Bone formation in mono cortical mandibular critical size defects after augmentation with two synthetic nanostructured and one xenogenous hydroxyapatite bone substitute - in vivo animal study.

OBJECTIVES: Healing characteristics as well as level of tissue integration and degradation of two different nanostructured hydroxyapatite bone substitute materials (BSM) in comparison with a deproteinized hydroxyapatite bovine BSM were evaluated in an in vivo animal experiment. MATERIAL AND METHODS: In the posterior mandible of 18 minipigs, bilateral mono cortical critical size bone defects were created. Randomized augmentation procedures with NanoBone(®) (NHA1), Ostim(®) (NHA2) or Bio-Oss(®) (DBBM) were conducted (each material n = 12). Samples were analyzed after five (each material n = 6) and 8 months (each material n = 6). Defect healing, formation of soft tissue and bone as well as the amount of remaining respective BSM were quantified both macro- and microscopically. RESULTS: For NHA2, the residual bone defect after 5 weeks was significantly less compared to NHA1 or DBBM. There was no difference in residual BSM between NHA1 and DBBM, but the amount in NHA2 was significantly lower. NHA2 also showed the least amount of soft tissue and the highest amount of new bone after 5 weeks. Eight months after implantation, no significant differences in the amount of residual bone defects, in soft tissue or in bone formation were detected between the groups. Again, NHA2 showed significant less residual material than NHA1 and DBBM. DISCUSSION: We observed non-significant differences in the biological hard tissue response of NHA1 and DBBM. The water-soluble NHA2 initially induced an increased amount of new bone but was highly compressed which may have a negative effect in less stable augmentations of the jaw.

Temporalis Flap for Soft Palate Reconstruction - More than an Alternative for Patients Unsuitable for Microvascular Reconstructive Surgery.

BACKGROUND/AIM: The treatment of squamous cell carcinoma (SCC) in the oral cavity for operable patients usually consists of surgical tumor resection, unilateral or bilateral neck dissection and defect reconstruction. In addition to local flaps, multiple, particularly microsurgical, distant flaps have been developed, which are mainly considered state of the art reconstruction. However, depending on previous operations and individual patient factors, microsurgical reconstruction is sometimes not suitable. CASE REPORT: A 54-year-old male presented to the Department of Oral and Maxillofacial Surgery with leukoplakia-like changes in the area of the soft palate. Radiological and histopathological findings revealed SCC of the soft palate. Due to the patient's reduced general condition, pronounced vasosclerosis and the patient's negative opinion towards microsurgical reconstruction, the indication for tumor resection with simultaneous temporalis flap reconstruction was made. The temporalis flap showed sufficient healing throughout the follow up. CONCLUSION: For patients who are unsuitable for microsurgery (previous operations, radiation, patient's request), well-known local flaps such as the temporalis flap represent more than an alternative treatment for defect reconstruction. The temporalis flap is particularly suitable for defect reconstruction of the maxilla and palate due to its easy flap raising and low complication rates. This case report shows the step-by-step flap raising of temporalis flap for soft palate reconstruction.

Risk factor analysis for perioperative complications in impacted third molar surgery - a single center experience.

BACKGROUND: The surgical removal of impacted third molars is usually carried out by an oral/maxillofacial surgeon. Two specific risks of surgical removal of impacted third molars are oroantral communication (OAC) when extracting ​​upper third molars and hypesthesia of the inferior alveolar nerve (IAN) ​​when extracting lower third molars. The aim of this study is to determine the distribution of complications in deeply impacted third molar surgery, to identify specific risk factors influencing the most common perioperative (OAC, IAN hypesthesia) and to compare these results with other studies. MATERIALS AND METHODS: The clinical findings, digital panoramic radiographs, intra- and postoperative data of 80 patients with a total of 232 impacted third molars that had been subjected for tooth extraction, from December 2022 and August 2023, were collected and analyzed. Perioperative complications (IAN hypesthesia, OAC, hypesthesia lingual nerve, postoperative bleeding, postoperative infection) were identified. A risk analysis for OAC and IAN hypesthesia was performed regarding perioperative data. RESULTS: Overall, the rate of OAC for the right upper third molar was 12.8% and for the left upper third molar 15.6%. The complication rates regarding transient hypesthesia were 8.1% for the left IAN and 7.3% for the right IAN. The distance to maxillary sinus, the depth score according to Pell and Gregory, the bone coverage score, the operation time, the tooth's angulation and the type of surgeon (oral surgeon, DMD) were identified as significant risk factors for the occurrence of OAC. The minimum distance to IAN, the bone coverage score, the total operation time and the operation by an oral surgeon (DMD) were identified as significant risk factors for hypesthesia of the IAN. CONCLUSION: Next to the risk factors from above, the present study is one of the first showing that patients who were primarily operated on by an oral surgeon (DMD) and not a maxillofacial surgeon (MD, DMD) showed higher rates of OAC and IAN hypesthesia in impacted third molar extraction. The results of this study can serve as a baseline for further studies to investigate complication patterns in impacted third molar surgery.

Distribution and impaction patterns of third molars in a sample of German population: Retrospective analysis in a high turnover maxillofacial department.

BACKGROUND: The surgical removal of impacted third molars is considered a routine procedure for oral and maxillofacial surgeons. However, the distribution of impacted molars varies among different populations. A study into impaction patterns in the German population is currently not described. The aim of this retrospective study is to determine patterns of impacted third molars in a sample of German population, to identify gender and age specific differences as well as further risk factors for impacted molar extraction and to compare these results with other studies. MATERIALS AND METHODS: The clinical findings and digital panoramic radiographs of 84 patients with a total of 243 impacted third molars that had been subjected for tooth extraction, from January to September 2023, were collected and analyzed. All third molars were analyzed according to Winter´s angulation, Pell and Gregory Score of depth and relationship to ramus. Furthermore, inferior alveolar nerve and maxillary sinus proximity were identified through a newly developed risk score and an analysis of patient´s gender and age regarding impaction patterns was performed. RESULTS: No significant gender specific differences were found regarding the impaction patterns. Third molar angulations significantly differed regarding patient´s age (cut-off 26 years). In comparison, third molar depth, bone coverage, nerve approximity and angulation patterns differed from the results of other populations. CONCLUSION: The results of this study can serve as a baseline for further studies of third molar impactions in the German population to minimize perioperative complications in impacted third molar surgery.

The "Lumpy Jaw" Disease-Treatment and Diagnostical Challenge of Actinomycotic Osteomyelitis.

Background: Osteomyelitis is a serious entity that can occur in many different locations. Especially in the mandible, osteomyelitis can show different clinical courses, which differ clearly from other anatomical regions in terms of severity and treatment. Osteomyelitis in the mandible is often caused by mixed species of the oral cavity. A species causing subacute/chronic osteomyelitis can be actinomyces. Actinomycotic osteomyelitis of the jaw represents a diagnostic and treatment challenging disease. Conclusion: This article describes our perspective on the therapy pillars treating actinomycotic osteomyelitis. The rapid introduction of the two therapeutic elements (antibiosis/surgical therapy) is crucial regarding the outcome of this entity.

Large Complex Odontoma in the Angulus Mandibulae - Intraoral Enucleation as an Alternative to Mandibular Continuity Resection.

BACKGROUND: Odontomas are among the most common odontogenic tumors and are generally considered as hamartomatous odontogenic lesions. These tumors can be histopathologically divided into complex odontomas and compound odontomas based on their composition. Odontomas show a slow growing behavior and typically lack characteristic symptoms. The standard surgical treatment for large odontogenic tumors is a mandibular (continuity) resection followed by primary or secondary plastic reconstruction. CASE REPORT: A 22-year-old male presented to the Department of maxillofacial surgery with an increasing feeling of pressure in the left mandible. An orthopantomogram revealed a large complex odontoma rg 038. Instead of mandible continuity resection an alternative minimally invasive technique/approach (intraoral) with a trapezoidal bone flap for the enucleation of an odontoma of the mandibular angle with subsequent flap reimplantation and osteosynthesis was performed. CONCLUSION: Surgical enucleation of large mandibular odontoma with a continuity resection through an extraoral approach represents the surgical standard treatment of this entity. The present case report describes an alternative minimally invasive technique/approach. This technique may reduce surgical risks of the continuity resection through an extraoral approach (nerve damage, scarring) and can improve the long-term stability of the mandible by bone preservation.

Treatment Challenges in Soft Tissue Reconstruction in Patients With MRONJ - The Nasolabial Flap.

BACKGROUND/AIM: Antiresorptive drugs (e.g., bisphosphonates, denosumab) are crucial in the treatment of oncological diseases. However, these antiresorptive drugs can cause medication-related osteonecrosis of the jaw (MRONJ). MRONJ is a challenging disease regarding the soft tissue defect treatment. There are various surgical reconstruction techniques. One of them is the nasolabial flap. CASE REPORT: The present case report describes a 76-year-old female suffering from MRONJ leading to a progressive abscess of the mandible as well as an intra/extraoral fistula with extent to the chin region. Surgical splitting of the abscess was performed immediately. In the further course, a surgical decortication of the mandible with soft tissue defect treatment using a mucoperiosteal flap was performed. Intraoperatively, the bone of the mandible showed severe necrotic defects in multiple locations. Therefore, a continuity resection of the mandible with an insertion of a reconstruction plate was performed. Postoperatively, however, there was a progressive wound dehiscence. Due to the persisting regression of the gingival mucosa, the soft tissue defect was treated with a caudally pedicled bilateral nasolabial flap. The further clinical follow-up showed no recurrence of MRONJ with a well-healed nasolabial flap. CONCLUSION: In addition to mucoperiosteal flaps and microvascular reconstructions, the nasolabial flap can be a sufficient surgical therapy for intraoral soft tissue defect reconstruction.

Septic Cervicofacial Phlegmon Following Basal Cell Carcinoma Excision: Life-threatening Complication of Routine Operation in Maxillofacial Surgery?

Background/Aim: Basal cell carcinoma (BCC) is a frequent tumor entity, especially in the facial region. The standard therapy for BCC is surgical tumor excision which is generally a low-risk procedure. One of the life-threatening surgical risks and complications when removing BCC in the facial area is infection with the possibility to spread across the deep neck spaces as well as systemic inflammation (sepsis). Case Report: A 73-year-old patient presented to the emergency department with a swelling of the right cheek, extended towards the neck. Based on his medical history, an outpatient BCC excision of the cheek had been performed the day before. Laboratory tests showed a fulminant inflammatory process of sepsis. Computed tomography (CT) revealed a buccal phlegmon on the right extended towards the deep neck. A diagnosis of septic cervicofacial phlegmon following BCC excision was made. The therapy consisted of intensive care sepsis treatment, surgical relief, and drainage of the phlegmon and a calculated antibiotic treatment (piperacillin/tazobactam, clindamycin). Conclusion: Removal of BCC in the facial region is generally a low-risk procedure. A possible complication is postoperative wound infection. In rare cases the clinical picture of a septic cervicofacial phlegmon can develop. Surgical focus sanitation, broad-based antibiotic therapy and intensive care sepsis management are the key therapeutic pillars of this postoperative complication.

Metastasis of a Solitary Fibrous Tumor in the Mandible: A Case Report.

BACKGROUND/AIM: The solitary fibrous tumor (SFT) is a mesenchymal neoplasm and belongs to the group of soft tissue sarcomas. The SFT is characterized by indolent, slowly progressive growth and manifests itself clinically by compression of neighboring structures. The treatment of choice is surgical removal of the tumor. In advanced stages, there is also the possibility of chemotherapy, systemic therapy, or immunotherapy, as well as radiotherapy. Depending on their location and severity, SFTs show different recurrence rates and survival functions. CASE REPORT: The present case report shows an extremely rare localization of a low-risk SFT in the floor of the mouth. Despite complete surgical removal of the SFT, the patient showed a metastasis of the SFT in the mandible two years postoperatively. Therefore, this case report shows that even a low-risk SFT in the localized stage can metastasize despite of total surgical removal. Consequently, SFTs of the head and neck region require close clinical and imaging follow-up. CONCLUSION: Although the localization of the SFT in the oral cavity is a rarity, this entity should be included in the differential diagnosis in the case of long-term space-occupying processes in the head and neck region. This report is the first regarding metastasis of a SFT to the mandible.

Fulminant Adenoid Cystic Carcinoma of the Maxillary Sinus - A Rare Finding: Case Report.

BACKGROUND: The most common malignant tumor of the small salivary glands in the head and neck region is adenoid cystic carcinoma (ACK). The most common localization of ACK is the hard palate. ACK does not show any sex predisposition and is mainly diagnosed in middle-aged patients. CASE REPORT: The present case report describes a fulminant ACK in the rare localization of maxillary sinus in a 36-year old male. The subsequent surgical treatment consisted of a radical hemimaxillectomy using an extraoral approach according to Weber-Fergusson-Dieffenbach and ipsilateral neck dissection. A magnetic epithesis was used for initial defect coverage of the maxillary bone accompanied by an obturator prosthesis. The surgical treatment was then followed by adjuvant proton therapy. CONCLUSION: This case report shows how individual patient care can be provided according to the latest therapy standards of ACK in the rare localization of the maxillary sinus.

Chronic Maxillary Sinusitis Caused by an Aspergilloma in the Context of Inadequately Treated Type II Diabetes Mellitus.

BACKGROUND/AIM: The prevalence of chronic sinusitis (CS) in Europe is greater than 10%. The causes of CS are diverse. In some cases, dental treatment in the maxilla as well as fungal infection, such as aspergilloma, can lead to CS. Inadequately treated illnesses, such as type II diabetes, are known risk factors for atypical infections. CASE REPORT: The present case report describes a 72-year-old female suffering from CS in the maxillary sinus. A few years earlier, the patient received endodontic treatment of a maxillary tooth. For further diagnostics a CT-scan was performed showing an obstructed maxillary sinus on the left due to a polypoid tumor. The patient had been suffering from type II diabetes that had been inadequately treated for several years. The patient was surgically treated with an osteoplasty of the maxillary sinus combined with a supraturbinal antrostomy. Histopathological findings revealed an aspergilloma. The surgical therapy was supplemented by antimycotic therapy. In addition, the patient received antidiabetic treatment leading towards stable blood sugar levels. CONCLUSION: Rare entities, such as aspergillomas, can also be the cause of CS. In particular, patients with previous illnesses relevant to the immune system are predisposed for Aspergilloma after dental treatment leading to CS.

Subacute Actinomycotic Osteomyelitis of the Mandible - An Underreported Disease?

BACKGROUND/AIM: Cervicofacial actinomycosis is a rare entity. The manifestation of this disease in the context of osteomyelitis in the mandible is even rarer. CASE REPORT: This case report describes a 70-year-old female with a painful swelling in the left mandible. The swelling was initially noticed four weeks ago. Furthermore, the patient reported problems with medications concerning her type II diabetes mellitus. Due to multiple decayed teeth, the patient had multiple teeth extracted in recent years, including teeth 36-38 in the left mandible. Orthopantogram (OPG) and computed tomography (CT) scan showed an unspecific osteolysis in the left mandible. An incisional biopsy was performed revealing subacute necrotizing osteomyelitis of the mandible due to actinomyces. Furthermore, the patient was treated with open debridement, curettage, and decortication as well as long term antibiotics (amoxicillin + clavulanic acid) for 6 weeks. In addition, type II diabetes mellitus could be controlled with various medications (Metformin, Dapagliflozin). Clinical follow-up revealed no evidence of recurrence. CONCLUSION: Even though actinomycosis is rare, it should be included in the differential diagnosis of unspecific osteomyelitis of the jaw. Antibiotics and surgical decortication are the crucial therapy pillars when treating actinomycotic osteomyelitis in the mandible.

Giant Cell Angiofibroma in the Buccal Mucosa - A Rising Entity?

BACKGROUND: Tumors of the oral cavity must be differentiated into benign and malignant. Rare tumors must also be considered throughout the differential diagnosis when dealing with pathologic changes in the oral mucosa. Examples of rare benign tumors within the oral cavity are solitary fibrous tumors (SFTs). In recent years, individual case reports of SFTs in the oral cavity have been published showing a rising incidence of this rare entity. CASE REPORT: The present case report describes the occurrence of a subtype of SFT in the right buccal mucosa, the so-called giant cell angiofibroma (GCA). Histopathologically, GCA are distinguishable from SFT (NOS) by pseudovascular spaces lined by multinucleated giant cells. GCA generally shows a benign tumor behavior. The treatment of choice was surgical excision through an intraoral approach. CONCLUSION: To the best of our knowledge, this is one of a few reports of GCA arising in the buccal mucosa.

Immunohistochemical characterization of nanocrystalline hydroxyapatite silica gel (NanoBone(r)) osteogenesis: a study on biopsies from human jaws.

OBJECTIVES: Bone substitute biomaterials may be osteogenic, osteoconductive or osteoinductive. To test for these probable characteristics in a new nanoporous grafting material consisting of nanocrystalline hydroxyapatite embedded in a porous silica gel matrix (NanoBone(s)), applied in humans, we studied biopsies from 12 patients before dental implantation following various orofacial augmentation techniques with healing times of between 3.5 and 12 months. MATERIAL AND METHODS: Sections from decalcified specimens were investigated using histology, histochemistry [periodic acid Schiff, alcian blue staining and tartrate-resistant acid phosphatase (TRAP)] and immunohistochemistry, with markers for osteogenesis, bone remodelling, resorption and vessel walls (alkaline phosphatase, bone morphogenetic protein-2, collagen type I, ED1, osteocalcin, osteopontin, runx2 and Von-Willebrand factor). RESULTS: Histologically, four specific stages of graft transformation into lamellar bone could be characterized. During early stages of healing, bone matrix proteins were absorbed by NanoBone(s) granules, forming a proteinaceous matrix, which was invaded by small vessels and cells. We assume that the deposition of these molecules promotes early osteogenesis in and around NanoBone(s) and supports the concomitant degradation probably by osteoclast-like cells. TRAP-positive osteoclast-like cells were localized directly on the granular surfaces. Runx2-immunoreactive pre-osteoblasts, which are probably involved in direct osteogenesis forming woven bone that is later transformed into lamellar bone, were attracted. Graft resorption and bone apposition around the graft granules appear concomitantly. CONCLUSIONS: We postulate that NanoBone(s) has osteoconductive and biomimetic properties and is integrated into the host's physiological bone turnover at a very early stage.

Biomechanical comparison of a multidirectional locking plate and conventional plates for the osteosynthesis of mandibular angle fractures-A preliminary study.

PURPOSE: The objective of surgical fracture management is to reduce and fixate fractures accurately and rapidly. Two osteosynthesis plates are usually used in the treatment of mandibular angle fractures to enhance torsional stiffness. We conducted biomechanical tests under static and cyclic loading to assess whether a single locking plate is as efficacious as two conventional plates in the osteosynthesis of mandibular angle fractures. MATERIALS AND METHODS: Fracture gaps were created in synthetic mandible replicas. After pretests, the stiffness of a single locking plate and different types of non-locking, two-plate systems was assessed and compared under static and cyclic loading. The plates were subjected to a maximum static load of 750 N and underwent cyclic loading at a constant force of 400 N during a maximum of 500,000 cycles. RESULTS: No plastic deformation occurred in the static tests. Both types of osteosynthesis showed high static stability. The locking plate was significantly stiffer than the non-locking plates (p = 0.0079). Cyclic loading tests did not reveal any significant differences. CONCLUSION: Within the limitations of this preliminary study, a single locking miniplate appears to be as efficacious in biomechanical tests as non-locking, two-plate systems for the management of mandibular angle fractures.