Use of stereolithographic drilling and cutting guides in bilateral mandibular distraction.

Mandibular distraction osteogenesis is used in the treatment of patients with syndromic and nonsyndromic class II mandibular hypoplasia. The three-dimensional distraction of the mandible is extremely complex. Past experience with mandibular distraction has demonstrated the indispensability of solid presurgical planning to achieve predictable results. We report a method for a virtual three-dimensional planning of the bilateral mandibular distraction with intraoperative transfer by stereolithographic guides. Five patients (mean age, 22.8 years) with bilateral mandibular hypoplasia were examined with preoperative and postoperative computed tomographic scans. The direction and dimension of the distraction were planned on the three-dimensional computed tomographic scans. Tooth- and bone-borne stereolithographic guides for transferring the planning were then applied intraoperatively. It was feasible to transfer and perform the surgery as planned by the use of the stereolithographic drilling and cutting guides. The mean distraction width was 11.33 (SD, 8.32) mm. The mean difference of the distraction width between the planning and the achieved final mandibular position was 1.80 (SD, 0.43) mm. The intercondyle distance decreased by 3.28 (SD, 1.01) mm. A parallel distraction within the planned vectors was achieved. Mandibular distraction osteogenesis in the treatment of severe mandibular hypoplasia needs careful presurgical planning. Parallel distraction and fast placement of the distractors are provided by the planning. The method provides a useful tool for both planning and intraoperative transfer of the virtually preplanned distraction vectors.

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

Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication in patients receiving antiresorptive medication, such as bisphosphonates and denosumab, for different oncologic and non-oncologic diseases. Here, we report a case of MRONJ in a patient treated with tocilizumab, a humanized anti-interleukin-6 receptor antibody that effectively treats moderate to severe rheumatoid arthritis in adults. Case description: A 45-year-old female patient diagnosed with severe rheumatoid arthritis, who had been undergoing intravenous tocilizumab therapy for three years without history of bisphosphonate use, was referred to our department. Four weeks previously, several teeth in the maxilla and mandible were removed under local anesthesia by her dentist. Two weeks after the extractions, she felt pain in both jaws. We diagnosed wound dehiscence and delayed healing of the alveolar bone after the tooth extractions. Digital volume tomography showed persistent dry alveolar sockets. The patient underwent surgical debridement of necrotic bone, and intravenous antibiotics were administered in hospital. Five months later, wound dehiscence reoccurred in the same regions. Histopathological analysis of bone biopsies revealed a diagnosis of MRONJ. Four months later, wound dehiscence occurred in the left maxillary alveolar ridge, and local bone resection was performed under antibiotic treatment. Twenty-four months after the last surgery, wound dehiscence had healed completely without signs of recurrence. Discussion: Osteomyelitis of the jaw in patients treated with tocilizumab has not been reported often. This case confirms the potential role of this interleukin-6 receptor inhibitor in the pathogenesis of MRONJ and shows that patients who receive tocilizumab with MRONJ-like symptoms should be closely monitored. The pathomechanism of MRONJ under tocilizumab therapy remains unclear, so dental practitioners, maxillofacial surgeons, and rheumatologists should look for signs of MRONJ in patients receiving tocilizumab to prevent MRONJ onset.

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

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

Recurrent craniofacial dermatofibrosarcoma protuberans: long-term prognosis after close surgical removal.

Dermatofibrosarcoma protuberans (DFSP) is a low-grade malignant neoplasm of the dermis that rarely manifests in the craniofacial area. In this retrospective analysis, we investigated the long-term survival of 7 patients with recurrent craniofacial DFSP. This study includes all patients in our department with recurrences of DFSP between 1989 and 2006. All patients were treated by radical surgery with 1-cm free safety margin in every direction and remained in routine long-term follow-up for tumor patients. Two of the 7 patients showed a local recurrence, which was again successfully treated surgically with the same technique. Advanced reconstruction with free full-thickness skin transfers, regional flaps, and forearm flaps, respectively, was required in 5 of the 7 patients. The other 2 patients were reconstructed locally. The long-term prognosis of craniofacial DFSP can be assessed optimistically even if the tumor already reoccurred. All 7 patients included in this study are still alive and so far not suffering from local recurrence. Advanced reconstructive techniques are often required in the management of reoccurring craniofacial DFSP. Late recurrences have been reported; therefore, a long-term follow-up for these patients should be considered.

The localization and risk factors of squamous cell carcinoma in the oral cavity: A retrospective study of 1501 cases.

Head and neck cancer is the tenth leading cause of cancer mortality. Ninety percent of tumours in the oral cavity are squamous cell carcinomas. Information about the exact localisation of OSCC is missing in the literature. In the present study, we retrospectively analysed a total of 1501 OSCC patients, who were treated between 1975 and 2009. The purpose of this study was to examine the localisation of OSCC tumours and to analyse the influence of various parameters on tumour localisation. 71.5% of these patients were male and 28.5% were female. The mean age was 60 years. The most common sites of OSCC occurrence were the floor of the mouth and the anterior base of the mouth. The hard palate was the most affected anatomical area of the maxilla. Descriptive statistical analysis, chi-square testing and a multivariate analysis using a multinomial logistical model showed a significant correlation of younger age and female gender with tumour occurrence in the maxilla and the tongue. We provide a very detailed anatomical mapping of OSCC.

Craniomaxillofacial patient-specific CAD/CAM implants based on cone-beam tomography data - A feasibility study.

Customized implants have simplified surgical procedures and have improved patient outcome in craniomaxillofacial surgery. Traditionally, patient-specific data is gathered by conventional computed tomography (CT). However, cone-beam CT (CBCT) can generate a 3D reconstruction of the area of interest with a lower dose of radiation at reduced cost. In this study, we investigated the feasibility of using CBCT data to design and generate customized implants for patients requiring craniomaxillofacial reconstruction. We used CBCT to generate 62 implants for 51 consecutive patients admitted to our department between January 2015 and December 2017. The indications for reconstruction and types of reconstruction were very variable. In all cases, the implants were well fitted and no implant-related complications were detected. Pre-surgical planning was faster and more efficient as we did not have to consult a radiologist. Although CBCT data is more difficult to process than conventional CT data for the implant provider, the clinical advantages are pronounced and we now use CBCT as standard in our department. In conclusion, we have shown that using CBCT to design and manufacture customized implants for reconstruction of the craniomaxillofacial area is feasible and recommend this approach to other departments.

Current concepts in cleft care: A multicenter analysis.

The current surgical techniques used in cleft repair are well established, but different centers use different approaches. To determine the best treatment for patients, a multi-center comparative study is required. In this study, we surveyed all craniofacial departments registered with the German Society of Maxillofacial Surgery to determine which cleft repair techniques are currently in use. Our findings revealed much variation in cleft repair between different centers. Although most centers did use a two-stage approach, the operative techniques and timing of lip and palate closure were different in every center. This shows that a retrospective comparative analysis of patient outcome between the participating centers is not possible and illustrates the need for prospective comparative studies to establish the optimal technique for reconstructive cleft surgery.

Moving the mandible in orthognathic surgery - A multicenter analysis.

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

The current state of facial prosthetics ­ A multicenter analysis.

Even though modern surgical techniques are dominating reconstructive facial procedures, the capability to use facial epitheses for reconstruction is still an important skill for the maxillofacial surgeon. We present an international multicenter analysis to clarify which techniques are used to fixate facial prostheses. We contacted all maxillofacial departments in Germany, Austria, Switzerland and Norway which were registered with the German society for oral and maxillofacial surgery (DGMKG). These centers were asked via electronical mail to provide information on the type of epithesis fixation systems currently in use. The return rate from 58 departments was 43.1% (n = 25). Overall, implant fixation was the preferred fixation system (92%). Plates were the second most common fixation technique (32%). No centers reported the standard use of non-invasive fixation techniques for permanent epithesis fixation. The main retention systems in use were magnets (24/25), other retention systems are used much less often. The current preferred fixation technique for facial epitheses consists of implant-based, magnet-fixated epitheses. For nasal prostheses, a plate-based, magnet-fixated system is often used.

Development of the clinical use of distant flaps for head and neck reconstruction.

The reconstruction of hard and soft tissue defects, mainly after ablative oncologic surgery in the head and neck area, is an evolving field. The use of free flaps for reconstruction of the head and neck is considered to be the surgical standard. In our analysis of more than 1000 free flaps we give an overview of the development of the use of different types of free tissue transfer to the head and neck area over the last 25 years. We show that the evolving field of head and neck reconstruction raises new possibilities with new types of flaps, whereas other types of flaps disappear in the everyday clinical use. The spectrum of reconstruction possibilities broadens with the number of different flap types available to the head and neck surgeon.

Facial basal cell carcinoma with successive metastases to the neck, thyroid gland and lung.

Basal cell carcinoma of the skin is the most common malignancy in the head and neck area. Regional and distant metastases rarely occur with this type of tumour. We report an uncommon case of a sclerodermiform basal cell carcinoma of the facial skin in which metastases developed several years after the primary tumour. The metastases occurred in the soft tissue of the neck, the thyroid gland and the lung. This is the first case of BCC with triple metastases which were histologically confirmed.

Neurosensory alterations and function of the temporomandibular joint after high oblique sagittal split osteotomy: an alternative technique in orthognathic surgery.

The current most common technique for repositioning of the mandible, bilateral sagittal split osteotomy (BSSO), was first described by Obwegeser and Dal Pont in the early1960s, and has since been modified several times. However, there is always a risk of damaging the inferior alveolar nerve. We have studied 50 consecutive patients who had high oblique sagittal split osteotomy (HSSO) as an alternative to avoid damage to the nerve. The patients were evaluated for sensory alterations and function of the temporomandibular joint (TMJ). Healing of both wound and bone were complete and uneventful in all 50 patients. Mean (SD) sagittal movement of the mandible was 6.6 (2.9)mm and length of the osteotomy line was 11.0 (3.1)mm. No patient had either temporary or permanent alteration in sensitivity. Pinprick tests showed no significant changes between the preoperative and postoperative readings (p>0.16) or in the chronological results (p>0.23). No disorders of the TMJ developed. Mean (SD) mouth opening 6months postoperatively was 41.6 (8.6)mm. The lateral excursion increased postoperatively by 1.86mm to the left and by 0.76mm to the right. Protrusion increased by 0.66mm. HSSO is therefore a suitable alternative to BSSO as it avoids injury to the inferior alveolar nerve without compromising the TMJ. Ossification was uneventful though bony attachment was less than with the classic BSSO.

Proximal segment positioning with high oblique sagittal split osteotomy: indications and limits of intraoperative mobile cone-beam computerized tomography.

OBJECTIVE: The purpose of this study was to evaluate the indications and limits for intraoperative proximal segment positioning control by mobile cone-beam computerized tomography (CBCT). STUDY DESIGN: For mandible osteotomy in orthognathic surgery, the high oblique sagittal split osteotomy (HSSO) is our standard procedure. In 22 patients, positioning control of the proximal segment was performed during and after surgery to check this alternative osteotomy technique. RESULTS: The mean intercondylar distance increased 0.31 mm in all patients. No significant change of the condyle positions was found in the axial and coronal planes. In the sagittal plane a significant change was found. In 1 case, revision was required because of a lateral shifting of the condyles. CONCLUSIONS: Intraoperative positioning control with CBCT is an effective and reliable method to avoid condyle malpositions. Only minor position changes occur when using HSSO in orthognathic surgery, without compromising temporomandibular joint function postoperatively.

Lack of evidence of human papillomavirus-induced squamous cell carcinomas of the oral cavity in southern Germany.

OBJECTIVES: The aim of the present study was to identify HPV-attributable SCC of the oral cavity (OSCC) in a cohort of patients from southern Germany. MATERIALS AND METHODS: A sensitive PCR-enzyme immunoassay (EIA) was followed by a more specific in situ hybridization (ISH) to detect high risk human papillomavirus (HPV). An immunohistochemical dual-staining for p16(INK4a) and the proliferation marker Ki-67 was used to assess whether co-expression of p16(INK4a)/Ki-67 is a better surrogate marker for HPV in OSCC than p16(INK4a) alone, based on the hypothesis that combined p16(INK4a) and Ki-67 expression might specifically discriminate oncogene-induced p16(INK4a) expression from cell-cycle arrest-inducing senescence-associated p16(INK4a) expression. RESULTS: HPV-DNA by PCR-EIA could be detected in 25.1% (69/275) of the tumors, but ISH was negative in all of them. Diffuse p16(INK4a) overexpression was detected in 11 HPV PCR-positive tumors, but also in 6 HPV PCR-negative tumors. p16(INK4a)-expressing cells in diffusely positive tumors co-expressed Ki-67, irrespective of the HPV status. Neither the sole HPV status nor combined HPV/p16(INK4a) status nor the sole p16(INK4a) status was significantly associated with disease free or overall survival, however a trend towards better overall survival of patients whose tumor expressed p16(INK4a) in a focal pattern (=p16(INK4a)-positive/Ki-67-negative cells) compared to no p16(INK4a) expression (p=0.09) was observed. CONCLUSION: Viral DNA can be detected in some tumors by a sensitive PCR, but absence of ISH signals indicates that the HPV-attributable fraction is smaller than estimated from PCR positivity. p16(INK4a)/Ki-67 co-expression is detectable in a fraction of OSCC irrespective of the HPV status.

The role of elective supraomohyoidal neck dissection in the treatment of early, node-negative oral squamous cell carcinoma (OSCC): a retrospective analysis of 122 cases.

The adequate treatment of the neck in early, clinically node-negative oral squamous cell carcinoma (OSCC) remains controversial. To assess whether elective supraomohyoid neck dissection is reasonable and efficient in early, locally circumscribed OSCC, the outcomes of treatment of 122 patients with an OSCC of clinical UICC stage I or II were retrospectively analysed in this study. Occult lymph node metastases were detected in 13.9% (17/122) of cases. They were more frequently found in T2 compared to T1 tumours (19.7% (14/71) vs. 5.9% (3/51), p=0.03), age, gender and grading had no influence on the prevalence of occult lymph node metastases (all p-values>0.05) in a multivariate logistic regression model. Subsequent multivariate survival analysis found that the presence of occult metastases was an independent predictor of reduced disease-free survival after 5 years (82.2% vs. 62.5%, p=0.004, and 61.9% vs. 17.8%, p<0.001, respectively). Elective supraomohyoid neck dissection detects occult metastases in early, node-negative OSCC, and patients with early OSCC exhibiting occult metastases should be considered as high risk patients, warranting additional therapeutic regimes.

Cranio-maxillofacial non-Hodgkin's lymphoma: clinical and histological presentation.

Non-Hodgkin's lymphoma represents about 5% of all malignant lesions of the head and neck. In this study we retrospectively evaluated clinical presentation, histological subtype and long-term prognosis of 42 patients with non-Hodgkin's lymphoma involving the craniofacial area. The mean age at diagnosis was 64 years. More than half of the patients presented with disseminated disease at multiple sites (55%, n=23). In 62% (n=26) the first manifestation was extranodal. The most common affected region was the oral cavity (65%, n=17). Treatment consisted of local therapy, including surgical resection and radiation, as well as chemotherapy with or without local therapy. Recurrence occurred in 31% (n=13) of the treated patients. Mean survival after first diagnosis varied from 17 months in patients presenting with diffuse large B-cell lymphoma (DLBCL), to 8.5 years in patients with follicular lymphoma. The most common histological subtype is DLBCL. Standard treatment for DLBCL consists of chemotherapy combined with CD 20 monoclonal antibody, even after total resection of the tumour. There is high risk of systemic disease in patients presenting with non-Hodgkin's lymphoma and high risk of post therapy recurrence.

Trigonocephaly: results after surgical correction of nonsyndromatic isolated metopic suture synostosis in 54 cases.

Children with nonsyndromatic isolated metopic suture synostosis suffer from a significant deformity of the supraorbital ridges, the temporal regions and hypotelorism. We retrospectively analyzed 54 consecutive cases of isolated nonsyndromatic metopic synostosis treated over a 14-year-period. The data were evaluated using patients' clinical records, skull radiographs in two planes, CT-scans, MRI scans and pre-/post-operative photographs. Surgery with standardized fronto-orbital advancement was performed at a median age of 11.5 months. Follow-up ranged from 4.5 months to 177.4 months, with an average of 51.9 months. The average blood loss was less than 255ml and the average post-operative length of stay was 5 days. Not a single major complication was observed except for uncomplicated dural tears in six cases. According to the classification of Whitaker, results were considered good to excellent (Category I and II) in all except one case (Category IV). As the current techniques have been standardized for routine use, surgical risks are reasonably low with no mortality or permanent morbidity. We think that the treatment of single metopic synostosis is safe with very low reoperation rates and short length of hospital stay. Overall, our results showed acceptable minor complication rates and generally satisfactory aesthetic outcomes.

Craniofacial metastases: a 20-year survey.

In this study we analysed the long-term prognosis of 52 patients with distant metastases to the craniofacial area. All patients were treated in our department between 1989 and 2009. Possible predictive factors for the overall survival prognosis like age, gender, histopathological type of the metastasis, location and tissue structure of the area in the head and neck region, time between primary tumour and metastasis and the therapy were evaluated. 62% of the patients with distant metastases in the craniofacial area were male (32/52), the average age was 63 years. Adenocarcinoma was the most common histological type (20/52) and lung (12/52), malignant melanoma of the skin (9/52) and breast (8/52) the most common primary tumour site. In 35% of all patients, the primary tumour was not known at the time of the diagnosis of the craniofacial metastasis, this number reduced to 17% without the patients with a CUP syndrome. Patients survived an average of 14.4 months after manifestation of the metastases and 43.4 months after the manifestation of the primary tumour.

Changes in the mandibular and dento-alveolar structures by the use of tooth borne mandibular symphyseal distraction devices.

PURPOSE: Different devices to perform a mandibular symphyseal distraction osteogenesis (MSDO) are available. This study evaluates how tooth borne distraction devices change to the teeth, the mandible and the condyles. MATERIALS AND METHODS: 19 patients (mean age 27.1) with anterior width deficiencies of the mandible were examined with routine pre- and postoperative CT-scans 1 month before and 4 months after a mean distraction width of 5.68 mm (SD 0.88). The anchorage teeth of the tooth borne device were examined concerning displacement of their axes as well as the movement of the condyles and the mandibular symphysis. The data were evaluated using Wilcoxon signed rank test and Spearman rho correlation. RESULTS: Significant tilting of the anchorage teeth was observed (p<0.01). The axes changed by 3.32° (SD 1.57) in the first premolar and by 2.63° (SD 1.75) in the first molar. A total of 2.67 mm (SD 1.17) of bone was formed on the symphysis. A significant correlation was found between distraction width and intercoronal distance changes of the anchorage teeth (p<0.01). No significant change of the intercondylar distance was found pre- and postoperatively in the Wilcoxon test. CONCLUSION: MSDO with tooth borne devices has strong effects on the anchorage teeth. No severe effects on the condyles were observed. The postoperative width gain is a result of newly generated bone in the symphysis and tooth tilting. Nevertheless stable postoperative bite corrections are achievable.