Condylar Shave For the Treatment of Active Condylar Growth Excess.

The authors present a novel approach for addressing excessive condylar growth in individuals exhibiting asymmetric mandibular growth patterns.

Growing skull fractures after craniosynostosis repair: risk factors and treatment algorithm.

Growing skull fractures (GSFs) are rare complications after severe head injuries in the early childhood and rarely occur after craniosynostosis repair. The aim of this study was to define an algorithm for sufficient treatment for GSF after craniofacial procedures. Literature research was performed to clarify risk factors for GSFs after cranial vault reshaping. Conclusions of the literature and experiences of the authors based on a case of GSF after craniofacial surgery were matched to establish guidelines for successful therapy.

3-Dimensional imaging for lower third molars: is there an implication for surgical removal?

PURPOSE: Surgical removal of impacted third molars may be the most frequent procedure in oral surgery. Damage to the inferior alveolar nerve (IAN) is a typical complication of the procedure, with incidence rates reported at 1% to 22%. The aim of this study was to identify factors that lead to a higher risk of IAN impairment after surgery. MATERIALS AND METHODS: In total 515 surgical third molar removals with 3-dimensional (3D) imaging before surgical removal were retrospectively evaluated for IAN impairment, in addition to 3D imaging signs that were supposed predictors for postoperative IAN disturbance. Influence of each predictor was evaluated in univariate and multivariate analyses and reported as odds ratio (OR) and 95% confidence interval (CI). RESULTS: The overall IAN impairment rate in this study was 9.4%. Univariate analysis showed narrowing of the IAN canal (OR, 4.95; P < .0001), direct contact between the IAN and the root (OR, 5.05; P = .0008), fully formed roots (OR, 4.36; P = .045), an IAN lingual course with (OR, 6.64; P = .0013) and without (OR, 2.72; P = .007) perforation of the cortical plate, and an intraroot (OR, 9.96; P = .003) position of the IAN as predictors of postoperative IAN impairment. Multivariate analysis showed narrowing of the IAN canal (adjusted OR, 3.69; 95% CI, 1.88 to 7.22; P = .0001) and direct contact (adjusted OR, 3.10; 95% CI, 1.15 to 8.33; P = .025) to be the strongest independent predictors. CONCLUSION: Three-dimensional imaging is useful for predicting the risk of postoperative IAN impairment before surgical removal of impacted lower third molars. The low IAN impairment rate seen in this study-compared with similar selected study groups in the literature of the era before 3D imaging-indicates that the availability of 3D information is actually decreasing the risk for IAN impairment after lower third molar removal.

Clinical reliability of radial forearm free-flap procedure in reconstructive head and neck surgery.

OBJECTIVE: The purpose of the study was to evaluate the indications, reliability, and complications of the radial forearm fasciocutaneous flap (RFFF) procedure in reconstructive head and neck surgery. METHODS: The records of 81 patients who were treated with an RFFF between 1998 and 2009 were systematically reviewed. Data of recipient localization, previous T status, and postoperative complications were analyzed. RESULTS: From the 50 male and 31 female patients, 4 patients (3 men and 1 woman) experienced flap failure during the first 36 hours: in 1 patient because of arterial and in 3 patients because of venous complications. None of the 4 patients had preoperative radiotherapy. A dehiscence was observed in 2 patients without a need for further surgery. CONCLUSIONS: With a success rate of more than 95%, the RFFF is a reliable flap and a workhorse, particularly in defects where thinness is needed to substitute for the oral mucosa, such as on the floor of the mouth or the tongue.

Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: a literature review.

Microvascular free tissue transfer is a reliable technique for head and neck reconstruction with success rates of 90-99%. Currently, there is no consensus concerning antithrombotic agents, antibiotics, or monitoring techniques. Therefore, the aim of this study was to review current literature dealing with microvascular free-tissue transfer and factors influencing the outcome. In addition to excellent microsurgical techniques, coupling devices are a promising new technique, but are not useful in all arteries. Antibiotics should be given in three doses, as a more lengthy dosage time seems to have no advantage. The risk for elderly patients can be best assessed by the American Society of Anesthesiologists (ASA) score, but early mobilization, including intense chest physiotherapy, is important. Anticoagulation can be considered in cases of small vessels, significant size mismatch, vein graft, or vessels of poor quality. Monitoring should be done hourly during the first 24 hours and then every 4 hours for the next 2 postoperative days.

New clinical-based evidence for the existence of 2 growth regulators in mandibular condyles: hemimandibular elongation in hemifacial microsomia mandible.

This is the first description of a secondary mandibular overgrowth due to condylar misregulation in a congenitally undergrown mandible. This case of unilateral hemifacial microsomia proves the postulated existence (Mandibular Growth Anomalies: Terminology, Aetiology, Diagnosis, Treatment, 2001) of 2 different growth regulators in the condyle of each side of the mandible. It shows clear and typical symptoms of hemimandibular hyperplasia on its right side and of hemimandibular elongation on its left mandible despite the existence of a well-developed hemifacial microsomia on the same side. Correction was carried out on the basis of our routine planning and planning principles, including condylectomy on the side of the hemifacial microsomia, because of still active hemimandibular elongation.

Extranodal manifestation of Rosai-Dorfman disease without involvement of lymph nodes.

BACKGROUND: Rosai-Dorfman disease is an uncommon sinus histiocytosis with massive lymphadenopathy. Rosai-Dorfman disease without lymphadenopathy is extremely rare. Extranodal pseudotumoral masses can occur--and have been identified and described--in the orbit, skin, bone, and upper respiratory tract. Because of its rareness, Rosai-Dorfman is seldom considered in the clinical differential diagnosis, particularly if extranodal manifestations predominate. METHODS AND RESULTS: We present herein a patient with extranodal manifestation of Rosai-Dorfman disease in the orbit and parotid without typical initial lymph node involvement that reacted on steroid therapy. CONCLUSIONS: The correct diagnosis of this entity with the knowledge that it can occur without lymphadenopathy is important. For these patients, diagnosis must be based on histologic and immunohistopathologic findings after surgical biopsy. Steroid therapy can be used for treatment.

Free flap monitoring protocol.

In microsurgery, the successful salvage of free tissue transfer is dependent on the rapid decision to return to the operating room. Therefore, a free flap monitoring protocol is presented, including checking color, temperature, capillary return, and signal from a handheld Doppler ultrasonograph in an intraoperatively marked skin area directly over the pedicle.

[Therapy of recurrent fixed anterior TMJ dislocation with mini-plates in an aged patient with other ailments. A case report]. / Die Therapie der rezidivierenden, fixierten anterioren Kieferluxation mittels einer T-förmigen Miniplatte bei einer älteren polymorbiden Patientin--ein Fallbericht]

Unilateral or bilateral dislocation of the TMJ is frequent. Usually it can be treated by the method described by Hippocrates. If conservative treatment (splint therapy, biofeedback, etc.) does not succeed related to recurrent fixed TMJ-dislocation, surgical therapy strategies become necessary. Above all mentally retarded or patients with neuromuscular disorders may necessitate surgical treatment. The two surgical main procedures are: 1. Removal of mechanical obstacles by reduction of the eminentia. 2. Creation of a mechanical obstacle towards the anterior condylar translation. The here presented case shows the treatment of a reccurent, fixed anterior TMJ-dislocation using a miniplate which enables a absolut heightening of the articular tubercle in a 76 years old lady with Morbus Alzheimer and Parkinson. Due to the high incidence of plate fractures, this well discribed therapy, known as miniplate eminoplasty, can not be considered as the treatment of choice for mandibular dislocation. It can be indicated in non-compliant patients or in patients with neuromuscular disorders or in the combination of both as in our case.

Motivation for orthognathic treatment and anticipated satisfaction levels-a two-centre cross-national audit.

PURPOSE: This audit investigated factors which motivate patients to seek orthognathic treatment, assessed how confident patients were that they would be satisfied with the outcome of treatment, and explored possible influencing factors. MATERIALS AND METHODS: Questionnaires were distributed to pre-surgical patients at two centres (United Kingdom and Switzerland); questions asked what patients wished to gain from orthognathic treatment and how confident they were that they would be satisfied with treatment outcome. Gender, age and location were recorded as demographic variables, and type of malocclusion was also recorded. RESULTS: A total of 202 questionnaires were returned (UK, n = 149; Switzerland, n = 53). Reported motivating factors focused on improvements in aesthetics (specified and unspecified) (UK vs. Switzerland: 91.3% vs. 83.0%), function (72.5% vs. 66.0%), psychosocial health (51.7% vs. 20.8%), speech (4.0% vs. 7.5%), alleviation of pain (5.4% vs. 17%) and normalization of breathing (1.3% vs. 7.5%). No significant relationships were observed relative to patient age, gender or malocclusion. The anticipated satisfaction levels were generally high (86.5% vs. 89.9%). CONCLUSION: Although the distribution of motivational factors varied between the two sites, it did not affect the anticipated satisfaction level. Patients were generally confident that they would be satisfied with their treatment outcome and that their reasons for seeking treatment would be addressed.

[Clonidine in oral medicine. Literature review and our experience]. / Clonidin in der Zahn-, Mund- und Kieferheilkunde. Literaturübersicht und eigene Erfahrungen.

There is a large experience in premedication with clonidine (Catapresan) for general anaesthesia. Clonidine is an alpha2-adrenoceptor agonist exerting central sympatholytic effects. Premedication with clonidine blunts the stress response to surgical stimuli and the narcotic and anaesthetic dose can be reduced. Furthermore, perioperative myocardial ischemic events can be prevented by preoperative application of clonidine. Oral clonidine at a dose of 1.5-2 microg/kg BW combines the advantages of benzodiazepines and morphine: anxiolysis, sedation and analgesia with stable hemodynamics and respiration. Clonidine does not have morphine related side effects such as nausea and vomiting. Doses of up to 5 microg/kg BW have been administered to young and healthy patients preoperatively in dental and maxillofacial surgery without significant side effects. However, Clonidine 2 microg/kg BW should be an adequate oral premedication dose for young and healthy patients scheduled for dental and facial surgery procedures performed under local anaesthesia in the ambulatory setting. In elderly patients clonidine 2 microg/kg BW administered orally should not be exceeded to avoid excessive hypotension and sedation. Bradycardia is a contraindication for the use of clonidine.

The bioconvertible osteosynthesis system-results of a prospective clinical study on stability of bimaxillary surgery.

The findings of a prospective clinical study with the purpose to evaluate the stability of bimaxillary orthognathic surgery using autoclaved allogenic cortical bone screws and bony plates in the fixation of osteotomies are presented. The results of 31 patients were compared with the outcome of 33 cases using metallic devices for osteotomy fixation. The follow-up time was one year. With the help of the structural superimposition of lateral cephalometric radiographs, the stability was evaluated in consideration of maxillary and mandibular movements caused by operation. Both groups showed excellent results in the anterior-posterior plane as in the vertical plane without any significant difference.

Malignancy mimicking bisphosphonate-associated osteonecrosis of the jaw: a case series and literature review.

OBJECTIVE: Bisphosphonate-related osteonecrosis of the jaw (BONJ) is a common complication of bisphosphonate treatment that has been well documented over the past decade. Nevertheless, its pathogenesis is poorly understood, and treatment guidelines are based mostly on expert recommendations. Clinicians must be aware of malignancy mimicking BONJ, of which a few cases have been documented in the literature. STUDY DESIGN: Three patients undergoing long-term treatment with intravenous bisphosphonates for malignant disease demonstrated the distinct diagnostic signs of BONJ. Surgical treatment was performed by resecting the affected bone. In all cases, histologic specimens were taken for analysis. RESULTS: Histologic analysis of the bone specimen with surrounding soft tissue revealed necrotic bone with signs of inflammation, but also with cells of the underlying malignant disease. CONCLUSIONS: Clinical and radiographic diagnosis of BONJ should be confirmed by histologic analysis in patients with underlying malignant disease.

Point-to-point registration with mandibulo-maxillary splint in open and closed jaw position. Evaluation of registration accuracy for computer-aided surgery of the mandible.

INTRODUCTION: Computer navigation plays an increasingly important role in craniomaxillofacial surgery. The difficulties in computer navigation at the craniomaxillofacial site lie in the accurate transmission of the dataset to the operating room. This study investigates the accuracy of the dental-splint registration method for the skull, midface, and mandible. MATERIAL AND METHODS: A synthetic human skull model was prepared with landmarks and scanned with cone beam computer tomography (CBCT). Two registration splints fixed the mandible against the viscerocranium in two different positions (closed vs. open). The target registration error was computed in all 278 landmarks spread over the entire skull and mandible in 10 repeated measurements using the VectorVision(2) (BrainLAB Inc., Feldkirchen, Germany) navigation system. RESULTS: If registered in the closed position an average precision of 2.07 mm with a standard deviation (SD) of 0.78 mm was computed for all landmarks distributed over the whole skull. Registration in the open position resulted in an average precision of 1.53 mm (SD=0.55 mm). For single landmarks the precision decreases linearly with distance from the reference markers. The longer the three-dimensional distance between the registration points, the more precise the computer navigation is, mainly in the most posterior area of the cranium. CONCLUSION: Our findings in the cranium are comparable with those of other studies. Artificial fixation of the lower jaw via splint seems to introduce no additional error. The registration points should be as far apart from each other as possible during navigation with the splint.

Squamous cell carcinoma arising in a skin flap: case report and review on malignant transformations in skin grafts and microvascular cutaneous flaps.

OBJECTIVES: Sufficient closure of intraoral defects can be challenging. Various methods of tissue transfer have been presented in the literature. From skin grafts to microvascular flaps, most techniques used for intraoral reconstruction use skin to line out the oral cavity to guarantee an epithelial surface. Native mucosa tolerates the moist environment of the oral cavity, whereas skin flaps do to just a certain extent. This may lead to chronic inflammation of the flap-skin. Under rare circumstances, these histologic changes can enhance the risk for malignant transformation of the skin graft. CASE REPORT: We present a case of a patient who derived a squamous cell carcinoma in the skin island of a jump flap raised from the abdominal wall 30 years earlier. The flap was used to close a very wide palatal cleft. The patient had no history of malignancy, smoking, drinking, or other risk factors. DISCUSSION: To the authors' knowledge, this is the first report on carcinoma in a skin flap in a patient without any history of intraoral malignancy. Although malignant transformations of skin grafts are very rare and usually appear years after the reconstruction, one should be aware that the moist environment can lead to chronic inflammation of the dermis of flap. This fact may increase the risk of malignant transformation in a skin graft.

Anatomy of impacted lower third molars evaluated by computerized tomography: is there an indication for 3-dimensional imaging?

OBJECTIVE: Surgical removal of impacted third molar is one of the most frequent procedures in oral surgery. Today 3-dimensional (3D) imaging is occasionally used. The aim of this study was to describe and estimate the frequencies of anatomic variations of lower third molars in patients with panoramic findings at high risk for inferior alveolar nerve (IAN) injury. STUDY DESIGN: The investigators designed and implemented a retrospective cases series study with a study population composed of patients presenting with an impacted lower third molar with projection of the tooth over the full width of the IAN in panoramic radiograph and, therefore, 3D imaging before a planned surgical removal. Spatial relationship to the IAN, type of angulation, root configuration and maturation were primary study variables. Descriptive statistics were computed for all variables. RESULTS: A total of 707 wisdom teeth in 472 patients (54% female, 46% male) were evaluated. A close relationship to the IAN was seen in 69.7%, and in 45.1% the diameter of the mandibular canal was reduced. In 52.8% the IAN was vestibular and in 37.3% lingual to the roots; there were 9.9% with an inter- or intraroot course. Most teeth had 1 or 2 roots (86.7%), but 13.3% had ≥3 roots. Mesial angulation was the main type (40.2%), followed by vertical (29%), horizontal (13.9%), distal (10.2%), and transverse (6.8%) positions. CONCLUSION: Based on the range of variations in the course of the nerve and the number of roots the authors recommend 3D imaging before surgical removal of a lower third molar that shows signs of a close relationship to the IAN.

Surgical navigation in cranio-maxillofacial surgery: an evaluation on a child with a cranio-facio-orbital tumour.

Surgical navigation, though well-established, is often associated with extra effort for both patient and surgeon, and with additional exposure to radiation as a result of the necessary extra imaging. Osteoblastoma is a benign bone tumour, malignant transformation of which is rare but possible, and so resection is indicated. The orbit with surrounding structures is a challenging region for accurate three-dimensional reconstruction. A virtual plan based on the patient's mirrored anatomy realised by intraoperative navigation can assist in achieving perfect results. An 8-year-old boy presented with a huge osteoblastoma of the frontal and temporal skull. The tumour had extracranial and intracranial parts, and reached into the orbital roof and the sphenoid and ethmoid bones. The ethmoid sinus was involved, the eye was displaced, and he had functional problems. Virtual planning and navigation were prepared without the need for any additional imaging. The tumour was resected through a coronal approach, and immediately reconstructed with an autologous calvarial split graft, designed and positioned under navigation with a preoperative plan that was based on the mirrored healthy side. Surgical navigation based on a virtual plan can achieve symmetrical results, particularly when dealing with complex three-dimensional anatomy. Navigation does not necessarily mean additional procedures or imaging. We think that virtual planning and navigation are useful for selected cases.

Evaluation of the pectoralis major flap for reconstructive head and neck surgery.

PURPOSE: The pectoralis major myocutaneous flap (PMMF) is a commonly used flap in reconstructive head and neck surgery, but in literature, the flap is also associated with a high incidence of complications in addition to its large bulk. The purpose of the study is the evaluation of the reliability and indication of this flap in reconstructive head and neck surgery. PATIENTS AND METHODS: The records of all patients treated with a PMMF between 1998 and 2009 were systematically reviewed. Data of recipient localization, main indication, and postoperative complications were analyzed. RESULTS: The male to female ratio was 17:3, with a mean age of 60 years (45-85). Indications in 7 patients were recurrence of a squamous cell carcinoma, in one case an osteoradionecrosis and in 12 cases an untreated squamous cell carcinoma. In 6 male patients (30%), a complication appeared leading to another surgery. CONCLUSION: The PMMF is a flap for huge defects in head and neck reconstructive surgery, in particular when a bulky flap is needed in order to cover the carotid artery or reconstructive surgery, but the complication rate should not be underestimated in particular after radiotherapy.