Haemostasis in oral surgical procedures involving patients with a ventricular assist device.

The purpose of this study was to determine whether tooth extraction for patients with ventricular assist devices (VADs) could be performed without interruption of anticoagulant and/or antiplatelet therapy and whether treatment with von Willebrand factor concentrates and desmopressin is required. The study consisted of three groups of patients undergoing oral surgery. The two experimental groups comprised patients with VADs, while the third group included cardiovascular patients without VADs who served as controls. All patients were treated intraoperatively with topical haemostatic agents (oxidized cellulose or collagen). The first group was additionally treated with fibrin glue. All 75 oral surgical procedures were performed under local anaesthesia without sedation. Three of 40 patients in the experimental groups and two of 20 patients in the control group suffered a haemorrhage, with no significant difference in the incidence of haemorrhage between the groups. The findings suggest that dental extraction can be performed without modification of oral anticoagulation or antiplatelet treatments, providing that INR is less than 3.5 on the day of the operation. It can further be hypothesized that an acquired coagulopathy in VAD patients does not influence the bleeding risk in dental extractions, and so the administration of desmopressin and/or von Willebrand factor concentrates is not required.

Maturation of capillary-like structures in a tube-like construct in perfusion and rotation culture.

In an effort to engineer capillary-like networks in vitro, different cultivation methods were compared. Five small-diameter tube-like constructs ('vessel equivalents') were fabricated from porcine gelatin scaffolds and seeded with human adipose tissue stromal cells and umbilical vein endothelial cells. After initial growth, the vessel equivalents were divided. One segment was exposed to pulsatile perfusion and the other was kept in rotating culture. Specimens harvested at the start of the experiments and after 16 days of rotation or perfusion were compared histomorphometrically with respect to capillary-like network formation in the vessel wall. Most capillary-like structures were found in the luminal portion of perfused vessel equivalents. Maturation of these capillary-like structures ascertained by recruitment of alpha-actin-positive cells also reached the highest degree in the luminal portion of perfused specimens. Perfused specimens showed significantly less apoptosis. Pulsatile perfusion promotes the development and maturation of a capillary-like network in this in-vitro approach.

Candidate Genes for Nonsyndromic Cleft Palate Detected by Exome Sequencing.

Nonsyndromic cleft palate only (nsCPO) is a facial malformation that has a livebirth prevalence of 1 in 2,500. Research suggests that the etiology of nsCPO is multifactorial, with a clear genetic component. To date, genome-wide association studies have identified only 1 conclusive common variant for nsCPO, that is, a missense variant in the gene grainyhead-like-3 ( GRHL3). Thus, the underlying genetic causes of nsCPO remain largely unknown. The present study aimed at identifying rare variants that might contribute to nsCPO risk, via whole-exome sequencing (WES), in multiply affected Central European nsCPO pedigrees. WES was performed in 2 affected first-degree relatives from each family. Variants shared between both individuals were analyzed for their potential deleterious nature and a low frequency in the general population. Genes carrying promising variants were annotated for 1) reported associations with facial development, 2) multiple occurrence of variants, and 3) expression in mouse embryonic palatal shelves. This strategy resulted in the identification of a set of 26 candidate genes that were resequenced in 132 independent nsCPO cases and 623 independent controls of 2 different ethnicities, using molecular inversion probes. No rare loss-of-function mutation was identified in either WES or resequencing step. However, we identified 2 or more missense variants predicted to be deleterious in each of 3 genes ( ACACB, PTPRS, MIB1) in individuals from independent families. In addition, the analyses identified a novel variant in GRHL3 in 1 patient and a variant in CREBBP in 2 siblings. Both genes underlie different syndromic forms of CPO. A plausible hypothesis is that the apparently nonsyndromic clefts in these 3 patients might represent hypomorphic forms of the respective syndromes. In summary, the present study identified rare variants that might contribute to nsCPO risk and suggests candidate genes for further investigation.

The adenoid cystic carcinoma. Special aspects of its growth and therapy.

In spite of its rare incidence the adenoid cystic carcinoma must be treated with respect because of its hidden malignant character. In 5 out of 21 patients recurrences occurred much longer than 5 years after the first operation. The extension of this tumour along branches of the trigeminal nerve could be well demonstrated in 7 of our patients where we were able to produce histological proof or radiographic evidence. The theory of tumour growth along the "tissue of least resistance" is illustrated by a special case report. As for the therapy, ultra-radical surgery has proved to be the most effective so far, whereas radio- or chemotherapy were only useful as palliative measures.

Obstructive sleep apnoea syndrome: results and conclusions of a principal component analysis.

A cephalometric analysis according to Hasund, supplemented by special obstructive sleep apnoea syndrome (OSAS) parameters, was performed on 169 patients who had been referred from the sleep laboratory. Statistical analysis showed a correlation between specific cephalometric landmarks including posterior airway space (PAS), a soft palate length, hyoid position and posterior growth development of the mandible and OSAS severity. A principal component analysis differentiated between four subgroups of OSAS patients: (1) orthognathic obese subjects; (2) patients with a long soft palate and low-positioned hyoid; (3) retrognathic patients with narrow PAS; and (4) prognathic ones. Lateral cephalometry is an important contribution to OSAS diagnostics and oral and maxillofacial therapy procedures.

Endoscopically assisted intraoral mandibular distraction osteogenesis.

Correct placement of intraoral devices for mandibular distraction osteogenesis is important to achieve the ideal vector of distraction. As visual inspection and intraoperative management in the inferior mandibular border or at the posterior ascending ramus is impaired, an endoscopically assisted method is presented. Since the introduction of this new technique operation time and ease have been significantly improved.

Long-term results in treating squamous cell carcinoma of the lip, oral cavity, and oropharynx.

At the department of Maxillofacial Surgery of the University of Münster, squamous cell carcinomas of the lip, oral cavity, and oropharynx are treated according to the principle of surgical resection of the tumour and, if indicated, radical neck dissection. In cases of lymph node infiltration, additional radiotherapy is given. The data of 352 patients, treated within 15 years, were evaluated with regard to 5-year minimal survival rate and to the incidence of recurrences in correlation to the tumour stages and form of treatment.

Impact of short-time nasal intubation on postoperative respiration.

Until now few data on postoperative nasal respiration after nasal intubation is known which is of special importance for surgery, where postoperative intermaxillary fixation is necessary. This study was planned to acquire information about nasal breathing during the first postoperative week. Twelve patients treated for mandibular retrognathism were examined repeatedly by way of anterior active rhinometry, acoustic rhinometry, and rhinoresistometry before and after surgery over one week. In addition the subjective evaluation was checked on a visual analogue scale. Following intubation, significant changes in "objective" and subjective measurements of nasal respiration could be noted only on the second postoperative day. Comparing rhinomanometric and subjective data, a correlation could be found on postoperative day two only. In this study group short-time nasal intubation had no significant impact on postoperative respiration.

A novel modular retention system for midfacial distraction osteogenesis.

Distraction osteogenesis of the midface offers new possibilities for the treatment of large sagittal discrepancies between the upper and lower jaws. The use of an extraoral halo-borne distractor, which allows free three-dimensional vector control, may cause problems in the connection between the midface and the distractor. To overcome these difficulties, we present a new modular retention system to gain bone anchorage whenever a toothborne appliance is not suitable. Distraction osteogenesis with an extraoral appliance is therefore possible even in edentulous elderly patients. We have used this system successfully in 11 patients.

Strong association of variants around FOXE1 and orofacial clefting.

Nonsyndromic orofacial clefting (nsOFC) is a common, complex congenital disorder. The most frequent forms are nonsyndromic cleft lip with or without cleft palate (nsCL/P) and nonsyndromic cleft palate only (nsCPO). Although they are generally considered distinct entities, a recent study has implicated a region around the FOXE1 gene in both nsCL/P and nsCPO. To investigate this hypothesis, we analyzed the 2 most strongly associated markers (rs3758249 and rs4460498) in 2 independent samples of differing ethnicities: Central European (949 nsCL/P cases, 155 nsCPO cases, 1163 controls) and Mayan Mesoamerican (156 nsCL/P cases, 10 nsCPO cases, 338 controls). While highly significant associations for both single-nucleotide polymorphisms were obtained in nsCL/P (rs4460498: p Europe = 6.50 × 10(-06), p Mayan = .0151; rs3758249: p Europe = 2.41 × 10(-05), p Mayan = .0299), no association was found in nsCPO (p > .05). Genotyping of rs4460498 in 472 independent European trios revealed significant associations for nsCL/P (p = .016) and nsCPO (p = .043). A meta-analysis of all data revealed a genomewide significant result for nsCL/P (p = 1.31 × 10(-08)), which became more significant when nsCPO cases were added (p nsOFC = 1.56 × 10(-09)). These results strongly support the FOXE1 locus as a risk factor for nsOFC. With the data of the initial study, there is now considerable evidence that this locus is the first conclusive risk factor shared between nsCL/P and nsCPO.

Fibular flap for mandibular reconstruction: are there old tricks for an old dog?

Fibular free flap is considered as an "old dog" in reconstructive surgery because it was first described by Taylor and his colleagues in 1975, and was then introduced for mandibular reconstruction by Hidalgo in 1989. There are some "tricks" for fibular free flap that have been used and recognized in many European maxillofacial surgical units over the past decade. These include: 1) harvesting the distal fibula when recipient vessels are distant; 2) flap selection based on the anatomy of perforators; 3) use of the skin paddle for postoperative flap monitoring; 4) protection of the flap's soft-tissue cuff; 5) preventing venous thrombosis which is essential to reduce flap complications; 6) aligning fibular struts and protecting the vascular pedicle when the double-barrel technique is used; 7) minimizing the gap between the double-barrel struts and implementing a long-term follow-up of dental implants; 8) selecting osteosynthesis materials; and 9) learning curve and clinical competence in microvascular reconstruction. We also reviewed current data from the literature, which would be useful for maxillofacial reconstructive surgeons. With these tricks, one can teach an "old dog" "old tricks".

Columellar flap for secondary cleft rhinoplasty with esthetic improvement of Millard's unilateral cheiloplasty scar.

INTRODUCTION: Columellar cartilage graft helps improve esthetic results in secondary cleft rhinoplasty for patients presenting with cleft lips. However, inadequate skin coverage of the cartilaginous graft can result in columellar necrosis and graft loss. Moreover, the scar after Millard's primary cheiloplasty may not be esthetic. The aim of this article was to present the columellar flap technique to cover the columellar graft and to improve the scar after unilateral Millard's cheiloplasty. TECHNICAL NOTE: The triangular flap is drawn on the edge of Millard's cheiloplasty scar. It is then moved in a V-Y fashion so as to cover the cartilaginous graft and improve the esthetic aspect of the new columella. DISCUSSION: Four hundred and twelve teenage/adult rhinoplasties were performed in our department over 10 years (October 2001 to October 2011). This flap was used in 10 patients who were followed-up for at least 1 year. There were no severe postoperative complications. Millard's unilateral cheiloplasty scar was less visible. A prospective study is ongoing.

Transient finite element analysis of a traumatic fracture of the zygomatic bone caused by a head collision.

Midfacial fractures rank first concerning maxillofacial traumatology. Collisions of two heads or head to object are the main causes for these fractures. An investigation based on a transient simulation using the finite element method was performed. A biomechanical head model was created and tested. A transient collision of two heads was simulated. The results were compared to a typical real patient case. This comparison revealed an identical fracture pattern, which can be interpreted as a clinical match of the simulation. The results of this study show the validity of biomechanical investigations, which may serve as a method to better understand maxillofacial fracture patterns. These results will be used for the optimization of fracture therapy or trauma prevention in the future.

An analysis of studies on piezoelectric surgery in the oral and craniomaxillofacial region with regard to human subject protection and financial conflicts.

This retrospective, observational study investigated whether published studies on the use of piezoelectric surgery (PS) in the oral and craniomaxillofacial region fulfilled the requirements of the International Committee of Medical Journal Editors (ICMJE) and the Declaration of Helsinki (DoH) with respect to human subject protections (HSP) and disclosure of financial conflicts (FC). A Medline/PUBMED search was performed in April 2008 to identify all clinical studies on PS, published in English, French and German. Disclosure of HSP (obtaining ethical approval and subjects' informed consent) and FC mentioned in the retrieved articles were analysed. 29 clinical articles were identified in 18 journals, of which 14 journals (78%) required the disclosure of both HSP and FC. Ethical approval was documented in two studies (7%); patient consent was reported in four publications (14%). Four articles disclosed no FC. 21 reports (72%) mentioned neither HSP nor FC. The relationships between funding source and study outcomes could not be identified. Most studies on the use of PS hardly adhered to the regulations recommended by the ICMJE and DoH, and do not mention HSP and FC, indicating the study results with a high degree of suspicion. It is recommended that oral and craniomaxillofacial surgery journals adhere strictly to these regulations because they carry a heavy responsibility regarding the scientific integrity of publications in this specialty.

Reporting of ethical protection in recent oral and maxillofacial surgery research involving human subjects.

This retrospective observational study investigated the frequency of reporting ethical approval and informed consent in recently published oral and maxillofacial surgery (OMS) research involving human subjects. All research involving human subjects published in the International Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, and Journal of Cranio-Maxillofacial Surgery during January to June 2005-2007 were analysed for disclosure of ethical approval by a local ethical committee and obtaining informed consent from the subjects. 534 articles were identified; ethical approval was documented in 118 (22%) and individual patient consent in 135 (25%). 355 reports (67%) did not include a statement on ethical approval or informed consent and only 74 reports (14%) disclosed statements of both. Ethical documentation in retrospective and observational studies was scant; 12% of randomised controlled trials and 38% of non-random trials did not report both of ethical protections. Most recent OMS publications involving humans failed to mention ethical review or subjects' consent. Authors must adhere to the international research ethics guidelines and journal instructions, while editors should play a gatekeeper role to protect research participants, uphold scientific integrity and maintain public trust in the experimental process and OMS profession.

[Nasal dermoid sinus cyst: accidental coincidence or syndrome association?]. / Nasendermoide bei Peters-Plus-Syndrom: Zufall oder Syndromexpression?

BACKGROUND: Peters anomaly is a rare congenital glaucoma disease. The Peters' plus syndrome is characterized by distinct malformations. As some of the common craniofacial malformations like cleft lip and palate are frequent in Peters' plus syndrome, no nasal dermoid sinus cysts has been reported so far. Nasal dermoid sinus cysts usually present in isolation, although associations to other anomalies or syndromes are possible. The occurrence of such an anomaly may be either accidental, or present a syndrome association. PATIENTS AND METHOD: One patient with an unilateral cleft lip and Peters' plus syndrome had undergone removal of nasal dermoid sinus cyst previously and was referred for management of recurrent disease. Complete surgical removal and plastic reconstruction was performed. RESULTS: Concerning the common (lateral) cleft lip nasal deformity with no midline nasal masses, there are reasons for the assumption that a coincidence of both anomalies might be accidental. Especially in Peters' plus syndrome no occurrence of nasal dermoids has thus far been documented. However, the embryological pathway of the frontonasal region differs from lip and palate development in time and location: So unique formation of both lesions seems inconsistent. Complete surgical removal and plastic reconstruction simultaneously or in a second step are recommended. CONCLUSION: As two cases of arhinia and Peters anomaly have been described in 1978, midline nasal masses might be a possible appearance of Peters' plus syndrome.

Management of osteoradionecrosis of the jaws: an analysis of evidence.

AIM: To review and discuss the management of jaw bone osteoradionecrosis (JORN) based on levels of evidence. METHODS: The Medline/PUBMED and Cochrane search was performed to identify all studies on the management of JORN, published in English, French, and German during January 1975-October 2007. Only clinical researches were identified and classified into four levels of evidence before being examined. All references of the retrieved articles were analysed. FINDINGS: Seventy three articles and their additional 45 citations were evaluated. Most of the eligible literature provided observational evidence. Hyperbaric oxygen therapy (HBOT) is an adjunct; however, its clinical usefulness remains controversial. A conservative approach should be limited to early-onset JORN, while radical surgery is indicated for an advanced or refractory lesion. Free tissue transfer is the reconstruction of choice for large defects without the need of HBOT. Some new technologies have also been studied, including ultrasound, biological molecules, distraction osteogenesis and antioxidant agents. CONCLUSIONS: Most of the reports on the treatment of JORN offer weak evidence. Current information seems insufficient for establishing the definite treatment guideline; thus, well-designed studies with long-term clinical data are encouraged.