Cleft lip and palate: the psychological burden of affected parents during the first three years of their children's lives.

The surgical treatment of cleft lip and palate (CLP) has been well described in the literature. Nevertheless, little is known about the psychological burden of affected parents. The aim of this study was to investigate the psychological burden in parents of children with CLP within the first 3 years of the children's lives. A standardized questionnaire (Parenting Stress Index, PSI) was administered to 33 parents of children with CLP to evaluate their psychological burden. The corresponding interview was conducted independent of any operative procedure during the yearly routine CLP consultation. Each participant's stress profile was assessed and compared with the average values of parents with non-cleft children. Psychological stress was substantially increased in all participants when compared to the parents of healthy children. This result was highly significant (P < 0.001). Parent depression (P < 0.001) and child-related requirements (P < 0.001) were the most critical subscales in the stress profile. Overall, the child-related burden was greater than the parent-related burden. These results indicate that parents of children with CLP have a higher level of psychological stress than parents of non-cleft children. This psychological stress might be reduced if addressed by specialist clinical psychologists in cleft-treating centres.

Quantitative analysis of soft tissue sagging after lateral midface fractures: A 10-year retrospective study.

BACKGROUND: Lateral midface fractures occasionally require open reduction and internal fixation to restore function and facial symmetry. However, some patients retain facial asymmetry despite undergoing surgery due to hard tissue displacement or soft tissue sagging. This study aimed to determine the influence of soft tissue sagging on the postoperative facial symmetry. METHODS: We examined the medical records of 590 patients who underwent planned plate removal after lateral midface or zygomatic bone fractures. After applying the inclusion and exclusion criteria, we analyzed 106 cases of lateral midface fractures for hard tissue displacement and soft tissue sagging using pre- and postoperative radiological imaging and postoperative face scanning. RESULTS: We observed significantly larger soft tissue sagging (p < 0.001) and hard tissue displacement (p = 0.006) on the fractured side than on the non-fractured side. There was no correlation between differences in the soft tissue sagging and those in the hard tissue displacement (|rho|=0). Linear regression analysis showed no statistical influence of sex or age group on the soft tissue sagging and hard tissue displacement. CONCLUSION: Therefore, we recommend treating soft tissue sagging as a discrete aspect of midfacial fracture treatment to achieve optimal postoperative facial symmetry. From a clinical perspective, we recommend better soft tissue management during open fracture treatment than focusing mainly on the reduction of bony hard tissues.

Reduction in perioperative blood loss using ultrasound-activated scissors during tumour surgery.

The aim of this study was to compare the effectiveness of Harmonic Focus+ scissors with the conventional surgical method regarding surgical blood loss and transfusion of blood products in the surgical treatment of head and neck tumours. In a retrospective study, the intraoperative blood loss, number of units of transfusion products given, operating time, and inpatient length of stay of 74 patients with squamous cell carcinoma were compared. Patients who underwent classic tumour surgery were compared with a group treated with Harmonic Focus+ scissors. A significantly lower intraoperative blood loss (496.15⬰ml vs 1096.0⬰ml, respectively; P⬰=⬰0.002) and shorter operation time (436.89 minutes vs 493.13 minutes, respectively; P⬰=⬰0.030) were achieved using the Harmonic Focus+ scissors when compared to the classic tumour surgery. Additionally, fewer units of blood products needed to be transfused (administration of red cell concentrates, P⬰<⬰0.001) and the length of stay in the intensive care unit was shorter for patients treated with the Harmonic Focus+ scissors (P⬰=⬰0.009). The study results indicate that the use of Harmonic Focus+ scissors during surgery for cancer of the oral cavity and pharynx is a safe and cost-effective method. This is of paramount importance during a pandemic when medical resources are scarce, including access to blood reserves.

Correction to: Patient-Specific Mandibular Reconstruction Plates Increase Accuracy and Long-Term Stability in Immediate Alloplastic Reconstruction of Segmental Mandibular Defects.

[This corrects the article DOI: 10.1007/s12663-019-01323-9.].

Intraoperative real-time navigation and intraoperative three-dimensional imaging for patient-specific total temporomandibular joint replacement.

Customized solutions for replacement of the temporomandibular joint (TMJ) along with surgical guides enable precise and fast transfer of the virtual plan to the patient. However, these guides lack information on screw vectors and length, and well-defined borders for bony resections towards the medial skull base. This retrospective study was performed to investigate the feasibility and benefit of real-time navigation and intraoperative three-dimensional imaging during total TMJ replacement (TJR), as well as patient clinical outcomes. Between 2016 and 2020, 26 customized prostheses were implanted in 21 patients either with or without real-time navigation and instrument tracking. The clinical, surgical, radiological, and navigational data were analysed. The accuracy of navigation registration with instrument tracking, precision of screw insertion, and implant and screw positions were analysed by fusion of the virtual plan and surgical outcome. Real-time navigation aided orientation during lateral skull base dissection and resection. However, the results of real-time navigation-aided drilling were inconclusive regarding vector and length control. At a mean 15.3±3.0 months of follow-up, average mouth opening had improved from 21.69±2.80mm to 36.40±1.25mm; the average pain score decreased from 6.18±0.74 to 1.06±0.52. Thus, intraoperative real-time navigation for TJR assists lateral skull base dissection and resection.

[Competence and communication in the implementation of computer-assisted surgical planning]. / Kompetenz und Kommunikation bei der Umsetzung computergestützter chirurgischer Planung.

In the past the planning of surgical interventions in oral and maxillofacial surgery was based on the clinical picture with the assistance of conventional 2­dimensional X­ray images. In cases in which the occlusion was affected, plaster cast models of the jaws were included as a planning aid. With introduction of computed tomography (CT) and the possibility to obtain a 3-dimensional picture of bony structures, it was possible for the first time to construct a virtual image of bony structures and therefore of traumatic, iatrogenic and congenital deformities. Using stereolithographic models, these 3­dimensional relationships were easily "understandable". Risks could be better classified in the planning of an operative intervention and these models could be used as a basis for communication. It was also possible to use the data acquired by CT for design and construction of so-called CAD/CAM patient-specific implants and to implant them; however, the resolution of the data sets and thus the level of detail did not yet correspond to the current standard, so that "delicate" structures could not be constructed. With the improvement of the resolution of CT and the possibility of additive construction processes, such as the selective laser melting (SLM) process or the 3D printing process, the improvement of precision and shaping of the implant practically without limits became reality. Through the bundling of competencies on both sides, engineer and physician, complex computer-aided planning has now become possible. The basis for this is precise communication to avoid errors in the planning process, which in particular needs individual patient information, e.g. about the structure and quality of the overlying soft tissues.

Patient-Specific Mandibular Reconstruction Plates Increase Accuracy and Long-Term Stability in Immediate Alloplastic Reconstruction of Segmental Mandibular Defects.

OBJECTIVES: The aim of the current study was to evaluate potential differences in the accuracy of mandibular reconstruction and long-term stability, with respect to different reconstructive procedures. METHODS: In total, 42 patients who had undergone primary segmental mandibular resection with immediate alloplastic reconstruction, with either manually pre-bent or patient-specific mandibular reconstruction plates (PSMRP), were included in this study. Mandibular dimensions, in terms of six clinically relevant distances (capitulum [most lateral points], capitulum [most medial points], incisura [most caudal points], mandibular foramina, coronoid process [most cranial points], dorsal tip of the mandible closest to the gonion point) determined from tomographic images, were compared prior to, and after surgery. RESULTS: Dimensional alterations were significantly more often found when conventionally bent titanium reconstruction plates were used. These occurred in the area of the coronoid process (p = 0.014). Plate fractures were significantly (p = 0.022) more often found within the manually pre-bent group than within the PSMRP group (17%/0%). CONCLUSION: The results suggest that the use of PSMRP may prevent rotation of the proximal mandibular segment, thus avoiding functional impairment. In addition, the use of PSMRP may potentially enhance the long-term stability of alloplastic reconstructions.

Oral health-related quality of life in tumour patients treated with patient-specific dental implants.

Dental rehabilitation after surgically acquired bone deficiency related to tumour treatment remains a challenge. The insertion of patient-specific implants geared to the contour of the remaining bone is a feasible method of supporting fixed or removable dentures. As oral health-related quality of life (OHRQoL) is of great interest in these cases, 12 individuals treated with patient-specific implants for severe bone deficiency were surveyed and their Oral Health Impact Profile (OHIP) scores after dental rehabilitation were evaluated. The OHIP-G53 questionnaire was used to measure overall treatment outcomes. The distribution of OHIP sum-scores for participants treated with patient-specific implants was almost homogeneous when compared to those cited in the literature for patients treated with conventional dental implants. OHIP items related to functional impairment and physical pain showed the highest scores (occurring occasionally), and financial loss related to treatment was frequently stated. Moreover, higher scores were detected in almost all OHIP dimensions for participants with patient-specific implant-supported removable dentures. Conversely, those treated with patient-specific dental implants and fixed dentures showed lower psychosocial impact scores and equal or superior OHRQoL. Hence, patient-specific dental implants, especially combined with fixed dentures, can lead to a positive OHRQoL in patients with severe bone deficiencies related to tumour therapy.

Intraorbital volume augmentation with patient-specific titanium spacers.

INTRODUCTION: Estimating the needed overcorrection of the globe position depends mainly on the clinical evaluation during an operation to correct hypo- and enophthalmos in primary and secondary orbital reconstruction for which several autogenous and alloplastic materials can be used. However, donor-side morbidity and time loss in obtaining autogenous materials are problematic. We developed a novel technique using titanium spacers that minimizes these factors. METHODS: We conducted a retrospective study of all patients treated with titanium spacers for orbital reconstruction at our department between 2014 and 2018. The primary predictor variable was a change in the deformity. The outcome variable was visual appearance, measured on a scale from 0 to 3. Other study variables included binocular vision and complications. Descriptive statistics and the Mann-Whitney rank sum test were used to check for statistical significances. The P-value was set at 0.05. RESULTS: The study sample was composed of 29 patients. Postoperative results were comparable to the results of other methods described in the literature with approximately 25% of our patients experiencing residual visual deformity. The overall visual deformity decreased in our study, and visual appearance improved significantly (P<0.001). Complication rates were also comparable to those reported by other investigators. CONCLUSION: Our method is an effective and safe procedure for correcting hypo- and enophthalmos while minimizing donor-side morbidity and treatment time.

Primary orbital reconstruction with selective laser melted core patient-specific implants: overview of 100 patients.

Contemporary advances in technology have enabled the transfer of industrial laser melting technology to surgery, and its use can improve the accuracy of orbital restoration. The aim of this study therefore was to evaluate the accuracy of primary orbital reconstruction with the use of selective laser melted, patient-specific implants and navigation. A total of 100 patients with complex orbital fractures were included. Planned orbital volumes were compared with those achieved, and angles were compared with the unaffected side. Analysis included the overlay of postoperative on planned images (iPlan® 3.0.5, Brainlab). The mean (SD) orbital volume of the unaffected side was 27.2 (2.8)ml in men and 25.0 (2.6)ml in women. Fractures that involved the posterior third of the orbital floor and comminuted fractures showed significant orbital enlargement (p=0.026). The mean (SD) reconstructed orbital volume was 26.9 (2.7)ml in men and 24.26 (2.5)ml in women. Three-dimensional analysis of the colour mapping showed minor deviations when compared with the unaffected side. The results suggest that a high degree of accuracy can be routinely achieved in these complex cases.

Reality or wishful thinking: do bicycle helmets prevent facial injuries?

Standard bicycle helmets are designed to protect the cranial vault. Numerous studies have demonstrated the beneficial effect of standard bicycle helmets on craniocerebral trauma, but their protective effect on facial injuries remains unclear. Therefore, this study used data obtained by an accident research unit to investigate the protective effect of standard bicycle helmets on facial injuries. A total of 31,634 bicycle accidents were registered between 1999 and 2015; of these, 7004 met the study requirements. Demographic characteristics, technical information (relative collision speed, collision type, collision partner, helmet use), and clinical data (injury type) relating to these accidents were analyzed. Of all affected cyclists, 1005 (14.3%) had a facial injury (fracture and/or soft tissue injury). Bicycle helmets were worn in 11.8% of accidents. Of these, 75.4% involved males and 24.6% involved females. The bicycle helmet did not protect against facial injuries. Furthermore, sex and the type of collision partner were found to be risk factors for facial injuries. In the future, helmet designs should be modified to improve facial protection, and better education should be provided to the public regarding the benefits of bicycle helmets.

Prelamination of the latissimus dorsi flap for reconstruction in head and neck surgery.

Free microsurgical tissue transfer of the latissimus dorsi flap may be indicated for the restoration of intra- and extraoral defects, especially when a large-sized skin island flap is required. In many cases, use of the latissimus dorsi flap for coverage of large-sized intraoral defects results in bulkiness due to the proportion of subcutaneous fat. Prelamination of free flaps appears to be a promising technique to overcome this flap bulkiness. This modification in flap design could improve the postoperative functional outcome, as well as reduce donor site morbidity. This article presents four novel clinical cases, in which the patients underwent prelamination of the latissimus dorsi flap with local skin grafts during oral cancer treatment in order to reduce the thickness of the free flap and allow tension-free primary closure of the donor site. These attempts successfully covered large-sized intraoral defects, achieving good functional outcomes with minimal donor site morbidity.

Scapula pre-augmentation in sheep with polycaprolactone tricalcium phosphate scaffolds.

A scapula free flap is a commonly used method to reconstruct intraoral defects of the mandible and maxilla. Despite its clear advantages, it shows some deficiencies concerning the amount and shape of the available bone, especially with respect to later implant placement. To overcome these limitations, we pre-augmented the scapula prior to a potential flap-raising procedure with polycaprolactone (PCL) tricalcium phosphate (TCP) scaffolds in a sheep model. In our study, the scapula angle was augmented with a block of PCL-TCP in three adult sheep. After 6 months, the amount of newly formed bone and scaffold degradation were evaluated using cone-beam computed tomography scans and histomorphometric analysis. All animals survived the study and showed no problems in the augmented regions. The scaffolds were attached firmly to the scapula and showed a bonelike consistency. A fair amount of the scaffold material was degraded and replaced by vital bone. Our method seems to be a valid approach to pre-augment the scapula in sheep. In further experiments, it will be interesting to determine whether it is possible to transplant a modified scapula flap to an intraoral defect site.

Modified lateral orbital wall decompression in Graves' orbitopathy using computer-assisted planning.

Graves' orbitopathy, a condition seen in the autoimmune syndrome Graves' disease, affects the fatty tissue and muscles inside the orbit. Graves' orbitopathy is associated with increasing exophthalmos and sometimes leads to compressive dysthyroid optic neuropathy, resulting in progressive vision loss. Dysthyroid compressive optic neuropathy, functional problems, and cosmetic problems are the main indications for surgical decompression of the orbit, especially if conservative treatment has not led to a reduction in symptoms. Many surgical techniques are described in the literature. This article presents a modification of the lateral orbital wall osteotomy, involving the rotation and reduction of the osteotomized bone segment using preoperative planning, intraoperative computed navigation, and piezoelectric surgery. This new method combines the advantages of different techniques and appears to be a valid approach to the treatment of severe cases of Graves' orbitopathy.

Interdisciplinary reconstruction of oncological resections at the skull base, scalp and facial region.

Extensive bone and soft tissue defects of the skull require unique plastic and reconstructive techniques to avoid and optimize aesthetic appearance following oncological resections. Procedures are ideally planned in an interdisciplinary board composed of neurosurgery, otorhinolaryngology, plastic and reconstructive surgery to facilitate reconstructive procedures of soft tissue and bone as early as possible in one approach. Large resections may require plastic surgery involvement from the beginning. Herein, we describe the function of a multidisciplinary approach to complex oncologic resections of the cranial base, scalp, and facial regions for neuro-oncologic patients.

In vivo tissue engineered bone versus autologous bone: stability and structure.

This pilot study investigated the biomechanical properties of prefabricated, vascularized bioartificial bone grafts, which may provide an alternative bone source for the restoration of segmental osseous defects. Vascularized bioartificial bone grafts comprise an artificial customized scaffold made of beta-tricalcium phosphate. Bone formation along the prefabricated scaffold is induced by autogenous cancellous bone. Vascularization of the bone graft is provided by the host's vascular system. Within 6 months, a mammalian bioreactor (sheep were used in the present study) creates heterotopic vascularized bioartificial bone grafts of a predetermined anatomical shape, which can be harvested for reconstructing osseous defects. The bioartificial bone grafts in this study contained up to 25% bone tissue, as shown by histomorphometric analysis and computed tomography. Moreover, unconfined compression tests revealed that the constructs had mechanical characteristics similar to those of ovine cancellous bone. Therefore, this method could be applied to generate vascularized prefabricated bone substitutes for critical-size defects.

Piezoelectric surgery and navigation: a safe approach for complex cases of Eagle syndrome.

Eagle syndrome was first described by Eagle in 1937. It is associated with an elongated styloid process and/or calcification of the stylohyoid ligament, mainly resulting in pain in the orofacial region. The treatment of Eagle syndrome includes conservative treatment with physical therapy supported by medication, or surgical removal of the styloid process. Two different surgical approaches are described in the literature: the transoral and transcervical approaches. Both have their limitations and specific intraoperative risks. A modification of the transcervical approach that adds an extra security measure to the treatment of complex cases of Eagle syndrome is presented herein. The styloid process was removed by combining piezoelectric surgery, preoperative digital planning, and surgical navigation. No complication was noted, and the patient recovered quickly after surgery. A follow-up visit 2 months later showed no remaining symptoms of Eagle syndrome on the treated side. Therefore, digital planning and surgical navigation could add valuable safety measures to the treatment of complex cases of Eagle syndrome.

[Prefabrication of vascularized facial bones]. / Präfabrikation vaskularisierter Gesichtsknochen.

Critical size defects in the craniomaxillofacial region often result from ablative tumor surgery, inflammation and posttraumatic deformities. To date, autologous bone grafts are still the gold standard for the reconstruction of these defects; however, they are frequently associated with severe donor site morbidity as well as functional and aesthetic compromises. In this context various resorbable and non-resorbable bone replacement materials have been developed and intensively investigated. Particularly in critical size defects these materials fail due to their lack of osteogenic potential and endogenous vascularization. The combination of alloplastic osteoconductive scaffolds, osteogenic cells, and axial prevascularization in bioartificial bone grafts might present an innovative approach for the microsurgical reconstruction of critical size defects.

Prospective study of the influence of psychological and medical factors on quality of life and severity of symptoms among patients with oral squamous cell carcinoma.

About 400,000 people worldwide are diagnosed with oral squamous cell carcinoma (SCC) annually, and the incidence is increasing. Many advanced carcinomas of the oral cavity require radical surgical treatment that can impair patient's quality of life (QoL) and severity of symptoms. We therefore aimed to identify coping strategies and disease-specific medical factors that affect QoL and severity of symptoms. Patients with oral SCC were asked to complete the Freiburg Questionnaire on Coping with Illness (FQCI), the University of Washington Quality of life Questionnaire (UW-QOL version 4), and the Brief Symptom Inventory (BSI) to measure psychological stress. We also assessed the impact of various factors on QoL and severity of symptoms, including stage and site of tumour, method of reconstruction, time of diagnosis, and social structure (age, sex, marital status, living arrangements, level of education, and employment). We enrolled a consecutive sample of 104 patients over a period of one year. Stepwise linear regression analyses indicated that both depressive coping and size of tumour had an adverse effect on QoL and severity of symptoms. Patients with high educational attainment and those who lived alone reported impaired QoL, and women experienced increased severity of symptoms. Impaired QoL and increased severity of symptoms were associated with a depressive style of coping, size of tumour, educational attainment, and living arrangements. It is important to identify these patients during treatment as they could benefit from psycho-oncological counselling.