The fibula free flap has been widely used for reconstructing large segmental bone defects in the maxillofacial region. While mandibular reconstruction requires a high degree of precision, the impact of surgical deviations on clinical outcomes remains poorly understood. This study addressed geometric inaccuracies during surgery and examined the effects of loading patterns on the biomechanical behavior of reconstructed mandibles. Patient-specific finite element (FE) models were developed using CT data from three representative cases - two with Brown Class II defects and one with a Class III defect - reconstructed with single, double, and triple fibula segments. The computational analysis results revealed that minimizing the gap between native and grafted bones reduces stress on the reconstruction plate by approximately 30%. When gaps are unavoidable, anterior placement results in the least biomechanical impact, increasing stress by only 6%. To optimize the outcome, alternating ipsilateral and contralateral posterior loading is recommended to ensure adequate contact pressure at the osteotomy site while minimizing the stress on the plate. In addition, incisor loading should be limited to patients with multiple grafted segments to prevent stress concentration on the plate. These in-silico findings provide critical biomechanical insights to refine surgical techniques and develop patient-specific occlusal loading guidelines, ultimately improving long-term outcomes in mandibular reconstruction.

This cohort study assesses the potential differences in facial contour and patient-reported outcomes in zygomatic implant perforated flap compared to fibula free flap maxillary reconstruction.

BACKGROUND:Regional metastasis occurs in 5% of cutaneous squamous cell carcinoma (cSCC). The aim of this study is to assess the impact of margin status of regional metastases on survival. METHODS:A retrospective review of 401 patients with nodal metastases from cSCC. Margin status of nodal metastases was classified as clear (>1 mm), close (<1 mm), or involved. Cox regression and Kaplan-Meier methods were used to assess associations with overall and disease-specific survival (OS and DSS). RESULTS:Of the 401 patients with nodal metastases (median age 75, 85.3% male), 43.6% had involved margins, 27.4% had close margins, and 28.9% had clear margins. Involved margins were significantly associated with reduced OS and DSS on univariable analysis. Multivariable analysis confirmed that involved margins independently predicted worse DSS (HR 1.92, 95% CI 1.15-3.19, p = 0.01). Other independent prognostic factors included size of deposit (HR 1.02, 95% CI 1.01-1.04, p < 0.001), number of deposits (HR 1.05, 95% CI 1.02-1.08, p < 0.001), and the presence of perineural invasion (HR 1.84, 95% CI 1.14-2.98, p = 0.01). CONCLUSIONS:Clear surgical margins during the removal of regional metastases of cSCC improves survival outcomes. This study highlights the importance of careful preoperative evaluation to achieve a complete (R0) surgical resection. LEVEL OF EVIDENCE:3 Laryngoscope, 135:2379-2384, 2025.

BACKGROUND:Submandibular gland pathology is common but rarely reported. This study was performed to evaluate demographic, pathological, and survival outcomes associated with submandibular gland extirpation. METHODS:Retrospective analysis of patients treated in a single quaternary-care institution between 1989 and 2022 was performed. RESULTS:Four hundred and sixty patients underwent submandibular gland extirpation with a female preponderance (n = 271, 59%) and a mean age of 51 years. Older age was associated with increased risk of malignancy (P < 0.001). Submandibular calculus was the most common pathology, with gland extirpation for this indication decreasing over time (P = 0.005). Pleomorphic adenoma was the most common benign tumour (n = 96, 52.7% of total tumours), and adenoid cystic carcinoma was the most common malignant tumour (n = 25, 13.7% of total tumours). CONCLUSIONS:Submandibular calculus remains the most common indication for submandibular gland extirpation, although the rate is decreasing over time. Pleomorphic adenoma continues to be the most common tumour of the submandibular gland, whilst adenoid cystic carcinoma is the most common malignant tumour. The incidence of benign versus malignant tumours has remained constant over the period of this study.

BackgroundThe Jaw-in-a-Day (JIAD) procedure aims to achieve immediate functional occlusion via a single-stage approach to maxillofacial reconstruction. While JIAD has gained popularity since its inception by Levine and colleagues, efficacy and outcome data remain limited. In this report, we discuss our experience with the JIAD technique at an Australian tertiary referral centre.MethodsA retrospective review of all JIAD procedures performed from April 2022 to December 2023 was conducted. Clinicopathologic data reviewed included demographic information, primary diagnosis, anatomical site of disease, and history of pre-operative radiotherapy. Outcome measures of interest included operative time, number of implants placed, post-operative complications and implant survival.ResultsNineteen patients were identified for the study. Two maxillary and 17 mandibular JIAD procedures were performed. The most common indications were squamous cell carcinoma (n = 8) and ameloblastoma (n = 5). Surgical complications included recipient site wound infection (n = 3), flap dehiscence (n = 2), haematoma formation (n = 1), and neck abscess associated with partial flap failure (n = 1). No total flap failures were identified. Of the 55 total implants placed, one implant failure occurred 2-months post-operatively. No loss of irradiated implants (n = 21) was observed. The median time to adjuvant radiotherapy was 57 days (range, 32-61). Eighteen of 19 patients (95%) achieved immediate dental rehabilitation, and 15/19 patients (79%) retained a functional prosthesis by the end of the follow-up period.ConclusionsOur series supports the feasibility of single-stage reconstruction for both benign and malignant indications. Further research is required to understand the long-term functional, aesthetic, and health-related quality-of-life outcomes with the JIAD technique. In this case series, we discuss our early experience with the Jaw in a Day (JIAD) technique at an Australian tertiary referral centre. Our research demonstrates that the JIAD procedure predictably achieves immediate dental restoration in patients undergoing major maxillofacial reconstruction, and supports the feasibility of its use for both benign and malignant indications.image

Patients treated for oral cancer, may experience restricted mouth opening (trismus). Barriers such as cost have limited the utilization of traditional jaw stretching devices, and consequently, patients experience problems with swallowing, oral care, communication, and cancer surveillance. The safety and efficacy of Restorabite™, a new device designed to overcome these barriers, is evaluated prospectively over 12 months. This phase II investigator-led trial included patients with chronic trismus underwent 10-weeks of trismus therapy using Restorabite™. Safety, adherence, changes in mouth opening, and patient-reported outcomes are presented. 114/120 participants with trismus completed the intervention, and 104 had their progress monitored for 12 months. Thirteen participants withdrew due to tumour recurrence. At the completion of the intervention, mouth opening improved by 10.4 mm (p < .001). This increased to 13.7 mm at 12 months (p < .001). Patient reported outcome all significantly improved and 47 participants were no longer classified as having trismus. There were no serious treatment related adverse events. In patients with trismus following head and neck cancer treatment, a 10-week programme of jaw stretching exercises using Restorbite™ safely improves mouth opening and associated quality of life outcomes with high adherence and the benefits are maintained for 12-months.

BACKGROUND:Trismus therapy is often delayed after jaw reconstruction to avoid hardware failure or non-union. The aim of this study is to document the forces that have been applied to patients undergoing free flap reconstruction of the oral cavity in the 12 months following oral cavity reconstruction, and to analyze the associations between force and maximal interincisal opening (MIO) over time. METHODS:Participants with trismus after free flap reconstruction of the oral cavity completed a 10-week jaw stretching program using Restorabite™. Primary outcome measures included the minimum and maximal force applied by a trismus device during rehabilitation, MIO, bone union, and health-related quality of life outcomes up to 12 months postoperatively. RESULTS:A mean of 20.6 Newtons (N) was used during passive exercises and 38.9 N during active exercises was used during trismus therapy. The mean increase in MIO for the 45 participants after 10 weeks, 6 months, and 12 months of therapy was 8.4 mm (p < 0.001), 12.6 mm (p < 0.001), 12.7 mm (p < 0.001), respectively. There was no significant difference in the mean minimal (p = 0.37) or mean maximal (p = 0.08) force applied between those who underwent osseous free flap reconstruction compared to fasciocutaneous only, respectively. In patients who underwent osseous reconstruction, 25 (67.6%) had complete bone union and 12 (32.4%) had partial union at 12 months postsurgery. CONCLUSIONS:In participants undergoing osseous free flap reconstruction, there was no association between the force applied to the rates of bone union. Further research to define safe and optimal loading may benefit patients undergoing jaw reconstruction.

Traditionally, pain has been a signal to de-intensify jaw exercises for trismus to prevent tissue damage. It is unknown whether patients who have undergone surgery or radiotherapy for head and neck cancer have sufficient sensation to detect changes in occlusal load. This study sought to compare the minimum detectable occlusal load in a cohort of patients with head and neck cancer (HNC) and compare this with healthy controls. Twenty patients who were treated for HNC and 20 healthy controls were recruited from a single institution. A purpose-built pressure transducer was used to measure the minimum detectable force (measured in Newtons) applied to the jaw and the interincisal distance. Analysis was conducted using a mixed effects linear regression. The mean minimum detectable occlusal load in patients with HNC was 18.7N compared to 4.5N in healthy controls (mean difference 14.3N, 95% CI 12.2N to 16.4N, p < 0.001). Adjusted IID predicted force (0.15N per-mm IID, 95% CI 0.09 to 0.2, p < 0.001) with a weak interaction between treatment with radiotherapy and IID in HNC patients (p = 0.85). Patients who have been treated for HNC are less sensitive to changes in force applied to the jaw. This is concerning given that most jaw stretching devices use an unregulated and unknown amount of force to achieve greater mouth opening.

Objectives: Occlusal-based virtual surgical planning (VSP) prioritises the placement of endosseous dental implants, over replicating native bone contour. This may compromise facial aesthetics. This study aimed to compare function and health-related quality of life (HRQOL) following maxillomandibular reconstruction according to the ability to replicate preoperative soft-tissue contour and virtual plan. Materials and methods: Patients who underwent occlusal based VSP osseous free flap reconstruction of the maxilla or mandible with high-resolution preand post-operative facial computerised tomography imaging and completed the FACE-Q questionnaire were retrospectively identified. Accuracy of reconstruction compared to preoperative soft tissue contour and virtual plan, was measured using 3DSlicer (R) and CloudCompare (R) in three dimensions. Random effects modelling determined the associations between bony and soft tissue accuracy and HRQOL/functional domains. Results: Twenty-two patients met the inclusion criteria. For mandibular and maxillary reconstructions, better soft tissue accuracy was associated with improved appearance (p = 0.048) and appearance distress (p = 0.034). For mandibular reconstructions, better soft tissue accuracy was associated with improved smile (p = 0.039) and smile distress (p = 0.031). For maxillary reconstructions, better bony accuracy was associated with improved appearance (p = 0.023) and drooling distress (p = 0.001). Unexpectedly, better bony accuracy was associated with worse eating and drinking (p = 0.015), oral competence (p = 0.005) and eating distress (p = 0.013) in mandibular reconstructions. Conclusion: Whilst soft tissue accuracy was associated with better functional and HRQOL outcomes, bone accuracy was associated with worse oral function or distress in mandibular reconstruction. These results require validation but should be considered when performing occlusal-based VSP, which prioritises dental rehabilitation over replicating facial bony contour. Crown Copyright (c) 2024 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

BACKGROUND:Digital surgical planning (DSP) has revolutionized the preparation and execution of the management of complex head and neck pathologies. The addition of virtual reality (VR) allows the surgeon to have a three-dimensional experience with six degrees of freedom for visualizing and manipulating objects. This pilot study describes the participants experience with the first head and neck reconstructive VR-DSP platform.METHODS:An original VR-DSP platform has been developed for planning the ablation and reconstruction of head and neck pathologies. A prospective trial utilizing this platform involving reconstructive surgeons was performed. Participants conducted a simulated VR-DSP planning session, pre- and post-questionnaire as well as audio recordings allowing for qualitative analysis.RESULTS:Thirteen consultant reconstructive surgeons representing three surgical backgrounds with varied experience were recruited. The majority of surgeons had no previous experience with VR. Based on the system usability score, the VR-DSP platform was found to have above average usability. The qualitative analysis demonstrated the majority had a positive experience. Participants identified some perceived barriers to implementing the VR-DSP platform.CONCLUSIONS:Virtual reality-digital surgical planning is usable and acceptable to reconstructive surgeons. Surgeons were able to perform the steps in an efficient time despite limited experience. The addition of VR offers additional benefits to current VSP platforms. Based on the results of this pilot study, it is likely that VR-DSP will be of benefit to the reconstructive surgeon.

The periosteum is a thin layer of connective tissue covering bone. It is an essential component for bone development and fracture healing. There has been considerable research exploring the application of the periosteum in bone regeneration since the 19th century. An increasing number of studies are focusing on periosteal progenitor cells found within the periosteum and the use of hydrogels as scaffold materials for periosteum engineering and guided bone development. Here, we provide an overview of the research investigating the use of the periosteum for bone repair, with consideration given to the anatomy and function of the periosteum, the importance of the cambium layer, the culture of periosteal progenitor cells, periosteum-induced ossification, periosteal perfusion, periosteum engineering, scaffold vascularization, and hydrogel-based synthetic periostea.

Adjunctive procedures, including autologous fat grafting and surgical debulking, may be required to optimise facial contours following maxillomandibular reconstruction. A standardised method for the quantitative analysis of volumetric change and the impact of restoration of facial symmetry on health-related quality of life remains unclear. We use two case studies to illustrate the value of a combination of objective 3-dimenmsional (3D) measurements, clinical assessments, and patient-reported outcomes, using the FACE-Q questionnaire to elucidate the benefits of adjunctive procedures.

Periosteum is a highly vascularized membrane lining the surface of bones. It plays essential roles in bone repair following injury and reconstruction following invasive surgeries. To broaden the use of periosteum, including for augmenting in vitro bone engineering and/or in vivo bone repair, we have developed an ex vivo perfusion bioreactor system to maintain the cellular viability and metabolism of surgically resected periosteal flaps. Each specimen was placed in a 3D printed bioreactor connected to a peristaltic pump designed for the optimal flow rates of tissue perfusate. Nutrients and oxygen were perfused via the periosteal arteries to mimic physiological conditions. Biochemical assays and histological staining indicate component cell viability after perfusion for almost 4 weeks. Our work provides the proof-of-concept of ex vivo periosteum perfusion for long-term tissue preservation, paving the way for innovative bone engineering approaches that use autotransplanted periosteum to enhance in vivo bone repair.

Virtual surgical planning (VSP) is commonly employed for the reconstruction of maxillofacial defects and involves the digital simulation of the planned resection and bony reconstruction. Production of patient specific plates, surgical guides and anatomical models assist the surgeon to predictably execute the digital plan. 1 Leinkram D. Wykes J. Palme C. Deshpande S. McLaughlin M. Garg P. Wallace C. Howes D. Clark J.R. Occlusal-based planning for dental rehabilitation following segmental resection of the mandible and maxilla. ANZ J Surg. 2021; 91: 451-452https://doi.org/10.1111/ans.16441 Crossref Scopus (6) Google Scholar , 2 Petrides G.A. Dunn M. Charters E. Venchiarutti R. Cheng K. Froggatt C. et al. Health-related quality of life in maxillectomy patients undergoing dentoalveolar rehabilitation. Oral Oncol. 2022; 126105757https://doi.org/10.1016/j.oraloncology.2022.105757 Crossref Scopus (7) Google Scholar , 3 Barry C.P. MacDhabheid C. Tobin K. Stassen L.F. Lennon P. Toner M. et al. ‘Out of house’ virtual surgical planning for mandible reconstruction after cancer resection: is it oncologically safe?. Int J Oral Maxillofac Surg. 2021; 50: 999-1002https://doi.org/10.1016/j.ijom.2020.11.008 Abstract Full Text Full Text PDF Scopus (5) Google Scholar , 4 Mazzola F. Smithers F. Cheng K. Mukherjee P. (Hubert) Low TH, Ch’ng S, et al. Time and cost-analysis of virtual surgical planning for head and neck reconstruction: A matched pair analysis. Oral Oncol. 2020; 100104491https://doi.org/10.1016/j.oraloncology.2019.104491 Crossref Scopus (43) Google Scholar The surgical guides include drill holes for the native mandible or maxilla as well as the osseus free flap for accurate positioning of the patient specific plate. Once the screw channels and osteotomies are created, the anatomical models can be used to confirm the length and angulation of osteotomies. This can be done at both the recipient and donor sites by placing the model of the osseous reconstruction into the ablative defect and by placing the osseous flap with the patient specific reconstruction plate into the resected model (Figure 1, Figure 2). This intermediate step allows the surgeon to correct or adjust for any inaccuracies whilst the flap remains vascularised. Following this, the pedicle is divided and the osseous free flap is inset to the defect created within the maxilla or mandible. Figure 2Alignment of resected model to fibula flap while perfused in leg to confirm fit of osteotomies View Large Image Figure Viewer Download Hi-res image

The inclusion of depth of invasion (DOI) in the American Joint Committee on Cancer's staging system for oral cavity squamous cell carcinoma (SCC) has major clinical impacts. Recent studies have evaluated the reliability of imaging modalities and biopsy techniques to measure DOI preoperatively. The objective of this systematic review and meta-analysis was to comprehensively include all previously described methods to measure preoperative DOI in oral tongue SCC (OTSCC) and to compare their reliability. A systematic review was conducted on PubMed, Embase and Cochrane according to the PRISMA guidelines. Studies that evaluated the reliability of DOI measured on biopsy or imaging (rDOI) by comparing it to DOI on histopathology (pDOI) were included for extraction. A meta-analysis was conducted to obtain pooled correlation coefficients for each imaging modality. The pooled correlation coefficients between rDOI and pDOI were 0.86 (CI95% = [0.82–0.88]) and 0.80 (CI95% = [0.70–0.87]) for magnetic resonance imaging (MRI) studies and computed tomography (CT) studies, respectively. For ultrasound (US), the correlation coefficient could only be measured by including studies which measured not only DOI but also tumor thickness. It was 0.89 (CI95%= [0.82–0.94]). Overall, MRI is the better studied modality. It has a good reliability to measure preoperative rDOI in OTSCC. CT is less studied but appears to be less reliable. US cannot be compared to these imaging modality as it has been used more often to measure TT than DOI.

Hypovitaminosis C, or scurvy, is thought to be an uncommon condition. Although prevalent in the 19th century, its ease of absorption and availability in a general diet has greatly reduced its incidence. Vitamin C is necessary for a number of physiological processes and deficiency can result in a number of complications including bleeding/bruising, anaemia and gingival hyperplasia. This case report demonstrates a case of hypovitaminosis C presenting to a tertiary hospital related to poor dietary intake in a patient with behavioural medical conditions. Treatment consisted of oral supplementation of vitamin C with almost immediate resolution of presenting symptoms.

Mandibular fractures are a common injury managed by oral and maxillofacial surgeons. Current open reduction and internal fixation (ORIF) treatment strategies are based on Champy's ideal line of osteosynthesis with the use of miniplate and load-sharing fixation techniques. Postoperative instructions for the duration of a soft diet have varied. This prospective, randomised study reviewed the outcomes of a patient led return to diet at 2 weeks and 4 weeks compared with 6 weeks (control group) following an ORIF of mandibular fractures. There was no significant difference in the incidence of complications between a graduated return to diet at 2, 4, or 6 weeks following an ORIF of the mandible, nor was there a difference in the quality of life during the postoperative period. Smoking has a notable risk factor for complications. The findings of this study suggest that strict adherence to a softened diet may not be necessary, and that patients identified at being of low risk of complications may be able to return to a normal diet from as early as two weeks.

Adequate nutrition is necessary in head and neck surgery. Enteral feeding via a nasogastric tube is often required due to the altered anatomy and to allow sufficient intraoral healing. Insertion of a nasogastric tube is commonly performed without complication and confirmation of its position by a number of different methods. Incorrect positioning can cause significant morbidity with associated mortality. This case report describes the inadvertent placement of a nasogastric tube in a patient with a mandibular squamous cell carcinoma, into the abdominal cavity following a failed traumatic nasal tube intubation. Chest radiography and auscultation failed to identify the abnormal position with subsequent commencement of feeds for a number of days. Following a laporotomy and insertion of abdominal drains, the patient recovered and was discharged from hospital. To prevent recurrence, it is suggested that direct laryngoscopy or direct visualisation of the upper aspect be performed.

Access to the mandibular ramus can be difficult. There are a number of described methods for accessing the mandibular ramus and condyle, including a transoral or transcutaneous approach. Access via a transoral approach prevents surgical scars but can result in an excessive amount of bone removal from the anterior mandibular ramus. The transparotid approach has been described and commonly used for the management of mandibular trauma. It allows for direct access to the mandibular ramus and condyle with a number of possible complications, including salivary fistula formation, sialocele and facial nerve injury. Despite these risks, this approach is commonly used in the setting of trauma. This case report describes an additional indication, the successful use of the transparotid approach for the management of benign odontogenic pathology.