Faculty Bibliography

OBJECTIVE: To report the associations of oro-nasal fistulae on the patient-centered outcomes oral health-related quality of life and self-reported speech outcomes in school aged-children. DESIGN: Prospective, nonrandomized multicenter design. SETTING: Six ACPA-accredited cleft centers. PARTICIPANTS: Patients with cleft palate at the age of mixed dentition. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Prevalence of fistula and location of fistula (Pittsburgh Classification System). Patients were placed into one of three groups based on the following criteria: alveolar cleft present, no previous repair (Group 1); alveolar cleft present, previously repaired (Group 2); no congenital alveolar cleft (Group 3). Presence of fistula and subgroup classification were correlated to oral health-related quality of life (Child Oral Health Impact Profile [COHIP]) and perceived speech outcomes. RESULTS: The fistula rate was 5.52% (62 of 1198 patients). There was a significant difference in fistula rate between the three groups: Group 1 (11.15%), Group 2 (4.44%), Group 3 (1.90%). Patients with fistula had significantly lower COHIP scores (F1,1188 = 4.79; P = .03) and worse self-reported speech scores (F1,1197 = 4.27; P = .04). Group 1 patients with fistula had the lowest COHIP scores (F5,1188 = 4.78, P =.02) and the lowest speech scores (F5,1188 = 3.41, P = .003). CONCLUSIONS: Presence of palatal fistulas was associated with lower oral health-related quality of life and perceived speech among youth with cleft. The poorest outcomes were reported among those with the highest fistula rates, including an unrepaired alveolar cleft.

PURPOSE: To compile the current evidence on biomechanical, biologic, and clinical outcomes of undersized surgical preparation protocols in dental implant surgery. MATERIALS AND METHODS: An electronic search using three different databases (PubMed, Web of Science, and Cochrane Library) and a manual hand search were performed including in vitro, animal, and clinical studies published prior to October 2015. Studies in which an undersized drilling protocol was compared with a nonundersized drilling protocol were included. RESULTS: From an initial selection of 1,655 titles, 29 studies met the inclusion criteria, including 14 biomechanical, 7 biologic, 6 biologic and biomechanical, and 2 clinical. Due to methodologic variation, meta-analysis was not performed. Several studies showed that implants inserted with an undersized drilling approach reached a significantly higher insertion torque value than conventional drilling in low-density substrates, while this effect is less evident if a thick cortical layer is present. Similar results in terms of boneto-implant contact (BIC) were achieved in the longer term between implants inserted with undersized and nonundersized protocols. Results in the short term were inconclusive. Clinical studies did not show negative outcomes for undersized drilling, although clinical evidence was sparse. No data are available on marginal bone loss. CONCLUSION: From the biomechanical standpoint, an undersized drilling protocol is effective in increasing insertion torque in low-density bone. Biologic response in long-term healing after undersized implant placement is comparable to that in the nonundersized surgical drilling protocol. Clinical studies indicate that performing an undersized drilling protocol on low-density bone is a safe procedure; however, more extensive studies are needed to confirm these data.

BACKGROUND: Reconstruction of maxillary defects following tumor extirpation is challenging because of combined aesthetic and functional roles of the maxilla. One-stage reconstruction combining osseous free flaps with immediate osseointegrated implants are becoming the standard for mandibular defects, and have similar potential for maxillary reconstruction. METHODS: A woman with maxillary Ewing sarcoma successfully treated at age 9 with neoadjuvant chemotherapy, right hemimaxillectomy, and obturator prosthetic reconstruction presented for definitive reconstruction, complaining of poor obturator fit, and hypernasality. Her reconstruction was computer-simulated by a multidisciplinary team, consisting of left hemi-Lefort I advancement and right maxillary reconstruction with a free fibula flap with immediate osseointegrated implants and dental prosthesis. RESULTS: Full dental restoration, midface projection, and oral fistula corrections were achieved in 1 operative stage using this approach. CONCLUSIONS: This patient demonstrates a successful approach for maxillary reconstruction using computer-planned orthognathic surgery with free fibula reconstruction and immediate osseointegrated implants with dental prosthesis.

BACKGROUND: The availability of acellular dermal matrix (ADM) and synthetic mesh products has prompted plastic surgeons to revisit subcutaneous implant-based breast reconstruction. The literature is limited, however, with regards to evidence on patient selection, techniques, and outcomes. METHODS: A systematic review of the Medline and Cochrane databases was performed for original studies reporting breast reconstruction with ADM or mesh, and subcutaneous implant placement. Studies were analyzed for level of evidence, inclusion/exclusion criteria for subcutaneous reconstruction, reconstruction characteristics, and outcomes. RESULTS: Six studies (186 reconstructions) were identified for review. The majority of studies (66.7%) were level IV evidence case series. Eighty percent of studies had contraindications for subcutaneous reconstruction, most commonly preoperative radiation, high body mass index, and active smoking. Forty percent of studies commenting on patient selection assessed mastectomy flap perfusion for subcutaneous reconstruction. Forty-five percent of reconstructions were direct-to-implant, 33.3% 2-stage, and 21.5% single-stage adjustable implant, with ADM utilized in 60.2% of reconstructions versus mesh. Pooled complication rates included: major infection 1.2%, seroma 2.9%, hematoma 2.3%, full nipple-areola complex necrosis 1.1%, partial nipple-areola complex necrosis 4.5%, major flap necrosis 1.8%, wound healing complication 2.3%, explantation 4.1%, and grade III/IV capsular contracture 1.2%. CONCLUSIONS: Pooled short-term complication rates in subcutaneous alloplastic breast reconstruction with ADM or mesh are low in preliminary studies with selective patient populations, though techniques and outcomes are variable across studies. Larger comparative studies and better-defined selection criteria and outcomes reporting are needed to develop appropriate indications for performing subcutaneous implant-based reconstruction.

BACKGROUND: Implementation science holds promise for better ensuring that research is translated into evidence-based policy and practice, but interventions often fail or even worsen the problems they are intended to solve due to a lack of understanding of real world structures and dynamic complexity. While systems science alone cannot possibly solve the major challenges in public health, systems-based approaches may contribute to changing the language and methods for conceptualising and acting within complex systems. The overarching goal of this paper is to improve the modelling used in dissemination and implementation research by applying best principles of systems science. DISCUSSION: Best principles, as distinct from the more customary term 'best practices', are used to underscore the need to extract the core issues from the context in which they are embedded in order to better ensure that they are transferable across settings. Toward meaningfully grappling with the complex and challenging problems faced in adopting and integrating evidence-based health interventions and changing practice patterns within specific settings, we propose and illustrate four best principles derived from our systems science experience: (1) model the problem, not the system; (2) pay attention to what is important, not just what is quantifiable; (3) leverage the utility of models as boundary objects; and (4) adopt a portfolio approach to model building. To improve our mental models of the real world, system scientists have created methodologies such as system dynamics, agent-based modelling, geographic information science and social network simulation. To understand dynamic complexity, we need the ability to simulate. Otherwise, our understanding will be limited. The practice of dynamic systems modelling, as discussed herein, is the art and science of linking system structure to behaviour for the purpose of changing structure to improve behaviour. A useful computer model creates a knowledge repository and a virtual library for internally consistent exploration of alternative assumptions. CONCLUSION: Among the benefits of systems modelling are iterative practice, participatory potential and possibility thinking. We trust that the best principles proposed here will resonate with implementation scientists; applying them to the modelling process may abet the translation of research into effective policy and practice.

This study extends the concept of third places to include community sites where older adults gather, often for meals or companionship. The Consolidated Framework for Implementation Research guided program implementation and evaluation. Depending upon health promotion program needs, the physical infrastructure of a site is important, but a supportive director (champion) can often overcome identified deficits. Senior centers may be locally classified into four types based upon eligibility requirements of residents in affiliated housing and services offered. Participants who attend these centers differ in important ways across types by most sociodemographic as well as certain health and health care characteristics.