Dentinogenic Ghost Cell Tumour in Childhood Involving the Temporomandibular Joint: Considerations and Therapy.

Background: Although the uncommon dentinogenic ghost cell tumour (DGCT) is a benign entity, it possesses the ability to cause widespread destruction of the jaws and to recur after bone-preserving therapy. Hence, clear margins should be achieved upon surgery, and reconstruction techniques must often be used to restore osseous defects. However, this can be challenging in cases with involvement of the temporomandibular joint (TMJ), and especially in children. Case report: We present a case of a DGCT in a 12-year-old boy with wide infiltration of the mandible and the TMJ. A two-staged reconstructive approach was performed. Upon primary surgery, tumour-free margins were obtained and mandibular anatomy was restored using an iliac crest graft and an alloplastic condyle implant for temporary TMJ reconstruction. In a second step 5 months later, having received a customized TMJ prosthesis consisting of a fossa and a condyle component, the TMJ was completely replaced for definitive reconstruction. Conclusion: A customized TMJ prosthesis could be a solution for reconstruction of the TMJ in children. However, the further course with respect to growth disturbances must be evaluated upon short-term follow-ups and might require additional corrective interventions.

Melanotic Neuroectodermal Tumour of Infancy: Clinical Courses and Therapeutic Options-A Review of Three Cases.

BACKGROUND: Melanotic neuroectodermal tumour of infancy (MNTI) is a rare benign neoplasm. MNTI appears most often during the first year of life, arises predominantly in the maxilla and tends to recur. We discuss possible therapeutic options given in the literature and within our experience in three cases. PATIENTS: In our recent case, we used an intraoral approach to perform resection of the right-sided maxilla. Despite tumour-positive margins, there was no recurrence over the course of one year. In a previous case of MNTI, two recurrences occurred and 6 months after last resection patient received a rib graft for maxillary reconstruction. However, at the age of 7 years, the infant displayed severe maxillary hypoplasia. In a third case of MNTI, the patient was followed up after initial therapy for two decades and underwent multiple reconstruction procedures to achieve successful rehabilitation. CONCLUSION: Surgical treatment of MNTI should respect vital anatomic structures to avoid gross mutilation. The need for extended and repetitive tumour resection in early childhood can lead to growth disturbances and to further multiple reconstruction procedures in adulthood. Because of the rarity of MNTI, an international database is warranted to evaluate therapies and clinical courses over decades.

Bisphosphonate-associated osteonecrosis of the jaw: what do we currently know? A survey of knowledge given in the recent literature.

Increasing application of bisphosphonates for therapy of osteopathies has led to reports of the severe associated adverse effects of osteonecrosis of the jaw (ONJ). We reviewed recent literature to assess several aspects of bisphosphonate-associated ONJ, and to provide healthcare professionals with an overview of treatment and preventive options. Literature databases were searched using keywords. Information of 54 articles were discussed and completed by additional literature. High-risk factors were application of nitrogen-containing bisphosphonates, teeth extractions, and ill-fitting dentures. Treatment included non-surgical options and radical surgery. Success and failure were described for all treatment options; further studies investigating long-term recovery and recurrence are warranted. Paying attention to effective prevention of ONJ before, during, and after treatment is essential.

Allografting combined with systemic FK506 produces greater functional recovery than conduit implantation in a rat model of sciatic nerve injury.

Implantation of allografts or nerve conduits has been used to promote regeneration following peripheral nerve injuries involving substantial axon loss. Both methods provide promising alternatives to autologous grafting and avoid donor site morbidity. We compared the relative efficacies of allografting versus conduit implantation in a rat model of sciatic nerve regeneration. Two rat strains (Lewis and Dark Agouti; n = 30) were employed. Unoperated animals served as controls (group I). Animals in groups II and III underwent left sciatic nerve resection over a distance of 15 mm; group II animals received implants of collagen type I conduits; and group III animals received allografts from the other rat strain and systemic low-dose (0.1 mg/kg/d) administration of FK506. Walking tracks were recorded after 4, 8, 12, and 16 weeks; nerve sections were stained for myelin basic protein after 16 weeks. Functional tests revealed significantly better recovery in group III animals compared with group II even though there was no significant difference in the extent of remyelination. Neither group achieved the functional or histomorphometric values of control animals. Improved functional recovery following allografting plus systemic FK506, in comparison with conduit implantation, underlines the importance of systemic administration of neurotrophic molecules for nerve regeneration.

Correlation of three sciatic functional indices with histomorphometric findings in a rat sciatic nerve allograft repair model.

Walking track analysis was used to measure global functional recovery following sciatic nerve injury. The correlation of morphologic outcome and different sciatic functional indices (SFIs) depends on different variables. The objective of this study was to compare three different SFIs and their correlation with histomorphometric findings in a sciatic nerve allograft repair model in the rat without (group I, n = 8) or with (group II, n = 8) daily intramuscular administration of 0.1 mg/kg FK 506. The correlation of SFIs with each other and with the myelin basic protein (MBP) density of nerve sections proximal, median, and distal to sciatic nerve grafts (1.5 cm) at 4, 8, 12, and 16 weeks postoperation (p.o.) was calculated, and unoperated animals served as controls (n = 8). Significant differences between SFIs calculated for experimental groups I and II at 12 and 16 weeks p.o. suggested that superior functional nerve recovery occurred in group II. However, there were significant differences between all SFIs at 16 weeks p.o. in group II, whereas only differences between SFI 1 and SFI 2 + 3 occurred in group I. SFIs of group II did not reach the values of the unoperated group. There were significant differences between the histomorphometric outcomes of groups I and II. There was no significant difference of MBP density between group II and the unoperated group, suggesting complete morphologic recovery. In conclusion, we found significant correlation between the MBP densities of groups I and II and all SFIs, suggesting a close relationship between histomorphometric and functional findings. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.

Case report: chronic inflammatory ulcer and osteoradionecrosis of the skull following radiotherapy in early childhood.

INTRODUCTION: Chronic inflammatory diseases of the skin are the most common differential diagnosis of tumorous lesions of the craniofacial region. Detailed information about a patient's medical history is important for the clinical diagnosis of such cases. Previous radiotherapy should be taken into account, especially in cases of chronic dermatitis, since complications include osteoradionecrois of the adjacent bone strucutres with surrounding inflammation. CASE REPORT: We present the case of a 77-year-old femal patient who was admitted to our department with a slightly progressive ulcerating lesion of the frontotemporal skull. The patient had received radiotherapy in early childhood as primary therapy for hemangioma. Diagnostic imaging and biopsies revealed a diagnosis of chronic ulceration with underlying osteonecrosis and fibrotic osteomyelitis of the skull. A complex reconstruction of osseous structures and soft tissue was necessary to resolve her complaints. CONCLUSION: Chronic radiodermatitis and osteoradionecrosis in adults, occurring as late complications, are uncommon, but can be observed even nearly 80 years after radiation. Large defects of the skull require a complete reconstruction to avoid several complications.

Total mandibular reconstruction following diffuse sclerosing osteomyelitis.

BACKGROUND: Diffuse sclerosing osteomyelitis (DSO) is a non-purulent chronic recurrent inflammation and affects the mandible in many cases. Belonging to the group of autoinflammatory diseases, in children and in cases with various additional symptoms including synovitis, acne, pustulosis, hyerostosis, and osteitis (SAPHO syndrome), therapy usually consists of non-surgical treatment. Against this background, we present an unusual course of DSO in an adult female patient. CASE REPORT: A 50-year-old female suffering from DSO without SAPHO syndrome was pretreated for years with conservative drug regimens and local surgery. Previous therapy was not successful, and subsequently, multiple surgical procedures were carried out focused on recurrent acute exacerbations of DSO. Surgery resulted in a total resection and alloplastic and autoplastic reconstruction of the mandible including both temporomandibular joints. Prosthetic rehabilitation was possible after dental implant loading, and the final outcome was very satisfactory. CONCLUSION: In the event that non-surgical options are not successful in DSO, an extended surgical therapy becomes necessary. Even if surgery results in complete resection of the mandible, a satisfactory rehabilitation can be achieved after complex reconstruction.

The incidence of Frey's syndrome.

AIMS: The incidence of Frey's syndrome after parotidectomy greatly varies in the literature. The aim of this study was to analyse the incidence with the help of a new series of patients and to discuss and review the results. PATIENTS: 372 patients (age: 50.7+/-11.6 yrs) underwent unilateral parotidectomy. In 203 subjects the insertion of a sternocleidomastoideus flap in the parotid area was performed intraoperatively. METHODS: Patients were followed-up concerning the clinical presence of gustatory sweating and flushing after secretory stimulation, and were questioned about suffering in everyday life. RESULTS: 86 patients (23.5%) developed Frey's syndrome after an average of 12 months (12.3+/-9.9 months) following parotidectomy. Only 44% of the patients with Frey's syndrome were symptomatic. No benefit concerning Frey's syndrome following application of a sternocleidomastoideus flap was seen. CONCLUSION: Gustatory sweating after parotidectomy must still be regarded as an unpleasant and common complication. Nevertheless, it is more the subjective suffering of the patients than the incidence that makes prevention important.

Continuity defects of the mandible: Comparison of three techniques for osseous reconstruction and their impact on implant loading.

Computer-aided design/manufacturing (CAD/CAM) is now widely used, but whether it can help to overcome complications in mandibular reconstruction and accelerate dental implantation is still a matter for debate. Therefore, we aimed to evaluate the benefits of this technique using vascularized iliac crest or fibula flaps in mandibular reconstruction, with respect to the time between reconstruction and implantation, and the ratio of planned to inserted implants. We reviewed retrospectively the records of 54 patients who underwent mandibular reconstructions between 2012 and 2016, and included in our study the last 10 cases representing each of the following groups: iliac crest flap with CAD/CAM (Group 1); fibula flap with CAD/CAM (Group 2); and fibula flap without CAD/CAM (Group 3). Groups 1 (p = 0.045) and 2 (p = 0.034) showed significantly shorter delays when compared with Group 3. Significant differences in average counts of implants placed were also found between Group 1 and Groups 2 (p = 0.04) and 3 (p = 0.019). The ratio of planned to placed implants was highest in Group 1. The observed differences between Group 1 and Groups 2 (p = 0.04) and 3 (p = 0.019) were significant. Our results indicate an accelerating effect of CAD/CAM on graft consolidation and dental rehabilitation.

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.

Injuries in combat from 1982-2005 with particular reference to those to the head and neck: A review.

The aim of this review was to examine the range of combat injuries with particular reference to those of the head and neck. We evaluated 10 retrospective studies selected from the period 1982-2005 that covered war injuries from Vietnam, Lebanon, Slovenia, Croatia, Iraq, Somalia, and Afghanistan. We found differences in the causes of injuries. Injuries from fragments were more common during the 90s than during the Vietnam War, where shooting injuries predominated. Injuries to the trunk were reduced in conflicts from 1991 onwards as military personal armour systems including protective vests were used. However, the mortality of wounded soldiers in all conflicts was consistently between 10% and 14%. There was a high incidence of injuries to the head and neck (up to 40%) though they affected only 12% of the body surface area. Though the data from the different military conflicts are not totally comparable, there are trends in the type of injuries and mortality, which may lead to changes in existing systems of medical care.

Longtime undetected microcystic adnexal carcinoma of the scalp: considerations and implications.

BACKGROUND: Microcystic adnexal carcinomas (MACs) are slow-growing and often asymptomatic malignant skin tumours that usually develop on the facial skin and may reach considerable size. We present an uncommon case of MAC arising on the hair-bearing scalp and discuss our experiences and considerations. CASE REPORT: A 58-year-old female was admitted with a histopathologically secured diagnosis of MAC of the temporal and occipital regions that had expanded to 10 × 12 cm. Magnetic resonance imaging revealed an infiltration of the skin and the subcutaneous adipose tissue. No lymphatic or haematogenic metastases were detected. Therapy consisted of resecting the tumour and reconstructing the area by applying an anterolateral thigh (ALT) flap. Histopathological evaluation revealed clear, 1-cm margins and a tumour-free periosteum. One-year postoperative follow-ups showed no evidence of recurrence, while the outcome was aesthetically pleasing. CONCLUSION: When screening for skin cancer, careful attention must be paid to the scalp. Resection of MAC with clear margins is mandatory to minimize the risk of recurrence. In this case, applying an ALT perforator flap to a large defect of the hair-bearing scalp led to a very satisfying result; it should be considered in comparable cases.

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.

Orbital lobe resection provides a definite diagnosis of lacrimal gland lesions: a report of three cases.

BACKGROUND: Entities of lacrimal gland lesions comprise almost inflammatory and lymphoproliferative processes as well as benign and malignant solid tumors and usually cannot be differentiated by magnetic resonance imaging (MRI) exclusively. Hence, representative tissue samples are needed to arrive at sufficient histopathological diagnosis for further treatment decisions. CASE REPORT: Three women aged between 18 and 67 years were admitted to our center with clinical signs of a space-occupying mass in the lacrimal fossa. MRI revealed a circumscribed lacrimal gland lesion in all three cases. The orbital lobe was resected through a lateral orbitotomy approach for histopathological evaluation. Findings confirmed the diagnoses of pleomorphic adenoma, dacryoadenitis, and low-grade B cell non-Hodgkin's lymphoma. Further surgery was not necessary. No recurrence or symptoms of "dry eye" were observed over the course of a 1-year follow-up. CONCLUSION: In cases of non-specific masses in the lacrimal gland on MRI, histopathological diagnoses are vital and can be sufficiently provided by resection of the orbital lobe. Symptoms of dry eye are uncommon, and secondary surgical intervention can be avoided in cases of the presented entities. Further studies with larger patient cohorts are warranted to confirm these findings.

Perceptions of Pre- to Postsurgical Profile Changes in Orthognathic Surgery Patients and Their Correlation with Photogrammetric Changes: A Panel Study.

PURPOSE: The objective was to compare the pre- and postsurgical profile changes after surgical correction of prognathism and maxillary hypoplasia, as perceived by panels of orthodontists, maxillofacial surgeons, laypersons and patients and to identify photogrammetric changes that might be related to preferred ratings. MATERIALS AND METHODS: Each panel consisted of six males and six females who rated sets of pre- and postsurgical lateral photographs of 20 female and 20 male patients using a five-point scale. Patients rated their own set of photographs. Pre- to postsurgical differences of photogrammetrically assessed landmarks were recorded as a surgical change. RESULTS: No significant differences in ratings between panels and patients could be detected. Significant correlation coefficients (r) were obtained between the ratings of all panel groups and between the ratings and changes in facial convexity (r = 0.351-0.542). Correlations with changes of the mentolabial angle were found to be significant for old orthodontists, male laypersons, and male patients (r = 0.332-0.609). Ratings of female and young laypersons were correlated with the horizontal changes in the lower face (r = 0.324-0.379). CONCLUSION: Information gathered from this study will support the cooperation of the medical staff and might assist in treatment planning.

Comparison of intraoperative time measurements between osseous reconstructions with free fibula flaps applying computer-aided designed/computer-aided manufactured and conventional techniques.

PURPOSE: We aimed to determine whether computer-aided designed/computer-aided manufactured (CAD/CAM) techniques could save intraoperative time compared with the conventional technique, by comparing flap harvesting and ischemia times, and subsequently impact flap survival. METHODS: Twenty patients underwent concurrent osteocutaneous fibula flaps, either with (n = 10) or without (n = 10) the CAD/CAM technique. Demographic data, clinical history, complications, number of osseous segments, and times for virtual planning, flap harvesting, flap ischemia, tourniquet inflation, and total reconstruction were recorded. RESULTS: There was no significant difference between CAD/CAM and conventional techniques with respect to age, number of osseous segments, complication rates, and tourniquet inflation time. Flap harvesting times were significantly shorter in the conventional group (112.1 vs. 142.2 min, p < 0.001), while flap ischemia and total ischemia times were significantly shorter in the CAD/CAM group (70.7 vs. 98.6 min, p < 0.001; 174.8 vs. 198.9 min, p = 0.002, respectively). However, while total reconstruction time did not differ between groups, overall operating time (including the amount of virtual planning time and surgical reconstruction time) was significantly longer in the CAD/CAM group (mean 256.0 vs. 210.7 min, p < 0.001). CONCLUSIONS: Despite the advantages of the CAD/CAM technique, including reduced ischemia time of osteocutaneous fibula flaps, there is no impact on total reconstruction time or flap survival.

Quantification of the neurodegenerative impact on the visual system following sudden retrobulbar expanding lesions - an experimental model.

INTRODUCTION: Afferent disorders of the visual system are a potential consequence following orbital trauma. The aim of this study was to investigate the tolerance of neurons in the retinal ganglion cell layer to acute expanding retrobulbar lesions. MATERIAL AND METHODS: In 42 male albino rats, intraorbital haemorrhage was simulated by transconjunctival insertion of a retrobulbar micro-balloon (filling volume 0.2-0.5 ml, duration of lesion 60 or 90 min). Neurodegeneration in the retinal ganglion cell layer was investigated by measuring the mean total neuron number and the mean neuron size. RESULTS: Increased retrobulbar volumes of 0.3 ml for 60 min led to a decrease in a number of neurons by 14.5% and in size of the neurons by 1.7%. Prolongation of the trauma to 90 min resulted in a decrease in number of neurons by 48.3% and in reduction of size of neurons by 22.1%. In contrast, a retrobulbar filling volume of 0.5 ml for 60 min resulted in a decrease in number of neurons by 11.4% and in size of neurons by 6.7%. CONCLUSION: The duration of a retrobulbar lesion leading to subsequent retinal ischaemia seems to be more important for neuron survival than the exerted pressure (once it is greater than a critical point for producing retinal ischaemia). The results strengthen the need for emergency treatment in cases of retrobulbar haemorrhage.

Costs incurred by applying computer-aided design/computer-aided manufacturing techniques for the reconstruction of maxillofacial defects.

This study aims to evaluate the additional costs incurred by using a computer-aided design/computer-aided manufacturing (CAD/CAM) technique for reconstructing maxillofacial defects by analyzing typical cases. The medical charts of 11 consecutive patients who were subjected to the CAD/CAM technique were considered, and invoices from the companies providing the CAD/CAM devices were reviewed for every case. The number of devices used was significantly correlated with cost (r = 0.880; p < 0.001). Significant differences in mean costs were found between cases in which prebent reconstruction plates were used (€3346.00 ± €29.00) and cases in which they were not (€2534.22 ± €264.48; p < 0.001). Significant differences were also obtained between the costs of two, three and four devices, even when ignoring the cost of reconstruction plates. Additional fees provided by statutory health insurance covered a mean of 171.5% ± 25.6% of the cost of the CAD/CAM devices. Since the additional fees provide financial compensation, we believe that the CAD/CAM technique is suited for wide application and not restricted to complex cases. Where additional fees/funds are not available, the CAD/CAM technique might be unprofitable, so the decision whether or not to use it remains a case-to-case decision with respect to cost versus benefit.

Application of computer-aided designed/computer-aided manufactured techniques in reconstructing maxillofacial bony structures.

BACKGROUND: Today, virtually planned surgery and computer-aided designed/computer-aided manufactured (CAD/CAM) tools to reconstruct bony structures are being increasingly applied to maxillofacial surgery. However, the criteria for or against the usage of the CAD/CAM technique are disputable, since no evidence-based studies are available. Theoretically, the CAD/CAM technique should be applied to complex cases. In this case report, we present our experiences and discuss the criteria for application. CASE REPORT: Three cases are reported in which subjects received an osseous reconstruction using CAD/CAM techniques. In the first case, resection of the mandibular body and ramus was carried out, and reconstruction with a vascularised iliac bone transplant was performed. During surgery, a repositioning of the ipsilateral condyle was necessary. The second case comprised a wide mandibular reconstruction together with a repositioning of the condyles and the soft tissue chin using a two-segment osteomyocutaneous fibula flap. In the third case, a two-flap technique consisting of a double-barrelled osseous fibula flap and a radial forearm flap was applied to cover a wide palatine defect. CONCLUSION: Our experience suggests that the CAD/CAM technique provides an accurate and useful treatment not only in complex cases, but also in simpler ones, to achieve an anatomically correct shape of the bone transplant and to reposition adjacent structures.

Clinical course and implications of congenital nasal pyriform stenosis and solitary median maxillary central incisor in a newborn: a case report.

INTRODUCTION: Congenital nasal pyriform aperture stenosis and solitary median maxillary central incisor are uncommon anomalies and are associated with further malformations. Solitary median maxillary central incisor itself has initially no impact on a child's health, but congenital nasal pyriform aperture stenosis is a potentially life-threatening condition. CASE PRESENTATION: A Caucasian baby boy showed severe dyspnoea and was intubated orotracheally. Multiple anomalies were detected, including urogenital and craniofacial malformations. Computed tomography scans revealed congenital nasal pyriform aperture stenosis with a diameter of 4.9mm and a solitary median maxillary central incisor. A 3.0mm tube was inserted in his left nasal cavity, and the baby was able to breathe sufficiently and spontaneously. The nasal tube was removed after seven days, and the baby was discharged under application of decongestant drops. After seven months, the baby was readmitted with respiratory distress, and surgery was carried out using an intraoral sublabial approach. The stenotic area of the pyriform aperture was widened, and 3.0mm tubes were inserted in both nasal cavities for 10 days. Over a period of six months, no further respiratory distress has occurred. CONCLUSIONS: The decision to perform surgery was delayed since the baby's nasal breathing was adequate as a result of the insertion of a nasal tube. Since treatment depends on the severity of symptoms, it is appropriate in some cases to take a conservative approach at first, and to keep surgery as a last resort. Once a conservative approach has been selected for congenital nasal pyriform aperture stenosis, awareness of the life-threatening nature of the condition should be kept in mind, and a surgical approach must still be taken into account.