[Conduction anesthesia of the infraorbital nerve - A guide to intraoral nerve block anesthesia of the infraorbital nerv]. / Leitungsanästhesie des Nervus infraorbitalis.

In order to be able to perform major oral surgery in the upper jaw, sufficient local analgesia is indispensable. While the inferior alveolar nerve is often blocked for dental treatments in the lower jaw, block anesthesia in the upper jaw is less common. This article gives pragmatic advice on how to block the infraorbital nerve. By using this method patients comfort is significantly improved and the surgeon can focus on the treatment at hand.

Accuracy of Computer-Guided Template-Based Implant Surgery: A Computed Tomography-Based Clinical Follow-Up Study.

OBJECTIVE: The aim of this clinical study was to analyze the accuracy of computer-guided implant surgery. MATERIALS AND METHODS: Assisted by computed tomography (CT)-based planning software and navigational templates, 16 patients successfully received 26 dental implants. Each implant parameter (a-d) was calculated based on superimposed preoperative and postoperative cone beam CT scans: (a) deviation at entry point; (b) deviation at apex; (c) angular deviation; and (d) depth deviation. RESULTS: Mean central deviation at implant entry point and apex was 0.91 mm (standard error [SE] = 0.11 mm; 95% confidence interval [CI]: 0.69-1.13) and 1.22 mm (SE = 0.11 mm; 95% CI: 0.99-1.45), respectively. Mean angulation deviation was 4.11 degrees (SE = 0.52 degrees; 95% CI: 3.04-5.17) and the average depth deviation was 0.65 mm (SE = 0.11 mm; 95% CI: 0.42-0.87). For the total number of implants placed, the maximum error was 2.34 mm at entry point, 2.71 mm at apex, 9.44 degrees in angular deviation, and 2.00 mm in depth deviation. CONCLUSION: Great accuracy was reached even in advanced cases with prior bone augmentation and complex traumas. This leads to the conclusion that particularly in advanced cases, computer-guided implantation can be beneficial.

Precision of Simultaneous Guided Dental Implantation in Microvascular Fibular Flap Reconstructions With and Without Additional Guiding Splints.

PURPOSE: Dental rehabilitation in patients receiving free flap reconstructive surgery on the mandible or maxilla is an important part of bringing patients back to normality in both a physical and psychological way. It is therefore important to be able to do this in the fastest way possible. Virtual preplanned reconstructions of jaws with implants placed simultaneously are a good way to expedite this process and have the advantage of allowing true backward planning to achieve bone placement where it prosthetically needs to be. Thus, the precise transfer of the virtually preplanned implant position to the intraoperative situation is crucial for prosthetic rehabilitation. PATIENTS AND METHODS: We compared a control group of patients (4 patients with 15 implants) with preplanned fibular reconstructions of the mandible with implants incorporated in the planning and a trial group of patients (4 patients with 13 implants) with an additional intraoperative splint for the verification of the implants' angulation. The preoperative planning and postoperative computed tomography scans were compared. RESULTS: The average positioning error at bone level was 0.9 mm in the trial group and 1.3 mm in the control group. The average angulation error in the buccolingual plane was 2.9° in the trial group and 5.5° in the control group; axially, the difference was 6.3° in the trial group and 4.1° in the control group. CONCLUSIONS: The use of digitally backward-planned fibula cutting guides with direct dental implant positioning is feasible, and the precision found is comparable with that of standard splint-guided implant placement in the general population. Although the axial angulation error has more to do with anatomic variance and positioning of the bony cutting guide, the trial population clearly profited from the additional splint in the important buccolingual angulation. Overall, we showed a high level of precision over all implants in both groups.

Outcome of Surgically Treated Fractures of the Condylar Process by an Endoscopic Assisted Transoral Approach.

PURPOSE: Fractures of the condylar process are frequent. Ideal management of these fractures, as discussed in the literature, is controversial. Some recent meta-analyses have favored open reduction and internal fixation using various approaches. A strictly transoral approach has been described to minimize scarring and risk of facial nerve injury but has restricted visibility. This retrospective study analyzed outcomes of patients with unilateral mandibular condyle fractures who were treated by open reduction and internal fixation through an endoscopic-assisted transoral approach. MATERIALS AND METHODS: This study included 40 patients who were operated on from January 2015 through December 2016. All patients underwent surgery for a condylar process fracture using an endoscopic-assisted transoral approach. Fracture classification, demographic, and outcome data were collected. RESULTS: Most condylar process fractures were caused by falls from a height less than 3 m. Most were condylar base fractures and classified according to Spiessl and Schroll as Classes I and II. Sixteen patients showed a preoperative malocclusion, whereas 2 patients showed a slight postoperative malocclusion. In cases in which only 1 plate could be placed, the proximal fragment was shorter. A higher Spiessl and Schroll class showed a tendency toward longer operation times. For postoperative outcomes, 1 case of temporary facial palsy was the worst complication (2.5%), 2 cases exhibited minimal occlusal interference (5%), and 1 case exhibited a deviated mouth opening (2.5%). Ramus height was restored in all cases. No chronic pain was found in any cases. CONCLUSIONS: It is feasible to treat condylar process fractures in a safe manner using a transoral approach with endoscopic assistance and angled instruments without facial scarring and at a low complication rate. The endoscope improves the restricted visibility of the transoral approach, although a learning curve is necessary. This applies especially to dislocated fractures or to fractures with a short proximal fragment.

Intraoperative 3-dimensional cone beam computed tomographic imaging during reconstruction of the zygoma and orbit.

OBJECTIVE: Fractures of the zygoma and orbit are common facial skeleton injuries. Inadequate reduction and internal fixation may result in functional and aesthetic impairment. The aim of this study was to assess the use of intraoperative 3-dimensional (3-D) cone beam computed tomography (CBCT) for determining the intraoperative revision rate and the need for additional reconstruction of the orbit. STUDY DESIGN: We conducted a retrospective analysis of 48 consecutive patients (15 females, 33 males) suffering from simple or complex zygomatic fractures, seen between June 2015 and October 2016. Intraoperative 3-D CBCT (Xoran Technologies, Ann Arbor, MI) was performed, and the intraoperative image was overlaid on the preoperative image by using iPlan software (Brainlab, Feldkirchen, Germany) for quality control. Categorical variables were cross-tabulated and compared using Fisher's exact test. P values and 95% confidence intervals were assessed. RESULTS: In 6 of 48 patients, intraoperative revision was deemed necessary on the basis of the superimposition on the preoperative images. Five of these 6 patients had comminuted fractures (P = .001). In 7 patients, the indication for orbital reconstruction was revised after intraoperative 3-D CBCT. CONCLUSIONS: Intraoperative 3-D CBCT allows for immediate revision and prevents unnecessary orbital reconstruction.

Cone Beam Computed Tomography Evaluation of the Artery in the Lateral Wall of the Maxillary Sinus: Retrospective Analysis of 602 Sinuses.

PURPOSE: This retrospective study evaluates the location of the arteries in the maxillary sinus, particularly in the middle portion, using cone beam computed tomography (CBCT) scans that can detect the lateral arteries with high reliability. METHODS: In this retrospective study, 2 experienced independent examiners evaluated 602 sinuses on CBCT scans. DISCUSSION: No significant correlation was found between the location of arteries and the patient's age, sex, or dentition. In 92.0% (P ≤ 0.001) of the sinuses, at least 1 arterial branch was detectable. CONCLUSION: Based on the CBCT scans, we found that a very high proportion of patients have the maxillary artery in their lateral sinus wall, which is important information for sinus augmentation or sinus surgery.

Retrospective analysis of 471 surgically treated zygomaticomaxillary complex fractures.

PURPOSE: Zygomaticomaxillary complex (ZMC) fractures are frequent in facial trauma; only fractures of the mandible are more common. Although the frequency of these fractures is geographically consistent, the aetiology differs widely among countries and even regions. Differences in socio-economic status and the ageing population seem to be two causes. This retrospective epidemiological study evaluates patients who were surgically treated for ZMC fractures at a Swiss university clinic. MATERIALS AND METHODS: This study included 471 patients who were surgically treated for ZMC fractures in an oral and maxillofacial surgery clinic at a Swiss university hospital between January 2004 and December 2012. Complicated fractures such as LeFort II/III and bilateral ZMC fractures were excluded. Data on gender, age, and type of trauma were recorded. Fractures were classified by aetiology: motorised road traffic (car or motorcycle), bicycle, interpersonal violence, sports, falls (both less than and greater than 3 m in height) and other causes. RESULTS: A total of 350 patients were male (74%), and 121 were female (26%). The ZMC fractures were most likely to occur in the third decade (117 cases, 25%). A predominance of male patients was found in the young age groups, but an equal ratio was found in the elderly groups. Etiologically, falls of less than 3 m were the most common cause of ZMC fractures (125 cases, 27%). Interpersonal violence was second (88 patients, 19%); male patients dominated this group, which had a male-to-female ratio of 21:1. A predominance of male patients was found in every subdivision when analysing by aetiology and gender. The lowest proportion of males (57%) was found for falls of less than 3 m. CONCLUSION: In our study, interpersonal violence and falls outnumbered road traffic accidents among causes of maxillofacial fractures. This is probably a consequence of strict road and work laws. Additionally, the older and more active populations accounted for the highest proportion of falls, and young male patients were the predominant victims of ZMC fractures.

Denosumab as a Treatment Alternative for Central Giant Cell Granuloma: A Long-Term Retrospective Cohort Study.

PURPOSE: Giant cell granuloma (GCG) of the jaw is a rare disease with high morbidity. Various treatment options have been discussed in the past. Since 2010, a pharmaceutical therapy with denosumab seems to have been successful for giant cell tumors of the femur. The authors hypothesized the equally successful use of denosumab for GCGs of the jaws. MATERIALS AND METHODS: In the present retrospective cohort study, 5 patients with large GCGs of the jaws were treated with denosumab with a follow-up of 25 to 49 months. Frequent clinical follow-ups and a radiologic follow-up were performed and systematically analyzed. RESULTS: All patients showed a curative treatment response and complete metabolic resolution of the GCGs under treatment with denosumab. CONCLUSION: A brief review of the relevant literature and a detailed evaluation of current cases led to the conclusion that denosumab therapy should be considered a therapeutic option for large central GCGs of the jaws. The results of this study suggest denosumab is a successful treatment option. A treatment length no shorter than 12 months is recommended and monitoring of treatment response can be well managed by positron-emission tomographic computed tomography or magnetic resonance imaging.

Use of a monopolar microneedle device in a transconjunctival, retroseptal approach.

Transconjunctival approach is a standard procedure to address fractures of orbit and the infraorbital rim. Modifications such as transcaruncular or lateral canthal widening allow for extended orbital wall exposure. Especially concerning aesthetics, the transconjunctival approach shows benefits compared to the transcutaneous incisions, such as the transciliary and infraorbital access. Moreover, transconjunctival approach is favored in the literature concerning lid retraction. Monopolar devices have become popular in surgery in the past decades because of good depth control and simultaneous hemostasis with consequently improved overview. Also numerous surgeons use monopolar device in orbital surgery, their safety have never been proved. In this study monopolar microneedle device is compared with conventional access by scalpel concerning lid retraction, foreign body sensation and formation of symblepharon. In our collective complication rates were comparable between the scalpel and the microneedle group. The monopolar microneedle device shows favorable results compared with the scalpel and is easy to handle. Weather the conventional access by scalpel or the access by monopolar device is selected, is rather driven by the surgeon's preferences than by statistical relevance. Nevertheless, monopolar microneedle device shows better depth control and simplifies readaptation of the conjunctival wound's margin.

Traitement médicamenteux du lichen plan buccal.

Oral lichen planus is a relatively common T-cell mediated inflammatory disease with potential malignant transformation. It may present itself with pain and oral lesions such as ulcers and Wickham’s striae. Treatment includes topical corticosteroids, preferably Clobetasol, immunosuppressive drugs and retinoids. Hyaluronic acid and aloe vera have been proven to be successful. If topical treatment fails, systemic therapy with corticosteroids may be needed. Because of the potential malignant transformation periodic follow-up is mandatory.

The Effects of Preoperative Radiotherapy on Head and Neck Free Flap Anastomosis Success.

PURPOSE: The long-term survival benefit of neoadjuvant radiotherapy for oropharyngeal tumors is controversially discussed in the literature. To bring more light into this important debate, we evaluated our cases. PATIENTS AND METHODS: In this retrospective study the main focus was the relationship between neoadjuvant irradiation and anastomosis failure. Other influencing factors including previous operative treatment and tumor stage and type also were studied. RESULTS: In total, 7 anastomoses failed (total failure rate, 8.4%; n = 83); 1 of the 7 underwent neoadjuvant irradiation (failure rate, 3.1%; n = 32). All 7 anastomosis failures were in squamous cell carcinoma cases, with 5 of them staged as T4. CONCLUSION: Our data suggest that neoadjuvant radiotherapy for oropharyngeal carcinoma does not increase the risk of postoperative anastomosis failure compared with surgical reconstruction alone. Furthermore, the data suggest a correlation between the stage and type of tumor.

Inferior alveolar nerve function after open reduction and internal fixation of mandibular fractures.

PURPOSE: Mandibular fractures are amongst the most common facial fractures and are usually treated by open reduction and internal fixation (ORIF). Inferior alveolar nerve (IAN) injuries are seen frequently in mandibular fractures as well as after ORIF of these fractures due to the exposition and the close proximity of the nerve during fracture reduction. Therefore the continuity of the IAN can be disrupted. Permanent injury to the IAN can result in diminished quality of life. This retrospective study was designed to objectively analyse the incidence and the outcome of pre- and postoperative mental nerve hypoesthesia after ORIF of mandibular fractures. MATERIAL AND METHODS: Patients who were consecutively treated at the Department of Cranio-Maxillofacial and Oral Surgery of the University Hospital Zurich between 2004 and 2010 with mandibular fractures who underwent ORIF were included. Follow-up period was 12 months. Demographic, pre-, peri- and postsurgical data were tabulated and statistically evaluated using the χ(2) test and the Kruskall-Wallis-Test. RESULTS: 340 patients met the inclusion criteria. 27% of the study population presented with postinjury (preoperative) mental nerve hypoesthesia, 46% suffered from purely postoperative hypoesthesia and 27% showed no nerve damage. Complete recovery was seen in 70% of all cases, partial recovery in 20% of the cases and less than 10% suffered from a permanent (>12 months) IAN damage. Mandibular angle fractures were accompanied with significantly higher rates of hypoesthesia (79% vs. 68%). Recovery rate was significantly worse in older patients, when preoperative hypoesthesia was present (66% vs. 73%) and in patients with multiple fractures in proximity to the IAN (36% vs. 52%). Mandibular body fractures showed worse recovery rates than fractures that did not affect the body (44% vs. 52%). CONCLUSION: The present study shows that IAN injury is seen frequently in mandibular fractures. Mental nerve hypoesthesia may influence quality of life. Nerve continuity may not be preserved due to the initial trauma or may result as a postoperative complication. Nevertheless the results of this study show a high potential for full recovery.

Comparison of in vivo cone-beam and multidetector computed tomographic scans by three-dimensional merging software.

In dentomaxillofacial radiology, cone-beam computed tomography (CT) is used to give fast and high-resolution 3-dimensional images of bone with a low dose of radiation. However, its use for quantitative measurement of bone density based on absolute values (Hounsfield units, HU) as in multidetector CT is still controversial. We know of no in vivo study of 3-dimensional merging software that will reliably match identical bone areas of cone-beam and multidetector CT datasets. We studied 19 multidetector, and 19 cone-beam, CT scans of the skull. The two datasets were fused, corresponding points were identified for measurement, and we compared mean density. We used linear regression to analyse the relation between the two different scanning methods, and studied a total of 4180 measurements. The mean time interval between scans was 5.2 (4.7) months. Mean R(2) over all measurements was 0.63 (range 0.22 - 0.79) with a mean internal consistency (Cronbach's α) of 0.86 (range 0.61 - 0.93). The strongest linearity, seen at the left mastoid, was R(2)=0.79 with high internal consistency (Cronbach's α 0.89), and the weakest was at the left zygomatic bone with R(2)=0.22 and Cronbach's α=0.61. Measurements of bone density based on cone-beam and multidetector CT scans generated in vivo showed high and reproducible internal consistency but poor linearity.

Preoperative 3D imaging in maxillary sinus: brief review of the literature and case report.

OBJECTIVE: The purpose of the present case report is to document the removal of a radix in antro without a hemorrhagic complication in presence of a posterior superior alveolar artery (PSAA) with a 2.8 mm diameter following a radiographic 3D planning by cone beam computed tomography (CBCT) scan. Furthermore, a brief literature overview on studies describing the existence and the variance of the PSAA is provided. METHOD AND MATERIALS: A foreign body removal in the right maxillary sinus was performed on a 33-year-old healthy man by using the lateral window osteotomy. The preoperative CBCT scan showed three arteries in the lateral maxillary sinus wall at a distance of 24.6 mm, 19.5 mm, and 13.5 mm to the alveolar crest. RESULTS: By removing a foreign body out of the maxillary sinus a vessel with a diameter of nearly 3 mm was exposed. Due to CBCT scan planning and the use of piezosurgery it was possible to avoid any damage to the vessel during the operation. The postoperative healing was uneventful and no complications occurred. CONCLUSION: Although laceration of vessels with a large diameter during lateral window osteotomy is not life-threatening it may compromise visualization and reduces the surgical outcome. Therefore, 3D imaging is recommended for the minimization of intra- and postoperative complications and for the localization of any foreign body in relation to other anatomical structures. This is of special interest in case of anatomical variances of blood vessels.

[Oral lichen ruber planus: treatment and drugs]. / Medikamentöse Therapie des oralen Lichen ruber planus.

Oral lichen planus is a relatively common T-cell mediated inflammatory disease with potential malignant transformation. It may present itself with pain and oral lesions such as ulcers and Wickham's striae. Treatment includes topical corticosteroids, preferably Clobetasol, immunosuppressive drugs and retinoids. Hyaluronic acid and aloe vera have been proven to be successful. If topical treatment fails, systemic therapy with corticosteroids may be needed. Because of the potential malignant transformation periodic follow-up is mandatory.

Outcome of comminuted mandibular fracture repair using an intraoral approach for osteosynthesis.

PURPOSE: Traditionally, the treatment of comminuted mandibular fractures involves both closed and open reduction. However, modern treatment principles increasingly tend toward open reduction and internal fixation to shorten oro-functional rehabilitation. Although this method increasingly gained popularity to date, a controversy regarding the extraoral versus the intraoral surgical approach still exists. The current study aimed to objectively evaluate the outcome of comminuted mandibular fracture treatment involving open reduction and internal fixation using an intraoral approach. PATIENTS AND METHODS: Consecutive patients treated at the Department of Cranio-Maxillofacial and Oral Surgery, University Hospital of Zurich, between 2005 and 2012 were included. Demographic, presurgical, perisurgical, and postsurgical data were tabulated and statistically evaluated using the χ test and the Mann-Whitney U test. RESULTS: Forty-five patients could be included. Excellent postoperative results were seen in 84% (38 patients) of the total cohort. Postoperative complications were seen in 16% (7 patients). These 7 patients had the following complications: wound dehiscence (7% [n = 3]), osteomyelitis (7% [n = 3]), abscess development (4% [n = 2]), bone necrosis (2% [n = 1]), and severe nonocclusion (2% [n = 1]). CONCLUSION: Present data showed that the intraoral approach for open reduction and internal fixation in comminuted mandibular fractures represents a comparable surgical technique regarding fracture repositioning and occlusal rehabilitation. Considerably, the risk of concomitant neurovascular damage or even facial scarring, as demonstrated in the extraoral approach, can be neglected by using this technique. Nevertheless, each case has to be judged on its own accord as to which technique can best treat the underlying fracture.