Tissue engineering technology and its possible applications in oral and maxillofacial surgery

Tissue engineering is a rapidly advancing discipline that combines the attributes of biochemical and biomaterial engineering with cell transplantation to create bio-artificial tissues and organs. For the oral and maxillofacial surgeon, the reconstruction of maxillofacial defects in hard and soft tissues is an ongoing challenge. While autologous grafts and vascularised free flaps are the current gold standard, they are not without complications at both the donor and reconstructed sites. Tissue engineering, which aims to create tissue-matched, prefabricated, prevascularised bony or soft tissue composite grafts, or both, therefore has the potential to revolutionise practice in maxillofacial surgery. We review the technology of tissue engineering and its current and future applications within the specialty, and discuss contemporary obstacles yet to be overcome.     

Role of robotic surgery in oral and maxillofacial, and head and neck surgery

We review the current status of robotic surgery in the head and neck region and its role in oral and maxillofacial surgery.     

Stereotactic navigation in oral and maxillofacial surgery

Navigation is an adjunct to existing surgical procedures. It is potentially useful in any procedure where it is possible to make a three-dimensional surgical plan from computed tomography (CT) or magnetic resonance imaging (MRI) data, but is not easy to translate this plan into surgical reality because of absolute limitations of access or lack of anatomical landmarks.     

Psychological issues in oral and maxillofacial reconstructive surgery

Many psychological problems affect patients who have oral and maxillofacial operations. This article reviews these problems among patients with craniofacial conditions, facial injuries, facial cancer, and those having orthognathic surgery. Facial cosmetic surgery is not addressed. Problems such as depression, anxiety, low self-esteem, poor social relationships, and changes in body image are considered. The roles of mental health professionals is emphasised to enhance postoperative satisfaction and to provide a better quality of life for these patients.     

Recent trends in cartilage regenerative medicine and its application to oral and maxillofacial surgery

Greater progress has been made in the clinical application of cartilage regenerative medicine, compared with that of other organs. A typical example of cartilage regenerative medicine is autologous chondrocyte implantation, in which chondrocytes isolated from the patient's cartilage are cultured and injected into the cartilage defects in a liquid- or gel-form. However, the classic autologous chondrocyte implantation has been applicable to only limited diseases, including focal cartilage lesion. Therefore, we developed “implant-type” tissue-engineered cartilage that shows mechanical strength and three-dimensional shape. This type of tissue-engineered cartilage uses scaffold composed of atelocollagen hydrogel and poly-l-lactic acid porous material, which is administered with cultured autologous auricular chondrocytes. Its clinical application to nasal deformity of cleft lip and palate patients has been ongoing at present. This review presents an overview of the current situation regarding cartilage regenerative medicine, as well as introducing our research and the development of implant-type tissue-engineered cartilage for the cleft-lip nose. The discussion of the future development of regenerative medicine is also mentioned.     

A systematic review of patient self-completed questionnaires suitable for oral and maxillofacial surgery

Patient reported outcomes (PRO) have an established role when reporting treatment outcomes. This data is usually collected using patient self-completed questionnaires. There are numerous questionnaires available and selecting the most appropriate one can be difficult.

Aim

The aim of this article was to carry out a systematic review of the literature to identify publications using patient self-completed questionnaires suitable for oral and maxillofacial surgery. The questionnaires were collated and grouped according to sub-speciality interests.

Method

The ISI search engine with cross-reference using Pub Med and Ovid was searched for publications between 1981 and March 2009. Abstracts written in English were reviewed by two of the authors independently.

Results

A total of 511 abstracts were reviewed and the paper cites 56 studies with self-administered instruments. The number of subsite specific questionnaires identified were; cleft lip and palate (1), craniofacial surgery (2), dentoalveolar surgery (6), distraction osteogenesis (1), facial aesthetic surgery (4), facial pain (1), head and neck cancer (14), maxillofacial injury (3), oral medicine and oral mucosal disorders (2), orthognathic surgery (1), pre-prosthetic surgery and dental implants (15), skull base surgery (7), temporomandibular joint (2).

Conclusion

There is a tremendous variety of validated questionnaires available that are suitable for oral and maxillofacial surgery. This summary serves as a useful reference point when selecting a questionnaire for an audit or research projects. It also describes publications, which have used the various questionnaires, thus readily identifying papers that might be useful for comparison.     

Advantages and disadvantages of the use of bisphosphonates in oral and maxillofacial surgery

Bisphosphonates are a class of drugs of proven efficacy in the prevention and treatment of various bone diseases, affecting bone turnover by decreasing bone resorption by different mechanisms. In recent years, this class of drugs has become the target of numerous studies in relation to oral and maxillofacial surgery. The aim of this paper is to review the literature on the effects of bisphosphonates in this context, especially in the development of osteonecrosis and as adjuvant in implant placement, osteogenic distraction and bone grafting surgery.     

Impact of indocyanine green fluorescent image-guided surgery for parapharyngeal space tumours

In parapharyngeal space dissection, significant complications such as dysphagia and carotid artery rupture have been reported. In order to resect tumours safely in narrow parapharyngeal space, we propose indocyanine green (ICG) florescence image for navigation surgery.ObjectiveTo evaluate the usefulness of ICG fluorescent image-guided surgery for parapharyngeal space tumours.Methods0.5 mg/kg of ICG was injected via the cephalic vein. Observation of the fluorescent image was performed with HEMS (HyperEye Medical System) at 10–30 min after injection. At first, the position of the tumour was marked over pharyngeal mucosa according to ICG fluorescence imaging with HEMS. We also confirmed submucosal tumours hidden under fascia using HEMS imaging again and resected them.ResultsAll tumours displayed bright fluorescence emissions which clearly contrasted with the normal structures. Even with the submucosal tumour covered with and obscured by fasciae, we could observe the tumour clearly under HEMS imaging. Tumours behind the carotid artery and lower cranial nerves also were displayed bright fluorescence emissions and were clearly detected. As a result, we could completely remove the tumour safely and noninvasively to preserve pharyngeal functions.ConclusionICG fluorescence imaging is effective for the detection and resection of the parapharyngeal space tumours with preserving functions.     

放射性粒子组织间植入治疗口腔颌面部恶性肿瘤初探

目的 应用^125Ⅰ放射性粒子植入组织间近距离治疗口腔颌面部恶性肿瘤，观察其近期疗效及副反应。方法 对36例口腔颌面部恶性肿瘤患者实施^125Ⅰ放射性粒子定向植入治疗（分别为术中即刻植入、术后经皮穿刺植入、单纯粒子植入），治疗前分别行靶区设计，平面植入计划或立体植入计划。植入后1周内及2个月后CT验证粒子分布及靶区剂量变化。随访观察患者的疗效及副反应。结果 本组患者随访6～36个月，平均14个月。晚期恶性肿瘤单纯植入2例，肿瘤明显缩小，症状减轻；早期舌癌单纯植入1例，肿瘤完全消退；33例手术及粒子植入后随访，靶区覆盖范围均无复发及转移，有3例出现靶区外复发或转移。除8例局部皮肤充血反应外，其余患者无特殊不适主诉及外照射副反应。结论 ^125Ⅰ放射性粒子植入组织间近距离治疗口腔颌面部恶性肿瘤，对控制复发及颈部淋巴转移近期效果显著。     

Non-technical skills in oral and maxillofacial and head and neck surgery: systematic review

The importance of teams’ and individuals’ non-technical skills in reducing adverse events is well-recognised. We undertook a systematic review of the published literature to assess the research undertaken to date on non-technical skills and behaviours within oral and maxillofacial, and head and neck (OMFS-H&N) surgery. The aim was to assess the applicability of published studies to current practice, to look at how these studies could guide future research, and look for areas that could be developed further. The search terms included ‘non technical skills’, ‘nontechnical skills’, ‘NOTSS’, ‘non-technical skills for surgeons’, ‘oral surgery’, ‘oral maxillofacial surgery’, ‘OMFS’, ‘maxillofacial surgery’, ‘head and neck surgery’, ‘microsurgery’, ‘behavioural markers’, ‘behavioural assessment tool’, and ‘behavioural ratings system’. Three publications were included, involving 83 participants. Participants consistently achieved the highest scores in the ‘situational awareness’ category and showed a tendency to achieve lower mean scores in the ‘communication and teamwork’ and ‘decision-making’ categories. The majority of research into surgeons’ non-technical skills has occurred in simulated environments and not in the genuine environments in which actual surgery is being performed on patients. Research involving ‘real’ patients has been done in the field of OMFS-H&N and this places the specialty in a stronger position than many other surgical specialties.     

Outcomes of free flap reconstructive surgery in head and neck cancer patients over 80-years old

An increasing elderly population in the United Kingdom has led to an increasing number of older patients with head and neck cancer, resulting in a greater demand for complex head and neck reconstructive surgery in this potentially high-risk age group. A possible perceived poorer tolerance to such major treatment risks under-treating some of these patients. The purpose of this study was to assess the outcomes in the elderly population (older than 80 years) who had undergone free flap reconstruction following head and neck cancer resection. A retrospective review of 127 patients was performed. Eighteen patients were 80 or older (14.2%) and 109 under 80 (85.8%). The elderly group experienced increased number of postoperative medical complications (p = 0.01), but the surgical complications were not significantly different in the two groups (p = 0.4). The average length of hospital stay was significantly longer in the older group (p = 0.01). There was one flap failure during the study period, which belonged to the younger group of patients. Elderly patients undergoing free flap reconstruction experience an increased rate of postoperative medical complications resulting in an increased length of hospital stay. However, good surgical outcomes can still be achieved in this age group, and therefore age alone should not be considered as a primary factor in head and neck cancer management.     

Free-flap failures and complications in an American oral and maxillofacial surgery unit

Free tissue transfer is a reliable surgical technique that enables primary reconstruction following ablative surgery. Widely practised in many European units, acceptance into mainstream oral and maxillofacial surgery in the USA has been slow. The authors reviewed free flap practice patterns and outcomes in a US oral and maxillofacial surgery training program with specific emphasis on failures and complications to illustrate obstacles encountered during the initial phase of practice implementation. The demographic and clinical data of 71 consecutive patients who underwent microvascular reconstruction over 3 years (2002–2005) were reviewed. The study group included 48 males and 23 females who underwent 72 free tissue transfer procedures. Fourteen patients required operative exploration in the perioperative period. Six patients were explored for clinically compromised flaps. Thrombotic events occurred in 4 patients; 1 flap was successfully salvaged. There were 4 flap failures and 9 complications related to the donor site. Two perioperative deaths occurred from non-flap-related complications. Prolonged hospital stay and ICU utilization was observed in patients with surgical complications. Complications in this study did not affect the overall success rates of free-flaps. Salvage rates from thrombotic events were unaffected despite rigid flap monitoring protocols.     

负压封闭引流在颌面外科术后严重颌面颈部感染的应用

目的探讨应用持续负压封闭引流技术（VSD）治疗口腔颌面外科术后经持续换药后未见明显好转、且呈持续性加重的颌面颈部感染的疗效。 方法采用VSD治疗8例口腔颌面外科术后经持续换药未见好转、且呈持续性加重的严重颌面颈部感染,在去除术后感染区坏死物质、彻底清创后,以负压封闭引流材料覆盖创口,0.9%氯化钠溶液冲洗,持续负压引流,直至引流液清亮、创缘组织无红肿、无压痛后,撤除VSD装置。 结果6例患者明确感染后,使用传统换药约7 ~ 8 d,感染呈进行性加重,遂使用VSD装置置于感染区,持续引流5 ~ 15 d后,可见引流液清亮,颌面部肿胀基本消失,创缘周围可见肉芽组织增生,伤口基本愈合;所有病例中有1例为放射性颌骨骨髓炎行腓骨肌皮瓣修复,明确感染、持续换药约20 d后,感染呈进行性加重,放置VSD 5 d后于手术室清除病灶骨,术后继续换药,伤口愈合;1例术后并发食管瘘患者使用VSD时间长,撤除VSD后,引流液清亮,颌面部肿胀较前明显减轻,创口可见肉芽组织增生,但左颈部仍可见到1个大小约1 cm × 1 cm的瘘管,邻近瘘管可见颈部膨隆明显,扪诊质硬,无波动感。左颈部磁共振成像（MRI）增强示：左颈部见3.9 cm × 2.3 cm × 5.0 cm大小的不规则占位病变,右颈部见1个大小约2.3 cm × 1.4 cm团块状病变,考虑淋巴结肿大（术后复发）。 结论VSD有利于控制感染,防止术后感染扩散,促进术后创面组织的愈合;同时肿瘤患者使用VSD存在促癌细胞转移、增殖的可能,在应用过程中应充分考虑其适应证,并密切监测创区变化,当发现可疑病变或创面延迟愈合时,应立即撤除VSD装置,根据具体情况行进一步治疗。     

Head and neck reconstruction in the vessel depleted neck using robot-assisted harvesting of the internal mammary vessels

We report a novel technique of robot-assisted harvesting of the internal mammary vessels to provide effective recipient vessels in a patient with bilateral vessel depleted neck (VDN). A 44-year-old with a Notani grade III osteoradionecrosis (ORN) of the anterior mandible underwent robot-assisted (Da Vinci® Surgical System, Intuitive Surgical) harvesting of the left internal mammary vessels (LIMA, LIMV). Reconstruction of the mandibular defect was done with a virtually planned composite fibular free flap and microvascular anastomosis of the peroneal vessels to the LIMA and LIMV. Successful reconstruction of the anterior mandible was achieved with excellent recipient arterial diameter and length, devoid of any significant thoracic morbidities resulting from robot-assisted harvesting of the internal mammary vessels. Robot-assisted harvesting of internal mammary vessels is a viable alternative to an open approach. The advantages in tissue handling, vessel length, and favourable profile of complications may extend the indications for this otherwise ‘niche’ solution in the VDN.     

Factors contributing to delayed decannulation of temporary tracheostomies following free tissue reconstructive surgery for head and neck cancer

Temporary tracheostomies (TT) are performed to secure the airway perioperatively and postoperatively in head and neck cancer patients undergoing tumour resection and free tissue reconstructive surgery. Patients report that having a TT is unpleasant and they appreciate its removal at the earliest opportunity. Early removal not only improves patient satisfaction but should allow for a more rapid recovery. The aim of this prospective study was to assess factors that contribute to delays in decannulation following TT and hence to provide an insight into the factors that will support earlier decannulation when it is safe to do so. Consecutive patients who had TT over a six-month period were included. Delayed decannulation was defined as that after day seven postoperatively. There were 42 patients with a median (IQR) age of 70 (60-74) years, 26 of whom were men. The tracheostomy was surgical in 29 and percutaneous in 13. The median (IQR) time to decannulation was 4 (3-5) days (range 1-11 days). Seven patients had delayed removal (7-11 days), the reasons being hospital-acquired pneumonia (HAP) (n = 4), prolonged stay in the high dependency unit (HDU) following postoperative myocardial infarction and cardiac arrest (n = 1), failure to tolerate TT occlusion (n = 1), and not stated (n = 1). There were early postoperative complications in 14 patients but despite this seven decannulations were still performed within two and six days. Additional multiprofessional assessment over weekends is likely to facilitate earlier decannulation. As some TTs are removed after a few days there is a need for better selection to avoid their use in certain patients.     

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口腔颌面部缺损严重影响面部各器官的生理功能,同时也导致不同程度的面部畸形,影响面容和美观.口腔颌面部缺损的修复重建目前被认为是整形和修复重建外科领域内最具挑战性的工作[1].     

Navigation-guided oral and maxillofacial surgery (reconstructive and plastic, orthognathic, oncology)

Purpose: Advance in the field of compeer assisted surgery enables the surgical procedures to be less invasive and more accurate for the support of diagnosis imaging, pre-operative simulation and intraoperative navigation.     

Evolution and Trends in Reconstructive Facial Surgery: An Update

Surgical correction of congenital and acquired facial deformities has transcended the primitive era of using non biologic materials to current attempts at own face growing through biotechnology. A summative account of this trend is still lacking in the literature. The objective of this article is to present an update on current knowledge in the strides to achieve functionally and aesthetically perfect facial reconstruction. It highlights the impact of advancements in 3D imaging, stereolithographic biomodelling, microvascular surgical tissue transplantation and tissue biotechnology in the surgical efforts to solve the problems of facial disfigurement whether congenital or acquired.