Klippel-Trenaunay-Weber syndrome: Oro-dental manifestations and management

INTRODUCTION

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare congenital systemic disease characterized by a classic typical triad: cutaneous haemangioma, arterio-venous fistulas or varicosities (or both) and unilateral hypertrophy of hard and soft tissue with different localizations. First described by the French physicians Marcel Klippel and Paul Trenaunay, in 1900, KTWS has a clinically incidence of 2-5/100000. The complete triad (port-wine stains, varicose veins, and soft tissue and/or bony hypertrophy) occurs in almost 2/3 of the patients. Moreover, these features may be present at birth or develops during growing becoming more evident with age. Typical orofacial manifestations include facial asymmetry, jaw enlargement and malocclusion.

CASE PRESENTATION

A previously diagnosed 55-year-old male patient was referred to the Department of Cranio-Maxillofacial Surgery presenting with extended mandibular ramus exostosis on the left side and concomitant malocclusion. Surgical removal of the hypertrophic bone was performed due to progressive mouth opening restriction, limited oral hygiene ability and increased mandible deviation. Bleeding complications and wound healing disorders were not observed. Consistent mouth opening training resulted in an improvement in mouth opening.

CLINICAL DISCUSSION AND CONCLUSION

It is suggested to consider KTWS as one of the differential diagnoses if vascular syndromes in the head and neck region occur. Special attention must be given to dental treatment due to eventual excessive haemorrhage that might occur after oral surgical procedures.

Distribution of bone thickness in the human mandibular ramus - a CBCT-based study

Background

The bone thickness of the human mandibular ramus is an important parameter in mandibular surgeries. The aim of this study was to systematically measure the bicortical bone thickness, the ramus dimensions and the position of the lingula. The measurements were tested on significant correlations to the patients’ parameters.

Methods

Based on CBCT scans 150 rami were reconstructed as 3D polygon surfaces. An anatomical grid was adapted to the ramus surface to mark the bone thickness measurement points and to achieve comparability between the measurements on different mandibles. The bone thickness, ramus height, ramus width and the gonion angle were measured. A cluster analysis was performed with these parameters to identify clinically relevant groups with anatomical similarities.

Results

The median distribution of the bone thickness was calculated and visualized in a pseudo-colour map. The mean ramus height was 44.78 mm, the mean width was 31.31 mm and the mean gonion angle was 124.8°. The average distance from the lingula to the dorsal tangent was 53% of the total width and its distance to the caudal tangent was 65% of the total height. Significant correlations between the bone thickness and the ramus proportions could be identified. Age and sex had no significant influence on the mean bone thickness. The measured rami could be divided into two groups by cluster analysis.

Conclusion

The dimensions of the human mandibular ramus can be determined from 3D reconstructed surface models from CBCT scans. Measurements could be made comparable by applying an anatomically oriented grid. A cluster analysis allowed the differentiation of two groups with different bone thickness distributions and geometries, which can be used for the optimization of osteosynthesis systems and their precision of adaptation to different ramus morphologies.

[Alternative therapy option for plastic-aesthetic treatment of defects after resection in the upper third of the facial region in the sense of subtotal scalping instead of local flap plastics]

In the presented case, the resulting defect size after resection of a dermatofibrosarcoma protuberans exceeded the treatment capability with local flaps in the region of the exposed facial skin. Through the use of conventional wound healing in combination with a meshed split-thickness skin graft, plastic aesthetic soft tissue treatment with an aesthetically satisfactory result was possible.

Sclerosing odontogenic carcinoma: current diagnostic and management considerations concerning a most unusual neoplasm

Sclerosing odontogenic carcinoma (SOC) is a primary intraosseous carcinoma of the jaws that has been listed as a separate entity for the first time in the latest version of the World Health Organization classification of Head and Neck Tumours (2017). The aim of this study was to analyse and interpret the existing literature on SOC in the context of a clinical case treated in the authors' department. A systematic search of the PubMed database was performed in accordance with the PRISMA guidelines, yielding nine cases of SOC reported so far. In summary, characteristic clinical and radiological features of SOC include asymptomatic swelling, location predominantly in the mandible, tumour primarily lytic in appearance, presence of cortical bone destruction, and lack of metastatic spread. Due to the rarity of the disease, close collaboration between oral/maxillofacial surgeons and pathologists is crucial to avoid misdiagnosis. With complete excision, no recurrence of SOC should be expected.

Development of a database to record orofacial manifestations in patients with rare diseases: a status report from the ROMSE (recording of orofacial manifestations in people with rare diseases) database

The aim of this working group was to establish a ROMSE (recording of orofacial manifestations in people with rare diseases) database to provide clinicians, patients, and their families with better information about these diseases. In 2011, we began to search the databases Orphanet, OMIM^® (Online Mendelian Inheritance in Man^®), and PubMed, for rare diseases with orofacial symptoms, and since 2013, the collected information has been incorporated into a web-based, freely accessible database. To date, 471 rare diseases with orofacial signs have been listed on ROMSE, and 10 main categories with 99 subcategories of signs such as different types of dental anomalies, changes in the oral mucosa, dysgnathia, and orofacial clefts, have been defined. The database provides a platform for general clinicians, orthodontists, and oral and maxillofacial surgeons to work on the best treatments.

Orthognathic surgery in Melnick-Needles-Syndrome. Case report and review of the literature

Melnick-Needles Syndrome (MNS) is a congenital syndrome associated with severe architectural disorder of the skeletal system that can cause significant effects on the craniofacial skeleton including poor aesthetics, impaired speech and masticatory problems. The authors report a case of a female patient who experienced masticatory constraint, hindered speech and functional problems related to a severe bite dysfunction due to the mandibular hypoplasia and the underlying bony architectural disorder associated with MNS. The patient underwent bilateral sagittal split osteotomy (BSSO) to correct her skeletal malocclusion and improve the characteristic aesthetics and speech. The inherent bony abnormalities with their altered collagen structure presented unique challenges to orthognathic surgery in this patient with an unpredictable bone healing process. In MNS patients a fragile trabecular bone structure and an increased bleeding tendency is thought to delay or forestall wound healing. The patient was treated successfully with BSSO and monocortical plate fixation following a well-established algorithm from orthodontic preparation to surgical protocol. A very satisfying outcome has been achieved, concerning functional rehabilitation and aesthetic improvement. A review of the literature revealed that little is known about bone regeneration and fracture healing in cases with MNS.

Free vascularized fibular grafting for reconstruction after tumor resection in the upper extremity

BACKGROUND

Limb salvage is viable in the majority of patients with malignant bone tumors, but especially in case of extensive tumors and bad soft tissue conditions, it is challenging in upper extremity.

OBJECTIVES/METHOD

The clinical and radiological results of 21 patients, who had free vascularized fibular grafts (VFG), for diaphyseal (14), and epipyseal (7) defect reconstruction of the upper extremity, are presented. The indications for VFG were resection after osteosarcoma (9 cases), Ewings sarcoma (9 cases), chondrosarcoma (1 case), rhabdomyosarcoma (1 case), and 1 case of fibrous dysplasia. The 20 malignant tumors were staged as follows: 2a (1), 2b (18), 3 (1). The mean follow-up was 43.6 months (min 6.0-max 131.9). Functional results were described and graded quantitatively according to the MSTS-score.

RESULTS

Results were satisfactory with regard to pain, emotional acceptance, manual dexterity, and function. Lifting ability was decreased in two patients. Hypertrophy index was 31% (min 13%-max 71%). Main complications were fracture (5), pseudoarthrosis (4), prolonged wound healing (4), temporary nerve irritation (2), and deep infection (1). Re-operation was required in eight patients (12 operations).

CONCLUSION

VFG offers a good possibility for biological reconstruction of large skeletal defects, with an acceptable complication and re-operation rate. When conservative treatment of complications was not successful, further surgery led to recovery in the majority of cases.

[Aggressive fibromatosis in the jaw and facial region with bone involvement. A review]

BACKGROUND

Aggressive fibromatosis (AF) involving bones of the head is rare and surgery is often complicated by a high recurrence rate. Interdisciplinary treatment is of the utmost importance to avoid extensive, mutilating resection. Two cases emphasize the difficulties in the management.

CASE REPORTS

A 67-year-old woman was referred to our unit with a blepharochalasis of the left upper palpebra and a palsy of the face on the left side. Her medical history included 12 operations over the previous 4 years for an extensive AF.

MATERIAL AND METHODS

Our review includes all case reports of AF involving bones of the head published between 1960 and 2004. Additionally, our two cases are presented. Signs, symptoms and outcome were analyzed in relation to different treatment options.

CONCLUSION

According to the literature, surgery is the most common treatment for AF in the head and neck region. Alternative modes of therapy must be considered because of the high recurrence rate and to avoid mutilating operations.

Score system for elective tracheotomy in major head and neck tumour surgery

BACKGROUND

This study was designed to evaluate prognostic parameters for respiratory failure after major oropharyngeal resections in head and neck cancer surgery, focusing on a score system to identify patients requiring an elective tracheotomy and to avoid tracheotomy under emergency conditions.

METHODS

One hundred and fifty-two out of 928 patients with oropharyngeal cancers, treated between January 1993 and June 2000 at our hospital, fulfilled the inclusion criteria for a retrospective analysis. This collective underwent tumour resection in different regions of the oropharynx combined with bony resection of the mandible and neck dissection without primary tracheotomy. The reconstruction was accomplished using radial forearm flaps (n1 = 59) or local flaps (n2 = 93). These two groups were subdivided into patients treated post-operatively by tracheotomy due to respiratory failure (n1 = 26; n2 = 12) and those without such treatment (n1 = 33; n2 = 81). The database comprising tumour localization and size, staging, general medical condition, smoking and alcohol consumption was evaluated by logistic regression.

RESULTS

We developed a score system which predicts the likelihood of post-operative respiratory failure. For indication of tracheotomy, tumour size and localization, multimorbidity, alcohol consumption and pathologic chest X-ray findings were identified as significant parameters with different weightings. The predictive value for tracheotomy (yes/no) using the score system was 96.7% for the total collective.

CONCLUSION

The decision on whether or not an elective tracheotomy in major head and neck tumour surgery is necessary can be facilitated using this score system which is based on objective facts. It may reduce post-operative complications and contribute to safer treatment.

Tierexperimentelle Evaluation des periimplant�ren Knochens bei zylindrischen gegen�ber konischen Implantattypen

BACKGROUND

The treatment of patients with early or immediately loaded dental implants has renewed interest in the behavior of osseointegration at the implant surface. Whereas it is generally accepted that peri-implant tissue formation and mineralization are dependent on the local mechanical environment in the interface zone, controversies exist concerning the impact of implant design on peri-implant bone formation. The aim of the present study was the in vivo evaluation of peri-implant bone formation by two different implant systems: cylindrical (ITI) versus conical (ILI).

MATERIAL AND METHOD

A total of 60 implants (30 ITI and 30 ILI) were placed in the cranial and caudal part of the tibia of eight Göttinger minipigs. Half of the minipigs were sacrificed at 7 days and 28 days of osseointegration. Implant-containing bone specimens were prepared for histological and ultrastructural investigations.

RESULTS

Histological and scanning electron-microscopic investigations showed a direct contact of bone-like minerals over the whole implant surface from day 7 of implant/bone interaction. Whereas the ILI implant showed direct contact up to the top of the crestal bone, ITI implants demonstrated a crestally located narrow gap without ossification over the whole experimental period.

CONCLUSION

Our investigations support the hypothesis of an implant design-inherent emergence and maintenance of crestal bone.

Primäre Implantatstabilität bei unterschiedlichen Knochenaufbereitungstechniken

The treatment concept of osseointegration is based on a stable embodiment of implants in bone and the maintenance of stability during functional load. A goal of the surgical preparation technique is therefore to obtain a stable and firm implant anchorage. The aim of this study was to evaluate implant stability after different surgical treatment of the bony implantation bed. Thirty cylindrical solid-screw-shaped implants with standard SLA ITI configuration were implanted into the explanted mandibles of five minipigs. The implant sites were prepared either by a conventional burr technique (group A), by burr technique with additional thread cutting (group B), or by the osteotome technique (group C). Primary implant stability was evaluated by resonance frequency analysis and removal torque test. The average value of the resonance frequency analysis (RFA) was 6000+/-469 cycles/s in group A, 5700+/-557 cycles/s in group B, and 5540+/-527 cycles/s in group C. Removal torque values of group A (507+/-57 Nmm) were significantly higher than those of group B (466+/-45 Nmm) and group C (240+/-31 Nmm) (between group A and C p<0.05, group A to B p=0.39, and B to C p<0.05). It can be concluded from this study that the conventional burr technique achieves a statistically significantly better primary bone anchorage than the osteotome technique.

[Odontogenic foci--possible etiology of urticaria?]

Recent studies have shown that chronic odontogenic infections could pose a risk for myocardial infarction, cerebral ischemia, and arteriosclerosis. However, the correlation between urticaria and dental infections has rarely been examined so far. Therefore, we performed a case-control study using a standardized questionnaire and examination. We investigated 66 patients suffering from an acute or chronic urticaria and 65 age- and sex-matched healthy patients as a control group. Dental status was determined by a so-called total dental index (TDI) which primarily reflects caries, periodontitis, periapical lesions, and nonvital and missing teeth. All 66 patients were referred from the department of dermatology. After their treatment in hospital, all patients received a questionnaire with questions on intensity and localization of the urticaria. The TDI of the urticaria patients was slightly better ( n=66; 2.6+/-1.98) than that of the control group ( n=65, TDI=3.3+/-1.86). Subsequently, it was determined if the urticaria had receded after dental treatment. In conclusion, chronic dental infections do not seem to correlate with an increased risk for urticaria.

Indications for treatment of subcondylar mandibular fractures

BACKGROUND AND OBJECTIVES

The purpose of this study was to establish a reliable criteria for implementation of either an open surgical or a closed conservative treatment of subcondylar fractures, based on clinical data and analytical mathematical model.

METHODS AND MATERIALS

A total of 512 subcondylar fractures were treated during a 3-year period. Of these, 256 were fractures characterized by either displacement or dislocation of the proximal (condylar) segment. Patients were treated with open reduction and internal fixation (ORIF) or closed reduction (CR) techniques. Patients were evaluated pre- and postoperatively by clinical examination, 3-dimensional axiography, radiographic imaging, and ultrasonography. A mathematical model was developed for estimating the loss of vertical ramus height.

RESULTS AND/OR CONCLUSIONS

When the displacements were less than 37 degrees from the sagittal axis of the ascending ramus, the ensuing loss of vertical height was negligible when fractures were treated by conservative techniques. When the displacements exceeded 37 degrees, the fractures resulted in a significant decrease of vertical ramus height. Based on these data, 37 degrees appears to be the point for decision of whether to use closed or open treatment.

Ultrasonographic versus conventional diagnostic procedures in dislocated subcondylar mandibular fractures

In patients with severe craniomaxillofacial trauma, immediate attention is directed primarily to the early diagnosis of cervical spine injuries, intracranial injuries, respiratory difficulties, and vascular compromises. Diagnostic studies, such as computed tomography scans, are sometimes not useful for the evaluation of mandibular fractures, since cuts are performed too superiorly. The plane radiographs obtained in emergency settings are frequently of minimal diagnostic value. Fractures of the mandibular symphysis, body, and angles are easily identified clinically; subcondylar fractures, however, are not directly accessible for clinical examination. The evaluation of suspected dislocated subcondylar fractures with the aid of ultrasonography is reliable, highly sensitive and specific, and cost-effective.

[Evaluating angiogenesis and osteogenesis modified by vascular endothelial growth factor (VEGF)]

PURPOSE

This intention of this study was to investigate the influence of controlled release of vascular endothelial growth factor (VEGF) on angiogenesis and osteogenesis in a mandibular defect model.

METHODS

A total of 56 rabbits were operated and bicortical holes were placed in the mandible. The defects were filled with collagen type I implants, collagen implants complexed with 0.8-microgram VEGF165, or left without any filling. After 3, 7, 14, and 28 days specimens were taken and histologic, histomorphometric, and immunohistologic analyses were carried out concerning density of vessels, total surface of vessels, bone surface, and bone density.

RESULTS

The number of vessels was increased in all groups up to 14 days, followed by physiologic regression in the control groups, whereas the study group showed persistently high numbers. The density of regenerated bone was significantly higher in the study group.

CONCLUSION

The activation of angiogenesis using VEGF165 leads to more intensive angiogenesis and bone regeneration.

Salivary levels of vascular endothelial growth factor (VEGF) in recurrent aphthous ulceration

BACKGROUND

Vascular endothelial growth factor (VEGF) is a multifunctional angiogenic cytokine involved in angiogenesis and wound healing. Its presence in recurrent aphthous ulceration has not been reported to date. The aim of this study was to investigate the association of salivary levels of VEGF with various stages of recurrent aphthous ulceration (RAU).

METHODS

VEGF levels were determined in a group of 27 age and sex-matched healthy controls and in 30 patients with minor and major RAU grouped into the three stages: (I) early active stage, (II) active stage, and (III) remission period. VEGF levels (pg/ml; mean +/- SD) in unstimulated whole saliva were determined by enzyme immunoassay.

RESULTS

Patients with major RAU - stages I and II - had decreased VEGF values (765 +/- 458 and 341 +/- 109, respectively) when compared both to healthy controls (1652 +/- 567; P < 0.01) and to stage III major RAU (1524 +/- 784; P < 0.005).

CONCLUSION

Salivary VEGF levels seemed to be associated with ulcer development in major RAU, showing stage-dependent alterations during the course of this disorder.

Imaging of cartilage and mimic muscles with MRI: anatomic study in healthy volunteers and patients with unilateral cleft lip and palate

OBJECTIVE

The aim of the study was to visualize different soft tissues in the perioral, nasal, and paranasal region by means of magnetic resonance imaging (MRI) in patients with unilateral cleft lip and palate (UCLP).

DESIGN

In this descriptive study, images of different MRI systems were assessed and compared.

METHOD

MRI was applied in five consecutive patients operated on for UCLP who underwent secondary lip and nasal correction, two patients who had not had UCLP operations, and five healthy volunteers as controls. The mimic muscles, vessels, and nasal cartilages were evaluated.

RESULTS

It was possible to visualize different parts of the paranasal and perioral mimic muscles and their interlacement in the upper lip. The nasal cartilages were also visible, and the changes after operation were demonstrated.

CONCLUSIONS

MRI shows differentiated visualization of soft tissues in the cleft region and their changes after surgery. It is a valuable tool in the preoperative planning and postoperative follow-up in patients with UCLP.

Three-dimensional magnetic resonance imaging of the orbit in craniofacial malformations and trauma

Craniofacial malformations and trauma often lead to changes in orbital soft tissues, requiring surgical correction of both hard and soft tissues. Computed tomographic scans and 3-dimensional reconstructions are the optimal tools for evaluation of the bony structures. However, there is no equivalent method for the orbital soft tissues. The aim of this study was to establish a 3-dimensional magnetic resonance imaging (3-D MRI) technique that allows a differentiated visualization of the different types of soft tissue in the orbit. A total of 8 patients with different pathologic conditions of the orbit was examined. Five of these patients underwent secondary correction after trauma, and 3 had craniofacial malformations. The 3-D reconstruction was performed in the volume-rendering technique after acquisition of 3-mm axial slices. It was shown that a differentiated visualization of the orbital soft tissues is possible. Although the thin bony structures have a weak signal and, therefore, the imaging is poor, reliable reconstruction of the globe was achieved by different radiologists because of its circular delimitation from the bone. This technique is an additional support in the planning of orbital surgery.

Natural immunity in recurrent aphthous ulceration

In the present study we investigated immunophenotypes of peripheral blood lymphocytes, natural killer (NK) cell activity as well as spontaneous migration, ingestion, digestion and antibody-dependent cell-mediated cytotoxicity (ADCC) as effector functions of polymorphonuclear neutrophil granulocytes (PMNs) in 51 patients with acute stage recurrent aphthous ulceration (RAU), during remission, and 47 age-matched healthy individuals. Statistically significant lower B-lymphocyte (CD19) values were found between patients with acute RAU, and those during the remission period (P<0.001), when compared with those of the controls. Total T-lymphocyte (CD3) percentages were lower in patients with RAU, and also during the remission period, when compared with the controls (P<0.001). The percentages of CD4 lymphocytes were significantly lower in patients with RAU in comparison with those of the controls (P<0.001). T-suppressor cells (CD8) were unchanged in all three groups of participants. Significantly lower spontaneous migration and ingestion values were found in patients with acute RAU, when compared with those of the controls, and during the remission period (P<0.001). Digestion values differed insignificantly between the patients with acute RAU and during the remission period. During the remission period, digestion values were significantly elevated when compared with those of the controls (P<0.05). ADCC values were lower during the remission period (P<0.001), when compared with the values during acute RAU and with those of the controls. Significantly depressed NK activity (P<0.001) was observed in patients with acute RAU, when compared with that of the controls. During the remission period, values of NK activity were also lower (P<0.001) when compared with those of the controls. These results suggest either a specific or nonspecific immunological disorder in patients with RAU.

[Prospective cephalometric evaluation of a new 3-dimensional adjustable osteosynthesis system for sagittal ramus osteotomy]

The aim of the study was the prospective cephalometric analysis of 58 patients who underwent sagittal split ramus osteotomy (SSRO). Stabilisation of the fragments was achieved with an adjustable monocortical bone fixation system. Lateral cephalograms were taken preoperatively, postoperatively, 6 months postoperatively, and 12 months postoperatively. The radiographs were digitised, and a computerised analysis was performed. The mean mandibular advancement was 8.5 mm with a mean relapse of 0.8 mm after 12 months (P < 0.05). The mean mandibular setback was 7.8 mm with a mean relapse of 1.2 mm after 12 months (P < 0.05). The results of the present study show a minimal relapse after mandibular advancement and setback for the SSRO and the new adjustable fixation system. Postoperative analysis reveals a safe intraoperative positioning of the condyles with subsequent prevention of an immediate relapse. The results after 12 months indicate sufficient long-term stability, although additional evaluations with results after 5 and 10 years are necessary for a final report.

[Effect of implant geometry on strain distribution in peri-implant bone]

Recent developments and results in the field of mechanical bone stimulation have made it possible to define limits between physiological and non-physiological transmission of strength to the bone. Now it is necessary to investigate the different geometries of dental implants regarding biomechanical reliability. The aim of this study was to examine the distribution of strain on the bone along different basic forms of implants during loading using finite element analysis (FEA). The following implant designs were included in the study: cylinder, threaded cylinder, cylinder with steps, threaded cylinder with steps, and double-disk implants. All implants had a length of 12 mm and a diameter of 4 mm, the axial loading was defined as 300 N. Threaded implants showed more homogeneous distribution of strain than stepped implants, however, the maximum values were below the physiological range. Shortening of the implants led to an increase of the values, however, there was a zone of hypophysiological strain apically. Disk implants showed extremely low values at the disk margins, possibly due to the lack of physiological bone stimulus by the disks. Overall, none of the implants showed optimal distribution of strain, even though homogeneous strain distribution is decisive for long-term implant stability.

Clinical anatomy and palpability of the inferior lateral pterygoid muscle

STATEMENT OF PROBLEM

The intraoral palpation technique of the inferior belly of the inferior lateral pterygoid (ILP) muscle is a standard diagnostic examination method for temporomandibular joint dysfunction syndrome, although different studies have revealed inconsistent results.

PURPOSE

This study assessed the feasibility of the ILP muscle palpation by a simulated clinical setting.

MATERIAL AND METHODS

Three dentists performed a bilateral palpation of the ILP muscle in 53 fresh and unfixed human cadavers and decided whether the muscle was palpable or unpalpable. In a second step, it was observed through the dissected infratemporal fossa, whether the examiner's finger did or did not touch the ILP muscle by simulating the performed palpation. Palpatory findings were supplemented by 1-dimensional measurements for determination of topographic relations of the ILP muscle within the infratemporal fossa. For statistical analysis, sensitivity, specificity, and negative and positive predictive values of the palpation technique were calculated. Interexaminer agreement was estimated with the kappa value.

RESULTS

In 86 of 106 dissected specimens, a superficial fascicle of the medial pterygoid muscle was found in direct proximity to the ILP muscle. In these cases, a residual distance of 7.8 +/- 3.2 mm remained between the ILP muscle and buccinator fascia indented by the tip of the examiner's finger. In 10 of 20 specimens with an absent superficial fascicle, the finger was able to reach the ILP muscle.

CONCLUSION

It is recommended that the ILP muscle palpation technique should no longer be considered as a standard clinical procedure because it is nearly impossible to palpate the ILP muscle anatomically and because the risk of false-positive findings (by palpation of the medial pterygoid muscle) is high.

Oral findings in three different groups of immunocompromised patients

The objective of this study was to determine the frequency of oral, dental and periodontal findings in three different groups of immunocompromised patients and in a healthy control group, to evaluate whether there is a correlation between manifestations of disease and immunologic parameters. The survey included 46 patients with a diagnosis of systemic lupus erythematosus, 48 heart transplant recipients, and 53 adult patients suffering from acute leukemias. Fifty matched healthy subjects were used as a control group. Each patient had to answer questions on medical and dental health and underwent a thorough oral, dental and serological investigation. Oral mucosal lesions were found in nearly half of all immunocompromised patients (49.6%), but in only 26% of control patients. No significant associations were found between different types of oral lesions and the underlying cause of immunosuppression. Leukemia patients showed age-unrelated higher scores in periodontal indices (P<0.05). Laboratory parameters failed to be significant in the assessment of oral health.

Reconstruction of the severely resorbed (Class VI) jaws: routine or exception?

After disappointing results with conventional preprosthetic procedures endosseous implants in combination with alveolar ridge augmentation opened up new prospects in reconstructive surgery. A total of 64 patients who underwent three-dimensional reconstruction of the alveolar ridge and insertion of endosseous implants for severe resorption were evaluated retrospectively. Despite the postoperative infection rate of 20.3% (13 patients), only 4.1% of the 266 inserted implants were lost in the long term. This indicates that augmentation using free autogenous iliac bone grafts and implants have a success rate of approximately 96% despite difficult initial situations. This success was mainly related to the soft tissue condition covering the graft. A technique for soft tissue dissection, especially in the maxilla, is presented.

Reproducible X-ray projection geometry in edentulous patients

OBJECTIVE

To evaluate a novel fixation system for reproducible radiography in edentulous patients.

METHODS

A conventional extra-oral fixation system was modified with a filmholder and adjustable scales. For measuring reproducibility and angulation errors two rods and two balls were fixed on the alveolar crests of the maxilla and the mandible and angular variations were measured. One hundred radiographs of a conventional phantom were taken by one of the authors and by ten dental students. The angular disparity was calculated and intra- and interoperator precision determined.

RESULTS

The average time taken to assemble the fixation system was 4 min. The 95% confidence interval for precision of the single operator was less than 2.5 degrees in both the maxilla and mandible. The 95% confidence interval for precision of the ten students was less than 2.2 degrees for the maxilla and 2.7 degrees for the mandible. There was no significant difference (P>0.05) in interoperator precision.

CONCLUSION

The novel extra-oral fixation system appears to be a potential means of obtaining reproducible radiographs of edentulous patients.

Three-dimensional visualization and quantification of the mandibular articular surface by optical profilometry

The aim of this study was to introduce a nondestructive optical technique for the quantitative assessment of natural biological surfaces as demonstrated with the example of the articular surface of the human temporomandibular joint. The computer-assisted quantitative evaluation of the surface is realized by the acquisition of three-dimensional images via the optical technique of phase measuring profilometry. After mathematical processing of the data set the resulting image can be visualized as three-dimensional object surface reconstructions or as grid surfaces from which arbitrary sections may easily be extracted. From such single sections we can calculate a value that represents the degree of height deviations of the section profile and can be regarded as a parameter for the surface roughness. Further quantitative information about the surface topography is provided by the Fourier transform analysis of the profiles. The Fourier spectrum contains information about the spatial distribution of roughness-causing protuberances along the overall surface. As an example one healthy condyle and one remodeled condyle from macerated cadaver mandibles were investigated. For the two samples evaluated we calculated a mean surface roughness of the entire articular surface with a value of 0.03 +/- 0.005 mm for the healthy condyle with its smooth surface and a value of 0.14 +/- 0.009 mm for the remodeled condyle. We recommend optical profilometry as a sophisticated technique for a more objective and quantitative pathological classification of articular surfaces and similar objects.

[Regeneration of mouth mucosa in the buccal plane following graft procurement for reconstruction of bulbar urethral stenoses]

The use of free buccal mucosal grafts in the treatment of urethral strictures has become very popular. In 1996 and 1997 we harvested free buccal mucosal grafts up to 7 cm long and 4 cm wide from 12 patients who underwent urologic surgery for urethral strictures. In 2 patients the donor site was closed primarily by sutures. Four patients received Lyodura and another 4 patients received Syspurderm as temporary wound coverage. In 2 patients Ethisorp patches were used. Donor site pain was judged by the patients on a visual analogue scale during the first postoperative week. The 2 patients who received the Ethisorp patches complained of more intense pain, probably caused by the rigidity of the material. In all patients regeneration of the donor site mucosa was good. During the follow-up period of 4-18 months scar formation at the lower vestibulum was noticed as the only complication. Permanent limitation of mouth opening, stenosis of the parotid duct or hypesthesia did not occur.

[Gigantic proliferating trichilemmal cyst of the scalp with central carcinoma and lymph node metastasis]

We report the case of a 77 year old woman with a giant proliferating trichilemmal cyst of the scalp and a central squamous-cell carcinoma. Six months after radical tumor-excision and dissection of the locoregionary lymph nodes the patient developed retroclavicular lymph node metastases. The tumor develops from cells of the hair matrix and tends to recur after excision; in rare cases malignant transformation may occur. We suggest radical excision and complete histological examination of the tumor. In cases of malignancy, lymph node-dissection is sometimes necessary. In these cases close postoperative follow-up of the patient is mandatory.

[MRI 3D imaging of the orbits in craniofacial abnormalities and injuries]

Craniofacial malformations and trauma often lead to changes in orbital soft tissues that require operative correction of both hard and soft tissues. CT scan and 3D reconstructions are optimal tools for the evaluation of the bony structures but there is no equivalent for the orbital soft tissues. The aim of this study was to establish a 3D-MRI technique that allows differentiated visualization of the different soft-tissue types of the orbit. A total of eight patients with different pathologic conditions of the orbit were examined. Five of these patients came for secondary correction after trauma and three showed a craniofacial malformation. 3D reconstruction was performed in volume-rendering technique after acquisition of 3 mm axial slices. It was shown that differentiated visualization of the orbital soft tissues is possible. Even though the thin bony structures have a weak signal and therefore the imaging is poor, the globe could be reconstructed reliably by different radiologists because of its circular delimitation from the bone. This technique provides additional support in the planning of orbital operations.

[Prospective study of the pathology of radiation-induced mucositis]

One of the most severe early side effects of radiation in head and neck cancer patients is mucositis. Inflammation of the oral mucose may lead to an extreme subjective burden, restricting the patients' well-being and even leading to an interruption of radiotherapy. The aim of our prospective study was to investigate the pathological alterations of the oral mucosa during irradiation. Therefore, samples from head and neck cancer patients were taken before radiation and a 30-G and a 60-G radiation dose. Pathogenetic alterations were determined by immunohistochemical staining of various cell surface molecules known to be involved in the pathogenesis of inflammation. Staining was performed with antibodies against ICAM 1, VCAM 1, ELAM, 25F9, 27E10, and RM3-1. Our study demonstrates the expression rates of the various surface molecules during inflammation. Expression of RM3-1 and ICAM 1 showed a steep increase during the time of radiation, whereas expression of ELAM reached a low constant value. Therefore, we conclude that distinct cell surface molecules demonstrate a characteristic time-dependent expression during radiation. Better insight into the pathogenesis of radiation-induced mucositis may help to develop a pathological classification of mucositis and to improve therapeutic strategies.

[Oral manifestations in patients with systemic lupus erythematosus]

Forty-six patients with systemic lupus erythematosus underwent thorough dental examination to determine the frequency and severity of oral lesions and periodontal diseases. According to clinical criteria, disease was classified as severe (n = 26) or less severe (n = 20). The overall rate of mucosal involvement in the studied patients was 48%-from 54% in patients with severe disease, 40% in those with less severe disease. Patients with severe disease were found to have a higher rate of tooth loss and an increased rate of gingival inflammation. The severity of periodontal lesions correlated with alterations in the immunoglobulin pattern, particularly with an increase in gamma-immunoglobulins. Thus it is suspected that complex immunodysregulation in combination with immunosuppressive therapy is responsible for the high rate of oral and periodontal lesions in patients with systemic lupus erythematosus.

[Oral manifestations of acute leukemia]

It is well known that non-specific mucosal alterations can occur during diseases of the leukopoetic system. In most cases they are an early sign and therefore provide the opportunity for timely diagnosis of the disease. In this clinical study type and frequency of oral lesions, gingival and periodontal indices, and hematologic status were examined at the time of diagnosis of the different types of acute leukemia. The results showed a significant difference in the frequency of oral lesions between acute myelogenous and acute lymphoblastic forms, irrespective of age and sex of the patient. There was no correlation between type and frequency of lesions and hematologic status.