Current concepts in cleft care: A multicenter analysis.

The current surgical techniques used in cleft repair are well established, but different centers use different approaches. To determine the best treatment for patients, a multi-center comparative study is required. In this study, we surveyed all craniofacial departments registered with the German Society of Maxillofacial Surgery to determine which cleft repair techniques are currently in use. Our findings revealed much variation in cleft repair between different centers. Although most centers did use a two-stage approach, the operative techniques and timing of lip and palate closure were different in every center. This shows that a retrospective comparative analysis of patient outcome between the participating centers is not possible and illustrates the need for prospective comparative studies to establish the optimal technique for reconstructive cleft surgery.

Moving the mandible in orthognathic surgery - A multicenter analysis.

Orthognathic surgery has always been a classical focus of maxillofacial surgery. Since more than 100 years, various surgical techniques for mandibular repositioning have been developed and clinically tested. Since the establishment of plate and screw osteosynthesis, orthognathic surgery became more stable and safe. Nowadays, different surgical methods for mobilising the mandible are existing. This international multicenter analysis (n = 51 hospitals) is providing first evidence based data for the current use of different surgical methods. The dominating techniques were Obwegeser/dal Pont (61%) followed by Hunsuck/Epker (37%) and Perthes/Schlössmann (29%). The main osteosynthesis materials were plates (82%), bicortical screws (23.5%), or a combination of both (5.9%). 47% of all centers reported to use several surgical methods at the same time, depending on the anatomical problem and the surgeon's preference. This shows that different surgical methods seem to work as comparable, safe, and reliable procedures in everydays clinical practise. On this basis, further prospective studies could evaluate possible advantages for our patients.

Quality of implant anchored craniofacial and intraoral prostheses: patient's evaluation.

BACKGROUNDS: Bone-anchored prostheses have become a major issue in the rehabilitation of patients with facial defects. The objective of this study was to analyze how patients perceived the quality of implant-retained orbit, ear, nose, maxilla, or partial face prosthesis. METHODS: The patients' satisfaction from implant-retained prostheses usage was evaluated by a group of 30 patients with various facial defects. The survey referred exclusively to oncologic patients. Surveyors were classified basing on their age, sex, and defect localization, and their satisfaction was assessed by standardized questionnaire with 6-grade scale. RESULTS: Overall, acknowledging some weaknesses, such as reduced condition of surrounding soft tissue and necessity to enhance hygienic care, most of the patients assessed their prostheses as "good" emphasizing excellent mechanical retention and high wearing comfort. More detailed analysis revealed itemized outcome: (i) auricular prosthesis was indicated as the most comfortable solution by the patients; (ii) women and patients older than 55 years were more satisfied with the treatment results than men and patients younger than 55 years; and (iii) implant-retained prostheses were generally rated better than conventional adhesive-retained solutions. CONCLUSIONS: The results of the study proved that generally implants improve the satisfaction of patients with craniofacial prostheses. However, the actual level of satisfaction depends, to a large extent, on the defect's localization, sex, and age of the patient.

Secondary mandibular reconstruction after oral squamous cell carcinoma resection: clinical reevaluation of transport disk distraction osteogenesis.

Besides bone grafting, transport disk distraction osteogenesis (TDDO) is an alternative approach that can be used for the reconstruction of the mandibular arch after neoplastic surgery. Although several animal experiments are reporting about the applicability of this technique, little is known about its long-term success in human beings. In this study, we report about the successful treatment of patients with defects of their mandibular arch due to tumor resection by means of the external bifocal TDDO. A total of 7 patients (n = 3 with lateral, n = 4 with anterior defects) were followed up for a mean period of 56 months. Although neither adjuvant nor neoadjuvant chemotherapy negatively influenced callus formation, prereconstructive radiation with a dose of 51 Gy led to an insufficient callus formation. The reconstruction of anterior defects was unsatisfying because tensions from the soft tissue on the fragile and rubber-like callus negatively influenced the natural arch shaping.In these cases, additional surgery was often required. However, reconstruction of lateral defects of the mandibular arch was more successful and resulted in functional bone with good quality, in which dental implants could be inserted. The results of this study emphasize that TDDO by means of bifocal distraction provides functional bone comparable to residual bone.Lateral defects of mandibular arch can be better reconstructed, whereas anterior defects often require additional surgery.

Tight spatial and temporal control in dynamic basal to distal migration of epithelial inflammatory responses and infiltration of cytoprotective macrophages determine healing skin flap transplants in mice.

OBJECTIVE: We aimed to elucidate to date unknown molecular patterns of dynamic inflammatory tissue responses during uncomplicated healing of caudally pedicled skin flap transplants in mice. SUMMARY BACKGROUND DATA: Distal skin flap ischemic necrosis is a well-known complication in surgery. To improve ischemic conditions in impaired skin flaps, recent work attempted to increase insufficient vascularity by application of angiogenic growth factors or pluripotent cells. Wound inflammation is in the center of tissue repair, but its temporal and spatial regulation remains nearly unstudied in conditions of transplanted skin flap tissue. METHODS: RNase protection assay, quantitative real-time polymerase chain reaction, immunohistochemistry, enzyme-linked immunosorbent assay (ELISA) and immunoblot techniques were used to determine expression and cellular localization of central inflammation-related chemokines, cytokines, enzymes and cell types upon skin flap transplantation. RESULTS: We observed a marked keratinocyte-driven inflammation that moved from the caudal base to distal flap regions during healing. Keratinocytes of the skin flap epithelium expressed increasingly large amounts of chemokines (MIP-2, MCP-1) and cyclooxygenase (Cox)-2 particularly in distal portions of the transplant. The underlying wound bed did not appear to contribute essentially to the inflammatory response. Despite strong attracting chemokine signals, distal flap tissue was not infiltrated by excess numbers of neutrophils and macrophages. Moreover, infiltrating macrophages exhibited an anti-inflammatory phenotype characterized by the absence of NFkappaB activation and Cox-2 in the presence of a marked heme oxygenase (HO)-1 expression in surviving skin flap tissue. CONCLUSION: Survival of skin flap tissue might be determined by a cytoprotective type of wound macrophage in the presence of an intense epithelium-derived inflammation.

Growth of the orbit after frontoorbital advancement using nonrigid suture vs rigid plate fixation technique.

PURPOSE: To demonstrate whether a measurable difference occurs on the growth of the orbit when using 2 forms of stabilization of the supra-orbital rim after upper orbital osteotomy in children with craniosynostosis. The 2 methods of fixation include sutures providing nonrigid fixation and titanium or resorbable osteosynthesis plates. PATIENTS AND METHODS: In this prospective randomized study, the influence of the mentioned fixation materials was analyzed in a tertiary care center (university hospital). Sixteen consecutive children with craniosynostoses (trigonocephaly, brachycephaly, plagiocephaly) were included. All patients underwent bilateral frontoorbital advancement surgery. In 8 patients each, the fixation of the mobilized and reshaped supraorbital rim was carried out using either miniplates or sutures, resulting in a rigid or nonrigid fixation. By means of computed tomography scans taken preoperatively (mean age, 8months) and postoperatively (mean age, 6.5years), the development of the orbit was measured using the anterior interorbital distance, lateral orbital distance, medial orbital-wall length, lateral orbital-wall length, and medial orbital-wall protrusion. The results were compared to norm values and statistically evaluated. RESULT: In all patients, a long-term improvement of the orbit was achieved with absolute distances staying below norm values. The choice of the fixation material was of minor importance. CONCLUSION: Sutures providing nonrigid fixation of bone flaps seem to be feasible in reaching the aims of surgery in craniosynostotic children.

Reliable surgically assisted rapid palatal expansion by maxillary widening device.

For surgically assisted rapid palatal expansion, bone-borne as well as tooth-borne devices to widen the maxilla are commonly used, both revealing advantages and disadvantages. In the area of bone-borne devices, several new designs have been introduced during the last years as an alternative to the tooth-borne Biederman-Hyrax screw. However, with these new distractors, new problems occurred. Therefore, we designed the Maxillary Widening Device (MWD; Normed, Tuttlingen, Germany), a new bone-borne distractor, being not only user-friendly but also universally applicable. We have used this device since 2005 in patients with upper jaw compression, and the MWD turned out to be easy and quick to insert. Using a minimal surgical approach such as the modified Le Fort I osteotomy, operation time was low. Fixating as well as activating the distraction cylinder turned out to be very user-friendly. The removal of the device after the retaining period was also unproblematic, and the later forming of the dental arch was good to satisfying in all patients.

The importance of the primary reconstruction of the traumatized anterior maxillary sinus wall.

This study evaluates the importance of specific posttraumatic reconstruction of the fractured anterior sinus wall. Several methods of different complexity of reconstruction are being compared by means of radiologic, rhinoscopic, and clinical data. Four groups of a total of 207 patients (age, 18-73 years; follow-up average, 4.2 years) with midfacial fractures, divided by operation technique and year, were evaluated. Control groups 1 to 3 received standard procedures without special regard on the reconstruction of the anterior sinus wall; the study group received specific reconstruction. The study group 4 showed a lower complication rate in nearly all measured parameters in comparison to groups 1 and 2. Study group 4 had the smallest incidences of posttraumatic sequelae in radiologic examinations; the clinical outcome was even to group 3. During open reduction and fixation procedures of midfacial fractures, attention should be given to the reconstruction of the anterior sinus wall to avoid postoperative discomfort.

Autologous repair of an internal carotid artery aneurysm by resection, caliber reduction, and external mesh tube reinforcement in a 9-year-old boy.

Extracranial internal carotid artery aneurysms in children are rare, with a reported incidence of 0.5% to 1.9% in internal carotid artery aneurysm operations compared with all carotid operations in adult patients. We report a case of surgical reconstruction of an extracranial internal carotid artery aneurysm in a 9-year-old boy. Our patient complained of episodic neck pain on the left site under the mastoid process for the last year. The child was otherwise healthy. Autologous reconstruction without graft interposition was planned. Surgical repair was performed by resection of the main body of the aneurysm and restoration of the arterial continuity with end-to-end anastomosis. Because nondilated proximal and distal vessels could not be approximated, the most distal end of the aneurysm was tapered over a mandril. To prevent redilation, a tubular polyester external stent was fitted around the diseased segment.

[First experiences in maxillary arch expansion using the MWD (Maxillary Widening Device)]. / Erste Erfahrungen mit dem "Maxilla Widening Device" (MWD) zur Expansion des Oberkiefers.

AIM: Conventional devices for surgical assisted rapid palatinal expansion are either tooth or bone borne. During clinical application over years, system dependant deficiencies, using either device became apparent. So together with Normed, Tuttlingen, we developed a new bone borne distractor (MWD, Maxillary Widening Device). In this article we introduce this distractor and present our first experiences in using this device. PATIENTS AND METHODS: In this study, 20 patients suffering from maxillary arch compression with anterior crowding were treated using MWD in combination with Glassman's modified Le-Fort-I-osteotomy. Additionally the MWD was inserted in two cleft lip and palate patients, as well as one patient with bilateral microsomy. RESULTS: The MWD turned out to be a safe, easy to handle and reliable bone borne distractor leading to excellent results. The MWD can be used in early adult as well as in syndromal patients. In early adult patients the complication rate averaged 25%, widening averaged 7,6mm. Relaps was not discovered. CONCLUSION: The MWD turned out to be a reliable, stable and user-friendly device leading to excellent results.