Faculty Bibliography

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.

BACKGROUND: Access to the frontal sinus remains a challenging problem for the craniofacial surgeon. A wide array of techniques including minimally invasive endoscopic approaches have been described. Here we present our technique using medical modeling to gain fast and safe access for multiple indications. METHODS: Computer-aided surgery involves several distinct phases: planning, modeling, surgery, and evaluation. Computer-aided, precise cutting guides are designed preoperatively and allowed to perfectly outline and then cut the anterior table of the frontal sinus at its junction to the surrounding frontal bone. The outcomes are evaluated by postoperative three-dimensional computed tomography scan. RESULTS: Eight patients sustaining frontal sinus fractures were treated with the aid of medical modeling. Three patients (37.5%) had isolated anterior table fractures, and 4 (50%) had combined anterior and posterior table fractures, whereas 1 patient (12.5%) sustained isolated posterior table fractures. Operative times were significantly shorter using the cutting guides, and fracture reduction was more precise. There was no statistically significant difference in complication rates or overall patient satisfaction. CONCLUSIONS: The surgical approach to the frontal sinus can be made more efficient, safe, and precise when using computer-aided medical modeling to create customized cutting guides.

Background The authors describe our current practice of computer-aided virtual planned and pre-executed surgeries using microvascular free tissue transfer with immediate placement of implants and dental prosthetics.Methods All patients with ameloblastomas treated at New York University (NYU) Medical Center during a 10-year period from September 2001 to December 2011 were identified. Of the 38 (36 mandible/2 maxilla) patients that were treated in this time period, 20 were identified with advanced disease (giant ameloblastoma) requiring aggressive resection. Reconstruction of the resultant defects utilized microvascular free tissue transfer with an osseocutaneous fibular flap in all 20 of these patients.Results Of the patients reconstructed with free vascularized tissue transfer, 35% (7/20) developed complications. There were two complete flap failures with consequent contralateral fibula flap placement. Sixteen patients to date have undergone placement of endosteal implants for complete dental rehabilitation, nine of which received immediate placement of the implants at the time of the free flap reconstruction. The three most recent patients received immediate placement of dental implants at the time of microvascular free tissue transfer as well as concurrent placement of dental prosthesis.Conclusions To our knowledge, this patient cohort represents the largest series of comprehensive computer aided free-flap reconstruction with dental restoration for giant type ameloblastoma.

PURPOSE: The purpose of this prospective multicenter study was to assess the accuracy of a computer-aided surgical simulation (CASS) protocol for orthognathic surgery. MATERIALS AND METHODS: The accuracy of the CASS protocol was assessed by comparing planned outcomes with postoperative outcomes of 65 consecutive patients enrolled from 3 centers. Computer-generated surgical splints were used for all patients. For the genioplasty, 1 center used computer-generated chin templates to reposition the chin segment only for patients with asymmetry. Standard intraoperative measurements were used without the chin templates for the remaining patients. The primary outcome measurements were the linear and angular differences for the maxilla, mandible, and chin when the planned and postoperative models were registered at the cranium. The secondary outcome measurements were the maxillary dental midline difference between the planned and postoperative positions and the linear and angular differences of the chin segment between the groups with and without the use of the template. The latter were measured when the planned and postoperative models were registered at the mandibular body. Statistical analyses were performed, and the accuracy was reported using root mean square deviation (RMSD) and the Bland-Altman method for assessing measurement agreement. RESULTS: In the primary outcome measurements, there was no statistically significant difference among the 3 centers for the maxilla and mandible. The largest RMSDs were 1.0 mm and 1.5 degrees for the maxilla and 1.1 mm and 1.8 degrees for the mandible. For the chin, there was a statistically significant difference between the groups with and without the use of the chin template. The chin template group showed excellent accuracy, with the largest positional RMSD of 1.0 mm and the largest orientation RMSD of 2.2 degrees . However, larger variances were observed in the group not using the chin template. This was significant in the anteroposterior and superoinferior directions and the in pitch and yaw orientations. In the secondary outcome measurements, the RMSD of the maxillary dental midline positions was 0.9 mm. When registered at the body of the mandible, the linear and angular differences of the chin segment between the groups with and without the use of the chin template were consistent with the results found in the primary outcome measurements. CONCLUSIONS: Using this computer-aided surgical simulation protocol, the computerized plan can be transferred accurately and consistently to the patient to position the maxilla and mandible at the time of surgery. The computer-generated chin template provides greater accuracy in repositioning the chin segment than the intraoperative measurements.

BACKGROUND: The free fibula flap is the standard of care in mandibular reconstruction; however, procedural nuances continue to optimize results. More accurate and efficient osteotomies for graft insetting can be envisioned, which address the difficulty in obtaining a perfect match between the cut ends of the fibula and the mandible and the subsequent giving up of maximal bone contact. We propose a method of complementary offset osteotomies. The angled cuts were virtually planned using three-dimensional computed tomographic images. Optimal offset cuts maximized surface area contact and facilitated intraoperative repositioning in the setting of additional native bone margin requirement. METHODS: Using previously described protocols, three-dimensional virtual reconstructions of the facial skeleton and the fibula (average, series of five) were used to simulate osteotomies at 25, 30, 45, 60, 75, and 90 degrees to the long axis of the fibula. Complementary osteotomies were then simulated at the mandibular body just distal to the first molar in simulated free fibula reconstructions. Total area of apposing surfaces was calculated using computer-aided design. The results from the 25-, 30-, 45-, 60-, and 75-degree cuts were compared with the conventional 90-degree cut. Resin-based mandibular osteotomy guides and a complementary fibula jig were manufactured using computer-aided design. Two representative clinical cases were presented to illustrate proof of principle and benefits. RESULTS: The total surface area of apposing fibula and mandible surfaces in a conventional 90-degree cut was 103.8 +/- 2.05 mm. Decreasing this angle to 75, 60, 45, 30, and 25 degrees yielded increased surface areas of 0.86%, 10.3%, 35.3%, 136.7%, and 194.3%, respectively. Cuts of 25 degrees also allowed for adequate bony contact in the setting of additional margin requirements up to 2.77 cm. Complementary 45-degree cuts provided excellent bone-to-bone contact in a free fibula reconstruction using resin guides and a jig. This angle also facilitated access of the saw to the distal mandible. CONCLUSIONS: Virtual surgical planning is an increasingly recognized technology for optimizing surgical outcomes and minimizing operative time. We present a technique that takes advantage of the precision complementary osteotomies that this technology affords. By creating offset cuts, we can maximize bony contact and ensure adequate contact should additional margins or intraoperative adjustments be required. This flexibility maximizes the precision of premanufactured cutting guides, mitigates the constraints of sometimes unpredictable intraoperative environments, and maximizes bony contact.

Statement of Problem: Reconstruction of maxillectomy defects is challenging due to the complex 3-dimensional anatomy of the region. It is diverse with multiple effective techniques that appear to functionally aid patients in speech and mastication. Defects can be secondary to benign or malignant pathology, craniofacial or post-traumatic deformities, and infection. Interocclusal and orthognathic relationships are tantamount to successful reconstruction. Rehabilitation must provide adequate upper lip support and maintain symmetrical alar bases as well as create an adequate seal from the oral cavity to nasal cavity to prevent regurgitation of fluids. Many different classification schemes have been discussed at length within the literature.¹ At our institution we utilize the maxillectomy classification system set forth by Brown et al.² The classification of the vertical component is as follows: Class 1, maxillectomy without an oro-antral fistula; Class 2, low maxillectomy not including orbital floor or contents; Class 3, high maxillectomy involving orbital contents; and Class 4, radical maxillectomy includes orbital exenteration. The horizontal component is classified as follows: a, unilateral alveolar maxillectomy; b, bilateral alveolar maxillectomy; and c, total alveolar maxillary resection. Methods: A retrospective review was performed of case records at Bellevue Hospital Center/New York University Langone Medical Center during a 6-year period from June 2006 to February 2012. In addition to patient demographics the charts were reviewed for Brown classification, tumor pathology, type of reconstruction, timing of feeding by mouth, and patient satisfaction. Methods of Data Analysis: This was a retrospective chart review from June 2006 to February 2012. Descriptive statistics were used to analyze the data. Results: Fifty patients were identified, the average age was 49. The lowest Brown classification was 1A; there were no orbital exenterations thus our highest Brown class was 3C. The pathology was reviewed; 40% of the lesions were malignant and 60% of lesions were benign. 24% of patients were treated with microvascular free tissue transfer: 38% osteocutaneous and 62% myofasciocutaneous. 18% were treated with obturators, 16% were treated with local flaps, 16% were treated with nonvascularized bone grafts, 14% were treated zygomatic implants, and 12% were treated using a combination of local flaps, obturators, zygomatic implants, and free tissue transfer. 34% of patients fell into Brown class one, 48% of patients were Brown class two, and 18% of patients were Brown class three. Postoperatively patients were fed immediately unless treated with free tissue transfer. Subjectively, all but one patient was satisfied with their maxillary reconstruction. This patient had an obturator placed after resection of squamous cell carcinoma of the maxilla, and was unable to tolerate the obturator. She was later reconstructed using a microvascular radial forearm free flap and is now able to function, phonate, and is content with her current status. Conclusion: All methods described above are viable surgical options and decisions for reconstruction must be on a patient specific basis. However, one can extrapolate that the higher the Brown class the larger the defect and thus the need for microvascular free tissue transfer increases. An algorithm for our reconstruction protocol will be presented

Introduction: Squamous cell carcinoma (SCC) is the most common form of cancer in the head and neck. Variants of this exist, including Basaloid Squamous Cell Carcinoma (BSCC) and Spindle Cell Carcinomas (SpCC). BSCC was first described by Wain et al in 1986 and is described as being a rare, aggressive, high grade variant of SCC that shows predilection for the tongue, larynx and hypopharynx.1 BSCC of the head and neck has also been associated with poorer clinical outcomes compared with conventional SCC.2 Spindle Cell Carcinomas account for 3% of head and neck SCCs and are derived from conventional SCCs. The objective of this study was to compare clinicopathologic features and postoperative course of variant SCCs to confirm reported propensity for aggressiveness. Materials & Methods: A retrospective chart review of patients with SCC at Bellevue Hospital Center and NYU Langone Medical Center by the Department of Oral & Maxillofacial Surgery from June 2006 until 2012 were retrospectively reviewed and classified based on histologic criteria. Classifications were confirmed by at least 2 pathologists and included BSCC and SpCC. Clinical information, including clinicopathologic and clinical course. Results: All cases of SCC since June 2006 were reviewed. Seven of the reviewed cases were SCC variants, six cases of BSCC and 1 case of SpCC. The age of the patients ranged from 30-68 with a mean age of 56. The majority of patients were causcasian males with history significant for tobacco and alcohol use. BSCC was most often found in the floor of the mouth with invasion into the mandible with other locations in the tongue, tonsil and buccal vestibule. In the case of the patient with SpCC, invasion included the maxilla, pterygopalatine fossa and orbit. TNM staging in BSCC varied from T1N0- T4N2. The TNM staging in SpCC was T4N1M1. Selective neck dissections were performed on 3 patients with BSCC and the patient with SpCC. Surgical margins were positive in 2 cases of BSCC as well as in the patient with SpCC. Perineural invasion was noted in 5 BSCC cases and the SpCC case. Three BSCC patients received chemotherapy as well as the patient with SpCC, while all patients underwent radiation therapy. One patient with BSCC had metastasis while the patient with SpCC had metastasis to the left globe and ultimately died. Conclusions: Most patients with variant SCCs were white males in their late 50s with a significant history of exposure to tobacco and alcohol. Of the total seven cases of BSCC and SpCC 43% had positive margins and 85% exhibited perineural invasion. Surgical treatment included neck dissection, wide resection with reconstruction and postoperative radiation and, in some cases, chemotherapy. BSCC and SpCC can be devastating and aggressive tumors and correct diagnosis is key. The importance of close follow up of these patients, and any patient with a history of SCC, was demonstrated by 28% of the patients presenting with recurrence within two years of diagnosis. Identifying the specific histologic cell type can determine aggressiveness of the tumor as well as help to guide treatment. Results of this study are consistent with previous studies showing rarity, however, significant difference in aggressiveness, recurrence, and death were not observed as compared to other SCC cases treated at our institution

Statement of Problem: Oral submucous fibrosis is a potentially devastating pre-malignant disease often associated with habitual chewing of the areca nut. Using this nut, colloquially referred to as "betel nut," is a well known tradition of many cultures in Southern Asia and throughout the Pacific rim, and with increasing globalization, American practitioners are likely to have current and former users as patients.1 Severity of submucous fibrosis from betel nut abuse can range from oral ulcerations to squamous cell carcinoma, with an array of reported treatments from medical to surgical.2 The following is a review of three surgically treated patients, all with history of chronic betel nut abuse, who presented to Bellevue Hospital in New York City from 2010-2012 with advanced oral submucous fibrosis with transformation to squamous cell carcinoma. Methods/Data Analysis: Retrospective chart review was performed on 3 patients from the Oral and Maxillofacial Surgery Clinic from Bellevue Hospital. Patient diagnosis, age/sex/race, location of submucous fibrosis and squamous cell carcinoma, history of betel nut/tobacco/ alcohol use, pre and post-maximal incisal opening (MIO), TNM staging, treatment modality, and current status was collected for each patient. Results: We report 3 cases of betel nut-induced oral submucous fibrosis from November 2010 to January 2012. All 3 patients are male and originally from Southern Asia. The average age of the patients who present to the OMFS clinic is 43.6 years old ranging from 33 years old to 58 years old. All patients admit to 10+ years of betel nut use while 2 patients also actively chew tobacco and consume alcohol socially. All patients present with submucous fibrosis in the buccal mucosa with spread to the palate in two patients and spread to the tonsillar ring in one patient. All patients were diagnosed with invasive squamous cell carcinoma by biopsy. Locations of the squamous cell carcinoma lesion include the buccal mucosa, mandible, and maxilla. All patients also exhibit bilateral field cancerization. The pre-operative MIO was 10 mm, 25 mm, and 20 mm respectively with no improvement in MIO postoperatively. All patients received complete resection of the submucous fibrosis/squamous cell carcinoma with negative margins, selective neck dissections, and reconstruction with micro-vascular free flap from iliac crest or radial forearm. Conclusion: Oral and maxillofacial surgeons must perform a thorough examination for patients who present with betel nut-induced submucous fibrosis since invasive squamous cell carcinoma is a potential lethal sequelae. Oral and maxillofacial surgeons must also be aware of the different treatment options for betel nut-induced submucous fibrosis/squamous cell carcinoma of the buccal mucosa. Despite wide surgical resection and reconstruction, the MIO remains unimproved due to the global involvement of the betel nut-induced submucous fibrosis

Statement of Problem: The microvascular free fibula flap is widely used to reconstruct complex craniomaxillofacial defects following ablative surgery. Since its popularization for mandibular bony reconstruction in 1989, many permutations of the fibula flap have been applied to composite head and neck defects. Several authors describe endosseous implantation of the fibula post operatively or at the time of surgery to aid in dental reconstruction, but this can leave a patient partially edentulous for up to 1 year after initial surgery. Many patients are lost to follow up and do not go on to complete dental rehabilitation. This may contribute to suboptimal nutritional status, poor cosmetic outcomes, and decreased patient satisfaction. We will discuss how these problems can be circumvented by single stage surgery that incorporates dental implants and a prosthesis to allow for complete jaw reconstruction. Methods: A retrospective chart review at NYU Langone Medical Center and Bellevue Hospital Center was completed to identify patients undergoing extirpative surgery of the maxilla or mandible with immediate reconstruction with a free fibula flap, dental implants, and dental prosthesis from 2011-2012. A total of 5 patients were treated for ameloblastoma (n=3), intraosseus hemangioma (n=1), and odontogenic myxoma (n=1) of the maxilla (n=1) and mandible (n=4). Virtual surgical planning was implemented in all cases. During the computer assisted design phase, a virtual dental construct of an implant supported prosthesis was applied to the planned resection site and the fibula flap was designed to support the desired prosthesis. The cutting jigs for the jaw and fibula were manufactured according to plan as well as the implant borne dental prosthesis. In addition to osteotomy cutting slots, the fibular jig had implant drill guides to aid in correct placement. The prosthesis was secured to the fibular implants with custom abutments and then placed into temporary maxillomandibular fixation with the native dentition prior to plate osteosynthesis of the fibula. Post operative physical examination and computed tomography was used to evaluate occlusion and flap position. Results: All patients were reconstructed successfully with this method without any flap or implant failures. Longest follow up time was 12 months with a mean of 6 months. A total of 23 implants were planned and placed with no implant failures. 1 implant was not used due to suboptimal position in relation to the prosthesis. All patients required post operative guiding elastics with all patients achieving a reproducible desired occlusion by 2 (Figure psented) weeks. All patients tolerated a soft diet by postoperative week 3 without the need for supplemental enteral or parenteral feeding. All patients reported satisfaction in their reconstruction. The mean operative time was 8 hours. One patient needed revision surgery for a mobile locking screw in the plate hardware. Conclusion: The fibula flap continues to be the workhorse of jaw reconstruction, and with proper patient selection and pre-operative planning, it can be used to successfully reconstruct complex maxillofacial defects from bone to teeth in a single operation. In our experience, computer assisted design and virtual planning is essential in achieving the above described results while maintaining appropriate operative times