Horseshoe Le Fort I osteotomy: an augmentation technique for the severely atrophied maxilla--an eight-year follow-up

Twenty-three patients (19 female, 4 male; 37-69 years old; mean age, 52 years) underwent horseshoe Le Fort I osteotomy from 1989 to 1997; 178 iMZ implants were placed either simultaneously by horseshoe Le Fort I osteotomy (76 implants) or in a second operation 6-12 months later (102 implants). Removable overdentures were made. Twenty-two patients wear an implant-borne overdenture; 1 patient refused an additional operation for placing implants and received a conventional, mucosally supported, upper-jaw prosthesis. The anteroposterior relationship satisfactorily improved in all patients, allowing for class I occlusion. All patients were satisfied with the aesthetic results, denture retention, speech, and mastication. Nevertheless, we lost 8 implants in 1 patient. We placed 178 endosteal implants in 22 patients; 8 were lost in 1 patient, and 7 more implants have been lost in 5 patients.

The L-shaped osteotomy for vertical callus distraction in the molar region of the mandible: a technical note

The following report refers to a well described surgical procedure using a prototype vertical distractor developed in Cologne in cooperation with Martin Medizintechnik GmbH. The surgical technique has been refined by an L-shaped osteotomy stabilized posteriorly by a miniplate to limit the amount of callus regeneration in the molar region where no increase in vertical height is required. The surgical technique with its advantages and one complication is described as used in four patients undergoing six distraction treatments.

[Telenavigation and expert consultation using a stereotaxic surgical videoserver]

The exponential increase of medical information creates a need for new methods in the visualization of medical imaging modalities for diagnosis and therapy. In this sense, visualization includes the display of medical image data and image-guided stereotaxic navigation as well as the advice of an expert. The Artma Virtual Patient System enables a remote expert to observe the surgical procedure via the Internet and interactively modify the interoperative visualization from the remote location. The expert in the remote location receives the planning data almost in real time over TCP/IP from a stereotaxic videoserver. In addition to live video streaming, stereotaxic navigation data are sent over the network as rigid body coordinates. The expert modifies the surgical simulation on the remote computer and the modified operating plan is sent back to the operating site. By teleconsulting, the composite images and overlapping graphics--instruments, target structures, landmarks, contour--can be seen in affiliated clinics with the possibility of interactive graphical assistance. With this image fusion technology the knowledge of a remote expert is included in virtual data structures and visualized by the overlay with live video data (augmented reality) in real time during surgery.

Cryptic splice site activation during RNA processing of MLL/AF4 chimeric transcripts in infants with t(4;11) positive ALL

Co-expression of multiple variants of the MLL/AF4 fusion transcript is a common phenomenon in patients with acute lymphoblastic leukemia (ALL) with t(4;11)(q21;q23). Different transcriptional and post-transcriptional mechanisms were found to contribute to the heterogeneity of the chimeric transcripts. Multiple splice variants are generated by utilizing alternative splice sites that result in the joining of different MLL-exons within the breakpoint cluster region to one of three exons in the AF4 fusion partner. To address the question of how splice site selection occurs during RNA processing, we investigated der(11) transcripts in 10 infants with t(4;11) positive ALL. Specific RT-PCR products were analyzed by Southern blot hybridization, SSCP, endonuclease digestion, cloning and sequencing. In patients co-expressing as many as six different chimeric mRNA species, activation of cryptic splice sites has been detected in MLL-exons 8 and 10. This led to the formation of four novel transcript variants, three of which maintained open reading frames (ORFs). Patients with cryptic donor site activation in MLL-exon 8 did not have any MLL-exon 8/AF4 transcripts using the authentic 5' splice site, although this site is 100% homologous to the consensus sequence. However, since MLL-exon 8 does not end in-phase, the use of the authentic splice site would result in loss of the ORF of the fusion message. The activated cryptic splicing sites are located in the vicinity of the polypurine stretches present in MLL-exons 8 and 10, which are known to function as splicing enhancers recognized by SR proteins. We postulate that both the nonsense-mediated decay eliminating correctly spliced MLL-exon 8/AF4 mRNAs and activation of suboptimal splicing sites contribute to the diversity of MLL/AF4 RNA species.

Clinical experience with interactive teleconsultation and teleassistance in craniomaxillofacial surgical procedures

PURPOSE

The objective of this study was to evaluate the clinical value and feasibility of surgical telenavigation and teleassistance technology in the field of craniomaxillofacial surgery.

MATERIALS AND METHODS

The technology is based on the principles of augmented reality environment technology and remote stereotactic visualization. A consultant surgeon in a remote location receives video, audio, and stereotactic navigation data from the operation site almost in real-time and, using a head-mounted display, is emerged in the surgical augmented reality environment. By telepresence or teleconsultation, the composite images and superimposed graphics (instruments, target structures, landmarks, contours) can be seen and discussed in connected clinics with the possibility of interactive manipulation and assistance.

RESULTS

Interactive teleassistance was used in 27 cases of various types craniomaxillofacial surgery. The principles of computer-aided telenavigation were applied successfully. Technical problems in 6 cases did not cause a breakdown of overall system performance.

CONCLUSION

Teleconsultation with remote experts is a useful tool, although some shortcomings exist. The financial and personal effort involved is considerable.

Computer-aided surgery in distraction osteogenesis of the maxilla and mandible

When using unidirectional intraoral distraction devices, it is desirable to be able to determine the final position of the bone fragment after the distraction procedure. However, additional constraining forces from adjacent tissues render the prediction of the distraction direction difficult. We have utilised computer-aided surgery in three patients for intraoperative control of the distraction direction. In one cleft palate patient, suffering from maxillary hypoplasia and anterior open bite, a modified Le Fort I osteotomy and maxillary distraction was performed. Despite a ventrocaudal position of the distraction device, intraoperative computer visualisation showed an unfavourable caudal vector of distraction without any anterior movement. The final result confirmed the direction indicated by the computer. Maxillary advancement remained insufficient. In two patients suffering from mandibular hypoplasia, intraoperative assessment revealed a favourable direction of distraction. The distraction procedure led to a satisfactory result in both cases. Computer-aided surgery is helpful in assessing the vector of distraction intraoperatively, making the result of the distraction procedure more predictable and allowing instant correction by adequate reapplication of the device.

[Horse shoe Le Fort I osteotomy. Surgical technique for reconstruction of the extremely atrophied maxilla]

Twenty-three patients with class VI atrophy of the maxilla were treated with horseshoe Le Fort I osteotomy. In ten patients, simultaneous placement of the implants was carried out, and in 12 the implantation was done in a second procedure 6-9 months later. A total of 178 implants were placed, and 15 were lost. In one patient, five implants were lost due to an oronasal fistula, leading to loss of part of the bone graft. The implant survival rate for all the implants was 89.0-88.2% in the one-step procedure and 90.0% in the two-step procedure. There was no difference between the one-step and the two-step procedure with respect to the peri-implant soft tissues in follow-up of least 2 years after implantation. We favor the two-step procedure because it allows more precise positioning of implants.

Positioning of dental implants using computer-aided navigation and an optical tracking system: case report and presentation of a new method

A navigation system for computer-aided surgery (Virtual Patient System, VPS) has been described in previous studies for different indications in oral and maxillofacial surgery. The aim of the system is the intraoperative transfer of preoperative planning on radiographs or CT scans on the patient, in real-time, and independent of the position of the patient's head. Until now an electromagnetic tracking system has been used for intra-operative position measurement. For placement of dental implants, the electromagnetic tracking system is not suitable since the motor of the implant drill leads to a considerable distortion of the magnetic field, thus direct visualization of drilling the implant socket was not possible. To overcome this problem, an optical tracking system which is not disturbed by conductive materials was integrated in the VPS system. The first patient operated on with this system had a posttraumatic loss of the upper incisors; three implants have been placed according to the prosthetic axis previously planned on radiographs and CT scans. The experience gained in this intervention led to the conclusion that computer-aided surgery provides a valuable tool in implant dentistry.

Systematic distortions in magnetic position digitizers

Medical devices equipped with position sensors enable applications like image guided surgical interventions, reconstruction of three-dimensional 3D ultrasound (US) images, and virtual or augmented reality systems. The acquisition of three-dimensional position data in real time is one of the key technologies in this field. The systematic distortions induced by various metals, surgical tools, and US scan probes in different commercial electromagnetic tracking systems were assessed in the presented work. A precise nonmetallic six degree-of-freedom measurement rack was built that allowed a quantitative comparison of different electromagnetic trackers. Also, their performance in the presence of large metallic structures was quantified in a phantom study on an acrylic skull model in an operating room (OR). The trackers used were alternating current (ac) and direct current (dc) based systems. The ac trackers were, on average, distorted by 0.7 mm and 0.5 degree by metallic objects positioned at a distance greater than 120 mm between the geometrical center of the sample and the sensor. In the OR environment, the ac system exhibits mean errors of 3.2 +/- 2.4 mm and 2.9 degrees +/- 1.9 degrees. The dc trackers are more sensitive to distortions caused by ferromagnetic materials (averaged value: 1.6 mm and 0.5 degree beyond a distance of 120 mm). The dc tracker shows no distortions from other conductive materials but was less accurate in the OR environment (typical error: 6.4 +/- 2.5 mm and 4.9 degrees +/- 2.0 degrees). At distances smaller than approximately 100 mm between sample and sensor error increases quickly. It is also apparent from our measurements that the influence of US scan probes is governed by their shielding material. The results show that surgical instruments not containing conductive material are to be preferred when using an ac tracker. Nonferromagnetic instruments should be used with dc trackers. Static distortions caused by the OR environment have to be compensated by precise calibration methods.

Calibration of tracking systems in a surgical environment

The purpose of this paper was to assess to what extent an optical tracking system (OTS) used for position determination in computer-aided surgery (CAS) can be enhanced by combining it with a direct current (dc) driven electromagnetic tracking system (EMTS). The main advantage of the EMTS is the fact that it is not dependent on a free line-of-sight. Unfortunately, the accuracy of the EMTS is highly affected by nearby ferromagnetic materials. We have explored to what extent the influence of the metallic equipment in the operating room (OR) can be compensated by collecting precise information on the nonlinear local error in the EMTS by using the OTS for setting up a calibration look-up table. After calibration of the EMTS and registration of the sensor systems in the OR we have found the average euclidean deviation in position readings between the dc tracker and the OTS reduced from 2.9+/-1.0 mm to 2.1+/-0.8 mm within a half-sphere of 530-mm radius around the magnetic field emitter. Furthermore we have found the calibration to be stable after re-registration of the sensors under varying conditions such as different heights of the OR table and varying positions of the OR equipment over a longer time interval. These results encourage the further development of a hybrid magnetooptical tracker for computer-aided surgery where the electromagnetic tracker acts as an auxiliary source of position information for the optical system. Strategies for enhancing the reliability of the proposed hybrid magnetooptic tracker by detecting artifacts induced by mobile ferromagnetic objects such as surgical tools are discussed.

High sequence similarity within ras exons 1 and 2 in different mammalian species and phylogenetic divergence of the ras gene family

We have determined the canine and feline N-, K-, and H-ras gene sequences from position +23 to +270 covering exons I and II which contain the mutational hot spot codons 12, 13, and 61. The results were used to assess the degree of similarity between ras gene DNA regions containing the critical domains affected in neoplastic disorders in different mammalian species. The comparative analyses performed included human, canine, feline, murine, rattine, and, whenever possible, bovine, leporine (rabbit), porcelline (guinea pig), and mesocricetine (hamster) ras gene sequences within the region of interest. Comparison of feline and canine nucleotide sequences with the corresponding regions in human DNA revealed a sequence similarity greater than 85% to the human sequence. Contemporaneous analysis of previously published ras DNA sequences from other mammalian species showed a similar degree of homology to human DNA. Most nucleotide differences observed represented synonymous changes without effect on the amino acid sequence of the respective proteins. For assessment of the phylogenetic evolution of ras gene family, a maximum parsimony dendrogram based on multiple sequence alignment of the common region of exons I and II in the N-, K-, and H-ras genes was constructed. Interestingly, a higher substitution rate among the H-ras genes became apparent, indicating accelerated sequence evolution within this particular clade. The most parsimonious tree clearly shows that the duplications giving rise to the three ras genes must have occurred before the mammalian radiation.

Extensive facial vascular malformations and haemangiomas: a review of the literature and case reports

We present 6 selected cases of extensive facial vascular anomalies extending to the skull base or actually involving it. These patients are compared with other cases in the literature. The spontaneous course of these vascular lesions is different and so variable treatment modalities are suggested depending on the age of the patient and the type of lesion. In young children, haemangiomas are common and spontaneous involution is characteristic. Conservative treatment in the sense of a wait-and-see approach is thereby favoured if there is no urgent indication such as involvement of essential structures, e.g. blockage of an orifice as demonstrated in one case or complications such as excessive bleeding. Vascular malformations most commonly appear in adults, there is no tendency to spontaneous involution and resection is usually necessary, especially in arteriovenous malformations. Nowadays, preoperative superselective embolization is recommended to minimize intraoperative blood loss. Superselective embolization is the treatment of choice in cases of a-v fistulae. Proximal ligation of the supplying arteries should be avoided because this may make embolization more difficult, and may be responsible for the common occurrence of rapid revascularization.

Computer-aided navigation in secondary reconstruction of post-traumatic deformities of the zygoma

Augmented reality technology was used in 5 patients for secondary reconstruction of post-traumatic unilateral deformities of the zygomaticomaxillary complex. Three electromagnetic sensors interfaced to a computer-aided navigation system (ARTMA Biomedical Inc.) were utilized. The computer navigation procedure was planned by drawing graphic lines on the CT scan at the level of the zygomatic arch, representing the outer surface of the zygoma. The desired position of the displaced zygoma was planned by mirroring from the healthy side, using a virtual mid-sagittal plane. These virtual graphics were presented intraoperatively on a TV monitor and also on the surgeon's see-through head-mounted display. Correct reduction was assumed when the virtual line representing the position of the zygoma before the osteotomy reached the virtual line defined preoperatively as the desired position. The advantages of the technique presented are that a complete exposure of the zygomatic bone is no longer necessary, and coronal and subciliary incisions may be avoided unless enophthalmos correction has to be carried out, which was in fact necessary in 2 patients. The results of zygomatic reconstruction have been satisfactory in all 5 patients.

Remote stereotactic visualization for image-guided surgery: technical innovation

Additional data from imaging sources using computer navigation assistance enables virtual visualization of anatomical structures in three dimensions for stereotactic navigation during an operation. Recent developments in communication technology enable the broadcasting not only of video data, but also of stereotactic navigation data via the network. By telepresence/teleconsulting, the composite images and overlapping graphics (instrument, target structure, landmark, contour) can be seen in connected clinics, with the possibility of interactive graphic assistance. In cranio-maxillofacial surgery, the first surgical teleconsultation in real time via telecommunication of stereotactic data was performed in August 1996. A patient suffering from a post-traumatic deformity following multiple comminuted midface fractures was re-osteotomized with the aid of image-guided surgery using teleconsultation: the intraoperative position achieved could be discussed with different surgeons with regard to symmetry, hard/soft tissue relationships and occlusal details, with the possibility of on-screen planning interaction and real time evaluation of the results, over a distance of 500 km.

Horseshoe Le Fort I osteotomy in combination with endosteal implants--a median-term follow-up study

Fourteen patients with Class VI resorption of the maxilla were treated with horseshoe Le Fort I osteotomy. In 11 cases, the procedure was followed by the placement of endosteal implants. In six patients, simultaneous placement of implants was carried out, while in five patients this was done in a second procedure. Ten patients wore their implant-supported dentures. In one patient, 5/8 implants were lost due to nonintegration. Three patients lost one implant each. The total number of implants placed was 76, and the survival rate of the implants was 88.1%. In the one-step procedure (n = 42), the survival rate was 84.8%; in the two-step procedure (n = 34), 92.3%. In comparison of the one-step to the two-step procedure, there was no statistically significant difference (P > 0.11) between the amount of marginal peri-implant bone loss and the condition of the peri-implant soft tissues as measured 2 years after implantation.

Endosteal implants in the irradiated lower jaw

Since 1990 Endosteal implants have been inserted in the irradiated lower jaw at our clinic. IMZ implants have been used for dental rehabilitation in 26 patients (21 male, 5 female) suffering from squamous cell carcinomas stage T2-T4 136. The implants were either placed in local bone and soft tissue (group 1, n = 60 implants), or in local bone after marginal mandibulectomy and transplanted soft tissue (group 2, n = 26 implants), or in transplanted bone and soft tissue (group 3, n = 52 implants). Life-table analysis according to Kaplan-Meier demonstrated a 3-year implant survival rate of 87.8% in Group 1, 69.1% in Group 2 and 58.3% in Group 3. There was no statistical significant difference in the amount of marginal bone loss and the degree of marginal infection between the three groups (P > 0.29). Major complications: A mandibular fracture passing through an empty implant socket 8 months after implant loss (Group 2) was caused by postradiation-osteonecrosis; implant removal and bone resection was mandatory. The poor results of the bone graft group may be explained by two patients, in whom simultaneous placement of implants in nonvascularized bone grafts was carried out, intraoral tissue breakdown led to graft failure and loss of the implants (n = 10).

Absence of N-ras mutations in myeloid and lymphoid blast crisis of chronic myeloid leukemia

Mutations within N-ras oncogene codons 12, 13, and 61 occur in approximately 25-30% of patients with acute nonlymphocytic leukemia and at a lower frequency (6-20%) in patients with acute lymphocytic leukemia. Moreover, N-ras mutations have been described in patients with chronic myeloid leukemia (CML) in blast crisis but have not been observed during the chronic phase of the disease. In view of the morphological and clinical similarities between acute leukemia and the blast crisis of CML, the question was raised whether the presence of N-ras mutations is associated with the phenotype of acute leukemia. We investigated leukemic cells from 100 patients with CML for the presence of N-ras mutations in the mutational hot spot codons. The cases analyzed included 87 diagnosed with different types of blast crisis and 13 cases in accelerated or chronic phase of the disease. Fragments from N-ras exons I and II containing the codons of interest were amplified by polymerase chain reaction and analyzed for the presence of point mutations by three different technical approaches, including specific oligonucleotide hybridization, direct sequencing, and single-strand conformation polymorphism analysis. N-ras mutations were not detected in any of the CML patients investigated. Only one patient, in whom the initial diagnosis of CML-blast crisis had been revised to chronic myelomonocytic leukemia, displayed an N-ras mutation within codon 13. Our data strongly suggest that N-ras mutations do not play a role in myeloid or lymphoid blast crisis of CML.