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Secondary deformities following mandibular reconstruction
279
CURRENT LITERATURE Oral Lesions RA, Thomason
in Organ Transplant Patients. Seymour JM, Nolan A. J Oral Path01 Med 26:297, 1997
Organ transplantation, once considered an unpredictable treatment modality has now become a widely accepted highly successful life prolonging procedure. Improvements in surgical and tissue matching techniques have helped contribute to the increased success, but the primary factor is considered to be the advances in antirejection drug therapy. The drug induced immunosuppression in transplant patients presents a new challenge for oral medicinetreatment in the post-transplantation phase. The immunosuppressed state is the direct cause of the dental problems that arise in transplant patients, including, oral infections, hairy leukoplakia (HL) malignant changes, and gingival overgrowth. Transplant patients are highly susceptible to oral infections especially those of fungal or viral origin. Candida is the most frequently implicated fungal infection, while herpes simplex virus (HSV) or cytomegalovirus (CMV) are the primary viral infections in the transplant patient. More than 75% of transplant patients are seropositive to CMV and 50% to HSV and these viruses can be reactivated in the transplant patients immunosuppressed state causing an acute exacerbation. HL originally thought to be exclusively associated with human immunodeficiency virus patients has now been proven to be found in other chronically immunosuppressed patients. The pathogenesis of HL in transplant patients appears to be intimately associated with immunosuppression and the Epstein Barr virus. Furthermore, studies have shown increased development of malignant neoplasms in transplant patients including, lymphomas; skin and lip cancers; squamous carcinomas of the cervix, vulva and perineum; and kaposis sarcoma. The most striking feature of the malignancies in transplant patients is they occur on average 20 to 30 years earlier than in nonsuppressed individuals. As a result patients should be examined regularly every 6 months and any suspicious lesion biopsied. Probably the most common complication observed in transplant patients is gingival hyperplasia. Drug induced gingival hyperplasia is exemplified in approximately 30% of dentate patients on chronic Cyclosporine regimen. The life expectancy of transplant patients is increasing everyday, so much so, that knowledge of the immunosuppressed state and its sequelae has become imperative to the development of effective treatment and preventive strategies.-Roa DORIOT Reprints requests to Dr Seymour: Department of Restorative Dentistry, Dental School, University of Newcastle upon Tyne, Framington Place, Newcastle upon Tyne NE2 4BW, England.
Secondary Deformities Following struction. Miller MJ, Schusterman 24551, 1997
Mandibular ReconMS. Clin Plast Surg
Advances in primary mandibular reconstruction mean that few cancer patients today must choose between an uncontrolled cancer death and crippling deformities resulting from treatment. Deformities after mandibular reconstruction are classified as musculoskeletal or soft tissue, with varying degrees of defects in shape, position, stability, and function. Secondary mandibular deformity is best avoided by proper flap selection, shaping, and insetting during the primary reconstruction. Secondary revisions are difficult and hazardous, particularly in patients who have been irradiated before reconstruction. Secondary deformities may arise from structural instability that occurs from infection, osteoradionecrosis, nonunion, or fracture of the reconstruction
plate for cases in which hardware was used alone without bone replacement. Replacement of a lost dentition may be aided by vestibuloplasty procedures and the placement of osseointegrated implants. Temporomandibular dysfunction may be addressed with physical therapy. Facial nerve injuries are less likely if an attempt is not made to reconstruct the mandible above the ramus. Soft tissue deformities are the most difficult to manage. Intraoral lining, lip deformities, and external skin defects may require local flaps and various plasty techniques.-R.H. HAUG Reprint requests to Dr IMiller: Division of Plastic Surgery, ment of Surgery, The University of Texas, IMD Anderson Center, 15 15 Holcombe Blvd, Houston, TX 77030.
DepartCancer
Diclofenac and Indomethacin Influence the Healing of Normal and Ischaemic Incisional Wounds in Skin. Quirinia A. Viidik A. Stand J Plast Reconstr Hand Surg 31:213, 1997 Because very few studies exist reporting effects of nonsteroidal anti-inflammatory drugs (NSAIDS) on healing of skin wounds, the authors report on the effects of diclofenac and indomethacin on normal and ischaemic skin wounds in rats. The project evaluated the two NSAIDS effects on the healing strength of normal and ischaemic skin wounds during a 10 and 20 day postoperative course while using different doses of each medication in each subgroup. The study was composed of two major groups-a normal skin wound and an ischaemic group. Each group was further divided into two groups to evaluate healing at 10 and 20 days post operatively. These groups were subdivided into five subgroups related to dosage of NSAIDs and control. The five groups included rats with no treatment, two groups with high and low dose diclofenac, and two groups with high and low dose indomethacin. Treatments began one day preoperatively and continued for 9 days postoperatively. With regard to the ischaemic wounds, the NSAID’s appeared to decrease the extent of the superficial necrosis of the skin flaps. No significant changes occurred after 10 days, and strength parameters were decreased in 20 day wounds; however, these decreases were considered clinically insignificant. Healing in normal wounds did appear improved in the lower-dose NSAID population after 10 days of healing with regard to strength. After 20 days, the wounds were stiffer but strength parameters did not improve significantly ln the normal wound groups.-K. BENSON Reprint Biology,
requests to Dr Quirinia: Department of Connective University of Aarhus, DK-8000 Aarhus C, Denmark.
Failures of Zidovudine Postexposure chimsen EM. Am J Med 102(5B):52,1997
Prophylaxis.
Tissue
Jo-
Since 1988, the use of zidovudine (ZDV) for postexposure chemoprophylaxis after occupational exposure to human immunodeficiency virus (HIV) infected blood has become increasingly widespread. Although there is evidence that ZDV may be effective as a postexposure prophylaxis, 11 cases of failure have been reported since 1990. The median time to seroconversion was 53 days, most within 12 weeks, and all within 6 months. Five failures have occurred in non-health care workers. Each of these patients received direct inoculations or transfusions of HIV-infected blood. Proposed failure mechanisms include: exposure to strains of HIV with reduced sensitivity to ZDV, ZDV-resistant HIV, high titre in source fluid and/or large innoculum, and a delay in prophylaxis administration.-R.H. HALIG
CURRENT LITERATURE Oral Lesions RA, Thomason
in Organ Transplant Patients. Seymour JM, Nolan A. J Oral Path01 Med 26:297, 1997
Organ transplantation, once considered an unpredictable treatment modality has now become a widely accepted highly successful life prolonging procedure. Improvements in surgical and tissue matching techniques have helped contribute to the increased success, but the primary factor is considered to be the advances in antirejection drug therapy. The drug induced immunosuppression in transplant patients presents a new challenge for oral medicinetreatment in the post-transplantation phase. The immunosuppressed state is the direct cause of the dental problems that arise in transplant patients, including, oral infections, hairy leukoplakia (HL) malignant changes, and gingival overgrowth. Transplant patients are highly susceptible to oral infections especially those of fungal or viral origin. Candida is the most frequently implicated fungal infection, while herpes simplex virus (HSV) or cytomegalovirus (CMV) are the primary viral infections in the transplant patient. More than 75% of transplant patients are seropositive to CMV and 50% to HSV and these viruses can be reactivated in the transplant patients immunosuppressed state causing an acute exacerbation. HL originally thought to be exclusively associated with human immunodeficiency virus patients has now been proven to be found in other chronically immunosuppressed patients. The pathogenesis of HL in transplant patients appears to be intimately associated with immunosuppression and the Epstein Barr virus. Furthermore, studies have shown increased development of malignant neoplasms in transplant patients including, lymphomas; skin and lip cancers; squamous carcinomas of the cervix, vulva and perineum; and kaposis sarcoma. The most striking feature of the malignancies in transplant patients is they occur on average 20 to 30 years earlier than in nonsuppressed individuals. As a result patients should be examined regularly every 6 months and any suspicious lesion biopsied. Probably the most common complication observed in transplant patients is gingival hyperplasia. Drug induced gingival hyperplasia is exemplified in approximately 30% of dentate patients on chronic Cyclosporine regimen. The life expectancy of transplant patients is increasing everyday, so much so, that knowledge of the immunosuppressed state and its sequelae has become imperative to the development of effective treatment and preventive strategies.-Roa DORIOT Reprints requests to Dr Seymour: Department of Restorative Dentistry, Dental School, University of Newcastle upon Tyne, Framington Place, Newcastle upon Tyne NE2 4BW, England.
Secondary Deformities Following struction. Miller MJ, Schusterman 24551, 1997
Mandibular ReconMS. Clin Plast Surg
Advances in primary mandibular reconstruction mean that few cancer patients today must choose between an uncontrolled cancer death and crippling deformities resulting from treatment. Deformities after mandibular reconstruction are classified as musculoskeletal or soft tissue, with varying degrees of defects in shape, position, stability, and function. Secondary mandibular deformity is best avoided by proper flap selection, shaping, and insetting during the primary reconstruction. Secondary revisions are difficult and hazardous, particularly in patients who have been irradiated before reconstruction. Secondary deformities may arise from structural instability that occurs from infection, osteoradionecrosis, nonunion, or fracture of the reconstruction
plate for cases in which hardware was used alone without bone replacement. Replacement of a lost dentition may be aided by vestibuloplasty procedures and the placement of osseointegrated implants. Temporomandibular dysfunction may be addressed with physical therapy. Facial nerve injuries are less likely if an attempt is not made to reconstruct the mandible above the ramus. Soft tissue deformities are the most difficult to manage. Intraoral lining, lip deformities, and external skin defects may require local flaps and various plasty techniques.-R.H. HAUG Reprint requests to Dr IMiller: Division of Plastic Surgery, ment of Surgery, The University of Texas, IMD Anderson Center, 15 15 Holcombe Blvd, Houston, TX 77030.
DepartCancer
Diclofenac and Indomethacin Influence the Healing of Normal and Ischaemic Incisional Wounds in Skin. Quirinia A. Viidik A. Stand J Plast Reconstr Hand Surg 31:213, 1997 Because very few studies exist reporting effects of nonsteroidal anti-inflammatory drugs (NSAIDS) on healing of skin wounds, the authors report on the effects of diclofenac and indomethacin on normal and ischaemic skin wounds in rats. The project evaluated the two NSAIDS effects on the healing strength of normal and ischaemic skin wounds during a 10 and 20 day postoperative course while using different doses of each medication in each subgroup. The study was composed of two major groups-a normal skin wound and an ischaemic group. Each group was further divided into two groups to evaluate healing at 10 and 20 days post operatively. These groups were subdivided into five subgroups related to dosage of NSAIDs and control. The five groups included rats with no treatment, two groups with high and low dose diclofenac, and two groups with high and low dose indomethacin. Treatments began one day preoperatively and continued for 9 days postoperatively. With regard to the ischaemic wounds, the NSAID’s appeared to decrease the extent of the superficial necrosis of the skin flaps. No significant changes occurred after 10 days, and strength parameters were decreased in 20 day wounds; however, these decreases were considered clinically insignificant. Healing in normal wounds did appear improved in the lower-dose NSAID population after 10 days of healing with regard to strength. After 20 days, the wounds were stiffer but strength parameters did not improve significantly ln the normal wound groups.-K. BENSON Reprint Biology,
requests to Dr Quirinia: Department of Connective University of Aarhus, DK-8000 Aarhus C, Denmark.
Failures of Zidovudine Postexposure chimsen EM. Am J Med 102(5B):52,1997
Prophylaxis.
Tissue
Jo-
Since 1988, the use of zidovudine (ZDV) for postexposure chemoprophylaxis after occupational exposure to human immunodeficiency virus (HIV) infected blood has become increasingly widespread. Although there is evidence that ZDV may be effective as a postexposure prophylaxis, 11 cases of failure have been reported since 1990. The median time to seroconversion was 53 days, most within 12 weeks, and all within 6 months. Five failures have occurred in non-health care workers. Each of these patients received direct inoculations or transfusions of HIV-infected blood. Proposed failure mechanisms include: exposure to strains of HIV with reduced sensitivity to ZDV, ZDV-resistant HIV, high titre in source fluid and/or large innoculum, and a delay in prophylaxis administration.-R.H. HALIG