Extracranial Hypoglossal Schwannoma: Case Report and Literature Review

BACKGROUND

Schwannomas are solitary neurogenic tumors originating from the myelin sheath of peripheral nerves. Extracranial hypoglossal schwannomas comprise <5% of all head and neck schwannomas and can mimic submandibular salivary gland tumors.

CASE REPORT

We report the diagnostic imaging, surgical treatment, and histopathological findings of a rare case of extracranial schwannoma of the hypoglossal nerve in a 73-year-old female, presented with an asymptomatic swelling in the left submandibular region that had been persisted for approximately three years.

CONCLUSION

Accurate diagnosis of this rare clinical entity requires comprehensive diagnostics. The optimal therapeutic strategy is nerve-sparing surgical excision, although it can be challenging.

Influence of analytical procedures on miRNA expression analyses in saliva samples

Aim of this study was to demonstrate the influence of different analytical procedures and techniques on the resulting miRNA expression profile in healthy control subjects and tumor patients using the oral squamous cell carcinoma (OSCC) model and to demonstrate the technical and biological reproducibility. Body fluids such as saliva are suitable for non-invasive miRNA analysis because ubiquitously circulating miRNA can be found in them. It was technically possible to distinguish between healthy and diseased samples based on the miRNA expression profile found. Regardless of the methodology used, good technical reproducibility of the results seems to be achievable. On the other hand, biological reproducibility was inadequate, which is why prompt sampling and sequencing is recommended. The data indicate that malignant lesions can be detected using miRNA signatures extracted from saliva. This could stimulate further research to establish standardized protocols and kits for sample collection, miRNA extraction, sequencing and interpretation of results.

Evaluation of Five-year Overall Survival Rates Among 18,331 Head and Neck Cancer Patients Exposed to Different Targeted Therapies Through Real-world Data in a Case-controlled Study

BACKGROUND/AIM

Targeted therapy is an important and fast developing aspect of modern tumor therapy including therapy of head and neck cancer (HNC). Surgically treated patients often experience significant limitations to their ability to swallow, speak, or mimic expressions. In cases of recurrent tumors or palliative situations, targeted therapies such as immune checkpoint inhibitors (ICI) are frequently employed. This study compared different targeted therapies focusing on survival probability.

PATIENTS AND METHODS

Data from patients with head and neck cancer treated with different therapy regimens from the TriNetX network were analyzed. Two groups were formed: Cohort I received one targeted therapy, whereas patients in cohort II received a different targeted therapy. Cohorts I and II were matched 1:1 with respect to certain confounders. After defining the primary outcome as "death", a Kaplan-Meier analysis was performed, and the risk ratio (RR), odds ratio (OR), and hazard ratio (HR) were calculated.

RESULTS

A total of 18,331 patients with HNC treated with targeted therapy were analyzed. Patients treated with VEGF inhibitors had a significantly longer overall survival than patients treated with c-MET or EGFR inhibitors. Patients treated with PI3K inhibitors showed a significantly reduced survival probability compared to those treated with c-MET, mTOR, and RET inhibitors.

CONCLUSION

EGFR inhibitors are one of the most frequently used targeted therapies in HNC. However, in the present analysis, a survival advantage of patients treated with c-MET inhibitors or VEGF inhibitors was observed compared to those treated with EGFR inhibitors.

Impact of antithrombotic therapy on acute and delayed intracranial haemorrhage and evaluation of the need of short-term hospitalisation based on CT findings after mild traumatic brain injury: experience from an oral and maxillofacial surgery unit

PURPOSE

The primary aim was to compare the prevalence of acute and delayed intracranial haemorrhage (ICH) following mild traumatic brain injury (mTBI) in patients on antithrombotic medication referred to a clinic for oral and plastic maxillofacial surgery. The secondary aim was to evaluate the need for short-term hospitalisation based on initial radiological and clinical findings.

METHODS

This was an observational retrospective single-centre study of all patients on antithrombotic medication who were admitted to our department of oral and plastic maxillofacial surgery with mTBI over a 5 year period. Demographic and anamnesis data, injury characteristics, antithrombotic medication, radiological findings, treatment, and outcome were analysed. Patients were divided into the following four groups based on their antithrombotic medication: (1) single antiplatelet users, (2) vitamin K antagonist users, (3) direct oral anticoagulant users, and (4) double antithrombotic users. All patients underwent an emergency cranial CT (CT0) at admission. Based on clinical and radiological evaluation, different treatment protocols were applied. Patients with positive CT0 findings and patients with secondary neurological deterioration received a control CT (CT1) before discharge. Acute and delayed ICH and patient's outcome during hospitalisation were evaluated using descriptive statistical analysis.

RESULTS

A total of 696 patients (mean age, 71.6 years) on antithrombotic medication who presented at our department with mTBI were included in the analysis. Most injuries were caused by a ground-level fall (76.9%). Thirty-six patients (5.1%) developed an acute traumatic ICH, and 47 intracerebral lesions were detected by radiology-most of these in patients taking acetylsalicylic acid. No association was detected between ICH and antithrombotic medication (p = 0.4353). In total, 258 (37.1%) patients were admitted for 48 h in-hospital observation. The prevalence of delayed ICH was 0.1%, and the mortality rate was 0.1%. Multivariable analysis identified a Glasgow Coma Scale (GCS) of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea as clinical characteristics significantly associated with an increased risk of acute ICH, whereas age, sex, and trauma mechanism were not associated with ICH prevalence. Of the 39 patients who underwent a control CT1, most had a decreasing or at least constant intracranial lesion; in three patients, intracranial bleeding increased but was not clinically relevant.

CONCLUSION

According to our experience, antithrombotic therapy does not increase the rate of ICH after mTBI. A GCS of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea are indicators of higher ICH risk. A second CT scan is more effective in patients with secondary neurological deterioration. Initial CT findings were not clinically relevant and should not indicate in-hospital observation.

Ibuprofen Reduces 5-Year Overall Survival of Head and Neck Cancer Patients With Immunotherapy - A Retrospective Case-controlled Real-World Data Analysis of 10,000 Patients

BACKGROUND/AIM

Resistance to immunotherapy can be explained by an abnormal microbiome of the gut. In Europe in particular, the use of ibuprofen, with or without proton-pump inhibitors to protect the gastric mucosa, is widespread. This study aimed to investigate the impact of ibuprofen use on the effectiveness of immunotherapy in patients with head and neck carcinoma.

PATIENTS AND METHODS

Data from patients with head and neck carcinoma (ICD-10-Codes: C00-C14) receiving pembrolizumab, from the TriNetX network, were analyzed. Two groups were formed for the analyses: Cohort I received ibuprofen at least once within 6 months before and after immunotherapy, whereas patients in cohort II received ibuprofen with proton-pump inhibitors or no ibuprofen at all. Cohorts I and II were matched 1:1 with respect to age, sex, lymph node metastases, nicotine dependence, alcohol dependence, and body mass index (BMI). The primary outcome was death and a Kaplan-Meier analysis was performed, and the risk ratio (RR), odds ratio (OR), and hazard ratio (HR) were calculated.

RESULTS

The analysis showed that 823 patients with ibuprofen and 724 patients without ibuprofen died within 5 years, showing a significant risk difference of 5.3% (p=0.001). The RR was 1.137 [95% confidence interval (CI)=1.053-1.227], OR was 1.245 (95% CI=1.093-1.418), and HR was 1.202 (95%CI=1.088-1.329).

CONCLUSION

Ibuprofen significantly decreases the drug effectiveness of immunotherapy and may be related to changes in the human microbiome. However, further prospective, randomized, and double-blind studies are needed to validate our data and to adequately address confounders.

Sex-specific Real-World 5-year Overall Survival Rates for (Radio)chemotherapy, Targeted Therapy, and Combinations in Patients With Head and Neck Cancer

BACKGROUND/AIM

Sex-specific medicine, an emerging field in healthcare, has gained significant recognition and importance in recent years. To the best of our knowledge, there are currently no valid data on the influence of sex on 5-year overall survival of patients with head and neck cancer undergoing (radio)chemotherapy, targeted therapy, and combination treatments, using Real-World Data. We hypothesize that sex has a significant impact on 5-year overall survival across different therapy regimens for head and neck cancer.

PATIENTS AND METHODS

Data from head and neck cancer patients treated with different regimens from the TriNetX network were analyzed. Two groups were formed: Cohort I (female) and cohort II (male), which were matched 1:1 with respect to certain confounders. After defining the primary outcome as "death", a Kaplan-Meier analysis was performed, and the risk ratio (RR), odds ratio (OR) and hazard ratio (HR) were calculated.

RESULTS

A total of 16,529 patients with OSCC were analyzed. This retrospective case-matched analysis found a tendency for female patients to have a greater 5-year overall survival probability than male patients with respect to the various therapeutic regimens for OSCC.

CONCLUSION

There is an urgent need for more personalized medicine in patients with head and neck cancer due to the limited data available. It is still questionable whether therapies are equally effective in men and women, although, according to the guidelines, the treatments are mostly the same for both sexes.

Prosthetically guided oral implant surgery. A retrospective cohort study evaluating the 5-year surgical outcome

Purpose

This study primarily evaluated the 5-year implant survival and success rate of prosthetically guided inserted implants. The secondary aim was to evaluate the impact of clinical variables on the development of mucositis, peri-implant bone resorption, peri-implantitis, as well as early and late implant failure.

Materials and methods

An observational retrospective single-centre study was conducted on patients who were treated with dental implants in the department of oral and plastic maxillofacial surgery of the military hospital of Ulm University between 2008 and 2010. In all patients, computer-assisted 3D planning after wax-up of the prosthetic restoration and template-guided surgery with titanium implants were performed. Bone augmentation procedures were performed primarily if needed. Intraoperative and postoperative complications as well as technical and mechanical complications after prosthesis loading were evaluated. In a 5-year clinical and radiological follow-up, implant success and implant survival were assessed using descriptive statistics. A multivariable regression analysis evaluated the potential impact of augmentation procedures, wound healing complications, smoking, history of periodontitis, and preoperative API (approximal plaque index) and SBI (sulcus bleeding index) values on peri-implant mucositis, peri-implant bone resorption, peri-implantitis, as well as early and late implant failure.

Results

In this study, 466 implants in 283 patients were considered for inclusion, and sufficient data were obtained for analysis from 368 (78.9%) implants in 229 (80.9%) patients. An overall implant survival rate of 98.1% (n=361/368) at the 5-year follow-up was revealed. According to the success criteria of the study, the 5-year success rate was 97.04% (n=263/271). An early implant failure of 1.07% (n=5/466) was recorded. 48.2% of the implants were affected by peri-implant mucositis (n=122/253), while peri-implant bone resorption was detected in 21.7% of the radiologically examined implants (n=59/271). Fifteen cases of peri-implantitis (5.5%) were detected. Peri-implant bone resorption increased significantly after bone augmentation procedures (p=0.028). Wound healing complications after implantation significantly increased the prevalence of late implant failure in the maxilla (p<0.001). Peri-implant bone resorption and peri-implantitis were significantly more prevalent in smokers (p=0.022/p=0.043). Implants in patients with API>20% presented significantly higher rates of peri-implant mucositis (p=0.042). Wound healing complications after augmentation, history of periodontitis, and SBI>20% had no significant impact on the study parameters.

Conclusions

The study confirms the reliability of prosthetically guided implant surgery, showing a high implant survival and success rate in a 5-year follow-up. Intraoperative complications and technical or mechanical complications after prosthesis loading remain within acceptable clinical limits. The rate of peri-implant mucositis, peri-implant bone resorption, and peri-implantitis was within the current literature range. Optimizing periodontal health and reducing smoking would improve the outcome. Further studies need to clarify the clinical indications and investigate the long-term surgical outcome of this treatment concept.

Accuracy Analysis of Computer-Assisted and Guided Dental Implantology by Comparing 3D Planning Data and Actual Implant Placement in a Mandibular Training Model: A Monocentric Comparison between Dental Students and Trained Implantologists

The aim of this study was to investigate how precisely implantation can be realized by participants on a phantom head according to preliminary planning. Of particular interest here was the influence of participants' previous knowledge and surgical experience on the precision of the implant placement. The placed implants were scanned using an intraoral scanner, saved as STL files, and superimposed with the 3D-planned implant placement. Deviations from the planning were indicated in millimeters and degrees. We were able to show that on average, the deviations from computer-assisted 3D planning were less than 1 mm for implantologists, and the students also did not deviate more than 1.78 mm on average from 3D planning. This study shows that guided implantology provides predictable and reproducible results in dental implantology. Incorrect positioning, injuries to anatomical structures, and implant positions that cannot be prosthetically restored can thus be avoided.

Airway Management of Orofacial Infections Originating in the Mandible

The primary aim of this study was to assess the incidence of a difficult airway and emergency tracheostomy in patients with orofacial infections originating in the mandible, and a secondary aim was to determine the potential predictors of difficult intubation. This retrospective single-center study included all patients who were referred between 2015 and 2022 with an orofacial infection originating in the mandible and who were surgically drained under intubation anesthesia. The incidence of a difficult airway regarding ventilation, laryngoscopy, and intubation was analyzed descriptively. Associations between potential influencing factors and difficult intubation were examined via multivariable analysis. A total of 361 patients (mean age: 47.7 years) were included in the analysis. A difficult airway was present in 121/361 (33.5%) patients. Difficult intubation was most common in patients with infections of the massetericomandibular space (42.6%), followed by infections of the mouth floor (40%) and pterygomandibular space (23.5%). Dyspnea and stridor were not associated with the localization of infection (p = 0.6486/p = 0.4418). Multivariable analysis revealed increased age, restricted mouth opening, higher Mallampati scores, and higher Cormack-Lehane classification grades as significant predictors of difficult intubation. Higher BMI, dysphagia, dyspnea, stridor and a non-palpable mandibular rim did not influence the airway management. Patients with a difficult airway were more likely to be admitted to the ICU after surgery than patients with regular airway were (p = 0.0001). To conclude, the incidence of a difficult airway was high in patients with orofacial infections originating in the mandible. Older age, limited mouth opening, a higher Mallampati score, and a higher Cormack-Lehane grade were reliable predictors of difficult intubation.

Factors Influencing Recurrence after Surgical Treatment of Odontogenic Maxillary Sinusitis: An Analysis from the Oral and Maxillofacial Surgery Point of View

The aim of the study was to determine the factors influencing the development of recurrence after the surgical treatment of odontogenic maxillary sinusitis in an oral and maxillofacial surgery clinic over a 7-year period. Demographic and anamnesis data, clinical and radiological findings, treatment and outcome were analyzed. A multivariable analysis was performed to find associations between patient age, causative focus, surgical access for sinus revision, multilayer closure with a buccal fat pad, inferior meatal antrostomy (IMA) for temporary sinus drainage and sinusitis recurrence. A total of 164 patients with a mean age of 51.7 years were included. Sinusitis recurrence was observed in nine patients (5.48%) within 6 months after primary surgery. No significant correlation was detected between patient age, causative focus, surgical access for sinus revision, multilayer closure with a buccal fat pad, IMA for sinus drainage and the development of recurrence (p > 0.05). Patients with a history of antiresorptive-related osteonecrosis of the jaw showed a significant tendency toward disease recurrence (p = 0.0375). In conclusion, except for antiresorptive administration, none of the investigated variables were related to a higher risk of sinusitis recurrence. We encourage a combined approach of intraoral removal of the infective focus and sinus drainage via FESS, as well as an individual treatment decision in a multidisciplinary setting with collaboration between dentistry, maxillofacial surgery and otorhinolaryngology to avoid sinusitis recurrence.

Justification of Indication for Cranial CT Imaging after Mild Traumatic Brain Injury According to the Current National Guidelines

The primary aim was to evaluate the compliance of cranial CT indication with the national guideline-based decision rules in patients after mTBI. The secondary aim was to determine the incidence of CT pathologies among justified and unjustified CT scans and to investigate the diagnostic value of these decision rules. This is a retrospective, single-center study on 1837 patients (mean age = 70.7 years) referred to a clinic of oral and maxillofacial surgery following mTBI over a five-year period. The current national clinical decision rules and recommendations for mTBI were retrospectively applied to calculate the incidence of unjustified CT imaging. The intracranial pathologies among the justified and unjustified CT scans were presented using descriptive statistical analysis. The performance of the decision rules was ascertained by calculating the sensitivity, specificity, and predictive values. A total of 123 intracerebral lesions were radiologically detected in 102 (5.5%) of the study patients. Most (62.1%) of the CT scans strictly complied with the guideline recommendations, and 37.8% were not justified and likely avoidable. A significantly higher incidence of intracranial pathology was observed in patients with justified CT scans compared with patients with unjustified CT scans (7.9% vs. 2.5%, p < 0.0001). Patients with loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures presented pathologic CT findings more frequently (p < 0.05). The decision rules identified CT pathologies with 92.28% sensitivity and 39.08% specificity. To conclude, compliance with the national decision rules for mTBI was low, and more than a third of the CT scans performed were identified as "likely avoidable". A higher incidence of pathologic CT findings was detected in patients with justified cranial CT imaging. The investigated decision rules showed a high sensitivity but low specificity for predicting CT pathologies.

Clinical Indicators for Primary Cranial CT Imaging after Mild Traumatic Brain Injury-A Retrospective Analysis

The primary aim was to determine the clinical indicators for primary cranial CT imaging in patients after mild traumatic brain injury (mTBI). The secondary aim was to evaluate the need for post-traumatic short-term hospitalization based on primary clinical and CT findings. This was an observational retrospective single-centre study of all the patients who were admitted with mTBI over a five-year period. Demographic and anamnesis data, the clinical and radiological findings, and the outcome were analyzed. An initial cranial CT (CT0) was performed at admission. Repeat CT scans (CT1) were performed after positive CT0 findings and in cases with in-hospital secondary neurological deterioration. Intracranial hemorrhage (ICH) and the patient's outcome were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between the clinical variables and the pathologic CT findings. A total of 1837 patients (mean age: 70.7 years) with mTBI were included. Acute ICH was detected in 102 patients (5.5%), with a total of 123 intracerebral lesions. In total, 707 (38.4%) patients were admitted for 48 h for in-hospital observation and six patients underwent an immediate neurosurgical intervention. The prevalence of delayed ICH was 0.05%. A Glasgow Coma Scale (GCS) of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of fracture were identified as clinical factors with significantly higher risk of acute ICH. None of the 110 CT1 presented clinical relevance. A GCS of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures should be considered absolute indicators for primary cranial CT imaging. The reported incidence of immediate and delayed traumatic ICH was very low and hospitalization should be decided individually considering both the clinical and CT findings.

Comparison of Anatomical Preformed Titanium Implants and Patient-Specific CAD/CAM Implants in the Primary Reconstruction of Isolated Orbital Fractures-A Retrospective Study

BACKGROUND/AIM

Reconstruction of the fractured orbit remains a challenge. The aim of this study was to compare anatomical preformed titanium orbital implants with patient-specific CAD/CAM implants for precision and intraoperative applicability.

MATERIAL AND METHODS

A total of 75 orbital reconstructions from 2012 to 2022 were retrospectively assessed for their precision of implant position and intra- and postoperative revision rates. For this purpose, the implant position after digital orbital reconstruction was checked for deviations by mirroring the healthy orbit at 5 defined points, and the medical records of the patients were checked for revisions.

RESULTS

The evaluation of the 45 anatomical preformed orbital implant cases showed significantly higher deviations and an implant inaccuracy of 66.6% than the 30 CAD/CAM cases with only 10% inaccuracy. In particular, the CAD/CAM implants were significantly more precise in medial and posterior positioning. In addition, the intraoperative revision rates of 26.6% vs. 11% after 3D intraoperative imaging and the postoperative revision rates of 13% vs. 0 for the anatomical preformed implants were significantly higher than for patient-specific implants.

CONCLUSION

We conclude that patient-specific CAD/CAM orbital implants are highly suitable for primary orbital reconstruction. These seem to be preferable to anatomical preformed implants in terms of precision and revision rates.

BRAF inhibitors in BRAF V600E-mutated ameloblastoma: systematic review of rare cases in the literature

BACKGROUND

Ameloblastoma in 66% of the cases harbor a somatic mutation of the "mitogen-activated protein kinase" signaling pathway (BRAF V600E). In V600E mutations, BRAF is in the permanent "on" state and relays the growth-promoting signals independently of the EGFR pathway. Therefore, mutant BRAF represents a target for handful of new drugs.

METHODS

We conducted a literature search, with the search terms "Vemurafenib, Dabrafenib, Ameloblastoma, and BRAF." These included seven case reports with nine patients who underwent monotherapy with Dabrafenib or Vemurafenib or combination therapy with Dabrafenib and Trametinib.

RESULTS

The patients age ranges from 10 years up to 86 years. The distribution of women and men is 4:5. Patients with an initial diagnosis of ameloblastoma, as well as recurrences or metastasized ameloblastoma were treated. Indications cover neoadjuvant therapy up to the use in metastasized patients in an irresectable state. Results ranging from "only" tumor size reduction to restitutio ad integrum.

CONCLUSION

We see the use of BRAF Inhibitors to reduce tumor size with consecutive surgical treatment as a reasonable option for therapy. However, we are aware that at present the data are based only on case reports with the longest follow-up of just 38 months. We encourage further clinical trials in the use of BRAF Inhibitors for selecting ameloblastoma patients in a multi-center setting.

Dental Root Injuries Caused by Osteosynthesis Screws in Orthognathic Surgery-Comparison of Conventional Osteosynthesis and Osteosynthesis by CAD/CAM Drill Guides and Patient-Specific Implants

BACKGROUND/AIM

The primary aim was to evaluate the prevalence and localisation of dental injuries caused by osteosynthesis screws during orthognathic surgery, comparing two different CAD/CAM planning/surgical approaches through retrospective evaluation of post-operative computed tomography.

MATERIAL AND METHODS

This study considered all patients who underwent orthognathic surgery from 2010-2019. The examination for dental root injuries between conventional osteosynthesis (Maxilla conventional cohort) and osteosynthesis with patient-specific implant (Maxilla PSI cohort) was performed by evaluating the post-operative CT scans.

RESULTS

A total of 126 patients were included in the study. Among the 61 patients of the Maxilla conventional cohort, 10 dental root injuries in 8 patients (13.1%) were detected in the post-operative CT scan, representing 1.5% (n = 10/651) of the osteosynthesis screws inserted in proximity of the alveolar crest. No dental injury occurred following osteosynthesis in the 65 patients of the Maxillary PSI cohort (n = 0/773 screws) (p < 0.001). During a mean follow-up period of 13 months after primary surgery, none of the injured teeth showed evidence of periapical alterations and no endodontic treatments were necessary.

CONCLUSIONS

Maxillary positioning using CAD/CAM-fabricated drill/osteotomy guide and osteosynthesis with PSI can significantly reduce the risk for dental injury compared to the conventional procedure. However, the clinical significance of the detected dental injuries was rather minor.

Management of older adults after mild head trauma in an oral and maxillofacial surgery clinic

PURPOSE

The primary aim was to determine the incidence of intracranial hemorrhage (ICH) after mild traumatic brain injury (mTBI) in patients aged ≥ 65 years. The secondary aim was to identify risk factors for intracranial lesions and evaluate the need for in-hospital observation in this age group.

METHODS

This observational retrospective single-center study included all patients aged ≥ 65 years who were referred to our clinic for oral and plastic maxillofacial surgery following mTBI over a five-year period. Demographic and anamnesis data, clinical and radiological findings, and treatment were analyzed. Acute and delayed ICH and patient outcomes during hospitalization were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between CT findings and clinical data.

RESULTS

A total of 1,062 patients (55.7% male, 44.2% female) with a mean age of 86.3 years were included in the analysis. Ground-level fall was the most frequent cause of trauma (52.3%). Fifty-nine patients (5.5%) developed an acute traumatic ICH, and 73 intracerebral lesions were radiologically observed. No association was detected between ICH rate and antithrombotic medication (p = 0.4353). The delayed ICH rate was 0.09% and the mortality rate was 0.09%. Significant risk factors for increased ICH were a Glasgow Coma Scale score of < 15, loss of consciousness, amnesia, cephalgia, somnolence, dizziness, and nausea according to multivariable analysis.

CONCLUSION

Our study showed a low prevalence of acute and delayed ICH in older adults with mTBI. The ICH risk factors identified here should be considered when revising guidelines and developing a valid screening tool. Repeat CT imaging is recommended in patients with secondary neurological deterioration. In-hospital observation should be based on an assessment of frailty and comorbidities and not on CT findings alone.

Comparison of Laser-Sintered and Milled Patient-Specific Reconstruction Plates for Complications and Outcomes in Mandibular Defects-Comparative Analysis of a Single-Center Cohort

CAD/CAM-manufactured implants are increasingly becoming the standard in current therapy. The question of whether the manufacturing-related rougher surface of selective laser fusion plates compared to milled, smoother reconstruction plates leads to increased postoperative complications such as infections, plate exposure, and fistulas has not yet been determined. A retrospective analysis of 98 patients who underwent surgical treatment with either a selective laser fusion plate or a milled reconstruction plate at our hospital was performed. The only significant predictors of the revision risk were the operation time and use of antiresorptive medication. In the KLS Martin^® group, the risk of revision decreased by approximately 20% for each additional hour by which the operation time was increased (OR = 0.81). In the Depuy Synthes^® group, the risk of revision increased by approximately 11% with each additional hour of operative time (OR = 0.81 × 1.37 = 1.11). Both groups showed no significant differences in the number of necessary revision surgeries as well as inpatient complications. In summary, we can say that the assumption that additively manufactured reconstruction plates have a rougher surface due to selective laser melting and thus make plaque accumulation and revisions more likely has not been confirmed. Overall, it seems imperative to select further studies regarding the clinical outcome depending on the selected plate system.

MRONJ of the Mandible—From Decortication to a Complex Jaw Reconstruction Using a CAD/CAM-Guided Bilateral Scapula Flap

Medication-related osteonecrosis of the jaw (MRONJ) has been an integral part of the maxillofacial patient population for some time. The therapeutic concept ranges from conservative approaches over less extended decortications to major jaw resections, which can result in a considerable loss of quality of life. Based on three case reports, this paper presents the long-term history of patients with MRONJ of the mandible, whose disease ultimately resulted in partial or total mandibular resection and subsequent multisegmental reconstruction using a microvascular anastomosed bone flap. Furthermore, a suitable alternative for complex mandibular reconstruction is demonstrated when using a free fibula flap is not possible. The options are limited, particularly when multisegmental restoration of mandibular continuity is required. One case presents a mandible reconstruction using a CAD/CAM-guided bilateral scapular free flap (CAD/CAM = Computer-Aided Design and Manufacturing), which has not been described for this purpose before. Due to the complexity, computer-assisted surgery and patient-specific implants seem reasonable, which is why a special focus was applied to this topic.

Correlation of local lightning activity with extra low frequency detector for Schumann Resonance measurements

A dedicated extremely low frequency (ELF) detector has been constructed and used successfully for Schumann Resonance (SRs) measurements in N.W. Greece. The main objective of this work was to investigate the effect of local lightning activity on the signal of our ELF detector and consequently on the estimated SRs parameters, namely the power, the frequency and the quality factor of each mode. Therefore, several measurements were taken into account for the ELF signal continuously recorded and the lightning intensity in a specific range around the ELF detector. Additionally, a simple filtering technique was used, in order to reject the distorted SRs spectra. The statistical analysis performed showed a positive and statistically significant correlation between the lightning events and the recorded magnetic component of the ELF signal. It was found that local lightnings have a significant impact on the SRs measurements, and it is necessary to be removed from the background signal.

Tocilizumab: Another medication related to osteonecrosis of the jaws? A case report and literature review

Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication in patients receiving antiresorptive medication, such as bisphosphonates and denosumab, for different oncologic and non-oncologic diseases. Here, we report a case of MRONJ in a patient treated with tocilizumab, a humanized anti-interleukin-6 receptor antibody that effectively treats moderate to severe rheumatoid arthritis in adults.

Case description: A 45-year-old female patient diagnosed with severe rheumatoid arthritis, who had been undergoing intravenous tocilizumab therapy for three years without history of bisphosphonate use, was referred to our department. Four weeks previously, several teeth in the maxilla and mandible were removed under local anesthesia by her dentist. Two weeks after the extractions, she felt pain in both jaws. We diagnosed wound dehiscence and delayed healing of the alveolar bone after the tooth extractions. Digital volume tomography showed persistent dry alveolar sockets. The patient underwent surgical debridement of necrotic bone, and intravenous antibiotics were administered in hospital. Five months later, wound dehiscence reoccurred in the same regions. Histopathological analysis of bone biopsies revealed a diagnosis of MRONJ. Four months later, wound dehiscence occurred in the left maxillary alveolar ridge, and local bone resection was performed under antibiotic treatment. Twenty-four months after the last surgery, wound dehiscence had healed completely without signs of recurrence.

Discussion: Osteomyelitis of the jaw in patients treated with tocilizumab has not been reported often. This case confirms the potential role of this interleukin-6 receptor inhibitor in the pathogenesis of MRONJ and shows that patients who receive tocilizumab with MRONJ-like symptoms should be closely monitored. The pathomechanism of MRONJ under tocilizumab therapy remains unclear, so dental practitioners, maxillofacial surgeons, and rheumatologists should look for signs of MRONJ in patients receiving tocilizumab to prevent MRONJ onset.

Eggerthia catenaformis infection originating from a dental abscess causes severe intestinal complications and osteomyelitis of the jaw

Introduction: Odontogenic foci may result to generalized infections spreading the bacteria through contiguous anatomic cavities or hematogenous spread. The most reported secondary infections caused by oral pathogens are intracranial abscesses. Although, few reports in the literature describe the bacterial spread to extracranial locations. Case description: We describe the case of a 52-year-old male Caucasian patient who was admitted to our hospital suffering from severe sepsis caused by a submandibular abscess. Eggerthia catenaformis was detected in blood and abscess material (confirmed by MALDI-TOF mass spectrometry). The patient subsequently developed a perihepatic abscess and colon perforation, and was stabilized after several surgical interventions. He remained hospitalized for 66 days receiving intravenous antibiotics. Five months later, jaw osteonecrosis with Actinomyces contamination was detected in the left mandible, which also had to be treated surgically. Three years after the last surgery, no signs of recurrence have been detected. Discussion: Oral and maxillofacial surgeons should understand the characteristics of systemic infections, in which the potentially causal intraoral odontogenic foci often lack acute symptoms. If other origins of infection are not detected, elimination of the potentially causal odontogenic foci should be performed. However, the decision making criteria to eliminate suspected causal teeth is needed to be elucidated through more studies.

Clinical Accuracy of 3D-Planned Maxillary Positioning Using CAD/CAM-Generated Splints in Combination With Temporary Mandibular Fixation in Bimaxillary Orthognathic Surgery

Study Design

The aim of this study was to evaluate the accuracy of 3-dimensional (3D)-planned maxillary positioning by using computer-assisted design (CAD)/computer-assisted manufacturing (CAM) splints combined with temporary mandibular fixation in bimaxillary orthognathic surgery. In orthognathic surgery, customized splints work sufficiently well to transfer preoperative planning into the operation site for transverse und sagittal positioning of the maxilla. The vertical positioning is more difficult due to the non-fixed mandibular reference. Therefore, the combined use of CAD/CAM splints and temporary mandibular fixation to the zygomatic region was applied for transferring the 3D-planned maxillary position into the operation site from 2012 until 2015 in our hospital.

Objective

In addition to the general accuracy, the precision should therefore be checked especially in the vertical plane compared to axial and sagittal plane.

Methods

In this retrospective study, we calculated the deviation of 5 occlusal landmarks of the maxilla in 35 consecutive patients by fusing preoperative 3D planning images and postoperative computed tomography scans after bimaxillary surgery.

Results

The overall median deviation of maxillary positioning between plan and surgical result was 0.99 mm. The accuracy of left-right positioning was median 0.96 mm. Anterior-posterior positioning of the maxilla showed a median accuracy of 0.94 mm. Just slightly higher values were determined for the upward-downward positioning (median 1.06 mm).

Conclusions

This demonstrates the predictability of maxillary positioning by using CAD/CAM splints in combination with temporary mandibular fixation in all 3 axes.

Study of the variations in the Schumann resonances parameters measured in a southern Mediterranean environment

Schumann resonances (SRs) provide a unique tool for exploring continuous and long-term monitoring of global environmental parameters, although their detection and study is a very complex task. This paper presents diurnal and seasonal variations of principal parameters, namely the resonance frequency, the Q-factor, and the power of SRs, in the North-South (NS) magnetic field component for the first five modes from Extra Low Frequency (ELF) measurements. These were acquired at the observation site located at Doliana, Kalpaki, in the Region of Epirus, North West Greece. These variations are the first ones reported for the principal parameters in the South Eastern Mediterranean area and correspond to the one-year measurement period from 2016 to 2017. The comparison with variations at several observations sites is also discussed. Moreover, correlation with global lighting centers, as well as local lightning activity, and SRs parameters variation is attempted.

Factors influencing the long-term prognosis of root tip resected teeth

Introduction: The aim of the study was to investigate possible predictive factors influencing the long-term success of root tip resection. Methods: The retrospective study included 216 patients (♂ 111, ♀ 106, median age 43.3 years). A total of 261 root tip resections were performed on these patients between 1989 and 2012. In addition to determining the success rates 5 and 10 years postoperatively, the factors gender, age, tooth type, use of bone replacement material and preoperative periodontal tooth status were examined with regard to their significance for the long-term prognosis of root tip resected teeth. Results: The evaluation showed an average success rate of 63.6% for all included teeth over the entire observation period (tooth at least one year postoperatively still in situ). The 5-year success rate was 78.2%, the 10-year success rate 63.1%. A dependence of the success rates on the tooth type could not be evaluated. However, the examination showed a clear dependence of the success on the age of the patients. Root tip resections in patients in the age group 60 years and older had significantly worse success rates compared to the age groups 20 to 39 years and 40 to 59 years. The prognosis was also significantly better for patients in the age group 20 to 39 years than for patients in the age group 40 to 59 years. Periodontally compromised teeth showed only a tendency for a poorer prognosis than periodontally healthy teeth. With regard to sex and intraoperative filling of the resection defect with bone replacement material, no differences in the success rates were found. Conclusions: A root tip resection is a good option, largely independent of the type of tooth, to preserve a tooth in the medium to long term after unsuccessful endodontic treatment. However, a revision of the endodontic treatment or even an extraction with subsequent implantation should always be considered as an alternative, especially with increasing age.

Translucency of Zirconia Ceramics before and after Artificial Aging

PURPOSE

The aging of zirconia ceramics (Y-TZP) is associated with tetragonal to monoclinic phase transformation. This change in microstructure may affect the optical properties of the ceramic. This study examines the effect of aging on the translucency of different zirconia materials.

MATERIALS AND METHODS

120 disc-shaped specimens were fabricated from four zirconia materials: Cercon ht white, BruxZir Solid Zirconia, Zenostar T0, Lava Plus (n = 30 per group). Accelerated aging was performed in a steam autoclave (134°C, 0.2 MPa, 5 hours). CIELab coordinates (L*, a*, b*) and luminous reflectance (Y) were measured with a spectrophotometer before and after aging. Contrast ratio (CR) and translucency parameter (TP) were calculated from the L*, a*, b*, and Y tristimulus values. The general linear model (Bonferroni adjusted) was used to compare both parameters before and after aging, as well as between the different zirconia materials (p ≤ 0.05).

RESULTS

CR and TP differed significantly before and after aging in all groups tested. Before aging, Zenostar T showed the highest and Lava Plus showed the lowest translucency. After aging, Cercon ht and Zenostar T showed the highest and BruxZir and Lava Plus the lowest translucency.

CONCLUSIONS

Aging reduced the translucency in all specimens tested. Furthermore, translucency differed between the zirconia brands tested. Nevertheless, the differences were below the detectability threshold of the human eye. The aging process can influence the translucency and thus the esthetic outcome of zirconia restorations; however, the changes in translucency were minimal and probably undetectable by the human eye.

Autogenous bone grafts in oral implantology-is it still a "gold standard"? A consecutive review of 279 patients with 456 clinical procedures

Background

This study assessed the clinical outcomes of graft success rate and early implant survival rate after preprosthetic alveolar ridge reconstruction with autologous bone grafts.

Methods

A consecutive retrospective study was conducted on all patients who were treated at the military outpatient clinic of the Department of Oral and Plastic Maxillofacial Surgery at the military hospital in Ulm (Germany) in the years of 2009 until 2011 with autologous bone transplantation prior to secondary implant insertion. Intraoral donor sites (crista zygomatico-alveolaris, ramus mandible, symphysis mandible, and anterior sinus wall) and extraoral donor site (iliac crest) were used. A total of 279 patients underwent after a healing period of 3–5 months routinely computer tomography scans followed by virtual implant planning. The implants were inserted using guided oral implantation as described by Naziri et al. All records of all the consecutive patients were reviewed according to patient age, history of periodontitis, smoking status, jaw area and dental situation, augmentation method, intra- and postoperative surgical complications, and surgeon’s qualifications. Evaluated was the augmentation surgical outcome regarding bone graft loss and early implant loss postoperatively at the time of prosthodontic restauration as well a follow-up period of 2 years after loading.

Results

A total of 279 patients underwent 456 autologous augmentation procedures in 546 edentulous areas. One hundred thirteen crista zygomatico-alveolaris grafts, 104 ramus mandible grafts, 11 symphysis grafts, 116 grafts from the anterior superior iliac crest, and 112 sinus lift augmentations with bone scrapes from the anterior facial wall had been performed. There was no drop out or loss of follow-up of any case that had been treated in our clinical center in this 3-year period. Four hundred thirty-six (95.6%) of the bone grafts healed successfully, and 20 grafts (4.4%) in 20 patients had been lost. Fourteen out of 20 patients with total graft failure were secondarily re-augmented, and six patients wished no further harvesting procedure. In the six patients, a partial graft resorption was detected at the time of implantation and additional simultaneous augmentation during implant insertion was necessary. No long-term nerve injury occurred. Five hundred twenty-five out of 546 initially planned implants in 259 patients could be inserted into successfully augmented areas, whereas 21 implants in 20 patients due to graft loss could not be inserted. A final rehabilitation as preplanned with dental implants was possible in 273 of the 279 patients. The early implant failure rate was 0.38% concerning two out of the 525 inserted implants which had to be removed before the prosthodontic restoration. Two implants after iliac crest augmentation were lost within a period of 2 years after loading, concerning a total implant survival rate after 2 years of occlusal loading rate of 99.6% after autologous bone augmentation prior to implant insertion.

Conclusions

This review demonstrates the predictability of autologous bone material in alveolar ridge reconstructions prior to implant insertion, independent from donor and recipient site including even autologous bone chips for sinus elevation. Due to the low harvesting morbidity of autologous bone grafts, the clinical results of our study indicate that autologous bone grafts still remain the “gold standard” in alveolar ridge augmentation prior to oral implantation.

Clinical results of autologous bone augmentation harvested from the mandibular ramus prior to implant placement. An analysis of 104 cases

Background: The aim of this study was the evaluation of the clinical success and complication rates associated with autologous bone grafts harvested from the mandibular ramus for alveolar ridge augmentation and the identification of possible risk factors for graft failure.

Methods: In a consecutive retrospective study 86 patients could be included. In these patients a total of 104 bone grafts from the mandibular ramus were harvested for alveolar ridge augmentation. Medical history, age of patient, smoking status, periodontal status and complications were recorded. The need for bone grafting was defined by the impossibility of installing dental implants of adequate length or diameter to fulfill prosthetic requirements, or for aesthetic reasons. The surgical outcome was evaluated concerning complications at the donor or at the recipient site, risk factors associated with the complications and graft survival. All patients were treated using a two-stage technique. In the first operation bone blocks harvested from the retromolar region were placed as lateral or vertical onlay grafts using augmentation templates and were fixed with titanium osteosynthesis screws after exposure of the deficient alveolar ridge. After a healing period of 3–5 months computed tomography scans were performed followed by virtual implant planning and the implants were inserted using guided dental implantation.

Results: 97 of the 104 onlay bone grafts were successful. In only 7 patients a graft failure occurred after a postsurgical complication. No long-term nerve damage occurred. Postoperative nerve disturbances were reported by 11 patients and had temporary character only. After the healing period between 4 to 5 months, 155 implants were placed (39 in the maxilla, 116 in the mandible). A final rehabilitation with dental implants was possible in 82 of the 86 patients. Except the 7 graft failures, all recorded complications were minor complications which could be easily treated successfully without any long-term problems. Complications at the donor site were recorded in 3 patients and 17 patients experienced complications at the recipient site. Three of 7 patients with graft failure, were secondarily augmented with a new retromolar graft, harvested from the contra-lateral site and dental implants could be successfully inserted later. No association between complications and smoking habit, age of patient, jaw area, and dental situation (tooth gap or free dental arch) could be detected.

Conclusions: Retromolar bone grafts are an effective and safe method for the reconstruction of small- to medium-sized alveolar defects of the maxilla and mandible prior to dental implantation and show a low graft failure rate.

Effect of Schneiderian membrane perforation on sinus lift graft outcome using two different donor sites: a retrospective study of 105 maxillary sinus elevation procedures

Background: Sinuslift is meanwhile an established method of bone augmentation in the posterior maxilla. Aim of the study was to evaluate the significance of intraoperative Schneiderian membrane perforations during maxillary sinus floor elevation surgery using autogenous bone harvested from two different donor sites using a Safescraper device on the success rate, graft survival and implant integration.

Methods: The investigators conducted a retrospective cohort study at the Department of Oral and Maxillofacial Surgery of Military Hospital Ulm composed of patients with severe maxillary atrophy who underwent sinus augmentation from January 2011 until December 2011. Ninety-nine consecutive patients (89 men, 10 women) with a mean age of 43.1 years underwent sinus graft procedures in a 2-stage procedure using the lateral wall approach, as described by Tatum (1986). Data on patient age, smoking status, donor site and surgical complications were recorded and the relationship between Schneiderian membrane perforation and complication rate was evaluated. Dental implants were inserted 4 months after grafting.

Results: A total of 105 sinus lift procedures were performed in 99 patients. Sixty-one patients (61.6%) underwent sinus elevation with autogenous bone from the buccal sinus wall, while 38 patients (38.4%) bone harvesting from the iliac crest. Intraoperative perforation of the Schneiderian membrane was observed in 11 of the 105 sinuses (10.4%). These perforations resulted in 4 (36.3%) of the cases in major postoperative complications accompanied by swelling and wound infection. Membrane perforations were slightly associated with the appearance of postoperative complications (p=0.0762). In 2.4% of all cases, regarding 2 patients the final rehabilitation with dental implants was not possible because of extensive bone resorption.

Conclusion: Intraoperative complications performing sinus augmentation may lead to postoperative complications. With careful clinical and radiographic evaluation and appropriate treatment, the complications and risk for graft material displacement and implant loss can be eliminated.

Incidentally discovered white subcupsular liver nodules during laparoscopic surgery: biliary hamartoma and peribiliary gland hamartoma

During routine laparoscopic surgery, the surgeon may encounter the presence of small white subcapsular liver nodules, either solitary or multiple. The lesions may mimic liver metastasis and in many cases are not demonstrated in the preoperative ultrasound or computed tomography. The aim of this article is to familiarize the laparoscopic surgeon with the incidental discovery of these nodules which represent the two types of intrahepatic benign bile duct proliferations and include biliary hamartomas, which are usually multiple benign malformations of the intrahepatic bile ducts, and peribiliary gland hamartoma, which is usually solitary and consists of a benign epithelial tumor of the liver derived from bile duct cells.