Faculty Bibliography

BACKGROUND: Papaverine remains popular for treating intraoperative vasospasm, but the recent shortage has forced surgeons to trial antispasmodic agents unproven in microsurgery but commonly used in other body areas. During this shortage, the authors have used topical lidocaine and nicardipine to break intraoperative vasospasm. This study aims to analyze the outcomes of these medications on flap complications compared with papaverine. METHODS: All consecutive free flaps performed for breast reconstruction at a single institution were reviewed. Data collected included patient demographics, comorbidities, complications, and type of antispasmodic agent. Rates of reexploration, complications, and flap salvage were compared between patients receiving antispasmodic agents and matched papaverine controls. RESULTS: Of the 1087 flaps treated with antispasmodic agents, nicardipine was used on 59 flaps and lidocaine was used on 55 flaps. Patients treated with lidocaine had higher body mass indexes (31.0 kg/m versus 27.4 kg/m; p = 0.001). Patients treated with nicardipine tended to be older (64.0 versus 48.5; p < 0.01) and have a history of hypertension (22.0 percent versus 10.4 percent; p = 0.08) or preoperative irradiation (32.2 percent versus 13.6 percent; p = 0.016) compared with papaverine controls. No differences in the rates of total or partial flap loss, unplanned return to the operating room, or fat necrosis were observed between any of the groups. However, the nicardipine group demonstrated a higher rate of infection (15.3 percent versus 3.4 percent; p = 0.027). CONCLUSION: Substituting lidocaine or nicardipine for papaverine to treat vasospasm did not demonstrate an increased rate of flap loss or return to the operating room, making these medications safe and efficacious alternatives to papaverine. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Historically, periodic academic meetings held by surgical societies have set the stage for discussion and exchange of ideas, which in turn have led to advancement of clinical practices. Since 2007, the AONA State of the Art: Facial Reconstruction and Transplantation Meeting (FRTM) has been organized to provide a forum for specialists around the world to engage in open conversation about the approaches currently at the forefront of facial reconstruction. Review of registration data of FRTM iterations from 2007 to 2015 was performed. The total number of participants, along with their level of medical training, location of practice, and medical specialty, was recorded. Additionally, academic programs and 2015 participant feedback were evaluated. From 2007 to 2011, there was a decrease in the overall number of participants, with a slight increase in the number of clinical specialties present. In 2013, a sharp increase in total participants, international attendance, and represented clinical specialties was observed. This trend continued in 2015. Adjustments to academic programs have included reorganization of lectures and optimization of content. FRTM is a unique forum for multidisciplinary professionals to discuss the evolving field of facial reconstruction and join forces to accelerate progress and improve patient care.

Radiation therapy (RT) is and essential treatment for many oral cavity and oropharynx tumors. However, radiation may cause significant long-term morbidity for survivors. A serious jaw complication from radiation includes osteoradionecrosis (ORN) requiring mandibulectomy and reconstruction, which has significant medical, economic, and quality of life implications for affected patients. Reconstructing ORN defects is challenging due to late effects of radiotherapy on bone and soft tissue tissues resulting in severe fibrosis and possibly infected wound environments. Microvascular free flaps (MVFF) are commonly used for mandibular reconstruction in ORN. When MVFF reconstructions are contraindicated, regional pedicle flaps combined with rigid fixation and autologous bone grafts are commonly reported options that can provide satisfactory functional and aesthetic outcomes. In the present case report we describe an osteomyocutaneous rotational flap using a rib to reconstruct a continuity defect due to ORN. The patient is a 64-year-old female with a history of successful simple surgical treatment for ORN of the left body of the mandible that included hyperbaric oxygen (HBO) therapy who developed ORN and pathologic fracture of the right body of the mandible. Another long-term concern was the prognosis for the clinically healed left mandible. Treatment options were presented to the patient including a microvascular osteocutaneous fibula free flap. However, the patient's ambulation and recovery time was a major concern and she preferred an osteomyocutaneous pectoralis major rib graft. The risks and benefits of both options were discussed. Three months postoperatively she developed an extraoral soft tissue dehiscence with exposure of the plate without infection. Computed tomography seven months postoperatively demonstrated a bone union of the rib at both the proximal and distal resection margins. She subsequently underwent examination of the graft which was found to be healed. The reconstruction plate was removed and the cutaneous defect was repaired using a full thickness skin graft to the right mandible. Reports on vascularized osteocutaneous rib grafts to reconstruct the mandible for ORN have been brief.1 Reconstruction of the mandible using rib has been reported primarily as a free bone graft.2,3 Additional considerations for our patient with a history of ORN of the left mandible include: the 25% failure rate associated with simple surgical treatment (i.e., sequestrectomy),4 the controversial efficacy of perioperative HBO therapy 5,6 and the increased risk of ORN over time.7An osteomyocutaneous pectoralis major rib graft was able to restore continuity of the right mandible and maintain the option for a microvascular fibula graft in the event of recurrent ORN in either or both sides of the mandible. The limitations for this option are the size of the defect and inability to place dental implants. The conclusion from this case report is that a rotational osteomyocutaneous rib graft may be an option for some patients with ORN

Healing chambers present at the interface between implant and bone have become a target for improving osseointegration. The objective of the present study was to compare osseointegration of several implant healing chamber configurations at early time points and regions of interest within bone using an in vivo animal femur model. Six implants, each with a different healing chamber configuration, were surgically implanted into each femur of six skeletally mature beagle dogs (n = 12 implants per dog, total n = 72). The implants were harvested at 3 and 5 weeks post-implantation, non-decalcified processed to slides, and underwent histomorphometry with measurement of bone-to-implant contact (BIC) and bone area fraction occupied (BAFO) within healing chambers at both cortical and trabecular bone sites. Microscopy demonstrated predominantly woven bone at 3 weeks and initial replacement of woven bone by lamellar bone by 5 weeks. BIC and BAFO were both significantly increased by 5 weeks (p < 0.001), and significantly higher in cortical than trabecular bone (p < 0.001). The trapezoidal healing chamber design demonstrated a higher BIC than other configurations. Overall, a strong temporal and region-specific dependence of implant osseointegration in femurs was noted. Moreover, the findings suggest that a trapezoidal healing chamber configuration may facilitate the best osseointegration. (c) 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2015.

PURPOSE: The aim of this study was to evaluate the probability of survival of cemented and screwed three-unit implant-supported fixed dental prostheses (ISFDP) using different implant-abutment horizontal matching configurations (regular vs switching platforms). METHODS: One hundred and sixty-eight implants with internal hexagon connection (4 mm diameter, 10 mm length, Emfils; Colosso Evolution System, Itu, SP, Brazil) were selected for this study according to the horizontal implant-abutment matching configuration (regular or switching) and retention method and divided in four groups (n = 21 per group) as follows: 1) regular platform cemented (IRC); 2) or screw-retained (IRS); 3) switched-platform cemented (ISC); or 4) screw-retained (ISS). Regular and platform-switched abutments (Colosso evolution, 4 mm and 3.3 mm, respectively) were torqued, and 84 three-unit metal bridges were fabricated (first molar pontic). Implants were embedded in polymethyl-methacrylate resin and subjected to step-stress accelerated life testing in water. Weibull distribution was used to determine the probability of survival for a mission of 100,000 cycles at 400 N (90% two-sided confidence intervals). Polarized light and scanning electron microscopes were used for fractographic analysis. RESULTS: The beta values of 0.50, 1.19, 1.25, and 1.95 for groups IRC, IRS, ISC, and ISS respectively, indicated that fatigue accelerated the failure for all groups, except IRC. The cement-retained groups presented significantly higher probability of survival (I

BACKGROUND: Nipple-sparing mastectomy with immediate, permanent implant reconstruction offers patients a prosthetic "breast in a day" compared to tissue expander techniques requiring multiple procedures. METHODS: Patients undergoing nipple-sparing mastectomy with immediate, permanent implant reconstruction were reviewed with patient demographics and outcomes analyzed. RESULTS: Of 842 nipple-sparing mastectomies from 2006 to June of 2015, 160 (19.0 percent) underwent immediate, permanent implant reconstruction. The average age and body mass index were 46.5 years and 23.3 kg/m. The majority of implants were either Allergan Style 20 (48.1 percent) or Style 15 (22.5 percent). The average implant size was 376.2 ml, and 91.3 percent of reconstructions used acellular dermal matrix. The average number of reconstructive operations was 1.3. Follow-up was 21.9 months. The most common major complication was major mastectomy flap necrosis (8.1 percent). The rate of reconstructive failure was 5.6 percent and implant loss was 4.4 percent. The most common minor complication was minor mastectomy flap necrosis (14.4 percent). The rates of full-thickness and partial-thickness nipple necrosis were 4.4 and 7.5 percent, respectively. Age older than 50 years (p = 0.0276) and implant size greater than 400 ml (p = 0.0467) emerged as independent predictors of overall complications. Obesity (p = 0.4073), tobacco use (p = 0.2749), prior radiation therapy (p = 0.4613), and acellular dermal matrix (p = 0.5305) were not associated with greater complication rates. CONCLUSION: Immediate, permanent implant reconstruction in nipple-sparing mastectomy provides patients with a breast in a day in less than two procedures, with a low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

This study describes the early soft tissue morphology around two different implant systems that received either smooth or laser-etched abutments in a beagle dog model. Implants were placed in the healed mandibular molar region of eight beagle dogs and allowed to heal for 7 weeks. When the most apical aspect of the junctional epithelium (JE) was above or within the upper half of the laser-etched region, fibers were oriented perpendicular to the abutment surface. In contrast, JE positioned within the lower half of the laser-etched region or within or below the implant-abutment gap level presented fibers oriented parallel to the abutment surface.

This study evaluated color variability in the A hue between the VITA Classical (VITA Zahnfabrik) shade guide and four other VITA-coded ceramic shade guides using a Canon EOS 60D camera and software (Photoshop CC, Adobe). A total of 125 photographs were taken, 5 per shade tab for each of 5 shades (A1 to A4) from the following shade guides: VITA Classical (control), IPS e.max Ceram (Ivoclar Vivadent), IPS d.SIGN (Ivoclar Vivadent), Initial ZI (GC), and Creation CC (Creation Willi Geller). Photos were processed with Adobe Photoshop CC to allow standardized evaluation of hue, chroma, and value between shade tabs. None of the VITA-coded shade tabs fully matched the VITA Classical shade tab for hue, chroma, or value. The VITA-coded shade guides evaluated herein showed an overall unmatched shade in all tabs when compared with the control, suggesting that shade selection should be made using the guide produced by the manufacturer of the ceramic intended for the final restoration.

In recent years oral mucosal injury has been increasingly recognized as an important toxicity associated with mammalian target of rapamycin (mTOR) inhibitors, including in patients with breast cancer who are receiving everolimus. This review addresses the state-of-the-science regarding mTOR inhibitor-associated stomatitis (mIAS), and delineates its clinical characteristics and management. Given the clinically impactful pain associated with mIAS, this review also specifically highlights new research focusing on the study of the molecular basis of pain. The incidence of mIAS varies widely (2-78%). As reported across multiple mTOR inhibitor clinical trials, grade 3/4 toxicity occurs in up to 9% of patients. Managing mTOR-associated oral lesions with topical oral, intralesional, and/or systemic steroids can be beneficial, in contrast to the lack of evidence supporting steroid treatment of oral mucositis caused by high-dose chemotherapy or radiation. However, steroid management is not uniformly efficacious in all patients receiving mTOR inhibitors. Furthermore, technology does not presently exist to permit clinicians to predict a priori which of their patients will develop these lesions. There thus remains a strategic need to define the pathobiology of mIAS, the molecular basis of pain, and risk prediction relative to development of the clinical lesion. This knowledge could lead to novel future interventions designed to more effectively prevent mIAS and improve pain management if clinically significant mIAS lesions develop.

This study was designed to compare the combined effect of two different drilling techniques (conventional expansion and one-step) and four different implant geometries in a beagle dog model. The nondecalcified bone-implant samples underwent histologic/metric analysis at 2 and 6 weeks. Morphologic analysis showed similarities between different drilling technique groups and implant geometries. Histomorphometric parameters, bone-to-implant contact (BIC), and bone area fraction occupancy (BAFO) were analyzed, and no statistical difference between drilling groups and/or implant geometry was found. Time was the only variable that affected BIC and BAFO, suggesting that the two protocols are equally biocompatible and osseoconductive.