It is difficult to standardize reconstructive surgery, particularly oral and maxillofacial reconstruction including mandibular reconstruction. The standardization of reconstruction has two meanings: standardization of surgical procedures, and standardization of objectives. There are various options for surgical procedures, and they tend to be selected according to the customs of institutions, trends, and the techniques of surgeons and their senses. It is a fact that reconstructive surgery is an art, and has the same characteristics as those of “tailored treatment provided by masters”. However, health care, including cancer treatment, based on scientific evidence and its standardization has become increasingly important, and reconstructive surgery cannot, and should not, go against this trend. In the near future, more emphasis will be placed on “practice” conducted by “scientists”. When considering the standardization of surgical procedures, it is necessary to set its ultimate goals, or to establish the “objectives of reconstruction” as a shared awareness or common recognition. This is essential for the selection of surgical procedures and their standardization. Standardization of the objectives of reconstruction is considered to be an important first step in order to decide on standard surgical procedures. The GRADE system is the optimal system to standardize oral and maxillofacial reconstruction, including mandibular reconstruction, which has the above-mentioned characteristics.

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It is indispensable for standardizing the treatment of a disease to state the goal of the treatment. Various treatments can be selected for reconstructive procedures after segmental mandibulectomy because most patients have relatively acceptable function. This study aims to order the specific goals after segmental mandibulectomy. The specific goals are classified into absolute, standard, and advanced goals, and achievement ratios are set for each goal.

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Standard guidelines for mandibular reconstruction procedures after cancer resection have not been developed. We analyzed operation time, operation blood loss and postoperative complications in patients undergoing mandibular reconstruction using free vascularized osteocutaneous or soft tissue free flaps and investigated the possibility of standardizing mandibular reconstruction. This was a retrospective study of 73 patients who had undergone segmental or subtotal mandibulectomy and free flap reconstruction from 2006 through 2013. Thirty-five patients underwent immediate mandibular reconstruction with free vascularized osteocutaneous flaps and 38 patients with soft tissue flaps. Postoperative complications such as wound infections and fistulas were seen in 20% and 16%. Regarding operation time and blood loss, there was no significant difference between the free vascularized osteocutaneous and soft tissue free flaps. Based on these results, we believe that the free vascularized fibula graft should be the standard choice for mandibular reconstruction after mandibulectomy. Accordingly, multicenter trials including detailed descriptions of individual cases are required.

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We evaluated the choice of methods for mandibular reconstruction after tumor ablative surgery in patients between January 1997 and December 2012, and especially in those patients with fibular graft for segmental manbibulectomy between July 1987 and December 2012. Our strategy for mandibular reconstruction after tumor ablative surgery is as follows: 1. If the vertical alveolar bone defect ranges within 4/1 to 1/3 and the height of the residual mandible is at least 15mm, neither alveolar bone reconstruction nor soft tissue reconstruction is performed, or soft tissue reconstruction alone is performed. 2. If the vertical alveolar bone defect is from 1/3 to 1/2 or if the height of the residual mandible is 10 to 15mm, a combination of alveolar ridge and soft tissue reconstruction using a radial forearm free flap with hemi-radius or (hemi-) fibular graft is performed. 3. If the bone defect accounts for more than 1/2 of the mandible or if the height of the residual mandible is less than 10 mm or in cases of segmental manbibulectomy, a combination of alveolar ridge and soft tissue reconstruction using a fibular graft is performed. The patients consisted of 77 cases and 47 cases, respectively. We examined the validity of our strategy and the choice of method for mandibular reconstruction after tumor ablative surgery.

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We have classified maxillofacial asymmetry from two viewpoints: the fact that all humans have an asymmetrical face, regardless of whether it appears to be normal and symmetrical, and the ability of humans to visually perceive asymmetry. In this study, based on this classification, we investigated skeletal factors influencing self-recognition after surgery in maxillofacial asymmetry patients, and attempted to apply the factors for mandibular reconstruction. We also investigated the limitation of the fibula with regard to these factors and grafted bone resorption and absolute indications. It was suggested that the positional adjustment of the chin (C: center of the mandible) is important, and that changes in the mandibular angle (A) markedly influence self-recognition of asymmetry in patients of mandibular reconstruction. Considering postoperative recognition of asymmetry, grafted fibular bone resorption, and the importance of preserving the peroneal artery for patients and prepositions towards peripheral arterial disease (PAD), the indication of mandibular reconstruction with a free fibular bone flap should be limited to the mandibular straight-line region (B: body of the mandible) not requiring osteotomy with a conserved mandibular angle.

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We investigated how to set the treatment goals for functional reconstruction of cases with mandibular defects from the standpoint of maxillofacial prosthodontists. There are many factors affecting the treatment goals for such cases. The tongue function is the most important factor that determines the recovery of masticatory function. It is important for the medical team to set the treatment goals for each patient.

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Although cetuximab, as a molecular-targeted drug against epidermal growth factor receptors, is expected to have significant therapeutic efficiency in oral cancer patients, it is important to apply cetuximab therapy to suitable cases and to deal with adverse effects such as infusion reaction and interstitial pneumonia during cetuximab therapy. In this report, we examined the expression levels of p16 and EGFRv III in oral cancer patients to elucidate the association between the expression and the efficacy of cetuximab treatment. EGFRv III expression was detected in 50.0% of oral cancer patients and p16 in 14.3%. A significant relation was detected only between EGFRv III expression and the treatment efficacy with cetuximab.

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Metastasis of oral cancer to the mandibular lymph nodes is uncommon. A case of mandibular gingival cancer with mandibular lymph node metastases is reported. A 70-year-old female complaining of gingival pain was referred to our department. Intraoral examination showed a 15×15mm-sized mass with ulcer behind the lower first molar. An incisional biopsy was carried out and revealed squamous cell carcinoma. The patient underwent partial mandibulectomy. However, three months after surgery, mandibular lymph node metastasis with a major axis of 11 mm was revealed by CT imaging, so lymph node resection was performed. There has been no evidence of metastasis at the operative site or other lymph nodes.

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Basal cell adenoma is a rare type of salivary gland tumor. It is benign and most frequently occurs in the parotid gland; it very rarely occurs in the minor salivary gland. We report a rare case of basal cell adenoma of the upper lip. A 75-year-old woman was referred to our hospital complaining of swelling of her upper lip. She had noticed a swelling, movable, painless, elastic-hard mass measuring about 10mm in her upper lip 5 years earlier which had been left untreated. Intraoral examination revealed a marked small swelling without inflammatory symptoms in the center of the upper lip. The lesion was a well-defined submucosal mass. The size of the lesion with high signal was about 5mm and showed mobility. We performed image examination, including magnetic resonance imaging and ultrasonography. The tumor was resected with adequate margin with its surrounding tissue. Histological and immunohistochemical studies were performed, and a diagnosis of basal cell adenoma was made. There has been no sign of recurrence or metastasis for 20 months postoperatively. We consider that careful follow-up remains necessary.

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