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The breakdown products buy generic modafinil on-line insomnia prevalence, such as laudanosine and acrylates 100 mg modafinil insomnia zanaflex, have no clinical significance at the doses of atracurium used in the clinical setting modafinil 200 mg low cost insomnia zoloft temporary. Cisatracurium (Table 21-3) was developed in an attempt to reduce atracurium’s propensity for histamine release. It is a potent cis-cis isomer of atracurium, and its onset time is longer than that of atracurium. For this reason, the plasma concentrations of the metabolite laudanosine are similarly lower when cisatracurium is used. Mivacurium (Table 21-3) was developed initially as the “ideal nondepolarizing neuromuscular blocking agent” that promised to achieve rapid onset with a duration of action significantly shorter than that of intermediate-duration agents. The cis-cis isomer has a much longer half-life (30 minutes) than the other two isomers (2 to 3 minutes), but it represents only 6% of the mixture, so its overall contribution to the drug’s duration of action is limited. In order to avoid histamine release when39 large doses are administered, some have suggested a “split-dose” technique in which a dose of 0. When mivacurium is administered for tracheal intubation, four factors increase the probability of achieving excellent conditions: increasing mivacurium dose; opioid coadministration; delaying time to intubation (from 1 minute to 2 minutes); and patient age (>70 years). Because of its rapid metabolism, the41 differential onset between the central (laryngeal) and peripheral (adductor pollicis) muscles is exaggerated. Thus, if the timing of tracheal intubation is guided by neuromuscular responses of peripheral muscles (e. Reversal of mivacurium-induced neuromuscular block is either spontaneous or pharmacologic, using anticholinesterases. Neostigmine also inhibits plasma cholinesterases (that should slow mivacurium metabolism), but these effects are less than the inhibition of acetylcholinesterases, resulting in a “net” reversal of nondepolarizing block. Administration of whole blood or fresh frozen plasma (each of which42 contains pseudocholinesterase) is not recommended unless there is another primary indication for the transfusion. Although mivacurium had been withdrawn from the United States market, it recently (2017) has been re- introduced into clinical use. Usually, combining two chemically similar drugs with similar duration of action (e. Combining different drugs43 25 95 with different duration of action is a special case of interaction: when a short- duration drug (mivacurium) is added at the end of a vecuronium-based block, recovery will follow the intermediate (vecuronium) block. In contrast, when vecuronium is added during recovery from mivacurium, the vecuronium recovery will be shorter, similar to that of mivacurium. This apparent paradox is due to the fact that recovery will always follow that of the drug that blocked the majority (70% to 90%) of the receptors (the loading dose drug); the additional, maintenance drug dose is in comparison very small, and only blocks a small proportion (10% to 15%) of the free receptors. Thus, the predominant characteristics of recovery will be those of the loading drug. Inhalational anesthetic agents potentiate neuromuscular block (desflurane > sevoflurane > isoflurane > halothane > nitrous oxide), likely by direct effects at the postjunctional receptors. The intravenous agent propofol has minimal effect on neuromuscular transmission, although the potency of rocuronium is enhanced after a 30-minute propofol infusion. It is likely that these apparently47 contradictory effects of local anesthetics on neuromuscular transmission depend more on their plasma concentration rather than the type of local anesthetic. Hypercarbia, acidosis, or48 hypothermia, however, may further potentiate the depressant effects of antibiotics in the critically ill patient. In patients receiving acute administration of anticonvulsants (phenytoin, carbamazepine), neuromuscular block is potentiated, whereas chronic administration significantly decreases the duration of action of aminosteroids while having little effect on benzylisoquinolinium compounds. Multiple reports have documented their benefits in facilitating tracheal intubation and maintenance of mechanical ventilation, particularly in patients requiring prone positioning for acute respiratory distress. In addition, continuous neuromuscular block for prolonged periods (days) should be avoided, particularly in patients who receive steroid therapy concurrently. In general, neuromuscular diseases can be classified into disorders of55 neuromuscular transmission, disorders of muscle and muscle membrane, disorders of lipid or glycogen storage, peripheral neuropathies, and disorders of the central nervous system with neuromuscular manifestations (Table 21- 4). Hypokalemia potentiates nondepolarizing block and decreases the effectiveness of anticholinesterases (neostigmine) in antagonizing nondepolarizing block. Acidosis interferes with the effects of anticholinesterases in reversing a nondepolarizing block. All drugs with significant hepatic and renal metabolism (aminosteroids) will be affected and their duration of action prolonged by liver and kidney dysfunction. Given that there are over 230 million major surgeries performed every year worldwide, the number of patients exposed to potential complications is56 huge, and appropriate monitoring is a major patient safety issue. Aside from the cost of the monitors and related disposables (electrodes), there are no significant potential complications from monitoring neuromuscular function, so the risk–benefit ratio is heavily in favor of monitoring. Several57 anesthesiology organizations around the world have recently published best- practice guidelines that recommend neuromuscular monitoring when neuromuscular blocking drugs are administered. Nerve stimulators (and the stimulation units of the neuromuscular monitors) deliver a range of currents between 0 and 70 milliamperes (mA). The impulse generated by the nerve stimulator should have a square-wave pattern (i. The intensity of60 neurostimulation (charge, in Coulombs, Q) is a product of current (in amperes, A) and the duration of stimulation (pulse width, in seconds). For61 instance, a charge of 4 μC can be achieved by either using a current stimulus of 20 mA with a pulse width of 200 μsec or a current stimulus of 10 mA with a pulse width of 400 μsec. The current should be constant over the duration of the impulse (which is at least 100 μsec to ensure depolarization of all nerve endings, but less than 300 to 400 μsec to avoid exceeding the nerve refractory period). The current is delivered via surface (skin) stimulating electrodes that have a silver–silver chloride interface with the skin, reducing its resistance. Surface electrodes are preferred to the invasive, transcutaneous needle electrodes. The optimal conducting surface area is circular, with a diameter of 7 to 8 mm; this area provides sufficient current density to depolarize peripheral nerves. Skin can have very high resistance (up to 100,000 Ohms), and “curing” the skin (i. Monitoring Modalities The first nerve stimulators delivered single repetitive stimuli at frequencies between 0. The amplitude of the evoked muscle response is plotted over time, and has a sigmoidal shape. Once the amplitude of the muscle response no longer increases as current intensity increases, the response is maximal, and the current required is called “maximal current. The characteristics of the various patterns of neurostimulation currently in use clinically are summarized in Table 21-5. B: Acceleromyographic neuromuscular monitor—StimPod (Xavant Technologies, Pretoria, South Africa). Electrodes are placed along the ulnar nerve, with the negative (black) electrode distal to the positive (red) electrode. The accelerometer is taped to the thumb, with the sensor perpendicular to the direction of thumb adduction. T = first stimulus in the sequence; T =1 2 second stimulus in the sequence; T = third stimulus in the sequence; T = fourth3 4 stimulus in the sequence. Unblocked state, no fade between tension at the beginning of the 5-second stimulation (S ) and the end of the stimulation (S ). The ratio of tension at the end of the1 5 5-second stimulation to that at the beginning is the tetanic ratio (S /S ratio).

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Complete destruction of the dermis requires wound excision and grafting to prevent a wound infection that may lead to local sepsis and systemic inflammation cheap 100 mg modafinil with visa insomnia light therapy. Fourth-degree burns involve muscle buy modafinil 100mg without prescription sleep aid pregnant, fascia best 100mg modafinil sleep aid magnesium, and bone, necessitating complete excision and leaving the patient with limited function. These proportions are somewhat different in children, depending on the age and size. To estimate the size of a burn, the child’s palmar surface (excluding the digits) represents about 0. For example, thermal trauma caused by flames in a closed space is likely to be associated with airway damage. Burns 3788 resulting from motor vehicle, airplane, or industrial accidents may be complicated by other traumatic injuries. Airway Complications Injury to various parts of the airway occurs following inhalation of heated air, steam, or toxic substances. Airway and lung injury also may occur in the absence of inhalation via the inflammatory mediators released from the burned tissues, infection, and fluid resuscitation. Respiratory distress in the initial phase of a burn is usually caused by direct heat or steam injury to the pharynx or larynx. Singed facial hair, facial burns, dysphonia or hoarseness, cough, soot in the mouth or nose, and swallowing difficulties in patients with or without respiratory distress should increase the suspicion of upper (frequent) and lower (occasional) airway injury. In the upper airway, glottic and periglottic edema and copious thick secretions may produce respiratory obstruction. This may be aggravated by fluid resuscitation even in the absence of significant inhalation injury. In lower airway burns, decreased surfactant and mucociliary function, mucosal necrosis and ulceration, edema, tissue sloughing, and secretions produce bronchial obstruction, air trapping, and bronchopneumonia. The presence of a lung injury markedly increases the fluid requirements (30% to 50%) and the mortality rate from thermal injuries. In patients with massive burns, stridor, respiratory distress, hypoxemia, hypercarbia, loss of consciousness, or altered mentation, immediate tracheal intubation is indicated. The intubation technique selected depends on the operator’s experience, the age of the patient, and the extent of airway compromise. In adults, awake fiberoptic intubation under adequate topical anesthesia, if feasible, is probably the safest approach, but other techniques using conventional blades or videolaryngoscopes with or without anesthetic induction or supraglottic airway–guided intubation may also be used. The presence of full stomach may preclude the use of a supraglottic airway, except as a bridge to a secure airway. Methylnaltrexone, which antagonizes the peripheral but not the central effects of morphine, antagonizes gastric effect of morphine and facilitates its emptying without causing agitation. Airway humidification, bronchial toilet, and bronchodilators if needed for bronchospasm are also indicated. Table 53-12 Lund–Browder Body Surface Area Calculation Table Used during Admission of the Patient to Determine Percent Burn Size, Location, and Estimated Burn Depth The pediatric airway is particularly challenging because its small diameter carries the risk of occlusion by minimal amounts of swelling. Prophylactic 3790 intubation may therefore be required in children who are suspected of having an inhalation injury, even though they are not yet in respiratory distress. Prophylactic tracheal intubation may also be indicated in adults when the resources for careful follow-up are insufficient. Prophylactic intubation carries the risk of dislodgment, especially during intra- or interhospital transport. Thus tracheal intubation should be based on clear criteria such as large full- thickness burns, inability to protect the airway, or signs of airway obstruction. It may avoid tracheal intubation in patients who would otherwise be considered candidates for this procedure. Fiberoptic bronchoscopy has the additional advantage of providing information about the lower airway, although it is more uncomfortable for the patient and requires topical anesthesia of the tracheobronchial tree. From days 2 to 5, hypoxia may result from atelectasis, bronchopneumonia, and airway edema resulting from mucosal necrosis and sloughing, viscous secretions, and distal airway obstruction. Lack of response to therapy because of severe ventilation–perfusion mismatching or shunt may be an indication for the use of nitric oxide, a potent, short-acting vasodilator, via the airway. It also interferes with mitochondrial function, uncoupling oxidative phosphorylation and reducing adenosine triphosphate production, thus causing metabolic acidosis. Cyanide or− hydrocyanic acid is produced by incomplete combustion of synthetic materials and may be inhaled or absorbed through mucous membranes. The usual clinical presentation is unexplained metabolic acidosis in the absence of cyanosis. Nonspecific neurologic symptoms such as agitation, confusion, or coma are also common findings. Immediate administration of O , which is2 required for all burn victims, may be lifesaving for this complication. Fluid Replacement Immediately after a serious burn microvascular permeability increases, causing the loss of a substantial amount of protein-rich fluid into the interstitial space. A major burn, a delay in initiation of resuscitation, or an inhalation injury increases the size of the leak. In addition, cardiac contractility may decrease because of circulating mediators, a diminished response to catecholamines, decreased coronary blood flow, and increased systemic vascular resistance. Smaller burns can be managed with oral or intravenous replacement at 150% of the calculated maintenance rate and careful monitoring of fluid status. Intravascular volume should be restored 3794 with utmost care to prevent excessive edema formation in both damaged and intact tissues resulting from the generalized increase in capillary permeability caused by the injury. Edema from overaggressive resuscitation has many deleterious and potentially life-threatening effects. Mention has already been made of the facilitation of upper airway edema after rapid fluid infusion in large cutaneous burns with or without smoke inhalation. Abdominal edema may also occur, and when resuscitation volume exceeds 300 mL/kg/24 hours, increased intra-abdominal pressure may produce abdominal compartment syndrome with impedance of venous return. This, together with decreased tissue oxygen tension, may produce necrosis of damaged but viable cells, increasing the extent of injury and the risk of infection. Crystalloid solutions are preferred for resuscitation during the first day following a burn injury; leakage of colloids during this phase may increase edema. Some centers use plasma with crystalloid routinely and partly attribute the good outcomes of their patients to this practice. Avoidance of early over- resuscitation, routine use of colloids, and adherence to protocols are recommended to prevent this problem. Albumin 5% may be administered after the first day following injury at a rate of 0. These formulas are guidelines only, and none can be expected to provide adequate restoration of intravascular volume in all burn victims, especially small children and patients with inhalation injuries. An increase in Hct during the first day suggests inadequate fluid resuscitation because hemolysis and sequestration are actually expected to cause a decrease in this parameter. Acute anemia, as may occur during excision and grafting of burns, is usually well tolerated. Blood replacement is usually not initiated until the Hct is decreased to 20% to 24% in healthy patients requiring limited operations, to approximately 25% in those who are healthy but need extensive procedures, and to 30% or more when there is a history of pre-existing cardiovascular disease. Dopamine in small doses (5 μg/kg/min) and/or β-adrenergic agents may improve urine output without further need for fluids.

Whether resuspending vesicles in water for electron micros- copy has any effect on vesicle morphology is unclear but within Isolation and Characterization of Placental Extracellular Vesicles 127 3 h discount 100 mg modafinil with mastercard sleep aid vs benadryl, micro- and nano-vesicles can still be observed under elec- tron microscopy suggesting that these vesicles are resistant to hypotonic lysis modafinil 200mg discount sleep aid in turkey. For the visualization of vesicles by electron microscopy cheap modafinil 200 mg on-line sleep aid tryptophan, less is more as excess loading onto the copper mesh grids will break the coating present. In our experience, extracellular vesicles from 4 frst trimester placental explants need to be resus- pended in at least 2 mL of ultrapure water to be dilute enough for visualization. From four placental explants, carefully do a 1:1000 dilution of the 1 mL of collected extracellular vesicles as a starting dilu- tion for analysis on the NanoSight system. Check the dynamic range of the NanoSight system used to adjust sample dilution as required. Rapidly infusing the sample into the NanoSight system will trigger and turn on the laser and camera for detection. Analysis of extracellular vesicles under fow conditions techni- cally increases the volume measured and therefore should be more representative and accurate. The measured concentration tends to reduce during the later analyses from any sample, potentially due to settling of the vesicles. Therefore, always try to complete recordings for each vesicle sample as quickly as possible, and if required, outliers can be removed before calculating the fnal averages. Acknowledgments Mancy Tong is a recipient of the University of Auckland Health Research Doctoral Scholarship and the Freemasons Postgraduate Scholarship. Cold Spring Harb Perspect Med 5(3): S, Mor G (2004) First trimester trophoblast a023028. Am J Obstet Gynecol 187(2): human placental syncytiotrophoblast 450–456 microvesicles in preeclampsia. Trophoblast debris extruded from preeclamp- 040196 tic placentae activates endothelial cells: a mech- 17. Aswad H, Jalabert A, Rome S (2016) Depleting measured using NanoSight nanoparticle track- extracellular vesicles from fetal bovine serum ing analysis. Interestingly, exosomes secreted from placental cells have been identifed in maternal circulation as early as in 6 weeks of gestation, and their concentration increases with the gestational age. While there is growing interest in elucidating the role of exosomes during normal and complicated pregnancies (such as preeclampsia), progress in the feld has been delayed because of the inability to isolate placental exosomes from maternal circulation. Therefore, here we describe a workfow to isolate placental exosomes from maternal circulation. Exosomes measure between 40 and 100 nm and have a very stable lipid bilayer, which is the result Padma Murthi and Cathy Vaillancourt (eds. Exosomes have been found to contain a diverse array of signaling molecules, however little is known about the mechanism by which they are packaged. These signaling molecules are thought to be released from the parent cell into the exosome following the exocytotic fusion of the multivesicular bodies with the cell membrane. Once the exosome is released into the extracellular space, some exosomes have the capability to travel along the systemic circulation to interact with distant tissues in the body as a form of non-hormonal signaling or communication. Since the exosomes are in the systemic circulation, they present an opportunity for the development of a noninvasive biopsy of the tissue of origin, which presents a new approach to the development of screening and diagnostic tests. There are no studies, however, that have isolated specifc placental exosomes from mater- nal circulation. For each reaction, transfer 20 μL of protein A-coated bead of Antibody to Protein slurry into a 0. Transfer diluted antibody solution to the beads and incubate the antibody solution with beads at room temperature for 60 min with rotation. Briefy centrifuge (~2690 × g) and aspirate antibody solution from beads and reserve 5 μL for analysis. If the reaction was successful, the antibody should only be detected in the input sample. Optional: Perform titration experiments on the antibody- conjugated beads by serial dilution using agarose beads (see Note 5). Exosomes were previously isolated from 500 μL plasma using of Exosome a combination of differential ultracentrifugation followed by with Antibody- ultrafltration (see Note 6). Make an additional replicate sample as the starting exo- some (sample input in Fig. Add diluted exosome to the antibody-conjugated beads and incubate overnight at 4 °C with rotation. Centrifuge and transfer the supernatant to tubes containing 10 μL of 1 M Tris pH 8. Isolation of Specifc Exosomes from Material Circulation 135 Crossed-linked 250 150 100 75 50 Heavy chain 37 25 Light chain 20 15 10 kDa Fig. Remove primary antibody and wash blot three times with Tris-buffered saline with 0. Remove secondary antibody, and wash blot six times with Tris-buffered saline with 0. This is due to protein G having a higher affnity for mouse antibodies compared to protein A. In addition, non-purifed sources of antibodies can also be used, such as from ascites fuid or conditioned medium. However, due to diffculties in quanti- fying the amount of antibody, a purifcation step should ideally be performed initially using protein A or G agarose. A simple method to completely remove the supernatant with- out disturbing the beads pellet is by the use of a rolled up wipers. Titration experiments should be performed due to the large excess of antibodies conjugated to a small volume of beads. The beads can be diluted with protein A agarose, or as a cheaper alternative, sepharose beads. This protocol has been designed to enrich placental exosomes from a total exosomes population. Therefore, this workfow can be used to enrich placental exosomes after exosomes isolation from maternal plasma. Trans-Blot® Turbo™ Transfer System is based on the transfer of proteins using semidry chemistries. Brit Med Hypertensive disorders and severe obstetric J 347:f6564 morbidity in the United States. Annu Rev Cell Dev Biol 30:255–289 techniques and assessment of the stability of 8. Sweeney E, Kobayashi M, Correa P et al (2015) Proteomics 13(22):3354–3364 Gestational diabetes mellitus is associated with 16. Schageman J, Zeringer E, Li M, Barta T, changes in the concentration and bioactivity of Lea K, Gu J et al (2013) The complete exo- placenta-derived exosomes in maternal circula- some workfow solution: from isolation to tion across gestation. Curr Protoc Cell Biol Chapter extravillous trophoblasts in preeclampsia: 3:Unit 3.

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Te Te survival rates of extraoral implants depend on the site viability of all components of the prosthesis should be assessed of implantation purchase 200mg modafinil with mastercard insomnia one-liners, ranging from 73 order modafinil 100mg on-line sleep aid pill. Radiographs do not need to highest failure rates are observed in the frontal bone modafinil 100 mg line sleep aid essential oil, zygoma, be performed routinely, because a right-angle projection, mandible, and nasal maxilla. Te lowest implant failure rates which allows assessment of the implant-bone interface, is not are observed in the oral maxilla. Clinical evaluation of implants placed into irradiated bone appears to be even the stability of the implant and the status of the surrounding higher and also depends on the retention system of the pros- tissues is crucial. Te time of the In addition, there appears to be a direct correlation between second-stage surgery, when the skin-penetrating abutments the level of hygiene and infammatory soft tissue reactions of are attached to the implant, needs to be adjusted accordingly the skin at extraoral implantation sites. In the mastoid, where and a radical neck dissection, the patient may be impaired in the success rate of osseointegrated implants is high, the his or her movements, or the patient many not be able to see second-stage procedure is performed after 3 to 4 months. Orbital implants are most difcult for the Alternatively, a one-stage procedure can be used. In all other patient to clean, and the failure rate is the highest among all craniofacial locations and in irradiated bone, a healing period facial locations. Te foor of the nose is the easiest to clean of 6 months is advised, as clinical experience has shown that and has the lowest rate of soft tissue reactions leading to loss osseointegration appears to be slower, likely due to difer- of the implant. Patient follow-up should there- tion and prosthetic restoration can be shortened in patients fore be adjusted to the individual needs. If soft tissue reac- with a poor tumor prognosis, for maximal improvement of tions are found and the patient is unable to clean the implant 31 quality of life. Infammation can be caused by Postoperative Considerations surrounding tissues that are too thick and mobile. It is there- fore favorable for the skin of mucosa to be thin and frmly A craniofacial prosthesis requires a lifetime commitment and attached to the underlying bone. For the survival of endosseous can be thinned out in the area where the implant is inserted craniofacial implants, it is especially important that the at the time of implantation. To avoid this problem, it is important to check the ties may have problems cleaning the implant sites. In addi- removed; it is not sufcient to excise the skin surrounding tion, implants in the temporal bone and the orbit are difcult the implant. In these situations, a split-thickness skin graft to visualize for cleaning purposes. Patients should be informed should be transplanted as a secondary procedure, as the that prostheses need to be replaced at certain intervals, implants are already in place. If skin grafts are performed in because the color and the material, and therefore the aesthetic the nasal or oral cavity, mucosa transplants should be used appearance of the appliance, will change due to sunlight, air for transplantation. In general, it is better to avoid such prob- pollution, or loss of fexibility of the material. Patients may lems by preparing the implant site several weeks prior to also require diferent prostheses as their skin color changes implantation with a skin graft, in cases where the locally due to diferent degrees of suntan. Osseointegrated implants in the treatment of cial prostheses: life span and aftercare, Int J Preoperative assessment of the maxilla for the edentulous jaw, Scand J Plast Reconstr Surg Oral Maxillofac Implants 23:89, 2008. Branemark P-I, Adell R, Breine U et al: Intra- Perkutane Verankerung von Gesichtsepithe- 12. In Haneke E, editor: Fortschritte der installation of osseointegrated implants in the J Plast Reconstr Surg 3:81, 1969. Tjellström A, Rosnehall U, Lindström J et al: 0- to 8-year follow-up, Otolaryngol Head Neck 14. Nimii A, Fujimoto T, Nosaka Y, Ueda M: A evaluation, J Oral Maxillofac Surg 70:1551, Implantaten als Halteelementen zur funktio- Japanese multicenter study of osseointegrated 2012. Jacobsson M, Tjellström A, Tomsen P, Tures- patients with oral malignancies treated with integrated craniofacial implants in the reha- son I: Integration of titanium implants in irra- radiotherapy and surgery without adjunctive bilitation of orbital defects: an update of a diated bone: histologic and clinical study, Ann hyperbaric oxygen, Int J Oral Maxillofac retrospective experience in the United States, Oto Rhino Laryng 97:337, 1988. Granström G: Osseointegration in irradiated tion efects on bone healing and reconstruc- Osseointegrated implants in the treatment of cancer patients: an analysis with respect to tion: interpretation of the literature, Oral Surg the edentulous jaw, Scand J Plast Reconstr Surg implant failures, J Oral Maxillofac Surg 63:579, Oral Med Oral Pathol Oral Radiol Endod 111:1, 1977. Karayazgan B, Gunay Y, Atay A et al: Facial oxygen, J Oral Maxillofac Surg 64:812, 2006. Micro- ric loss to restore mandibular continuity and to separate the 5-8 vascular free tissue transfer has revolutionized the way sur- oral cavity from sinonasal cavities. Soft tissue defects geons address composite defects from ablative surgery of involving the overlying skin, mucosal defects involving the large tumors in a single-stage procedure. Furthermore, con- lip or cheek, and sensory and motor nerve defcits all defne temporary management of the patient with head and neck which reconstructive option is best for functional recovery. Vascularized lomandibular defects reconstructed with vascularized bone bone faps from the fbula or iliac crest donor sites provide free faps makes it necessary to devise treatment strategies good to excellent bone volume and quality, which are required that meet the patient’s expectations in terms of function, for osseointegration to enhance prosthetic rehabilitation. Edentulous Composite free faps from the scapula are selected when the cancer patients who do not achieve oral rehabilitation after soft tissue requirements of the defects are signifcant or when cancer surgery can exhibit signifcant psychological morbid- the use of the fbula donor site is contraindicated due to poor ity. However, this bone fap has a comparatively poor provide a more conventional setting for prosthetic recon- bone volume for osseointegration (Table 24-1). If it is struction of the dentoalveolar arch and surrounding selected, two to four implants, no more than 10 mm in structures. Subsequent as the primary setting and subsequently irradiated as 86% (n debulking of the overlying soft tissue most likely will be = 81 implants). One such strategy is to take advantage of the rich vas- cular bed for osseointegration before the delivery of adju- If a patient has received radiation therapy to the head and vant radiation therapy. Implant placement at the time of the neck region, review of the simulation plan, including dosim- initial reconstructive procedure also shortens the overall etry and felds, is necessary to determine whether native bone treatment time to a defnitive prosthetic restoration. Patients who undergo a hyper- anastomosis of recipient vessels is complete, implant place- baric oxygen protocol15,16 do so to enhance the vascularity of ment can be performed before the insetting of the soft the surgical bed before implant surgery. After primary has been reported as benefcial to postirradiated native man- implant placement, the restorative team must allow 12 to dible17,18 and fbula free faps. When addressing the recon- stent can be used and secured to the implants for healing struction of the dental arch with osseointegrated fxtures, our purposes before the fabrication of the defnitive prosthesis. When the remaining arch is edentu- depending on the clinical situation and the patient’s wishes. A reconstruction, and prosthodontic rehabilitation with adjunc- minimum of four or fve implants, with the greatest anterior- tive radiation. Tis also holds true for implant placement into posterior spread to minimize cantilever forces of the distal native bone at the time of tumor resection to optimize pros- extension of the prosthesis, is recommended to restore the thetic rehabilitation without additional surgical reconstruc- total dental arch. Primary implant placement can circumvent on the contralateral side of the mandible is potentially limited the need for hyperbaric oxygen before secondary placement by the inferior alveolar neurovascular bundle and mental of fxtures in patients who will receive radiation therapy nerve. Tis problem may Issues regarding peri-implant soft tissue maintenance also require excision and simple repair to possible split thickness arise. Te dibular and maxillary defects are reviewed in the following reader is encouraged to review Chapter 19 for technical sections. A Doppler may The dissection plane should be advanced to the level of the under- be helpful in fnding the location of these vessels. Orientation of skin and will determine whether the base tissue procedures such as debulking or deepithelialization of the or apex of the triangle is oriented as the neoridge of the maxilla 24 skin paddle often must be performed, along with implant place- or mandible. These factors have signifcant implications for ment, to facilitate a more favorable tissue emergence of the whether implants can be placed in the immediate setting at the dental implants. As men- The advantages of the fbula free fap have made this a “work- tioned, the fbula is best positioned at the inferior border of the horse” fap for mandibular reconstruction of discontinuity defects.