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By: W. Fraser, M.A.S., M.D.

Medical Instructor, University of Oklahoma College of Medicine

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Anterior arch reconstructions depression mentality definition 20mg geodon mastercard, for example depression symptoms ehow buy 80 mg geodon otc, require multiple osteotomies to duplicate the shape of the arch; the bone must be wide enough to take the placement of osseointegrated dental implants and strong enough to withstand the stresses of mastication. Lateral segment defects are less likely to require dental implants and, particularly in the ascending ramus, require smaller quantities of bone. In doing so, this will minimize subsequent problems with trismus and malocclusion. More specifically, the fibula flap is best suited for anterior, lateral or hemi-mandibular reconstructions with small to moderate-sized soft tissue defects of the external skin or intraoral lining. The radius is sometimes a better alternative for the rare patient who requires a large quantity of thin, pliable skin for intraoral lining and/or who has a small, non-load-bearing lateral bony defect that does not require osteotomy. These defects are less likely to require dental implants and require smaller quantities of bone. An ideal example is a defect of the oropharynx after composite resection of cancer of the tonsil and lateral pharyngeal wall with resection of the ascending ramus of the mandible. The relative lack of both bone and soft tissue bulk with this flap constitutes a strong contraindication for this particular application. Major anterior reconstructions performed with the radius typically have poor lower lip support, an accentuated edentulous appearance and a concavity of the anterior neck soft tissues (2,3). Similarly, patients with extensive skin and soft tissue defects with minimal bone defects that do not require osteotomy tend to be the best candidates for the scapular osteocutaneous flap. For example, when an extensive soft tissue defect necessitates reconstruction of both the intraoral lining and external skin, the scapular flap may be the best option (2,3). The iliac crest osteocutaneous flap provides a large amount of bone, with the shape of the crest resembling the hemimandible. However, the bone usually cannot be osteotomized without compromising the blood supply and therefore the shaping of anterior segment mandibular reconstructions becomes less precise. This flap, therefore, is only indicated when the other options are unavailable (3). Finally, in defects of the posterior or lateral mandible associated with extensive defects of the posterior and superior soft tissue, the fibula or other osteocutaneous flaps may not be adequate to meet either the volume or surface area requirements of the defect. For example, coverage of multiple zones including the soft palate, lateral inferior pharynx, tonsillar pillars and lateral sulcus of the cheek is often necessary. In addition to the skin and mucosal lining requirements, there are often very substantial soft tissue and volume/space-filling requirements. For example, the resection may include the soft tissue of the lateral pharynx with or without the masseter muscle, which can result in a very large-volume soft tissue defect. Resections extending superiorly into the glenoid fossa and/or all the way up to the temporal bone are also not uncommon. Furthermore, in addition to the mucosal lining, the ablative resection may result in a through-and-through defect extending to the skin, thereby requiring reconstruction of both the intraoral mucosa and external skin. In these circumstances, soft tissue flaps alone, such as the vertical rectus abdominus myocutaneous flap or anterolateral thigh flap, may be required. Composite soft tissue defects can also be closed with a single folded double island flap such as an anterolateral thigh or vertical rectus abdominus myocutaneous, rather than with a fibula skin island, which has a limited rotational degree of freedom around the intramuscular septum (2,21). The exceptional attributes of the fibula flap make this the first choice in the majority of cases, particularly in anterior reconstruction and in patients requiring multiple osteotomies (3). The fibula flap is based on the peroneal artery, one of three branches of the popliteal artery. In the proximal third of the lower leg, the peroneal artery descends beneath the flexor hallucis longus muscle to reach the medial aspect of the fibula. In the middle third of the fibula at its approximate midpoint, it gives rise to the nutrient artery, providing the major endosteal blood supply. In addition to the nutrient artery, there are usually vessels arising directly from the peroneal artery that supply the fibular diaphysis. Because the fibula has both an interosseous (nutrient artery) and segmental blood supply, multiple osteotomies can be made as close as 2 cm apart without concern for bone viability (22,23). The straight quality of the bone with adequate height and thickness makes it the ideal bone stock for precise shaping and receipt of osteointegrated implants.

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Tumor invades lateral pterygoid muscle mood disorder children geodon 80mg visa, pterygoid plates depression definition icd 10 cheap geodon 40 mg online, lateral nasopharynx or the skull base or encases the carotid artery Regional lymph nodes (N stage) the N staging system for regional cervical lymph nodes is uniform for all epithelial tumors of the upper aerodiges tive tract (37). The nodal staging system in the past took into account only the size and multiplicity as well as the unilateral or bilateral presence of metastatic nodes as the parameters for N staging. Important prognostic parameters such as the location of the metastatic lymph node as well as the presence of capsular penetration and extranodal exten sion were not used as parameters in the N staging system. However, it is well known that the presence of metastatic lymph nodes beyond the firstechelon locations and the presence of extranodal soft tissue extensions of metastatic tumor carry a significant negative impact on prognosis (38,39). The new nodal staging system (8th edition) has addressed these issues and included extranodal extension References 263 Table 7. Predictive value of tumor thickness in squamous carcinoma confined to the tongue and floor of the mouth. Determination of deep surgical margin based on anatomical architecture for local control of squamous cell carcinoma of the buccal mucosa. Relationship between appearance of tongue carcinoma on intraoral ultrasonography and histopathologic findings. Oral cavity squamous cell carcinoma: role of pretreatment imaging and its influence on management. Prospective, blinded trial of whole-body magnetic resonance imaging versus computed tomography positron emission tomography in staging primary and recurrent cancer of the head and neck. The relative prognostic utility of standardized uptake value, gross tumor volume, and metabolic tumor volume in oropharyngeal cancer patients treated with platinum based concurrent chemoradiation with a pre-treatment [18F] fluorodeoxyglucose positron emission tomography scan. Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. Human papillomavirus in non-oropharyngeal head and neck cancers: a systematic literature review. Low etiologic fraction for high-risk human papillomavirus in oral cavity squamous cell carcinomas. Molecular classification identifies a subset of human papillomavirusassociated oropharyngeal cancers with favorable prognosis. Improved survival is associated with treatment at high-volume teaching facilities for patients with advanced stage laryngeal cancer. Importance of the treatment package time in surgery and postoperative radiation therapy for squamous carcinoma of the head and neck. Prophylactic percutaneous endoscopic gastrostomy tube placement in treatment of head and neck cancer: a comprehensive review and call for evidence-based medicine. Analyses of distant metastases in squamous cell carcinoma of the head and neck and lesions above the clavicle at autopsy. Integration of the totality of treatment intentions is a concept that has not been paid attention to in the past. With advancing stage of the disease at presentation or with recurrent disease, the probability of cure diminishes and the need for addressing the issues pertaining to quality of life and symptomatic palliation becomes increasingly important. Thus, covering all bases at the outset allows smooth transition from curative, invasive and expensive therapies into cost-effective symptomatic care with control of pain, nutrition and overall optimization of quality of life and eventually quality of death. This approach allows delivery of value-based care, with optimal utilization of available resources. Primary and secondary prevention strategies including lifestyle changes are also important to address. Due to the acute short-term as well as long-term sequelae of multimodal therapy, such strategies are generally reserved for advancedstage disease, where single-modality treatments are not effective in controlling the disease. Surgery remains central in the management of oral cavity cancers and is sometimes required in oropharyngeal cancer patients. For oral cavity lesions, most small tumors (T1 and T2) can be accessed via a transoral approach with retention of function. Surgical resection is further required in salvage treatment after persistent or recurrent disease after failing primary radiation or chemoradiation therapy. The benefits of radiation therapy as the initial definitive treatment are primarily anatomical organ preservation, coverage of a wider treatment field and its use in patients who cannot tolerate surgery for medical reasons. Radiation is preferred for patients in whom surgical resection would result in irreversible morbidity, including total glossectomy or laryngectomy. Due to the sensitivity of surrounding normal tissues exposed to ionizing radiation, several factors need to be considered during the treatment selection process. Long-term sequelae of radiation therapy are common, particularly in tissues with low radiation tolerance, such as the salivary glands (leading to xerostomia), dentoalveolar structures (increasing the risk of osteoradionecrosis) and neural tissues as a result of ischemic nerve injury.

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