Profile Changes and Stability following Distraction Osteogenesis with Rigid External Distraction in Adult Cleft Lip and Palate Deformities

OBJECTIVES

The objective of this study is to analyze the hard and soft-tissue profile changes as well as the upper airway changes after distraction osteogenesis (DO) using rigid external distraction device in adult cleft lip and palate (CLP) patients. The study also evaluates the stability of the surgical result.

MATERIALS AND METHODS

Three lateral cephalometric radiographs were taken: Predistraction (T1), postdistraction (T2), and 1 year after distractor removal (T3). The treatment changes (T1 vs. T2) and the stability (T2 vs. T3) were analyzed. The overall treatment changes after 1 year were also evaluated (T1 vs. T3). The lateral cephalograms were digitally analyzed with the help of software named Dolphin.

STATISTICAL ANALYSIS USED

Wilcoxon Signed-Ranks test was used, and the probability value (P value) of 0.05 was considered as statistically significant level.

RESULTS

Eleven adult patients with CLP were retrospectively analyzed. After distraction, there was a significant mean maxillary advancement of 14 mm (P < 0.01) from a T1 value of 73.54 ± 10.38 to a T2 value of 88.2 ± 10.49. The lower facial height and the incisor exposure were significantly increased. The nasolabial angle had a significant improvement of 24.5° (P < 0.01) from a T1 value of 56.6 ± 21.03 to a T2 value of 81.18 ± 14.4.The upper airway was significantly improved by 3.7 mm (P < 0.01) with a T1 value of 13.5 ± 3.8 to a T2 value of 17.2 ± 3.66. After 1-year follow-up, there was a significant maxillary relapse of 3.20 mm (P < 0.05) from a T2 value of 8.29 ± 6.84 to a T3 value of 5.09 ± 5.59. However, the soft-tissue profile and upper airway remained stable.

CONCLUSION

The clinician should have an understanding of the related hard and soft tissues as well as airway changes which may assist him when planning for maxillary advancement for CLP patients with DO. There were significant improvements immediately after distraction, but during the 1-year follow-up, some relapse was seen. This stressed on the need for overcorrection of about 35%-40% for adult CLP patients.

Rehabilitation of edentulous atrophic anterior mandible - the role of vertical alveolar distraction osteogenesis

The rehabilitation of patients with edentulous alveolar ridge is always a challenge, more so in case of a long standing atrophic mandible. Mandible, the largest movable bone in the maxillofacial skeleton is associated with many soft tissue attachments which imparts dislodging forces to prosthesis. In addition to this, the rate of resorption of the mandibular ridge is four times that of the maxilla. These factors make the environment of the mandibular arch less favorable to complete denture stability and retention. An ideal solution would be to augment the atrophic alveolar ridge with native bone of the individual which shall eliminate the possible complications, associated with conventional ridge augmentation procedures. With advent of modern technology, and increased biological understanding, the principles of distraction osteogenesis are increasingly being applied to the craniofacial skeleton and have been found to be a viable option in augmenting the native alveolar bone in the mandible. Here the application of an indigenous stainless steel vertical alveolar distraction device to augment atrophic anterior mandibular ridge is assessed in six patients.

A 'pen' in the neck: an unusual foreign body and an unusual path of entry

Penetrating injuries to head and neck region with varying objects have been reported in the literature. Majority of these injuries occur in interpersonal violence or bomb blasts or road traffic accidents. Despite the improvement in imaging technologies and surgical methods, penetrating injuries to head and neck with impacted foreign bodies are very challenging due to the proximity to vital structures and/or difficulties in accessing them for the removal. Following injury the normal anatomy could be altered because of edema or tissue destruction, which makes the diagnosis or retrieval more difficult. Parapharyngeal or prevertebral space is an unusual place for lodgment of foreign bodies and in these cases the usual point of entry is the oral cavity, cheek or neck. Here, we report a case of a ball point pen extending to the prevertebral region at the level of C1-C2 vertebrae from point of entry at the suprazygomatic region in the temporal fossa.

Modification of the dingman mouth gag for better visibility and access in the management of cleft palate

Palatal and pharyngeal surgeries often require wide visibility and access. Various mouth gags and retractors have been devised and many modifications suggested to optimize these surgeries. The Dingman mouth gag, one of the commonly used retractors, offers a lot of advantages in terms of good mouth opening, tongue retraction, self-retaining cheek retractors, and anchorage for sutures, but it has a main limitation in that it allows only limited visibility of the anterior palate and alveolus. Hence, a modification of the Dingman mouth gag is presented for better visibility of and accessibility to the anterior palate.

Mandibular conservation in oral cancer

Surgery is one of the established modes of initial definitive treatment for a majority of oral cancers. Invasion of bony or cartilaginous structures by advanced upper aero-digestive tract cancer has been considered an indication for primary surgery on the basis of historic experience of poor responsiveness to radiation therapy [1]. The mandible is a key structure both in the pathology of intra-oral tumours and their surgical management. It bars easy surgical access to the oral cavity, yet maintaining its integrity is vital for function and cosmesis. Management of tumours that involve or abut the mandible requires specific understanding of the pattern of spread and routes of tumour invasion into the mandible. This facilitates the employment of mandibular sparing approaches like marginal mandibulectomy and mandibulotomy, as opposed to segmental or hemimandibulectomy which causes severe functional problems, as the mandibular continuity is lost. Accurate preoperative assessment that combines clinical examination and imaging along with the understanding of the pattern of spread and routes of invasion is essential in deciding the appropriate level and extent of mandibular resection in oral squamous cell carcinoma. Studies have shown that local control rates achieved with marginal mandibulectomy are comparable with that of segmental mandibulectomy. In carefully selected patients, marginal mandibulectomy is an oncologically safe procedure to achieve good local control and provides a better quality of life. This article aims to review the mechanism of spread, evaluation and prognosis of mandibular invasion, various techniques and role of mandibular conservation in oral squamous cell carcinoma.

Predictors of mandibular involvement in cancers of the oromandibular region

PURPOSE

Invasion of the mandible by oral squamous carcinoma is not only a relative contraindication to mandible conservation but also an indicator of poor prognosis. This study looks at clinical, radiologic, and operative variables that may help in predicting mandibular bone involvement.

PATIENTS AND METHODS

A prospective study was carried out to evaluate the mandibular involvement and its predictors in 51 cases of oral squamous carcinoma located in the mandibular region. All patients underwent segmental- or hemimandibulectomy. A detailed clinical examination was followed by radiologic assessment and operative assessment. Statistic analysis was carried out by chi(2) test (odds ratio [OR] with a significance level of 5%). Multivariate analysis was carried out by logistic regression analysis.

RESULTS

Univariate analysis identified location of tumor on lower alveolus (OR = 8.5), sensory disturbances of inferior alveolar nerve (OR = 16.2), location of tumor within 1 cm of mandible (OR = 1.4), presence of findings on periosteal striping (OR = 2.0) like subperiosteal reaction (OR = 3.5), cortical expansion (OR = 8.8) and presence of pathologic fracture (OR = 2.3) as predictor of bone invasion. Grade of tumor (P = .05) and radiologic bone involvement (P = .02) were found to be significant independent predictors of pathologic bone involvement on multivariate analysis.

CONCLUSIONS

It is possible to identify mandibular invasion in almost all cases of oral squamous carcinoma by combining clinical examination, radiologic findings, and findings on periosteal stripping. This helps surgeons to make an informed preoperative and intraoperative decision about mandibular conservation. However, one should be careful when evaluating bone involvement on periosteal stripping as this cannot be recommended as a method of choice due to fear of tumor dissemination and violation of oncologic principles.

Patterns of mandibular invasion in oral squamous cell carcinoma of the mandibular region

BACKGROUND

Mandibular resections are routinely carried out for achieving a R0 resection for oral cancers. However, the need of mandibular resection to achieve this has always been questioned. The present study was carried out to define the pattern of mandibular involvement in carcinoma of the mandibular region.

PATIENTS AND METHODS

A total of 25 consecutive patients who had undergone mandibular resection and were found to have mandibular invasion were studied in a prospective open fashion. After decalcification the specimens were serially sectioned at 1 cm interval to identify invasion of mandibular bone. Type of invasion, route of spread and host cell reactions were also recorded.

RESULTS

The mandibular involvement was infiltrative in 14(56%) and erosive in 11(44%). It was cortical in 5(20%), marrow involvement was seen in 15(60%) while 5(20%) had spread through the inferior alveolar canal. Of the 25, 24(96%) lesions were located with in 1 cm of the mandible.

CONCLUSION

The possibility of mandibular involvement is higher in patients where tumours are located with in 1 cm of the mandible. Involvement of mandible through the canal of inferior alveolar nerve in the present study was relatively high (20%). Therefore it is recommended that before a decision is taken to preserve the mandible it should be thoroughly screened for possible involvement.

Mandibular invasion in oral squamous cell carcinoma: investigation by clinical examination and orthopantomogram

Assessing the relationship of oral squamous carcinoma with the mandible prior to definitive therapy poses a perplexing problem for the head and neck oncologist. We carried out a prospective open study of 51 (21 female and 30 male; mean age of 53.4 years) patients undergoing mandibular resections for oral squamous cell carcinoma to examine the incidence of mandibular bone invasion and to assess the predictive capabilities of clinical and radiological examination in detecting bone involvement. A detailed clinical examination was followed by radiographic evaluation of mandible for bone invasion. After resection, the mandible was sectioned serially at every cm to find the pathological bone involvement. Sensitivity, specificity, and positive and negative predictive values of clinical and radiological findings were calculated. Specimens from 25 patients (49%) (4 segmental 21 hemi) demonstrated tumour invasion on histological examination. Clinical impression of mandibular invasion showed a sensitivity of 96% and specificity of 65%, whereas radiological examination had a sensitivity of 92% and specificity of 88%. When considered together, clinical and radiological examinations were able to detect all the cases of bone invasion, but specificity was only 58%. This study advocates careful correlation of clinical and radiological findings prior to definitive therapy, as clinical examination tends to over diagnose bone invasion in tumours adjacent to the mandible. The specificity of imaging was also found to be low pointing towards the need for more specific diagnostic tools in doubtful cases. Aggressive surgical therapy, namely segmental or hemi resection of mandible is warranted in case of tumours of the lower alveolus with definite bone invasion. In case of carcinomas of the buccal mucosa and tongue the mandibular resection can be limited to that required for clearance of margins provided the radiology is negative.