Oral mucosa - an examination map for confocal laser endomicroscopy within the oral cavity: an experimental clinical study

OBJECTIVES

Confocal laser endomicroscopy (CLE) is an optical method that enables microscopic visualization of oral mucosa. Previous studies have shown that it is possible to differentiate between physiological and malignant oral mucosa. However, differences in mucosal architecture were not taken into account. The objective was to map the different oral mucosal morphologies and to establish a "CLE map" of physiological mucosa as baseline for further application of this powerful technology.

MATERIALS AND METHODS

The CLE database consisted of 27 patients. The following spots were examined: (1) upper lip (intraoral) (2) alveolar ridge (3) lateral tongue (4) floor of the mouth (5) hard palate (6) intercalary line. All sequences were examined by two CLE experts for morphological differences and video quality.

RESULTS

Analysis revealed clear differences in image quality and possibility of depicting tissue morphologies between the various localizations of oral mucosa: imaging of the alveolar ridge and hard palate showed visually most discriminative tissue morphology. Labial mucosa was also visualized well using CLE. Here, typical morphological features such as uniform cells with regular intercellular gaps and vessels could be clearly depicted. Image generation and evaluation was particularly difficult in the area of the buccal mucosa, the lateral tongue and the floor of the mouth.

CONCLUSION

A physiological "CLE map" for the entire oral cavity could be created for the first time.

CLINICAL RELEVANCE

This will make it possible to take into account the existing physiological morphological features when differentiating between normal mucosa and oral squamous cell carcinoma in future work.

Relevant parameters for laser surgery of soft tissue

In recent years, the laser has become an important tool in hospitals. Laser surgery in particular has many advantages. However, there is still a lack of the understanding of the influence of the relevant parameters for laser surgery. In order to fill this gap, the parameters pulse frequency, use of an exhaustion system, air cooling, laser power, laser scan speed, laser line energy and waiting time between cuts were analysed by ANOVA using inter-animal variation as a benchmark. The quality of the cuts was quantized by a previously published scoring system. A total of 1710 cuts were performed with a [Formula: see text] laser. Of the parameters investigated, laser power and scan speed have the strongest influence. Only the right combination of these two parameters allows good results. Other effects, such as the use of pulsed or continuous wave (CW) laser operation, or air cooling, show a small or negligible influence. By modulating only the laser power and scan speed, an almost perfect cut can be achieved with a [Formula: see text] laser, regardless of the external cooling used or the laser pulse duration or repetition rate from CW to nanosecond pulses.

Raman spectroscopy and U-Net deep neural network in antiresorptive drug-related osteonecrosis of the jaw

OBJECTIVE

Application of an optical method for the identification of antiresorptive drug-related osteonecrosis of the jaw (ARONJ).

METHODS

We introduce shifted-excitation Raman difference spectroscopy followed by U-Net deep neural network refinement to determine bone tissue viability. The obtained results are validated through established histological methods.

RESULTS

Discrimination of osteonecrosis from physiological tissues was evaluated at 119 distinct measurement loci in 40 surgical specimens from 28 patients. Mean Raman spectra were refined from 11,900 raw spectra, and characteristic peaks were assigned to their respective molecular origin. Then, following principal component and linear discriminant analyses, osteonecrotic lesions were distinguished from physiological tissue entities, such as viable bone, with a sensitivity, specificity, and overall accuracy of 100%. Moreover, bone mineral content, quality, maturity, and crystallinity were quantified, revealing an increased mineral-to-matrix ratio and decreased carbonate-to-phosphate ratio in ARONJ lesions compared to physiological bone.

CONCLUSION

The results demonstrate feasibility with high classification accuracy in this collective. The differentiation was determined by the spectral features of the organic and mineral composition of bone. This merely optical, noninvasive technique is a promising candidate to ameliorate both the diagnosis and treatment of ARONJ in the future.

Experimental Validation of Shifted Position-Diffuse Reflectance Imaging (SP-DRI) on Optical Phantoms

Numerous diseases such as hemorrhage, sepsis or cardiogenic shock induce a heterogeneous perfusion of the capillaries. To detect such alterations in the human blood flow pattern, diagnostic devices must provide an appropriately high spatial resolution. Shifted position-diffuse reflectance imaging (SP-DRI) has the potential to do so; it is an all-optical diagnostic technique. So far, SP-DRI has mainly been developed using Monte Carlo simulations. The present study is therefore validating this algorithm experimentally on realistic optical phantoms with thread structures down to 10 μm in diameter; a SP-DRI sensor prototype was developed and realized by means of additive manufacturing. SP-DRI turned out to be functional within this experimental framework. The position of the structures within the optical phantoms become clearly visible using SP-DRI, and the structure thickness is reflected as modulation in the SP-DRI signal amplitude; this performed well for a shift along the x axis as well as along the y axis. Moreover, SP-DRI successfully masked the pronounced influence of the illumination cone on the data. The algorithm showed significantly superior to a mere raw data inspection. Within the scope of the study, the constructive design of the SP-DRI sensor prototype is discussed and potential for improvement is explored.

Validation of a classification and scoring system for the diagnosis of laryngeal and pharyngeal squamous cell carcinomas by confocal laser endomicroscopy

INTRODUCTION

Confocal laser endomicroscopy is an optical imaging technique that allows in vivo, real-time, microscope-like images of the upper aerodigestive tract's mucosa. The assessment of morphological tissue characteristics for the correct differentiation between healthy and malignant suspected mucosa requires strict evaluation criteria.

OBJECTIVE

This study aims to validate an eight-point score for the correct assessment of malignancy.

METHODS

We performed confocal laser endomicroscopy between March and October 2020 in 13 patients. 197 sequences (11.820 images) originated from the marginal area of pharyngeal and laryngeal carcinomas. Specimens were taken at corresponding locations and analyzed in H&E staining as a standard of reference. A total of six examiners evaluated the sequences based on a scoring system; they were blinded to the histopathological examination. The primary endpoints are sensitivity, specificity, and accuracy. Secondary endpoints are interrater reliability and receiver operator characteristics.

RESULTS

Healthy mucosa showed epithelium with uniform size and shape with distinct cytoplasmic membranes and regular vessel architecture. Confocal laser endomicroscopy of malignant cells demonstrated a disorganized arrangement of variable cellular morphology. We calculated an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 83.2%, 81.3%, 85.5%, 86.7%, and 79.7%, respectively, with a κ-value of 0.64, and an area under the curve of 0.86.

CONCLUSION

The results confirm that this scoring system is applicable in the laryngeal and pharyngeal mucosa to classify benign and malignant tissue. A scoring system based on defined and reproducible characteristics can help translate this experimental method to broad clinical practice in head and neck diagnosis.

Development and evaluation of a scoring system for assessing incisions in laser surgery

The idea of laser surgery is nearly as old as the laser itself. From the first trials to modern laser surgery systems, it was and is the aim to selectively cut the tissue in the focus spot without causing harm to surrounding structures. This is only possible when the correct parameters for the surgical laser are chosen. Usually, this is done by parameter studies. However, the concrete evaluation scheme often differs between groups and more precise approaches require staining and microscopic evaluation. To overcome these issues, a macroscopic scoring system is presented and evaluated. It can be shown that the scoring system works well and, thus, a laser cut can be evaluated within a few seconds. At the same time, the whole cutting front is taken into account. The presented scoring system is evaluated by the intra class correlation (ICC). The final agreement between different raters is more than 0.7. Therefore, the scoring system can be used to optimize and evaluate the cutting process and it should be suitable for comparing the results between different groups. Definitely, it can be applied for scoring within a group to enable e.g., a profound statistical analysis for a parameter study.

Systematic classification of confocal laser endomicroscopy for the diagnosis of oral cavity carcinoma

INTRODUCTION

Confocal laser endomicroscopy (CLE) is an optical imaging technique that allows in vivo microscope-like images of the upper aerodigestive tract's mucosa in 1000-fold magnification. The assessment of morphological tissue characteristics for the correct differentiation between healthy and malignoma suspected mucosa requires strict evaluation criteria. This study aims to validate a score for oral cavity squamous cell carcinoma (OCSCC) diagnostic.

METHODS

We performed CLE and examined a total of twelve patients. All 95 sequences (778 s, 6224 images) originate from the area of the primary tumor 260 s, 2080 images) and unsuspicious mucosa of the oral cavity (518 s, 4144 images). Specimen were taken at corresponding locations and analyzed histologically in H&E staining as a reference standard. A total of eight examiners (four experienced and four inexperienced) evaluated the sequences based on a scoring system. The primary endpoints are sensitivity, specificity, and accuracy. Secondary endpoints are inter-rater reliability and receiver operator characteristics.

RESULTS

Healthy mucosa showed epithelium with uniform size and shape with distinct cytoplasmic membranes and regular vessel architecture. CLE of malignant cells demonstrated a disorganized arrangement of variable cellular morphology. We calculated an accuracy, sensitivity, specificity, PPV, and NPV of 88.7 %, 90.1 %, 87.4 %, 87.5 %, and 90.0 %, respectively, with inter-rater reliability and κ-value of 0.775, and an area under the curve of 0.935.

CONCLUSIONS

The results confirm that this scoring system is applicable in the oral cavity mucosa to classify benign and malignant tissue.

Validity of tissue homogeneity in confocal laser endomicroscopy on the diagnosis of laryngeal and hypopharyngeal squamous cell carcinoma

Purpose

Confocal laser endomicroscopy (CLE) allows imaging of the laryngeal mucosa in a thousand-fold magnification. This study analyzes differences in tissue homogeneity between healthy mucosa and squamous cell carcinoma (SCC) via CLE.

Materials and methods

We included five SCC patients with planned total laryngectomy in this study between October 2020 and February 2021. We captured CLE scans of the tumor and healthy mucosa. Analysis of image homogeneity to diagnose SCC was performed by measuring the signal intensity in four regions of interest (ROI) in each frame in a total of 60 sequences. Each sequence was assigned to the corresponding histological pattern, derived from hematoxylin and eosin staining. In addition, we recorded the subjective evaluation of seven investigators regarding tissue homogeneity.

Results

Out of 3600 images, 1620 (45%) correlated with benign mucosa and 1980 (55%) with SCC. ROIs of benign mucosa and SCC had a mean and standard deviation (SD) of signal intensity of, respectively, 232.1 ± 3.34 and 467.3 ± 9.72 (P < 0.001). The mean SD between the four different ROIs was 39.1 ± 1.03 for benign and 101.5 ± 2.6 for SCC frames (P < 0.001). In addition, homogeneity yielded a sensitivity and specificity of 81.8% and 86.2%, respectively, regarding the investigator-dependent analysis.

Conclusions

SCC shows a significant tissue inhomogeneity in comparison to the healthy epithelium. The results support this feature’s importance in identifying malignant mucosa areas during CLE examination. However, the examiner-dependent evaluation emphasizes that homogeneity is a sub-criterion that must be considered in a broad context.

Systematic interpretation of confocal laser endomicroscopy: larynx and pharynx confocal imaging score

OBJECTIVE

Development and validation of a confocal laser endomicroscopy (CLE) classification score for the larynx and pharynx.

METHODS

Thirteen patients (154 video sequences, 9240 images) with laryngeal or pharyngeal SCC were included in this prospective study between October 2020 and February 2021. Each CLE sequence was correlated with the gold standard of histopathological examination. Based on a dataset of 94 video sequences (5640 images), a scoring system was developed. In the remaining 60 sequences (3600 images), the score was validated by four CLE experts and four head and neck surgeons who were not familiar with CLE.

RESULTS

Tissue homogeneity, cell size, borders and clusters, capillary loops and the nucleus/cytoplasm ratio were defined as the scoring criteria. Using this score, the CLE experts obtained an accuracy, sensitivity, and specificity of 90.8%, 95.1%, and 86.4%, respectively, and the CLE non-experts of 86.2%, 86.4%, and 86.1%. Interobserver agreement Fleiss' kappa was 0.8 and 0.6, respectively.

CONCLUSIONS

CLE can be reliably evaluated based on defined and reproducible imaging features, which demonstrate a high diagnostic value. CLE can be easily integrated into the intraoperative setting and generate real-time, in-vivo microscopic images to demarcate malignant changes.

The influence of the optical properties on the determination of capillary diameters

Various clinically applicable scores and indices are available to help identify the state of a microcirculatory disorder in a patient. Several of these methods, however, leave room for interpretation and only provide clues for diagnosis. Thus, a measurement method that allows a reliable detection of impending or manifest circulatory malfunctions would be of great value. In this context, the optical and non-invasive method of shifted position-diffuse reflectance imaging (SP-DRI) was developed. It allows to determine the capillary diameter and thus to assess the state of the microcirculation. The aim of the present study is to investigate how the quantification of capillary diameters by SP-DRI behaves in different individuals, i.e. for a wide range of optical properties. For this, within Monte-Carlo simulations all optical properties (seven skin layers, hemoglobin) were randomly varied following a Gaussian distribution. An important finding from the present investigation is that SP-DRI works when the optical properties are chosen randomly. Furthermore, it is shown that appropriate data analysis allows calibration-free absolute quantification of the capillary diameter across individuals using SP-DRI. This underpins the potential of SP-DRI to serve as an early alert system for the onset of microcirculatory associated diseases.

[Confocal laser endomicroscopy of head and neck squamous cell carcinoma: a systematic review]

OBJECTIVE

 Confocal laser endomicroscopy (CLE), with a magnification of up to 1000 ×, offers the possibility to visualize intercellular spaces in vivo. CLE has already established itself in different disciplines. This article gives an overview of the current research on CLE in the diagnosis of the head and neck squamous cell carcinoma.

MATERIAL AND METHODS

 Systematic bibliographic research in the following online databases: PubMed, MEDLINE, Thompson Reuters Web of Science, SPIE using the following keywords: confocal laser endomicroscopy, CLE, endomicroscopy, head and neck, larynx. Evaluation of the scientific relevance according to defined criteria.

RESULTS

 All studies were analyzed concerning the clinical application, clinical findings, and computer-aided data processing.

CONCLUSIONS

 The recently published data suggest that CLE has a high potential to improve the diagnosis of malignant mucosal lesions in the upper aerodigestive tract.

Impact of intraepithelial capillary loops and atypical vessels in confocal laser endomicroscopy for the diagnosis of laryngeal and hypopharyngeal squamous cell carcinoma

PURPOSE

Confocal laser endomicroscopy (CLE) allows surface imaging of the laryngeal and pharyngeal mucosa in vivo at a thousand-fold magnification. This study aims to compare irregular blood vessels and intraepithelial capillary loops in healthy mucosa and squamous cell carcinoma (SCC) via CLE.

MATERIALS AND METHODS

We included ten patients with confirmed SCC and planned total laryngectomy in this study between March 2020 and February 2021. CLE images of these patients were collected and compared with the corresponding histology in hematoxylin and eosin staining. We analyzed the characteristic endomicroscopic patterns of blood vessels and intraepithelial capillary loops for the diagnosis of SCC.

RESULTS

In a total of 54 sequences, we identified 243 blood vessels which were analyzed regarding structure, diameter, and Fluorescein leakage, confirming that irregular, corkscrew-like vessels (24.4% vs. 1.3%; P < .001), dilated intraepithelial capillary loops (90.8% vs. 28.7%; P < .001), and increased capillary leakage (40.7% vs. 2.5%; P < .001), are significantly more frequently detected in SCC compared to the healthy epithelium. We defined a vessel diameter of 30 μm in capillary loops as a cut-off value, obtaining a sensitivity, specificity, PPV, and NPV and accuracy of 90.6%, 71.3%, 57.4%, 94.7%, and 77.1%, respectively, for the detection of malignancy based solely on capillary architecture.

CONCLUSION

Capillaries within malignant lesions are fundamentally different from those in healthy mucosa regions. The capillary architecture is a significant feature aiding the identification of malignant mucosa areas during in-vivo, real-time CLE examination.

Determination of the diameter of simulated human capillaries using shifted position-diffuse reflectance imaging

Multiple diseases are associated with a wide spectrum of microvascular dysfunctions, microangiopathies and microcirculation disorders. Monitoring the microcirculation could thus be useful to diagnose many local and systemic circulatory disorders and to supervise critically ill patients. Many of the scores currently available to help identify the condition of a microcirculation disorder are invasive or leave scope for interpretation. Thus, the present study aims to investigate with Monte-Carlo simulations (as numerical solutions of the radiative transfer equation) whether shifted position-diffuse reflectance imaging (SP-DRI), a non-invasive diagnostic technique, reveals information on the capillary diameter to assess the state of the microcirculation. To quantify the SP-DRI signal, the modulation parameter K is introduced. It proves to correlate almost perfectly with the capillary diameter ( R¯2≈1 ), making it a valid parameter for reliably assessing microcirculation. SP-DRI is emerging as an important milestone on the way to early and conveniently diagnosing microcirculation associated diseases.

Intraoperative free margins assessment of oropharyngeal squamous cell carcinoma with confocal laser endomicroscopy: a pilot study

PURPOSE

This pilot study aimed to assess the feasibility of intraoperative assessment of safe margins with confocal laser endomicroscopy (CLE) during oropharyngeal squamous cell carcinoma (OPSCC) surgery.

METHODS

We included five consecutive patients confirmed OPSCC and planned tumor resection in September and October 2020. Healthy appearing mucosa in the marginal zone, and the tumor margin, were examined with CLE and biopsy during tumor resection. A total of 12,809 CLE frames were correlated with the gold standard of hematoxylin and eosin staining. Three head and neck surgeons and one pathologist were asked to identify carcinoma in a sample of 169 representative images, blinded to the histological results.

RESULTS

Healthy mucosa showed epithelium with uniform size and shape with distinct cytoplasmic membranes and regular vessel architecture. CLE optical biopsy of OPSCC demonstrated a disorganized arrangement of variable cellular morphology. We calculated an accuracy, sensitivity, specificity, PPV, and NPV of 86%, 90%, 79%, 88%, and 82%, respectively, with inter-rater reliability and κ-value of 0.60.

CONCLUSION

CLE can be easily integrated into the intraoperative setting, generate real-time, in-vivo microscopic images of the oropharynx for evaluation and demarcation of cancer. It can eventually contribute to a less radical approach by enabling a more precise evaluation of the cancer margin.

Optical diagnosis of oral cavity lesions by label-free Raman spectroscopy

Oral squamous cell carcinoma (OSCC) is one of the most prevalent cancers and frequently preceded by non-malignant lesions. Using Shifted-Excitation Raman Difference Spectroscopy (SERDS), principal component and linear discriminant analysis in native tissue specimens, 9500 raw Raman spectra of OSCC, 4300 of non-malignant lesions and 4200 of physiological mucosa were evaluated. Non-malignant lesions were distinguished from physiological mucosa with a classification accuracy of 95.3% (95.4% sensitivity, 95.2% specificity, area under the curve (AUC) 0.99). Discriminating OSCC from non-malignant lesions showed an accuracy of 88.4% (93.7% sensitivity, 76.7% specificity, AUC 0.93). OSCC was identified against physiological mucosa with an accuracy of 89.8% (93.7% sensitivity, 81.0% specificity, AUC 0.90). These findings underline the potential of SERDS for the diagnosis of oral cavity lesions.

Feasibility of intraoperative assessment of safe surgical margins during laryngectomy with confocal laser endomicroscopy: A pilot study

OBJECTIVE

This pilot study aimed to assess the feasibility of intraoperative assessment of safe margins with Confocal Laser Endomicroscopy (CLE) during planned partial or total laryngectomy.

METHODS

Eight patients with confirmed larynx squamous cell carcinoma (SCC) and planned partial or total laryngectomy were included in this study in March 2020. Two head and neck surgeons and one pathologist were asked to classify carcinoma or healthy epithelium in a sample of 94 representative sequences (5.640 images), blinded to the histological results (H&E staining).

RESULTS

Healthy mucosa areas showed epithelium with cells of uniform size and shape with distinct cytoplasmic membranes and regular vessel architecture. CLE optical biopsy of SCC demonstrated a disorganized arrangement of variable cellular morphology. We calculated an accuracy, sensitivity, specificity, PPV, and NPV of 80.1%, 72.3%, 87.9%, 85.7%, and 76.1%, respectively. A distinct transition between healthy appearing tissue and suspicious lesions could also be detected.

CONCLUSION

CLE can be easily integrated into the intraoperative setting, generate real-time, in-vivo microscopic images of the larynx for evaluation and demarcation of cancer. If validated in further studies, CLE could eventually contribute to a less radical approach by enabling a more precise evaluation of the cancer margin.

[Minimal invasive esthetic con-struction of teeth with composite body shades]

Minimally invasive dentistry includes a wide range of treat­ment options for replacing lost tooth substance or constructing new tooth shapes. An additive restoration concept in combina­tion with composite or ceramic restorations ensures that the tooth substance is protected. The dentist’s preferences deter­mine the choice of the restoration material. In this case, a direct composite restoration was selected to close a diastema between tooth 11 and 21.

A quantitative evaluation of the use of medical lasers in German hospitals

The laser has become an integral part of modern medicine, procedures based on this technique have found their way into a multitude of medical disciplines. There is, however, no data available on the detailed quantitative development of laser use in the medical sector. This fact gave rise to the idea of the present study, which analyzed the raw data of the quality report of German hospitals with respect to this subject. Over the 9 years of report, a steady increase in the cumulative number of cases was evident, although not all body regions in which the medical laser is used followed this trend. The CO₂ laser was found to be the most commonly applied laser, even though a large spectrum of different laser types is used. Based on the present study, the importance of the laser for medical purposes can be confirmed.

Biologic and Technical Complications of Implant-Supported Immediately Loaded Fixed Full-Arch Prostheses: An Evaluation of Up to 6 Years

PURPOSE

Treatment by means of implant-supported immediately loaded fixed full-arch prostheses is known to be related to biologic and technical complications. The aim of this retrospective study was to investigate the prevalence and moment of occurrence of biologic and technical complications happening in immediately loaded fixed full-arch prostheses.

MATERIALS AND METHODS

This study investigated patients who received treatment with immediately loaded fixed full-arch prostheses using four to six implants from 2007 to 2013. The investigation included biologic and technical complications. Complications were depicted regarding their prevalence and their first time of occurrence. Statistical analysis was performed regarding the differences of the mean complication values between the mandible and the maxilla and between technical and biologic complications.

RESULTS

The investigation included 482 immediately loaded fixed full-arch prostheses (380 patients, mean observation period: 23.5 months). In 193 arches (40%), either technical (30.9%), biologic (6.5%), or both (3.1%) types of complications occurred. Technical complications occurred significantly more often than biologic complications (P < .000). The most frequent technical complication was "fracture of veneering material" (24.7%, arch level). The most frequent biologic complication was "marginal bone loss ≥ 2 mm" (16.3%, implant level). The median first advents of technical complications were after 23/26 months (implant-/prosthesis-related) and after 3 months for biologic complications, respectively. There was no significant difference of the mean complication rates between the maxilla and the mandible (P = .409). In 99.0% of the arches with complications, the restorations could be obtained.

CONCLUSION

Within this treatment concept, biologic and technical complications may occur over time. However, the vast majority of complications (99.0%) do not affect the overall prosthesis survival. Technical complications are assumed to occur significantly more often than biologic complications. It is suggested that not only stress and material fatigue but also function is a matter concerning this treatment option and, thus, may be a factor related to complication rates.

Speech intelligibility in patients with oral cancer: An objective baseline evaluation of pretreatment function and impairment

BACKGROUND

This study seeks to identify those factors that influence the pre-therapeutic speech intelligibility in patients with oral squamous cell carcinoma (OSCC).

METHOD

A group of 172 patients (125 males, 47 females, mean age = 61 ± 11 a) with different OSCC stages ranging from T1 to T4 and N0 to N2 was examined for their speech intelligibility using a computerized measuring tool, and compared to a healthy reference group (30 males, 10 females, mean age = 59 ± 12 a).

RESULTS

It was found that the pre-therapeutic speech intelligibility in patients with OSCC is decreased when compared to a healthy collective. Two demographic factors that influence speech intelligibility could be identified: sex and age. It was determined that the only disease-related factor that influences speech intelligibility before therapy is the location of the tumor.

CONCLUSION

The results of this study reveal that a preoperative speech intelligibility impairment in patients suffering from OSCC occurs independent of tumor stage, size of the tumor and infiltration status.

Local anaesthesia training for undergraduate students - how big is the step from model to man?

BACKGROUND

Local anesthesia is an important skill and a prerequisite for most dental treatments. However, the step from theory to application on the patient is huge for the novice. Hence, a mannequin training model course was developed and implemented into the existing local anesthesia curriculum in undergraduate dental students. It was the aim of this study to evaluate the relation between training-model and real-life anesthesia performance and to measure whether a gain in skill on the model translates to the actual patient situation.

METHODS

Thirty-six third-year students (14 males, 22 females, age 24 years±2.98) attended the four-day course comprising each 4 h of lectures and practical training. The student cohort gave subjective ratings about the didactical components of the course after attendance by using the TRIL questionnaire (TRIL-mod; University of Trier). At the end of the course the performance of each student in administering an inferior alveolar nerve (IAN) block on the training model as well as on a fellow dental student was investigated using a standardized checklist. To evaluate the successful performance, the in vivo IAN-block was assessed using subjective patient-feeling, the sharp-blunt test and an objective pain- and thermal sensitivity tester (PATH).

RESULTS

The course was rated with an average score of 5.25 ± 0.44 (range 1-6; 6 = best). On the training model, 69.4% of the students successfully performed an IAN-block. The in vivo assessment, objectified by the PATH test, showed a successful anesthesia in 36.9% of the cases. The assessment of local anesthesia by using the sharp blunt test and the subjective patient feeling significantly correlated with these findings (k = 0.453-0.751, p < 0.05). The model performance did not correlate with the performance on the patient (k = 0.137, p = 0.198).

CONCLUSIONS

Although subjective ratings of the course were high, the anesthesia success rate on mannequin models did not imply an equal performance on the in vivo setting. As local anesthesia training models are a valuable didactic complement, the focus of the training should be on to the actual real life situation. Chair side feedback should be offered to the students using one of the presented evaluation methods.

The differentiation of oral soft- and hard tissues using laser induced breakdown spectroscopy - a prospect for tissue specific laser surgery

Compared to conventional techniques, Laser surgery procedures provide a number of advantages, but may be associated with an increased risk of iatrogenic damage to important anatomical structures. The type of tissue ablated in the focus spot is unknown. Laser-Induced Breakdown-Spectroscopy (LIBS) has the potential to gain information about the type of material that is being ablated by the laser beam. This may form the basis for tissue selective laser surgery. In the present study, 7 different porcine tissues (cortical and cancellous bone, nerve, mucosa, enamel, dentine and pulp) from 6 animals were analyzed for their qualitative and semiquantitative molecular composition using LIBS. The so gathered data was used to first differentiate between the soft- and hard-tissues using a Calcium-Carbon emission based classifier. The tissues were then further classified using emission-ratio based analysis, principal component analysis (PCA) and linear discriminant analysis (LDA). The relatively higher concentration of Calcium in the hard tissues allows for an accurate first differentiation of soft- and hard tissues (100% sensitivity and specificity). The ratio based statistical differentiation approach yields results in the range from 65% (enamel-dentine pair) to 100% (nerve-pulp, cancellous bone-dentine, cancellous bone-enamel pairs) sensitivity and specificity. Experimental LIBS measuring setup.

Automatic Classification of Cancerous Tissue in Laserendomicroscopy Images of the Oral Cavity using Deep Learning

Oral Squamous Cell Carcinoma (OSCC) is a common type of cancer of the oral epithelium. Despite their high impact on mortality, sufficient screening methods for early diagnosis of OSCC often lack accuracy and thus OSCCs are mostly diagnosed at a late stage. Early detection and accurate outline estimation of OSCCs would lead to a better curative outcome and a reduction in recurrence rates after surgical treatment. Confocal Laser Endomicroscopy (CLE) records sub-surface micro-anatomical images for in vivo cell structure analysis. Recent CLE studies showed great prospects for a reliable, real-time ultrastructural imaging of OSCC in situ. We present and evaluate a novel automatic approach for OSCC diagnosis using deep learning technologies on CLE images. The method is compared against textural feature-based machine learning approaches that represent the current state of the art. For this work, CLE image sequences (7894 images) from patients diagnosed with OSCC were obtained from 4 specific locations in the oral cavity, including the OSCC lesion. The present approach is found to outperform the state of the art in CLE image recognition with an area under the curve (AUC) of 0.96 and a mean accuracy of 88.3% (sensitivity 86.6%, specificity 90%).

Autofluorescence spectroscopy for nerve-sparing laser surgery of the head and neck-the influence of laser-tissue interaction

The use of remote optical feedback systems represents a promising approach for minimally invasive, nerve-sparing laser surgery. Autofluorescence properties can be exploited for a fast, robust identification of nervous tissue. With regard to the crucial step towards clinical application, the impact of laser ablation on optical properties in the vicinity of structures of the head and neck has not been investigated up to now. We acquired 24,298 autofluorescence spectra from 135 tissue samples (nine ex vivo tissue types from 15 bisected pig heads) both before and after ER:YAG laser ablation. Sensitivities, specificities, and area under curve(AUC) values for each tissue pair as well as the confusion matrix were statistically calculated for pre-ablation and post-ablation autofluorescence spectra using principal component analysis (PCA), quadratic discriminant analysis (QDA), and receiver operating characteristics (ROC). The confusion matrix indicated a highly successful tissue discrimination rate before laser exposure, with an average classification error of 5.2%. The clinically relevant tissue pairs nerve/cancellous bone and nerve/salivary gland yielded an AUC of 100% each. After laser ablation, tissue discrimination was feasible with an average classification accuracy of 92.1% (average classification error 7.9%). The identification of nerve versus cancellous bone and salivary gland performed very well with an AUC of 100 and 99%, respectively. Nerve-sparing laser surgery in the area of the head and neck by means of an autofluorescence-based feedback system is feasible even after ER-YAG laser-tissue interactions. These results represent a crucial step for the development of a clinically applicable feedback tool for laser surgery interventions in the oral and maxillofacial region.

Gingival esthetics and oral health-related quality of life in patients with cleft lip and palate

While the oral health-related quality of life (OHRQoL) is known to be reduced in patients with cleft lip and palate (CLP), its inter-dependency with the soft tissue characteristics of the CLP area remains unclear. This study aimed to evaluate the soft tissue characteristics in the treated cleft area in order to investigate whether gingival esthetics correlate with OHRQoL. Thirty-six patients with unilateral or bilateral CLP (46 cleft areas) were investigated after secondary/tertiary alveolar bone grafting and orthodontic/prosthetic implant treatment using an adapted score to rate gingival esthetics (clinical esthetic score, CES). The patient's OHRQoL was determined using the German short version of the Oral Health Impact Profile questionnaire (OHIP-G14). The results showed a significantly better rating in patients with their own teeth in situ (12.05±1.10) than in patients with implants (6.95±4.78) or prosthetics (4.00±3.58). The best OHRQoL values were achieved by patients with their own teeth integrated into the cleft area (1.32±2.31), followed by patients with implants (2.33±2.33) and prosthetics (3.75±5.87). A significant (P=0.017) correlation was found between OHIP-G14 and CES scores, suggesting an increased OHRQoL in cases with higher oral esthetics in the cleft area. The therapeutic strategy contributes to both gingival esthetics and OHRQoL. The patient's subjective perception of OHRQoL can be attributed to objective gingival esthetic ratings.

Investigation of the differentiation of ex vivo nerve and fat tissues using laser-induced breakdown spectroscopy (LIBS): Prospects for tissue-specific laser surgery

In the present study, the elemental compositions of fat and nerve tissue during their plasma mediated laser ablation are studied in the context of tissue differentiation for laser surgery applications by using Laser-Induced Breakdown Spectroscopy (LIBS). Tissue samples of porcine fat and nerve were prepared as ex vivo experimental objects. Plasma mediated laser ablation is performed using an Nd : YAG laser in open air and under normal stray light conditions. The performed measurements suggest that the two tissue types show a high similarity in terms of qualitative elemental composition while at the same time revealing a distinct difference in the concentration of the constituent elements. Different analysis approaches are evaluated and discussed to optimize the tissue-differentiation performance of the LIBS approach. Plasma mediated laser tissue ablation.

Fabrication of a turbid optofluidic phantom device with tunable μa and μ's to simulate cutaneous vascular perfusion

Microfluidic devices are oftenly used to calibrate the imaging reconstruction, because they simulate the morphology of microvasculature. However, for lack of optical properties in microfluidics, the functional recovery of oximetry information cannot be verified. In this work, we describe the fabrication of a novel turbid optofluidic tissue phantom. It is designed to mimic the vascular perfusion and the turbid nature of cutaneous tissue. This phantom contains an interior hollow microfluidic structure with a diameter of ϕave = 50 μm. The microfluidic structure includes the geometry of an inlet, a river-like assay and an outlet. This structure can be perfused by hemoglobin solution to mimic the cutaneous micro-circulation. The multiple-layered phantom matrices exhibit the representative optical parameters of human skin cutis, namely the absorption coefficient μa and the reduced scattering coefficient . The geometry of the generated microfluidic structure is investigated by using Spectral-Domain Optical Coherence Tomography. This optofluidic phantom bridges the gap between tissue equivalent phantoms and Lab-On-Chip devices. Perspectively, this device can be used to calibrate a variety of optical angiographic imaging approaches.

Development and validation of a classification and scoring system for the diagnosis of oral squamous cell carcinomas through confocal laser endomicroscopy

Background

Confocal laser endomicroscopy (CLE) is an optical biopsy method allowing in vivo microscopic imaging at 1000-fold magnification. It was the aim to evaluate CLE in the human oral cavity for the differentiation of physiological/carcinomatous mucosa and to establish and validate, for the first time, a scoring system to facilitate CLE assessment.

Methods

The study consisted of 4 phases: (1) CLE-imaging (in vivo) was performed after the intravenous injection of fluorescein in patients with histologically confirmed carcinomatous oral mucosa; (2) CLE-experts (n = 3) verified the applicability of CLE in the oral cavity for the differentiation between physiological and cancerous tissue compared to the gold standard of histopathological assessment; (3) based on specific patterns of tissue changes, CLE-experts (n = 3) developed a classification and scoring system (DOC-Score) to simplify the diagnosis of oral squamous cell carcinomas; (4) validation of the newly developed DOC-Score by non-CLE-experts (n = 3); final statistical evaluation of their classification performance (comparison to the results of CLE-experts and the histopathological analyses).

Results

Experts acquired and edited 45 sequences (260 s) of physiological and 50 sequences (518 s) of carcinomatous mucosa (total: 95 sequences/778 s). All sequences were evaluated independently by experts and non-experts (based on the newly proposed classification system). Sensitivity (0.953) and specificity (0.889) of the diagnoses by experts as well as sensitivity (0.973) and specificity (0.881) of the non-expert ratings correlated well with the results of the present gold standard of tissue histopathology. Experts had a positive predictive value (PPV) of 0.905 and a negative predictive value (NPV) of 0.945. Non-experts reached a PPV of 0.901 and a NPV of 0.967 with the help of the DOC-Score. Inter-rater reliability (Fleiss` kappa) was 0.73 for experts and 0.814 for non-experts. The intra-rater reliability (Cronbach’s alpha) of the experts was 0.989 and 0.884 for non-experts.

Conclusions

CLE is a suitable and valid method for experts to diagnose oral cancer. Using the DOC-Score system, an accurate chair-side diagnosis of oral cancer is feasible with comparable results to the gold standard of histopathology—even in daily clinical practice for non-experienced raters.

Implant-Supported Immediately Loaded Fixed Full-Arch Dentures: Evaluation of Implant Survival Rates in a Case Cohort of up to 7 Years

BACKGROUND

The treatment of severely atrophied and edentulous jaws by means of fixed implant supported solutions is a challenging procedure.

PURPOSE

The immediate loading of four to six axial and tilted implants offers the possibility to overcome elaborate hard tissue augmentation procedures but lacks implant and patient related data on implant survival rates.

MATERIALS AND METHODS

This retrospective 7-years clinical trial investigated the implant survival rates of 2,081 implants (380 patients, 482 jaws) using an immediate loading protocol with either 4, 5, or 6 implants per restoration. Survival rates were calculated concerning implantation related factors (jaws/number of supporting implants/angulations/diameters/lengths) and patient related factors (medical status/smoking).

RESULTS

Overall survival of 2,081 implants was 97.0% on implant level. Survival rates of implantation related factors did not yield significant differences. Significant differences were yield between healthy patients and patients with osteoporosis (p = .002) and the medical status group "other" (p = .032), respectively. Smokers yielded a significantly higher survival than nonsmokers (p = .002).

CONCLUSIONS

It is assumed that four implants per jaw serve as a sufficient implant number for full arch restorations in both, the mandible and the maxilla. Osteoporosis under the medication with bisphosphonates seems to be a risk factor for implant survival. The authors suggest that the effect of smoking on ISRs remains controversial within this treatment concept.

[Speech Ability and Psychological Outcome After Treatment of Oral Cancer]

BACKGROUND

In recent years interactions between surgical treatment of oral carcinoma and incidence of anxiety or depression have become a subject of discussions. This prospective study is a comparison between the extent of loss of speech intelligibility and presence of depressive symptoms or anxiety as a result of oral carcinoma.

MATERIAL AND METHODS

One year after surgical therapy for oral carcinoma, 90 patients of an average age of 60±12 years were examined. Their speech intelligibility degree was measured using standardized automatic speech recognition (word recognition rate, WR). Symptoms of anxiety and depression were detected by use of HAD-Scales (HADS). Next to the relationship between WR and HADS other influential variables related to WR and HADS were statistically evaluated.

RESULTS

The WR average was 53.2±17.2. Female WR was better than male. The difference between tumor classifications T1 and T4 compared to the WR reached statistical significance. Significant differences were detected between WR and "tumor localization", "graft donor site", "graft morphology", "tongue motility", and "tracheostoma" groups. There was a relationship between tongue motility and graft morphology, graft donor site and tumor localization. HAD-Scores in the mean were elevated: HADS-Total=43.3%, HADS-A=43.3% und HADS-D= 51.1%. WR correlates with HADS-D-Subscale, but not with HADS-A-Subscale.

CONCLUSION

Communication disorders as a result of neoplasmic orofacial surgery may be related to extent of the treatment and to affective impairments. This should receive attention in the concept of rehabilitation.

Does Laser Surgery Interfere with Optical Nerve Identification in Maxillofacial Hard and Soft Tissue?--An Experimental Ex Vivo Study

The protection of sensitive structures (e.g., nerves) from iatrogenic damage is of major importance when performing laser surgical procedures. Especially in the head and neck area both function and esthetics can be affected to a great extent. Despite its many benefits, the surgical utilization of a laser is therefore still limited to superficial tissue ablation. A remote feedback system which guides the laser in a tissue-specific way would provide a remedy. In this context, it has been shown that nerval structures can be specifically recognized by their optical diffuse reflectance spectra both before and after laser ablation. However, for a translation of these findings to the actual laser ablation process, a nerve protection within the laser pulse is of utmost significance. Thus, it was the aim of the study to evaluate, if the process of Er:YAG laser surgery--which comes with spray water cooling, angulation of the probe (60°) and optical process emissions--interferes with optical tissue differentiation. For the first time, no stable conditions but the ongoing process of laser tissue ablation was examined. Therefore, six different tissue types (nerve, skin, muscle, fat, cortical and cancellous bone) were acquired from 15 pig heads. Measurements were performed during Er:YAG laser ablation. Diffuse reflectance spectra (4500, wavelength range: 350-650 nm) where acquired. Principal component analysis (PCA) and quadratic discriminant analysis (QDA) were calculated for classification purposes. The clinical highly relevant differentiation between nerve and bone was performed correctly with an AUC of 95.3% (cortial bone) respectively 92.4% (cancellous bone). The identification of nerve tissue against the biological very similar fat tissue yielded good results with an AUC value of 83.4% (sensitivity: 72.3%, specificity: of 82.3%). This clearly demonstrates that nerve identification by diffuse reflectance spectroscopy works reliably in the ongoing process of laser ablation in spite of the laser beam, spray water cooling and the tissue alterations entailed by tissue laser ablation. This is an essential step towards a clinical utilization.

Erratum: Raman difference spectroscopy: a non-invasive method for identification of oral squamous cell carcinoma: publisher's note

The author list appeared incorrectly in [Biomed. Opt. Express 5(9), 3252-3265 (2014)]. The author names were corrected online as of January 17, 2015: https://www.osapublishing.org/boe/abstract.cfm?uri=boe-5-9-3252.[This corrects the article on p. 3252 in vol. 5, PMID: 25401036.].

Competency in managing cardiac arrest: A scenario-based evaluation of dental students

OBJECTIVE

Advanced Cardiovascular Life Support (ACLS) in life-threatening situations is perceived as a basic skill for dental professionals. However, medical emergency training in dental schools is often not standardized. The dental students' knowledge transfer to an ACLS setting thus remains questionable. The aim of the study was to evaluate dental pre-doctorate students' practical competence in ACLS in a standardized manner to enable the curriculum to be adapted to meet their particular needs.

MATERIALS AND METHODS

Thirty dental students (age 25.47 ± 1.81; 16 male/14 female) in their last year of dental studies were randomly assigned to 15 teams. Students' ability to successfully manage ACLS was assessed by a scenario-based approach (training module: Laerdal® ALS Skillmaster). Competence was assessed by means of (a) an observation chart, (b) video analysis and (c) training module analysis (Laerdal HeartSim®4000; Version 1.4). The evaluation was conducted by a trained anesthesiologist with regard to the 2010 guidelines of the European Resuscitation Council (ERC).

RESULTS

Only five teams (33.3%) checked for all three vital functions (response, breathing and circulation). All teams initiated cardiopulmonary resuscitation (CPR). Only 54.12% of the compressions performed during CPR were sufficient. Four teams stopped the CPR after initiation. In total, 93% of the teams used the equipment for bag-valve-mask ventilation and 53.3% used the AED (Automated external defibrillator).

CONCLUSIONS

ACLS training on a regular basis is necessary and, consistent with a close link between dentistry and medicine, should be a standardized part of the medical emergency curriculum for dental students with a specific focus on the deficiencies revealed in this study.

Qualitative tissue differentiation by analysing the intensity ratios of atomic emission lines using laser induced breakdown spectroscopy (LIBS): prospects for a feedback mechanism for surgical laser systems

The research work presented in this paper focuses on qualitative tissue differentiation by monitoring the intensity ratios of atomic emissions using 'Laser Induced Breakdown Spectroscopy' (LIBS) on the plasma plume created during laser tissue ablation. The background of this study is to establish a real time feedback control mechanism for clinical laser surgery systems during the laser ablation process. Ex-vivo domestic pig tissue samples (muscle, fat, nerve and skin) were used in this experiment. Atomic emission intensity ratios were analyzed to find a characteristic spectral line for each tissue. The results showed characteristic elemental emission intensity ratios for the respective tissues. The spectral lines and intensity ratios of these specific elements varied among the different tissue types. The main goal of this study is to qualitatively and precisely identify different tissue types for tissue specific laser surgery.

Laser induced breakdown spectroscopy for bone and cartilage differentiation - ex vivo study as a prospect for a laser surgery feedback mechanism

Laser surgery enables for very accurate, fast and clean modeling of tissue. The specific and controlled cutting and ablation of tissue, however, remains a central challenge in the field of clinical laser applications. The lack of information on what kind of tissue is being ablated at the bottom of the cut may lead to iatrogenic damage of structures that were meant to be preserved. One such example is the shaping or removal of diseased cartilaginous and bone tissue in the temporomandibular joint (TMJ). Diseases of the TMJ can induce deformation and perforation of the cartilaginous discus articularis, as well as alterations to the cartilaginous surface of the condyle or even the bone itself. This may result in restrictions of movement and pain. The aim of a surgical intervention ranges from specific ablation and shaping of diseased cartilage, bone or synovial tissues to extensive removal of TMJ structures. One approach to differentiate between these tissues is to use Laser Induced Breakdown Spectroscopy (LIBS). The ultimate goal is a LIBS guided feedback control system for surgical laser systems that enables real-time tissue identification for tissue specific ablation. In the presented study, the authors focused on the LIBS based differentiation between cartilage tissue and cortical bone tissue using an ex-vivo pig model.

Novel method for early signs of clinical shock detection by monitoring blood capillary/vessel spatial pattern

The ability to monitor capillary/vessel spatial patterns and local blood volume fractions is critical in clinical shock detection and its prevention in Intensive Care Units (ICU). Although the causes of shock might be different, the basic abnormalities in pathophysiological changes are the same. To detect these changes, we have developed a novel method based on both spectrally and spatially resolved diffuse reflectance spectra. The preliminary study has shown that this method can monitor the spatial distribution of capillary/vessel spatial patterns through local blood volume fractions of reduced hemoglobin and oxyhemoglobin. This method can be used as a real-time and non-invasive tool for the monitoring of shock development and feedback on the therapeutic intervention.

Preparation of a skin equivalent phantom with interior micron-scale vessel structures for optical imaging experiments

A popular alternative of preparing multilayer or microfluidic chip based phantoms could have helped to simulate the subsurface vascular network, but brought inevitable problems. In this work, we describe the preparation method of a single layer skin equivalent tissue phantom containing interior vessel channels, which mimick the superficial microvascular structure. The fabrication method does not disturb the optical properties of the turbiding matrix material. The diameter of the channels reaches a value of 50 μm. The size, as well as the geometry of the generated vessel structures are investigated by using the SD-OCT system. Our preliminary results confirm that fabrication of such a phantom is achievable and reproducible. Prospectively, this phantom is used to calibrate the optical angiographic imaging approaches.

Elevation forces and resilience of the sinus membrane during sinus floor elevation: preliminary measurements using a balloon method on ex vivo pig heads

PURPOSE

Because the maxilla and its alveolar process are prone to resorption after tooth loss, it is often necessary to perform a bone augmentation procedure to successfully carry out implant treatment in that region. The aim of this study was to determine the adhesive force between the sinus membrane and the osseous sinus floor that occurs during sinus floor elevation with a balloon lift system.

MATERIALS AND METHODS

Twenty-two ex vivo pig heads were used for this study. Access to the maxillary sinus was gained via the lateral sinus wall. Sinus elevation was performed using an inflatable balloon, which was consecutively filled with 3 mL of a radiopaque fluid. Pressure was monitored directly and continuously during the elevation procedure with an electronic pressure gauge. The integrity of the membrane was checked microscopically and macroscopically.

RESULTS

The average adhesion force of the sinus membrane was found to be 748 ± 65.56 mmHg. On microscopic and macroscopic inspection, no mucosal tearing occurred during sinus floor elevation. Underwood septa, when present, did not significantly influence the adhesion forces.

CONCLUSIONS

The balloon system allowed for reproducible real-time measurement of the elevation forces and soft tissue resilience of the sinus membrane during the elevation process in this animal model. No mucosal ruptures were caused with this technical setup, in which effective elevation pressure ranging from 660 to 880 mmHg was not exceeded. A possible transfer of this technical setup to clinical procedures in humans requires investigation.

Comparing classification methods for diffuse reflectance spectra to improve tissue specific laser surgery

Background

In the field of oral and maxillofacial surgery, newly developed laser scalpels have multiple advantages over traditional metal scalpels. However, they lack haptic feedback. This is dangerous near e.g. nerve tissue, which has to be preserved during surgery. One solution to this problem is to train an algorithm that analyzes the reflected light spectra during surgery and can classify these spectra into different tissue types, in order to ultimately send a warning or temporarily switch off the laser when critical tissue is about to be ablated. Various machine learning algorithms are available for this task, but a detailed analysis is needed to assess the most appropriate algorithm.

Methods

In this study, a small data set is used to simulate many larger data sets according to a multivariate Gaussian distribution. Various machine learning algorithms are then trained and evaluated on these data sets. The algorithms’ performance is subsequently evaluated and compared by averaged confusion matrices and ultimately by boxplots of misclassification rates. The results are validated on the smaller, experimental data set.

Results

Most classifiers have a median misclassification rate below 0.25 in the simulated data. The most notable performance was observed for the Penalized Discriminant Analysis, with a misclassifiaction rate of 0.00 in the simulated data, and an average misclassification rate of 0.02 in a 10-fold cross validation on the original data.

Conclusion

The results suggest a Penalized Discriminant Analysis is the most promising approach, most probably because it considers the functional, correlated nature of the reflectance spectra.

The results of this study improve the accuracy of real-time tissue discrimination and are an essential step towards improving the safety of oral laser surgery.

A retrospective evaluation of the aesthetics of the nasolabial complex after unilateral cleft lip repair using the Tennison-Randall technique: a study of 44 cases treated in a single cleft center

INTRODUCTION

Among numerous techniques that have been described for lip repair, the Tennison-Randall method has gained popularity over time and is preferred by many surgeons due to the predictability of the outcome. This study aims to evaluate the esthetic outcome reached in the nasolabial region following primary lip repair with the use of this method.

MATERIALS AND METHODS

Forty-four patients with unilateral cleft lip (with or without alveolar cleft) were assessed retrospectively through a photographic evaluation by two clinicians with regard to the aesthetics of the lip and nose separately as anatomical subunits as well as of the nasolabial region as an anatomical complex. The collected data were statistically analyzed with regard to the cleft subtype and the performance of corrective surgeries for the lip and/or the nose.

RESULTS

The method was associated with good results, especially when it comes to the appearance of the nose as an anatomical subunit, as well as of the nasolabial region as a complex, regarding cleft lip patients without an alveolar cleft.

CONCLUSION

The Tennison-Randall technique proved to be a very satisfying method in terms of the esthetic long-term outcome in our patient collective.

Do cleft lip and palate patients opt for secondary corrective surgery of upper lip and nose, frequently?

Purpose

This prospective study was aimed at assessing cleft lip and palate (CLP) patients’ opinions and attitudes towards their upper lip and nose and the number of secondary corrective surgical interventions electively undertaken to upper lip and nose that were carried out during a 2 year follow-up period.

Materials and methods

During a 2 year follow-up period CLP outpatients were recruited for the study who attended follow-up examinations at a cleft lip and palate craniofacial center and received a recommendation for secondary corrective facial surgery. The participants filled in a questionnaire that included questions regarding the patients’ opinions and attitudes towards appearance of lip and nose and need for secondary corrective facial surgery. During an additional interval of 2 years the rate of patients who underwent secondary corrective surgery to lip and nose was documented.

Results

Out of 362 CLP patients 37 (mean age 13.6 ± 7.6 years) received a recommendation for secondary corrective surgery to upper lip and/or nose. 22 patients (mean age 12.6 ± 6.3 years) filled in the questionnaire (response rate of 62.1%). The satisfaction with the overall facial appearance following the first corrective operation was statistically significantly better than the satisfaction with the nose (p = .016). The satisfaction with facial symmetry (5.6 ± 2.0) did not differ statistically significantly from the overall satisfaction with the facial appearance (6.2 ± 1.8; p = .093). Significantly fewer patients (n = 9) opted for corrective surgery compared to the number of patients who got the recommendation to have secondary corrective surgery done (n = 22, p < .0005).

Conclusions

The findings of the present study may reflect a high overall patient satisfaction with the primary treatment outcome following surgery for CLP. Perceived patient need for secondary operation for the lip/nose may be as low as 5%.