Covering skin defects with a xenogeneic collagen matrix in comparison with a skin graft - A multicenter randomized controlled trial.

The objective of this study was to analyze, in a randomized controlled multicenter trial, whether a xenogeneic collagen matrix (XCM) could be used to cover skin defects. Patients with the need for skin excisions were recruited and randomized to treatment with a skin graft after a period of granulation or to treatment with an XCM. The results were evaluated by two independent observers on the Patient and Observer Scar Assessment Scale. On this scale, scars are ranked from 1 to 10 in six different categories. Results range from 6 to 60, with lower scores representing scars closer to normal skin. The results 6 months after reconstruction were used as primary endpoint and compared in a non-inferiority approach. A total of 39 wounds in the head and neck region were analyzed. The mean results were 16.55 (standard deviation 6.8) for XCM and 16.83 (standard deviation 8.21) in the control group. The result of the XCM was not significantly inferior to the result of the skin graft (p = 0.91). Within the limitations of the study, it seems that the use of xenogeneic collagen matrices is a viable alternative to other approaches in small skin defects, and therefore should be taken into account whenever the reduction of patient morbidity to a minimum is the priority. TRIAL REGISTRATION: This trial was registered in the German Clinical Trials Register under registration identification number DRKS00010930 and can be found under the following URLs: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00010930. https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00010930.

Differences in velopharyngeal pressures during speech sound production in patients with unilateral cleft lip and palate (UCLP) and healthy individuals.

Background: During articulation the velopharynx needs to be opened and closed rapidly and a tight closure is needed. Based on the hypothesis that patients with cleft lip and palate (CLP) produce lower pressures in the velopharynx than healthy individuals, this study compared pressure profiles of the velopharyngeal closure during articulation of different sounds between healthy participants and patients with surgically closed unilateral CLP (UCLP) using high resolution manometry (HRM). Materials and methods: Ten healthy adult volunteers (group 1: 20-25.5 years) and ten patients with a non-syndromic surgically reconstructed UCLP (group 2: 19.1-26.9 years) were included in this study. Pressure profiles during the articulation of four sounds (/i:/, /s/, /ʃ/ and /n/) were measured by HRM. Maximum, minimum and average pressures, time intervals as well as detection of a previously described 3-phase-model were compared. Results: Both groups presented with similar pressure curves for each phoneme with regards to the phases described and pressure peaks, but differed in total pressures. An exception was noted for the sound /i:/, where a 3-phase-model could not be seen for most patients with UCLP. Differences in velopharynx pressures of 50% and more were found between the two groups. Maximum and average pressures in the production of the alveolar fricative reached statistical significance. Conclusions: It can be concluded that velopharyngeal pressures of patients with UCLP are not sufficient to eliminate nasal resonance or turbulence during articulation, especially for more complex sounds. These results support a general understanding of hypernasality during speech implying a (relative) velopharyngeal insufficiency.

Exceptional Cases Demand Exceptional Personalized Solutions: The Next Level in Dental Rehabilitation.

Defects and bone loss in the maxilla and mandible pose significant challenges for dental rehabilitation. This paper focuses on complex cases of bimaxillary dental rehabilitation, where traditional dental implant protocols were not feasible in at least one jaw. Four patients were examined conceptually, where conventional dental implant placement (n = 20) was combined in either the same or opposite jaw with a patient-specific subperiosteal implant (n = 5). This study evaluates aspects such as primary stability, prosthodontic restoration, complications, and soft tissue management over the observation period. None of the five patient-specific subperiosteal implants (IPS Implants® Preprosthetic; KLS-Martin Group, Tuttlingen, Germany) experienced failure or showed any loosening of screws, with the longest observation period extending to 68 months. These implants were securely fixated away from the posts, without any biomechanical restrictions on loading from the time of insertion. Planning and manufacturing, including the initial suprastructure, followed a fully digital workflow. The number of screws required for multivector fixation ranged from 13 to 22. All dental implants placed remain functional, definitive prosthodontic restoration has been performed, and no stability loss or peri-implantitis has been observed. The IPS Implants® Preprosthetic emerges as a valuable consideration when conventional implant dentistry protocols encounter limitations.

Goldenhar Syndrome: Quality-of-Life Analysis of 43 Consecutive Patients.

Goldenhar syndrome is a rare congenital disease, characterized by the malformation of craniofacial features, spine, and other organs. Its pathogenesis and impact on patients' quality of life (QoL) have not been fully elucidated as yet. Therefore, data of all patients with Goldenhar syndrome, who were treated at Hannover Medical School between 1997 and 2020, were analyzed. Forty-three patients were identified. Their medical records were carefully reviewed for data regarding their age, sex, demographics, Pruzansky classification, surgical history, and affected side. Goldenhar syndrome-associated medical conditions, therapeutic procedures, and the impact of disease on QoL were assessed. Their QoL was assessed using the Oral Health Impact Profile (OHIP)-14 questionnaire. The χ 2 test and Pearson correlation were performed for statistical evaluation. Female sex was positively correlated with OHIP outcomes, whereas male sex had a negative correlation with OHIP outcomes. Therefore, females had significantly worse QoL than males. No significant correlation was observed between the Pruzansky classification and QoL or between surgical history and QoL. Goldenhar syndrome is a rare disease that presents with varying severity. Hence, prospective studies are required to further investigate the impact of Goldenhar syndrome on the QoL.

A Novel Method for Secondary Mandible Reconstruction to Re-Achieve a Native Condyle Position Comprising a New Design for Cutting Guides and New Positioning Devices.

Secondary mandibular reconstruction using fibular free flaps (FFF) is a technical challenge for surgeons. Appropriate operation planning is crucial for postoperative quality control and is notably necessary for the (re-) achievement of a physiological condylar position, and the sensible expansion and shaping of the transplant. Computer-assisted planning may help to reconstruct mandibular defects in a patient-specific and precise manner. Herein, we present a newly-developed workflow for secondary mandibular reconstruction using FFF; it comprises digital planning and in-house manufacturing to perform precise secondary mandible reconstruction. This method utilizes a newly designed positioning device to ensure the precise positioning of the fibula segments in relation to each other and the mandibular stumps. The presented in-house-printed positioning device made it possible to achieve digital planning with high precision during surgery.

Dental rehabilitation in irradiated oral cancer patients using patient-specific dental implants - Clinical outcome and oral health-related quality of life.

INTRODUCTION: Dental rehabilitation in oral cancer patients is essential for good oral health-related quality of life (OHRQoL). Patient-specific dental implants are suitable for treating tumor-related bony defects, resulting in satisfactory OHRQoL. However, knowledge concerning the clinical outcome and OHRQoL following tumor irradiation is lacking. MATERIAL AND METHODS: A retrospective analysis was carried out to evaluate clinical outcomes and OHRQoL in eight patients who received patient-specific dental implants and implant-supported dentures after surgical treatment for oral cancer with additional irradiation. OHRQoL assessment was performed using the German long version of the oral health impact profile (OHIP) questionnaire (OHIP-G53). RESULTS: Clinical examination revealed successful dental rehabilitation in all the patients with only minor impairments. Restricted stability and function of implants were not observed. OHIP sum-scores of all the patients indicated acceptable OHRQoL, but this varied between patients treated in the upper or lower jaw. Single-item sum-scores concerning the adverse events "difficulty in chewing," "food catching," "sore jaw," "sore spots," and "unclear speech" were detected to be the worst, and pain-related OHIP dimensions demonstrated the highest scores (followed by functional limitation, physical disability, and psychosocial impact) with a worse OHRQoL following lower jaw treatment. Other dimension sum-scores were overall lower and nearly equally distributed in patients. CONCLUSIONS: Dental rehabilitation of irradiated oral cancer patients using patient-specific dental implants may be suitable, leading to acceptable OHRQoL. However, implant insertion in the upper jaw seems to be more favorable. Further studies on patient-specific dental implants are warranted to validate the current results.

Computer-assisted orbital and midfacial reconstruction.

Objective: Computer assistance has become indispensable in the reconstruction of the orbit and midface. Although these are key areas of an individual's esthetic appearance, defects or deformities of the midface, especially those of the orbit, are treated diversely. Methods: The aim of this article is to present the wide utility of computer-assistance in modern craniomaxillofacial surgery, including virtual planning, computer-aided design, guided surgery, navigational control, patient-specific implants, and quality control via image fusion. Results: There have been rapid advances in both digital planning and manufacturing processes, with continual improvements. Conclusions: Patient-specific implants have pushed the boundaries of reconstructive surgery in all surgical specialties.

Alendronate reduces periosteal microperfusion in vivo.

Objectives: Bisphosphonates are known to induce a severe adverse effect known as medication-related osteonecrosis of the jaw (MRONJ). Previous studies have proven the impact of bisphosphonates on microperfusion; therefore, this study aimed to investigate alendronate-induced microcirculatory reactions in the calvarial periosteum of rats. Study design: Bone chambers were implanted into 48 Lewis rats. Microhemodynamics, inflammatory parameters, functional capillary density and defect healing were examined after alendronate treatment for two and six weeks using repetitive intravital fluorescence microscopy for two weeks. Results: Microhemodynamics remained unchanged. In alendronate-treated rats, inflammation was slightly increased, functional capillary density was significantly reduced (day 10: controls 100.45 ± 5.38 cm/cm2, two weeks alendronate treatment 44.77 ± 3.55 cm/cm2, six weeks alendronate treatment 27.54 ± 2.23 cm/cm2) and defect healing was decelerated. The changes in functional capillary density and defect healing were dose-dependent. Conclusion: The bisphosphonate alendronate has a significant negative impact on periosteal microperfusion in vivo. This could be a promising target for the treatment of MRONJ.

Improving instrument detection for a robotic scrub nurse using multi-view voting.

PURPOSE: A basic task of a robotic scrub nurse is surgical instrument detection. Deep learning techniques could potentially address this task; nevertheless, their performance is subject to some degree of error, which could render them unsuitable for real-world applications. In this work, we aim to demonstrate how the combination of a trained instrument detector with an instance-based voting scheme that considers several frames and viewpoints is enough to guarantee a strong improvement in the instrument detection task. METHODS: We exploit the typical setup of a robotic scrub nurse to collect RGB data and point clouds from different viewpoints. Using trained Mask R-CNN models, we obtain predictions from each view. We propose a multi-view voting scheme based on predicted instances that combines the gathered data and predictions to produce a reliable map of the location of the instruments in the scene. RESULTS: Our approach reduces the number of errors by more than 82% compared with the single-view case. On average, the data from five viewpoints are sufficient to infer the correct instrument arrangement with our best model. CONCLUSION: Our approach can drastically improve an instrument detector's performance. Our method is practical and can be applied during an actual medical procedure without negatively affecting the surgical workflow. Our implementation and data are made available for the scientific community ( https://github.com/Jorebs/Multi-view-Voting-Scheme ).

Congenital Mandibular Hypoplasia: Patient-Specific Total Joint Replacement as a Line Extension in the Treatment of Complex Craniofacial Anomalies.

Introduction: Congenital mandibular hypoplasia (CMH) remains challenging because of the underlying combined hard and soft tissue deficiency. Treatment options include craniofacial distraction, orthognathic surgery, and autologous grafts, although the latter produces inadequate results after distraction and autologous grafting. Unsatisfactory long-term stability may cause relapse, necessitating reoperation. Material and Methods: We investigated the feasibility of using alloplastic total joint replacement (TJR) in growing and young adult CMH patients. The primary outcome was long-term reconstruction stability, without implant failure. Secondary outcomes were TMJ function and pain, and jaw movements achieved during surgery. Results: Three patients (age: 9-22 years) were treated by the same surgeon at one institution during 2018-2021. Anamnesis and clinical parameters were obtained from patient records. Preoperative 3D-scans were superimposed with postoperative 3D-scans and preoperative plans, including TJR-implant STL files, to measure jaw movement. All patients underwent prior reconstructive surgery. Mandibular movement of 16.4-20.1 mm in the sagittal direction was achieved. Post-TJR follow-up ranged from 24 to 42 months. No long-term complications occurred. At the latest follow-up, the maximal interincisal opening was between 21 and 40 mm, and all implants were functioning, without failure. Conclusion: In selected CMH cases, alloplastic TJR can deliver satisfactory medium-term results with predictable and stable outcomes, even in growing patients.

Patient-specific implants for reconstruction of orbit and skull following resection of spheno-orbital meningiomas: A two-implant concept.

INTRODUCTION: The surgical treatment of spheno-orbital meningioma (SOM) is challenging. In addition to anatomical constraints that lead to a difficult resection, the reconstruction of the resulting defect is demanding. Uniform recommendations concerning the best reconstruction technique are not available in the existing literature. We propose a novel two-piece concept for reconstructing post-ablative defects using patient-specific implants. MATERIAL AND METHODS: Between 2018 and 2021, seven patients underwent SOM resection using two digitally planned patient-specific implants for orbit and skull reconstruction. To analyze the accuracy of the reconstruction, preoperative plans were merged with postoperative data sets. The clinical outcome was evaluated by comparing the pre- and postoperative exophthalmos index (EI). RESULTS: In all cases, adequate reconstruction and a satisfactory match between the final implant position and preoperative planning were achieved. The EI was reduced in all cases from a mean of 1.27 to 1.09 (p = 0.003). CONCLUSIONS: The proposed concept of a two-piece reconstruction after SOM resection is an excellent way to manage the concern around post-ablative defects. The current technical conditions allow for a precise, safe, and predictable reconstruction.

Implants placed in an alveolar ridge with a sloped configuration. A 3-year prospective multicenter study.

AIM: The aim of the present study was to evaluate soft and hard tissue alterations around implants with a modified marginal portion placed in a healed, sloped ridge over 3 years of follow-up. MATERIAL AND METHODS: 65 patients with a single recipient implant site in an alveolar ridge with a lingual-buccal sloped configuration were recruited. Implants with a modified geometry in the marginal portion were installed in such a way that the sloped part of the device was located at the buccal and most apical position of the osteotomy preparation. Crowns were placed 21 weeks after implant placement. Radiologic examinations were performed at implant installation and at 1 and 3 years of follow-up. Bleeding on probing (BoP), probing pocket depth (PPD), and clinical attachment level (CAL; from the crown margin) were recorded at the insertion of the prosthesis and after 1 and 3 years. RESULTS: 57 patients with 57 implant-supported restorations attended the 3 years follow-up examination. The radiographic analysis revealed a mean marginal bone loss of 0.57 mm during the 3 years period. While the average bone loss between 1 and 3 years amounted to 0.30 mm, approximately 50% of the implants showed no bone loss during this period. The results from the clinical examinations showed a CAL gain of 0.11 ± 0.85 mm between baseline and 3 years of follow-up. About 65% of the implants showed no loss of attachment between 1 and 3 years. BoP and PPD ≥5 mm were identified at <10% of implants at the 3 years examination. CONCLUSION: Hard and soft tissues formed around dental implants that were designed to match the morphology of an alveolar ridge with a lingual-buccal sloped configuration remained stable over 3 years.

Time is crucial in malignant tumor cases: Speeding up the process of patient-specific implant creation.

Purpose: Patient-specific implants are commonly used to reconstruct lower jaw defects following surgical treatment for head and neck squamous cell carcinoma. The planning process of surgery is time-consuming and can delay the "time to surgery," which should be as short as possible. Therefore, this study aimed to evaluate the planning process to speed up and identify any sources of problems. Patients and methods: In this retrospective study, we enrolled patients who underwent continuous resection of the mandible in combination with reconstruction with a patient-specific implant between 2016 and 2021. The predictor variables were in-house training of the engineers and implant complexity (complex [with additional features] vs. less complex [resembling standard reconstruction plates]). The outcome variables were the duration of communication, message length, and the need for synchronous communication or modifications to the original design. Descriptive and univariate statistics were computed, and statistical significance was set at P < 0.05. Results: The data from 83 patients were included in this study. The mean duration of communication was 14.05 ± 13.58 days. The implant complexity and training status of the engineer had no statistically significant influence on the primary outcome variables. As for the secondary outcome variables, the implant complexity significantly influenced the chance that the planned operation had to be postponed (15/16 [93.75%] were complex cases, P = 0.001). The most frequent cause of problems in the planning process was an insufficient dataset, which was not dependent on the type of imaging. Conclusions: The overall duration of the patient-specific implant creation process is too long to meet oncological requirements. Therefore, standardization of the planning process to accelerate implant creation is of utmost importance. In addition, a common standard imaging format (independent of the type of imaging) for oncological cases could eliminate all delays caused by insufficient datasets in the future.

Socio-demographic aspects and treatment-related factors on oral cancer patients' participation in rehabilitation.

Objectives: After resection of an oral carcinoma, patients are faced with physical, psychological, and socioeconomic challenges. Rehabilitation plays an essential role in patients' reintegration into their social and professional environment. This study evaluated whether socioeconomic aspects affect oral cancer patients' participation in rehabilitation treatment. Materials and methods: A retrospective analysis was conducted with 1,532 patients following surgical treatment of oral cancer during an international multicenter rehabilitation study of the German-Swiss-Austrian Cooperative Working Group on Maxillofacial Tumors using a questionnaire comprising disease-related and psychosocial items postoperatively and at least 6 months after surgery. Results: Only 35.4% of patients participated in rehabilitation. Age (p<0.001), sex (p<0.001), and marital status (p<0.05) significantly influenced participation in rehabilitation. Postoperative impairment (p<0.05) as well as quality of life (p<0.01) were significantly worse in patients who participated in rehabilitation. Nevertheless, this group of patients returned to work significantly more often, although later, than those who did not participate in rehabilitation (p<0.05). Conclusions: The findings show social inequalities and suggest a general undersupply of rehabilitative follow-up treatment in patients with oral cancer. More patients, especially older people and women should be referred to rehabilitation.

[Optic nerve decompression-state of the art]. / Optikusdekompressionen ­ Stand der Technik.

Rarely, but often with serious consequences for the patient, the optic nerve is affected during the course of head injuries. Traumatic optic nerve compression is always an emergency situation, which is why time is of the essence for both diagnosis and treatment. Precise knowledge of this accident sequelae but also of the resulting conditions, especially in terms of traumatic optic neuropathy, is indispensable for adequate patient care. The aim of this paper is to provide an overview of this clinical picture, particularly with regard to etiology, diagnosis, and treatment options, and to discuss this in the context of the current literature.

Prospective Clinical Multicenter Study Evaluating the 5-Year Performance of Zirconia Implants in Single-Tooth Gaps.

PURPOSE: In recent years, ceramic implants made of zirconia have secured a niche position next to established titanium implants, due partly to new scientific findings and positive clinical experience with the handling of ceramic implants. The aim of this study was to assess the clinical and radiographic data for monotype ceramic implants that have remained in place for 60 months under masticatory loading. MATERIALS AND METHODS: In 2011, this prospective clinical study included patients with a single-tooth gap in the maxilla and mandible. Monotype ceramic implants (Straumann) were used according to a standard protocol. Provisional prostheses were placed after 3 months, followed by final prostheses 3 months later. Patients were invited for a 60-month follow-up. Implant survival was analyzed from lifetime data. Success rates and crestal bone levels were evaluated from implant placement to 6, 12, 36, and 60 months after surgery. RESULTS: From the initial 44 patients recruited, 36 were analyzable for the 60-month follow-up. With one implant lost before the 6-month followup, the survival rate after 60 months was 97.7%, and the mean survival time was 58.7 months. Sixty months after implant placement, the success rate was 97.2% (95% confidence interval = 84.6% to > 99.9%). Mean bone loss after 60 months was 0.99 (± 0.59) mm. CONCLUSION: After 60 months, monotype ceramic implants made of zirconia achieved success and survival rates comparable with those reported for titanium implants in selected patient populations. Ceramic implants can be used as an alternative to titanium implants at the request of patients and if specifically indicated, for example, due to titanium intolerance.

Deep-learning-based instrument detection for intra-operative robotic assistance.

PURPOSE: Robotic scrub nurses have the potential to become an attractive solution for the operating room. Surgical instrument detection is a fundamental task for these systems, which is the focus of this work. We address the detection of the complete surgery set for wisdom teeth extraction, and propose a data augmentation technique tailored for this task. METHODS: Using a robotic scrub nurse system, we create a dataset of 369 unique multi-instrument images with manual annotations. We then propose the Mask-Based Object Insertion method, capable of automatically generating a large amount of synthetic images. By using both real and artificial data, different Mask R-CNN models are trained and evaluated. RESULTS: Our experiments reveal that models trained on the synthetic data created with our method achieve comparable performance to that of models trained on real images. Moreover, we demonstrate that the combination of real and our artificial data can lead to a superior level of generalization. CONCLUSION: The proposed data augmentation technique is capable of dramatically reducing the labelling work required for training a deep-learning-based detection algorithm. A dataset for the complete instrument set for wisdom teeth extraction is made available for the scientific community, as well as the raw information required for the generation of the synthetic data ( https://github.com/Jorebs/Deep-learning-based-instrument-detection-for-intra operative-robotic-assistance ).

No Significant Bone Resorption after Open Treatment of Mandibular Condylar Head Fractures in the Medium-Term.

Open treatment of condylar head fractures (CHF) is considered controversial. In this retrospective cohort study our primary objective was therefore to assess bone resorption and remodeling as well as patients function after open treatment of CHF in a medium-term follow-up (15.1 ± 2.2 months). We included 18 patients with 25 CHF who underwent open reduction and internal fixation, between 2016 and 2021, in our analysis. The clinical data and cone-beam computed tomography (CBCT) datasets were analyzed. The condylar processes were segmented in the postoperative (T1) and follow-up (T2) CBCT scans. Volumetric and linear bone changes were the primary outcome variables, measured by using a sophisticated 3D-algorithm. The mean condylar head volume decreased non-significantly from 3022.01 ± 825.77 mm3 (T1) to 2878.8 ± 735.60 mm3 (T2; p = 0.52). Morphological alterations indicated remodeling and resorption. The pre-operative maximal interincisal opening (MIO) was 19.75 ± 3.07 mm and significantly improved to 40.47 ± 1.7 mm during follow-up (p = 0.0005). Low rates of postoperative complications were observed. Open reduction of CHF leads to good clinical outcomes and low rates of medium-term complications. This study underlines the feasibility and importance of open treatment of CHF and may help to spread its acceptance as the preferred treatment option.

Outcome and Quality of Life after Individual Computer-AssistedReconstruction of the Midface. / Ergebnisse und Lebensqualität nach individueller computer-gestützter Rekonstruktion des Mittelgesichtes.

Often, midfacial defects are not only relevant regarding functional aspects but also esthetics of such congenital or acquired deformities impair significantly the patients' quality of life. Reconstructions of the midface do not only include replacing lost or non-developed tissue but moreover to achieve predictable results with regard to esthetics as well as function for the individual patient. Digital planning modalities including different surface and volume data in combination with modern additive manufacturing techniques for biomodel and implant production and intraoperative support by using real and virtual 3D volume data for navigation and intraoperative imaging, but also securing the outcome based on postoperative analysis have been implemented in modern midface reconstruction and represent new standards for medical care. The objective of this paper is to describe modern options of patient-specific midfacial reconstruction with integration of computer-assisted planning and production techniques.