Aim: Capillary flowmotion protects composite flaps bycounteracting critical perfusion conditions. However,recent studies have indicated that the flap transfer pro-cedure blunts this protective mechanism. Because heatshock priming is known to protect transferred flaps, theaim of the present study was to analyze whether heatshock priming is capable to preserve the incidence offlowmotion in transferred composite flaps during condi-tions of critical perfusion.

Materials and Methods: Osteomyocutaneous flapswere harvested on the left hindlimb of anesthetizedSprague-Dawley rats (n � 10). The flaps were isolated onthe femoral vessels, and consisted of a tibial bone seg-ment, which was connected with the gracilis and semi-tendinosus muscles and the overlying subcutis and skin.Using a tourniquet, critical perfusion conditions wereinduced by reducing the femoral artery blood flow from0.22 to 0.15 mL/min (controlled by ultrasonic blood flowmeasurement). In 5 animals heat shock priming wasinduced by local heating of left hindlimb in a water bath(42.5°C, 30 min) 24 hours prior to flap harvest. Exterio-ration of the flap allowed for intravital fluorescencemicroscopy (FITC-Dextran 5%) with analysis of inci-dence of flowmotion and functional capillary density inmuscle, skin, subcutis, and periosteum. Results are ex-pressed as means � standard error of the mean. Forstatistical analysis, normality of distribution and equalvariance were tested and ANOVA or Kruskal-Wallis anal-ysis of variance was performed, followed by appropriatepost-hoc comparison.

Results: Before transfer, reduction of femoral arteryblood flow to 0.15 mL/min induced capillary flowmotionin muscle of all flaps, while one hour after transferflowmotion could only be induced in muscle of thoseflaps which were primed by local heat shock. In addi-tion, the functional capillary density was found signifi-cantly (P � .05) enhanced in heat shock-primed osteo-myocutaneous flaps (muscle: 124 � 3; skin: 111 � 4;subcutis: 169 � 15; periosteum: 157 � 7 [1/cm]) com-pared with unprimed controls (muscle: 98 � 1; skin:98 � 1; subcutis: 140 � 1; periosteum: 134 � 7 [1/cm]).

Conclusion: Our study indicates that during the initialreperfusion period of critically perfused flaps, capillaryflowmotion develops only after heat shock priming butnot in controls. Therefore, the protection of transferredcomposite flaps by local heat shock priming depends, atleast in part, on flowmotion-induced maintenance ofnutritive perfusion.

References

Koenig WJ, Lohner RA, Perdrizet GA, et al: Improving acute skin-flapsurvival through stress conditioning using heatshock and recovery.Plast Reconstr Surg 90:659, 1992

Rucker M, Vollmar B, Roesken F, et al: Microvascular transfer-relatedabrogation of capillary flow motion in critically reperfused compositeflaps. Br J Plast Surg 55:129, 2002

Funding Source: Grant of the Deutsche Forschungsgemeinschaft(Me 900/1-3).

Reconstruction With ZygomaticusImplants Following ExtensiveMaxillectomyBrian Schmidt, DDS, MD, PhD, University of California,San Francisco, School of Dentistry, 521 ParnassusAvenue, C-522, Box 0440, San Francisco, CA 94143-0440 (Pogrel MA)

Introduction: The reconstruction of a maxillary defectfollowing tumor resection continues to pose a challengefor the oral and maxillofacial surgeon. Following a max-illectomy patients have difficulty with nasal leakage,speech, chewing, swallowing, and cosmetic disfigure-ment. The reconstructive options following maxillec-tomy include a prosthetic obturator, nonvascularizedgrafts, local flaps and microvascular free flaps. While theobturator can be used to effectively manage the func-tional, cosmetic, and psychological problems associatedwith a maxillectomy defect, difficulties with retention,support, and stability can be encountered following ex-tensive maxillary resections. Zygomaticus implants offera reconstructive option to overcome the loss of retentiveanatomy following an extensive maxillectomy.

Materials and Methods: The design of this study was aretrospective review. Seven patients treated with zygo-maticus implants following maxillary resection wereevaluated. The charts, radiographs, and clinical photoswere reviewed to characterize the maxillary defect, de-scribe the method of zygomaticus implant placement,and determine the technique of maxillary obturator con-struction. In addition, records were reviewed to deter-mine the outcome following prosthesis insertion.

Results: A total of 7 patients with extensive maxillaryresections were reconstructed with a combination of 21zygomaticus and 8 endosseous implants. The indicationsfor extensive maxillary resection in this series of caseswere as follows: squamous cell carcinoma (n � 4), ade-noid cystic carcinoma (n � 1), polymorphous low gradeadenocarcinoma (n � 1), and extensive maxillary mu-cormycosis infection (n � 1). Four of 7 patients havebeen fully reconstructed with a maxillary obturator withexcellent speech, swallowing, and aesthetics. The 3 re-maining patients have had no loss of implants and are inthe process of osteointegration of the implants prior toconstruction of the maxillary obturator.

Discussion: The results of this study demonstrate thatthe combination of zygomaticus and endosseous im-plants can be used to retain and support a maxillaryobturator following extensive resection of the maxilla.Zygomaticus implants are associated with a high successrate and allow for retention of the obturator. In conclu-sion, patients have highly favorable speech, swallowing,and eating following reconstruction of extensive maxil-

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52 AAOMS • 2003

lary defects with zygomaticus and endosseous implantsand a maxillary obturator.

References

Rogers SN, Lowe D, Brown JS, et al: Health-related quality of life aftermaxillectomy: A comparison between prosthetic obturation and freeflap. J Oral Maxillofac Surg 61:174, 2003

Davison SP, Sherris DA, Melan NB: An algorithm for maxillectomydefect reconstruction. Laryngoscope 108:215, 1998

Management of Salivary GlandNeoplasms: A 10-Year SurgicalExperienceR. Bryan Bell, DDS, MD, 1849 NW Kearney, Suite 300,Portland, OR 97209 (Dierks EJ; Homer L; Potter BE)

Refined imaging technology and the use of adjuvantradiotherapy has altered management strategies for pa-tients with benign and malignant salivary gland tumorsduring the last 2 decades. Optimal treatment regimenshave yet to be fully realized.

Purpose: The purpose of this preliminary analysis is toreview our 10-year experience in the management ofpatients with a variety of salivary gland tumors treatedwith various combinations of surgery, radiation, andchemotherapy.

Methods: The medical records of patients who under-went surgery for major and minor salivary gland tumorsat a regional referral center from 1992 to 2002 wereretrospectively reviewed. The data collected includeddemographics, symptoms, site, histological diagnosis,pathologic features, stage, treatment, and outcome. De-scriptive statistics are presented and preliminary statisti-cal analysis performed in an attempt to identify predic-tors of survival and locoregional control.

Results: One hundred twenty-eight patients were iden-tified in whom adequate follow-up could be confirmed;67 (52%) of these patients were treated for benign tu-mors and 61 (48%) had malignant disease. Pleomorphicadenoma was the most common salivary gland neoplasmin the series (49/128, 38%), the most common benigntumor (49/67, 73%), and was located primarily in theparotid gland (44/49, 90%). Mucoepidermoid carcinomawas the second most common salivary gland neoplasm(30/128, 23%), the most common malignancy (30/61,49%), and was slightly more prevalent in the minorsalivary glands (17/30, 57%). Thirty-nine percent (24/61)of the patients with malignant tumors presented withadvanced stage disease (stage � 3 or 4) and/or nodalmetastasis (8/61, 13%). Treatment was surgical in all but2 of the patients with benign neoplasm. All patients withmalignant tumors were treated primarily with surgery.Adjuvant radiotherapy was utilized for patients with ad-vanced stage disease, high grade histopathology, peri-neural invasion, or inadequate surgical resection mar-gins. Chemotherapy or neutron beam therapy was, in

general, reserved for unresectable or recurrent cases.With follow-up of 3 months to 10 years, disease-freesurvival and locoregional control rates were 63% and77%, respectively.

Conclusion: The management of salivary gland tumorsremains primarily surgical. The impact of adjuvant ther-apies on locoregional control and disease-free survivalawaits further study.

References

Garden AS, El-Naggar AK, Morrison WH, et al: Postoperative radio-therapy for malignant tumors of the parotid gland. Int J Radiat OncolBiol Phys 37:79, 1997

Armstrong JG, Harrison LB, Spiro RH, et al: Malignant tumors ofmajor salivary origin: A matched pair analysis of the role of combinedsurgery and postoperative radiotherapy. Arch Otolaryngol Head NeckSurg 116:290, 1990

Comparisons of Treatment: Cherubismand Cleidocranial Dysplasia: TheToronto ExperienceRobert P. Barron, DMD, BSc, FADSA, 152 Maple SugarLane, Thornhill, Ontario L4J 8T8 Canada (Zosky J;Sandor GKB)

Introduction: Cherubism is an autosomal dominantdisorder mapped to the SH3-binding protein (SH3BP2)on chromosome 4p16.3. Treatment traditionally has in-volved correcting the aesthetic deformity and removal ofmultiple impacted teeth. Cleidocranial dysplasia (CCD)is an autosomal dominant bone disease and is thought tobe caused by heterozygous mutations in RUNX2/PEBP2alphaA/CBFA1. CCD patients also manifest multi-ple impacted teeth necessitating comprehensive man-agement. This paper compares treatment in both ofthese unique patient groups and looks for predictivefactors for their management.

Materials and Methods: The 2 study groups comprisedthe following patients. Group 1 included 22 patientsdiagnosed with CCD that were followed prospectivelyfor 6 years. In Group 2 there was a 22-year follow-up forfamilial cherubism from one family comprised of motherplus 4 children. The success of their treatment wasjudged by the ability to bring teeth into the occlusion.

Results: In the patients with CCD 98 teeth were ex-posed and bonded, of which 91 teeth were successfullyerupted into occlusion. This group consisted of 14 inci-sors, 24 cuspids, 41 premolars, and 12 molars. Seventeeth did not erupt. In the cherubism patients therewere 10 teeth which were congenitally absent, 2 ofwhich were from the primary dentition. Nine teeth wereimpacted or ectopically erupted including one supernu-merary amorphous tooth. An additional 9 teeth requiredremoval from 5 patients. The statistical analysis consistedof a paired t test comparing the 2 groups. Statisticallysignificant differences existed between patients in thecherubism group and the CCD group.

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