Faculty Bibliography

BACKGROUND: Virtual surgical planning (VSP) has contributed to a number of technical innovations in mandible reconstruction. We report on these innovations and the overall evolution of mandible reconstruction using free fibula flaps at our institution. METHODS: We performed a retrospective chart review of all patients who underwent virtually planned free fibula flap reconstruction of the mandible. Comparisons were made between cohorts based on distinct eras related to the virtual planning approach. RESULTS: Seventy-six patients underwent a total of 78 VSP-assisted mandible reconstructions with free fibula flaps. Significant differences were noted among the groups with regard to mean number of segments, percentage of flaps that had at least 3 segments, percentage of flaps that had double-barrel components, and innovations per flap. CONCLUSION: VSP-assisted mandible reconstruction has contributed to more complex surgeries at our institution. The technology ensures functional restoration, permitting an optimized aesthetic reconstruction that has not increased operative times or complications. (c) 2016 Wiley Periodicals, Inc. Head Neck, 2016.

Reconstruction of large maxillary and mandibular defects following ablative surgery has posed a challenge to the head and neck surgeon due to the high functional and esthetic demands requiring precise three-dimensional reconstruction. Previous issues with maxillofacial reconstruction have included poor facial contour, unfavorable orthognathic relationships, and inability to provide adequate dental rehabilitation. The advent of the fibula flap along with (3D) facial analysis and virtual surgical simulation has revolutionized surgical interventions of the head and neck. Recent reports on the long-term success of dental implants in fibula reconstructions have made dental rehabilitation a reality. However, the loading and restoration of these implants are usually delayed prior to final prosthodontic rehabilitation leading to adverse functional, esthetic and psychological effects. Rohner et al. has documented the success of a two-stage surgery of fibula harvest and dental implant placement (Stage 1) followed by ablative surgery, inset and immediate loading with a dental prosthesis (Stage 2)⁽²⁾; this procedure is a two stage process that involves a 10-week delay between each surgery and will leave the patient edentulous. At our institution, computer-aided surgery and CAD/CAM technologies have enabled us to virtually plan complex surgery and have afforded our group the opportunity of providing a "Jaw in a Day '¹ This technique is a one-stage complete surgery including ablation, free flap, implant, and prosthetic reconstruction. A retrospective chart review was conducted for all patients who received immediate dental implants with a dental prosthesis in a fibular free flap following mandibular resection due to benign tumors. "Jaw in a Day 'procedures were completed at two of our affiliated hospitals (Bellevue Hospital Center and NYU Langone Medical Center) from January 2011 to January 2015. We looked at success rate of flaps, implants, and prostheses. We also looked at primary and long-term complications. Of the 8 patients who underwent the above procedure, a total of 35 immediate implants were placed along with a fixed prosthesis. Patients received maxillary/mandibular resection, fibula free flap reconstruction with immediate implant and dental prosthesis placement. All patients treated were diagnosed with benign mandibular (7) and maxillary (1) tumors, including ameloblastoma (6), odontogenic myxoma (1), and AV malformation (1). Of the 35 implants placed, 1 implant failed and was removed. The cumulative survival of fibular-free flaps was 100%. The cumulative implant success rate was 97%. Complications included soft tissue perimplantitis (2), plate exposure (2), and (1) prosthesis that did not adequately fit. The followup of the 8 patients was from January 2011 to January 2015. Single-stage maxillofacial reconstruction with virtual surgical planning has greatly impacted the field of maxillofacial reconstruction allowing for precision and accuracy while improving patient's function and quality of life. The above study shows its feasibility and low complication rates. Immediate implant and dental prosthesis placement has helped reduce the time for dental prosthetic rehabilitation and avoid the traditional 3- to 6-month delay period. Reconstruction with a MVFFF and immediate dental rehabilitation has revolutionized the treatment of benign tumor following ablative surgery

With the advent of the microvascular fibula free flap (MVFFF), maxillofacial reconstruction following ablative surgery has been a viable solution for patients with large maxillary or mandibular defects. Furthermore, total maxillofacial reconstruction in a two-stage process, where the fibula is harvested and dental implants placed (Stage I) followed by ablative surgery, inset and immediate loading with a dental prosthesis (Stage 2) has been well documented.1 This procedure, however, requires two separate surgical procedures and a delay of at least 10 weeks between each stage where the patient is often left partially or completely edentulous. The incorporation of computer-aided surgical simulation (CASS) and computer-aided design/computer-aided manufacturing (CAD/CAM) has made it possible to not only complete total maxillofacial reconstruction from tumor ablationto immediate insertion of an implant-retained dental prosthesis in a single OR procedure, butithas also increased the predictability and accuracy of maxillofacial reconstruction and decreased intraoperative time.2 Patients requiring more complex maxillofacial reconstruction heavily benefit from increased precision of the final surgical outcome as the accuracy of each osteotomy influences subsequent steps. The aim of our study is to assess the predictability and accuracy of virtually planned, single-stage total maxillofacial reconstruction, also known as 'Jaw in a Day'.³ We conducted a retrospective chart review of all patients who underwent maxillofacial tumor ablation, MVFFF reconstruction, implant placement and immediate implant loading with a dental prosthesis in a single OR procedure. These procedures were completed at Bellevue Hospital Center and NYU Langone Medical Center from January 2011 to January 2015. All cases were virtually planned with Medical Modeling (Golden, CO), and stereolithographic models, osteotomy guides, implant guides, and dental prosthesis were fabricated via CAD/CAM technology. To determine the precision and accuracy of the post-surgical outcomes, we compared the final positions of the implants and fibula on postoperative CT imaging with the planned positions of the implants and fibula based on preoperative virtual planning with Medical Modeling. A total of 8 patients underwent tumor ablation, MVFFF reconstruction, implant placement and immediateimplant loading with a dental prosthesis in a single OR procedure. All patients were diagnosed with benign mandibular (7) and maxillary (1) tumors, including ameloblastoma (6), odontogenic myxoma (1), and AVmalformation (1).Atotal of 35implants were placed with satisfactory primary stability at the time of surgery. On average, the final positions of the implants placed were within 2mm of the virtually treatment planned positions within the fibula. To date, there have been no flap failures and only one implant has failed osseointegration into the MVFFF. Total maxillofacial reconstruction via CASS and CAD/CAM technology has made it possible for surgeons to complete these procedures with high precision and accuracy while minimizing intraoperative time. Additionally, immediate dental rehabilitation is possible at the time of ablation, eliminating the period of edentulism for these patients. Given the highly predictable and accurate postoperative outcomes and low complications rates of virtually planned total maxillofacial reconstruction with a MVFFF and immediate dental rehabilitation, this technique is quickly becoming the standard of care for patients requiring complex maxillofacial reconstruction

The present study aims to determine the risk of early secondary nasal revisions in patients with complete unilateral and bilateral cleft lip and palate (U/BCLP) treated with and without nasoalveolar molding (NAM) and examine the associated costs of care. A retrospective cohort study from 1990 to 1999 was performed comparing the risk of early secondary nasal revision surgery in patients with a CLP treated with NAM and surgery (cleft lip repair and primary surgical nasal reconstruction) versus surgery alone in a private practice and tertiary level clinic. The NAM treatment group consisted of 172 patients with UCLP and 71 patients with BCLP, whereas the non-NAM-prepared group consisted of 28 patients with UCLP and 5 with BCLP. The risk of secondary nasal revision for patients with UCLP was 3% in the NAM group and 21% in the non-NAM group. The risk of secondary nasal revision for patients with BCLP was 7% in the NAM group compared with 40% in the non-NAM group. Using multicenter averages, the non-NAM revision rates were calculated at 37.8% and 48.5% for U/BCLP, respectively. Applying these risks of revision, NAM treatment led to an estimated savings of between $491 and $4893 depending on the type of cleft. In conclusion, NAM can reduce the number of early secondary nasal revision surgeries and, therefore, reduce the overall cost of care.

BACKGROUND: The free fibula osteocutaneous flap has become the criterion standard for reconstruction of complex mandibular defects. The authors present their institutional experience with optimization of flap contouring and inset using virtual planning and prefabricated cutting jigs. METHODS: All free fibula-based mandible reconstructions performed at the authors' institution using virtual planning technology between 2009 and 2012 were retrospectively analyzed. The authors evaluated a variety of patient and procedural variables and outcomes. A series of cases performed before virtual planning was reviewed for comparison purposes. RESULTS: Fifty-four reconstructions were performed in 52 patients. Patients were divided evenly between a private university-affiliated medical center and a large county hospital. The most common indications were malignancy (43 percent), ameloblastoma (26 percent), and osteonecrosis/osteomyelitis (23 percent). Thirty percent of patients had irradiation of the recipient site and 38 percent had previous surgery. Sixty-three percent of patients received dental implants, with 47 percent achieving functional dentition. Twenty-five percent of patients had immediate dental implant placement, and 9 percent had immediate dental restoration. Postoperative imaging demonstrated excellent precision and accuracy of flap positioning. Comparison with cases performed before virtual planning demonstrated increased complexity of flap design along with reduced operative time in the virtually planned group. CONCLUSIONS: Preoperative virtual planning along with use of prefabricated cutting jigs allows for precise contouring and positioning of microvascular fibula free flaps in mandibular reconstruction. Using this technique, the authors have achieved unprecedented rates of dental rehabilitation along with reduced operative times. The authors believe that virtual planning technologies are an emerging criterion standard in mandible reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Recent advances in surgery and orthodontics have resulted in improvements in the management of patients with a cleft lip or palate. Early surgical intervention and bone-grafting procedures have frequently been used to ensure closure of the cleft and continuity of the alveolar bone. However, a need for the prosthodontic management of patients with a cleft palate still exists. Most frequently, the indication is to restore the edentulous spaces located anteriorly in the vicinity of the residual cleft defect. In addition to improving the esthetic outcome, prosthodontic management also is required to restore function, especially occlusion and speech. This clinical report illustrates the management of an adult patient with a unilateral cleft of the lip and palate who required prosthodontic rehabilitation after surgery. The patient had previously undergone multiple surgeries and did not want to consider implant therapy as a treatment option. Thus, the patient was managed with fixed and removable prosthodontics with a maxillary overdenture prosthesis retained by microextracoronal resilient attachments, which were laser welded onto crowns on abutment teeth to obtain a functionally and esthetically acceptable result.

Statement of the Problem: Reconstruction of the atrophic edentulousmaxilla canbe a challenge, particularly in individuals where extensive bone grafting is required prior to dental implant placement or in patients where bone grafts have been tried and failed. Likewise, dental rehabilitation after tumor ablation and reconstruction can be problematic if there is inadequate maxillary bone to support traditional dental implants. Zygomaticus implants, which make use of the dense type I-II bone of the zygoma, are one solution that allows for dental implant reconstruction of the atrophic or reconstructed maxilla. Materials and Methods, Data Analysis: We performed a retrospective chart review of all patients who received dental implants in the operating room at two of our affiliated hospitals from June 2007 to March 2013. We identified those patients who received either unilateral or bilateral zygomaticus implants.We then collected available data including gender, diagnosis, adjunctive surgical procedures, and indication for zygomaticus implants. Patients receiving zygomaticus implants following maxillectomy procedures were compared to a cohort of patients who did not receive implants following maxillectomy to determine which variables may have influenced surgeon choice of zygomaticus implants. In addition, we report on two recent cases of zygomaticus implants placed followingenucleation of maxillary bone cysts. Follow-up was available for all patients and ranged from one month to five years. All implants were placed by and with the supervision of a single attending surgeon, DLH. Results: From 2007 to 2013, a total of 25 zygomaticus implants were placed in 12 patients at two affiliated hospitals. Indications for zygomatic implants were varied. Patients received zygomatic implantation for cleft reconstruction, maxillectomy defect with and without free tissue transfer, and atrophic maxilla not amenable to traditional implant surgery. Two patients received bilateral zygomaticus implants for a diagnosis of !

BACKGROUND: : Tumors of the mandible are complex, often requiring replacement of bone, soft tissue, and teeth. The fibula flap has become a routine procedure in large tumors of the jaw, providing bone and soft tissue at the time of the resection. In current practice, dental reconstruction is delayed for 3 to 6 months, leaving the patient without teeth in the interim. This can be disfiguring and anxiety provoking for the patient. METHODS: : In this article, the authors present three patients with benign tumors of the mandible who underwent virtually guided resection, fibula reconstruction, and insertion of an implant-retained dental prosthesis in one operation. In addition, the authors report their early experience using this technique in the maxilla. RESULTS: : The authors present a case series of three patients with benign mandibular tumors and one patient with a benign maxillary tumor who underwent total reconstruction using computer-aided design and computer-aided manufacturing technology in a single stage. CONCLUSIONS: : In the right situation, total mandibular reconstruction is possible in a single stage. This is demonstrated by the successful outcomes of these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, V.

ABSTRACT: Preoperative nasoalveolar molding (NAM) in combination with primary gingivoperiosteoplasty (GPP) reduces the need for secondary alveolar bone grafting by 60% in patients with unilateral cleft lip and palate (CL/P). Herein, we investigate the efficacy of NAM and primary GPP in patients with bilateral CL/P. All patients (n = 38) with bilateral CL/P who underwent NAM and primary GPP from 1988 to 1998 with at least 14 years of follow-up were included in this study. Panoramic and periapical radiographs were used to assess dentoalveolar bone formation. A total of 38 patients were identified with median follow-up of 18 years (range 14-26 years). Of the 27 patients who underwent bilateral GPP, 14 (51%) patients had successful dentoalveolar bone formation bilaterally and 13 (49%) had unilateral bone formation. No patient had a bilateral failure. Of the 11 patients who underwent unilateral GPP, 7 (63%) patients had successful dentoalveolar bone formation. Bilateral successful dentoalveolar bone formation following primary bilateral GPP has a dependent probability of 52% and a conditional probability of 82%.