Diagnosis and treatment planning for the surgical-orthodontic patient

J Oral Maxillofac 49212216,

Surg

1991

Abstracts defined but yet multifocal. Those of greater than 8 mm in diameter are accompanied by a very significant likelihood of nodal metastasis. Marginal mandibulectomy together with a wide resection is indicated if there is encroachment onto the periosteum. Extension to the tongue or gingiva will obviously leave the patient with a significant cosmetic and functional disability. Five-year cure rates for stage III and IV lesions were 66% and 32%, respectively. Cancer of the lip is initially superficial and slow growing which if left unattended will grow to a massive, ulcerative, destructive lesion with fatal outcome. Resections that involve up to one third of the lip can be closed primarily. Neck node metastasis was noted in less than 10% of the patients. Stage I S-year survival was 94%. Stage IV 5-year survival was 50%. Patients that were seen with recurrence were successfully reexcised in 75% of patients. Cheek lesions are predominantly tumors of elderly men. the bulk of which were not diagnosed until they were stage II or III lesions. Thirty-eight per cent had positive cervical nodes and complete removal required reconstruction with distant free flaps with microvascular anastomosis. Cancer of gingiva is unusual in a patient prior to age 50. Fifty per cent of the patients with gingiva or retromolar trigone lesions admitted to smoking and alcohol consumption. With surgical resection and immediate appropriate reconstruction, 77% of patients with stage I lesions had 5-year survival as did twenty-four percent of patients with stage IV lesions. Cancer in the area of the hard palate will give rise to a varied spectrum of neoplastic lesions. Seventy-one per cent of cases showed tumor extending beyond the palate and 29% having lymph node metastasis. In evaluating hard-palate lesions, it is imperative to assure that the primary is on the palate rather than within the antrum or nasal cavity. Anything but the smallest, most superficial lesion will require through and through excision of the palate. Reconstruction is rarely indicated because of the acceptability and quality of maxillofacial prosthetic replacements. The predominance of minor salivary gland tumors showed only 15 months of disease-free survival and only 5% of the patients showed IO-year survival. Combined surgical and radiotherapy was used in an attempt to maximize local and region control. If treatment of oral cancer is aimed at small and localized lesions, 70% of the patients can be cured. Thus, it is imperative to recognize the precursor of early oral cancers and institute immediate proper treatmerit.-E.L. MOSBY

Surgical Management of Oral Cancer. Strong E. Dent Clin North Am 34:185, 1990 Oral cancer constitutes 4% of cancers in men and 2% of the cancers in women. Almost 22,OOOnew cases were reported in 1989, and an estimated 4,650 deaths occurred. The prognosis is directly related to the stage of the disease when it is treated. Early oral cancer is eminently curable, but is asymptomatic and frequently unrecognized. The likelihood of regional lymph node metastasis varies from site to site, but generally increases with the size and thickness of the lesion. If spread occurs the overall prognosis can be reduced by 50%. With distant metastasis, almost universally fatal results occur. The 1988 version of the TNM staging is presented and accepted worldwide. The overwhelming portion of cancer in the oral cavity is squamous cell carcinoma (90% to 95%). The goal of surgery is the complete removal with preservation of uninvolved structures whenever possible without compromise of the adequacy of the resection. Single modality treatment is usually adequate for T, and T, lesions. The role of chemotherapy is under intense study. If a mandibulotomy is used to facilitate surgical access, the two bone ends should be reapproximated and stabilized with bone plates and screws. Resection of a portion of the mandible for access is no longer justified. To ascertain if there is bony involvement, computed tomography scans are probably the most accurate. Marginal resection of the mandible in selected patients is as effective in achieving local tumor control as is segmental mandibulectomy, with less of a cosmetic and functional defect. However, segmental mandibulectomy may be indicated in extensive cases. Neck dissections are indicated for the adequate resection of involved lymph nodes with or without continuity. Neck dissections in a clinically negative neck is controversial. The so-called supraomohyoid neck dissection is a satisfactory way of adequately sampling lymph nodes considered at risk and significantly decreases the morbidity of a neck dissection. Definitive reconstruction should be performed whenever possible as part of the ablative procedure. Myocutaneous flaps and the use of reconstruction bone plate systems are increasingly being employed. Aggressive reconstruction for the very elderly and emotionally and intellectually compromised patient should be limited. Tongue lesions are the most common oral primary lesion, and there appears to be a significant increase in the incidence of tongue cancer in patients under 40. Most involve the lateral borders or ventral aspects. Dorsum and midline lesions are rare. Metastasis to regional lymph nodes were noted in 35% of patients. Surgical management of tongue cancer is dictated by the extent of the disease and the more extensive is the involvement, the more significant the functional sequelae. There is a greater likelihood of lymph node metastasis in tongue cancer than in mouth cancer, so elective neck treatment may be indicated. In most T, lesions and in all T, and T4 lesions, single modality treatment is probably inappropriate and inadequate in tongue lesions. Only 31% of stage III and IV lesions survived 5 years. Cancer of the floor of the mouth is the second most common oral lesion, most of these occurring in the anterior half. They are often ill

Reprint requests to Dr Strong: Head and Neck Service, Memorial Sloan-Kettering Cancer Center, 1275York Ave. New York, NY 10021-6007. Diagnosis and Treatment Planning for the SurgicalOrthodontic Patient. Vig KD, Ellis E III. Dent Clin North Am 34:361, 1990 Dentofacial deformities effect approximately 5% of the US population. The age of the patient will influence both the diagnosis and treatment planning. Orthodontic treatment is intended to level and align the teeth on the dental arches; the surgical correction is aimed at the skeletal

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CURRENT LITERATURE

component, relocating the skeletal bases, and thereby achieving a more ideal occlusion by combination of orthodontics and surgery, provided the surgeon and orthodontist collaborate closely in the diagnosis and treatment planning of these patients. It should be understood that surgery compliments, but does not eliminate, the need for orthodontic treatment. After taking a comprehensive medical and dental history, an extraoral and intraoral clinical examination are done. Then necessary radiographs, photographs, and study casts are obtained. Demographic data and documentation of the patient’s chief concerns are crucial. Treatment should not be initiated until the patient has been fully informed of both the treatment options and expected outcomes. The clinical examination should include evaluation of the face, the intraoral structures, a functional analysis of the dynamic aspects of jaw movement, and facial balance. Analysis of the facial profile should include evaluation of both the right and left sides, especially if asymmetry is present. Vertical facial balance refers to arbitrary divisions of the face in equal thirds: the upper face (hairline to glabella), the middle face (eyebrows to subnasale), and the lower face (subnasale to menton). Transverse facial symmetry is a comparison of the right to the left side of the face, and, again, is most easily achieved by dividing the face into equal thirds after having established a midfacial plane. It is important, from the clinical examination and evaluation, to recognize and make plans for treating any pathological condition that is encountered or that manifests as asymmetry. In assessing the face, the nose, the mouth, and chin, it should be noted that these are important midline features, and asymmetries such as unequal height deviation or abnormal or unequal width are noted. The profile provides two dimensional vertical and sagittal information. When combined with the frontal evaluation, three-dimensional information is then available. Diagnosis of conditions that may require dental fillings or restorative procedures, or periodontal procedures should be part of the evaluation. It should also be noted that patients who have dentofacial deformities may also have temporomandibular joint (TMJ) disorders, and clinicians should thoroughly document the function of the masticatory apparatus prior to treatment, both subjectively and objectively, and should document symptoms of temporomandibular disorders as well as signs of dysfunction. The radiographic examination should include a lateral and anterior cephalogram, as well as a panoramic view of the jaws. If other abnormalities are detected, specific radiographs may be requested as needed for complete diagnosis and treatment planning of these abnormalities. Once the examination has been completed, a problem list, with possible solutions, should be prioritized so that the most severe problems and the chiefs concerns of the patient are addressed prior to lesser problems. Consultations should be arranged as necessary. Medical and or systemic problems, and any pathology, should be under control prior to the elective surgery and orthodontic treatment. The practitioner must be aware that not every problem on the list must have an active solution. The practitioner should also note that functional problems, such as internal derangements of the TMJ and/or hypomobility may be the main concern of the patient. If this is the patient’s only concern, it would be important to inform the patient that correction of the dentofacial deformity may not improve the TMJ disorder. Usually, more than one treatment plan is feasible, and the options for comprehensive care should range from relatively simple treatment to a complex de-

finitive treatment plan to correct all components of the dentofacial deformity and address the concerns of the patient. Cephalometric prediction tracings demonstrate the planned dental and skeletal movements and how they will affect the soft-tissue balance and harmony of the face. Orthodontics prior to surgical intervention is usually necessary to align the dental arches and eliminate crowding and dental compensations. This may create a worse malocclusion, as compensations for the skeletal discrepancy are removed and the teeth placed in an ideal position. The surgical correction is undertaken when the dental casts can be articulated into a compatible occlusal relationship. This may necessitate segmental osteotomies. A postsurgical phase of orthodontics is commenced when adequate bony healing and function have occurred. Care should be taken in the growing individual not to predict the final amount or direction of growth by overcorrection surgically. Retention after surgery and orthodontic correction is similar to other orthodontic patients. Secondary surgical procedures, such as rhinoplasty, may be performed during this retention phase. The sequence of treatment procedures should follow logical steps which should be explained carefully to the patient by both the surgeon and orthodontist.-E.L. MOSBY Reprint requests to Dr Vig: Department of Orthodontics and Pediatric Dentistry, University of Michigan School of Dentistry, Ann Arbor, MI 48109-1078.

Late Management of Secondarily Grafted Clefts. Stoelinga PJW, Haers PEJJ, Leenen KJ, et al. Int J Oral Maxillofac Surg 19:97, 1990 This article describes the long-term results of secondary bone grafting of clefts to guide the lateral incisors or canines into occlusion. Thirty-four patients (40 clefts) received alveolopalatal bone grafts for closure of the residual cleft. Selected presurgical treatment was limited to alignment of teeth to improve cleft access. No orthodontic expansion was done. In 14 (41%) of the patients, uninterrupted arches with a normal relationship was achieved by orthodontic means alone. Thirteen (38%) of the patients required segmental osteotomies to eliminate the edentulous space, and only seven (20%) of the cases needed bridges. Le Fort I advancement osteotomies were performed in nine patients who developed maxillary hypoplasia despite optimal orthodontic treatment. Segmental osteotomies to advance the minor fragment to correct transverse collapse and improve alar base support are discussed. This should be considered when orthodontic treatment alone will not lead to a satisfactory result. A complete archform without bridges or removable prostheses should be achievable in every cleft patient. A rational orthodontic-surgical approach is suggested with respect to nasomaxillary growth and development-J.A. LINDHOUT Reprint requests to Dr Stoelinga: Department of Oral and Maxillofacial Surgery, Rijnstate Ziekenhuis (Municipal Hospital), Arnhem, The Netherlands.

The Effect of Hydroxyapatite Coating on Bone Growth into Porous Titanium Alloy Implants. Oonishi H, Yamamoto M, Ishimaru H, et al. J Bone Joint Surg 71:213. 1989 These authors present the results of a study in which test implants with a porous surface of two layers of Ti-