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Avascular necrosis of the midface secondary to disseminated intravascular coagulation
e116
Oral Presentation
produced different concentrations (equal and 3-folds; x1FD-PRP, x3FD-PRP) by resolving FD-PRP to equal or 1/3 amount of water. We assessed the property changes of FD-PRP in gelation ability and also the release of growth factors (PDGF-BB, TGF-1 and VEGF) in vitro. We also examine the in vivo bone forming ability. PRPs (f-PRP, x1FD-PRP or x3FD-PRP) were mixed with -TCP granules and onlay-grafted on mice calvaria. After 4 weeks, the specimens were harvested and the new bone-formation is assessed histologically. Findings and conclusions: Each PRP (f-PRP, x1FD-PRP or x3FD-PRP) equally formed gel. In terms of growth factors release, x1FD-PRP released the identical concentrations of PDGF-BB and TGF-1 to f-PRP, while x3FD-PRP did approximately 3-fold concentrations of them to f-PRP. In vivo, x1FD-PRP promoted identical level of the bone formation to f-PRP, and x3FD-PRP induced more abundant bone formation. These results suggest that f-PRP can be stored without functional-loss by freeze-drying and the concentration of PRP may promote its validity on bone engineering. http://dx.doi.org/10.1016/j.ijom.2015.08.715 Free bone grafts for mandibular reconstruction in patients who have not received radiotherapy – the 6 cm rule – myth or reality B. Nandra 2,∗ , N. Uppal 2 , T. Martin 2 , P. Praveen 2 , T. Fattahi 1 , R. Fernandes 1 , S. Parmar 2 1
Department of Oral and Maxillofacial Surgery, University of Florida, Jacksonville, USA 2 Department of Oral and Maxillofacial Surgery, University Hospital Birmingham, England, UK
Background: Bony reconstruction of the mandible after surgical resection, results in improved rehabilitation and aesthetics. Free tissue transfer with bone has transformed reconstruction and particularly in patients who have received radiotherapy. However, there is a morbidity related to free tissue transfer as well as failure of free flaps. Free non-vascularized bone grafts have much lower morbidity. However, many surgeons feel that any mandibular defect greater than 6.0 cm are prone to failure1 and thus will only use free flaps in these defects. Methods: A retrospective study using theatre log books, case notes and radiographs was carried out of all the patients who had free bone grafts greater than 6.0 cm at University of Florida, Jacksonville and the Hospital Birmingham, United Kingdom. None of these patients received radiotherapy. Patents were assessed clinically and with standard radiographs. The patients were then planned for dental rehabilitation using dental implants. Findings: Six patients in Jacksonville and 8 patients in Birmingham, UK, were identified who had free bone grafts from the iliac crest for segmental defects greater then 6.0 cm over a 3 year period. All the bone grafts were successful, none infected and there was evidence of bony union. Conclusions: Contrary to the literature and many surgeons belief, our study has shown that long segmental mandibular defects are not a contraindication to the use of free bone grafts. The key principles are discussed.
Reference 1Foster, R., Pogrel, A., et al. (1999). Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction. Head Neck, 21(1).
http://dx.doi.org/10.1016/j.ijom.2015.08.716 Cervicopectoral rotational flap for cheek reconstruction: a case report and review of literature N.A. Ngah 1,∗ , W.M. Mustafa 2 1 2
Universiti Teknologi MARA, Shah Alam, Malaysia Oral Surgery Department, Kuala Lumpur Hospital, Malaysia
Restoration of full thickness cheek defect post-ablative cancer surgery can be challenge technically, functionally and cosmetically. Matching the colour, texture and hair-bearing characteristic to the surrounding skin are important aesthetics consideration. It is also utmost vital for psychological health of the patient. One on the simplest, unique and aesthetically pleasing option is the use of cervicopectoral rotational flap. In this case report, we seek awareness to expand its usefulness by discussing its versatility, modification, numerous advantages, complications and improvement of cervicopectoral rotational flap by retrieving the literature. We believe this flap is a complementary in restoring form, function and esthetics for full thickness cheek defect. A case of dual locoregional flap using the cervicopectoral rotational flap and temporalis myofascial flap to provide both inner and outer lining for full thickness cheek defects following ablative cancer surgery is discussed. http://dx.doi.org/10.1016/j.ijom.2015.08.717 Avascular necrosis of the midface secondary to disseminated intravascular coagulation E.V.A. Nguyen 1,∗ , A.A.C. Heggie 2 1
Monash Health, Melbourne, Victoria, Australia Oral and Maxillofacial Surgery Unit, Epworth Hospital, Richmond, Victoria, Australia
2
Avascular necrosis of the midface is a rare condition due to the rich vascular supply from bilateral branches of the external carotid artery. On mobilization of the maxilla during the Le Fort I downfracture, the hard and soft tissues remain well-perfused despite detachment of circum-vestibular vessels and, on occasion, loss of one or both of the contributions of the greater palatine arteries. The reliable perfusion of the maxilla during this procedure is well documented. The more commonly reported causes of osteonecrosis of the midface include orthognathic surgery, trauma, infection, bisphosphonates, and radiation. Disseminated intravascular coagulation (DIC) is also a rare condition that is characterized by the widespread pathological activation of the coagulation cascade, and can lead to ischaemic necrosis of tissues and, more seriously, ‘end-organ’ failure. DIC is commonly associated with major trauma, head injuries, infection, and obstetric complications. To the best of authors’ knowledge, avascular necrosis of the midface secondary to disseminated intravascular coagulation has yet to be described following a hypoxic syncopal episode secondary to ‘heat stroke’. A slow, progressive loss of anterior maxillary bone and the collapse of the nasal dorsum in a healthy
Oral Presentation young man with no other known medical co-morbidities led to the diagnosis. Following debridement, a staged reconstruction of the maxilla–nasal complex was successfully performed. The clinical presentation of this rare event and the approach to reconstruction of the patient’s maxillary and nasal complex are described. http://dx.doi.org/10.1016/j.ijom.2015.08.718 Multipaddled anterolateral thigh chimeric flap for reconstruction of complex defects in head and neck L. Ning ∗ , W. Liu, C. Jiang, F. Guo Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China Background: The anterolateral thigh flap has been the workhouse flap for coverage of soft-tissue defects in head and neck for decades. However, the reconstruction of multiple and complex soft-tissue defects in head and neck with multipaddled anterolateral thigh chimeric flaps is still a challenge. Objectives: In the present study, we aim to apply multipaddled anterolateral thigh chimeric flaps to reconstruct multiple and complex soft-tissue defects in head and neck, and access the reliability. Methods: Here, a clinical series of 12 cases is reported in which multipaddled anterolateral thigh chimeric flaps were used for complex soft-tissue defects with several separately anatomic locations in head and neck. Of the 12 cases, 7 patients presented with trismus were diagnosed as advanced buccal cancer with oral submucous fibrosis, 2 tongue cancer cases were found accompanied with multiple oral mucosa lesions or buccal cancer, and 3 were hypopharyngeal cancer with anterior neck skin invaded. Findings: All soft-tissue defects were reconstructed by multipaddled anterolateral thigh chimeric flaps, including 9 tripaddled anterolateral thigh flaps and 3 bipaddled flaps. The mean length of skin paddle was 19.2 (range: 14–23) cm and the mean width was 4.9 (range: 2.5–7) cm. All flaps survived and all donor sites were closed primarily. After a mean follow-up time of 9.1 months, there were no problems with the donor or recipient sites. Conclusions: This study supports that the multipaddled anterolateral thigh chimeric flap is a reliable and good alternative for complex and multiple soft-tissue defects of the head and neck. http://dx.doi.org/10.1016/j.ijom.2015.08.719 Platelet rich fibrin in the treatment of ONJ – outcome of surgical treatment of 15 consecutive patients S. Noerholt ∗ , H. Krogh Aarhus University Hospital, Aarhus, Denmark Background: Osteonecrosis of the jaws (ONJ) is a serious side effect to antiresorptive treatment (AR). Various treatment strategies are advocated, and it is recognized that refined techniques are necessary to obtain successful outcome. Platelet rich fibrin (PRF) promotes the healing process and may thus improve surgical outcome in ONJ patients. Objectives: To report the results of surgical treatment in 15 consecutive ONJ patients with use of PRF as part of the procedure. Methods: Surgery of ONJ was performed in 15 patients (11 females and 4 males). Age ranged from 54 to 83 years (mean 69). Eight patients had high-dose AR treatment because of skeletal involvement of malignancy; seven had low-dose AR for osteoporosis.
e117
Surgical treatment included resection of necrotic bone, mobilization of flaps for tension free closure and coverage of the bone with PRF membranes derived from 4 to 8 blood samples (of 10 ml) obtained immediately before surgery. Eleven lesions occurred in the mandible, three in the maxilla and one in both jaws. Minimum 4 months follow-up was performed. Findings: In 13 patients a complete mucosal coverage of the exposed bone was obtained. The remaining two patients had small areas of exposed bone without symptoms. Conclusions: Surgical treatment of ONJ is challenging with a risk of recurrence of bone exposure. Therefore, we have sought for means to improve the surgical procedure. In this series of cases a success rate of 87% was obtained. The use of PRF membranes appears to be a promising technique that warrants further investigation. http://dx.doi.org/10.1016/j.ijom.2015.08.720 Successful management of head and neck necrotizing fasciitis (case report) H. Nurahadi 1,∗ , H. Badeges 2 , V. Julia 1 1 2
Universitas Indonesia, Jakarta, Indonesia Persahabatan Hospital, Jakarta, Indonesia
Background: Necrotizing fasciitis, a serious infective process, causes extensive tissue damage, resulting in critical illness, high morbidity and mortality rate that require early diagnosis, radical debridement and broad spectrum antibiotics. Objectives: To present the clinical features, and successful surgical management of necrotizing fasciitis on the head and neck region. Case and management: 52 years old patient came to the Persahabatan Hospital Emergency Room, Jakarta with chief complaint of swelling on the left jaw, mouth opening limitation and difficulties on dietary intake for about a week before admission. He was diagnosed with left submandibular abscess and surgical drainage were performed to evacuate the pus. Afterward the wound became necrotized and extended aggressively to the lower neck region tissue within days. Radical surgical debridement was performed to eradicate the necrotic tissue and facilitate wound healing. Daily wound toilet were performed until epithelization occurred. Finally we performed Split Thickness Skin Graft procedure to close the open wound and the results were successful. Conclusion: This case report presents the successful surgical management of necrotizing fasciitis on head and neck area. The clinical features, differential diagnosis, treatment and prognosis are discussed. Wide surgical debridement is the successful management for the necrotizing fasciitis. http://dx.doi.org/10.1016/j.ijom.2015.08.721 Preoperative upper incisor crown length in Le Fort I osteotomies M. Oeckher 1,∗ , C. Czembirek 1 , E. Polska 1 , H. Stewart 2 , D. O’Rourke 2 , I. Watzke 1 1 Sozialmedizinisches Zentrum Ost – Department of Craniomaxillofacial and Oral Surgery, Vienna, Austria 2 Texas Center for Occlusal Studies, Flower Mound, Texas, USA
Background: Upper incisor crown length plays a crucial functional and esthetic role. It is commonly agreed upon to be around 11–12 mm for unworn teeth. When Le Fort I osteotomies are
Oral Presentation
produced different concentrations (equal and 3-folds; x1FD-PRP, x3FD-PRP) by resolving FD-PRP to equal or 1/3 amount of water. We assessed the property changes of FD-PRP in gelation ability and also the release of growth factors (PDGF-BB, TGF-1 and VEGF) in vitro. We also examine the in vivo bone forming ability. PRPs (f-PRP, x1FD-PRP or x3FD-PRP) were mixed with -TCP granules and onlay-grafted on mice calvaria. After 4 weeks, the specimens were harvested and the new bone-formation is assessed histologically. Findings and conclusions: Each PRP (f-PRP, x1FD-PRP or x3FD-PRP) equally formed gel. In terms of growth factors release, x1FD-PRP released the identical concentrations of PDGF-BB and TGF-1 to f-PRP, while x3FD-PRP did approximately 3-fold concentrations of them to f-PRP. In vivo, x1FD-PRP promoted identical level of the bone formation to f-PRP, and x3FD-PRP induced more abundant bone formation. These results suggest that f-PRP can be stored without functional-loss by freeze-drying and the concentration of PRP may promote its validity on bone engineering. http://dx.doi.org/10.1016/j.ijom.2015.08.715 Free bone grafts for mandibular reconstruction in patients who have not received radiotherapy – the 6 cm rule – myth or reality B. Nandra 2,∗ , N. Uppal 2 , T. Martin 2 , P. Praveen 2 , T. Fattahi 1 , R. Fernandes 1 , S. Parmar 2 1
Department of Oral and Maxillofacial Surgery, University of Florida, Jacksonville, USA 2 Department of Oral and Maxillofacial Surgery, University Hospital Birmingham, England, UK
Background: Bony reconstruction of the mandible after surgical resection, results in improved rehabilitation and aesthetics. Free tissue transfer with bone has transformed reconstruction and particularly in patients who have received radiotherapy. However, there is a morbidity related to free tissue transfer as well as failure of free flaps. Free non-vascularized bone grafts have much lower morbidity. However, many surgeons feel that any mandibular defect greater than 6.0 cm are prone to failure1 and thus will only use free flaps in these defects. Methods: A retrospective study using theatre log books, case notes and radiographs was carried out of all the patients who had free bone grafts greater than 6.0 cm at University of Florida, Jacksonville and the Hospital Birmingham, United Kingdom. None of these patients received radiotherapy. Patents were assessed clinically and with standard radiographs. The patients were then planned for dental rehabilitation using dental implants. Findings: Six patients in Jacksonville and 8 patients in Birmingham, UK, were identified who had free bone grafts from the iliac crest for segmental defects greater then 6.0 cm over a 3 year period. All the bone grafts were successful, none infected and there was evidence of bony union. Conclusions: Contrary to the literature and many surgeons belief, our study has shown that long segmental mandibular defects are not a contraindication to the use of free bone grafts. The key principles are discussed.
Reference 1Foster, R., Pogrel, A., et al. (1999). Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction. Head Neck, 21(1).
http://dx.doi.org/10.1016/j.ijom.2015.08.716 Cervicopectoral rotational flap for cheek reconstruction: a case report and review of literature N.A. Ngah 1,∗ , W.M. Mustafa 2 1 2
Universiti Teknologi MARA, Shah Alam, Malaysia Oral Surgery Department, Kuala Lumpur Hospital, Malaysia
Restoration of full thickness cheek defect post-ablative cancer surgery can be challenge technically, functionally and cosmetically. Matching the colour, texture and hair-bearing characteristic to the surrounding skin are important aesthetics consideration. It is also utmost vital for psychological health of the patient. One on the simplest, unique and aesthetically pleasing option is the use of cervicopectoral rotational flap. In this case report, we seek awareness to expand its usefulness by discussing its versatility, modification, numerous advantages, complications and improvement of cervicopectoral rotational flap by retrieving the literature. We believe this flap is a complementary in restoring form, function and esthetics for full thickness cheek defect. A case of dual locoregional flap using the cervicopectoral rotational flap and temporalis myofascial flap to provide both inner and outer lining for full thickness cheek defects following ablative cancer surgery is discussed. http://dx.doi.org/10.1016/j.ijom.2015.08.717 Avascular necrosis of the midface secondary to disseminated intravascular coagulation E.V.A. Nguyen 1,∗ , A.A.C. Heggie 2 1
Monash Health, Melbourne, Victoria, Australia Oral and Maxillofacial Surgery Unit, Epworth Hospital, Richmond, Victoria, Australia
2
Avascular necrosis of the midface is a rare condition due to the rich vascular supply from bilateral branches of the external carotid artery. On mobilization of the maxilla during the Le Fort I downfracture, the hard and soft tissues remain well-perfused despite detachment of circum-vestibular vessels and, on occasion, loss of one or both of the contributions of the greater palatine arteries. The reliable perfusion of the maxilla during this procedure is well documented. The more commonly reported causes of osteonecrosis of the midface include orthognathic surgery, trauma, infection, bisphosphonates, and radiation. Disseminated intravascular coagulation (DIC) is also a rare condition that is characterized by the widespread pathological activation of the coagulation cascade, and can lead to ischaemic necrosis of tissues and, more seriously, ‘end-organ’ failure. DIC is commonly associated with major trauma, head injuries, infection, and obstetric complications. To the best of authors’ knowledge, avascular necrosis of the midface secondary to disseminated intravascular coagulation has yet to be described following a hypoxic syncopal episode secondary to ‘heat stroke’. A slow, progressive loss of anterior maxillary bone and the collapse of the nasal dorsum in a healthy
Oral Presentation young man with no other known medical co-morbidities led to the diagnosis. Following debridement, a staged reconstruction of the maxilla–nasal complex was successfully performed. The clinical presentation of this rare event and the approach to reconstruction of the patient’s maxillary and nasal complex are described. http://dx.doi.org/10.1016/j.ijom.2015.08.718 Multipaddled anterolateral thigh chimeric flap for reconstruction of complex defects in head and neck L. Ning ∗ , W. Liu, C. Jiang, F. Guo Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China Background: The anterolateral thigh flap has been the workhouse flap for coverage of soft-tissue defects in head and neck for decades. However, the reconstruction of multiple and complex soft-tissue defects in head and neck with multipaddled anterolateral thigh chimeric flaps is still a challenge. Objectives: In the present study, we aim to apply multipaddled anterolateral thigh chimeric flaps to reconstruct multiple and complex soft-tissue defects in head and neck, and access the reliability. Methods: Here, a clinical series of 12 cases is reported in which multipaddled anterolateral thigh chimeric flaps were used for complex soft-tissue defects with several separately anatomic locations in head and neck. Of the 12 cases, 7 patients presented with trismus were diagnosed as advanced buccal cancer with oral submucous fibrosis, 2 tongue cancer cases were found accompanied with multiple oral mucosa lesions or buccal cancer, and 3 were hypopharyngeal cancer with anterior neck skin invaded. Findings: All soft-tissue defects were reconstructed by multipaddled anterolateral thigh chimeric flaps, including 9 tripaddled anterolateral thigh flaps and 3 bipaddled flaps. The mean length of skin paddle was 19.2 (range: 14–23) cm and the mean width was 4.9 (range: 2.5–7) cm. All flaps survived and all donor sites were closed primarily. After a mean follow-up time of 9.1 months, there were no problems with the donor or recipient sites. Conclusions: This study supports that the multipaddled anterolateral thigh chimeric flap is a reliable and good alternative for complex and multiple soft-tissue defects of the head and neck. http://dx.doi.org/10.1016/j.ijom.2015.08.719 Platelet rich fibrin in the treatment of ONJ – outcome of surgical treatment of 15 consecutive patients S. Noerholt ∗ , H. Krogh Aarhus University Hospital, Aarhus, Denmark Background: Osteonecrosis of the jaws (ONJ) is a serious side effect to antiresorptive treatment (AR). Various treatment strategies are advocated, and it is recognized that refined techniques are necessary to obtain successful outcome. Platelet rich fibrin (PRF) promotes the healing process and may thus improve surgical outcome in ONJ patients. Objectives: To report the results of surgical treatment in 15 consecutive ONJ patients with use of PRF as part of the procedure. Methods: Surgery of ONJ was performed in 15 patients (11 females and 4 males). Age ranged from 54 to 83 years (mean 69). Eight patients had high-dose AR treatment because of skeletal involvement of malignancy; seven had low-dose AR for osteoporosis.
e117
Surgical treatment included resection of necrotic bone, mobilization of flaps for tension free closure and coverage of the bone with PRF membranes derived from 4 to 8 blood samples (of 10 ml) obtained immediately before surgery. Eleven lesions occurred in the mandible, three in the maxilla and one in both jaws. Minimum 4 months follow-up was performed. Findings: In 13 patients a complete mucosal coverage of the exposed bone was obtained. The remaining two patients had small areas of exposed bone without symptoms. Conclusions: Surgical treatment of ONJ is challenging with a risk of recurrence of bone exposure. Therefore, we have sought for means to improve the surgical procedure. In this series of cases a success rate of 87% was obtained. The use of PRF membranes appears to be a promising technique that warrants further investigation. http://dx.doi.org/10.1016/j.ijom.2015.08.720 Successful management of head and neck necrotizing fasciitis (case report) H. Nurahadi 1,∗ , H. Badeges 2 , V. Julia 1 1 2
Universitas Indonesia, Jakarta, Indonesia Persahabatan Hospital, Jakarta, Indonesia
Background: Necrotizing fasciitis, a serious infective process, causes extensive tissue damage, resulting in critical illness, high morbidity and mortality rate that require early diagnosis, radical debridement and broad spectrum antibiotics. Objectives: To present the clinical features, and successful surgical management of necrotizing fasciitis on the head and neck region. Case and management: 52 years old patient came to the Persahabatan Hospital Emergency Room, Jakarta with chief complaint of swelling on the left jaw, mouth opening limitation and difficulties on dietary intake for about a week before admission. He was diagnosed with left submandibular abscess and surgical drainage were performed to evacuate the pus. Afterward the wound became necrotized and extended aggressively to the lower neck region tissue within days. Radical surgical debridement was performed to eradicate the necrotic tissue and facilitate wound healing. Daily wound toilet were performed until epithelization occurred. Finally we performed Split Thickness Skin Graft procedure to close the open wound and the results were successful. Conclusion: This case report presents the successful surgical management of necrotizing fasciitis on head and neck area. The clinical features, differential diagnosis, treatment and prognosis are discussed. Wide surgical debridement is the successful management for the necrotizing fasciitis. http://dx.doi.org/10.1016/j.ijom.2015.08.721 Preoperative upper incisor crown length in Le Fort I osteotomies M. Oeckher 1,∗ , C. Czembirek 1 , E. Polska 1 , H. Stewart 2 , D. O’Rourke 2 , I. Watzke 1 1 Sozialmedizinisches Zentrum Ost – Department of Craniomaxillofacial and Oral Surgery, Vienna, Austria 2 Texas Center for Occlusal Studies, Flower Mound, Texas, USA
Background: Upper incisor crown length plays a crucial functional and esthetic role. It is commonly agreed upon to be around 11–12 mm for unworn teeth. When Le Fort I osteotomies are