PURPOSE:Systematic inflammation plays an integral role in tumor development and metastasis. High neutrophil counts, among various peripheral blood biomarkers, have been shown to be associated with worse outcomes in multiple cancer types. To evaluate the absolute neutrophil count (ANC) as a prognostic biomarker in head and neck cancer, we performed an observational cohort study of patients undergoing definitive chemoradiation. METHODS:Our institutional database was queried for patients with non-metastatic head and neck cancer who underwent definitive chemoradiation between June 2007 and April 2023. ANC was analyzed as a continuous variable. Cox multivariable analysis (MVA), Fine-Gray MVA, and propensity score matching with its median value as a cutoff were performed. Subgroup analyses were performed among p16-positive cohorts. RESULTS:A total of 668 patients who met our criteria. Median follow up was 30.3 months (interquartile range 9.9-60.7). Elevated ANC as a continuous variable was associated with worse overall survival (OS; adjusted hazards ratio [aHR] 1.02, 95% confidence interval [CI] 1.01-1.04, p = 0.003), progression free survival (PFS; aHR 1.03, 95% CI 1.01-1.04, p < 0.001), and distant failure (DF; aHR 1.03, 95% CI 1.01-1.05, p = 0.007), but not locoregional failure (LRF; aHR 1.02, 95% CI 1.00-1.05, p = 0.10). Similar findings were noted among 278 matched pairs. Among 344 patients with p16-positive tumors, high ANC was associated with worse OS (aHR 1.03, 95% CI 1.00-1.06, p = 0.046), PFS (aHR 1.05, 95% CI 1.02-1.07, p < 0.001), LRF (aHR 1.08, 95% CI 1.05-1.12, p < 0.001), and DF (aHR 1.04, 95% CI 1.01-1.08, p = 0.02). CONCLUSIONS:Our study suggested that elevated ANC was an independent, adverse prognostic factor for worse survival and distant metastasis outcomes. It was also associated with worse locoregional failure among patients with p16-positive tumors.

Objective Augmented reality (AR) has recently emerged as a potential alternative to 3D-printed technology in craniomaxillofacial surgery. The purpose of this study was to evaluate the feasibility and accuracy of AR craniotomy guides for fronto-orbital advancement (FOA) compared to conventional 3D-printed guides.Design Retrospective comparative study.Setting Cleft and craniofacial center at a tertiary children's hospital.Patients 3D-printed skull models from 9 patients with metopic or coronal craniosynostosis who underwent FOA between January 2022 and November 2023.Interventions A novel application was developed to project AR craniotomy guides onto 3D-printed skull models. AR guides were compared to conventional 3D-printed guides by utilizing both guidance modalities. The discrepancy at 8 pre-determined reference points was measured, including bilateral nasofrontal (NF), zygomaticofrontal (ZF), barrel stave (BS), and tenon extension (TE).Main Outcomes Measure Measured discrepancy in millimeters between AR guides and 3D-printed guides at the pre-determined reference points.Results The anterior reference points (NF, ZF) had mean discrepancies ranging from 0.31 to 0.61 mm. The posterior points had mean discrepancies ranging from 1.39 to 3.28 mm (BS, TE). There was no statistically significant difference found between the two modalities at any reference point.Conclusions AR craniotomy guides had a high level of accuracy, particularly at the anterior reference points. AR guides demonstrated feasibility as an alternative to 3D-printed craniotomy guides, in-vitro. Further research is required to translate this novel application to cadaver models and improve precision at posterior landmarks.

Rigidly fixated custom subperiosteal implants (SPIs) have been reported in the literature for fixed retention of a prosthesis when there is limited or absent alveolar bone for placement of endosteal implants. Advances in digital technology and manufacturing have provided excellent adaptation and stability for this latest generation of SPIs, and the applications for this technique extend beyond fixed restorations of the partially or completely edentulous arch. In this case report, a modern patient-specific SPI was utilized to retain a surgical obturator without additional interdental or interosseous wiring.

Importance: Patient with head and neck cancer of the oropharynx (HNC-OROP) undergo curative-intent definitive or post-operative radiation therapy. The systemic inflammation response index (SIRI) has independent prognostic capacity in HNC-OROP. We hypothesized that the use of SIRI may produce a parsimonious model of HNC-OROP outcomes. Objective: We aimed to investigate the prognostic utility of systemic inflammatory response index (SIRI) in oropharyngeal head and neck cancer patients who underwent radiation therapy. Design, Setting, and Participants: Random survival forest (RSF) machine learning was used to model survival in 568 oropharyngeal cancer patients in this retrospective cohort study. SIRI was calculated via pre-treatment bloodwork. Model validation was performed in an external cohort of 421 oropharyngeal cancer patients. Exposures: Exposure was curative-intent definitive or post-operative radiation therapy for head and neck cancer of the oropharynx (HNC-OROP). Results: This is a retrospective study with 568 and 421 patients in the Roswell Park and external Ohio State University cohorts. We evaluated full and reduced RSF models and a robust decision tree model. The C-index of the models was 0.758 (RSF full), 0.725 (RSF reduced), and 0.702 (decision tree). The incorporation of SIRI (with performance status and smoking history) into a machine learning model identified three risk-groups that significantly stratified overall survival (p < 0.0001). These findings were validated in the external validation cohort (p = 0.0019). Progression-free survival was also significantly different for the three groups in the validation cohort (p = 0.0025). Conclusions and Relevance: An integrated machine learning model using SIRI, performance status, and smoking history was successfully developed and externally validated in oropharyngeal head and neck cancer patients.

Introduction Peripheral ameloblastoma is an unusual variant of ameloblastoma that arises from either remnants of dental lamina or basal epithelial cells of surface epithelium. This condition is relatively rare, representing only 1-5% of all ameloblastoma cases. It primarily affects middle-aged individuals, with a male-to-female ratio of 2:1. Clinically, peripheral ameloblastoma presents as a slow-growing, firm, painless, non-ulcerated lesion with normal pink color. The lesion can be either sessile or pedunculated and is typically found in the posterior gingiva and alveolar mucosa; however, occurrences in extra-gingival regions, such as the buccal mucosa, are rarely reported. Materials and Methods Case Report. Results An 84-year-old male presented with an ulcerated sessile mass on the right buccal mucosa, adjacent to the second maxillary molar. He reported no pain or discomfort associated with the lesion, and his medical history was unremarkable. A biopsy was performed. Microscopic examination revealed multiple sections of soft tissue covered by non-keratinizing stratified squamous epithelium with acanthosis. Budding of basaloid epithelial cells into the connective tissue was observed. The budding basaloid epithelial cells showed follicular and plexiform patterns exhibiting nuclear hyperchromatism, reversed nuclear polarization, and vacuolization of the cytoplasm. Interstitial basophilia was noted. IHC was performed to confirm the diagnosis of peripheral ameloblastoma. Tumor cells showed focal positive nuclear and cytoplasmic staining for calretinin. Most tumor cells exhibited strong cytoplasmic staining for CK19, and basaloid tumor cells showed cytoplasmic staining for CD56. Subsets of lesional cells displayed mild to moderate membranous staining with Ber-EP4. A diagnosis of peripheral ameloblastoma of the right buccal mucosa was rendered. Conclusion Peripheral ameloblastoma of the buccal mucosa is an uncommon variant that histologically overlaps with basal cell carcinoma. Evaluation with Ber-EP4, CK19, CD56, and calretinin are valuable ancillary probes to confirm a diagnosis of peripheral ameloblastoma of the buccal mucosa.

BACKGROUND/OBJECTIVES:There is a varying need for nutritional support among head and neck cancer (HNC) patients. Unplanned hospitalization is frequent with definitive chemoradiation. However, the association of unplanned hospitalizations with cancer control outcomes and percutaneous endoscopic gastrostomy (PEG) tube placement is not well-understood. This study aims to evaluate the clinical outcomes stratified by unplanned hospitalizations and to identify the prognostic factors associated with unplanned hospitalizations. METHODS:This retrospective cohort study included 657 HNC patients treated with definitive chemoradiation at a single institution between 2007 and 2023. Relevant clinical data were evaluated for unplanned hospitalizations, prophylactic vs. therapeutic PEG tube placement, and clinical outcomes. Multivariable, subgroup, and matched-pair analyses were performed to account for potential confounding variables. The main outcomes and measures used are overall survival (OS), progression-free survival (PFS), locoregional failure (LRF), distant failure (DF), and incidence of unplanned hospitalization. RESULTS:Unplanned hospitalizations occurred in 190 (29%) patients, which were associated with worse OS (adjusted hazards ratio [aHR] of 2.07, 95% confidence interval [CI] of 1.53-2.81, p < 0.001) and progression-free survival (aHR 1.83, 95% CI 1.38-2.41, p < 0.001). However, hospitalizations were not associated with LRF or DF outcomes. Similar findings were noted on 180 matched pairs as well as subgroups stratified by p16 status. In addition, when compared to patients with a prophylactic PEG tube, therapeutic PEG tube placement was associated with a higher risk of hospitalization (adjusted odds ratio [aOR] of 1.96, 95% CI 1.10-3.54, p = 0.02), while those without PEG tubes were less likely to be hospitalized (aOR 0.48, 95% CI 0.27-0.86, p = 0.01). CONCLUSIONS:Unplanned hospitalization was an independent, adverse prognostic factor for poor survival, but not oncologic outcomes. Unplanned hospitalization incidence was largely driven by those who required a therapeutic PEG tube, while it was the lowest for those who never needed a PEG tube.

BACKGROUND:Velopharyngeal insufficiency (VPI) is common in patients with repaired cleft palate. Speech surgery, which encompasses operative procedures to improve velopharyngeal function and speech resonance, is associated with postoperative obstructive sleep apnea (OSA). However, the relative risk of OSA between different speech surgery procedures remains unclear. PURPOSE:The purpose of this study was to compare the relative risk of OSA following pharyngeal flap versus nonpharyngeal flap procedures, which included dynamic sphincter pharyngoplasty (DSP), Furlow palatoplasty, and buccal myomucosal flaps (BMMF). DATA SOURCES:An electronic literature search was conducted utilizing PubMed, Cochrane, Embase, and Web of Science databases. STUDY SELECTION:Eligible studies included patients with a history of repaired cleft palate and VPI requiring speech surgery, published between 1994 and 2024. Studies specifically included comparison data between pharyngeal flap and nonpharyngeal flap techniques. Exclusion criteria were case reports, abstracts, and reviews. DATA EXTRACTION AND SYNTHESIS:Data were extracted per the the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Demographics, speech procedure data, OSA frequency, and follow-up data were recorded. The primary comparison was procedure type including pharyngeal flap versus non-pharyngeal flap procedures. Meta-analysis was performed using a random-effects model, with P values <.05 considered statistically significant. MAIN OUTCOMES AND MEASURE:The primary outcome was relative risk of postoperative OSA between procedure types. RESULTS:Four studies met inclusion criteria, which included 751 subjects. Pharyngeal flap use was associated with a significantly greater risk of postoperative OSA compared to nonpharyngeal flap procedures (pooled risk ratio = 2.45, 95% CI: 1.20 to 5.01, P = .01). Subgroup analysis demonstrated that palatal lengthening procedures had a significantly lower risk of OSA than pharyngeal flap (risk ratio = 0.39, P = .002); however, there was no difference in postoperative OSA between DSP and pharyngeal flap (P = .68) CONCLUSIONS AND RELEVANCE: Palatal lengthening procedures had a lower risk of postoperative OSA than pharyngeal flap. There was no difference in postoperative OSA between pharyngeal flap and DSP. As such, for patients with preoperative OSA or patients at high risk for developing OSA, it may be prudent to use palatal lengthening procedures as a first-line option for correction of VPI.

BACKGROUND:Orbital fractures commonly result in functional and esthetic deficits, demanding precise reconstruction of orbital volume and globe position. Patient-specific implants (PSIs) have emerged as promising solutions, yet their definitive clinical and cost-effectiveness benefits remain debated. PURPOSE:The study purpose was to estimate and compare orbital volume restoration, globe position, functional outcomes, and complications between PSI versus conventional orbital reconstruction. STUDY SELECTION:A systematic search of PubMed, Embase, Cochrane Library, and Web of Science from inception to May 2025 identified studies comparing PSIs with conventional orbital reconstruction techniques in adults with post-traumatic orbital defects. Studies exclusively reporting technical aspects, pediatric samples, or nontraumatic defects were excluded. Of 385 identified studies, 23 met the inclusion criteria. RESULTS:The included studies involved 1,222 subjects. PSIs demonstrated significantly better orbital volume restoration compared to conventional methods (mean volume difference: PSI, 0.73 ± 0.28 cm3; conventional, 1.54 ± 0.38 cm3, P < .05). Globe position outcomes were also consistently better in PSI groups, with significantly reduced persistent enophthalmos (PSI 7.3% vs conventional 18.2%, P = .03). Functional outcomes, specifically persistent diplopia, were significantly lower with PSI (PSI 11.7% vs conventional 30.1%, P = .01). Revision rates were also significantly reduced with PSI usage (PSI 5.9% vs conventional 13.7%, P = .01). Despite higher initial costs, PSI reduced operative times by an average of 15.7 minutes, which may offset overall treatment expenses. CONCLUSIONS AND RELEVANCE:PSIs offer superior outcomes in orbital volume restoration, globe positioning, and reduced complication and revision rates compared to conventional reconstruction. These findings strongly support PSI utilization in complex post-traumatic orbital reconstruction, particularly when integrated with intraoperative navigation systems. Further research, especially prospective randomized studies with long-term follow-up, is needed to strengthen these recommendations.

Objective:To investigate the prognostic utility of systemic inflammatory response index (SIRI) as a biological readout of stress associated immune modulation in head and neck cancer patients who underwent radiation therapy. Methods:Random survival forest machine learning was used to model survival in 568 head and neck cancer patients. SIRI was calculated via pre-treatment bloodwork. Model validation was performed in an external cohort of 345 patients. Baseline financial toxicity (FT) and SIRI were studied in 638 patients. Results:Incorporation of SIRI (with performance status and smoking history) into a machine learning model identified three risk-groups that significantly stratified overall survival (p<0.0001,) and these findings were validated in the external validation cohort (p<0.001.) Increasing levels of FT were significantly associated with increasing SIRI levels. (p=0.001.). Conclusions and Relevance:An integrated machine learning model using clinical features was successfully developed and externally validated. SIRI was significantly associated with increasing FT. Our findings highlight the potential utility of SIRI as a biological marker of FT in head and neck cancer patients.

Reconstructive surgery is necessarily guided by application of principles rather than identical procedures, given that each defect and normal appearance is unique. To protect critical structures, maintaining compartmentalization between the cranium, orbit, sinuses, and pharynx is critical. Staging reconstruction throughout growth may be required to achieve the most precise definitive outcome.

Background: Ablative mandibular resection with sacrifice of the inferior alveolar nerve (IAN) results in loss of sensation and decreased quality of life. Purpose: The purpose of this study is to evaluate functional sensory recovery (FSR) of immediate IAN allograft reconstruction performed during ablative mandibular resection at 1 year following surgery. Study Design, Setting, Sample: This is a single-center retrospective cohort study that included consecutive subjects who underwent mandibular resection with IAN discontinuity and used a nerve allograft of >= 40 mm. Predictor/Exposure/Independent Variable: The primary predictor variable is the use of an immedi-ate nerve allograft in mandibular reconstruction. Main Outcome Variable(s): The main outcome variable is FSR at 1 year using the Medical Research Council Scale. Covariates: Covariates include subject age, sex, specific pathology, nerve gap length, and development of neuropathic pain. Analyses: Statistical analysis of comparison of neurosensory outcomes was measured by bivariate statistics, weighted values, repeated measures, analysis of variance, and McNemar test. Results: The study sample was composed of 164 subjects, of whom 55 (33.5%) underwent nerve allo-graft reconstruction and 30 (18.3%) did not have nerve reconstruction. Seventy-nine subjects (48.2%) did not meet the inclusion criteria. In the entire nerve allograft group of 55 subjects, FSR was achieved in 80% at 1 year; however, in benign disease alone, 31 of 33 (94%) achieved FSR at 1 year. In the nonallograft group (all benign disease), only 2 of 30 (7%) achieved FSR at 1 year. The significant covariates were age and pathology. Benign pathologic resections were 5.2 times more likely to achieve FSR than malignancies, and all subjects # 18 years of age achieved FSR. After adjusting for age, sex, pathology, nerve gap length, nerve allograft was significantly associated with achieving FSR at 1 year (adjusted odds ratio = 5.52, 95% confidence interval = (1.03, 29.51), P value = .045 < .05). Conclusion and Relevance: Immediate long-span IAN allograft reconstruction is effective in restoration of sensation with an overall 80% of subjects achieving FSR at 1 year, while benign disease resulted in 94% FSR at 1 year. Immediate IAN reconstruction should be considered with mandibular resection involving the IAN, especially for children and benign disease. (c) 2023 American Association of Oral and Maxillofacial Surgeons

With this second part of Maxillary and Midface Reconstruction, the editors Melville, Fernandes, and Markiewicz are proud and honored to bring to a close the Atlas of the Oral and Maxillofacial Surgery Clinics of North America issue on Maxillary and Midface Reconstruction. This marks not only the culmination of our collective efforts but also the beginning of a new chapter in the field of maxillofacial reconstruction, a chapter that we are all part of.

Craniofacial fibrous dysplasia (CFD) is a rare developmental disease of bone, which typically presents as a painless, expansile mass causing deformity of the craniofacial skeleton. In rare circumstances, compression of neurovascular structures may arise, causing symptoms such as pain, visual impairment, and hearing loss. Traditionally, CFD debulking has been performed with “freehand” techniques using preoperative imaging and anthropometric norms to determine the ideal amount of tissue removal. The advent of computer-assisted surgery, computer-aided design, and computer-aided manufacturing (CAD/CAM) has revolutionized the management of CFD. Surgeons can now fabricate patient-specific osteotomy/ostectomy guides, allowing for increased accuracy in bone removal and improved cosmetic outcomes. This series of 3 cases describe our institution’s technique using patient-specific ostectomy “depth guides”, which allow for maximum removal of fibro-osseous tissue while sparing deep and adjacent critical structures. These techniques can be widely applied to the craniofacial skeleton to assist in the surgical management of CFD.

Importance The role of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement in head and neck cancer (HNC) patients treated with chemoradiation remains controversial and varies by center. Objective To evaluate the impact of prophylactic PEG tube placement in patients undergoing chemoradiation for HNC PEG tube use for more than 6 months and weight loss. Design, Setting, and Participants This single-institution retrospective study included 502 patients with head and neck cancer. Exposures Concurrent Chemoradiation (CCRT) and prophylactic PEG tube placement. Main Outcomes and Measures Univariate analyses were performed to determine risk factors for long term PEG tube and weight loss. Outcomes that were significantly associated with prophylactic PEG were selected for a multivariate analysis. The Kaplan-Meier method was used to estimate survival and the time to PEG removal, with comparisons between groups analyzed by log-rank tests. The global health status score from the EORTC QLQ30 was utilized to assess impact on quality of life. Results Significantly higher weight loss was seen with the following variables: 1) omitting prophylactic PEG tube (p < 0.00001), 2) younger age (p = 0.0032), and 3) adjuvant CCRT (p = 0.0005). There was significantly higher risk of feeding tube duration longer than 6 months in those who: received prophylactic PEG tube (p < 0.0001) and were older than the median age of 60.8 years (p = 0.0165) on multivariate analysis. Prophylactic PEG tube was not associated with improved global health status, overall survival, or progression-free survival on univariate analysis. Conclusions and Relevance Prophylactic feeding tubes significantly decreased weight loss during treatment. Prophylactic PEG tube and older than median age was significantly associated with higher risk of feeding tube duration longer than 6 months.

The goals of maxillary reconstruction incorporate both form and function. Externally, it is important to restore facial volume and midface projection as well as support the orbital contents to minimize the consequences of volume-related changes of the globe such as hypoglobus. Internally, and functionally, it is important to obtain oronasal/oroantral separation while simultaneously planning for subsequent dental rehabilitation. Not all maxillectomy defects impact form and function to the same extent.