The scope of computerized simulation in competency-based maxillofacial training: a systematic review

Oral and maxillofacial surgery (OMS) teaching is set to undergo a paradigm shift towards competency-based training. With increasing focus on resident skill development and patient safety, computerized simulators are likely to play a more mainstream role in OMS training. A systematic review of the available literature was conducted, in accordance with the PRISMA guidelines, to highlight the scope of computerized simulation in OMS teaching. A PubMed search was performed by two independent reviewers, and 35 articles published in English between 2010 and 2021 that reported the use of computerized simulation for teaching maxillofacial procedures were included in the analysis. Eight articles on minor oral surgery, seven on orthognathic surgery, five on maxillofacial trauma, five on cleft lip and palate surgery, three articles each on nerve block techniques, endoscopic procedures, and reconstructive surgery, and one article on fibre-optic intubation reported the use of computerized simulation that can be applied to OMS training. Ten randomized controlled trials were identified in the search. However there was marked heterogeneity among the studies. Simulator training for skill acquisition mentored by an expert OMS educator could offer holistic resident training; however more studies that test common themes of resident training such as knowledge acquisition and skill development are necessary.     

Scientometric evaluation of endodontic publications by Gulf Cooperation Council region in 21st century

ObjectivesThe appraisal of research productivity is one of the key indicators to evaluate any area of knowledge. The current study aimed to analyze the Scopus-indexed publications on endodontics produced by Gulf Cooperation Council (GCC) region from 2000 to 2020.MethodologyThe dataset was extracted in May 2021 from Elsevier’s Scopus database. Two keywords (“endodontic” and “endodontics”) were entered into the basic search with the Boolean operator of OR for a period of 20 years from 2000 to 2020.ResultsOverall, the GCC region contributed 2.82% of the global endodontic research. This share has shown a remarkable increase between 2001 and 2020 from 0.82% to 7.20%. About 60% of documents’ volumes were produced during the 2016–2020 period. Around 80% of research was produced by Saudi Arabia, while research articles produced by Kuwait gained the highest citation impact. Out of the ten productive institutions, nine belonged to Saudi Arabia and one was from Kuwait. The majority of research collaboration was conducted with the United States, but research articles produced in collaboration with Japan yielded the highest citation impact.ConclusionThe study highlighted various scientometric attributes of endodontic publications produced by GCC affiliated researchers. The ongoing growth of endodontic literature by GCC countries along with the increasing international collaboration is considered aspiring.     

Single-step surgical treatment of odontogenic maxillary sinusitis: A retrospective study of 98 cases

PurposeThe aim of this study was to review clinical and radiological presentation, surgery, and results of treatment in patients with chronic odontogenic maxillary sinusitis (OMS) treated with a single surgical procedure, including endoscopic sinus surgery (ESS) and oral surgical approaches to treat the odontogenic source of infection.Materials and methodsA retrospective case series analysis of 98 patients was performed. All the patients received ESS. 88 patients required oral surgical approaches.ResultsNasal symptoms were present in 58 patients (59.2%). Nasal endoscopy was positive in 65 patients (66.3%). A positive nasal endoscopy was significantly associated with nasal symptoms (p < 0.05). 60 patients (61.2%) had OMS of iatrogenic origin. Total opacification of the maxillary sinus was the most common radiological presentation (74.5%) and was significantly associated with nasal symptoms (p < 0.05). 91 patients (92.9%) had complete clinical and radiological resolution of the OMS.ConclusionsIatrogenic origin, sinonasal symptoms and positive clinical endoscopy are common in patients with OMS. Nasal symptoms were significantly associated with total maxillary sinus opacification and positive endoscopic clinical examination. Combining treatment of the odontogenic source of infection via an oral surgical approach and of the sinus inflammation by ESS appears to be sufficient for successfully treating patients with OMS.     

Integration of the medical degree in oral and maxillofacial surgery: A 10-year follow-up

PURPOSE: Ten years ago, the American Association of Oral and Maxillofacial Surgeons membership was surveyed to evaluate the influence that integration of a medical degree might have on oral and maxillofacial training. The intent of the current survey was to reassess the influence a medical degree has had on the specialty over the past 10 years. PATIENTS AND METHODS: The effects of a medical degree on privileges, referral patterns, and its role in the office, hospital, and academic settings were studied. Biographical data was collected and responses were evaluated for the following groups: 1) the nation as a whole, 2) MD versus non-MD oral and maxillofacial surgeons (OMS), 3) geographic regions of practice, 4) population, 5) number of years in practice, and 6) involvement in academic programs. RESULTS: The results of this survey were similar to the previous one. Substantially different responses were seen between the dual-degree and single-degree OMS as well as differences between geographic locations, years in practice, and academic involvement. MD-DDS and academic OMS again possessed a broader spectrum of privileges than their colleagues. Recently trained OMS again possessed a greater number of privileges than more experienced surgeons. CONCLUSION: Overall there has been a trend toward increasing surgical privileges over the past 10 years for both single- and dual-degree OMS. The results presented emphasize the need to continually assess the influence that a medical degree has on the specialty.     

Cervical necrotizing fasciitis of odontogenic origin: A report of 11 cases

PURPOSE: Although most cases of cervical necrotizing fasciitis (CNF) are odontogenic in origin, reports of this disease in the dental literature are sparse. The purpose of this study was to review the cases treated on our service, and to analyze the features of this disease and the responses to management, to supplement the understanding of this relatively rare and life-threatening disease. PATIENTS AND METHODS: All cases of infection admitted to the OMS service in a period of 10.5 years were studied retrospectively. The diagnosis of CNF was established by the findings on surgical exploration and histologic examination. The patients' age, sex, medical status, causes of the infection, bacteriology, computed tomography scan findings, surgical interventions, complications, survival, and other clinical parameters were reviewed. RESULTS: A total of 422 cases of infection were admitted, and 11 cases of cervical necrotizing fasciitis were found. The incidence of CNF was 2.6% among the infections hospitalized on the OMS service. There were 7 male and 4 female patients. Eight patients were older than 60 years of age. Seven patients had immunocompromising conditions, including diabetes mellitus in 4, concurrent administration of steroid in 2, uremia in 1, and a thymus carcinoma in 1. All patients showed parapharyngeal space involvement; four also showed retropharyngeal space involvement. Gas was found in the computed tomography scan in 6 patients, extending to cranial base in 3 of them. Anaerobes were isolated in 73% of the infections, whereas Streptococcus species were uniformly present. All patients received 1 or more debridements. Major complications occurred in 4 patients, including mediastinitis in 4, septic shock in 2, lung empyema in 1, pleural effusion in 2, and pericardial effusion in 1. All major complications developed in the immunocompromised patients, leading to 2 deaths. CONCLUSION: The mortality rate in this study was 18%. Early surgical debridement, intensive medical care, and a multidisciplinary approach are advocated in the management of CNF.     

53例牙源性上颌窦炎功能性治疗和疗效评价

目的: 分析牙源性上颌窦炎治疗方法并评价其疗效,为临床诊治提供参考。方法: 回顾2011年1月—2020年12月于上海交通大学医学院附属第九人民医院就诊的53例牙源性上颌窦炎(odontogenic maxillary sinusitis, OMS)患者的临床资料。采用去除各种牙源性病灶、保存窦黏膜和牙槽骨的功能性手术治疗OMS。应用Lund-Mackay评分法定量评价手术前、后上颌窦炎,采用SPSS 17.0软件包中的配对t检验比较手术前、后Lund-Mackay均值差异。另外,评估术后反应及术后并发症情况。结果: OMS常见病因为牙源性囊性病变 (49.05%)、根尖炎 (20.75%)、口腔-上颌窦瘘(16.98%) 和异物 (13.21%)。功能性手术后患者上颌窦炎恢复明显,Lund-Mackay评分术前为3.72±0.51,术后为0.05±0.32,评分显著下降 (P<0.001)。术后反应小,无严重并发症发生。结论: 治疗OMS应着重处理牙源性病灶,行功能性手术,保护上颌窦黏膜。     

Orofacial clefts in low- and middle-income countries: A scoping review of quality and quantity of research based on literature between 2010-2019

This paper assesses the research literature on OFC in LMIC over the last decade across various geographical settings and project focus of the indexed literature. A scoping review of the indexed literature was performed using a set of predefined keywords. The articles were filtered by a ten-year time frame (2010-2019) and a strict inclusive-exclusive criterion. Two authors screened the titles/abstracts/full text of the final included papers and input the desired data (year of publication, type of publication, geographical country/region and project focus to a coded spreadsheet). Six hundred and twenty publications were inventoried from the indexed literature on OFC in LMIC settings over the 10-year period. Five hundred and eighty-three derived from single LMIC countries and 37 from multi-settings. More than half of the articles were reported from Asia (57%), then from Americas (22.8%), Africa (15.4%) and the rest from cross-regional, Europe and Oceania (4.9%). The top 3 LMIC contributors towards OFC publications were China (21.5%), Brazil (13.1%) and India (11.6%). The most discussed OFC project themes were prevalence, surgical repair, aetiology and genetics. This study helps OFC researchers, humanitarian missions and research grant funders to identify gaps in the literature on issues impacting on children and adults born with OFC, in which issues were subjected to research and which were less explored in which LMIC regions. In addition, this study offers recommendations for established OFC researchers and international research bodies to identify areas of deficiency in the literature and what information is required to support LMIC governments achieve SDGs by 2030.     

21st century gender trends of authorship in the British Journal of Oral and Maxillofacial Surgery

Despite forming the majority in undergraduate medicine and dentistry programmes, females remain under-represented in all surgical specialties, including oral and maxillofacial surgery (OMFS). Efforts are ongoing to promote female uptake in surgery. Research output is a key metric in measuring leadership and academic advancement within a specialty. The aim of this study was to assess female authorship in research published in the British Journal of Oral and Maxillofacial Surgery from 2000-2020 with a retrospective cohort study of original articles and reviews published in the journal from five different volumes of the journal (2000, 2005, 2010, 2015, 2020 as representative time points). The gender of the first and last authors were assessed for gender by first name recognition and verified with a web-search of the author using their stated institutional affiliation when this was not clear. Articles were excluded if the gender of one of the first or last author could not be determined. A total of 501 articles were included with the gender of 1002 authors analysed. 173 (17.3%) authors were female, and 828 (82.7%) were male. The most common author combination was male-male (70.3%) and the least common female-female (4.8%). The proportion of female authors increased over time from 9.3% in 2000 to 23.4% in 2020. Females remain under-represented within surgery, but female presence in academic output is increasing at a similar rate to the numbers of female uptake in the clinical workforce which is a promising sign and indicative of progress towards gender parity.     

Effectiveness and safety of botulinum toxin in comparison with surgery for drooling in paediatric patients with neurological disorders: a systematic review

Different therapeutic methods for chronic drooling in paediatric patients with neurological problems have been described in the scientific literature. However, there is no consensus on the ideal strategy of treatment. The aim of this study was to compare botulinum toxin injection therapy and surgical modalities to control drooling in paediatric patients with neurological disorders. A systematic literature search was conducted on nine electronic databases for publications until April 2020. Six articles were included with a total sample of 209 patients, 67.4% (n = 141) of whom had cerebral palsy. All studies used injections of botulinum toxin type A with application to the submandibular and/or parotid salivary glands. The surgical treatments were duct ligation in the parotid and/or submandibular salivary glands, duct relocation in the submandibular salivary glands, and glandular excision of the submandibular and sublingual salivary glands. There were complications in only 16.1% (n = 27) of the sample (11 cases due to botulinum toxin application and 16 due to surgery). Drooling control was assessed by objective and subjective measures. Although surgical procedures presented a higher risk of adverse effects than botulinum toxin type A in all the studies and measurements performed, they presented larger and longer-lasting positive effects on drooling. We suggest bilateral submandibular duct relocation with bilateral sublingual gland excision or isolated bilateral submandibular duct ligation, which were the surgical techniques with the largest samples in this review. Nevertheless, further studies are necessary to compare samples with botulinum toxin type A and surgical treatment.     

Periodontal disease and quality of life: Umbrella review of systematic reviews

This umbrella review appraised existing systematic reviews and meta‐analysis to establish the impact of periodontal disease and therapy on general and oral health‐related quality of life. A systematic electronic literature search was carried out in accordance with the PRISMA guideline up to January 2020 using PubMed, LIVIVO, EMBASE and OpenGrey (PROSPERO CRD 42020163831). Hand searching was performed through the reference lists of periodontal textbooks and related journals. All English language‐based systematic reviews and meta‐analysis that assessed the impact of periodontal disease and treatment interventions on general and oral health‐related quality of life were included. Overall, eight articles met the inclusion criteria and their methodological quality was assessed using the AMSTAR2 criteria. Two systematic reviews showed a significant impact of oral conditions on general health‐related quality of life, although the specific impact of periodontal disease remains inconclusive. Three systematic reviews established a negative impact of periodontal disease on oral health‐related quality of life. Another three systematic reviews concluded that periodontal treatment can improve oral health‐related quality of life. Oral conditions, like periodontal disease, can impact the general health‐related quality of life. Periodontal disease is negatively correlated with oral health‐related quality of life, although treatment interventions can improve self‐reported quality of life. In view of the heterogeneity of generic instruments currently utilized to assess the self‐reported quality of life of periodontal patients, the development of a general and oral health‐related quality of life instrument specific for periodontal disease is strongly recommended.     

Reporting of ethical protection in recent oral and maxillofacial surgery research involving human subjects

This retrospective observational study investigated the frequency of reporting ethical approval and informed consent in recently published oral and maxillofacial surgery (OMS) research involving human subjects. All research involving human subjects published in the International Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, and Journal of Cranio-Maxillofacial Surgery during January to June 2005–2007 were analysed for disclosure of ethical approval by a local ethical committee and obtaining informed consent from the subjects. 534 articles were identified; ethical approval was documented in 118 (22%) and individual patient consent in 135 (25%). 355 reports (67%) did not include a statement on ethical approval or informed consent and only 74 reports (14%) disclosed statements of both. Ethical documentation in retrospective and observational studies was scant; 12% of randomised controlled trials and 38% of non-random trials did not report both of ethical protections. Most recent OMS publications involving humans failed to mention ethical review or subjects’ consent. Authors must adhere to the international research ethics guidelines and journal instructions, while editors should play a gatekeeper role to protect research participants, uphold scientific integrity and maintain public trust in the experimental process and OMS profession.     

Systematic review of the software used for virtual surgical planning in craniomaxillofacial surgery over the last decade

Craniomaxillofacial surgery has been experiencing a deep conceptual change in surgical planning over the last decade, with virtual reality technologies becoming widely adopted. The high demand has led to an exponential increase in available software. The aim of this review was to outline the current literature and provide evidence on the most used software for virtual surgical planning (VSP), and also to define contemporary knowledge on which procedures are more ready candidates for VSP. A search was performed in the major databases, and screening of the results according to the PRISMA statement identified 535 articles reporting the implementation of preoperative VSP during the years 2010–2020. A total of 77 different software programs were identified. The surgical procedures were assigned a standardized nomenclature and further simplified into 10 categories for analysis: temporomandibular joint (TMJ), implants (IMPL), malformations (MALF), reconstruction (REC), oncology (ONCO), oral surgery (ORAL), orthognathic surgery (ORTH), cranial surgery (CRANIO), trauma (TRAUMA), miscellaneous (OTHER). The journals they were reported in and the sample size of each study were also investigated. The results showed that the Materialise suite was the most widespread tool for VSP, with a prevalence of 36.3%, followed by the Geomagic family. Several packages were found to be associated with a specific type of surgical procedure. This review offers a synopsis of the array of VSP software reported in the literature and sets the basis for an informed, evidence-based use of this software in craniomaxillofacial surgery.     

牙源性上颌窦炎病因及诊断

牙源性上颌窦炎（OMS）是由牙源性感染和牙科手术等引起,多为单侧上颌窦炎,伴有鼻腔异味或有异常分泌物流出,且对传统上颌窦炎症治疗无效的一类疾病。认清上颌窦炎症的牙源性因素十分重要,如果仅仅治疗上颌窦疾病而忽略牙的诊治,会导致治疗失败。本文就OMS发病率、病因、临床表现及影像学检查作一综述,为其防治提供一定帮助。     

Levels of evidence and journal impact factor in oral and maxillofacial surgery: a 15-year follow-up

This study was performed to assess changes over time in the quality of research in oral and maxillofacial surgery (OMS) by examining the level of evidence of published articles. A secondary aim was to determine the relationship of the journal impact factor to these levels of evidence. The four major OMS journals with an impact factor were assessed. Articles published in 2017 and 2018 were categorized based on their level of evidence, and their correlation with the 2019 journal impact factor was investigated using Spearman’s rank correlation coefficient (rho). The total number of published articles increased by a factor of 2.4 over a 15-year period, from 932 in 2002–2003 to 2253 in 2017–2018. The percentage of articles increased by 1.0% for level I evidence, 3.4% for level II, 8.2% for level III, and 4.1% for level IV. Non-evidence articles reduced by 16.7%. All journals showed an increase in impact factor, and a significant correlation was noted between the proportion of published higher-level evidence articles and the impact factor over time (rho = 0.811, P = 0.001). It is concluded that OMS journals currently display a higher proportion of good quality articles leading to a better impact factor than 15 years ago.     

A review of feeding interventions for infants with cleft palate.

OBJECTIVE: A literature review was conducted to identify feeding interventions recommended for infants with cleft conditions. Selected articles were critically appraised using an evidence-based practice framework to determine the strength of the evidence underpinning each intervention. DESIGN: Electronic databases were searched for reports of cleft palate feeding interventions. The selected articles were coded as being data driven or not; those containing data were then critically appraised using a recognized evidence hierarchy. Finally, each report was ascribed a level of evidence (from I to IV), depending on the quality of data presented. RESULTS: Fifty-five articles published between 1955 and 2002 were reviewed. There are currently no completed systematic reviews relevant to this body of literature (level I evidence). Two well-designed randomized controlled trials (level II evidence) were found. These were considered to provide the strongest evidence for feeding intervention techniques. These articles described a combination of interventions, including early feeding and nutrition education, as well as assisted feeding methods for infants with isolated cleft conditions. Three examples of level III.3 evidence were also found. Fifty (91%) of 55 articles reviewed were non-data-driven reports of expert opinion (level IV). CONCLUSIONS: A paucity of evidence rated as either moderate or strong prevailed, underscoring the need for ongoing scientific evaluation of feeding interventions used with infants who have cleft palate. A number of factors, including the heterogeneity of samples studied, lack of replication of trials, and small sample sizes, affected the type and strength of evidence underpinning specific feeding interventions.     

CLEANING OF REMOVABLE DENTAL PROSTHESES – A SYSTEMATIC REVIEW

Objectives The aim of this systematic review was to provide an overview of the scientific evidence available from prospective clinical studies regarding denture hygiene interventions. Therefore, investigations addressing the efficacy of removing microorganisms and biofilms formed on the surface of removable dental prostheses (RDPs) and denture base materials in situ and their impact on the properties of denture base materials, such as color stability, surface roughness, and dimensional stability, were included.Methods A systematic literature search was conducted from June 1975-May 2020 and included articles published in English that have been indexed in the digital archives of PubMed and Cochrane (including PubMed, Embase, ICTRP, CT.gov). A complementary manual search of the initially retrieved studies was conducted. Inclusion criteria comprised prospective clinical trials with a minimum of ten participants investigating (1) approaches and methods to remove biofilms formed on the surface of RDPs and denture base materials in situ and/or (2) the influence of these biofilms on denture base materials. A total of forty-four studies were included in this systematic review, which was registered in the PROSPERO database (CRD42020189649).Results and Conclusions Data gathered from the systematic review indicate that the combined use of chemical and mechanical denture hygiene interventions is significantly more effective than single cleaning approaches. Only limited evidence is available from clinical studies regarding the effect of denture hygiene interventions on the properties of denture base materials.     

Maternal and child oral health interventions in Middle East and North Africa regions: a rapid review

Objectives: To conduct a rapid review to identify any maternal and/or child oral health interventions implemented and/or tested in Middle East and North Africa (MENA) countries generally, and Lebanon, Palestine and Syria specifically, and to compile information on the relative effectiveness of these interventions. Methods: A systematic search was conducted for primary and secondary literature indexed in five online databases, and the websites of the World Health Organisation (WHO), the International Union for Health Promotion and Education (IUHPE), the United Nations Children’s Fund (UNICEF), United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), and the United Nations Refugee Agency (UNHCR). Results: Two independent researchers reviewed 1,180 records from the online databases, and 3,120 reports from the WHO, UNRWA, UNICEF and UNHCR. Four unique studies were included and conducted in Syria, Saudi Arabia and Iran. No systematic reviews were found for targeted interventions in MENA regions. However, interventions using fluoridated toothpaste (Syria), preventive treatment and fluoridated chewing gum (Saudi Arabia), and oral health education with oral health reminders (Iran) were significantly effective in reducing early child caries (ECC) experience. In Syria and Iran, mother and child oral health promotions integrated into ongoing vaccination programmes were effective in reducing ECC. These interventions formed part of WHO and Ministry of Health programmes. Conclusion: Further investigation is essential to verify the effectiveness of incorporating multi-disciplinary, theory-driven oral health interventions into ongoing WHO maternal and child health programmes in MENA countries to assist in promoting oral health and wellbeing.Key words: Maternal, children, oral health, interventions, Middle East and North Africa regions     

Ameloblastoma in children.

PURPOSE: The purpose of this report was 1) to report the experience of the University of Maryland, Department of Oral and Maxillofacial Surgery (OMS Department) in the treatment of ameloblastoma in children and 2) to review the world literature on the treatment of ameloblastoma in children from 1970 to 2001. METHODS AND MATERIALS: This study first reviews the experience of the OMS Department of the University of Maryland with ameloblastomas in children and then reviews the literature on this subject. The first part of the study was undertaken by a retrospective chart review of all patients with a diagnosis of ameloblastoma in the OMS Department between May 1991 and December 1999. The literature on ameloblastoma in Western societies and Africa was separately reviewed from 1970 through 2001. Reports earlier than 1970 were not reviewed, as the histologic diagnosis of ameloblastoma was not well defined before that period. RESULTS: In the Maryland series, 11 patients under the age of 20 years with ameloblastoma were treated. Eight patients were seen primarily, and 3 presented with recurrent lesions. The average age was 15.5 years; 5 of 11 patients were black, and 9 of 11 tumors were unicystic ameloblastomas. The literature review showed 85 children in the Western reports and 77 reported from Africa. The average ages were 14.3 and 14.7 years, respectively, but unicystic ameloblastomas accounted for 76.5% of the Western and only 19.5% of the African children, with an increased frequency of occurrence in the mandibular symphisis in African (44.2%) versus Western (5.8%) patients. Analysis of recurrence after enucleation of unicystic ameloblastomas in 20 children followed at least 5 years or until recurrence showed a recurrence of 40%. CONCLUSIONS: Ameloblastomas in children differ from adults, with a higher percentage of unicystic tumors. African children appear to resemble the adult pattern. Although enucleation has been claimed to give acceptable recurrence rates in unicystic ameloblastoma, there are no large series with long follow-up in children. The histologic pattern that exhibits mural invasion in unicystic ameloblastoma suggests that more aggressive surgery is necessary.     

An analysis of distant metastasis cases from HPV-associated oropharyngeal squamous cell carcinoma

Although mostly associated with good survival outcomes, some patients with HPV-positive oropharyngeal squamous cell carcinoma develop distant metastasis and face dire prognosis. The aim of this study was to analyze distant metastatic patients in regards to survival, clinical staging, therapy approach and p16/HPV status.This retrospective single-centre study assessed patients with HPV-associated oropharyngeal cancer with distant metastasis treated in a tertiary referral center from 2005 to 2019. Overall- (OS) and survival after diagnosis of distant metastasis (OMS), clinical staging and different therapy approaches were assessed. Moreover, the overall mortality was assessed, as well as the association of different therapy approaches and p16/HPV status with the survival outcome.Out of 211 patients with HPV-associated oropharyngeal cancer that were treated in the study period, 15 developed distant metastases (7.1%). Median OS and OMS of the total group were 11 months (range 0.1–32 months) and 3 months (range 0.1–21 months), respectively. The overall mortality rate was 53.3% (n = 8). Significantly better outcome was present in patients treated with primary chemoradiotherapy (median OS 17 months vs. not reached, p = .03, median OMS 8 months vs not reached, p = .05). The OMS was significantly better in patients treated with chemotherapy initially after diagnosis (mean OMS 21 months vs 4 months; P = .001). Surgical resection after initial diagnosis was associated with a significantly shorter OMS (median OMS 3 vs. 21 months, p = .005). Interestingly, postoperative adjuvant therapy was delayed in all of these cases due to surgical site complications.Systemic treatment after initial diagnosis may be beneficial in clinical outcome of HPV associated distant metastases. Furthermore, surgical site complications should be treated with immediate care in order to avoid delay of adjuvant therapy. Further studies are warranted for validation of our results.