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Brief Clinical Studies

FIGURE 2. One month postoperative images. A, Lateral view showing increased protrusion of tongue. B, Frontal view showing tongue protrusion. C, Uneventful wound healing.

black braided silk sutures (Silkam, Braun Ref No: 0766513IN) for the tissues to heal by primary intention thereby minimizing the scar tissue formation. Immediately after surgery, it was noted that tissue mobility had been reestablished. The patient was discharged on the same day and was called for follow-up on the first, seventh, 15th, and 30th day postoperatively. The patient was prescribed an antibiotic (Cap Amoxicillin 500 mg thrice daily) and a non-steroidal anti-inflammatory drug (Tab Ketorol DT 10 mg thrice daily) postoperatively for 5 days to prevent postoperative infection and pain. The postoperative period was uneventful with no surgical site infection or delayed hemorrhage. Sutures were removed after 1 week which showed no scar tissue formation following which the patient was sent for speech therapy sessions. After a follow-up of 1 month, the tongue showed good healing and satisfactory protrusion beyond the lower lip (Figs. 2AYC).

DISCUSSION Lingual frenectomy can be done either by conventional method using scalpel and blade or by lasers. Lasers are more accurate and have theoretical advantages like less bleeding and discomfort. However, these parameters are not significantly better than the conventional technique.9 It is also difficult to justify the amount of time and finances concurred considering the resource implications in a developing country like ours. Thus, we recommend the use of conventional technique for release of tongue-tie (lingual frenectomy). It is less time consuming and is a cost-effective way for management of tongue-tie with equally good results as compared to using lasers for the same procedure.

CONCLUSIONS Tongue-tie division (lingual frenectomy) with conventional method using is a relatively straightforward, safe, and cost-effective procedure with very low complication rates when performed by a trained healthcare professional. Speech therapy is a must if release of tongue-tie is done in adulthood. Using lasers for this simple procedure would mean making simple things complicated.

REFERENCES 1. Tuerk M, Lubit EC. Ankyloglossia. Plast Reconstr Surg Transpl Bull 1959;24:271Y276 2. Rogers JG, Douglas BL. Surgical correction of ankyloglossia. U S Armed Forces Med J 1952; 3:695Y697 3. Messner AH, Lalakea ML, Aby J, et al. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg 2000;126:36Y39 4. Lalakea ML, Messner AH. Ankyloglossia: does it matter? Pediatr Clin North Am 2003;50:381Y397 5. Forlenza GP, Paradise Black NM, McNamara EG, et al. Ankyloglossia, exclusive breastfeeding, and failure to thrive. Pediatrics 2010; 125:e1500Ye1504

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6. Dollberg S, Botzer E, Grunis E, et al. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized prospective study. J Pediatr Surg 2006;41:1598Y1600 7. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002;110:e63 8. Kotlow LA. Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Quintessence Int 1999;30:259Y262 9. Atwal A, Cottom H, Cousin GC, et al. Re: Use of carbon dioxide laser in lingual frenectomy. Is the light sabre greater than the sword? Br J Oral Maxillofac Surg 2013;51:e42Ye43

A Technical Note About Flap Fixation Technique to Prevent Salivary Fistulas in Reconstructive Oral Cavity Surgery Luca Raimondo, MD,* Silvia Germano, MD,Þ Massimiliano Garzaro, MD,* Maria Alessandra Bocchiotti, MD,Þ Pierluigi Tos, MD,þ Giancarlo Pecorari, MD* Abstract: Salivary fistulas are frequent complications in oral oncological reconstructive surgery by means of pedicled or free flaps. The most common risk factors are malnutrition, advanced disease, and healing alterations due to radiation therapy or infections. However, they can be observed also in healthy patients where the flap suture breakdown is the only cause. During the reconstructive phase, flaps are anchored to the remnant tongue, hyoid bone, and residual gingival mucosa; the last structure often does not offer suitable margins for a strong suture. The aim of this study was to propose a transmandibular fixation of the flap that allows, in a safe, efficient, and unexpensive way, the creation of a saliva-proof neofloor of the mouth, independently from the quality and thickness of residual gingival mucosa. Key Words: Oral cancer, oral reconstruction, salivary fistula, flap fixation

A

blative oral surgery, performed for squamous cell carcinomas of the mobile tongue or of the floor of the mouth, heavily affects mastication, swallowing, speech, and cosmesis; these functions can be restored using pedicled or free flaps. After flap elevation, the soft tissue myofascial, myocutaneous, or fasciocutaneous component is From the *First ENT Division, Department of Surgical Sciences, †Department of Plastic Surgery, University of Turin; and ‡Department of Orthopedics and Traumatology, UOD Reconstructive Microsurgery, CTO-M. Adelaide Hospital of Turin, Turin, Italy. Received November 27, 2013. Accepted for publication December 28, 2013. Address correspondence and reprint requests to Luca Raimondo, MD, First ENT Division, Department of Surgical Sciences, University of Turin, Via Genova, 3-10126 Turin, Italy; E-mail: [email protected] The authors report no conflicts of interest. Luca Raimondo, MD, and Silvia Germano, MD, equally contributed to the study. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000706

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Brief Clinical Studies

TABLE 1. Characteristics of Patients, Tumor, and Surgical Intervention Patient’s Characteristics Patient 1 45 Male Yes Yes Yes No

Patient 2 54 Male No No No No

Patient 3 45 Male Yes Yes No No

16.5

16.0

16.0

Left tongue border and lateral floor of the mouth pT2 N2b M0

Body of the tongue pT3 N0 M0

Left portion of the tongue body and left lateral floor of the mouth pT3 N2a M0

IVa

III

IVa

Partial oral tongue + left floor of the mouth ALT (fasciocutaneous) 10  6 cm T-T superior tyroid artery T-T thyrolinguofacial venous trunk

Tongue ALT (myofasciocutaneous) 12  8 cm T-T facial artery T-T thyrolinguofacial venous trunk

Partial oral tongue + left floor of the mouth ALT (myofasciocutaneous) 15  7 cm T-T facial artery T-T thyrolinguofacial venous trunk

Age, y Sex Alcohol Cigarette smoking Previous RT Diabetes MNA* Tumor Characteristics Tumor site pTNM† Stage Resection and Flap Characteristics Type of resection Flap type Flap dimensions Arterial anastomosis Venous anastomosis

*Mini Nutritional Assessment score G17 = malnutrition5 †AJCC Cancer Staging Manual, 7th edition. MNA, Mini Nutritional Assessment; RT, radiotherapy.

FIGURE 1. A lateral view of the upper and lower jaw and that of their relationship with maxillary and mandibular nerves (V2 and V3). The red spots represent the mandibular holes created by means of a bone drill between dental roots on a line passing just above the mandibular canal.

FIGURE 2. A coronal view of the oral cavity after total tongue resection and its reconstruction with a myofasciocutaneous ALT flap. Muscular fascia is fixed to the mandible by means of transmandibular stitches.

placed in the oral cavity defect and its free margins are sutured to the free edge of the gingiva and remnant tongue.1 The intraoral suture is now exposed to the action of saliva that reduces the tensile strength of chromic sutures in as few as 7 days.2 A suture breakdown results in salivary fistulas that are an early local complication of such surgery. They are very frequent and generally occur in patients with malnutrition, advanced disease, healing alterations due to radiation therapy, or infections; however, they can be observed also in healthy patients.1,3 Salivary fistulas incidence vary between 13.5% and 29% after local or regional flap reconstruction and between 0% and 15.4% after free flap use. The management of such complication is still discussed: as reported by several authors, conservative approaches are successful in many patients, whereas operative management is considered

FIGURE 3. A schematic representation of muscular fascia fixation to the mandible: the suture thread fixed to a straight needle is passed through a mandibular hole, anchors the fascia, and comes out from the next hole; the stitch is closed using a basic square knot plus an additional loop to prevent its unraveling.

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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FIGURE 4. An intraoperative view of transmandibular stitches placement.

when conservative treatments fail or if loose/infected hardware is present.3,4 This clinical report describes a novel technique of flap suturing that can be used in the reconstruction of tongue and floor of the mouth to reduce the incidence of salivary fistulas.

PATIENTS Between January and February 2013, a total of 3 patients with oral squamous cell carcinoma involving the tongue and floor of the mouth were admitted to our department and underwent oral demolitive surgery, followed by flap reconstrucion. The study was approved by University of Turin review board, and a written informed consent was collected for each subject. The patients’ and tumor characteristics are summarized in Table 1. Each patient underwent primary tumor exeresis using a ‘‘pull through’’ approach to preserve the mandibular arch continuity. The bilateral selective neck dissection, levels I to IV, (according to the latest classification of Robbins et al6) was always performed in continuity with the primary lesion. The oral defect was reconstructed using a fasciocutaneous or myofasciocutaneous anterolateral thigh flap (ALT) harvested from the left or right thigh on the basis of Doppler evaluation of the perforators. After flap insetting and revascularization, the skin paddle was folded to create a neotongue and a neofloor of the mouth, then it was sutured to the remnant tongue (patients 1 and 3) or to the hyoid bone (patient 2); thereafter, on the basis of a preoperative computed tomographic study, an adequate number of mandibular holes was created by means of a drill on a line passing just above the mandibular canal to preserve V3, between dental roots (Fig. 1), and the fascia was fixed to the mandibular body using a size 0 absorbable, synthetic, braided suture (Figs. 2Y4). The patients were discharged after a mean of 20 days, and no clinical signs of salivary fistula were detected in the following 2 postoperative months.

DISCUSSION Salivary fistulas are a frequent complication of head and neck reconstructive surgery. Although microvascular reconstruction decreases the incidence of such complication, as demostrated by several authors,7Y10 it cannot prevent them at all. Malnutrition, advanced disease, healing alterations due to radiation therapies, or infections are the most common risk factors for salivary fistulas formation; however, they can occur also in healty patients.3 When no risk factors are present, a possible cause should be identified in a flap fixation bug. Several articles discuss about flap choice, harvesting, modeling, and insetting techniques but none about flap fixation. Usually, after a partial/total tongue or floor of the mouth resection, the flaps used to reconstruct the surgical defect are sutured to the gingiva, remnant tongue, and hyoid bone. The last 2 structures offer a robust support

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for the suture, whereas the gingival mucosa is often unsuitable to provide an adequate margin for a strong suture because of tumor extension. On the basis of the previously mentioned considerations, we selected 3 patients with oral squamous cell carcinoma and at a high risk for developing a salivary fistula because of advanced disease, malnutrition, and previous radiotherapy (only patient 1). Each patient underwent demolitive surgery, followed by microsurgical reconstruction using an ALT flap directly fixed to the mandibular body by means of transmandibular stitches. The proposed fixation technique allows the surgeon to create a saliva-proof neofloor of the mouth, independent from the quality and thickness of residual gingival mucosa. As previously explained, mandibular holes are created on a line just above the mandibular canal; therefore, the neofloor of the mouth lies on a plane just a little bit lower than the mylohyoid muscle one; afterward, when a myofasciocutaneous flap is used for tongue reconstruction, particularly after a total glossectomy, the surgeon, during flap harvesting, must take a voluminous portion of the vastus lateralis muscle; this technical trick is essential to ensure an adequate bulk to the neotongue and to contrast the physiological depletion of the flap due to the progressive atrophy of soft tissues. Despite the high risk for salivary fistula development, during a 2-month postoperative follow-up, no clinical signs of fistula were recorded. A disadvantage can be represented by a 40-minute lengthening of the operative time, but in our opinion, it could be acceptable if compared with the patient’s discomfort and medical costs related to salivary fistula management. Possible complications of this procedure are damages of mandibular nerve and dental roots; moreover, osteomyelitis can be expected because of bone drilling. They can be avoided by performing a correct patient selection as well as a detailed radiologic study of the patient’s mandible and by maintaining optimal sterility during bone drilling, even if the oral cavity is included in the surgical field. In conclusion, the previously discussed flap fixation technique, in well-selected and studied patients, could be a safe, unexpensive, effective, and easily appliable trick in preventing salivary fistulas after the reconstruction of the tongue and floor of the mouth after oncological demolitive surgery.

REFERENCES 1. Lerrick AJ, Zak MJ. Oromandibular reconstruction with simultaneous free and pedicled composite flaps. Oper Tech Otolaryngol 2000;11:90Y101 2. Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg 2004;130:962Y966 3. Hyman JH, Disa JJ, Cordiero PG, et al. Management of salivary fistulas after microvascular head and neck reconstruction. Ann Plast Surg 2006;57:270Y273 4. Bomeli RS, Desai SC, Johnson JT, et al. Management of salivary flow in head ad neck cancer patientsVa systematic review. Oral Oncol 2008;44:1000Y1008 5. Guidoz Y, Wellas BJ, Garry PJ. Mini Nutritional Assessment: a pratical assessment tool for grading the nutritional state of elderly patient. In: Wellas BJ, Guidoz Y, Garry PJ, et al., eds. Nutrition in the Elderly, the Mini Nutritional Assessment (MNA). Facts and Research in Gerontology 1994/1995. 2nd ed. Paris: Serdi Publishing Company, 1995:15Y60 6. Robbins K, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of OtolaryngologyYHead and Neck Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751Y758 7. Kroll SS, Goepfert H, Jones M, et al. Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. Ann Plast Surg 1990;25:93Y97

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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8. Shah JP, Haribhaki V, Loree TR, et al. Complications of the pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1990;160:352Y355 9. Mehrof AI, Rosenstock A, Neifeld JP, et al. The pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1983;146:478Y480 10. Baek SM, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast Reconstr Surg 1982;69:460Y465

A Clinicoradiographic and Pathological Study of Pericoronal Follicles Associated to Mandibular Third Molars Fa´bio Wildson Gurgel Costa, DDS, PhD,* Thales Salles Angelim Viana, DDS,Þ Galyle´ia Meneses Cavalcante, DDS,Þ Paulo Goberlaˆnio de Barros Silva, DDS,Þ Roberta Barroso Cavalcante, DDS, PhD,þ Alexandre Simo˜es Nogueira, DDS, MSc,§ Karuza Maria Alves Pereira, DDS, PhD,§ Background: Third molar surgery is considered the most frequently performed procedure in oral surgery. Although there are some indications for the removal of this tooth, such as the possibility of cystic degeneration or a tumor of the adjacent pericoronal follicle, there is no consensus in the literature about their prophylactic removal. Objectives: The aims of this study were to investigate the pathological alterations related to mandibular third molar dental follicles and to perform a narrative literature review. Methods: A prospective clinical, radiographic, and histopathologic study was conducted with pericoronal follicles of third molars. After histopathologic evaluation and establishment of diagnosis, 2 groups were defined: G1 (pericoronal tissues with pathological alterations based on histopathologic analysis) and G2 (pericoronal tissues without pathological alterations based on histopathologic analysis). In addition, a systematic review of the literature was performed. Results: One hundred thirteen specimens were analyzed. G1 was the most prevalent (P = 0.0004). Lesions were found in patients between 20 and 25 years of age (P < 0.004). The most prevalent histological diagnosis was the paradental cyst (47.7%; P < 0.0001). The narrative literature review showed that the majority of cases were mainly dentigerous cysts (P < 0.05). Conclusions: The mandibular third molars in young adults showed a direct relationship with age and a statistical propensity for the development of these cystic alterations, notably paradental cysts. From the *Oral Radiology Department and †Stomatology Department, School of Dentistry, Federal University of Ceara´; and ‡Oral Pathology Department, School of Dentistry, Fortaleza University, Fortaleza; and §Stomatology and Oral Pathology Department, School of Dentistry, Federal University of Ceara´, Campus Sobral, Ceara´, Brazil. Received November 30, 2013. Accepted for publication January 6, 2014. Address correspondence and reprint requests to Fa´bio Wildson Gurgel Costa, DDS, PhD, Rua Joa˜o Sorongo, 1016, apto. 205, Jardim Ame´rica; CEP 60416-000, Fortaleza-Ce, Brazil; E-mail: [email protected] No funding was received for this study. The authors report no conlficts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000712

Brief Clinical Studies

Key Words: Third molar, pathology, pericoronal follicles, paradental cysts

T

hird molar (3M) surgery is considered the most frequently performed procedure in oral surgery.1,2 Although there are some indications for the removal of this tooth, such as the possibility of cystic degeneration or a tumor of the adjacent pericoronal follicle, there is no consensus in the literature about their prophylactic removal.3 Thus, this research aimed to conduct a prospective clinicoradiographic and pathological study of pericoronal follicles associated to mandibular 3Ms in a Brazilian population and to perform a narrative literature review to compare the results of this study with previously published data.

METHODS AND MATERIALS A prospective study was conducted in which clinical, radiographic, and histopathologic data were collected from patients who presented at the dental specialties clinic ‘‘Centro de Especialidades Odontolo´gicas Sanitarista Se´rgio Arouca’’ in Sobral, Brazil, for the surgical removal of 3Ms between March 2007 and August 2011. Patients who had undergone at least 1 surgery for removal of mandibular 3Ms were included in the current study. Patients were excluded from the study when their reports referred to pathologies associated with other teeth or when the information contained in the reports was incomplete. This study was approved by the Ethics Committee of the Universidade Vale do Acarau´, Sobral, Brazil (protocol 1018/11). All patients sent the term of consent signed. The data were analyzed according to sex, age, histopathologic type, degree of dental eruption (erupted, partially erupted, and nonerupted), angulation, and radiographic and macroscopic size. A researcher who was blind to the group to which the analyzed radiograph belonged measured the radiographic size of the radiolucent area around the 3Ms. For this purpose, measurement was standardized as follows: the pericoronal radiolucency was measured by means of an endodontic millimeter ruler (Golgran, Brası´lia, Federal District, Brazil) on a negatoscope, tracing a straight line parallel to the occlusal surface of the tooth along its longest mesiodistal axis on the crown. The diameter of the radiolucency was measured by the following formula: longest diameter of radiolucency = longest diameter between the mesial face of the tooth and the end of the radiolucent area j longest coronal diameter between the mesial and distal faces of the tooth (Fig. 1). The macroscopic size of the tissue was collected according to its largest size as shown on the anatomopathological report. The histopathologic diagnosis was established in accordance with the most recent World Health Organization criteria.4,5 The histopathologic characteristics of the paradental (pathological cavity lined by a hyperplastic epithelium and the presence of intense chronic inflammation) and dentigerous cysts (thin fibrous cystic wall lined by 2- to 3-layer-thick stratified nonkeratinizing squamous epithelium and the presence of scarce inflammatory infiltration in the cellular connective tissue) are illustrated in Figures 2 and 3, respectively.4,5 After histopathologic evaluation and establishment of diagnosis, 2 groups were defined: G1 (pericoronal tissues with pathological alterations based on histopathologic analysis) and G2 (pericoronal tissues without pathological alterations based on histopathologic analysis). In addition, a narrative literature review was conducted to compare the presented sample with previously published studies. The search strategy was applied in the PubMed, MEDLINE and LILACS databases with the keywords ‘‘third molar,’’ ‘‘dental follicle,’’ and ‘‘pathology.’’ The search resulted in an initial sample of 221 scientific articles. After an initial refinement, only 34 articles remained;

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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A technical note about flap fixation technique to prevent salivary fistulas in reconstructive oral cavity surgery.

Salivary fistulas are frequent complications in oral oncological reconstructive surgery by means of pedicled or free flaps. The most common risk facto...
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