Search

Purpose Microvascular free tissue transfer (MFTT) is a reliable reconstructive option with variation in perioperative care and a general lack of clinical practice guidelines. Oral and maxillofacial surgeons’ (OMSs) current MFTT perioperative practices in the United States have not been described. This study describes these practices including surgeon practice environment, operative practices, perioperative management, and success. Methods The study design is cross sectional. The sample is composed of OMSs who completed an Oral/Head and Neck Oncologic and Microvascular Surgery Fellowship prior to 2018 in the United States. Data were collected by means of a survey of the study sample. Descriptive statistics were reported. Results Forty surgeons responded to the survey for a response rate of 33.9%. Respondents were 97.5% (n = 39) male and worked in private (n = 8), combination (n = 10), and academic practices (n = 23). Surgeons in private and academic practice performed an average of 23.3 (SD 13.9) and 48.6 (SD 28.6) flaps per year, respectively. The 2-team approach was used by 88.2% of surgeons. Immediate dental implants were placed in osteocutaneous free flaps by 28.6% (n = 2) of private practice surgeons and 70% (n = 14) of academic surgeons. Postoperatively, most patients went to an intensive care unit (ICU) (82.7%, average duration 2.6 days). Anticoagulation or antiplatelet medications were routinely used with the most common choice being aspirin (77.4%, n = 24). Antibiotics were universally administered, often for 3 days or longer (74.2%, n = 23). Self-reported success rates were 95.3% (SD 4.1) and 96.0% (SD 1.7) in private and academic settings, respectively. Conclusion This is the first report of practice trends by microvascular OMSs in the United States. The results of this study suggest that there is variation in MFTT operative and perioperative practices by individual surgeons and practice environment with minimal variation in self-reported success rates.

Depth of invasion (DOI) is an independent predictor of regional metastasis in oral squamous cell carcinoma. Measurement criteria for DOI were modified in the American Joint Committee on Cancer (AJCC) eighth edition. The purpose of this study was to compare DOI AJCC seventh (DOI7) and eighth (DOI8) edition criteria on frozen section accuracy for decisions regarding elective neck dissection (END) in cT1N0 oral squamous cell carcinoma.A blinded, retrospective, comparative study of patients who underwent ablative surgery at the University of Michigan was completed. The predictor variable was criteria for DOI measurement. The outcome variables were concordance between DOI7 and DOI8 measurements and accuracy using thresholds for END. Effect of tumor growth pattern and worst pattern of invasion, and the difference between DOI8 on frozen and permanent specimen were assessed.A total of 30 specimens of T1N0 oral squamous cell carcinoma (16 tongue, 5 alveolus, 5 floor of mouth, 4 buccal mucosa) were included. DOI7 versus DOI8 on frozen and permanent specimen were significantly different (P .05) but clinically insignificant and highly correlated (r 0.99, P .001). One hundred percent concordance between DOI7 and DOI8 was noted on frozen specimen in predicting the need for END when compared with permanent pathology DOI. There was no significant impact of tumor growth pattern or worst pattern of invasion on measurements and no significant difference in DOI on frozen and permanent specimen for DOI8 (P = .68). Excellent agreement between pathologists for all measurements was observed (ICC0.99, P 0001).High concordance between DOI measurements by AJCC seventh and eighth edition criteria suggests that guidelines for DOI thresholds for END in patients with T1N0 tumors developed using the AJCC seventh edition can be safely applied using AJCC eighth edition criteria. DOI measurement by AJCC 8 criteria on frozen specimen can be used to guide decision-making regarding END, given the high correlation to AJCC 8 permanent DOI measurement.

We investigated the overall survival (OS), disease-specific survival (DSS), and disease-free survival among patients with oral lichen planus-associated oral cavity squamous cell carcinoma (OLP-OCSCC). The secondary objective was to assess the annual risk of tumor recurrence or second primary tumor (SPT).A comparative retrospective study was performed of patients with OLP-OCSCC presenting between June 2007 and December 2018 to the Department of Oral and Maxillofacial Surgery, Michigan Medicine (Ann Arbor, MI) and patients with OCSCC in the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database (1973 to 2015).A total of 87 patients with OLP-OCSCC met the inclusion criteria, and 55,165 patients with OCSCC from the SEER database were included. The proportion of women was greater in the OLP group than in the SEER group (56.3 vs 38.0%; P .001). In the OLP group, 47.1% had no smoking history and 43.7% had no alcohol history. Most patients in the OLP group had presented with stage I disease (46.0%) compared with 31.7% in the SEER group (P = .004). Overall, the OS and DSS were significantly greater in the OLP group than in the SEER group at all points from 1 to 5 years (P ≤ .01). In the OLP group, 46 patients (52.9%) had at least 1 recurrence or SPT. At 10 years, the predicted mean number of recurrences was 1.93 per patient (95% confidence interval, 1.56 to 2.39).OLP-OCSCC frequently affects women, nonsmokers, and nondrinkers and presents with localized disease at a high frequency. Patients with OLP-OCSCC have increased OS and DSS and a greater risk of tumor recurrence or SPT compared with OCSCC in the general population. Lifelong, frequent surveillance is recommended for patients with OLP-OCSCC owing to the risk of late recurrence. Future studies are needed to understand the pathophysiology of OLP-OCSCC.

Purpose First branchial cleft fistula/sinus is a rare congenital developmental deformity that can sometimes be acquired from incision and drainage of a branchial cleft cyst. The aim of the present study was to explore the clinical manifestations, diagnosis, and surgical management of first branchial cleft fistula/sinus in both a large patient series and a review of the pertinent literature. Materials and Methods The data from 31 cases diagnosed from February 2004 to April 2019 as first branchial cleft fistula/sinus were retrospectively reviewed. The patient demographic data and outcomes were explored. In addition, we performed a literature review of studies reported from 1923 to 2018 for first branchial cleft fistula/sinus and summarized those results. Results The present study included 31 patients (15 males, 16 females) with a median age of 4 years. All the patients reviewed had presented with a unilateral first branchial cleft fistula/sinus. The parotid region was the most frequent site of presentation (41.9%) in these cases. The fistula/sinus had occurred on the left side in 13 patients (41.9%) and on the right side in 18 patients (58.1%). Of the 31 patients, 24 (77.4%) had acquired the disease from infection of an existing brachial cleft cyst or incomplete previous excision. Of the 31 cases, 28 (90%) had an intimate relationship between the tract and the facial nerve. Despite this close association, no patient developed postoperative facial nerve palsy. Of the 31 operations, 30 (97%) successfully accomplished complete resection with no recurrence postoperatively. Only 1 patient with a history of multiple recurrences experienced a subsequent recurrence, which was successfully treated with a second surgery. Conclusions First branchial cleft fistula/sinus is a frequently misdiagnosed and, therefore, undertreated entity, which leads to recurrence. It is closely associated with the facial nerve and extra auditory canal. The correct diagnosis and meticulous removal can be effectively achieved with minimal risk to the facial nerve.

Strategies for management of patients with, or at risk for, medication-related osteonecrosis of the jaws (MRONJ) - formerly referred to as bisphosphonate-related osteonecrosis of the jaws (BRONJ)-were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position papers in 2007, 2009 and 2014. The position papers were developed by a committee appointed by the AAOMS Board of Trustees and comprising clinicians with extensive experience in caring for these patients, as well as clinical and basic science researchers. The knowledge base and experience in addressing MRONJ continues to evolve and expand, necessitating modifications and refinements to the previous position papers. Three members of the AAOMS Committee on Oral, Head, and Neck Oncologic and Reconstructive Surgery (COHNORS) and three authors of the 2014 position paper were appointed to serve as a working group to analyze the current literature and revise the guidance as indicated to reflect current knowledge in this field. This update contains revisions to diagnosis and management strategies and highlights the current research status. AAOMS maintains that it is vitally important for this information to be disseminated to other relevant healthcare professionals and organizations.

Purpose The purpose of this study was to describe 3 cases of tongue cancer in patients less than 21 years of age. Secondarily, a literature review was performed to examine disease presentation, risk factors, prognosis, and treatment strategies for young persons with tongue cancer. Methods The authors presented 3 cases of childhood tongue cancer between 2009 and 2020 at the University of Michigan Department of Oral and Maxillofacial Surgery (Ann Arbor, MI). An electronic literature review was conducted via PubMed, Embase, Web of Science, and MLibrary. Results Including the present case series, 64 studies reporting 108 cases were identified. Age at presentation ranged from newborn to 20 years, with a mean age of 14.5 years. The majority of patients were female (52.2%); 68.1% of patients presented with T1 or T2 disease. Nodal metastases were seen in 56.1% of patients. The most commonly identified predisposing factors included Fanconi anemia (13.9%), bone marrow transplant (9.3%), tobacco use (6.5%), and xeroderma pigmentosum (4.6%). Most patients received surgery alone (37.5%), followed by surgery with adjuvant radiation (33.8%); 60.6% underwent neck dissection. Overall survival was 60.3% at 1 year and 43.6% at 5 years. Conclusions Oral tongue cancer in the young is a rare disease with poorly understood etiology. There is a need for oncologists and maxillofacial surgeons to collaborate in the study of genetic, social, environmental, and medical risk factors contributing to the disease. All patients should undergo high-throughput genetic sequencing to expand our understanding of the disease process and allow for targeted treatment strategies.

Purpose Perineural invasion (PNI) is considered an adverse histological feature in oral squamous cell carcinoma (OSCC). Controversy exists regarding elective neck dissection (END) in cT1N0M0 OSCC with PNI as the only risk factor. The purpose of this study was to evaluate PNI as an indicator for END, as well as its utility when combined with the depth of invasion (DOI) as a second indicator. Patients and Methods cT1N0M0 (AJCC8) OSCC patients treated from August 1998 to July 2017 in the Department of Oral and Maxillofacial Surgery, University of Michigan (MI), and Beijing Stomatological Hospital, Capital Medical University (BSH) were reviewed. Data from these sites included both prospectively captured data housed in a database and retrospective data. Results 283 cT1N0M0 OSCC patients were analyzed. The tongue was the most common subsite (56.2%). Ninety-nine (99) patients received END and 184 neck observation. PNI was found in only 8 patients (2.83%) all in the tongue or inferior gingiva. END was performed in 7 of the PNI patients. The mean depth of invasion for tumors with PNI was 3.97 mm, compared to 2.54 mm in tumors without PNI. PNI was statistically correlated with nodal disease (pN+) and extranodal extension (ENE+). After using DOI as a primary indicator for END, no additional PNI patients benefited from END. In addition, only 2 patients had PNI identified preoperatively both with 5 mm DOI, and therefore, already indicated for END on the basis of DOI status. Conclusions PNI status is statistically correlated with pN+ and ENE + pathology in cT1N0M0 OSCC. After using DOI as a primary indicator for END, PNI status had no added value in decision making. Even surgeons who do not use DOI will find very limited value in PNI status with less than 1% preoperative prevalence (0.71%) in this patient population.

Buccal squamous cell carcinoma (BSCC) is rare in the United States. Given its location, few anatomic barriers to its spread exist, and it has been found to have a high locoregional recurrence rate. The role of elective neck dissection (END) in the clinically negative neck (N0) is not clear. In the present study, we measured the effect of END on the locoregional and distant metastasis rates among patients with clinically N0 BSCC.A retrospective cohort study was conducted. The sample included subjects diagnosed with BSCC. The primary predictor variable was END status (yes vs no). The primary outcome variable was locoregional recurrence. The secondary outcome variables were distant metastasis and the 2- and 5-year survival rates. Other variables collected included demographic data, initial operation, adjuvant therapy, pathologic data, and stage. Kaplan-Meier and Cox proportional hazards statistics were computed.The sample included 20 subjects with clinical N0 BSCC and a mean age of 67 years (range 42-88); 55% were men. The disease stage was T1 in 30%, T2 in 40%, T3 in 15%, and T4 in 15%. Fifteen subjects underwent END. Of the 5 who had not undergone END, all 5 (100%) had locoregional recurrence and 1 (20%) had metastasis. Of the 15 who had undergone END, 5 (33%) had locoregional recurrence and 1 (7%) had metastasis (P = .002). The 2- and 5-year survival rates for N0 patients without END was 80% and 40%, respectively, compared with 93% and 87% for those who had undergone END.END had a therapeutic role, resulting in a lower locoregional recurrence rate. Also, the 2- and 5-year survival rates were greater for those who had undergone END.

Surgery is the primary treatment modality for oral cavity squamous cell carcinoma (OCSCC). Care team factors, patient factors, and procedure-related factors affect surgical outcomes and overall prognosis. The management of the primary tumor per oral cavity subsite, the management of the neck, and the evaluation of margin status are fundamental surgical principles. In addition, dental rehabilitation is an important functional consideration in the reconstruction following tumor ablation. The use of adjunct surgical tools including surgical navigation and virtual surgery planning allows for patient-specific and highly precise bony ablation and reconstruction. Evidence-based surgical decision-making can optimize treatment outcomes and improve survival.

Oral and Maxillofacial Surgeons have increasing opportunities to train in head and neck oncologic and reconstructive surgery. The development of a fellowship training programs within our speciality has had a transformative effect on the speciality. This survey by the commitee on Maxillofacial Oncology and Reconstructive is aimed to evaluate the impact of fellowship training on the careers of the fellows and speciality from 2005-2015.

Purpose Depth of invasion (DOI) is one predictor of nodal metastasis in oral cavity squamous cell carcinoma (OCSCC) and can facilitate the decision to complete an elective neck dissection (END) in early-stage disease with a clinically negative neck. The purpose of this study was to investigate the accuracy of DOI in intraoperative frozen specimens for T1N0 oral OCSCC. Materials and Methods To compare the accuracy of DOI in frozen versus permanent specimens, we completed a prospective, blinded study of 30 patients with cT1N0 OCSCC who presented between October 2016 and December 2017. Results DOI in frozen specimens was 96.8% accurate in predicting the need for END with a sensitivity of 90.9%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 95.2%. A strong correlation was found between DOIs in frozen and permanent specimens measured by head and neck (HN) pathologists (r = 0.96; 95% confidence interval [CI], 0.93 to 0.97), between HN pathologists using frozen specimens (r = 0.98; 95% CI, 0.95 to 0.99) and permanent specimens (r = 0.95; 95% CI, 0.91 to 0.98), and in DOIs in frozen specimens communicated intraoperatively versus measured by HN pathologist 1 (r = 0.93; 95% CI, 0.86 to 0.97) and HN pathologist 2 (r = 0.95; 95% CI, 0.89 to 0.98). Only 1 patient who did not undergo an END based on frozen specimens was undertreated owing to upgrading of the DOI in permanent specimens. Conclusions DOI in intraoperative frozen sections has an accuracy of 96.8% and may be reliably used as a clinical tool to determine the need for END in early-stage OCSCC.

Purpose Buccal squamous cell carcinoma (BSCC) is rare in the United States. Given its location, few anatomic barriers to spread exist and it has been found to have a high locoregional recurrence rate. The role of elective neck dissection (END) in patients with clinically negative neck (N0) is not clear. This study aims to answer the following research question: Among patients with N0 BSCC, does END improve locoregional control rates, distant metastasis rates, and 2- and 5-year survival rates? Materials and Methods A retrospective cohort study was conducted. The sample included patients who received a diagnosis of BSCC. The primary predictor variable was END status (yes or no). Five institutions participated between June 2001 and June 2011: University of Washington, University of Michigan, University of Tennessee, North Memorial Oral and Maxillofacial Surgery in Minnesota, and Head and Neck Surgical Associates (Portland, OR). The primary outcome variable was locoregional recurrence. Secondary outcome variables were distant metastasis and 2- and 5-year survival rates. Other variables collected were demographic characteristics, initial operation, adjuvant therapy, clinical and pathologic data, and staging. Kaplan-Meier and Cox proportional hazards statistics were computed. Results The sample was composed of 98 patients with clinical N0 BSCC. The mean age was 66 years (range, 30-88 years), and 54% were men. Of the patients, 74 (76%) underwent END. The locoregional recurrence–free rate was 61% for END versus 38% for no END (P = .042). The distant metastasis rate was 4% for END versus 9% for no END. The 2- and 5-year disease-free survival rates were 91% and 75% (P = .042), respectively, for END and 85% and 63% (P = .019), respectively, for no END. Conclusions END had a therapeutic effect, as evidenced by a lower locoregional recurrence rate, lower distant metastasis rate, and improved 2- and 5-year survival rates.

Purpose A variety of modalities has been suggested for treatment of keratocystic odontogenic tumor (KOT), including Carnoy's solution (CS) and modified Carnoy's (without chloroform) solution (MC). The purpose of the present study was to investigate the effect of CS versus MC as it relates to the KOT recurrence rates when used in conjunction with simple enucleation and curettage (EC hazard ratio 6.9). Conclusion In the present retrospective study, the recurrence rate of KOTs treated by E&C with application of CS is significantly lower than that of MC. The data provided could be considered by the Food and Drug Administration for a clinical trial of CS in patients with KOT.

Purpose Despite data showing worse outcomes and aggressive disease behavior, perineural invasion (PNI) has not been well characterized in terms of tumor location, histopathologic features, or cervical lymph node status. The specific aims of this study were to measure correlations between PNI, tumor location, and other known histopathologic characteristics used to define aggressive disease. Materials and Methods This was a retrospective cohort study of adult patients with primary squamous cell carcinoma of the oral cavity who underwent neck dissection. We excluded patients whose neck was previously treated with surgery or radiation therapy. Demographic and histopathologic variables of interest were obtained from patient charts. The primary outcome of interest was PNI, and the predictors of interest included tumor location, histopathologic tumor characteristics, and cervical lymph node status. For continuous variables, mean differences were compared by t tests. For categorical variables, the differences in the distribution of the proportions were analyzed with the χ2 test. All variables were entered simultaneously into a multivariate logistic regression model to control for possible confounding. Statistical significance for the study was set at P Results Three hundred sixty-eight patients met the study criteria. PNI showed statistically significant correlations with lymph node status, tumor depth, and specific primary tumor location. PNI was more likely to be seen in tumors located in the tongue or floor of the mouth. Tumors with PNI had a deeper depth of invasion: 15.9 ± 10.9 mm versus 10.2 ± 10.0 mm (P Conclusions PNI is statistically correlated with tongue and floor-of-the-mouth subsites within the oral cavity, as well as larger tumors, deeper tumors, and disease that has progressed to the lymph nodes. Whether this correlation represents causation in either direction remains unknown.

The need for oral and maxillofacial surgeons to replace and reconstruct defects of the head and neck is common. Trauma, pathology, and congenital etiologies may all lead to the necessity of pedicled or free vascularized flaps. These procedures are a growing part of the specialty and have become important skills in the armamentarium of many maxillofacial surgeons. Although there is plenty of literature in the method of harvest and the usage of each flap, the day-to-day care of these flaps and the perioperative considerations have not been as frequently outlined. In this chapter, we will discuss perioperative management of patients with flap reconstruction.

The desire to target therapies to specific cancers while leaving the host unharmed remains an ongoing quest for scientists, surgeons, radiation oncologists, and medical oncologists. In recent years, great scientific progress has been made in targeted therapies. Although many modalities remain in preclinical validation, some advances affect patient care today. This article summarizes the concepts of targeting and explores current examples of successful targeting and emerging targeting technologies in head and neck oncology.

Epidemiologic data have shown changes in the demographic profile of patients presenting with oral cavity squamous cell carcinoma (SCC) during the past 4 decades. In particular, there has been a marked increase in the number of young women without a history of smoking presenting with SCC of the tongue. A Surveillance, Epidemiology, and End Results review of patients with head and neck cancer identified 5.3% younger than 40 years. After comparing cohorts from 1973 to 1984 with 1985 to 1997, a 60% increase in tongue cancer in patients younger 40 years was noted. Epidemiologic data also have shown that women are tending to delay childbearing to an older age. These 2 factors have resulted in an increasing prevalence of cancer diagnosed during pregnancy. If current trends continue, oral surgeons and maternal fetal medicine obstetric specialists will see an increasing number of pregnant patients presenting with malignancies. This in turn will lead to a number of complex surgical and adjuvant treatment considerations resulting in ethical and moral decisions for which limited data exist to guide best practice. The treatment chosen will affect not only the health of the patient, but also the health of the fetus and ongoing pregnancy. This report describes the case of a woman who was diagnosed with SCC of the tongue at 14 weeks' gestational age. This report presents her treatment course and a review of the literature to support her decisions related to the care given.

Lymph node density is defined as the number of positive lymph nodes per total number of excised lymph nodes. In oral and maxillofacial cancer, there are recent data showing that increased lymph node density leads to worse outcomes for patients. However, data correlating lymph node density with other known risk parameters are lacking. This study investigated whether a direct correlation exists among cervical lymph node density, depth of invasion, perineural invasion, and extracapsular tumor spread.A retrospective chart review was undertaken to include all patients who underwent neck dissection with resection of primary oral and maxillofacial squamous cell carcinoma from January 2009 through July 2014. After applying the exclusion criteria, 286 patients were identified. Primary tumor depth of invasion, perineural invasion, and lymph node status, including extracapsular spread, were obtained from the standard pathology report. Descriptive statistics were applied. The association between 2 continuous tumor characteristics was summarized with the Pearson correlation coefficient, and the association between a continuous and a binary tumor characteristic was summarized with 2-sample t test. Statistical significance for the study was set at a P value less than .05.Mean age at time of surgery was 63.9 ± 12.5 years. The final study included 169 men and 117 women (N = 286). The mean depth of invasion was 12.3 ± 11 mm (range, 1 to 69 mm). Mean lymph node density was 0.04 ± 0.1 (range, 0 to 0.81). There was a positive association between lymph node density and depth of tumor invasion (Pearson correlation coefficient, r = 0.21; P.001). Tumors with perineural invasion had a statistically significant difference in mean lymph node density (0.074 for positive vs 0.024 for negative; P.001). There also was a significant association in mean lymph node density with the presence of extracapsular spread (0.143 for positive and 0.010 for negative; P.001).Statistically relevant positive linear relations among lymph node density, depth of invasion, perineural invasion, and extracapsular spread were identified. Lymph node density could have prognostic implications, because it is statistically correlated with other known prognostic features that lead to poor outcomes. Lymph node density could be an important feature to capture in future prospective trials. Pathology standards would be crucial in this endeavor.

Purpose of reviewThe clinical management of patients with multiple myeloma or solid tumors involving the bone often includes the use of intravenous bisphosphonate therapy. This intervention can decrease the risk of skeletal-related events and help manage bone pain. Osteonecrosis of the jaw – a pheno

Considering the wide variety of options for the reconstruction of posttraumatic and postablative intraoral defects, the palatal flap holds many advantages over other forms of reconstruction. It has been used successfully with minimal morbidity for reconstruction of defects within the reach of the flap. The cases presented herein demonstrate the versatility of this flap, which should be part of the armamentarium of the reconstructive surgeon.

Purpose Nanoparticle drug delivery offers a potential solution in the treatment of cancer. Using a heterotopic tumor model for head and neck squamous cell carcinoma (HNSCC), tumors of variable folate binding protein–alpha (FBP-α) have been treated to delineate receptor necessity as well as efficacy and toxicity of folate targeted chemotherapy. Materials and Methods University of Michigan Squamous Cell Carcinoma (UM-SCC) and American Type Culture Collection (ATCC) cell lines were screened using quantitative real-time polymerase chain reaction for FBP-α expression. Acetylated generation 5 dendrimers conjugated to the targeting moiety folic acid and the therapeutic moiety methotrexate were fabricated and administered to severe combined immunodeficiency (SCID) CB-17 mice inoculated with UM-SCC-1, UM-SCC-17B, and UM-SCC-22B cancer cells. Mice were injected with targeted therapy, free methotrexate, or saline control and monitored for drug efficacy and toxicity. Results Targeted therapy was effective relative to receptor level expression. Targeted therapy could be delivered in molar doses 3 times that of free drug. The treatment of a high folate expression tumor cell population was noted to have increased efficacy over saline ( P P = .03) as well as decreased systemic toxicity. Conclusions This report represents the first translation of dendrimer-based chemotherapy to HNSCC and underscores its effectiveness as an antitumor agent in human cancer cell lines with lower levels of FBP-α than the in vitro and in vivo models previously reported.

One year before the 1918 founding of the American Society of Oral Surgeons and Exodontists, Chalmers J. Lyons, at the request of Cyrenius Darling, MD, Chief of Surgery at the University of Michigan Hospital and Dean of the College of Dentistry, founded an oral surgery training program at the University of Michigan Hospital. It was one of the two first training programs in the United States formed that year and is currently the oldest running US oral and maxillofacial surgery (OMS) training program. Since then, the University of Michigan has been at the forefront of the scope of practice and training in OMS in the United States and beyond (Fig 1). Dr Lyons was a central figure in the development of oral surgery at the University of Michigan and establishing its clinical focus. In 1915 Chalmers J. Lyons was appointed instructor of oral surgery at the University of Michigan College of Dentistry and consultant dentist to University Hospital. With the establishment of the training program, he served as chairman until 1935 (Fig 2). Dr Al Kany, a 1916 graduate of the University of Michigan College of Dentistry, became the first trainee in the 1-year program. By 1922, the length of training was increased to 2 years, and in 1923 a third year was added along with a master of science in oral surgery. In addition to performing exodontia and repairing facial fractures, Dr Lyons had a great interest in cleft lip and palate surgery, having been a student of Dr Truman Brophy in Chicago and Dr Cyrenius Darling, a general surgeon at the University of Michigan. His considerable skill in this arena helped him establish

Treatment of the atrophic maxilla with sinus lift bone graft augmentation and endosseous implants has become common practice and enjoys a strong record of success in the treatment of edentulous patients. Sinusitis has been reported as a complication of sinus lift surgery or perforation of the sinuses by implants. We present an unusual case of methicillin-resistant Staphylococcus aureus (MRSA) infection associated with endosseous implants of the sinuses that illustrates a potentially serious complication of this seemingly benign procedure and illustrates the importance of considering implant exposure and infection as a part of the differential diagnosis in sinusitis.

Purpose To evaluate the current practice of oral and maxillofacial surgeons in Michigan regarding perioperative warfarin therapy and dentoalveolar surgery in defined procedure risk groups. Materials and Methods Surveys were distributed to all surgeons (n = 188) registered with the Michigan Society of Oral and Maxillofacial Surgeons. Low/moderate/high surgery risk groups were defined based on retrospective data accumulated for procedures on pretransplant liver failure patients. We requested the surgeon’s maximum tolerated International Normalized Ratio (INR) for each risk group. In addition, surgeons were asked if their routine practice for each group included continuation or discontinuation of therapeutic warfarin perioperatively. Results A 72.6% response rate was achieved. The average maximum INR cutoff values for the various risk groups were: low, 2.68; moderate, 2.28; and high, 2.01. Routine discontinuation of warfarin occurred in these groups 23.6%, 48.8%, and 70.5%, respectively. Using a paired t test, these results showed statistically significant differences in patient management practices (P < .001) between the low, moderate, and high risk groupings. Conclusion Lack of uniformity exists regarding warfarin therapy and dentoalveolar surgery. No studies to date involve significant numbers of moderate/high risk procedures to provide evidence-based support of safety with maintenance of therapeutic INR. For moderate or high risk procedures, the majority of surgeons prefer warfarin discontinuation with minimally therapeutic or subtherapeutic levels, a practice that secondarily increases risk for thromboembolism. Based on these preliminary data, we believe a prospective trial to elucidate stronger management guidelines for both the moderate and high risk surgery population is indicated.

Purpose A retrospective review of a protocol-driven single institutional experience for treatment of pretransplant liver failure patients requiring dentoalveolar procedures for transplant clearance. Materials and Methods Between January 2003 and June 2005, 30 liver failure patients requiring pretransplant dentoalveolar surgery at the University of Michigan Hospital were treated in the Department of Oral and Maxillofacial Surgery/Hospital Dentistry undergoing 35 total procedures. These patients were stratified preoperatively into 3 different “risk” groups (minimal, moderate, high) based on number and complexity of teeth to be extracted as well as any planned adjunctive preprosthetic procedures. Results Analysis of variance (ANOVA) comparison of groups was conducted, as well as logistic regression analysis and 2-tailed Pearson correlation using χ2 and the Fisher exact test. The only statistically significant (P < .05) predictors of long-term postoperative bleeding were surgeon-defined “risk,” the number of simple extractions, and quadrants of alveoplasty. Additional postoperative correlations were found between long-term bleeding and the need for hospital admission as well as the use of blood products for treatment. Model for end-stage liver disease (MELD), preoperative prothombin time (PT), preoperative partial thromboplastin time (PTT), preoperative international normalized ratio (INR), and preoperative platelet count were not statistically significant in predicting postoperative bleeding. Despite a more aggressive protocol for preoperative management of “high risk” patients, 5/10 (50%) experienced prolonged postoperative bleeding, with 3/5 (60%) requiring admission, while 1/5 (20%) experienced significant prolongation of their current inpatient stay. Review of the data showed that 5/9 (56%) of patients with 10 or more simple extractions developed long-term postoperative bleeding, all of whom had been classified in the “high risk” grouping. Admitted patients remained hospitalized an average of 4 days (range of 1-6 days). Conclusion Even with aggressive preoperative management, pretransplant liver failure patients requiring extraction of at least 10 teeth prior to placement on the liver transplant list are at significant risk of long-term postoperative bleeding and hospital admission for its management.

9607 Background: Head and neck cancer (HNCa) treatment results in unfavorable changes in physical function, body composition and quality of life. The ability of these patients to perform physical activity after cancer treatment has not been previously evaluated. To develop clinical models that will guide the care of HNCa survivors, it is important to characterize these physical activity changes. Methods: From 2008 to 2011, as part of an institutional Head and Neck SPORE longitudinal epidemiology project, health survey data including the Physical Activity Scale in the Elderly (PASE) was collected at baseline, 6 months and annually thereafter. The PASE score assesses the hours doing leisure time physical activity, walking, occupational, and household chores over a typical 7-day period. During follow up, subjects deceased, were lost to follow-up, or refused survey completion. Paired t-test was used to compare the mean PASE score at various endpoints from baseline. Results: 294 HNCa patients completed the survey at baseline. Following a mean follow-up of 25.7 (+/-11.9) months, 66%(n=193), 73%(n=215) and 42%(n=124) of patients completed the assessment at 6-months, 1-year and 2-years respectively. Majority (97%) of the HNCa patients had oropharynx, oral cavity or larynx cancer, which were treated by chemoradiation (36%), surgery followed by chemoradiation (23%) or surgery alone (20%). Results of the PASE score revealed the lowest levels of physical activity at baseline with steady statistically significant improvement at each subsequent timepoint (p