Treated Versus Untreated Positional Head Deformity.

BACKGROUND: Positional head deformity in early childhood is asserted to be a benign and in some cases spontaneously correcting entity encountered in craniofacial surgery. Although many authors have stated that helmet therapy is indicated in moderate and severe cases of deformational plagiocephaly and brachycephaly; others have reported resolution of these conditions within the first 2 to 3 years of life. A recent randomized controlled trial found that helmet therapy does not have beneficial effects for patients with positional head deformity. METHODS: The authors evaluated the clinical course of positional cranial deformation during a period of 5 years and compared the anthropometric parameters of orthotically treated versus untreated children within this timeframe. RESULTS: Although the patients were matched with respect to their cranial deformation at baseline, there were significant differences in the cranial vault asymmetry (CVA), cranial vault asymmetry index (CVAI), and oblique cranial length ratio (OCLR) between Groups 1 and 2 at the initial point (P < 0.05). The mean CVA was 0.95 cm in Group 1 (no helmet) and 1.74 cm in Group 2 (helmet). The mean CVAI at baseline was 7.25 for Group 1 and 13.77 for Group 2. Approximately 5 years after the first examination, the authors found clear improvement in the mean CVA in Group 2 (ΔCVA 1.35 cm) compared with Group 1 (ΔCVA 0.01 cm) and the mean CVAI. CONCLUSIONS: In contrast to recently published studies, the authors found clear improvement in nonsynostotic head deformity treated with an individual molding helmet and no clear evidence of improvement of absolute measurements in untreated cranial deformity within a 5-year follow-up period.

Estimation of legal age using calcification stages of third molars in living individuals.

The increased number of adolescents and young adults with unknown or inaccurately given date of birth is a current issue in justice and legal medicine. The objective of this study was to determine the extent to which third molar calcification stages assessed on panoramic X-rays could be useful as additional criteria for forensic age estimation in living individuals, focusing on the legally important ages 17 and 18. In a retrospective multi-center study, the developmental stage of each individual's third molar was analyzed using Demirjian's scale in 2360 cases. Additionally, sex, age and ancestry were assessed. Individuals with the lowest calcification stage of all present molars in stage H were ≥18 years with a likelihood of ≥99.05% in the female (n=388), and ≥99.24% in the male (n=482) population. The lowest calcification stage of all present third molars proved to be useful as an additional reliable criterion for the determination of an age ≥18 years.

A prospective randomized trial on preventative methods for positional head deformity: physiotherapy versus a positioning pillow.

OBJECTIVE: To evaluate the impact of stretching exercises versus available bedding pillows on positional head deformities. STUDY DESIGN: Fifty children aged 5 months or younger with positional head deformity were included in this prospective clinical trial (n=20 plagiocephaly, n=10 brachycephaly, n=20 combination). A random distribution was performed for treatment with the bedding pillow alone (n=25) or with stretching exercises (n=25) for 6 weeks. Anthropometric caliper measurements were done before and after that interval. Cranial vault asymmetry index (CVAI) and cranial index (CI) were calculated and analyzed using a descriptive statistical general linear model. RESULTS: ΔCVAI in the stretching group was 2.09% for plagiocephaly and 2.34% for combined head deformities. Using the bedding pillow, ΔCVAI was 3.01% in plagiocephal children and 2.86% for combined head deformity. The ΔCI in the stretching group was 0.94% for isolated brachycephal children and 2.24% for combined head deformity. ΔCI in the pillow group was 3.63% for brachycephaly and 3.23% in children with combined head deformities, respectively. CONCLUSIONS: Bedding pillows and stretching exercises both resulted in improvements in positional cranial deformation. For children with combined plagiocephaly and brachycephaly, improvement in cranial asymmetry was slightly greater when using bedding pillows versus stretching.

Clinical classification of infant nonsynostotic cranial deformity.

OBJECTIVE: Based on a pilot study including >400 children and a comprehensive database analysis of >2500 children, we sought to define the craniofacial norm and to objectify the categorization of positional head deformity. STUDY DESIGN: A database was created containing clinical information on children assessed for nonsynostotic cranial deformity. The findings of standardized anthropometric measurements were compared with data from a group of 401 healthy children with a normal head shape collected in terms of a prospective pilot study. Using a statistical analysis of all anthropometric craniofacial measurements, cut-off percentiles for discriminating different groups of deformation and severity classes were generated. RESULTS: Normative percentiles for all dimensions in cranial vault anthropometric measurements during the first year of life were calculated. Children with definite nonsynostotic head deformity could be clearly allocated into 3 different groups: positional plagiocephaly (abnormal Cranial Vault Asymmetry Index), positional brachycephaly (abnormal Cranial Index), and combined positional plagiocephaly and brachycephaly (abnormal Cranial Vault Asymmetry Index and Cranial Index). Additionally, a reliable 3-level severity categorization (mild, moderate, and severe) for each group of cranial deformation could be obtained according to age and sex. CONCLUSIONS: Our results allow a meaningful and reliable classification of nonsynostotic early childhood cranial deformity.

Odontogenic Cervicofacial Necrotizing Fasciitis: Microbiological Characterization and Management of Four Clinical Cases.

Necrotizing fasciitis of the head and neck is a rare, very severe disease, which, in most cases, originates from odontogenic infections and frequently ends with the death of the patient. Rapid surgical intervention in combination with a preferably pathogen-specific antibiotic therapy can ensure patients' survival. The question arises concerning which pathogens are causative for the necrotizing course of odontogenic inflammations. Experimental 16S-rRNA gene analysis with next-generation sequencing and bioinformatics was used to identify the microbiome of patients treated with an odontogenic necrotizing infection and compared to the result of the routine culture. Three of four patients survived the severe infection, and one patient died due to septic multiorgan failure. Microbiome determination revealed findings comparable to typical odontogenic abscesses. A specific pathogen which could be causative for the necrotizing course could not be identified. Early diagnosis and rapid surgical intervention and a preferably pathogen-specific antibiotic therapy, also covering the anaerobic spectrum of odontogenic infections, are the treatments of choice. The 16S-rRNA gene analysis detected significantly more bacteria than conventional methods; therefore, molecular methods should become a part of routine diagnostics in medical microbiology.

Sinusoidal coronal incision.

BACKGROUND: The coronal incision is a standard surgical approach in craniofacial surgery. For pediatric patients, it holds a certain risk for unbeneficial aesthetic outcome due to a broadening of the scar in the fast-growing infant skull. METHODS: We readopted the coronal approach over the last decade and developed a sinusoidal type of incision based on the "stealth incision" by Munro and Fearon. We present a calculative standardization of our approach. RESULTS: The sinusoidal coronal approach assures superior aesthetical results with equivalent skeletal exposure. The surgical procedure is simplified and standardized. Even in the fast-growing infant skull, broadening of the scar or vertical divergence is avoided.

Automatic detection and monitoring of abnormal skull shape in children with deformational plagiocephaly using deep learning.

Craniofacial anomaly including deformational plagiocephaly as a result of deformities in head and facial bones evolution is a serious health problem in newbies. The impact of such condition on the affected infants is profound from both medical and social viewpoint. Indeed, timely diagnosing through different medical examinations like anthropometric measurements of the skull or even Computer Tomography (CT) image modality followed by a periodical screening and monitoring plays a vital role in treatment phase. In this paper, a classification model for detecting and monitoring deformational plagiocephaly in affected infants is presented. The presented model is based on a deep learning network architecture. The given model achieves high accuracy of 99.01% with other classification parameters. The input to the model are the images captured by commonly used smartphone cameras which waives the requirement to sophisticated medical imaging modalities. The method is deployed into a mobile application which enables the parents/caregivers and non-clinical experts to monitor and report the treatment progress at home.

Microbiome of Odontogenic Abscesses.

Severe odontogenic abscesses are regularly caused by bacteria of the physiological oral microbiome. However, the culture of these bacteria is often prone to errors and sometimes does not result in any bacterial growth. Furthermore, various authors found completely different bacterial spectra in odontogenic abscesses. Experimental 16S rRNA gene next-generation sequencing analysis was used to identify the microbiome of the saliva and the pus in patients with a severe odontogenic infection. The microbiome of the saliva and the pus was determined for 50 patients with a severe odontogenic abscess. Perimandibular and submandibular abscesses were the most commonly observed diseases at 15 (30%) patients each. Polymicrobial infections were observed in 48 (96%) cases, while the picture of a mono-infection only occurred twice (4%). On average, 31.44 (±12.09) bacterial genera were detected in the pus and 41.32 (±9.00) in the saliva. In most cases, a predominantly anaerobic bacterial spectrum was found in the pus, while saliva showed a similar oral microbiome to healthy individuals. In the majority of cases, odontogenic infections are polymicrobial. Our results indicate that these are mainly caused by anaerobic bacterial strains and that aerobic and facultative anaerobe bacteria seem to play a more minor role than previously described by other authors. The 16S rRNA gene analysis detects significantly more bacteria than conventional methods and molecular methods should therefore become a part of routine diagnostics in medical microbiology.

Clinical Relevance of the Microbiome in Odontogenic Abscesses.

Odontogenic abscesses are usually caused by bacteria of the oral microbiome. However, the diagnostic culture of these bacteria is often prone to errors and sometimes fails completely due to the fastidiousness of the relevant bacterial species. The question arises whether additional pathogen diagnostics using molecular methods provide additional benefits for diagnostics and therapy. Experimental 16S rRNA gene analysis with next-generation sequencing (NGS) and bioinformatics was used to identify the microbiome of the pus in patients with severe odontogenic infections and was compared to the result of standard diagnostic culture. The pus microbiome was determined in 48 hospitalized patients with a severe odontogenic abscess in addition to standard cultural pathogen detection. Cultural detection was possible in 41 (85.42%) of 48 patients, while a pus-microbiome could be determined in all cases. The microbiomes showed polymicrobial infections in 46 (95.83%) cases, while the picture of a mono-infection occurred only twice (4.17%). In most cases, a predominantly anaerobic spectrum with an abundance of bacteria was found in the pus-microbiome, while culture detected mainly Streptococcus, Staphylococcus, and Prevotella spp. The determination of the microbiome of odontogenic abscesses clearly shows a higher number of bacteria and a significantly higher proportion of anaerobes than classical cultural methods. The 16S rRNA gene analysis detects considerably more bacteria than conventional cultural methods, even in culture-negative samples. Molecular methods should be implemented as standards in medical microbiology diagnostics, particularly for the detection of polymicrobial infections with a predominance of anaerobic bacteria.

Three-dimensional photographic analysis of outcome after helmet treatment of a nonsynostotic cranial deformity.

Cranial asymmetries due to nonsynostotic deformation of the skull have been reported with increasing frequency during the last decade. Conservative approaches using helmets and physiotherapy have been shown to be effective in their treatment. Traditionally, documentation has been carried out using anthropometric caliper measurements. The present study evaluates the use of a new three-dimensional photographic system in the improved validation of changes in head deformities. This prospective analysis introduces a new technique for digital anthropometric measurement. The study series comprised 181 children with nonsynostotic head deformities. Three-dimensional photographs were obtained before and after treatment with an orthotic helmet device. The oblique head diagonals and head width and length were measured from three-dimensional photographs using 3dMD customer software. The cranial vault asymmetry index, cranial vault asymmetry, and cranial index were compared before and after treatment. The measurements obtained on three-dimensional images were able to demonstrate significant improvement in early infant cranial deformity after treatment with an orthotic helmet. The cranial vault asymmetry index in plagiocephaly was reduced by 7.16%, and cranial vault asymmetry was reduced by 0.86 cm. The cranial index in brachycephaly decreased by 7.32%. In children with combined plagiocephaly and brachycephaly, the cranial vault asymmetry index improved by 5.77%, cranial vault asymmetry improved by 0.71 cm, whereas the cranial index changed by 5.48%. Three-dimensional photogrammetry can support treatment control in patients with deformational plagiocephaly. This new technology offers several advantages such as easy acquisition of images, detection of landmarks without patient movement, repeatable measurements without patient discomfort, and the opportunity for unbiased evaluation.

Accuracy of photographic assessment compared with standard anthropometric measurements in nonsynostotic cranial deformities.

OBJECTIVE: Anthropometric landmarks of the skull have traditionally been used to describe cranial deformities resulting from nonsynostotic plagiocephaly or brachycephaly. Recently, digital photography has become an important tool for characterizing facial and cranial pathologies. The purpose of this study was to compare standard anthropometric cranial measurements with measurements taken from cranial photographs. PATIENTS: Standardized digital images in the supracranial view and cranial anthropometric measurements were obtained from 122 children between the ages of 3 and 15 months. The photographs were assessed using Quick Ceph® software. The cephalic index and cranial vault asymmetry index were used to indicate the degree of cranial deformity. Children were classified into plagiocephaly, brachycephaly, and the combination of both. To determine interobserver variability, two clinicians separately measured the cephalic index and cranial vault asymmetry index from digital photographs in 70 infants of the plagiocephalic group. RESULTS: To compare interassay reliability for these methods of obtaining the cephalic index and cranial vault asymmetry index, the differences between photographically and anthropometrically derived values were plotted against anthropometrically derived values alone (Bland-Altman plots). The photographic method satisfied the limits of agreement (cephalic index, 7.51%; cranial vault asymmetry index, 6.57%) and showed slightly lower values represented by the respective bias (cephalic index, 1.79%; cranial vault asymmetry index, 3.03%). Comparison between observers revealed excellent agreement, detected by the intraclass correlation coefficient of .982 for the cephalic index and .946 for the cranial vault asymmetry index. CONCLUSION: Our results demonstrate that digital photography is a reliable tool for quantifying cranial deformities. Furthermore, it is rapid, noninvasive, and reproducible. However, we continue to use both methods in clinical practice.

Indication for an additional postoperative antibiotic treatment after surgical incision of serious odontogenic abscesses.

INTRODUCTION: Serious abscesses of an odontogenic origin occur frequently in the oral and maxillofacial surgery departments. Rapid surgical incision and drainage constitutes the most important therapeutic action. However, additional surgical therapy and supplementary administration of antibiotics is often carried out, such that the efficiency of this supplementary therapeutic option has been questioned. METHODS: All patients with severe odontogenic infections who received surgical treatment under general anaesthesia were recruited to this retrospective study. We determined whether they received additional antibiotic therapy on the ward and if it was possible to improve therapeutic outcomes using this option. RESULTS: A total of 258 patients with a severe odontogenic infection between January 2008 and August 2014 were included. The most frequent infection observed was a submandibular abscess (56%), followed by a perimandibular abscess (18%) and a submental abscess (9%). About 65% of the patients were treated with antibiotics in addition to surgery. The median CRP level prior to surgical treatment was 87.8 mg/l (Q1: 40.3 mg/l; Q3: 143.5 mg/l) in patients who were administered an additional antibiotic and 83.8 mg/l (Q1: 37.3 mg/l; Q3: 135.0 mg/l) in those who received no antibiotic treatment after surgery. The postoperative median CRP levels were 116.5 mg/l (Q1: 52.1 mg/l; Q3: 159.3 mg/l) and 106.5 mg/l (Q1: 40.6 mg/l; Q3: 152.6 mg/l), respectively. Neither the preoperative CRP level (p = 0.546) nor the postoperative CRP level (p = 0.450) differed significantly between the groups. But patients who received additional antibiotic therapy had a significantly longer hospital stay (median: 6 days; range: 1-22 days) than patients who had no additional antibiotic therapy (median: 4 days; range: 1-19 days) (p = 0.002). CONCLUSIONS: This study did not show an improvement in the therapeutic outcome with administration of supplementary antibiotics in addition to surgery. Thus, surgically incising an abscess is the most important therapeutic action and administration of antibiotics must be critically scrutinised.

A New Type of Chronic Wound Infection after Wisdom Tooth Extraction: A Diagnostic Approach with 16S-rRNA Gene Analysis, Next-Generation Sequencing, and Bioinformatics.

Delayed-onset infections are rare postoperative complications of lower third molar extractions. This article presents a case of a chronic combined hard and soft tissue infection after the extraction of a third molar, where the causative organisms could only be elucidated by molecular methods. Experimental 16S-rRNA gene analysis with next-generation sequencing and bioinformatics was used to identify the bacterial spectrum of the infection. 16S-rRNA gene analysis delivered the microbiome of the abscessing inflammation while standard culture and laboratory examinations were all sterile. The microbiome showed a mixed bacterial infection with a dominance of Delftia and Alcanivorax (spp.) besides other bacteria of the normal oral flora. Using 16S-rRNA-gene analysis, next-generation sequencing, and bioinformatics, a new type of chronic wound infection after wisdom tooth extraction was found. The property of Delftia and Alcanivorax (spp.) as water-affine environmental bacteria raises suspicion of infection from contaminated water from a dental unit. Thus, osteotomies of teeth should only be done with sterile cooling water. The 16S-rRNA gene analysis should become a part of the routine diagnostics in medical microbiology.

Functional and aesthetic treatment outcomes after immediate jaw reconstruction using a fibula flap and dental implants.

PURPOSE: Microvascular fibula flap surgery is a reliable and effective procedure for reconstructing the jaws after tumour surgery. This procedure allows the placement of dental implants after bone consolidation. This study was designed to evaluate the oral, functional, and aesthetic rehabilitation of tumour patients with immediate fibula transfer and dental implants and included assessment of diet, speech, and aesthetics. MATERIALS AND METHODS: The study included 34 patients who underwent ablative tumour surgery and immediate jaw reconstruction using a fibula free flap with consecutive rehabilitation by dental implants. In total, 134 implants were inserted into the transferred fibula. The functional and aesthetic results were assessed using a questionnaire. Implant loss and oral excursion were compared with diet type, speech ability, functionality, and patient satisfaction. RESULTS: Of the 34 patients included in this study, 33 completed the questionnaire. Twenty-six patients (76%) could eat normally without the limitation of a hard or soft diet, 73% could speak intelligibly, and 31 rated the aesthetic result from good to excellent. CONCLUSION: The fibula flap with the early application of endosseous implants allowed primary immediate reconstruction of the jaw, significantly leading to functional and aesthetic satisfaction in patients who underwent ablative tumour surgery.

Donor-site Morbidity after Retromolar Bone Harvesting Using a Standardised Press Fit Cylinder Protocol.

Precise fitting and immobilisation of bone transplants at the recipient site is of utmost importance for the healing process. With the help of the standardised Osseo Transfer System, the recipient site is adjusted to the graft, rather than vice versa as it is typically done. The aim of this study was to analyse donor-site morbidity after harvesting cylindrical bone grafts from the retromolar region using the Osseo Transfer System. The patient satisfaction with the surgical procedures was also evaluated. All patients treated with this standardised reconstruction method between 2006 and 2013 at the Department of Cranio-Maxillofacial Surgery, University Hospital Giessen, were included in this study. Complications were recorded and evaluated. Bone graft success and patient satisfaction were documented with a questionnaire, and then confirmed by clinical and radiological follow-up examinations. Fifty-four patients were treated and 64 harvested cylindrical autologous bone grafts were transplanted. In all cases, dental implants could be inserted after bone healing. One patient lost an implant, associated with failure of the bone graft. Six patients who were examined continued to show neurological disorders in locally limited areas. No complete or long-term damage of the inferior alveolar nerve occurred. More than 94% (n = 52) of the patients were 'very satisfied' or 'satisfied' with the results and would recommend this surgical treatment to other patients. The standardised Osseo Transfer was an effective treatment option for small and mid-sized alveolar ridge augmentations. A low donor-site morbidity rate and a high transplant success rate were verified. The Osseo Transfer System demonstrated to be a reliable surgical technique without major complications. We highly recommend this surgical augmentation procedure as a surgical treatment for local bone defects.

Evaluation of Implant Success in Patients with Dental Aplasia.

INTRODUCTION: Dental aplasia is an anomaly in which the number of teeth is reduced. It is the most commonly occurring dental anomaly during tooth development. Treatment management of patients with dental aplasia is challenging. OBJECTIVES: The aim of this retrospective clinical study was to analyze the survival and success rates of dental implants placed in hypodontic patients, rated with different criteria. METHODS: Forty-three patients were diagnosed with dental aplasia and treated with dental implants between November 2000 and February 2016. The variables assessed included the plaque level, bleeding on probing, probing depth, implant mobility, implant stability, and implant loss. To analyze the peri-implant bone level, a panoramic X-ray of each patient was taken. The results were compared with X-rays taken immediately after implantation. RESULTS: Thirty-seven patients (16 males; 21 females) participated in this study. In total, 155 implants (86 maxillary; 69 mandibular) were inserted. Two of the 155 implants failed; the in situ survival rate was 98.7%. The success rate according to the criteria of Buser et al. was 96.8%, and that according to the criteria of Albrektsson et al. was 88.4%. CONCLUSION: The survival and success rates of dental implants in patients with congenitally absent teeth were very high and did not differ significantly from results achieved in an unaffected population. Dental implants are a reliable therapy for patients with dental aplasia.

Survival of dental implants placed in vascularised fibula free flaps after jaw reconstruction.

PURPOSE: Ablative oncological surgery to treat head-and-neck cancer often triggers a requirement for jaw reconstruction. Modern surgical procedures using free microvascular flaps afford acceptable outcomes in terms of restoration of bony and soft tissue defects. A fibula free flap is often the preferred flap, as the bone length is considerable and a two-surgeon approach is possible. Dental implants play important roles in functional rehabilitation. Our aim was to evaluate the survival of dental implants placed in reconstructed areas after transfer of fibula tissue to the jaw. MATERIALS AND METHODS: We retrospectively studied 34 patients who underwent ablative tumour surgery and jaw reconstruction using osteocutaneous fibula free flaps and who then received dental implants. We evaluated implant survival and success, survival of the fibula flap, and clinical and radiographic data. RESULTS: We included 34 patients, 23 of whom were diagnosed with squamous cell carcinoma. In total, 134 dental implants were inserted in transferred fibula bone. The cumulative implant survival rate was 81%. The survival rate of the 34 fibula flaps transplanted after surgical reconstruction was 97%. CONCLUSION: The insertion of endosseous implants after jaw reconstruction using vascularised fibula tissue yields successful dental rehabilitation in patients with oral cancers.

Ex corpore linguae: A cohort analysis after a unique surgical technique in oral cancer resection.

OBJECTIVE: Resection of posteriorly located oral squamous cell carcinomas (OSCCs) remains challenging for head and neck surgeons. However, several surgical techniques, such as lip and mandibular splitting, as well as submental "visor drop-down" of intraoral soft tissues, have been proposed for this purpose. Merrick et al. suggested that a pedicled genial drop-down surgical approach should be used to resect dorsally located OSCCs. Our study investigated patient outcomes following this surgical procedure, as no previous study has analyzed long-term follow-up data. MATERIAL AND METHODS: All patients who underwent surgery using the pedicled genial "visor drop-down" approach at the Maxillofacial Department of the University Hospital Giessen in Germany between 1995 and 2010 were included in this study. In addition, our study required that patients diagnosed with OSCC had no history of other intraoral malignancy or any other form of malignancy. A preliminary questionnaire was completed for each patient based on retrospective analysis of available data from medical reports. RESULTS: A total of 51 patients fulfilled all inclusion and exclusion criteria and were evaluated retrospectively. In total, 32 patients were excluded from the study due to OSCC recurrence or acquisition of a different type of malignancy. The male to female distribution of patients in our study was 30 to 21 (58.8%-41.2%), and the mean ages of female and male patients were 57.7 (SD 14.3) and 55.7 (SD 14.4) years, respectively. Approximately 76.5% of tumors were located along the dorsal aspect of the tongue, 17.6% were along the floor of the mouth, 3.9% were in the dorsal mandibular region, and 1.9% were in the dorsal palatal region. The mean overall operation time was 6.25 h, and 28 patients received microvascular flaps for reconstruction. Results of final histopathological examination suggested primary in-sano resection of the tumor in 84.3% of patients. Overall, the 5-year postoperative survival rate was 52.9%; 31.3% of the patient cohort was not followed up for the full 5-year period. In addition, 15.7% of the patients included in our study died during the study period. Unimpaired functional outcomes in terms of swallowing and speech were observed in 86.3% of patients. CONCLUSION: The pedicled genial "visor drop-down" approach, also known as the ex corpore linguae, is a suitable method for the radical resection of dorsally located OSCCs, with a promising 5-year survival rate and satisfactory postoperative oral function.