Odontogenic deep neck space infection as life-threatening condition in pregnancy.

Odontogenic deep neck space infections represent a severe disease with possible life-threatening complications. Despite knowledge of these infectious diseases, treatment remains a challenge for every maxillofacial surgeon. Therapy of severe neck infections is even more crucial during pregnancy because of the possible life-threatening situation for both the mother and the foetus. The possible compromise of oral health during pregnancy is well known, however severe odontogenic infections are rarely considered in the literature. The following case report describes the dramatic course of a deep neck space infection in a pregnant patient, commencing with typical symptoms of localized odontogenic infection and ending in a critical, life-threatening condition for the patient and a lethal condition for the foetus. The case represents the first description of intrauterine, foetal death caused by a deep neck space infection. Implications for dental and medical treatment during pregnancy, especially regarding odontogenic infections, are presented and discussed with findings in the international literature.

Looking for landmarks in medial orbital trauma surgery.

Knowledge of the precise location of anatomical landmarks such as the anterior (AEC) and posterior ethmoid (PEC) canals facilitates medial orbital wall surgery and is of major importance for the protection of the orbital nerve. The aim of this study was to identify these anatomical structures in 100 consecutive CT scans and measure the distance between them. The authors investigated whether a predictable symmetry existed between the left and right side. The AEC was not identified unilaterally in one patient, the PEC was not identified unilaterally in six patients and not bilaterally in one patient. An additional PEC was found unilaterally in 12 and bilaterally in five patients. If an anatomical structure was found bilaterally, the authors obtained a strong Pearson's correlation between the sides (r=0.798-0.903, p<0.001). An anatomical variation was found in nearly every fourth patient. The authors think that these data call into question the use of the PEC and AEC as reliable surgical landmarks in medial orbital surgery.

Necrotizing periodontitis as a possible manifestation of common variable immunodeficiency.

Common variable immunodeficiency (CVID) is an inherited disease characterized by hypogammaglobulinaemia and impaired humoural immunoresponse and is mainly associated with recurrent infections of the airway and the digestive tract. An 18-year old female with a diagnosis of CVID associated with a devastating necrotizing periodontitis, ultimately resulting in complete destruction of the periodontium and loss of all teeth, is reported. Clinical, biochemical, microbiological and radiographic examinations are presented. The report highlights the likely importance of immunoglobulin replacement and intensive dental hygiene in CVID patients, and the devastating effect of non-compliance in such patients.

Fourier transform infrared imaging analysis in discrimination studies of squamous cell carcinoma.

Oral squamous cell carcinoma (OSCC) of the oral cavity and oropharynx represents more than 95% of all malignant neoplasms in the oral cavity. Histomorphological evaluation of this cancer type is invasive and remains a time consuming and subjective technique. Therefore, novel approaches for histological recognition are necessary to identify malignancy at an early stage. Fourier transform infrared (FTIR) imaging has become an essential tool for the detection and characterization of the molecular components of biological processes, such as those responsible for the dynamic properties of tumor progression. FTIR imaging is a modern analytical technique enabling molecular imaging of a complex biological sample and is based on the absorption of IR radiation by vibrational transitions in covalent bonds. One major advantage of this technique is the acquisition of local molecular expression profiles, while maintaining the topographic integrity of the tissue and avoiding time-consuming extraction, purification, and separation steps. With this imaging technique, it is possible to obtain unique images of the spatial distribution of proteins, lipids, carbohydrates, cholesterols, nucleic acids, phospholipids, and small molecules with high spatial resolution. Analysis and visualization of FTIR imaging datasets are challenging and the use of chemometric tools is crucial in order to take advantage of the full measurement. Therefore, methodologies for this task based on the novel developed algorithm for multivariate image analysis (MIA) are often necessary. In the present study, FTIR imaging and data analysis methods were combined to optimize the tissue measurement mode after deparaffinization and subsequent data evaluation (univariate analysis and MIAs). We demonstrate that it is possible to collect excellent IR spectra from formalin-fixed paraffin-embedded (FFPE) tissue microarrays (TMAs) of OSCC tissue sections employing an optimised analytical protocol. The correlation of FTIR imaging to the morphological tissue features obtained by histological staining of the sections demonstrated that many histomorphological tissue patterns can be visualized in the colour images. The different algorithms used for MIAs of FTIR imaging data dramatically increased the information content of the IR images from squamous cell tissue sections. These findings indicate that intra-operative and surgical specimens of squamous cell carcinoma tissue can be characterized by FTIR imaging.

High resolution ultrasound investigation of the temporomandibular joint in patients with chronic polyarthritis.

40 patients with chronic polyarthritis were investigated prospectively. The TMJ was investigated to detect clicking, crepitation, and pain. High resolution ultrasound (HR-US) assessed destructive changes, effusion, and disc dislocation. The results of the clinical investigation and the HR-US investigation were compared using the χ(2) test. The statistical calculation of the correlation between the HR-US results and the clinical TMJ investigation by the χ(2) test showed a significant correlation between TMJ sounds, destructive changes and disc dislocation. A significant correlation between TMJ joint effusion, TMJ pathology and TMJ pain was detected using the χ(2) test. Pain on palpation of the masseter and temporal muscle correlated significantly with TMJ effusion. There was significant correlation between TMD and the HR-US diagnosis of destructive changes and effusion. The significant correlation between TMJ effusion and actual TMJ pain and TMJ pain on palpation shows the ability of HR-US to detect acute TMJ affection with high significance. There was a significant correlation between effusion and pain on palpation of the masticatory muscles, which could be interpreted as the ability of HR-US to determine acute TMD. That any TMD correlated significantly with destructive changes and TMJ effusion suggests that HR-US could detect chronic and acute TMD.

Complications related to midfacial fractures: operative versus non-surgical treatment.

The treatment of midfacial fractures depends on the dislocation of the fracture and patient-related limitations. Surgical treatment risks iatrogenic complications. In 740 patients with midfacial fractures, the age, sex, fracture type, concomitant injuries, cause of accident and the decision to use operative or non-surgical treatment were recorded. Follow-up was performed 6 and 12 months after the injury. In 41% the fractures were isolated; they were multiple in 59%. Initially, hypaesthesia of the infraorbital nerve was present in 10% of the single and 16% of the multiple fracture patients. Surgical treatment was performed in 57% of the single and in 75% of the multiple fracture patients. Women underwent surgical treatment considerably less frequently than men. After 6 and 12 months, significantly more complications were present in the surgically treated cohort. Nerve disturbances and 'meteorosensitivity' were most prominent. These results, together with previous findings, indicate that there is a need for prospective clinical investigations that fulfil the criteria of evidence-based medicine to generate guidelines for decision making in trauma surgery. In the meantime, the decision to use surgical treatment for midfacial fractures has to be made carefully.

The impact of ageing on cranio-maxillofacial trauma-a comparative investigation.

The number of patients older than 65 is increasing in developed societies. The impact of age on injuries and their outcome has been well documented in several fields of traumatology. Data on a broad cohort suffering from oral and maxillofacial injuries are missing. In this study, the data of 12,572 such patients were collected, of which 11,798 were younger and 774 were older than 65 years. With increasing age the risk of a domestic accident increased. The accident mechanism in elderly people was most frequently a fall (72%) or was not reproducible (12%). There was a significant difference between groups regarding concomitant injuries. Additional neurological symptoms occurred in 26% of the older and 15% of the younger patients (P<0.001). Until the age of 65 the risk of concomitant neurological injury increases. Injuries in the older patients mainly affected the soft tissue and midface. No statistical differences in surgical postoperative complications were observed. Due to the changing face of society, the treatment of elderly people is of high relevance. To enable an independent life after trauma, pre- and post-therapeutic care is of major importance. These data support surgical treatment of all patients, regardless of age, driven by general health condition whenever possible.

[Dentoalveolar trauma. Analysis of 4763 patients with 6237 injuries in 10 years]. / Dentoalveoläre Traumen. Analyse von 4763 Patienten mit 6237 Verletzungen in 10 Jahren.

PURPOSE: The purpose of this study was to evaluate the overall place of dental trauma in facial injuries. This was a retrospective investigation based on the analysis of a large amount of dentoalveolar injuries over a 10-year period. PATIENTS AND METHODS: Between 1991 and 2000, 4763 of 9543 patients suffering from oral and maxillofacial injuries, sustained dentoalveolar trauma. Records of 6237 different dental injury patterns were reviewed according to the five main injury mechanisms: age, sex, type of injury, cause of accident, and frequency of dentoalveolar trauma. They were statistically analyzed using frequency distribution, chi-square test, t-test, Mann-Whitney U test, Kolmogorov-Smirnov test, and logistic regression analysis. RESULTS: Household and play (2117), sports (1533), traffic accidents (438), acts of violence (426), and work-related accidents (201) were noted. A total of 4763 patients had 2988 subluxations, 2356 showed crown fractures, 444 had avulsions, 176 root fractures, 154 intrusions, and 119 patients suffered from concussions. This number of patients accounts for the prevalence of 49.9% for dentoalveolar trauma among all facial injuries. CONCLUSION: Only the analysis of a large number of injuries reveals the risk of suffering from dentoalveolar trauma. Due to this fact, preventive methods can be recommended and demanded more effectively.

[Genioplasty alone and in combination. Long-term results with emphasis on sensitivity and photoanalysis]. / Kinnosteotomie isoliert und in Kombination. Langzeitergebnisse unter besonderer Berücksichtigung der Sensibilität und der Fotoanalyse.

PURPOSE: Striving for beauty and expressiveness is a deeply rooted human attitude. The lower jaw-especially the mentum-plays an important role in the perception of the face as an instrument of communication. According to Grammer a distinctive lower jaw is an essential characteristic feature of male attractiveness. MATERIAL AND METHODS: During a period of 10 years 58 patients underwent genioplasty. A follow-up examination was performed in 49 patients (complete sensitivity evaluation: 33 patients, complete photoanalysis: 30 patients). To reduce radiation due to cephalometric radiography a simple photometric method for cephalometry was developed and applied. Particular attention was directed at sensitivity of the mental nerve after genioplasty. RESULTS: To the best of our knowledge, this is the first time that photos of the right profile were compared with those of the left side. Unexpectedly, intraindividual differences dependent on the facial side (right and left) could be found in the relationship of the lower to the upper face and in the proportion of the profile angle and the nasomental angle. After three-dimensional genioplasty these differences were reduced and facial asymmetry was improved. Comparing the right with the left side the average difference of the nasomental angle was reduced from 2.5 degrees to 0.6 degrees on average. The profile angle was changed by genioplasty from 19 degrees on average to 15 degrees ("ideally" 10 degrees , the so-called upright face). According to Schwarz the ideal height of the mentum (stomion-menton) should amount to 66% of the total lower face. Especially by combined dorsal and cranial positioning of the mentum a reduction from 85 to 68% was achieved. Postoperatively 24 of 33 patients (73%) showed disturbances of the mental nerve. After at least 1 year following the operation, normal sensitivity of the lower lip and chin of both sides was evaluated by almost all of these patients (19 of 24 = 79%). Especially all patients having had only a single genioplasty recovered totally from a neurosensory deficit. CONCLUSIONS: Genioplasty can be considered to be a reliable procedure to achieve harmony of the lower face.

[Applying an osteoinductive protein complex for regeneration of osseous defects]. / Anwendung eines osteoinduktiven Proteinkomplexes zur Regeneration knöcherner Defekte.

INTRODUCTION: Growth factors are still not commercially available for routine clinical use. One possibility might be the application of Colloss, which is supposed to have osteoinductive properties. Therefore, it was the aim of the following animal experimental study to compare Colloss with autogenous bone and to investigate its osteoproductive potential. MATERIAL AND METHODS: In 24 pigs clinically relevant defects were created in the forehead area. Defects were filled with autogenous bone and Colloss. One defect was left unfilled and served as control. After 2, 4, 12 and 26 weeks, six animals were sacrificed and microradiography, light microscopy and immunohistochemistry were carried out using BMP-2 and osteocalcin as antibodies. RESULTS: After 2 weeks the defects filled with the bovine protein complex showed a mineralization of 52.6% +/-4.03 compared to autogenous bone (38% +/-9.9; p=0.068) and the control defect (30% +/-2.94; p=0.05). After 4 weeks the results became assimilated. Light microscopy revealed especially after 2 weeks an enhanced de novo bone formation in the Colloss-group. This was also evident in an early expression maximum of BMP-2 after 2 weeks. Autogenous bone and the control defect showed a later expression maximum. CONCLUSION: Colloss showed an acceleration of bone regeneration in the early phase. Nevertheless, after 26 weeks the results were comparable with the autogenous bone group.

Bone regeneration in critical size defects by cell-mediated BMP-2 gene transfer: a comparison of adenoviral vectors and liposomes.

Large bone defects resulting from nonunion fractures or tumour resections are common clinical problems. Recent studies have shown bone morphogenetic protein-2 (BMP-2) gene transfer using adenoviral vectors to be a promising new therapeutic approach. However, comparative studies of different vectors are required to identify the optimal system for possible clinical trials. This study compares the use of liposome-mediated and adenoviral gene transfer for the generation of autologous BMP-2-producing bone marrow stromal cells (BMSC). Primary BMSC isolated from the rat femur were treated ex vivo with either an adenovirus or a liposome carrying human BMP-2 cDNA. The genetically modified cells were evaluated in vitro and transplanted into critical size defects in the rat mandible in vivo. BMSC treated with a reporter gene vector or untreated BMSC served as controls. The newly formed tissue was analysed by in situ hybridization, radiography and immunohistochemistry. Both groups of genetically modified cells produced BMP-2 for at least 2 weeks, and markers of new bone matrix such as osteopontin and osteocalcin were observed within 2 weeks following gene transfer. In the liposome group, the critical size defects were found completely healed at 6 weeks after the gene transfer, whereas the more efficient adenoviral gene transfer allowed for complete bone healing within 4 weeks. None of the three control groups showed bone healing, not even after 8 weeks. Thus, both liposome-mediated and adenoviral BMP-2 gene transfer to primary BMSC are suitable methods to achieve the healing of critical size bone defects in rats. As liposomes have proven sufficient for this purpose and offer several advantages over any other vector, such as ease of preparation, theoretically no limitation of the size of the DNA, and less immunological and safety problems, they may represent the best vector system for future clinical trials of bone regeneration by BMP-2 gene therapy.

[Osseous defect regeneration using autogenous bone alone or combined with Biogran or Algipore with and without added thrombocytes. A microradiologic evaluation]. / Tierexperimentelle Untersuchung zum Einfluss verschiedener Thrombozytenkonzentrate auf die Defektregeneration mit autogenem Knochen und Kombinationen von autogenem Knochen und Knochenersatzmaterialien (Biogran und Algipore). Mikroradiographische Ergebnisbewertung.

In addition to autogenous bone, a variety of bone substitute materials is used to regenerate bony defects. The aim of the study was to evaluate the reossification of critical size defects in the os frontale of adult pigs ( n=16) with microradiography. The defects were filled randomly with autogenous bone or the bone substitute materials Algipore and Biogran each combined with a defined quantity of autogenous bone. Additionally, platelet-rich plasma (PRP) was added in defined quantities (0.5 ml) in two different concentrations (4-fold and 6.5-fold). At 2, 4, 12, and 26 weeks four animals were sacrificed and the osseous regeneration documented by quantitative evaluation of the microradiographic findings. Microradiographic results in the autogenous bone group showed an earlier PRP concentration-dependent mineralization. Over the whole observation period the peak value of autogenous bone as filler alone could not be reached in both PRP groups. Using Algipore, no accelerated effect of mineralization however could be observed. In our study, Biogran proved to be a defect filler only partially suitable for bony defect healing, no matter whether PRP was added or not.

Degradation characteristics of alpha and beta tri-calcium-phosphate (TCP) in minipigs.

In seven Goettingen minipigs 3.5--4.7-ml cancellous bone defects were created in the area of the tibial head on both sides. The defects were filled with alpha-TCP or beta-TCP (tricalciumphosphate). ITI implants (Straumann, Freiburg, Germany) of 3.2 x 12-mm length were inserted into the underlying ceramic substitutes. Two additional pigs were used as control. Within the periods of observation (4, 16, 20, 28, 46, 68, and 86 weeks) fluorescent dyes were applied. Nondecalcified thin-sliced sections were examined by means of light and fluorescence microscopy. In addition microangiography and microradiography were performed. Bony regeneration occurred basally and on the sides of the defect according the angiogenetic reossification pattern. Resorption was due to a hydrolytic and cellular degradation process. After 46 weeks histomorphological evaluation showed an incomplete osseointegration of the simultaneously implanted dental implants. The bone contact surface ratio was lower than 25%. After 86 weeks 95--97% of both alpha- and beta-TCP were resorbed. Ceramic residuals stayed within the newly formed trabeculae thus resisting further degradation until remodeling occurred. Both alpha- and beta-TCP show a comparable degradation process. At the 86-week postoperative point only small residuals of the ceramic can be found. These residuals stay within the newly formed trabeculae, which show a functional orientation. In comparison control defects showed only sparse reossification. The beta-TCP material shows an accelerated degradation mode and has an optimal reactivity with the surrounding tissues. According to the results of this animal experiment both materials can be classified as bone-rebuilding materials.

Morbidity of harvesting of chin grafts: a prospective study.

In a prospective study, 20 patients who underwent harvesting of chin grafts as outpatients, were followed up for 12 months (3 further patients with incomplete follow-up data were excluded from the study). Preoperatively and 7 days, 1, 3, 6 and 12 months postoperatively, follow-up data were assessed. Evaluation of the superficial sensory function of the inferior alveolar nerve was determined by the Pointed-Blunt Test and the Two-Point-Discrimination Test. Sensory disturbances were objectively assessed by testing thermal sensitivity with the "Pain and Thermal Sensitivity" Test (PATH Test). In addition, evaluation of the pulp sensitivity of teeth 35-45 was carried out by cold vitality testing. One week postoperatively, 8 patients were affected by superficial sensory impairment. 8 nerve territories showed hypoaesthetic reactions and 5 showed hyperaesthetic reactions. After 12 months, two patients still suffered from hypoaesthesia of one side of the chin. There was a statistically significant sensitivity impairment of the chin for all patients comparing the preoperative data of the Two-Point-Discrimination Test (left/right median: 8.17/8.17 mm, interquartile range (IQR) 1.00/2.00 mm) with the first postoperative measurement (left/right median 9.00/8.33 mm, IQR 1.67/2.66 mm). Comparing the latter to the last postoperative measurement there was significant tendency for regeneration of a nerve function (left/right median 8.00/7.84 mm, IQR 0.66/2.00 mm). In the PATH Test all hypoaesthetic areas could be identified by a reduction of thermal sensitivity. After the first postoperative examination 21.6% (n=38/176) of the examined teeth had lost their pulp sensitivity. After 12 postoperative months 11.4% (n=20/176) still did not react sensitively. Many of these were canines (n=8/20). Comparing the preoperative to the first postoperative examination, there was a significant reduction of pulp sensitivity. However, statistically significant recovery until the last postoperative follow-up could not be detected. The assessed data show that patients have to be informed extensively about disturbances of the inferior alveolar nerve function lasting longer than 12 months. Moreover, the loss of pulp sensitivity is a very frequent event which has always to be taken into account. Considering the high rate of complications with harvesting of chin grafts, more prospective trials should be done to find out whether there are other donor sites for autogenous bone which put less strain on patients.

Correlation of telomerase activity, clinical prognosis and therapy in oral carcinogenesis.

Telomerase activity is associated with most malignant tumors. To evaluate the role of telomerase reactivation as a diagnostic and prognostic marker in oral carcinogenesis activity was investigated in mortal and immortal cell lines in eight oral leukoplakias (OL) and 46 oral squamous cell carcinomas (OSCC). Activity was also investigated in 13 histopathologically unaffected mucosas from distant sites or tumor-free margins of the same patients using a modified, highly sensitive, non-radioactive telomeric repeat amplification protocol (TRAP). This was correlated with histopathological stages and the clinical course of the disease. 50% of OL and 46% of OSCC showed activity. One patient with positive, high dysplastic OL developed an OSCC 11 month later. One of three specimens of adjacent tissue presented activity and a recurrence occurred after 6 months. Out of 10 tissues of distal normal mucosa, 2 demonstrated activity which could also be proved in the corresponding tumor. Detection of telomerase reactivation may be a novel method for early detection of immortalised cell clones and malignant cells in histopathologically normal oral squamous epithelium.