Accuracy of the CAD/CAM technique compared with the conventional technique used for stand-alone genioplasty

The benefit of the computer-aided design and manufacturing (CAD/CAM) technique for stand-alone genioplasty remains uncertain and was evaluated in this study. Patients who underwent a conventional genioplasty (n = 20) or genioplasty with the CAD/CAM technique (n = 20), and for whom cephalometry and photogrammetry were performed before and 6 months after surgery, were included. Deviations from predictions of the soft tissue pogonion (Pg'), lip inferior point to aesthetic line (Li-Esth), facial convexity angle (FCA), mentolabial angle (MLA), and ratios of soft to hard tissue movements were calculated. No significant deviation was observed for Pg' in either the conventional group (3.85 ± 4.36 mm; 1.91 ± 1.11 mm) or CAD/CAM group (1.28 ± 1.16 mm; 2.81 ± 3.08 mm), for horizontal and vertical movements, respectively. However, for forward movement, deviation from the prediction of Pg´ in the CAD/CAM group was significantly lower than that in the conventional group (P = 0.015). Deviations of Li-Esth, MLA, and FCA did not differ significantly between the groups. No definite preference for the CAD/CAM technique could be established, because deviations from predictions were not significant in either of the technique groups and lay within the clinically acceptable range.

Dentinogenic Ghost Cell Tumour in Childhood Involving the Temporomandibular Joint: Considerations and Therapy

Background

Although the uncommon dentinogenic ghost cell tumour (DGCT) is a benign entity, it possesses the ability to cause widespread destruction of the jaws and to recur after bone-preserving therapy. Hence, clear margins should be achieved upon surgery, and reconstruction techniques must often be used to restore osseous defects. However, this can be challenging in cases with involvement of the temporomandibular joint (TMJ), and especially in children.

Case report

We present a case of a DGCT in a 12-year-old boy with wide infiltration of the mandible and the TMJ. A two-staged reconstructive approach was performed. Upon primary surgery, tumour-free margins were obtained and mandibular anatomy was restored using an iliac crest graft and an alloplastic condyle implant for temporary TMJ reconstruction. In a second step 5 months later, having received a customized TMJ prosthesis consisting of a fossa and a condyle component, the TMJ was completely replaced for definitive reconstruction.

Conclusion

A customized TMJ prosthesis could be a solution for reconstruction of the TMJ in children. However, the further course with respect to growth disturbances must be evaluated upon short-term follow-ups and might require additional corrective interventions.

Melanotic Neuroectodermal Tumour of Infancy: Clinical Courses and Therapeutic Options-A Review of Three Cases

Background

Melanotic neuroectodermal tumour of infancy (MNTI) is a rare benign neoplasm. MNTI appears most often during the first year of life, arises predominantly in the maxilla and tends to recur. We discuss possible therapeutic options given in the literature and within our experience in three cases.

Patients

In our recent case, we used an intraoral approach to perform resection of the right-sided maxilla. Despite tumour-positive margins, there was no recurrence over the course of one year. In a previous case of MNTI, two recurrences occurred and 6 months after last resection patient received a rib graft for maxillary reconstruction. However, at the age of 7 years, the infant displayed severe maxillary hypoplasia. In a third case of MNTI, the patient was followed up after initial therapy for two decades and underwent multiple reconstruction procedures to achieve successful rehabilitation.

Conclusion

Surgical treatment of MNTI should respect vital anatomic structures to avoid gross mutilation. The need for extended and repetitive tumour resection in early childhood can lead to growth disturbances and to further multiple reconstruction procedures in adulthood. Because of the rarity of MNTI, an international database is warranted to evaluate therapies and clinical courses over decades.

Case report: chronic inflammatory ulcer and osteoradionecrosis of the skull following radiotherapy in early childhood

INTRODUCTION

Chronic inflammatory diseases of the skin are the most common differential diagnosis of tumorous lesions of the craniofacial region. Detailed information about a patient's medical history is important for the clinical diagnosis of such cases. Previous radiotherapy should be taken into account, especially in cases of chronic dermatitis, since complications include osteoradionecrois of the adjacent bone strucutres with surrounding inflammation.

CASE REPORT

We present the case of a 77-year-old femal patient who was admitted to our department with a slightly progressive ulcerating lesion of the frontotemporal skull. The patient had received radiotherapy in early childhood as primary therapy for hemangioma. Diagnostic imaging and biopsies revealed a diagnosis of chronic ulceration with underlying osteonecrosis and fibrotic osteomyelitis of the skull. A complex reconstruction of osseous structures and soft tissue was necessary to resolve her complaints.

CONCLUSION

Chronic radiodermatitis and osteoradionecrosis in adults, occurring as late complications, are uncommon, but can be observed even nearly 80 years after radiation. Large defects of the skull require a complete reconstruction to avoid several complications.

Total mandibular reconstruction following diffuse sclerosing osteomyelitis

BACKGROUND

Diffuse sclerosing osteomyelitis (DSO) is a non-purulent chronic recurrent inflammation and affects the mandible in many cases. Belonging to the group of autoinflammatory diseases, in children and in cases with various additional symptoms including synovitis, acne, pustulosis, hyerostosis, and osteitis (SAPHO syndrome), therapy usually consists of non-surgical treatment. Against this background, we present an unusual course of DSO in an adult female patient.

CASE REPORT

A 50-year-old female suffering from DSO without SAPHO syndrome was pretreated for years with conservative drug regimens and local surgery. Previous therapy was not successful, and subsequently, multiple surgical procedures were carried out focused on recurrent acute exacerbations of DSO. Surgery resulted in a total resection and alloplastic and autoplastic reconstruction of the mandible including both temporomandibular joints. Prosthetic rehabilitation was possible after dental implant loading, and the final outcome was very satisfactory.

CONCLUSION

In the event that non-surgical options are not successful in DSO, an extended surgical therapy becomes necessary. Even if surgery results in complete resection of the mandible, a satisfactory rehabilitation can be achieved after complex reconstruction.

Continuity defects of the mandible: Comparison of three techniques for osseous reconstruction and their impact on implant loading

Computer-aided design/manufacturing (CAD/CAM) is now widely used, but whether it can help to overcome complications in mandibular reconstruction and accelerate dental implantation is still a matter for debate. Therefore, we aimed to evaluate the benefits of this technique using vascularized iliac crest or fibula flaps in mandibular reconstruction, with respect to the time between reconstruction and implantation, and the ratio of planned to inserted implants. We reviewed retrospectively the records of 54 patients who underwent mandibular reconstructions between 2012 and 2016, and included in our study the last 10 cases representing each of the following groups: iliac crest flap with CAD/CAM (Group 1); fibula flap with CAD/CAM (Group 2); and fibula flap without CAD/CAM (Group 3). Groups 1 (p = 0.045) and 2 (p = 0.034) showed significantly shorter delays when compared with Group 3. Significant differences in average counts of implants placed were also found between Group 1 and Groups 2 (p = 0.04) and 3 (p = 0.019). The ratio of planned to placed implants was highest in Group 1. The observed differences between Group 1 and Groups 2 (p = 0.04) and 3 (p = 0.019) were significant. Our results indicate an accelerating effect of CAD/CAM on graft consolidation and dental rehabilitation.

Moving the mandible in orthognathic surgery - A multicenter analysis

Orthognathic surgery has always been a classical focus of maxillofacial surgery. Since more than 100 years, various surgical techniques for mandibular repositioning have been developed and clinically tested. Since the establishment of plate and screw osteosynthesis, orthognathic surgery became more stable and safe. Nowadays, different surgical methods for mobilising the mandible are existing. This international multicenter analysis (n = 51 hospitals) is providing first evidence based data for the current use of different surgical methods. The dominating techniques were Obwegeser/dal Pont (61%) followed by Hunsuck/Epker (37%) and Perthes/Schlössmann (29%). The main osteosynthesis materials were plates (82%), bicortical screws (23.5%), or a combination of both (5.9%). 47% of all centers reported to use several surgical methods at the same time, depending on the anatomical problem and the surgeon's preference. This shows that different surgical methods seem to work as comparable, safe, and reliable procedures in everydays clinical practise. On this basis, further prospective studies could evaluate possible advantages for our patients.

Longtime undetected microcystic adnexal carcinoma of the scalp: considerations and implications

BACKGROUND

Microcystic adnexal carcinomas (MACs) are slow-growing and often asymptomatic malignant skin tumours that usually develop on the facial skin and may reach considerable size. We present an uncommon case of MAC arising on the hair-bearing scalp and discuss our experiences and considerations.

CASE REPORT

A 58-year-old female was admitted with a histopathologically secured diagnosis of MAC of the temporal and occipital regions that had expanded to 10 × 12 cm. Magnetic resonance imaging revealed an infiltration of the skin and the subcutaneous adipose tissue. No lymphatic or haematogenic metastases were detected. Therapy consisted of resecting the tumour and reconstructing the area by applying an anterolateral thigh (ALT) flap. Histopathological evaluation revealed clear, 1-cm margins and a tumour-free periosteum. One-year postoperative follow-ups showed no evidence of recurrence, while the outcome was aesthetically pleasing.

CONCLUSION

When screening for skin cancer, careful attention must be paid to the scalp. Resection of MAC with clear margins is mandatory to minimize the risk of recurrence. In this case, applying an ALT perforator flap to a large defect of the hair-bearing scalp led to a very satisfying result; it should be considered in comparable cases.

Comparison of intraoperative time measurements between osseous reconstructions with free fibula flaps applying computer-aided designed/computer-aided manufactured and conventional techniques

PURPOSE

We aimed to determine whether computer-aided designed/computer-aided manufactured (CAD/CAM) techniques could save intraoperative time compared with the conventional technique, by comparing flap harvesting and ischemia times, and subsequently impact flap survival.

METHODS

Twenty patients underwent concurrent osteocutaneous fibula flaps, either with (n = 10) or without (n = 10) the CAD/CAM technique. Demographic data, clinical history, complications, number of osseous segments, and times for virtual planning, flap harvesting, flap ischemia, tourniquet inflation, and total reconstruction were recorded.

RESULTS

There was no significant difference between CAD/CAM and conventional techniques with respect to age, number of osseous segments, complication rates, and tourniquet inflation time. Flap harvesting times were significantly shorter in the conventional group (112.1 vs. 142.2 min, p < 0.001), while flap ischemia and total ischemia times were significantly shorter in the CAD/CAM group (70.7 vs. 98.6 min, p < 0.001; 174.8 vs. 198.9 min, p = 0.002, respectively). However, while total reconstruction time did not differ between groups, overall operating time (including the amount of virtual planning time and surgical reconstruction time) was significantly longer in the CAD/CAM group (mean 256.0 vs. 210.7 min, p < 0.001).

CONCLUSIONS

Despite the advantages of the CAD/CAM technique, including reduced ischemia time of osteocutaneous fibula flaps, there is no impact on total reconstruction time or flap survival.

Orbital lobe resection provides a definite diagnosis of lacrimal gland lesions: a report of three cases

BACKGROUND

Entities of lacrimal gland lesions comprise almost inflammatory and lymphoproliferative processes as well as benign and malignant solid tumors and usually cannot be differentiated by magnetic resonance imaging (MRI) exclusively. Hence, representative tissue samples are needed to arrive at sufficient histopathological diagnosis for further treatment decisions.

CASE REPORT

Three women aged between 18 and 67 years were admitted to our center with clinical signs of a space-occupying mass in the lacrimal fossa. MRI revealed a circumscribed lacrimal gland lesion in all three cases. The orbital lobe was resected through a lateral orbitotomy approach for histopathological evaluation. Findings confirmed the diagnoses of pleomorphic adenoma, dacryoadenitis, and low-grade B cell non-Hodgkin's lymphoma. Further surgery was not necessary. No recurrence or symptoms of "dry eye" were observed over the course of a 1-year follow-up.

CONCLUSION

In cases of non-specific masses in the lacrimal gland on MRI, histopathological diagnoses are vital and can be sufficiently provided by resection of the orbital lobe. Symptoms of dry eye are uncommon, and secondary surgical intervention can be avoided in cases of the presented entities. Further studies with larger patient cohorts are warranted to confirm these findings.

Perceptions of Pre- to Postsurgical Profile Changes in Orthognathic Surgery Patients and Their Correlation with Photogrammetric Changes: A Panel Study

PURPOSE

The objective was to compare the pre- and postsurgical profile changes after surgical correction of prognathism and maxillary hypoplasia, as perceived by panels of orthodontists, maxillofacial surgeons, laypersons and patients and to identify photogrammetric changes that might be related to preferred ratings.

MATERIALS AND METHODS

Each panel consisted of six males and six females who rated sets of pre- and postsurgical lateral photographs of 20 female and 20 male patients using a five-point scale. Patients rated their own set of photographs. Pre- to postsurgical differences of photogrammetrically assessed landmarks were recorded as a surgical change.

RESULTS

No significant differences in ratings between panels and patients could be detected. Significant correlation coefficients (r) were obtained between the ratings of all panel groups and between the ratings and changes in facial convexity (r = 0.351-0.542). Correlations with changes of the mentolabial angle were found to be significant for old orthodontists, male laypersons, and male patients (r = 0.332-0.609). Ratings of female and young laypersons were correlated with the horizontal changes in the lower face (r = 0.324-0.379).

CONCLUSION

Information gathered from this study will support the cooperation of the medical staff and might assist in treatment planning.

Mucoepidermoid carcinoma of the palate in a 5-year-old girl: case report and literature review

BACKGROUND

Minor salivary gland tumors in children are uncommon. However, despite the low overall incidence, there is a high incidence of malignancy in these young patients which is reported to be above 50 %, with mucoepidermoid carcinoma (MEC) predominating. We hope that this case report will contribute to the enlightenment of the behavior and prognosis of pediatric MEC of palatal minor salivary gland tumors.

CASE REPORT

A 5-year-old girl was admitted to our center with a histologically confirmed MEC of the left hard palate. Primary incision for drainage of a supposed abscess and secondary biopsy had been performed elsewhere 14 days before. After further workup, we excised the tumor and the adjacent bone; clear margins of 10 mm were revealed. Adjuvant therapy was not necessary. The defect was allowed to undergo secondary wound healing. As of the 1-year follow-up, there had been no recurrences.

CONCLUSION

For differential diagnosis, MEC should be considered in cases of soft, slow-growing, painless, pale bluish-purple lumps of the palate even in young patients. Especially for nonresponders to initial treatment, early biopsy is recommended for histological confirmation or exclusion of a minor salivary gland tumor.

Clinical course and implications of congenital nasal pyriform stenosis and solitary median maxillary central incisor in a newborn: a case report

Introduction

Congenital nasal pyriform aperture stenosis and solitary median maxillary central incisor are uncommon anomalies and are associated with further malformations. Solitary median maxillary central incisor itself has initially no impact on a child’s health, but congenital nasal pyriform aperture stenosis is a potentially life-threatening condition.

Case presentation

A Caucasian baby boy showed severe dyspnoea and was intubated orotracheally. Multiple anomalies were detected, including urogenital and craniofacial malformations. Computed tomography scans revealed congenital nasal pyriform aperture stenosis with a diameter of 4.9mm and a solitary median maxillary central incisor. A 3.0mm tube was inserted in his left nasal cavity, and the baby was able to breathe sufficiently and spontaneously. The nasal tube was removed after seven days, and the baby was discharged under application of decongestant drops. After seven months, the baby was readmitted with respiratory distress, and surgery was carried out using an intraoral sublabial approach. The stenotic area of the pyriform aperture was widened, and 3.0mm tubes were inserted in both nasal cavities for 10 days. Over a period of six months, no further respiratory distress has occurred.

Conclusions

The decision to perform surgery was delayed since the baby’s nasal breathing was adequate as a result of the insertion of a nasal tube. Since treatment depends on the severity of symptoms, it is appropriate in some cases to take a conservative approach at first, and to keep surgery as a last resort. Once a conservative approach has been selected for congenital nasal pyriform aperture stenosis, awareness of the life-threatening nature of the condition should be kept in mind, and a surgical approach must still be taken into account.

Osteonecrosis of the maxilla related to long-standing methamphetamine abuse: a possible new aspect in the etiology of osteonecrosis of the jaw

BACKGROUND

Osteonecrosis of the jaw (ONJ) related to toxic effects of illicit drugs such as cocaine is not very common and might be overshadowed today by the incidence of bisphosphonate-related osteonecrosis of the jaw. However, we present a case which suggests a close relationship between abuse of the illicit drug methamphetamine (MA) and ONJ.

CASE REPORT

A 44-year-old male with extended osteonecrosis of the maxilla admitted chronic abuse and synthesis of MA for at least the previous two decades. Furthermore, he confessed self-extracting teeth since he became addicted to MA. However at presentation, he had been successfully cured of his addiction to MA. A step-by-step surgical treatment was planned using computer-aided design/computer-aided manufacturing techniques. After resection of necrotic bone, a vascularized osteomyocutaneous fibular flap was applied secondarily.

DISCUSSION

Two possible mechanisms, alone or in combination, could possibly lead to MA-related ONJ. Self-extraction of teeth as a psychopathologic behavior of self-destruction among MA abusers results in wounds that allow unhindered invasion of microorganisms causing osteomyelitis and ONJ, while on the other hand, the heating of white phosphor releases toxic phosphorous vapor, which could be inhaled and consequently cause ONJ of the maxilla. However, since the worldwide prevalence of MA abuse is remarkably high, a relationship between MA abuse and ONJ will offer a new aspect in the etiology of ONJ and might present a further therapeutic challenge.

Adenoid cystic carcinoma of the skull base mimicking temporomandibular disorder

BACKGROUND

Temporomandibular disorder (TMD) involves problems of the temporomandibular joint and its adjacent muscular system. Because TMD prevalence is high among Western populations, complaints in these regions are generally attributed to TMD. However, in rare cases, TMD symptoms are mimicked by malignant tumors of the head.

CASE REPORT

Upon first presentation, an 18-year-old female complained about typical symptoms of TMD. After an initial splint therapy and physiotherapy, painful symptoms increased significantly. Twelve weeks after initial diagnosis, further diagnostic imaging revealed a tumor formation at the skull base with infiltration of the infratemporal fossa. Histological evaluation confirmed the diagnosis of adenoid cystic carcinoma. Two years after resection of the tumor, lung metastases were detected with no option of curative treatment.

CONCLUSION

TMD symptoms, which are refractory to treatment or exhibit significant worsening during therapy, should be regarded as warning signals and as an indication that early further diagnostic imaging is warranted.

Microcystic adnexal carcinoma of the upper lip misdiagnosed benign desmoplastic trichoepithelioma

BACKGROUND

Desmoplastic trichoepithelioma (DT) is a benign appendageal tumour predominately localized on the facial skin. The histological diagnosis can be difficult in some cases. Partial malignant transformation of a DT is a rarity and a complete transformation has never been described in literature.

CASE REPORT

A DT of the upper lip was diagnosed histologically by a small biopsy 4 years previously. At presentation, the tumour had enlarged and had partly infiltrated the left side of the upper lip and subnasal region. Histological evaluation confirmed a microcystic adnexal carcinoma but without evidence of malignant transformation of the DT. It appeared that a too-small initial biopsy had led to the incorrect histological diagnosis of a benign tumour. Thus, it was necessary to perform a tumour resection and reconstruction using a two-flap technique including a rotation flap and an Abbé flap. Functional and aesthetic outcomes were good after 6 months. There were no recurrences during a 12-month follow-up.

CONCLUSION

A facial DT should be resected completely. Patients should be attended for follow-ups, keeping in mind the difficulty of making a proper histological diagnosis from small biopsies or excisions and the consequences of ablative facial surgery. However, in particular cases, subtotal defects of the upper lip region are amenable to reconstruction without gross functional or aesthetic deficits.

Limits and chances in an unfortunate course of recurrent orbital rhabdomyosarcoma

BACKGROUND

Orbital rhabdomyosarcoma (RMS) in childhood has an excellent survival rate after chemotherapy and radiation, and mutilating surgery can often be avoided.

CASE REPORT

As a rarity we present an unfortunate disease course in a child suffering from orbital embryonal RMS which did not enduringly respond to multimodal therapy including local excision and exenteration orbitae. After short intervals and despite tumor-free margins, orbital RMS recurred twice and led to an extended exenteration orbitae including the bony margins. Because of the lack of standards for adjuvant therapy in cases of recurrences after exenteration orbitae, therapy had to be restricted to a wait- and- see strategy as the only chance of tumor control.

CONCLUSION

Although survival rates of orbital RMS are high, the possibility of recurrence should not be underestimated. In cases of refractory RMS, new concepts are needed to offer further chances for survival.

Soft tissue response in orthognathic surgery patients treated by bimaxillary osteotomy: cephalometry compared with 2-D photogrammetry

Purpose

Since improvement of facial aesthetics after orthognathic surgery moves increasingly into the focus of patients, prediction of soft tissue response to hard tissue movement becomes essential for planning. The aim of this study was to assess the facial soft tissue response in skeletal class II and III patients undergoing orthognathic surgery and to compare the potentials of cephalometry and two-dimensional (2-D) photogrammetry for predicting soft tissue changes.

Material and methods

Twenty-eight patients with class II relationship and 33 with class III underwent bimaxillary surgery. All subjects had available both a traced lateral cephalogram and a traced lateral photogram taken pre- and postsurgery in natural head position (median follow-up, 9.4 ± 0.6 months).

Results

Facial convexity and lower lip length were highly correlated with hard tissue movements cephalometrically in class III patients and 2-D photogrammetrically in both classes. In comparison, cephalometric correlations for class II patients were weak. Correlations of hard and soft tissue movements between pre- and postoperative corresponding landmarks in horizontal and vertical planes were significant for cephalometry and 2-D photogrammetry. No significant difference was found between cephalometry and 2-D photogrammetry with respect to soft to hard tissue movement ratios.

Conclusions

This study revealed that cephalometry is still a feasible standard for evaluating and predicting outcomes in routine orthognathic surgery cases. Accuracy could be enhanced with 2-D photogrammetry, especially in class II patients.

Changes in quality of life and their relation to cephalometric changes in orthognathic surgery patients

OBJECTIVE

To evaluate correlations between presurgical and postsurgical changes in quality of life (QoL) and cephalometric hard and soft tissue changes in patients undergoing orthognathic surgery.

MATERIALS AND METHODS

The study sample consisted of 30 patients (mean age 24.3 ± 4.5 years) with Class III malocclusion undergoing orthognathic surgery for mandibular setback with a median follow-up of 8.3 ± 1.2 months. Presurgical and postsurgical cephalograms were traced and Oral Health Impact Profile (OHIP) questionnaires were completed. Each questionnaire consisted of 14 items designed to evaluate functional, physical, psychological, and social impacts.

RESULTS

Significant correlations between significant presurgical-to-postsurgical changes in individual items and OHIP parameters were found between labiomental angle (LA) and question 5 ("feeling self-conscious"; correlation coefficient [r]  =  0.530), between LA and question 6 ("feeling tense"; r  =  0.598), between nasion-pogonion and question 5 (r  =  0.523), and between facial convexity and question 5 (r  =  -0.540). Hence, reduction of both LA and nasion-pogonion led to a significant decrease in the impact scores of items covering psychological discomfort, while reduced facial convexity led to increased impact scores.

CONCLUSIONS

Although the associations were moderate, changes in QoL following cephalometric modifications should be considered as a major concern when planning orthognathic surgery. Postsurgical changes to a more convex profile after mandibular setback should be emphasized before surgery to help patients become accustomed to their new appearance more easily without negatively affecting QoL.

Assessment of soft tissue changes by cephalometry and two-dimensional photogrammetry in bilateral sagittal split ramus osteotomy cases

Objectives

We aimed to compare the standard methods of cephalometry and two-dimensional photogrammetry, to evaluate the reliability and accuracy of both methods.

Material and Methods

Twenty-six patients (mean age 25.5, standard deviation (SD) 5.2 years) with Class II relationship and 23 patients with Class III relationship (mean age 26.4, SD 4.7 years) who had undergone bilateral sagittal split ramus osteotomy were selected, with a median follow-up of 8 months between pre- and postsurgical evaluation. Pre- and postsurgical cephalograms and lateral photograms were traced and changes were recorded.

Results

Pre- and postsurgical measurements of hard tissue angles and distances revealed higher correlations with cephalometrically performed soft tissue measurements of facial convexity (Class II: N-PG, r = - 0.50, P = 0.047; Class III: ANB, r = 0.73, P = 0.005; NaPg , r = 0.71, P = 0.007;) and labiomental angle (Class II: SNB, r = 0.72, P = 0.002; ANB, r = - 0.72, P = 0.002; N-B, r = - 0.68, P = 0.004; ANS-Gn, r = 0.71, P = 0.002; Class III: ANS-Gn, r = 0.65, P = 0.043) compared with two-dimensional photogrammetry. However, two-dimensional photogrammetry revealed higher correlation between lower lip length and cephalometrically assessed angular hard tissue changes (Class II: SNB, r = 0.98, P = 0.007; N-B, r = 0.89, P = 0.037; N-Pg, r = 0.90, P = 0.033; Class III: SNB, r = - 0.54, P = 0.060; NAPg, r = - 0.65, P = 0.041; N-Pg, r = 0.58, P = 0.039).

Conclusions

Our findings suggest that cephalometry and two-dimensional photogrammetry offer the possibility to complement one another.

A rare association: basal cell carcinoma in a vitiliginous macula

Background

Today, no proven significant association was detected between sun-exposed vitiliginous patches and non-melanotic skin cancers. In fact, the occurrence of a basal cell carcinoma (BCC) in vitiliginous patches seems to be extremely rare.

Case report

We present a case of a 33-year-old female patient suffering from BCC in a vitiliginous patch on the cheek. This is the first report of the occurrence of a sclerodermiform type of BCC in a vitiliginous macula.

Conclusion

Our case report challenges the long-standing belief that the occurrence of BCC in vitiligo is nearly impossible. However, even if this association is apparently fortuitous, our report contributes to the awareness of the risk of BCC in young patients with vitiligo.

Complications after nasal skin repair with local flaps and full-thickness skin grafts and implications of patients' contentment

PURPOSE

The range of complications after plastic surgical repair of nasal skin defects is not clearly known. The aim of this study was to identify complications after reconstruction of nasal skin defects to determine what typical complications occur after standard surgical options including full-thickness skin graft (FTSG) and local flap plastics (LFP).

MATERIALS AND METHODS

In 210 patients with defects of the nasal tip, the nasal ala or dorsum of the nose (average diameter 1.1 +/- 0.3 cm) surgical skin repair was performed with LFP or FTSG. Complications within 6 months after surgery were recorded.

RESULTS

Some 41 patients (19.5%) suffered complications; there was no significant difference in total complication rate between LFP (20.5%) and FTSG (18.3%). However, FTSG patients had significantly more infections postoperatively than LFP patients (5.4% vs. 2.6%). LFP patients presented a significantly higher rate of wound or suture dehiscence (FTSG 2.2%, LFP 5.9%). FTSG patients exhibited a significantly higher rate of partial or complete loss (total rate FTSG 8.5%, LFP 5.2%). The LFP technique led to significantly more aesthetic deficits (FTSG 2.1%, LFP 6.8%).

CONCLUSIONS

LFP showed advantages with regard to infection and loss rates but with a higher rate of aesthetic deficits compared to FTSG. It remains an individual decision as to which procedure is used to repair defects of the nose, depending on patient and surgical variables.

Snoring in cleft patients with velopharyngoplasty

Some patients with cleft lip/palate or isolated cleft palate seem to develop snoring as one possible symptom of an obstructive sleep apnoea syndrome after velopharyngoplasty (VPP). The aim of this paper was to determine whether there was a difference in the posterior airway space (PAS) between patients with a VPP who snored and those who did not. Four standard parameters were measured in lateral cephalograms of 20 patients with cleft lip/palate and isolated cleft palate, without diagnosis of further syndromes (e.g. Pierre Robin sequence), having undergone VPP, to examine the dimensions of the PAS. Data were set in correlation to the symptom of snoring, and compared with those of 40 patients without cleft undergoing orthodontic treatment and with 20 patients with cleft lip/palate or isolated cleft palate but not VPP. Metric parameters were significantly different after VPP in patients with clefting and snoring compared to the group of cleft patients without snoring. All patients with clefts exhibited at least in one dimension a constriction when compared to patients without clefting. In conclusion, cleft lip/palate and isolated cleft palate patients tend to have constrictions of the PAS. VPP may induce snoring and further narrowing. Recall and analysis for obstructive sleep apnoea syndrome should be mandatory.

Injuries in combat from 1982–2005 with particular reference to those to the head and neck: A review

The aim of this review was to examine the range of combat injuries with particular reference to those of the head and neck. We evaluated 10 retrospective studies selected from the period 1982-2005 that covered war injuries from Vietnam, Lebanon, Slovenia, Croatia, Iraq, Somalia, and Afghanistan. We found differences in the causes of injuries. Injuries from fragments were more common during the 90s than during the Vietnam War, where shooting injuries predominated. Injuries to the trunk were reduced in conflicts from 1991 onwards as military personal armour systems including protective vests were used. However, the mortality of wounded soldiers in all conflicts was consistently between 10% and 14%. There was a high incidence of injuries to the head and neck (up to 40%) though they affected only 12% of the body surface area. Though the data from the different military conflicts are not totally comparable, there are trends in the type of injuries and mortality, which may lead to changes in existing systems of medical care.

Patients’ knowledge and expectations regarding dental implants: assessment by questionnaire

Today, modern implant dentistry appeals to a wide population, but the decision for and the success of implants depend on the knowledge and expectations of patients. The aim of this study was, with the help of a questionnaire, to evaluate the level of patient knowledge before a professional consultation was performed, and hence to be better prepared in the interests of patient awareness. Fifty-eight percent of 315 patients questioned thought that implants require the same care as natural teeth, 61% expected an additional payment of 2000 Euro or less, 80% held the function of an implant-supported overdenture as very important and 54% attached great importance to the aesthetics. The expectations that patients have for an implant-supported set are high in contrast to their willingness to make additional payments. There are still misconceptions regarding costs, and these must be resolved individually in practice.

Thermography and thermoregulation of the face

BACKGROUND

Although clinical diagnosis of thermoregulation is gaining in importance there is no consistent evidence on the value of thermography of the facial region. In particular there are no reference values established with standardised methods.

METHODS

Skin temperatures were measured in the facial area at 32 fixed measuring sites in 26 health subjects (7-72 years) with the aid of a contact thermograph (Eidatherm). A total of 6 measurements were performed separately for the two sides of the face at intervals of equal lengths (4 hours) over a period of 24 hours. Thermoregulation was triggered by application of a cold stimulus in the region of the ipsilateral ear lobe.

RESULTS

Comparison of the sides revealed significant asymmetry of face temperature. The left side of the face showed a temperature that was on the average 0.1 degrees C lower than on the right. No increase in temperature was found following application of the cold stimulus. However, a significant circadian rhythm with mean temperature differences of 0.7 degrees C was observed.

CONCLUSION

The results obtained should be seen as an initial basis for compiling an exact thermoprofile of the surface temperature of the facial region that takes into account the circadian rhythm, thus closing gaps in studies on physiological changes in the temperature of the skin of the face.

Necessity of surgical dental foci treatment prior to organ transplantation and heart valve replacement

Diagnosis and surgical treatment of septic foci (e.g., apical or marginal and profound periodontitis, cysts, unrestorable teeth, or abscesses) in patients awaiting organ transplants and heart valve replacement (HVR) have become a recommended, yet controversial standard procedure. This study aims to evaluate the numerical extent of the required oral surgical procedures removing septic foci in these patients. Data of 204 patients (115 males/89 females) of the Department of Oral- and Maxillofacial Surgery with an average age of 58 years were evaluated in terms of necessary oral surgical procedures before HVR or kidney (K), heart (H), or liver (L) transplant (T) and were compared with data from patients not undergoing transplantation or HVR, who were referred for other reasons such as oral surgery. The number of tooth extractions or apicoectomies per patient averaged two to five for each of the four patient groups (KT, 0-7 affected teeth; HT, 0-5; LT, 1-5; and HVR, 1-10). Treatment of periodontitis was necessary in 64% of patients. A total of 70% of patients required oral surgical procedures before HT, LT, and HVR, while 84% needed before KT. Removal of oral septic foci is necessary to avoid jeopardizing the success of transplantations. With regard to the surprisingly high need for surgical treatment in this patient population, assessment of these patients by the appropriate specialist and continuation with a follow-up program is still highly recommended.

[Experiences with surgical management of facial basal cell carcinoma and procedures for plastic reconstruction]

BACKGROUND

No recurrences and optimal aesthetic outcomes after R0 resection and plastic reconstruction of the face are the goals in the surgical treatment of basal cell carcinoma. The aim of this study was to evaluate recurrence rates and to evaluate different reconstructive techniques.

PATIENTS AND METHODS

This study included 205 follow-up patients undergoing R0 resection of primary basal cell carcinoma and facial skin reconstruction between 1998 and 2002; data were analyzed retrospectively.

RESULTS

The most frequent locations of basal cell carcinoma were the nasal (40.5%) and orbital (22.9%) regions. The rate of recurrence after 2.5 years (6 months-5 years) was 7.3%. Local flaps, full-thickness skin grafts, and sliding flaps were usually performed; indications for split-thickness skin grafts were rare. Disturbances of sensation were found in only 3.6% of the sliding flaps and in 11.7% of the local flaps, but 22.7% in full-thickness and 38.7% in split-thickness skin grafts. The aesthetic outcome, evaluated by clinical inspection and a patient satisfaction score, was classified as "unobtrusive" and "good or excellent" for 88.4% of local flaps, 92.6% of sliding flaps, but only for 66.4% of full-thickness and 54% of split-thickness skin grafts.

CONCLUSION

Local flaps and sliding flaps result in better aesthetic and neurological outcomes after reconstruction of facial skin regions. Skin grafts have their indications as an alternative procedure in cases of critical indications for flaps.

Outcomes after surgical treatment of facial skin basal cell carcinomas

BACKGROUND

Missing recurrences and the aesthetic outcomes after reconstructions of the face are preoccupations in the surgical treatment of basal cell carcinomas. Hence, the different reconstructive techniques in particular and the rate of recurrence are evaluated in this study.

PATIENTS

205 patients receiving resections of basal cell carcinomas and facial skin reconstructions were included and data were analyzed.

RESULTS

The rate of recurrence was 7.3% after follow-up at an average of 2.5 years (0.5-5 years). Local flaps, full-thickness skin grafts and skin extension closures were carried out most often; indications for split-thickness skin grafts were rare. Sensitivity disturbances occurred in only 3.6% of skin extension closures and in 11.7% of local flaps, but in 22.7% of full-thickness skin grafts and in 38.7% of split-thickness skin grafts. The aesthetic outcomes were evaluated through clinical inspection and by using patients' scale. They were classified as "unobtrusive" and "excellent or good" in 88.4% of local flaps and in 92.6% of skin extension closures, but in only 66.4% of full-thickness skin grafts and in 54% of split-thickness skin grafts.

CONCLUSION

Local flaps and skin extension closures provide better aesthetic and neurological outcomes after facial skin reconstructions. However, skin grafts are alternative procedures for critical indications of local flaps.

Pierre-Robin-Sequenz — postoperative Komplikationen nach Gaumenspaltverschluss

BACKGROUND

In a 25-year retrospective review of 1976-2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied.

PATIENTS AND METHODS

The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life.

RESULTS

A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.

Quantification of the neurodegenerative impact on the visual system following sudden retrobulbar expanding lesions - an experimental model

INTRODUCTION

Afferent disorders of the visual system are a potential consequence following orbital trauma. The aim of this study was to investigate the tolerance of neurons in the retinal ganglion cell layer to acute expanding retrobulbar lesions.

MATERIAL AND METHODS

In 42 male albino rats, intraorbital haemorrhage was simulated by transconjunctival insertion of a retrobulbar micro-balloon (filling volume 0.2-0.5 ml, duration of lesion 60 or 90 min). Neurodegeneration in the retinal ganglion cell layer was investigated by measuring the mean total neuron number and the mean neuron size.

RESULTS

Increased retrobulbar volumes of 0.3 ml for 60 min led to a decrease in a number of neurons by 14.5% and in size of the neurons by 1.7%. Prolongation of the trauma to 90 min resulted in a decrease in number of neurons by 48.3% and in reduction of size of neurons by 22.1%. In contrast, a retrobulbar filling volume of 0.5 ml for 60 min resulted in a decrease in number of neurons by 11.4% and in size of neurons by 6.7%.

CONCLUSION

The duration of a retrobulbar lesion leading to subsequent retinal ischaemia seems to be more important for neuron survival than the exerted pressure (once it is greater than a critical point for producing retinal ischaemia). The results strengthen the need for emergency treatment in cases of retrobulbar haemorrhage.

[Foreign body in paranasal sinuses]

AIMS

All cases of the last 5 years requiring foreign bodies to be removed from the paranasal sinuses were investigated as to causes, special aspects in diagnostics and therapy, occurrence of pathologic germs and possible sequels.

PATIENTS

68 cases were evaluated: 43 patients were male, 25 female. Average age was 29 years in males and 37 years in females.

RESULTS

In our patients foreign bodies in the paranasal sinuses were in more than 60% the result of medical or dental procedures followed by industrial accidents (25%). The maxillary sinus was affected in 75%, the frontal sinus in about 18%. Involvement of the ethmoid or sphenoid sinus was rare. The spectrum of pathologic microbes was dominated by mixed infections, the share of actinomyces and aspergillus was unexpected high. Most important acute complications were bleeding, compression of the optic nerve and liquorrhoe. Late complications consisted mainly of pain--often associated with disturbances of sensibility- and infections.

CONCLUSIONS

A smear should be taken whenever the foreign body remained in the sinus for more than 4 days. Foreign bodies jammed in the posterior wall of the sinus require a sufficiently open view since the risk of heavy bleeding is especially high.

Reasons for patients' discontent and litigation

INTRODUCTION

Discontent and litigation among patients is a problem which increasingly preoccupies the medical profession.

AIM

We aim to analyse the origin of discontent and litigation and to help avoiding these claims.

MATERIAL

One hundred and seventy-eight medical expert opinions were evaluated, all made following examination of the complainant.

METHODS

Depending on the results of the clinical examination and the study of the files it was determined whether there was either a case of malpractice or insufficient informed consent, or no fault at all in a legal sense. In addition the patient and the surgeon were questioned as to their point of view regarding the procedure and their communication and relationship before and after treatment.

RESULTS

Frequent complaints were pain (either during treatment or afterwards), major swelling or bleeding, disturbances of trigeminal or facial nerve function, poor scar formation, loss of teeth or fixtures, faulty occlusion and discrepancies between the expected and the actual result of treatment. In 26 cases actual faults made during medical treatment were discovered. In 49 further cases, poor explanation of the proposed procedure was the reason for complaint. In the majority of remaining cases, neither faulty treatment nor insufficient information given to the patient lead to the complaint but the patient's expectations were unrealistically high.

CONCLUSION

A considerable proportion of lawsuits originate from misunderstandings, and not treatment errors: The surgeons often concentrate on the legal requirements of informed consent and neglect to explain the practical consequences of the operation; the patients in turn tend not to ask about possible complications.

[Melanotic neuroectodermal tumor of infancy]

BACKGROUND

The melanotic neuroectodermal tumor of infancy is a rare and so far as being classified neoplasm with a high rate of recurrence for one year after diagnosis. Since Krompecher described 1918 the tumor at first, only about 200 cases are reported until today, mostly with manifestation in the maxillary region.

CASE-REPORTS

The authors present two infants at the age of six and eight weeks with first clinical manifestation of the tumor in the maxillary region. Although there were no other common signs, the tumor destroyed wide areas of the mid-face. In spite of a treatment with radical surgery, recurrences occur rapidly in the first living year.

CONCLUSIONS

Our clinical and histological findings show characteristics of local malignant growth. For these facts the radical resections of the primary tumor and its recurrences are individually the therapeutical consequences. A follow up of seven years of one infant shows a hypoplasm of the mid-face as a result of the inhibition of further growth by the loss of germs after maxillary hemisection.

[Frey syndrome]

AIMS

The incidence of Frey's syndrome after parotidectomy as cited in the literature varies distinctively. Strategies for successful treatment are also assessed differently.

PATIENTS

Between 1980 and 1994 a total of 372 parotidectomies were performed in 364 patients at the Bochum University Hospital.

RESULTS

After an average of 18 months following parotidectomy, 86 patients (23.5%) developed Frey's syndrome. Thirty-five patients were treated with scopolamine ointment. The symptoms improved in nine cases after an average of 25 months of therapy. Of the patients receiving no treatment (n = 20), seven improved after an average follow-up of 20 months. Therapy with scopolamine ointment did not elicit significantly better results compared to no treatment at all.

CONCLUSION

Gustatory sweating after parotidectomy still has to be regarded as an unpleasant complication which is difficult to cure.

[Associated anomalies in lip-maxillopalatal clefts]

BACKGROUND

Retrospective studies of cleft lip and palate patients suggest a multifactorial aetiology for this condition. Many patients exhibit multiple defects, often removed from the orofacial region. The frequency and location of such coexistent abnormalities vary between studies.

PATIENTS

A retrospective case-note study of 1,737 individuals with orofacial cleft, treated between 1974 and 1998 at our centre, was undertaken to assess the frequency of associated malformations and syndromes.

RESULTS

Associated malformations were found to be present in 33% of all cases investigated. In nearly one half of these individuals (48%), defects could be attributed to recognisable syndromes. Patients with isolated palatal clefts (45.6%) and those with bilateral clefts of the lip and palate (35.3%) were particularly well-represented. The following problems were observed relatively frequently: Cerebral anomalies (16%), facial anomalies (14%), heart malformations (15%), anomalies of the extremities (9%) and urogenital tract abnormalities (8%). In contrast, endocrine aberrations were identified sporadically (0.5%). A partial situs inversus was found only in one case.

CONCLUSION

As clefts of the lip and palate are frequently associated with additional malformations, the importance of thorough interdisciplinary neonatal screening cannot be over emphasised.

Amplification of the mdr1-gene is uncommon in recurrent ovarian carcinomas

Ovarian carcinomas are known to rapidly develop drug resistance against chemotherapeutic agents. This phenomenon is often associated with the expression of pl70-glycoprotein. A high rate of transcription of the corresponding mdr1-gene in resistant tumors is reported. Amplification of the mdr1-gene has been observed in tumor cell lines exposed to cytotoxic drugs; however, significant information is lacking as to whether this holds true in clinical carcinomas. To fill this gap, we investigated the rate of gene amplification of the mdr1-gene in 63 recurrent ovarian carcinomas and we determined the resistance pattern of these cells using an ex vivo assay. The tumors showed varying ex vivo resistance patterns which did not correlate to clinical parameters. Amplification of the mdr1-gene was not observed in any of the cancer specimens. Therefore, we conclude that mdr1-gene amplification is not a common pathway for the development of chemoresistance in clinical ovarian carcinomas.

[20 years geriatric rehabilitation at the Hannover at the Henrietta Foundation]

This report includes the historical formation of the institution in regard to the background of the development of the German Society of Gerontology. A description of the newly formed clinic and its special institute for geriatric rehabilitation is supposed to provide a survey about the conditions of clinical work as well as the special courses and training possibilities. This is followed by the presentation of treatment methods and results.