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The role of Pentoxifylline–Tocopherol–Clodronate (PENTOCLO) in osteoradionecrosis (ORN) of the mandible
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Abstracts / British Journal of Oral and Maxillofacial Surgery 53 (2015) e37–e110
PP 68 Management of large oroantral communications: use of temporal extension of buccal fat pad – our experience S.K. Hussain ∗ , K. Ganesan Southend Hospital, United Kingdom Aim and objectives: This study evaluates the effectiveness and success of using temporal extension of buccal fat pad for closure of oro-antral communications. It aims to describe the technique to reduce the morbidity associated with using the buccal extension of the buccal fat pad. Methods: 20 cases were done between September 2011 to October 2014. 19 were managed with a two layer approach using temporal extension of buccal fat pad with buccal advancement flap and one case where temporal extension of buccal fat pad was used on its own. Two of these cases had previously failed buccal advancement flaps. Results: All cases were followed up to assess for post-op complications such as wound dehiscence, necrosis, and infection. Complete epithelisation from adjacent mucosal regions in all cases were observed in 6–8 weeks with no complications. Conclusion: Temporal extension of buccal fat pad is a reliable and effective flap for repair of large oro-antral communications. It preserves the normal anatomical architecture of oral mucosa, and provides increased stability, versatility, tension free closure and is easy to harvest without any complications. Discussion: By using the temporal extension of buccal fat pad risk of damage to the parotid duct and the patient experiencing tightness around the cheek or dimpling on the face and facial asymmetry is eliminated. http://dx.doi.org/10.1016/j.bjoms.2015.08.076 P 69 Use of lone star retractor in surgical neck dissections S.K. Hussain ∗ , J. Siddiqi Basildon Hospital, United Kingdom Aim: To describe the technique of using lone star retractor in neck dissections. Objective: This article is to evaluate the effectiveness lone star retractor (Cooper Surgical, 95, Corporate Drive, Trumbull, CT 06611) in neck dissections. Method: Lone star single use retractor is a totally customisable self-retaining retractor with different types of stay hooks to obtain unobstructed anatomical visualisation during neck dissections. The adaptability of ring shape retractor helps to accommodate different types of surgical fields. The ability of malleable joints helps in its flexion and extension.
It also helps to lift skin up consistently which enables the surgeon to go under the incision. It quickly repositions to reveal additional layers as the surgery proceeds. It widens the surgical field and provides better visualisation. When retracting delicate tissue or more substantial structures, the retractor ring safely adapts to the site’s exact anatomy. Conclusion: The use of lone star retractor provides better and consistent visualisation of the surgical field. It reduces the need for additional pair of hands allowing juniors to concentrate in the surgery and reduces fatigue. As it is made of plastic, it is safe to use with mono polar diathermy unlike the metal retractors which conduct charge. The lone star retractor stays create less damage to the tissues than with other types of manual retraction. http://dx.doi.org/10.1016/j.bjoms.2015.08.077 P 70 The role of Pentoxifylline–Tocopherol–Clodronate (PENTOCLO) in osteoradionecrosis (ORN) of the mandible R. Kulkarni ∗ , J. Cymerman, K. Gilbert, A. Pick, M. Ho, D. Sutton, J. McCaul Royal Marsden and Northwick Park Hospitals, United Kingdom Introduction: Four hypotheses have been proposed for the pathogenesis of ORN and the most recent is the Fibroatrophic theory. The synergistic use of Pentoxifylline and Tocopherol are proposed to act as antifibrotic agents, facilitating conversion of myofibroblasts back to fibroblasts and affecting TNF␣ and TGF-1 signalling pathways to improve bone healing. Clodronate, a first generation non-nitrogenous bisphosphonate, has shown positive results when used in combination with Pentoxifylline and Tocopherol. This study analyses the progress of patients placed on Pentoxifylline and Tocopherol and patients where the third agent was added (PENTOCLO regime) for ORN. Methods: Patients diagnosed with ORN and treated with Pentoxifylline, Tocopherol and Clodronate over the past five years were selected. Case notes and imaging were rigorously reviewed. Patients were graded according to the Notani classification at presentation and any additional intervention or change in clinical status recorded as treatment progressed. Results: To date 31 patients with ORN of the mandible have commenced this therapy. Three could not tolerate therapy. Seven (23%) patients are on PENTOCLO with no adverse events to date. Seven patients treated with Tocopherol and Pentoxifylline alone have undergone ORN resolution. Four of these also had surgical debridement. Three patients had HBO as part of management. Of patients treated with PENTOCLO four have already shown signs of improvement.
Abstracts / British Journal of Oral and Maxillofacial Surgery 53 (2015) e37–e110
Conclusion: Tocopherol and Pentoxifylline is associated with reduction of ORN stage and the introduction of PENTOCLO in more severe cases of ORN may be beneficial. Further analysis in a pilot, feasibility randomized controlled trial is indicated. http://dx.doi.org/10.1016/j.bjoms.2015.08.078 PP 71 Flap observations – are they a waste of time? J. Lee ∗ , M. Coyle, M. Singh, D. Godden Gloucester Royal Hospital, United Kingdom Introduction: Reconstruction using free tissue transfer is integral to the management of surgical defects in the head and neck. Success of free tissue is dependent on continuous arterial inflow and venous outflow through patent microvascular anastomosis. Early recognition of vascular compromise is essential if salvage is to be successful. A 2007 survey reported that clinical monitoring is the only technique that is universally used to monitor flaps postoperatively. The aim of this study was to examine if clinical monitoring i.e. traditional flap observations had any effect on salvage outcomes. Materials and methods: A retrospective review of all patients who had free tissue transfer from 2005 to 2014 in whom there was a flap failure. Flap type, frequency of flap observations, time when flap observation suggested failure, time until patient returned to theatre, cause of failure and whether flap was salvaged were all recorded. Results: 8/263 (3%) patients were identified as having a flap failure. The time of flap observations suggesting failure ranged from 38 to 380 h (average 97.2). The time until return to theatre ranged from 1 to 32 h (average 12.1). Failure was noted to be arterial in 2 patients and venous in 7 patients. Salvage was unsuccessful in all cases. Conclusion: Despite work from other units that confirm a 75% flap salvage rate, at our unit we have been singularly unsuccessful in salvaging any flaps. This raises the question, are we not sensitive enough with observations alone in detecting flap failure and are flap observations therefore a waste of time? http://dx.doi.org/10.1016/j.bjoms.2015.08.079 P 72 Ameloblastic carcinoma of the mandible: report of a rare case D. McAuley ∗ , M. Paley, J. Morrison, B. Conn St John’s Hospital, Livingston, West Lothian, United Kingdom Introduction: Ameloblastic carcinoma is a rare malignant odontogenic neoplasm that tends to occur in the mandible rather than the maxilla. The World Health Organisation
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(WHO) 2005 have classified this carcinoma into two subtypes, primary and secondary. The former develops de novo and demonstrates malignancy in the primary tumour with characteristics of ameloblastoma and cytologic atypia. The secondary type exhibit malignant changes which develop in a previously existing ameloblastoma regardless of presence or absence of metastasis. Case: We present the case of an 18 year old male with biopsy proven ameloblastic carcinoma, secondary type (dedifferentiated), peripheral type of his right posterior mandible. The clinical, radiological and histological features are discussed. He was referred by his dentist with an ulcerated soft tissue lesion on his gingiva over his right posterior mandible and a suspected underlying cystic lesion which had not been present 4 years previously on orthopantogram, at the time of orthodontic assessment. Radiological investigations revealed no evidence of metastatic disease. As per WHO recommendations he underwent surgical resection with a wide margin, right level I–IV neck dissection and composite fibula flap reconstruction. The patient is now 8 months following surgery and follow up MRI scan at 6 months revealed no evidence of local or regional recurrence. He will be kept under long term follow up. Conclusion: Ameloblastic carcinoma is a rare odontogenic neoplasm but it should be included in the list of differential diagnosis of radiolucent lesions affecting the mandible, particularly when there is displacement of roots. http://dx.doi.org/10.1016/j.bjoms.2015.08.080 P 73 Surgical mission planning in the developing world F. McClenaghan ∗ , D. Martin, G. Smith, M. McGurk Hammersmith Hospital, United Kingdom Introduction: Surgical missions to the developing world have been criticised for their lack of outcome analysis. The few reported studies indicate a high rate of post-operative complications. Presented is an integrated pathway developed for surgical missions and its performance in action. Methods: Patients were optimised for surgery in a residential facility by a medical team from the UK for 14 days pre-operatively. They were then transferred to hospital for surgery and returned when stable. At the completion of the mission a junior doctor remained for 3 weeks to chart the patients’ progress. Results: 30 cases patients were treated over two weeks. The complication rate at three weeks post-operatively was 23% (7/30). 22 operations were classified as complex (over 1 h with more than one flap) and 8 simple (under 1 h with minimal flaps). Of the simple operations 25% (2/8) encountered complications at an average of 5 days post-operatively (3–7 days). Both complications were minor (patient discharge within a week of expectation). 23% (5/22) of complex operations encountered complications at an average of 8 days
Abstracts / British Journal of Oral and Maxillofacial Surgery 53 (2015) e37–e110
PP 68 Management of large oroantral communications: use of temporal extension of buccal fat pad – our experience S.K. Hussain ∗ , K. Ganesan Southend Hospital, United Kingdom Aim and objectives: This study evaluates the effectiveness and success of using temporal extension of buccal fat pad for closure of oro-antral communications. It aims to describe the technique to reduce the morbidity associated with using the buccal extension of the buccal fat pad. Methods: 20 cases were done between September 2011 to October 2014. 19 were managed with a two layer approach using temporal extension of buccal fat pad with buccal advancement flap and one case where temporal extension of buccal fat pad was used on its own. Two of these cases had previously failed buccal advancement flaps. Results: All cases were followed up to assess for post-op complications such as wound dehiscence, necrosis, and infection. Complete epithelisation from adjacent mucosal regions in all cases were observed in 6–8 weeks with no complications. Conclusion: Temporal extension of buccal fat pad is a reliable and effective flap for repair of large oro-antral communications. It preserves the normal anatomical architecture of oral mucosa, and provides increased stability, versatility, tension free closure and is easy to harvest without any complications. Discussion: By using the temporal extension of buccal fat pad risk of damage to the parotid duct and the patient experiencing tightness around the cheek or dimpling on the face and facial asymmetry is eliminated. http://dx.doi.org/10.1016/j.bjoms.2015.08.076 P 69 Use of lone star retractor in surgical neck dissections S.K. Hussain ∗ , J. Siddiqi Basildon Hospital, United Kingdom Aim: To describe the technique of using lone star retractor in neck dissections. Objective: This article is to evaluate the effectiveness lone star retractor (Cooper Surgical, 95, Corporate Drive, Trumbull, CT 06611) in neck dissections. Method: Lone star single use retractor is a totally customisable self-retaining retractor with different types of stay hooks to obtain unobstructed anatomical visualisation during neck dissections. The adaptability of ring shape retractor helps to accommodate different types of surgical fields. The ability of malleable joints helps in its flexion and extension.
It also helps to lift skin up consistently which enables the surgeon to go under the incision. It quickly repositions to reveal additional layers as the surgery proceeds. It widens the surgical field and provides better visualisation. When retracting delicate tissue or more substantial structures, the retractor ring safely adapts to the site’s exact anatomy. Conclusion: The use of lone star retractor provides better and consistent visualisation of the surgical field. It reduces the need for additional pair of hands allowing juniors to concentrate in the surgery and reduces fatigue. As it is made of plastic, it is safe to use with mono polar diathermy unlike the metal retractors which conduct charge. The lone star retractor stays create less damage to the tissues than with other types of manual retraction. http://dx.doi.org/10.1016/j.bjoms.2015.08.077 P 70 The role of Pentoxifylline–Tocopherol–Clodronate (PENTOCLO) in osteoradionecrosis (ORN) of the mandible R. Kulkarni ∗ , J. Cymerman, K. Gilbert, A. Pick, M. Ho, D. Sutton, J. McCaul Royal Marsden and Northwick Park Hospitals, United Kingdom Introduction: Four hypotheses have been proposed for the pathogenesis of ORN and the most recent is the Fibroatrophic theory. The synergistic use of Pentoxifylline and Tocopherol are proposed to act as antifibrotic agents, facilitating conversion of myofibroblasts back to fibroblasts and affecting TNF␣ and TGF-1 signalling pathways to improve bone healing. Clodronate, a first generation non-nitrogenous bisphosphonate, has shown positive results when used in combination with Pentoxifylline and Tocopherol. This study analyses the progress of patients placed on Pentoxifylline and Tocopherol and patients where the third agent was added (PENTOCLO regime) for ORN. Methods: Patients diagnosed with ORN and treated with Pentoxifylline, Tocopherol and Clodronate over the past five years were selected. Case notes and imaging were rigorously reviewed. Patients were graded according to the Notani classification at presentation and any additional intervention or change in clinical status recorded as treatment progressed. Results: To date 31 patients with ORN of the mandible have commenced this therapy. Three could not tolerate therapy. Seven (23%) patients are on PENTOCLO with no adverse events to date. Seven patients treated with Tocopherol and Pentoxifylline alone have undergone ORN resolution. Four of these also had surgical debridement. Three patients had HBO as part of management. Of patients treated with PENTOCLO four have already shown signs of improvement.
Abstracts / British Journal of Oral and Maxillofacial Surgery 53 (2015) e37–e110
Conclusion: Tocopherol and Pentoxifylline is associated with reduction of ORN stage and the introduction of PENTOCLO in more severe cases of ORN may be beneficial. Further analysis in a pilot, feasibility randomized controlled trial is indicated. http://dx.doi.org/10.1016/j.bjoms.2015.08.078 PP 71 Flap observations – are they a waste of time? J. Lee ∗ , M. Coyle, M. Singh, D. Godden Gloucester Royal Hospital, United Kingdom Introduction: Reconstruction using free tissue transfer is integral to the management of surgical defects in the head and neck. Success of free tissue is dependent on continuous arterial inflow and venous outflow through patent microvascular anastomosis. Early recognition of vascular compromise is essential if salvage is to be successful. A 2007 survey reported that clinical monitoring is the only technique that is universally used to monitor flaps postoperatively. The aim of this study was to examine if clinical monitoring i.e. traditional flap observations had any effect on salvage outcomes. Materials and methods: A retrospective review of all patients who had free tissue transfer from 2005 to 2014 in whom there was a flap failure. Flap type, frequency of flap observations, time when flap observation suggested failure, time until patient returned to theatre, cause of failure and whether flap was salvaged were all recorded. Results: 8/263 (3%) patients were identified as having a flap failure. The time of flap observations suggesting failure ranged from 38 to 380 h (average 97.2). The time until return to theatre ranged from 1 to 32 h (average 12.1). Failure was noted to be arterial in 2 patients and venous in 7 patients. Salvage was unsuccessful in all cases. Conclusion: Despite work from other units that confirm a 75% flap salvage rate, at our unit we have been singularly unsuccessful in salvaging any flaps. This raises the question, are we not sensitive enough with observations alone in detecting flap failure and are flap observations therefore a waste of time? http://dx.doi.org/10.1016/j.bjoms.2015.08.079 P 72 Ameloblastic carcinoma of the mandible: report of a rare case D. McAuley ∗ , M. Paley, J. Morrison, B. Conn St John’s Hospital, Livingston, West Lothian, United Kingdom Introduction: Ameloblastic carcinoma is a rare malignant odontogenic neoplasm that tends to occur in the mandible rather than the maxilla. The World Health Organisation
e63
(WHO) 2005 have classified this carcinoma into two subtypes, primary and secondary. The former develops de novo and demonstrates malignancy in the primary tumour with characteristics of ameloblastoma and cytologic atypia. The secondary type exhibit malignant changes which develop in a previously existing ameloblastoma regardless of presence or absence of metastasis. Case: We present the case of an 18 year old male with biopsy proven ameloblastic carcinoma, secondary type (dedifferentiated), peripheral type of his right posterior mandible. The clinical, radiological and histological features are discussed. He was referred by his dentist with an ulcerated soft tissue lesion on his gingiva over his right posterior mandible and a suspected underlying cystic lesion which had not been present 4 years previously on orthopantogram, at the time of orthodontic assessment. Radiological investigations revealed no evidence of metastatic disease. As per WHO recommendations he underwent surgical resection with a wide margin, right level I–IV neck dissection and composite fibula flap reconstruction. The patient is now 8 months following surgery and follow up MRI scan at 6 months revealed no evidence of local or regional recurrence. He will be kept under long term follow up. Conclusion: Ameloblastic carcinoma is a rare odontogenic neoplasm but it should be included in the list of differential diagnosis of radiolucent lesions affecting the mandible, particularly when there is displacement of roots. http://dx.doi.org/10.1016/j.bjoms.2015.08.080 P 73 Surgical mission planning in the developing world F. McClenaghan ∗ , D. Martin, G. Smith, M. McGurk Hammersmith Hospital, United Kingdom Introduction: Surgical missions to the developing world have been criticised for their lack of outcome analysis. The few reported studies indicate a high rate of post-operative complications. Presented is an integrated pathway developed for surgical missions and its performance in action. Methods: Patients were optimised for surgery in a residential facility by a medical team from the UK for 14 days pre-operatively. They were then transferred to hospital for surgery and returned when stable. At the completion of the mission a junior doctor remained for 3 weeks to chart the patients’ progress. Results: 30 cases patients were treated over two weeks. The complication rate at three weeks post-operatively was 23% (7/30). 22 operations were classified as complex (over 1 h with more than one flap) and 8 simple (under 1 h with minimal flaps). Of the simple operations 25% (2/8) encountered complications at an average of 5 days post-operatively (3–7 days). Both complications were minor (patient discharge within a week of expectation). 23% (5/22) of complex operations encountered complications at an average of 8 days