Richard Shaw

Background. Advances in the management of oral malignancy have resulted in significant improvements in survival and functional outcome. Ablation of oral tissues and radiotherapy render many patients unable to wear conventional prostheses, and these patients are, thus, candidates for oral rehabilitation with osseointegrated implants. We aim to present outcomes and complications of such treatment over a 14‐year period in a single unit. Methods. Data were collected for 81 consecutive patients, most of whom had received microvascular free flap reconstruction after surgical ablation of oral squamous cell carcinoma. Three hundred eighty‐six implants were placed after a delay of 12 months after surgery. Sixty‐five percent of implants were placed in the anterior mandible. Radiotherapy was used in 47% of the patients, and hyperbaric oxygen treatment was routinely used in irradiated subjects during the latter half of the series. Retrospective analysis of implants and prostheses was made by use of case notes, radiographs, and a computerized database. Results. Data are presented for 364 of the 386 implants in 77 of the 81 patients after a median follow‐up of 4 years. Two hundred sixty‐five (73%) of the implants were in function supporting prostheses, 56 (15%) had been lost, and 43 (12%) were present but not loaded (ie, “sleepers”). Implant loss seemed patient specific and was also correlated with host bone type. Thirteen percent of patients in whom implants were placed in the mandible lost at least one implant, and the equivalent values for the maxilla was 40%. Thirty‐six percent of patients in whom implants were placed in bone graft or flap lost at least one implant. The effects of implant manufacture, dimensions, radiotherapy, and hyperbaric oxygen did not reach statistical significance in this series. Cases of a second primary malignancy were noteworthy; however, the impact of recurrence was minimized by the delay between resection and rehabilitation. Of the 42 fixed and 29 removable prostheses fitted, 12 (17%) failed. Conclusions. Implants placed in mandible were reliable, but failure rates in vascularized bone graft and maxilla were higher. Radiotherapy did not seem to prejudice implant survival, and hyperbaric oxygen had no demonstrable benefit in this series. Despite some persistent soft tissue problems and implant loss, most patients reached a successful prosthetic and functional outcome. © 2005 Wiley Periodicals, Inc. Head Neck 27: XXX–XXX, 2005

Background.: Controversy exists over the predictive value of the presence and pattern of tumor invasion of the mandible in oral squamous cell carcinoma (SCC). Many authors have questioned increasing the classification of small tumors to T4 on the basis of mandibular invasion alone. There are little data on the influence of the pattern of invasion on prognosis.Methods.: We prospectively reviewed 100 consecutive mandibular resections for previously untreated oral SCC. Clinical and pathologic data collected included details of soft and hard tissue histologic findings. Outcomes included recurrence (local, regional, and distant metastases), disease‐specific survival, and death from other causes. The median follow‐up for survivors was 65 months.Results.: Of 100 cases, 65 involved segmental and 35 involved marginal resections. Sixty‐two percent of mandibles were invaded by tumor. Local recurrence occured in 21% and was strongly correlated with tumor size, nodal involvement, and pattern of soft tissue invasion. The 5‐year disease‐specific survival was 68%, and the crude survival was 50%. Mandibular invasion predicted for recurrence and disease‐specific survival, even after correcting for the effects of other variables. The pattern of mandibular invasion (erosive/infiltrative) was also predicted for recurrence and disease‐specific survival.Conclusions.: Even in the presence of mandibular invasion, soft tissue factors are the most important determinants of prognosis. Upstaging tumors on the basis of mandibular invasion is justified. An infiltrative pattern of bone invasion is a marker of aggressive tumor biology and should be included in the pTNM classification. © 2004 Wiley Periodicals Inc. Head Neck 26: 861–869, 2004

Due to a processing error, an early version of this manuscript was inadvertently published online in Head & Neck on September 23, 2003. The publisher has replaced the incorrect version of the published article with the final, accepted version of the manuscript. For archival purposes, the earlier version is available by contacting the publisher at headandneck@wiley.com. This should be considered the definitive version of this article. Background. The aim of this study is to compare complication rates of miniplates versus reconstruction plates in the fixation of vascularized grafts into segmental mandibular defects.Methods. Retrospective analysis of 143 consecutive successful microvascular composite flaps performed between 1993 and 2001 was performed. Data were gathered from a computerized database, case notes and pathology reports. Complications were classified as dehiscence, infection, plate or bone removal.Results. In the series, 49% of patients received miniplates, and 51% received plates. No significant differences in complication rates were found between those grafts fixed with miniplates (27%) and those with reconstruction plates (30%). Plate choice was primarily determined by consultant preference. No significant differences were found in patient, defect, treatrnent, or follow‐up characteristics between the plate groups. Twenty‐nine percent of patients had at least one late complication at the reconstructed site, and this was higher (39%) in those who had postoperative radiotherapy.Conclusions. No evidence was found in this study that the increased rigidity offered by reconstruction plates influences the rate of plate or bone removal, infection, or plate exposure. Thus, the decision to use reconstruction or miniplates is not dependent on the rate of plate complications. © 2003 Wiley Periodicals, Inc. Head Neck 25:456–463, 2003

Nephrogenic diabetes insipidus (NDI) presents an uncommon but formidable clinical challenge in the surgical patient. Two recent cases of NDI with differing aetiology are presented. These cases and a review of the literature illustrate well the diagnosis, fluid and electrolyte imbalances seen and the strategy of treatment required in the post-operative setting. The central role of the recently discovered aquaporin channels in this condition is briefly outlined. Nephrogenic diabetes insipidus has a diverse aetiology and many of the hazards of the condition are peculiar to the surgical setting. The importance of management in a high dependency environment is highlighted.