Total virtual workflow in CAD-CAM bony reconstruction with a single step free fibular graft and immediate dental implants.

The Surgical reconstruction of defects of the face is challenging. Local and regional flaps have an important part to play, but large defects of bone and soft tissue are a greater problem. Microvascular tissue transfer has become the standard for such patients, and preoperative planning of bony reconstructions is now common. To use these preplanning tools best the implants should be placed in the prosthetically ideal place, and the bone positioned to surround the implants - that is, truly backward planning of the position of the bone. The buccolingual angulation and the actual position of the implants during operation can be difficult to verify. Using commonly available software and 3-dimensional printing solutions, therefore, we have constructed an algorithm to optimise the position of these implants during the operation, and to get their position as close to the planned outcome as possible. This algorithm is adaptable to any implant system and is potentially possible in any implant or preplanning software unit.

[Reconstructive orbital surgery]. / Rekonstruktive Orbitachirurgie.

BACKGROUND: In complex orbital reconstructions ideal positioning of the bony buttress and surrounding soft tissue is a prerequisite for an aesthetic and functional result. The use of computer-assisted surgery can support the surgeon before and during the reconstruction procedure and facilitate quality control processes. This is illustrated using three clinical examples. MATERIAL AND METHODS: The areas of interest (bony defect areas, surrounding tissues) are segmented in a 3D image series. In most cases, the contralateral non-affected side can serve as the reference in virtual reconstruction. The virtual model obtained can now be used for the manufacturing of patient specific models and implants, as well as for intraoperative navigation or direct quality control with the use of intraoperative cone beam computed tomography (CBCT). RESULTS: For the reconstruction of primary and secondary traumatic defects as well as for congenital malformations or neoplastic diseases, the presented workflow can be used. Preoperative virtual visualization, patient specific reconstruction and direct quality control using intraoperative CBCT ensure that the preoperatively planned result can be achieved. Together with the interplay of hard and soft tissue the best possible results can be achieved. CONCLUSION: Computer-assisted surgery has been continuously further developed over the last two decades and is currently used in the clinical routine. Patient specific implants in combination with the use of direct intraoperative quality control facilitate the reconstruction of complex orbital injuries and defects and enable the ideal reconstruction from both aesthetic and functional aspects.

Patient-specific biodegradable implant in pediatric craniofacial surgery.

Surgical correction of premature fusion of calvarial sutures involving the fronto-orbital region can be challenging due to the demanding three-dimensional (3D) anatomy. If fronto-orbital advancement (FOA) is necessary, surgery is typically performed using resorbable plates and screws that are bent manually intraoperatively. A new approach using individually manufactured resorbable implants (KLS Martin Group, Tuttlingen, Germany) is presented in the current paper. Preoperative CT scan data were processed in iPlan (ver. 3.0.5; Brainlab, Feldkirchen, Germany) to generate a 3D reconstruction. Virtual osteotomies and simulation of the ideal outer contour with reassembled bony segments were performed. Digital planning was transferred with a cutting guide, and an individually manufactured resorbable implant was used for rigid fixation. A resorbable patient-specific implant (Resorb X-PSI) allows precise surgery for FOA in craniosynostosis using a complete digital workflow and should be considered superior to manually bent resorbable plates.

En bloc prefabrication of vascularized bioartificial bone grafts in sheep and complete workflow for custom-made transplants.

The aim of this pilot study was to determine, in a new experimental model, whether complex bioartificial monoblocs of relevant size and stability can be prefabricated in a defined three-dimensional design, in which the latissimus dorsi muscle serves as a natural bioreactor and the thoracodorsal vessel tree is prepared for axial construct perfusion. Eighteen sheep were included in the study, with six animals in each of three experimental groups. Vitalization of the ß-tricalcium phosphate-based constructs was performed by direct application of unmodified osteogenic material from the iliac crest (group A), in vivo application of nucleated cell concentrate (NCC) from bone marrow aspirate (group B), and in vitro cultivation of bone marrow stromal cells (BMSC) in a perfusion bioreactor system (group C). The contours of the constructs were designed digitally and transferred onto the bioartificial bone grafts using a titanium cage, which was bent over a stereolithographic model of the defined subvolume intraoperatively. At the end of the prefabrication process, only the axial vascularized constructs of group A demonstrated vital bone formation with considerable stability. In groups B and C, the applied techniques were not able to induce ectopic bone formation. The presented computer-assisted workflow allows the prefabrication of custom-made bioartificial transplants.

Elongated coronoid process: CT-based quantitative analysis of the coronoid process and review of literature.

Impingement of the enlarged coronoid processes against the medial surfaces of the zygomatic arches and posterior surfaces of the body of the zygomatic bones results in mechanical restriction of the mouth opening. The authors introduce a helpful tool for easy assessment and estimatation of the length of the coronoid process, measured on the CT scans of 40 patients (20 adults, 20 adolescents) and report a case of a 13-year-old boy suffering from restricted mouth opening caused by bilateral hyperplasia of the coronoid process. The CT based analysis resulted in a mean length of the coronoid process of 13.02mm in adults and 12.43mm in adolescents. The 13-year-old boy had a length of nearly 2cm. For comparison, a coronoid/condyle ratio was developed. This ratio showed a value of 0.78 for all patients compared with a value of about 2.0 for the boy. The literature review revealed comparable results to the reported case. Most of the patients were adolescent, male and presented a median history of 2 years until correct diagnosis.

[Reconstruction of complex midfacial defects with individualized titanium implants]. / Rekonstruktion komplexer Mittelgesichtsdefekte durch individualisierte Titanimplantate.

BACKGROUND: Loss of hard and soft tissue structures of the midface due to resection or trauma is associated with substancial functional and aesthetic deficits. Besides reconstruction of bony contours for preservation of orbit position and facial symmetry, reconstruction often requires simultaneous transplantation of soft tissue flaps for separation of nasal and oral cavities and refilling of soft tissue volume deficits. PATIENTS AND METHODS: A well-established procedure of our institution will be demonstrated in 10 exemplary patients, in which titanium meshes are customized for individual defect situations using computer-assisted techniques in combination with soft tissue transfer if required. RESULTS: According to our experience, this procedure provides satisfactory results in functional as well as in aesthetic respects. Especially in patients with loss of bony structures of the orbit and preservation of orbital contents, this procedure forms optimal preconditions for prevention of enophthalmos and diplopia by preservation of the original orbital volume. CONCLUSION: Individualized titanium implants should be used more frequently in clinical routine for reconstruction of complex midfacial defects.

[Orbital tumours in children and adolescents. Differential diagnostics and clinical symptoms]. / Orbitale Raumforderungen im Wachstumsalter. Differenzialdiagnostik und Krankheitsbilder.

BACKGROUND: The aim of this retrospective study was to determine the incidence of and surgical strategies used for treating orbital tumours in children and adolescents. PATIENTS AND METHODS: A retrospective chart review was carried out for 22 patients between the ages of 2 weeks and 18 years who were treated in the years 1997-2007 for suspected space-occupying orbital lesions. The specific investigation methods, therapy, and treatment results were described. RESULTS: The most frequent orbital lesions in the children in this study were mesenchymal tumours; the second most common were dermoids. Nineteen patients were surgically treated. Three children with malignant tumours underwent radiochemotherapy after surgery, and two died in the first year after diagnosis. Two other children with benign tumours suffered recurrence of their disease. CONCLUSION: The variety of orbital diseases in paediatric patients includes benign and malignant tumours as well as nonneoplastic lesions. The treatment of orbital disease is a diagnostic and therapeutic challenge for the attending physician.

Prefabrication of vascularized bioartificial bone grafts in vivo for segmental mandibular reconstruction: experimental pilot study in sheep and first clinical application.

The key elements for bioartificial bone formation in 3D matrices are large numbers of osteogenic cells and supplies of oxygen and nutrition. Vascularization becomes more important with the increasing size and complexity of seeded scaffolds required for clinical application in reconstructive craniomaxillofacial surgery. Prefabrication of vascularized bioartificial bone grafts in vivo might be an alternative to in vitro tissue engineering techniques. Two cylindrical beta-TCP-scaffolds (25 mm long) were intraoperatively filled with autogenous bone marrow from the iliac crest for cell loading and implanted into the latissimus dorsi muscle in 12 sheep. To determine the effect of axial perfusion, one scaffold in each sheep was surgically supplied with a central vascular bundle. Sheep were killed 3 months after surgery. Histomorphometric analysis showed autogenous bone marrow from the iliac crest was an effective source of osteogenic cells and growth factors, inducing considerable ectopic bone growth in all implanted scaffolds. Bone growth, ceramic resorption and angiogenesis increased significantly with axial perfusion. The results encourage the application of prefabricated bioartificial bone for segmental mandibular reconstruction in man. In clinical practice, vascularized bioartificial bone grafts could change the principles of bone transplantation with minimal donor site morbidity and no shape or volume limitations.

Cone beam CT imaging of airgun injuries to the craniomaxillofacial region.

In airgun injuries, the removal of the projectile is often recommended. The material properties of airgun projectiles make it difficult to determine their precise anatomical location using conventional radiological techniques. Conventional X-rays give only a two-dimensional representation of projectiles and do not allow a foreign object to be located precisely. Multi-slice computed tomography (CT) has become a standard tool in diagnosis. Metal objects can cause artefacts in CT scans and make it difficult to identify adjacent anatomical structures. By contrast, cone-beam CT (CBCT) provides three-dimensional images largely free from metal artefacts. The authors present three cases of airgun injuries and discuss the diagnostic and treatment approaches used. CBCT has proved to be a useful diagnostic tool in planning the treatment of craniofacial airgun injuries. It is superior to CT in detecting hard-tissue structural damage in the immediate vicinity of high-density metal projectiles.

Innate immunity in human bone.

Bone has exceptional regenerative properties. Oral bone appears to be particularly resistant to infection despite exposure to oral flora, even in circumstances such as oral surgery where the thin mucosal layer covering the bone is disrupted. The goal of this study was to determine whether the innate immune system of antimicrobial peptides exists inside bone. Biopsies of non-infected and chronically infected mandibular bone were harvested from patients during maxillofacial surgical procedures. Bone biopsies from the iliac crest and fibula served as controls. Immunohistochemical staining was performed, directed against the human beta-defensin antimicrobial peptides (hBD) -1, -2 and -3. In addition, cultures of osteoblast-like cells were examined for the presence of each of the three beta-defensins and their mRNA transcripts. All three human beta-defensins were detected within the mineralized bone matrix of chronically infected mandibular bone in the vicinity of the endosteum and osteocytes. hBD-1, -2 and -3 were also found in the cytoplasm of osteocytes. Expression of all three beta-defensins was detected in each of the non-infected bone types including the controls, however, to a lesser degree than that found in the chronically infected mandibular bone. This may reflect upregulation of antimicrobial peptide expression in the presence of chronic infection. Cultures of non-infected osteoblast-like cells were found to express mRNA for each of hBD-1, -2 and -3. Immunohistochemical staining of the cultures was positive for hBD-1 and -2, but not for hBD-3. We provide the first evidence of a previously unrecognized innate immunological function of bone through the demonstration of the presence of the human beta-defensins hBD-1, -2 and -3 in bone.

Effects of ammoniation of endophyte fungus-infested fescue hay on serum prolactin concentration and rectal temperature in beef cattle.

A group of 48 crossbred steers (approx 250 kg each) were used to determine the effects of various diets and treatments on serum prolactin concentrations and rectal temperatures. The steers were randomly assigned to groups fed the following: (1) endophyte fungus-infested fescue hay; (2) ammoniated endophyte fungus-infested fescue hay; (3) endophyte fungus-infested fescue hay plus 1 g of thiabendazole (TBZ)/9.1 kg of body weight at 7-day intervals; (4) ammoniated endophyte fungus-infested fescue hay plus 1 g of TBZ/9.1 kg at 7-day intervals; (5) ground Bermuda grass hay; and (6) endophyte-fungus-free fescue hay. Blood samples for prolactin determinations and rectal temperatures were obtained biweekly beginning on week 3 and continuing through week 9. A significant correlation (P less than 0.05) between low prolactin concentrations and high rectal temperatures in cattle eating endophyte-infested fescue hay was determined; however, as the prolactin concentrations approached normal (control animal) concentrations, this relationship between serum prolactin and rectal temperatures was not observed. Two antifungal agents used in this experiment (thiabendazole and ammonia) appeared to have different effects on the variables measured. Thiabendazole had no significant effect on prolactin concentrations or rectal temperatures of cattle ingesting endophyte-infested fescue hay, whereas ammoniation of this hay induced significantly higher (P less than 0.05) prolactin concentrations and lower rectal temperatures than in steers receiving only endophyte-infested fescue hay. Therefore, ammonia may be valuable not only as an aid in determining the cause of the fescue problem but also as a practical solution to some of the fescue-related economic problems in the cattle industry. Also, prolactin concentrations may be valuable in diagnosing fescue-related problems.

Effects of 4-methylimidazole in young calves.

Clinical signs, gross and histologic necropsy findings and dose response curves of 4-methylimidazole (4-MI) were determined in young Holstein calves. Three-day-old Holstein bull calves were given an oral dose of 0,25,50,100,200 or 400 mg 4-MI/kg body weight. Acute clinical signs were hypersalivation, mouth chomping, diarrhea, muscle fasciculations, tremors, hyperexcitability, convulsions, coma and death. Death occurred within 3 hr for calves given the highest dose of 400 mg/kg. Two of 3 calves dosed at 200 mg/kg died within 8 and 3/4 hr of dosing. Only 1 of 3 calves showed mild signs at the 100 mg/kg dose level and no effects were observed at the 50 or 25 mg/kg dose level. Signs due to 4-MI in this experiment were similar to signs observed in calves whose dams were consuming ammoniated hay. No pathological lesions attributable to 4-MI toxicosis were found during gross or microscopic necropsy examination. Blood chemistry values from calves treated with 4-MI were within normal ranges except for potassium, phosphorus and glucose which were elevated (P less than .05) at the time of death for those calves dosed at 400 mg/kg.

Jimson weed seed toxicity in cattle.

A subacute experiment was undertaken for 14 days. The results obtained from these studies suggest that: 1) unless a highly Jimson weed seed contaminated feed is ingested (greater than 0.09% of body weight) or force fed, death should be a rare consequence of Jimson weed seed contamination; 2) Jimson weed seed toxicity in cattle as a result of feed contamination appears a self-limiting problem (rumen atony and anorexia prevent further intoxication until the blood levels of alkaloids are reduced to allow normal ruminant intestinal function); 3) cattle may exhibit signs of atropine toxicity at contamination levels of 881 seed/kg of feed or higher; 4) rumen fluid from heifers fed diet containing 4,408 Jimson weed seed had the greatest VFA concentration change from day 0 to 7; 5) in vitro fermentation of diets resulted in no difference in IVDMD values, but VFA concentration values tended to increase with increased concentrations of Jimson weed seed in the diet.

Effects of xanthene dyes in cattle diets for insect control: diet digestibility and fecal excretion.

The effects of rose bengal, erythrosin B and fluorescein on ruminant digestion were evaluated by an in vitro rumen technique. Rose bengal reduced in vitro dry matter disappearance (IVDMD) values starting at .5 mM in the nutrient media and erythrosin B reduced IVDMD values starting at .05 mM in the nutrient media. Maximum reduction in IVDMD values was observed at 3.0 mM of rose bengal and erythrosin B. Fluorescein depressed digestion but not as severely as rose bengal or erythrosin B. Dry matter digestibility (DMD) values for steers given erythrosin B at a daily dosage of 6.5 mg/kg body weight were higher (P less than .05) than DMD values for control steers. DMD values were higher for steers given 16.3 or 26.1 mg erythrosin B/kg body weight daily than for the control steers, but the differences were not significant. There were no significant differences among animals given the different dosages in digestible energy. Recovery of erythrosin B from feces of treated steers varied with time, indicating that steers fed erythrosin B at a dosage of 6.5 mg/kg body weight might excrete feces during some periods of the day which would not control face fly development; however, administration of erythrosin B at a dosage of 16.3 mg/kg body weight would provide enough erythrosin B in feces to control face fly development throughout a 24-h period.