

PATIENTS

Eligible patients had squamous cell carcinoma of the upper aerodigestive tract, were employed or had an active professional career at the time of initial diagnosis, and were disease free for at least 2 years at the time of interview. The survey instruments were a specific questionnaire to evaluate patient socioeconomic status and a Portuguese version of the University of Washington Quality of Life questionnaire.

MAIN OUTCOME MEASURES

Descriptive analysis of the results and associations between clinical, social, and quality of life variables with work disability.

RESULTS

A total of 301 patients were studied. There were 236 (78.4%) men (median age, 52 years). The tumor sites were the oral cavity in 158 (52.5%), oropharynx in 55 (18.3%), larynx in 78 (25.9%), and hypopharynx in 10 (3.3%). Most patients presented with advanced clinical disease and underwent surgical treatment initially. There were 36 (12.0%) illiterate patients, and only 23 (7.6%) patients had completed college. Ninety-nine patients (32.9%) became unable to work, and 126 (41.9%) reported a significant decrease in household income. Multivariate analysis showed that advanced clinical stage (P = .02), alcohol consumption (P = .02), and low educational level (P = .007) were associated independently with work disability.

CONCLUSIONS

We observed a high rate of work-related disability that led to significant decrease in household income. Several clinical, social, and quality of life variables were associated with this degree of disability. These results could be used to better define who should undergo more intensive rehabilitation aiming to reduce work disability. If intensive rehabilitation is unsuccessful, these patients should receive more comprehensive social support.

Complete rehabilitation of the mandible following segmental resection

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.

Oral rehabilitation after treatment for head and neck malignancy

BACKGROUND

Advances in the management of oral malignancy have resulted in significant improvements in survival and functional outcome. Ablation of oral tissues and radiotherapy render many patients unable to wear conventional prostheses, and these patients are, thus, candidates for oral rehabilitation with osseointegrated implants. We aim to present outcomes and complications of such treatment over a 14-year period in a single unit.

METHODS

Data were collected for 81 consecutive patients, most of whom had received microvascular free flap reconstruction after surgical ablation of oral squamous cell carcinoma. Three hundred eighty-six implants were placed after a delay of 12 months after surgery. Sixty-five percent of implants were placed in the anterior mandible. Radiotherapy was used in 47% of the patients, and hyperbaric oxygen treatment was routinely used in irradiated subjects during the latter half of the series. Retrospective analysis of implants and prostheses was made by use of case notes, radiographs, and a computerized database.

RESULTS

Data are presented for 364 of the 386 implants in 77 of the 81 patients after a median follow-up of 4 years. Two hundred sixty-five (73%) of the implants were in function supporting prostheses, 56 (15%) had been lost, and 43 (12%) were present but not loaded (ie, "sleepers"). Implant loss seemed patient specific and was also correlated with host bone type. Thirteen percent of patients in whom implants were placed in the mandible lost at least one implant, and the equivalent values for the maxilla was 40%. Thirty-six percent of patients in whom implants were placed in bone graft or flap lost at least one implant. The effects of implant manufacture, dimensions, radiotherapy, and hyperbaric oxygen did not reach statistical significance in this series. Cases of a second primary malignancy were noteworthy; however, the impact of recurrence was minimized by the delay between resection and rehabilitation. Of the 42 fixed and 29 removable prostheses fitted, 12 (17%) failed.

CONCLUSIONS

Implants placed in mandible were reliable, but failure rates in vascularized bone graft and maxilla were higher. Radiotherapy did not seem to prejudice implant survival, and hyperbaric oxygen had no demonstrable benefit in this series. Despite some persistent soft tissue problems and implant loss, most patients reached a successful prosthetic and functional outcome.

A Method Using Vestibulo-sulcoplasty Combining a Split-thickness Skin Graft and a Palatal Keratinized Mucosa Graft for Peri-implant Tissue Secondary to Oral Cancer Surgery

Twelve patients presented with oral submucosal fibrosis and loss of keratinized gingiva in a compromised vestibule of a severely deficient mandibular edentulous ridge secondary to oral cancer surgery. They received implant rehabilitation with a total of 49 fixtures without major bone graft augmentation. To overcome vestibular compromise, soft tissue management consisting of simultaneous vestibulo-sulcoplasty, split-thickness skin graft (STSG), and palatal keratinized mucosa graft (KMG) was performed as a second stage when healing abutment was transferred to replace the cover screw of the dental implant. Postoperative follow-up of all patients consisted of clinical and radiographic examinations for an average of 4 years, revealing good stability of implant fixtures with a 91.8% success rate and generally healthy peri-implant tissue, the latter with an average sulcus depth of 2.9 +/- 0.6 mm. Satisfactory results were also demonstrated regarding improved morphology of the vestibule, cosmetics, and prosthetic functionality. Vestibulo-sulcoplasty combining STSG and palatal KMG offers a stable and convenient method for rebuilding peri-implant tissue without need for bone grafting in selected patients who have compromised atrophic ridges secondary to cancer surgery.

[Provisional silicone obturator for closure of hard and soft palatal defects]

Treatment of intraoral squamous cell carcinomas is guided by the clinical stage of the disease and includes surgical resection. The resulting defect may be closed surgically or prosthodontically. This article describes a technique for provisional closure of a surgical defect. The interim obturator permits normal oral functioning until permanent rehabilitation is performed.

Speech and swallowing following radial forearm flap reconstruction of major soft palate defects

Velopharyngeal function is often compromised by the resection and reconstruction of oropharyngeal and palatal tumours. While free tissue transfer has improved the outcomes of head and neck reconstruction. In general, palatal reconstruction remains a challenge. Velopharyngeal function was analysed in eight patients following microsurgical reconstruction of defects of between 50 and 100% of the soft palate. The radial forearm fasciocutaneous free flap was used in all cases. The outcome of reconstruction was analysed by patient questionnaire and with standardised tests of speech and swallowing function. Velopharyngeal function post-operatively ranged from poor to near normal. Poor function appeared due to the loss of active elevation and contracture of the reconstructed palate producing failure of velopharyngeal closure during swallowing and speech. The results emphasise the limitations of reconstruction of a dynamic structure such as the soft palate with the static fold of skin and soft tissue produced by a fasciocutaneous flap. The relatively poor results obtained suggest that an anatomical approach to soft palate reconstruction is inadequate and reduction of the calibre of the velopharyngeal aperture is required to compensate for the lack of mobility in the reconstructed palate.

Use of the buccal fat pad in the reconstruction and prosthetic rehabilitation of oncological maxillary defects

We evaluated the effectiveness of the buccal fat pad as a pedicled flap for intraoral reconstruction after partial maxillectomy for neoplastic disease in 24 patients, and subsequently, in providing support for a denture. In all patients the buccal fat pad was covered with a split-skin graft and an acrylic plate. There was complete healing of the buccal fat pad flap within 6 weeks in 18 patients with no major complications, and minimal effects on speech and eating. In six cases there was partial dehiscence of the flap, which healed spontaneously in one patient and was repaired with local flaps in two others. There were no cases of complete breakdown of the flap. Eight patients so far have been rehabilitated with small dentures. In conclusion, the buccal fat pad flap is a simple, quick, and reliable method of reconstruction of small to medium-sized posterior maxillary alveolar defects.

Reconstruction of mandibular defects following tumor ablation by vertical distraction osteogenesis using intraosseous distraction devices

OBJECTIVES

Distraction osteogenesis has recently evolved a challenging technique to overcome major drawbacks of conventional augmentation procedures. We, therefore, report the application of miniaturized intraosseous distraction devices for the rehabilitation of mandibular defects due to ablative tumor surgery.

METHODS

In 10 patients who had undergone box-shaped or segmental resections, augmentation of the residual mandibular bone or of full thickness iliac crest grafts was performed by intraosseous implant-shaped distractors. Distraction and reconsolidation was monitored by ultrasonography. Implants were inserted within 1 week after active distraction. Median follow-up after implant insertion was 38 months.

RESULTS

On average, a vertical gain of 7.3 mm was obtained by distraction. Except for one case (local infection), all distraction zones showed complete ossification by radiologic and ultrasonographic evaluation. Overall 28 implants were placed in the distracted bone. Two implants were lost at 2.4 and 22 months after placement. The estimated 4-year implant survival rate in this population was 90%. For the endpoint 'bone loss' (>1.5 mm in the first and >1 mm in following years), the estimated 4-year success rate was 59% with four out of seven events occurring in a single patient (patient No. 1 of this series).

CONCLUSION

Vertical distraction by means of implant distractors could be performed with reasonable success in tumor patients with box-shaped resection defects or undercontoured bone grafts. Overall morbidity was very low. Even though blood supply is continuously maintained in distraction osteogenesis, bone resorption remains a critical issue for this reconstruction technique too.

[Rehabilitation of patients with newly generated malignant tumor of jaw-facial region with inner osseous implants]

Malignant tumors of the mouth cavity are characterized by aggressive progression as well as early metastasizing. As a rule, these patients need to undergo wide combined operations with resection of fragments of the jaw, causing some functional as well as psychosomatic disturbances. The purpose of the present investigation was the perfection of the methods for the rehabilitation of the given contingent of patients. The investigated patients (53 persons) underwent the treatment based on a single conception, i.e. on the 1st stage--chemical therapy, after elapsing of 4-6 weeks--radical surgical interference with a single moment plastic surgery, in the period of 6-8 months occurred total grafting of transplant tissue, giving an opportunity for implantation that was followed by prosthetic appliance. During the estimation of the results, various clinical and instrumental methods of investigation were taken into consideration. Summing up, we would like to note that application of inner bone implants with the subsequent prosthesis, seems to be an optimal method for maximal rehabilitation of patients with tumors of the jaw-facial region.

The use of free fibular flap for functional mandibular reconstruction

PURPOSE

The purpose of this investigation is to document our experience using the free vascularized fibular flap for comprehensive reconstruction of discontinuity defects in the mandible, after combined resections of malignant and aggressive odontogenic tumors, with special emphasis on functional aspect of the reconstruction process.

MATERIALS AND METHODS

The study group consisted of consecutive patients treated for reconstruction of discontinuity defects of the mandible, using the fibular vascularized free flap, between 1997-2002. All procedures were performed in the same hospital and by the same surgical team.

RESULTS

A total of 13 patients (9 males, 4 females) were treated in our department in a period of 6 years for reconstruction of discontinuity mandibular defects using the free fibula vascularized flap. Wound healing disturbances at the donor site occurred in 4 cases. Two flaps were lost, 1 because of total failure in a patient who was heavily irradiated because of osteosarcoma, the other because of resorption of the bone tissue transfer in a case of total avulsion of the mandible caused by a fall from height.

CONCLUSION

Fibula free vascularized flap is a safe and reliable method for comprehensive functional and esthetic mandibular defect reconstruction. Our protocol has a significant impact on preserving the patients quality of life.

Survey of oral rehabilitation in a consecutive series of 130 patients treated by primary resection for oral and oropharyngeal squamous cell carcinoma

The purpose of this study was to investigate the use of oral rehabilitation in a group of patients who had primary resection of oral and oropharyngeal squamous cell carcinoma. Of 132 consecutive patients operated on for previously untreated disease between January 1995 and June 1997, 130 were recruited. The University of Washington Quality of Life questionnaire was completed on the day before operation at 6 and 12 months, and at last review. A larger similar dataset was used to predict survival. Twenty-eight patients (22%) were seen by the oral rehabilitation team. The median (IQR) time from operation to start of treatment was 12 months (6-21). The median (IQR) time from beginning to end of rehabilitation was 14 months (5-49). Patients with larger tumours (P=0.06) and patients who were edentulous with dentures in the maxilla (P=0.07) were most likely to be seen for oral rehabilitation.

Prosthetic intervention in the era of microvascular reconstruction of the mandible--a retrospective analysis of functional outcome

PURPOSE

The purpose of this retrospective study was to compare the functional outcomes of patients who had mandibular resection and reconstruction with and without prosthetic intervention, and to identify predictive factors that may have an impact on functional outcomes.

MATERIALS AND METHODS

Two hundred twenty head and neck cancer patients who had undergone mandibular resection and reconstruction with at least 6 months of postoperative convalescence formed the basis of this retrospective review. Patients who did not receive prosthetic intervention formed group I (n = 142); those who received prosthetic intervention formed group II (n = 78). Functional outcomes were measured using four individual assessments (nutritional status, swallowing, masticatory performance, and speech) and one that combined the information from these assessments, the global measure of functional outcome (GMFO). Statistical analyses were used to compare the baseline characteristics and functional outcome between groups I and II and to analyze independent predictors for GMFO.

RESULTS

Of the 220 patients reviewed, 78 (35%) had prosthetic intervention; group II patients had better individual functional outcome measures and GMFO. Use of a prosthesis remained associated with GMFO after controlling for other significant predictors; other independent predictors were xerostomia, number of remaining mandibular teeth, number of tooth-to-tooth contacts, type of reconstruction, flap interference, and tongue defect. Patients who had fewer mandibular teeth and received a smaller prosthesis had better overall outcome than patients who received a larger prosthesis.

CONCLUSION

Patients who had prosthetic intervention after mandibular reconstruction had significantly better functional outcomes than patients who did not receive prosthetic intervention, even after adjusting for confounding variables.

Two stage reconstruction with revascularized grafts after resection of retromolar and oropharyngeal carcinoma

The clinical outcome of two stage reconstruction with revascularized grafts after resection of extensive retromolar and oropharyngeal squamous cell carcinoma in 17 patients is presented. In the first operation, the intraoral soft tissue defect was covered by a revascularized jejunal flap, and the mandibular defect was bridged by a reconstruction plate. After a period of 5-28 months, mandibular reconstruction was performed with a microsurgically revascularized iliac crest graft that was positioned under the jejunal graft. Clinical follow up included tumour recurrence rate, the form of nutrition, speech disorders and mouth opening restrictions. Quality of life was analysed by the EORTC questionnaires. Fifteen patients were free of recurrence and alive. Twelve patients were able to swallow food. The jejunal flap provided perfect lining of the soft palate, the pharynx and the base of the tongue, thus supporting functional restoration. Despite the gravity of disease and invasiveness of therapy, the two stage procedure leads to satisfying functional and aesthetic results thus obtaining appropriate QOL.