Assessment of the intrasinusidal volume before and after maxillary sinus augmentation using mri - a pilot study of eight patients.

PURPOSE: The purpose of this study was to evaluate the suitability, accuracy, and reliability of a non-invasive 3-Tesla magnetic resonance imaging technique (3 T-MRI) for the visualization of maxillary sinus grafts in comparison to conventional, X-ray-based, established standard imaging techniques. METHODS: A total of eight patients with alveolar bone atrophy who required surgical sinus floor augmentation in the course of dental implantation were included in this pilot study. Alongside pre-operative cone-beam computed tomography (CBCT), 3 T-MRI was performed before and 6 months after sinus floor augmentation. Two investigators measured the maxillary sinus volume preoperatively and after bone augmentation. RESULTS: In all cases, MRI demonstrated accurately the volumes of the maxillary sinus grafts. Following surgery, the bony structures suitable for an implant placement increased at an average of 4.89 cm3, corresponding with the decrease of the intrasinusidal volumes. In general, interexaminer discrepancies were low and without statistical significance. CONCLUSION: In this preliminary study, we could demonstrate the feasibility of MRI bone volume measurement as a radiation-free alternative with comparable accuracy to CT/CBCT before procedures like sinus floor augmentation. Nevertheless, costs and artifacts, also present in MRI, have to be taken into account. Larger studies will be necessary to justify the practicability of MRI bone volume evaluation.

Correction to: Induced surface proteins of Staphylococcus epidermidis adhering to titanium implant substrata.

There is a mistake in the original published version of this article. The word 'Streptococcus' in the article title should have been 'Staphylococcus'.

Induced surface proteins of Staphylococcus [corrected] epidermidis adhering to titanium implant substrata.

OBJECTIVE: Staphylococcus epidermidis, as a primary colonizer, is strongly associated with infections of (dental) implants (i.e., peri-implantitis), but little is known about the surface proteome of this bacterium. For the identification of bacterial adhesins, this study investigated the surface proteome of S. epidermidis adhering directly to titanium implant substrata. MATERIALS AND METHODS: S. epidermidis strain ATTC 35984 was cultured either planktonically or on titanium implant specimens. The surface proteomes were isolated by mutanolysin digestion, and proteins were separated by 2D gel electrophoreses to reveal highly expressed proteins only. Protein spots were visualized by silver staining and proteins were identified by mass spectrometry. RESULTS: Surface proteome analyses of S. epidermidis on titanium identified six expressed proteins. Three proteins were highly expressed on the titanium implants including accumulation-associated protein Q8CQD9. These specific proteins could be potential pathogenicity factors of bacteria in peri-implant biofilms. CONCLUSION: For the first time, our study identified S. epidermidis surface proteins, which are expressed after adhesion to titanium implant materials. CLINICAL RELEVANCE: Our study reveals possible candidates for a newly protein-based vaccine against peri-implantitis.

The influence of third molars in the line of mandibular angle fractures on wound and bone healing.

OBJECTIVES: The objective of this study was to evaluate postoperative complications after removal or retention of the third molar in the line of mandibular angle fractures. MATERIALS AND METHODS: This retrospective study included the data of 98 patients with a molar in the line of a mandibular angle fracture treated with internal reduction and mini-plate fixation at our department over 9 years. Patients were classified into two groups: tooth removal during osteosynthesis (n = 45) and tooth retention (n = 55). The primary target criterion was the incidence of minor (outpatient treatment, local measures) and major (surgical revision, rehospitalisation) complications. Time between trauma and surgery was 1.4 days (range 0 to 12), and the average follow-up 291 days (range 66 to 863). RESULTS: Regarding the eruption status, 26 of 52 (50.0 %) impacted third molars, 11 of 19 (57.9 %) incompletely erupted and 8 of 27 (29.6 %) completely erupted molars had been removed during open reduction. Overall, 17 (17.3 %) patients had postoperative minor (n = 7) or major (n = 10) complications, in detail 10/45 (22.0 %) patients after tooth removal and 7/55 (13 %) patients after tooth retention (p = 0.286). Complication rates between impacted and incompletely erupted third molars (impacted molars 15.0 %, incompletely erupted molars 10.0 %) did not differ significantly, but completely erupted molars had a complication rate of 26.0 %. CONCLUSIONS: Mandibular angle fractures with a completely erupted third molar show the highest complication rate after open reduction and osteosynthesis. Retention of a non-infectious third molar facilitates open reduction and does not increase the complication risk. CLINICAL RELEVANCE: The study helps with the decision of removing or retention of a third molar during surgical treatment of a mandibular angle fracture.

EGR1 supports the osteogenic differentiation of dental stem cells.

AIM: To evaluate whether and how the transcription factor early growth response gene 1 (EGR1) affects the osteogenic differentiation of dental stem cells. METHODOLOGY: Dental stem cells from apical papilla (SCAPs) and from the dental follicle (DFCs) were transfected with EGR1-specific siRNA or EGR-1 expression plasmid. Gene regulation was verified at protein level by Western blotting. The expression of the transcription factors distal-less homeobox 3 (DLX3), alkaline phosphatase (ALP) and bone morphogenetic protein 2 (BMP2), which are all regulators and markers of the osteogenic differentiation in dental stem cells, was determined by quantitative reverse transcription-polymerase chain reaction (qRT-PCR). To investigate mineralization, SCAP long-term cultures were stained with alizarin red after EGR1 over-expression. RESULTS: EGR1 was induced in SCAPs during osteogenic differentiation. DLX3 and bone morphogenetic protein 2 (BMP2) were up-regulated after EGR1 over-expression and down-regulated after EGR1 depletion. The expression of ALP was also down-regulated after EGR1 depletion. The over-expression of EGR1 in SCAPs promoted mineralization after osteogenic differentiation. CONCLUSIONS: EGR1 supported the osteogenic differentiation of dental stem cells by potentially regulating the expression of DLX3 and BMP2.

The functional and aesthetic reconstruction of midfacial and orbital defects by combining free flap transfer and craniofacial prosthesis.

OBJECTIVES: The reconstruction of complex facial defects should satisfy both aesthetic and functional requirements. In the midfacial area, the nasal passage should be sufficiently separated from the orbit and the oral cavity to avoid both dysphagia and articulation disorders and to allow unimpaired nasal breathing. In the case of large defects, the use of craniofacial prostheses alone is ineffective in the restoration of functional units in the majority of patients. Therefore, we evaluated the combination of microvascular tissue transfer and episthetic constructions in a series of patients. MATERIAL AND METHODS: Our case series included ten patients requiring one or more free flaps in combination with extraoral implants and episthetic work. RESULTS: Four women and six men with a mean age of 68 years were included. All patients were treated because of tumours in the midface area. Eight patients were free of recurrence, one patient died during the follow-up. For the reconstructions, we used anterolateral thigh flaps, radial forearm flaps, fibular flaps and iliac crest bone flaps. On average, we inserted four extraoral implants in the periorbital region. Seven implants of four patients did not osseointegrate and had to be removed. CONCLUSIONS: For complex reconstructions of extensive defects in the midfacial area, microvascular free tissue transfer in combination with extraoral implants and craniofacial prosthetic work yields reasonable functional and aesthetic outcomes and noticeably improves the quality of life. CLINICAL RELEVANCE: This work investigates patient cases with extensive defects in which free flap or episthetic work alone proved ineffective for reconstruction.

Migration of human dental follicle cells in vitro.

BACKGROUND AND OBJECTIVES: The objective of this study was to elucidate the effects of different growth factors on the migration of dental follicle cells (DFCs). DFCs are ectomesenchymally derived easily accessible multipotent stem cells. Cell migration is a crucial step in many biological processes but also for tissue engineering. Growth factors such as epidermal growth factor (EGF), bone morphogenetic protein-2 (BMP2) or transforming growth factor ß1 (TGF-ß1) can be used to modify the behavior of cells. MATERIAL AND METHODS: We used different migration assays (gel spot assay, scratch assay, transwell assay) to evaluate the influence of EGF, BMP2 and TGF-ß1 on the migration of DFCs. We investigated the expression of migration-related genes after growth factor stimulation using the PCR array human cell motility. RESULTS: DFCs treated with BMP2 or TGF-ß1 migrated faster than DFCs treated with EGF. Additionally, more migration-related genes are regulated after treatment with BMP2 or TGF-ß1 than with EGF. TGF-ß1 additionally functions as a chemoattractant for DFCs. Osteogenic differentiation markers were regulated after BMP2 treatment only. CONCLUSION: Whereas the strong migration induced by BMP2 was accompanied by beginning osteogenic differentiation the strong migration induced by TGF-ß1 was directional. EGF exhibited not only the weakest migration stimulation but also the weakest induction of differentiation into mineralizing cells.

ß-Tricalcium phosphate induces apoptosis on dental follicle cells.

Dental stem cells represent a good treatment option in regenerative dentistry. Regeneration of large bone defects can be achieved by a cell-based therapy consisting of osteogenic progenitor cells, such as dental follicle precursor cells (DFCs), in combination with bone substitute material used as a scaffold. A previous trial had shown that ß-tricalcium phosphate (TCP) improves the osteogenic differentiation of DFCs. In the present trial, we investigated the attachment, survival, and proliferation of DFCs on TCP in more detail. A high initial cell number was required for the adhesion, attachment, and sufficient proliferation of DFCs on a TCP scaffold. The TCP scaffold released fine soluble particles enriched in TCP eluates that induced cell death and showed typical characteristics of programmed cell death (apoptosis) in DFCs. During cultivation on the TCP scaffold, DFCs showed a highly upregulated expression of antiapoptotic genes but a downregulated expression of proapoptotic markers. In conclusion, TCP supports osteogenic differentiation in DFCs but also induces programmed cell death. Our data suggest that surviving DFCs avoid programmed cell death by inducing antiapoptotic genes.

Quantitative assessment of bone microvascularization after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS).

BACKGROUND: Extensive wound defects frequently have to be covered by free flap transplantation. A monitoring device for measuring capillary level perfusion of bone is currently not available. OBJECTIVE: The aim of the study was to detect complications after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS). Additionally quantitative analysis was performed by special perfusion software (QONTRAST®; Bracco, Italy). METHODS: 22 patients were examined after osteocutaneous flap transplantation during the first 72 h after operation. CEUS was performed with a linear transducer (6-9 MHz, LOGIQ E9/GE) after bolus injections of 2.4 ml ultrasound contrast agent (SonoVue®; Bracco, Italy). The osseous perfusion and soft tissue perfusion were analyzed separately and quantitative perfusion analysis was performed. Five patients had to undergo reoperation due to compromised flap microvascularization. RESULTS: In all 5 complications reduced osseous and soft tissue perfusion was seen using CEUS. Additionally using the perfusion parameters TTP (time to PEAK), RBV (regional blood volume), RBF (regional blood flow) und MTT (mean transit time), significantly lower soft tissue and osseous perfusion was detected. CONCLUSION: CEUS seems to be capable of detecting vascular disturbances and of assessing microvascularization of the osseous component after osteocutaneous flap transplantation.

Relative size of fungiform papillae in patients with neurofibromatosis Type 1.

OBJECTIVE: To explore possible manifestations of neurofibromatosis on the tongue, especially, enlarged papillae fungiformes. According to the literature, enlarged fungiform papillae of the tongue are a very common oral finding in patients with Neurofibromatosis Type 1 (NF1). MATERIALS AND METHODS: Firstly, photos of 18 NF1 patients' tongues, taken at different times were compared to rule of possible fluctuating papillae size. Secondly, 60 photos of 60 patients with NF1 were age/sex matched, blinded and compared to 60 photos of 60 healthy patients. Three independent medical doctors rated the photos in regard of the fungiform papillae as smaller/same/larger at two different times. The inter- and intraindividual results were compared. Thirdly, fungiform papillae of 11 NF1 patients were quantitatively measured using the Denver protocol. RESULTS: The fungiform papillae showed a stable size. The comparison of the healthy individuals to the NF1 patients suggests that the larger papillae are significantly more frequent in NF1 patients than in age- and gender-matched non-NF1 individuals. The agreement between two ratings of each of the 3 raters at different time points was two moderate and one substantial, the agreement among raters was only fair, since the Fleiss' Kappa value of all 6 ratings was 0.38. CONCLUSION: Although this study confirms that the evaluation of the size of the fungiform papillae by visual inspection only is very subjective, the fungiform papillae in NF1 patients do seem to be enlarged at a statistically significant level. Nonetheless the statistical difference is not distinctive enough to establish this as a diagnostic tool in diagnosing NF1. CLINICAL RELEVANCE: Facilitating the diagnosis of NF1 is an important factor in finding the correct treatment for these patients. A clinical inspection of the tongue is a simple and non-invasive procedure. This paper addresses the question if an inspection of the tongue, especially the fungiform papillae is a reliable indicator for the diagnosis of NF1.

Loss of PTEN is associated with elevated EGFR and HER2 expression and worse prognosis in salivary gland cancer.

BACKGROUND: Activity of the tumour-suppressor gene PTEN is reduced in different types of cancer and implicates non-responsiveness to targeted therapy. This study evaluates the gene and protein status of PTEN in salivary gland carcinomas. METHODS: A total of 287 carcinomas of the major and minor salivary glands were investigated for phosphatase and tensin homologue located on chromosome 10 (PTEN) deletion and loss of PTEN expression using fluorescence in situ hybridisation (FISH) and immunohistochemistry (IHC), respectively. Results were correlated to clinicopathological parameters, long-term survival, epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor 2 (HER2) (IHC and FISH) status of the tumours. RESULTS: Hemizygous deletions of PTEN were found in 35 out of 232 (15.1%) carcinomas, while homozygous deletions were observed in 17 out of 232 (7.3%) tumours. Phosphatase and tensin homologue located on chromosome 10 deletion was common in certain histological subtypes and especially homozygous deletion was associated with high-grade malignancy, lymph node metastases and unfavourable long-term prognosis (P<0.001). Loss of PTEN expression was present in 59 out of 273 (21.6%) carcinomas and was significantly correlated to genomic PTEN deletion, high-grade malignancy (P<0.001), increased tumour size (P=0.036), lymph node metastases (P=0.007) and worse disease-specific survival (P=0.002). Genomic PTEN deletion, in particular homogenous deletion (P<0.001) predominantly occurred in tumours with increased gene copy number of EGFR (60.0%) and/or amplification of HER2 (63.6%). Loss of PTEN expression was frequently found in tumours overexpressing EGFR (28.6%) and/or HER2 (52.6%). CONCLUSION: PTEN function is reduced in different types of salivary gland cancer indicating unfavourable prognosis. Its association with EGFR and HER2 signalling might affect targeted therapy.

Cancer stem cell-like cells from a single cell of oral squamous carcinoma cell lines.

Resistance of oral squamous cell carcinomas (OSCC) to conventional chemotherapy or radiation therapy might be due to cancer stem cells (CSCs). The development of novel anticancer drugs requires a simple method for the enrichment of CSCs. CSCs can be enriched from OSCC cell lines, for example, after cultivation in serum-free cell culture medium (SFM). In our study, we analyzed four OSCC cell lines for the presence of CSCs. CSC-like cells could not be enriched with SFM. However, cell lines obtained from holoclone colonies showed CSC-like properties such as a reduced rate of cell proliferation and a reduced sensitivity to Paclitaxel in comparison to cells from the parental lineage. Moreover, these cell lines differentially expressed the CSC-marker CD133, which is also upregulated in OSCC tissues. Interestingly, CD133(+) cells in OSCC tissues expressed little to no Ki67, the cell proliferation marker that also indicates reduced drug sensitivity. Our study shows a method for the isolation of CSC-like cell lines from OSCC cell lines. These CSC-like cell lines could be new targets for the development of anticancer drugs under in vitro conditions.

[Maxillary and mandibular fractures. Treatment concepts in maxillofacial surgery]. / Frakturen von Maxilla und Mandibula. Kieferchirurgische Behandlungskonzepte.

Maxillary and mandibular fractures are a relatively frequent occurrence due to the exposed location of the jaws and are caused mainly by acts of violence, traffic and recreational accidents. Mandibular fractures can be treated conservatively with dental splints and intermaxillary fixation. Since Michelet, miniplate osteosynthesis via intraoral access has become the method of choice. Champy showed that the monocortical fixation of miniplates at the level of the linea obliqua results in stable osteosynthesis, despite postoperative micro-movements in the fracture gap, and postulated the principle of dynamic compression. Dislocated fractures of the mandibular collum are treated with stable osteosynthesis via an intra- or extraoral approach, while fractures of the mandibular joint are usually treated conservatively and early functional rehabilitation is favored. For mandibular fractures, the principle of load-bearing and load-sharing should be considered, i.e. in the case of sufficient bone and uncomplicated fractures, the bone can bear most of the force, such that miniplates are sufficient (load-sharing). If bones are weakened by atrophy or in the case of infected, comminuted or defect fractures osteosynthesis plates must bear the load alone (load-bearing).

Release of gentamicin sulphate from biodegradable PLGA-implants produced by hot melt extrusion.

For a long-term local treatment of osteomyelitis biodegradable poly(lactic-co-glycolic acid) (PLGA) implants loaded with gentamicin sulphate (GS) were prepared, analysed and compared to the marketed product Septopal (Biomet, Darmstadt, Germany), which consists of polymethylmethacrylate (PMMA) beads loaded with the same active ingredient. The implants were manufactured by hot melt extrusion with a twin screw extruder. In order to decrease the processing temperature and to improve the drug release behaviour, polyethylene glycol 400 (PEG 400) was added as plasticizer in different concentrations. The glass transition temperature of PLGA measured by differential scanning calorimetry declined in the same manner as the extrusion temperature with increasing PEG 400 concentration. The extrudates of all batches exhibited good encapsulation efficiency between 85% and 115% of the specified content. The behaviour of the implants during exposure to a release medium were characterised by scanning electron microscopy, gravimetric analysis and finally in vitro drug release studies. The results suggest that drug liberation is not affected by the addition of PEG 400, and depends on the drug-PLGA ratio only. Extrudates with 25% GS showed a release pattern with an initially higher drug release followed by a zero order kinetic for about four weeks and showed release profiles equivalent to Septopal.

The effects of surgical expansion of the maxillary arch and its consequences for the incisor axis.

PURPOSE: Reduced transverse maxillary dental arch width may be treated either by surgically supported rapid maxillary expansion (SRME) with conservative orthodontic appliances or by means of Le Fort I osteotomy (LFIO). Both are means of transverse maxillary expansion. METHODS: Both surgical methods (SRME and LFIO) were evaluated with regard to the presurgical and postsurgical form of the maxillary dental arch and its consequences for the incisor axis by means of 32 dental casts and cephalometric analysis. RESULTS: In both groups, anterior and posterior dental arch width showed significant changes after surgery, but changes in anterior dental arch width were less significant after LFIO (p = 0.004) than after SRME (p < 0.000; t-test). Cephalometric analysis (OK1/N1) did not show any significant differences between the two surgical methods (p = 0.1266; t-test). Anterior arch length was not reduced after LFIO but significantly reduced after SRME. Thus, the ideal elliptical shape of the dental arch was lost in the SRME group, which may impede esthetic outcome of the maxillary dental arch. CONCLUSION: Le Fort I osteotomy achieving direct transverse expansion should be favored over surgically supported rapid maxillary expansion if transverse expansion does not exceed 7 mm.

The role of hypoxia in orthodontic tooth movement.

Orthodontic forces are known to have various effects on the alveolar process, such as cell deformation, inflammation, and circulatory disturbances. Each of these conditions affecting cell differentiation, cell repair, and cell migration, is driven by numerous molecular and inflammatory mediators. As a result, bone remodeling is induced, facilitating orthodontic tooth movement. However, orthodontic forces not only have cellular effects but also induce vascular changes. Orthodontic forces are known to occlude periodontal ligament vessels on the pressure side of the dental root, decreasing the blood perfusion of the tissue. This condition is accompanied by hypoxia, which is known to either affect cell proliferation or induce apoptosis, depending on the oxygen gradient. Because upregulated tissue proliferation rates are often accompanied by angiogenesis, hypoxia may be assumed to fundamentally contribute to bone remodeling processes during orthodontic treatment.

Luminescence ratiometric oxygen imaging (LROI) in microvascular anastomosed fibular and radial forearm flaps.

BACKGROUND: In a preliminary trial, we were able to show first promising results in the analysis of perioperative and postoperative perfusion of free flaps by means of a new monitoring system for detecting thrombotic vessel occlusion before clinical signs become evident. OBJECTIVE: We investigated whether flap monitoring by measuring perfusion-dependent parameters differs between radial forearm and fibular free flaps and whether a threshold value requiring anastomosis revision could be determined. METHODS: 37 radial forearm flaps (RF) and 15 fibular flaps (FF) were harvested and transplanted. Perfusion was determined by measuring a fluorescent oxygen sensor foil covering a flap's skin surface with a handheld fluorescence microscope. The sensor contained an oxygen reservoir, which was consumed by the tissue corresponding to the perfusion status of the flap. Measurements were done before explantation, after successful anastomosis and one day after surgery. RESULTS: We found a significant difference (p < 0.005) in the relative transdermal oxygen consumption (RTOC) between clinically well-perfused grafts (RF: mean: 0.13 ± 0.08; FF: mean: 0.15 ± 0.07) and clinically poorly perfused grafts (RF: mean: 0.40 ± 0.09; FF: mean: 0.55 ± 0.28). A threshold RTOC value of 0.3 for differentiating between well-perfused and poorly perfused flaps was confirmed for both RF and FF.

Simple, fast and reliable perfusion monitoring of microvascular flaps.

BACKGROUND: Free tissue transfer in head and neck reconstructions has a very high success rate, but thrombotic vessel occlusion is still a serious complication occurring in up to 10% of all cases. Thus, a simple, fast and reliable monitoring system for free flaps would be of advantage. OBJECTIVE: The aim of this study was to investigate whether free flap monitoring by measuring perfusion-dependent parameters is a suitable method for discovering vessel thrombosis in free flaps. METHODS: 10 patients requiring tissue reconstruction after tumour surgery or because of chronic wounds were included in this study. 10 microvascular flaps were harvested and transplanted. Perfusion was determined by measuring a fluorescent oxygen sensor foil covering the flap's skin surface by means of a USB-handheld fluorescence microscope prototype. The sensor contained an oxygen reservoir which was consumed by the tissue corresponding to the perfusion status of the flap. Measurements were done before explantation, after successful anastomosis and 1 day after surgery. RESULTS: Clinically well-perfused grafts showed slope values between 0.07 and 0.27 (mean: 0.18 ± 0.07), and clinically poorly perfused grafts showed slope values between 0.35 and 0.75 (mean: 0.52 ± 0.19). In the present study, we used a threshold slope value of 0.3 for differentiating between well-perfused and poorly perfused flaps. CONCLUSION: Flap monitoring via oxygen imaging by means of fluorescent sensor foils appears to be a fast, non-invasive, cost-effective and thus suitable method for analyzing flap perfusion with the additional advantage of aiding decision making on flap revision.

High resolution contrast-enhanced ultrasound and 3-tesla dynamic contrast-enhanced magnetic resonance imaging for the preoperative characterization of cervical lymph nodes: First results.

The reliable detection of cervical lymph node (LN) metastases is the planning basis of a selective neck dissection for patients with oral squamous cell carcinoma (OSCC). The aim of this study was to evaluate whether contrast-enhanced ultrasound (CEUS) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) together are able to improve the preoperative characterisation of LNs. A time intensity curve analysis has been performed using CEUS and DCE-MRI for ten LNs, where one LN has been examined per patient. The studied LNs consist of five with and five without metastases. In CEUS the mean time to peak (TTP) was 18 s (range 13-29 s, standard deviation (SD) ± 7 s) for benign and 12 s (range 9-16 s, SD ± 4 s) for malignant LNs. In DCE-MRI the mean TTP was 27 s (range 18-36 s, SD ± 9 s) for benign and 21 s (range 18-27 s, SD ± 5 s) for malignant LNs. Moreover, the relative signal change with respect to reference tissue was significantly higher for LNs with than for those without metastases in both CEUS and DCE-MRI. A combination of imaging morphology, CEUS and DCE-MRI might be a promising method for a reliable differentiation of benign and malignant LNs.

Postoperative evaluation of microvascularization in mandibular reconstructions with microvascular flaps - first results with a new perfusion software for contrast-enhanced sonography (CEUS).

PURPOSE: Quantitative measurement of dynamic contrast values obtained by contrast-enhanced ultrasound (CEUS) for evaluating microvascularization in osseous and osseocutaneous free flaps used for maxillofacial reconstructions. PATIENTS AND METHODS: 22 patients (6 women, 16 men, mean age: 57 years, range: 47 to 82 years) who had received mandibular reconstructions with 3 avascular and 19 microvascular free osseous or osseocutaneous transplants were included in this trial. 16 patients had received a microvascular osseocutaneous fibular flap, 2 patients a microvascular osseous fibular flap and 1 patient a microvascular osseous iliac crest flap. Patients were followed up for 12 months on average (range: 3 to 20 months). Ultrasound examination was carried out by one experienced examiner with a linear probe (6-9 MHz, LOGIQ E9, GE) after the intravenous bolus injection of 2.4 ml contrast agent (SonoVue®, BRACCO, Germany). Digital cine loops were analysed with a quantification software (VueBox™) for determining wash-in parameters: Rise Time (RT), Peak Enhancement (PE), Wash-in Area Under the Curve (WiAUC) and Wash-in Rate (WiR). Results were compared with the patients' postoperative clinical outcome. RESULTS: For the bone area the median of the RT was 10.0 s (range 3.1 to 65.0 s), for the ratio between bone tissue and soft tissue for the PE the median was 10.4% (range 2.6 to 29.8%), the median for the WiAUC was 11.1% (range 1.5 to 77.7%) and the median for the WiR was 5.7 %(range 0.7 to 61.1%). None of the patients with microvascular osseocutaneous and osseous flaps showed any signs of transplant bone loss, which corresponded with the qualitative CEUS assessment. The patients with microvascular re-anastomosed transplants showed widely varying values for the investigated parameters (RT, PE, WiAUC, WiR). For patients with avascular bone transplants, these parameters were reduced to zero values for the bone area resulting in a significant difference (p < 0.05) for the PE compared to the patients with microvascular bone transplants. CONCLUSION: CEUS allowed the qualitative assessment of bone microvascularization by observing the transition of the contrast agent from the periostal area into the bone. However, defining a critical lower border by quantification of bone perfusion was difficult because of the inconstant perfusion of the bone transplants used in the trial.