Severe postoperative dysphagia as an early predictor for decreased overall survival in patients with oral cancer Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s): Christoph Klingelhöffer, Annegret Obst, Tobias Ettl, Johannes Meier, Steffen Müller, Torsten Reichert, Gerrit Spanier Abstract Objectives The aim of this retrospective study was to analyze the early postoperative swallowing outcome in oral cancer patients considering risk factors and localization. Materials and methods Four hundred patients with primary cases of oral cancer were included. Tumors’ locations were categorized into four main groups (central, lateral, anterior and posterior). Swallowing function was evaluated at day 7 after surgery. Results Ninety-eight percent (393/400) of the patients had a swallowing impairment including 41 (10.2%) patients who were unable to swallow. Strong risk factors with p values of 0.001 were tumor size, nodal stage, tracheotomy, insufficient dental status and reconstruction with a flap. The inability to swallow was increased at T1 und T2 patients, if they were reconstructed with a flap compared to patients who had a primary wound closure (p = 0.04). Decreased swallowing function was determined if the tumor was located central (OR = 1.8; p = 0.141) and additionally posterior (OR = 5.8; p = 0.110). Inability to swallow, even at that early point in time, (p = 0.001) was as significant as tumor size (p = 0.009) and nodal stage (p = 0.020), referring to overall survival. Conclusion The impact of early dysphagia should not be underestimated. By considering swallowing impairment at the primary therapy patients can profit concerning survival and comorbidity.

Announcements Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s):

Gingival fibroblasts and medication-related osteonecrosis of the jaw: Results by real-time and wound healing in vitro assays Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s): Anna Yuan, Adelheid Munz, Siegmar Reinert, Sebastian Hoefert Abstract Objective This study investigated the effects of bisphosphonates and denosumab on human gingival fibroblasts (HGFs) that could influence inflammation, wound healing, and angiogenesis in medication-related osteonecrosis of the jaw (MRONJ). Methods A real-time in vitro assay was performed on HGFs with and without the addition of bacterial lipopolysaccharide and a mononuclear cell co-culture to observe the effects of zoledronate, ibandronate, alendronate, clodronate, denosumab, and combinations of zoledronate and denosumab at varied concentrations. A wound healing assay was performed, and gene and protein expression was analyzed for inflammatory, angiogenic, and osteoclastogenic cytokines and mediators including interleukin (IL)-1β, IL-6, tumor necrosis factor alpha (TNFα), IL-8, vascular endothelial growth factor (VEGF), RANKL, and osteoprotegerin. Results Higher concentrations of antiresorptives resulted in impaired wound healing and HGF death, which also occurred without mechanical damage. These effects were increased with bacterial lipopolysaccharide and mononuclear cells. Increased levels of IL-1β, TNFα, IL-8, VEGF, osteoprotegerin, and decreased levels of IL-6 were observed. Conclusions Antiresorptive exposure was associated with HGF death and delayed wound healing, which could be attributed to an elevated inflammatory response and immune dysfunction contributing to MRONJ development. There was no evidence of anti-angiogenic effects. Our experiments present the first results of denosumab with HGFs.

Understanding the relevance of comprehensive facial injury (CFI) score: Statistical analysis of overall surgical time and length of stay outcomes Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s): Gabriele Canzi, Elena De Ponti, Chiara Fossati, Giorgio Novelli, Stefania Cimbanassi, Alberto Bozzetti, Davide Sozzi Abstract Comprehensive facial injury (CFI) score is a powerful and extremely simple scale used to grade the clinical severity of all facial injuries, and is expressed in terms of the overall surgical time needed for definitive treatment. Its statistical validation was previously reported in 2019. The aim of this study was to investigate further the link with duration of surgery, applying the score to a larger sample of patients, and to evaluate the relationship between CFI score and other extremely relevant dependent variables: length of stay (LOS) in high care units (HCU) and in intensive care units (ICU). 1406 patients with diagnosis of at least one facial bone fracture, and treated by the same team in two highly specialized trauma centers, were studied. For each patient a specific CFI score is assigned and overall surgical time, length of stay, and presence of associated injuries were recorded. Data were divided into six clusters according to CFI score: (1) 0–5, (2) 6–10, (3) 11–15, (4) 16–20, (5) 21–25, and (6) >25. Regressions between CFI clusters and duration of surgery (minutes), LOS in ICU (days), and in HCU (days) were established. In addition, the presence of associated head and/or somatovisceral injuries was analyzed and related to CFI score. Statistical analysis confirmed linear regression existing between each CFI cluster and overall surgical time (p < 0.00001), with improved significance of the results using median values of surgical duration for each cluster (p = 0.0001). It also demonstrated the existence of linear regression between all CFI clusters and LOS in HCU (p = 0.0001) and between CFI clusters 3–6 and median values of LOS in ICU (p = 0.0001). Finally, associated injuries were observed to be more frequent in high CFI score clusters, occurring in around 90% of patients with a CFI score >25 (p < 0.00001). Association of head and facial injuries play a major role in high LOS in ICU values, whereas coexistence of facial, head and somatovisceral involvement increases LOS in ICU to over twice that for single association. Surgical time and length of stay are outcomes traditionally used to assess the statistical significance of many new proposed trauma score. The strong correlation demonstrated between CFI score and each of these variables confirms its value and reliability. CFI score is proven to be an ideal, simple, informative, and reproducible tool for measuring severity of facial injuries and their clinical impact. It allows correlation with associated head and somatovisceral injuries, focusing attention on the interesting field of reciprocal influences in simultaneous, multidistrectual involvement. None of the previously proposed facial injury severity scales have offered such informative and statistically significant features.

Maxillofacial surgery in wartime Middle-East: Paul Tessier's missions to Iran Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s): Quentin Hennocq, Amin Bennedjaï, François Simon, Sylvie Testelin, Bernard Devauchelle, Jean-François Tulasne, Stéphanie Dakpé, Roman Hossein Khonsari Abstract The Iraq–Iran war (1980–88) resulted in numerous maxillofacial injuries. More than 400,000 people were wounded and required specialist care. Paul Tessier, a leading French plastic surgeon and pioneering craniofacial surgeon, was involved in several missions to Iran and operated on a vast cohort of patients with complex war trauma sequelae. Our study included 322 files relating to patients with war injuries operated on by Paul Tessier in Iran from 1990 to 1993. The files were the property of the Association Française des Chirurgiens de la Face. Relevant epidemiological parameters and data on surgical indications and procedures were collected. Descriptive statistics were used in order to characterize the cohort, and a multivariate logistic model was developed in order to assess factors associated with severe eye injuries within all facial injuries. Age range at admission was 5–67 years (average: 27.15 ± 6.97). The most common trauma mechanisms were shell fragments (161 patients; 50 %) and bullets (27 patients; 8.38 %). The bone and orbital contents in the upper third of the face were affected in 124 patients (38.50%); 72 patients (22.36%) had trauma of the middle third of the face; and 86 patients (26.71%) had trauma of the lower third. A total of 175 bone grafts were harvested by Tessier: 72 (41.14%) iliac grafts and 94 (53.71%) frontal and/or parietal grafts. Tessier managed 60 orbital fractures (18.63%) and 95 patients with uni- or bilateral enucleations (29.50%). A multivariate logistic model showed that patients injured by shells were 4.04 (1.32; 17.60) more likely (p = 0.03) than patients with gunshot wounds to have had uni- or bilateral enucleation, regardless of age and gender. Tessier's files provide first-hand information on the injury patterns that resulted from a regional war in the 1980s, and on the reconstruction challenges faced by a country during its post-war recovery period.

Follow-up study to investigate symmetry and stability of cranioplasty in craniosynostosis – Introduction of new pathology-specific parameters and a comparison to the norm population Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s): Anne Klausing, Andreas Röhrig, Guido Lüchters, Helen Vogler, Markus Martini Abstract Purpose Cranioplasty and modulation of frontoorbital advancement (FOA) in children with craniosynostosis aims to achieve an attractive aesthetic and functional rehabilitation of the forehead area, comparable to that in unaffected children. Based on a three-dimensional surface scan, a cephalometric data evaluation with new parameters for the quantification of physiological and pathological cranial morphologies, and objective evaluation of postoperative follow-up in comparison to an age-equivalent standard population, were performed. Materials and methods In a prospective study, 80 children were operated on with non-syndromic craniosynostosis (trigonocephalus, n = 30; plagiocephalus, n = 10; scaphocephalus, n = 38; brachycephalus, n = 2) and pre- and 3, 6, 12, 18 and 30 months postoperative three-dimensional surface scans were obtained (3DShape, Erlangen, Germany) and morphometrically measured (Onyx Ceph, Image Instruments, Chemnitz, Germany). In addition, 49 healthy children who were not operated on were measured at equivalent ages (n = 25 [6 months]; n = 20 [9 months]; n = 4 [12 months]). Results All patient groups showed stable long-term results with regard to shaping of the forehead. Cranioplasty in patients with scaphocephalus resulted in a significant widening of the anterior (73.9 ± 3.5 mm; p < 0.001) and posterior (132.2 ± 5.2 mm; p < 0.001) cranial width, with no significant difference from the norm population 1 year after surgery (p = 0.6597). As parameters for the correction of trigonocephaly, the frontal angle showed significant improvement (145.9 ± 3.7°; p < 0.001). While the parietal angle 12 months after surgery showed similar values as the norm population, the frontal angle was about 10° smaller than in healthy children (p = 0.0055), despite a clinically inconspicuous physiognomy. As part of the correction of plagiocephaly, the patients tended to relapse in the postoperative course, although there was no statistically significant difference in the frontal angle compared to that in the norm population (153.3 ± 3.9°; p = 0.06). While 6 months after surgery all patients showed a normal cranial volume development compared to healthy children of the same age, the volumes of brachycephalic patients remained below the norm (1244.2 ± 153.2 cm3; p = 0.0244). Overall, the analysis of the norm population showed a growing dispersion of measurement values with increasing age, which was observed to be more concentrated in the operated cranial morphologies. Conclusion The determination of new pathology-specific morphometric parameters on the three-dimensional surface scan enables an objective quantification of physiological and pathological cranial morphologies of children. A comparison of operated children with a healthy, age-appropriate comparison group showed that preoperative and statistically significant deviations of the new measuring parameters in long-term follow-up could be normalized through surgical intervention, although this does not apply without limitations to children with coronary suture synostosis.

Multidirectional cranial distraction osteogenesis technique for treating bicoronal synostosis Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s): Ataru Sunaga, Yasushi Sugawara, Akira Gomi, Daekwan Chi, Hideaki Kamochi, Hirokazu Uda, Kotaro Yoshimura Abstract Fronto-orbital advancement by distraction osteogenesis is a useful means of surgically correcting bicoronal synostosis. However, the scope for morphological revision is limited. To address this issue, we developed a multidirectional cranial distraction osteogenesis (MCDO) technique that we quantitatively assessed in patients with bicoronal synostosis. In this case series, five patients with bicoronal synostosis were treated with MCDO at a mean age of 13.4 months (range 9–22 months). Distraction started 5 days after surgery and the activation period was 11.2 days (range 10–14 days). The distraction devices were removed 47.2 days (range 33–67 days) after completing distraction. Improved cranial shape was confirmed by CT data. Mean preoperative CI, APL, and ICV readings of 102.1%, 13.5 cm, and 1179.4 ml, respectively, had reached 94.0%, 14.9 cm, and 1323.9 ml, respectively, upon device removal. These values were well preserved at 1 year (90.4%, 15.8 cm, and 1461.3 ml, respectively). In conclusion, MCDO successfully enables both cranial expansion and correction of a flat forehead, constituting a valid treatment alternative for patients with bicoronal synostosis.

Enlarged anterior cranial fossa and restricted posterior cranial fossa, the disproportionate growth of basicranium in Crouzon syndrome Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s): Xiaona Lu, Antonio Jorge Forte, Derek M. Steinbacher, Michael Alperovich, Nivaldo Alonso, John A. Persing Abstract Crouzon syndrome patients develop normal intracranial volume and potential restricted posterior cranial fossa volume with growth. This study aims to trace the segmental anterior, middle and posterior cranial fossae volume, and structural morphology in these patients, in order to help discern more focused and individualized surgical treatment plan. Ninety-two preoperative CT scans (Crouzon, n = 36; control, n = 56) were included, and divided into 5 age related subgroups. CT scans were measured using Mimics and 3-matics software. Overall, Crouzon syndrome patients grew to a 27% (p = 0.011) increased anterior cranial fossa volume and a 20% (p = 0.001) decreased posterior cranial fossa volume, with normal middle cranial fossa and entire intracranial volume measurement. The posterior cranial fossa of Crouzon syndrome initially developed significantly reduced volume (19%, p = 0.032), compared to normals, from 6 months of age, and remained reduced thereafter. The 7.63 mm shortening of posterior cranial fossa length contributed most to the shortened entire cranial length (9.30 mm, p = 0.046). Although the entire cranial volume of Crouzon syndrome is normal overall, the segmental anterior, middle and posterior cranial fossae developed disproportionately. The early significant and lifelong restricted posterior cranial fossa addresses the importance of early posterior cranial expansion. Ideally expansion would have vectors in all three dimensions.

Factors related to failure of autologous cranial reconstructions after decompressive craniectomy Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s): S.E.C.M. van de Vijfeijken, C. Groot, D.T. Ubbink, W.P. Vandertop, P.R.A.M. Depauw, E. Nout, A.G. Becking, A.G. Becking, L. Dubois, L.H.E. Karssemakers, D.M.J. Milstein, S.E.C.M. van de Vijfeijken, P.R.A.M. Depauw, F.W.A. Hoefnagels, W.P. Vandertop, C.J. Kleverlaan, T.J.A.G. Münker, T.J.J. Maal, E. Nout, M. Riool Abstract Purpose Cranioplasty is customary after decompressive craniectomy. Many different materials have been developed and used for this procedure. The ideal material does not yet exist, while complication rates in cranioplasties remain high. This study aimed to determine factors related to autologous bone flap failure. Materials and methods In this two-center retrospective cohort study, 276 patients underwent autologous bone cranioplasty after initial decompressive craniectomy between 2004 and 2014. Medical records were reviewed regarding patient characteristics and factors potentially related to bone flap failure. Data were analyzed using univariable and multivariable regression analysis. Results Independent factors related to overall bone flap failure were: duration of hospitalization after decompressive craniectomy [OR: 1.012 (95%CI: 1.003–1.022); p = 0.012], time interval between decompressive craniectomy and cranioplasty [OR: 1.018 (95%CI: 1.004–1.032); p = 0.013], and follow-up duration [OR: 1.034 (95%CI: 1.020–1.047); p < 0.001]. In patients with bone flap infection, neoplasm as initial diagnosis occurred significantly more often (29.2% vs. 7.8%; RD 21.3%; 95%CI 8.4 –38.3%; NNH 5; 95%CI 3 –12) and duration of hospitalization after decompressive craniectomy tended to be longer (means 54 vs. 28 days, MD 26.2 days, 95%CI −8.6 to 60.9 days). Patients with bone flap resorption were significantly younger (35 vs. 43 years, MD 7.7 years, 95%CI 0.8–14.6 years) and their cranial defect size tended to be wider than in patients without bone flap resorption (mean circumference 39 vs. 37 cm; MD 2.4 cm, 95% CI -0.43–5.2 cm) and follow-up duration was significantly longer (44 vs. 14 months, MD 29 months, 95%CI 17–42 months). Conclusion A neoplasm as initial diagnosis, longer hospitalization after decompressive craniectomy, larger time interval between decompressive craniectomy and cranioplasty, and longer follow-up duration are associated with a higher risk of failure of autologous bone flaps for cranioplasty. Patients with these risk factors may be better served with an early recovery program after decompressive surgery or an alloplastic material for cranioplasty.

Reconstruction of residual cleft nasal deformities in adolescents: Effects on social perceptions Publication date: September 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 9 Author(s): Jeffrey C. Posnick, Srinivas M. Susarla, Brian E. Kinard Abstract Purpose The investigators hypothesized that a layperson's social perceptions of a primarily repaired adolescent cleft lip and palate (CL/P) patient is more favorable after definitive nasal reconstruction with regard to perceived social traits. Methods The investigators implemented a survey comparing layperson's social perceptions of 6 personality traits, 6 emotional expression traits, and 7 perceptions of interpersonal experiences before and >6 months after definitive nasal reconstruction in CL/P adolescent subjects by viewing standardized facial photographs. The sample was composed of consecutive CL/P subjects treated by one surgeon using a consistent technique involving a rib cartilage caudal strut graft through an open approach. Five non-cleft adolescent subjects who underwent cosmetic rhinoplasty involving a septal cartilage caudal strut graft through an open approach were used as a comparison group. The outcome variable was change in 6 perceived personality, 6 emotional expression traits studied, and 7 perceptions of interpersonal experiences. Descriptive and bivariate statistics were computed (p-value <0.05). Results The sample was composed of 10 consecutive CL/P subjects and 5 non-cleft adolescent comparison subjects. 500 respondents (raters) completed the survey. The respondents were 54% male with 56% age 25 to 34. After definitive cleft nasal reconstruction, study subjects were perceived to be significantly more attractive (p = 0.04) and less threatening (p = 0.04). They were also perceived as less angry (p < 0.01), sad (p < 0.01), or disgusted (p < 0.01) than prior to surgery. The subjects were also perceived to be less likely to have negative interpersonal experiences (p < 0.01). Conclusion We confirmed that laypeople consistently report positive changes in adolescent CL/P subject's perceived social traits after definitive cleft nasal reconstruction. Overall, the positive changes were largely comparable between the cleft and non-cleft groups.