Faculty Bibliography

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%.

ABSTRACT: The incidence of postoperative complications in cleft care is low. In this 19-year retrospective analysis of cleft lip and palate patients treated with preoperative nasoalveolar molding, we examine the incidence of postoperative oronasal fistulae. The charts of 178 patients who underwent preoperative nasoalveolar molding by the same orthodontist/prosthodontist team and primary cleft lip/palate repair by the same surgeon over a 19-year period were reviewed. Millard, Mohler, Cutting, or Mulliken-type techniques were used for cleft lip repairs. Oxford-, Bardach-, or von Langenbeck-type techniques were used for cleft palate repairs. One nasolabial fistula occurred after primary cleft lip repair (0.56% incidence) and was repaired surgically. Four palatal fistulae (3 at the junction between soft and hard palate and 1 at the right anterior palate near the incisive foramen) occurred, but 3 healed spontaneously. Only 1 palatal fistula (0.71%) required surgical repair. All 5 fistulae occurred within the first 8 years of the study period, with 4 (80%) of 5 occurring within the first 3 years. Although fistula rate may be related to surgeon experience and the evolution of presurgical techniques, nasoalveolar molding in conjunction with nasal floor closure contributes to a low incidence of oronasal fistulae.

Craniofacial vascularized composite allotransplantation is especially challenging when bony components are required. Matching the complex three-dimensional anatomy of the donor and recipient craniofacial skeletons to optimize bony contact and dental occlusion is a time-consuming step in the operating room. Currently, few tools exist to facilitate this process. The authors describe the development of a virtual planning protocol and patient-specific device design to efficiently match the donor and recipient skeletal elements in craniofacial vascularized composite allotransplantation. The protocol was validated in a cadaveric transplant. This innovative planning method allows a "snap-fit" reconstruction using custom surgical guides while maintaining facial height and width and functional occlusion. Postoperative overlay technology in the virtual environment provides an objective outcome analysis.

ABSTRACT: Nearly 60 years ago, Joseph Murray described several advancements to Bradford Cannon's Abbe flap reconstruction of secondary bilateral cleft lips in order to simplify the technique and improve results. Unlike their predecessors, Drs. Cannon and Murray modified the Abbe flap by splitting its apex in order to obtain a symmetrical correction of the upper lip and allow the 2 suture lines to extend vertically and laterally past the base of the columella and disappear within the floor of the nose. Eighteen years later, Dr. Murray reviewed the evolution of his own secondary cleft lip reconstruction experience to include a new approach to advance the maxilla rather than set back the mandible. In this Signature Issue, we reflect on contemporary innovations in secondary bilateral cleft lip Abbe flap reconstruction. Today, we approach the secondary reconstruction of the bilateral cleft lip in 3 stages. First, we establish normal anatomic positioning of the midface. Second, we perform secondary cleft nasal surgery as necessary. Finally, only after the midfacial skeleton and nose have been treated do we proceed with Abbe flap reconstruction of the upper lip. We inset the Abbe flap a quarter of the way out on the columella and wrap the Abbe darts around the sides of the columella. We find that designing the Abbe flap this way avoids the saber cut-like notching at the lip-columella junction, redundant vermilion, and excess flap length, and it also reduces or eliminates the need for upper or lower lip scar revision.

Primary malignant melanoma arising from the eustachian tube is extremely rare. We report the case of a 63-year-old white man who presented with a 1-month history of left-sided hearing loss and aural fullness. Flexible fiberoptic laryngoscopy detected a blue-purple mass that appeared to arise from the left lateral nasopharynx. Computed tomography demonstrated an enhancing mass arising from an orifice of the left eustachian tube. The tumor was debulked endoscopically and was confirmed to have originated in the left eustachian tube. Histologically, the tumor was made up of heavily pigmented pleomorphic spindle cells with frequent mitoses. The tumor cells were immunohistochemically positive for S-100 protein, HMB-45, Melan-A, and PNL-2. The final diagnosis was a mucosal malignant melanoma. We also performed a nested polymerase chain reaction assay for several genes of interest, including CTLA-4, IL-17A, IL-17B, IL-17C, IL-17D, IL-17E, IL-17F, PLZF, Foxp3, RORgammat, CD27, and CD70. These genes have been studied mainly in cutaneous melanomas, especially for the development of immunotherapy, but only very limited studies have been done on mucosal melanomas. Our investigation found upregulation of CTLA-4, IL-17A, IL-17C, and IL-17E. Based on our finding of CTLA-4 upregulation, it may be suggested that our patient might have had low antitumor immunity and that he might have benefited from CTLA-4 blockade. On the other hand, upregulation of IL-17A and IL-17E might reflect increased antitumor immunity, which could suggest that patients with a mucosal melanoma might benefit from immunomodulators associated with the effect of Th17. These genes also have great potential to help melanoma patients obtain tailored treatment, and they can be used as biomarkers for predicting prognosis.

Frontal sinus mucoceles may present many years after traumatic injuries or surgical procedures involving the frontal bone, but have been rarely reported after fronto-orbital advancement. We describe a case of frontal sinus mucocele development in a 43-year-old patient with Apert syndrome who underwent fronto-orbital advancement as a child. This was treated with resection and free fibula osteomuscular flap reconstruction. Computer-aided design and manufacturing techniques were used to virtually plan the procedure and guide the osteotomies intraoperatively. Follow-up at 1 year postoperatively revealed no evidence of recurrence.

PURPOSE: This study evaluated the reliability and failure modes of anterior implants with internal-hexagon (IH), external-hexagon (EH), or Morse taper (MT) implant-abutment interface designs. The postulated hypothesis was that the different implant-abutment connections would result in different reliability and failure modes when subjected to step-stress accelerated life testing (SSALT) in water. MATERIALS AND METHODS: Sixty-three dental implants (4 x 10 mm) were divided into three groups (n = 21 each) according to connection type: EH, IH, or MT. Commercially pure titanium abutments were screwed to the implants, and standardized maxillary central incisor metallic crowns were cemented and subjected to SSALT in water. The probability of failure versus number of cycles (95% two-sided confidence intervals) was calculated and plotted using a power-law relationship for damage accumulation. Reliability for a mission of 50,000 cycles at 150 N (90% two-sided confidence intervals) was calculated. Polarized-light and scanning electron microscopes were used for failure analyses. RESULTS: The beta values (confidence intervals) derived from use-level probability Weibull calculation were 3.34 (2.22 to 5.00), 1.72 (1.14 to 2.58), and 1.05 (0.60 to 1.83) for groups EH, IH, and MT, respectively, indicating that fatigue was an accelerating factor for all groups. Reliability was significantly different between groups: 99% for MT, 96% for IH, and 31% for EH. Failure modes differed; EH presented abutment screw fracture, IH showed abutment screw and implant fractures, and MT displayed abutment and abutment screw bending or fracture. CONCLUSIONS: The postulated hypothesis that different implant-abutment connections to support anterior single-unit replacements would result in different reliability and failure modes when subjected to SSALT was accepted.

BACKGROUND: Management of maxillary defects is among the most challenging and controversial areas of head and neck reconstruction. The authors develop a treatment algorithm based on outcomes following free flap reconstruction of various maxillary defects. METHODS: A review of 246 maxillary free flap reconstructions was performed. RESULTS: The authors' analysis demonstrated that the palatoalveolar resection predicted use of soft-tissue (n = 200) versus osteocutaneous (n = 46) free flaps, depending on the location and extent of the defect. Whether the orbital floor or the entire orbital contents were resected also had implications for flap choice and whether bone grafts or alloplasts were needed. The perioperative complication rate was 37.8 percent, including a 3.3 percent incidence of flap loss. The long-term complication rate was 12.1 percent, including a 7.5 percent fistula rate. Complications related to orbital floor reconstruction were not dependent on the material used (p = 0.18). Greater than 80 percent speech intelligibility was achieved by 95.1 percent of patients, and 90.6 percent tolerated an unrestricted or soft diet. CONCLUSIONS: To restore both midfacial form and function, the palatoalveolar defect and the status of the orbital floor and orbital contents must be addressed. Defects that involve the anterior maxilla should be addressed with osteocutaneous free flaps if possible, and posterior defects can often be reconstructed with soft-tissue free flaps. The orbital floor requires rigid reconstruction, with either bone grafts or alloplasts, unless the orbital contents have also been exenterated, in which case a soft-tissue free flap should be used to close the orbital cavity.