Faculty Bibliography

BACKGROUND: In managing late facial paralysis, association of cross-facial nerve grafting and free muscle transfer proves superior to any other method of mid-face reanimation. Nevertheless, predicting functional recovery remains a struggle, and in a minority of patients, results are deceiving. In this study, cases of fair or moderate outcomes from a free muscle transfer received a segmental temporalis transposition to upgrade the functional and aesthetic results. METHODS: From 1981 to 2007, 153 patients received a free muscle transfer for smile restoration in the authors' center. Of all patients, 72 percent (110 patients) required a third stage of revisions. In 41 cases, mini-temporalis transfer was used to augment moderate outcomes of a free muscle transfer. The exclusion criterion was less than 3 months' follow-up; thus, six patients were not evaluated. Each patient was videotaped at three successive time points (preoperatively, following free muscle transfer, and following mini-temporalis transfer). Five independent observers graded patients' videos using a five-category scale from poor to excellent. RESULTS: In all of the patients, the averaged scores were higher after free muscle transfer in comparison with the preoperative scores (Wilcoxon signed rank test, p < 0.0001). After mini-temporalis transfer, 97.1 percent of the patients had scores that were increased further and 2.8 percent had the same scores. Alopecia along the coronal incision was seen in four patients, and hollowing of the infratemporal fossa was seen in five. CONCLUSION: Analysis of these clinical data supports the use of mini-temporalis transfer as a safe and reliable method of correcting imperfect outcomes following a free muscle transfer for smile restoration

BACKGROUND: The authors' experience in the management of late ulnar nerve injuries is presented. METHODS: A retrospective study of 44 patients with severe ulnar nerve injuries was conducted and the outcomes were analyzed in relation to various factors, such as age at injury, denervation time, level of injury, length of nerve graft, and type of reconstruction (e.g., neurolysis, secondary end-to-end repair, or nerve grafting). Most patients were late cases who were referred to the authors' center for treatment. The mean time between injury and surgery was 14.6 months (range, 2 to 64 months). The mean follow-up period was 2.6 years. RESULTS: Overall, good and excellent motor results (>or=M3+) were seen in 31 of 44 cases (70 percent) and good and excellent sensory results were seen in 28 of 44 cases (64 percent). The age of the patient, level of injury, denervation time, length of nerve graft, and type of surgical reconstruction significantly influenced the functional outcome. CONCLUSIONS: Functional results were significantly better if surgery was performed within 5 months, the length of the graft was 5 cm or less, and the patient was younger than 25 years. Advanced microsurgical techniques, such as interfascicular neurolysis and the use of vascularized nerve grafts or vascularized fascia, should be kept in mind in complex and/or previously failed cases

Oral squamous cell carcinoma (SCC) has an unpredictable capacity to metastasize to the neck, an event that dramatically worsens prognosis. Metastasis occurs even in earlier stages when no neck lymph node involvement is clinically detectable (N0). Management of the N0 neck, namely when and how to electively treat, has been debated extensively. This article presents the controversies surrounding management of the N0 neck, and the benefits and pitfalls of different approaches used in evaluation and treatment. As current methods of assessing the risk for occult metastasis are insufficiently accurate and prone to underestimation of actual risk, and because selective neck dissection (SND) is an effective treatment and has minimal long-term detriment to quality of life, the authors believe that all patients who have oral SCC, excluding lip SCC, should be prescribed elective treatment of the neck lymphatics. However, this opinion remains controversial. Because of the morbidity of radiation therapy and because treatment of the primary tumor is surgical, elective neck dissection is the preferred treatment. In deciding the extent of the neck dissection, several retrospective studies and one randomized clinical trial have shown SND of levels I through III to be highly efficacious

In this study, we investigated the role of the peripheral endothelin-1 (ET-1) concentration in a cancer pain model. To test the hypothesis that the concentration of ET-1 in the tumor microenvironment is important in determining the level of cancer pain we used two cancer pain mouse models that differed significantly in production of ET-1. The two mouse cancer models were produced by injection of cells derived from a human oral squamous cell carcinoma (SCC) and melanoma into the hind paw of female mice. Pain, as indicated by reduction in withdrawal thresholds in response to mechanical stimulation, was significantly greater in the SCC group than the melanoma group. The peripheral concentration of ET-1 within the cancer microenvironment was significantly greater in the SCC group. Intra-tumor expression of both ET-1 mRNA and ET-1 protein were significantly higher in the SCC model compared to the melanoma model. ET receptor antagonism was effective as an analgesic for cancer pain in the SCC model only. To address the potential confounding factor of tumor volume we evaluated the contribution of tumor volume to cancer pain in the two models. The mean volumes of the tumors in the melanoma group were significantly greater than the tumors in the SCC group. In both groups, the pain level correlated with tumor volume, but the correlation was stronger in the melanoma group. We conclude that ET-1 concentration is a determinant of the level of pain in a cancer pain mouse model and it is a more important factor than tumor volume in producing cancer pain. These results suggest that future treatment regimens for cancer pain directed at ET-1 receptor antagonism show promise and may be tumor type specific

PURPOSE: Squamous cell carcinomas of the hard palate, maxillary gingiva, and maxillary alveolus occur at relatively low rates compared with squamous cell carcinomas in other oral sites. There is little within the surgical literature to guide treatment for maxillary squamous cell carcinoma. To date, only 1 other group has addressed neck management in the oral maxillary squamous cell carcinoma patient presenting with a clinically negative neck. Adequate characterization of maxillary gingival carcinoma behavior with respect to regional cervical metastasis is wanting. PATIENTS AND METHODS: We present a retrospective review of our own clinical experience as well as a review of the existing literature. RESULTS: In our University of California San Francisco patient group, cervical disease was detected in 20% of those individuals with maxillary squamous cell carcinoma presenting for initial consultation. After ablative surgery, those individuals who presented with clinically negative necks had a 21.4% rate of regional node metastasis. Ultimately, 50% of our patients with squamous cell carcinomas of the palate, maxillary gingiva, and maxillary alveolus developed regional or metastatic distant disease; 42.9% of the patients manifested disease to the cervical lymph nodes alone. CONCLUSIONS: The cases of oral maxillary squamous cell carcinomas reviewed herein exhibit aggressive regional metastatic behavior comparable to that of such carcinomas of the tongue, floor of the mouth, and mandibular gingiva. Based on the findings presented herein, we recommend selective neck dissection in the setting of a clinically negative neck as a primary management strategy for patients with oral maxillary squamous cell carcinomas involving the palate, maxillary gingiva, and maxillary alveolus

For years, the notion of chin ptosis was somehow integrated with the concept of witch's chin. That was a mistake on many levels because chin droop has four major causes, all different and with some overlap. With this article, the surgeon can quickly diagnose which type and which therapeutic modality would work best. In some cases the problem is a simple fix, in others the droop can only be stabilized, and in the final two, definite corrective procedures are available. Of note, in certain situations two types of chin ptosis may overlap because both the patient and the surgeon may each contribute to the problems. For example, in dynamic ptosis, a droop that occurs with smile in the unoperated patient can be exacerbated and further produced by certain surgical methods also. This paper classifies the variations of the problems and explains the anatomy with the final emphasis on long-term surgical correction, well described herein. This article is the ninth on this subject and a review of them all would be helpful (greatly) for understanding the enigmas of the lower face

The implementation of an implant dental curriculum in U.S. dental schools has been consistently increasing from 33 percent in 1974 to 97 percent in 2004. Among these, only 51 percent have clinical components implemented. A survey of students conducted in 2004 at New York University College of Dentistry (NYUCD) showed an inadequacy in clinical implant restoration experience by graduation. This prompted the development of an extensive dental implant curriculum at NYUCD to meet the needs of the dental students. This report addresses the challenges in implementing such a curriculum and describes a step-by-step approach to develop a program that encompasses didactic, simulation, and patient care components. In 2005, a fully integrated predoctoral implant curriculum was initiated. In 2008, nearly all of the NYUCD students (91.8 percent) completed implant restorations/prosthesis on patients. An assessment revealed a 30 percent increase in students' positive perceptions of the implant curriculum. Based on our experiences at NYUCD, it is recommended that an implant curriculum become part of the core predoctoral curriculum and be integrated throughout the four years of dental education. This article reports on a model for a pre-doctoral implant curriculum, which includes planning, curriculum implementation, program management, and post-implementation stages. Using this model, dental schools can develop implant education for their students that is adapted to their institutional missions, priorities, and resources

AIM: Static Hertzian contact tests of monolayer glass-ceramics in trilayer configurations (glass-ceramic/cement/composite) have shown that thick cement layers lower strength. This study sought to test the hypothesis that thick resin cement layers lower mouth motion fatigue reliability for flat glass-ceramic/cement/composite trilayer systems and that aging in water reduces reliability. METHODS: Dicor plates (n > or = 12 per group) (10 x 10 x 0.8 mm(3)) were aluminum-oxide abraded (50 microm), etched (60 s), silanized, and bonded (Rely X ARC) to water aged (30 days) Z100 resin blocks (10 x 10 x 4 mm(3)). Four groups were prepared: (1) thick cement layer (>100 microm) stored in water for 24-48 h, (2) thick cement layer stored for 60 days, (3) thin cement layer (< or =100 microm) stored for 24-48 h, and (4) thin cement layer stored for 60 days. The layered structures were fatigued (2 Hz) utilizing mouth motion loading with a step-stress acceleration method. A master Weibull distribution was calculated and reliability determined (with 90% confidence intervals) at a given number of cycles and load. RESULTS: The aged group (60 d) with thick cement layer had statistically lower reliability for 20,000 cycles at 150 N peak load (0.11) compared with both nonaged groups (24-48 h) (thin layer = 0.90 and thick layer = 0.82) and aged group with thin cement layer (0.89). CONCLUSION: Trilayer specimens with thick cement layers exhibited significantly lower reliability under fatigue testing only when stored for 60 days in water. The hypothesis was accepted. These results suggest that diffusion of water into the resin cement and also to the glass-ceramic interface is delayed in the thick cement specimens at 24-48 h.