Evaluation of oral prophylaxis during and after intensity-modulated radiotherapy due to head and neck cancer--a retrospective study.

OBJECTIVES: The aim of this study was to retrospectively analyze the influence of a prophylaxis protocol of head and neck tumor (HNT) patients during and after intensity-modulated radiotherapy (IMRT). MATERIAL AND METHOD: In this 5-year retrospective study (2009-2013), 70 (m 55, f 15; age range 28-8 years; median 58.7 years) out of 248 HNT patients of the Clinic of Cranio-Maxillofacial and Oral Surgery at the University of Zurich, Switzerland, fulfilled the inclusion criteria. Parameters of investigation were the salivary flow rates, possible dental foci and the dental status, oral side effects of radiotherapy, the prophylaxis protocol, and patient's compliance to this protocol. The following time points before during and after IMRT (6 weeks) were analyzed: prior to IMRT, 2-4 weeks, 6 weeks and 3, 6, and 12 months after the onset of radiotherapy. RESULT: Unstimulated salivary flow rate, pH value of unstimulated salivary, and stimulated salivary flow rate showed a significant reduction over time (p < 0.001). One year after IMRT, both unstimulated and stimulated salivary flow showed a statistically significant lower salivary flow. The number of caries-affected sites per patient was significantly higher for patients with low compliance to the prophylaxis protocol (mean: low compliance 1.36, high compliance 0.26). Almost 75% of the evaluated patients suffered immediate gustatory change, and 47.1% showed signs of radiostomatitis through IMRT. CONCLUSIONS: High compliance to the prophylaxis protocol during and after radiotherapy is a key factor for the reduction of radiation side effects on dental hard tissue. CLINICAL RELEVANCE: High compliance to a monitored prophylaxis program is crucial for patients after head and neck surgery.

Oral lichen planus (OLP), oral lichenoid lesions (OLL), oral dysplasia, and oral cancer: retrospective analysis of clinicopathological data from 2002-2011.

INTRODUCTION: This 10-year retrospective study analyzed the incidence of malignant transformation of oral lichen planus (OLP). The study also included dysplasia and oral lichenoid lesion (OLL) in the initial biopsy as a potential differential diagnosis. MATERIAL AND METHODS: A total of 692 scalpel biopsies were taken from 542 patients (207 [38.2%] men and 335 [61.8%] women). Clinical and histopathological parameters were analyzed. RESULTS: The parameters gender (p = 0.022) and smoking behavior (p < 0.001) were significantly associated with the severity of diagnosis. Mucosal lesions with an ulcerative appearance (p = 0.006) and those located on the floor of the mouth (p < 0.001) showed significantly higher degrees of dysplasia or were diagnosed as oral squamous cell carcinoma (OSCC). Smoking and joint disease appeared to be significant risk factors. Treatment with tretinoin in different concentrations (0.005-0.02%) significantly improved diagnosis. Twelve patients (8 female, 4 male) showed malignant transformation to OSCC within an average period of 1.58 years. The malignant transformation rate (MTR) was higher for OLL (4.4%) than OLP (1.2%). If the first biopsy showed intraepithelial neoplasia, the risk of developing OSCC increased (by 3.5% for squamous intraepithelial neoplasia (SIN) II and by 6.7% for SIN III). CONCLUSION: Although we cannot rule out that OLP is a premalignant oral condition, we can confirm that OLP had the lowest MTR of all diagnoses.

Medium-term outcome of Astra Tech implants in head and neck oncology patients.

Rehabilitation with implant-retained prostheses is a key step in the rehabilitation of patients after ablative head and neck surgery. Data of patients who underwent mandibular restoration with Astra Tech implants were gathered consecutively and analyzed retrospectively. Implant survival was calculated by Kaplan-Meier analysis, and Cox models were used to identify any association between implant failure and contributing factors. In total, 136 implants were placed in 33 patients. The main reason for ablative surgery was squamous cell carcinoma. Twenty-one patients received adjuvant radiotherapy with a cumulative radiation dose of 56-76Gy prior to implantation. Failure occurred in six patients, resulting in the loss of 17 implants. The cumulative implant survival rate was 92.7% after 1 year and 87.5% after 20 months. Smoking and alcohol consumption were associated with a significantly higher implant failure rate. Most patients had a stable implant status after 20 months.

The phosphorous necrosis of the jaws and what can we learn from the past: a comparison of "phossy" and "bisphossy" jaw.

INTRODUCTION: The osteopathology of the jaws associated with bone resorption inhibitors is a current topic that engages a variety of clinical specialists. This has increased after the approval of denosumab for treatment of osteoporosis and skeletal-related events in patients with solid malignancy. Early after the first publications, there is a possible connection between phosphorous necrosis of the jaws, a dreadful industrial disease mentioned, and bisphosphonate-induced pathology. The nineteenth century was the prime time for phosphorus necrosis of match factory workers. RESULTS: This occurrence provides an interesting insight into the medical and surgical profession in the nineteenth century. There are striking parallels and repetition of current and old ideas in the approach to this "new disease." There are similar examples in case descriptions when compared with today's patients of bisphosphonate-related osteonecrosis of the jaws (BRONJ). DISCUSSION: Phosphorus necrosis was first described in Austria. Soon after this, surgeons in German-speaking countries including well-known clinicians Wegner (1872) and von Schulthess-Rechberg (1879) pioneered the analysis, preventative measures, and treatment of this disease. The tendency at this time was to approach BRONJ as a "special kind of osteomyelitis" in pretreated and metabolically different bone. Not only the treatment strategy to wait until sequestrum formation with subsequent removal and preventative measures but also the idea of focusing on the periosteum as the triggering anatomical structure may have been adopted from specialists in the nineteenth century. Therefore, phosphorous necrosis of the jaw is an excellent example of "learning from the past."

Osteopathology associated with bone resorption inhibitors - which role does Actinomyces play? A presentation of 51 cases with systematic review of the literature.

BACKGROUND: Bone resorption inhibitor-related osteopathology of the jaw (BRIOJ) is a severe complication in patients treated with bisphosphonates or denosumab. However, the precise pathogenesis of BRIOJ is not yet fully understood. Recent studies discovered the presence of Actinomyces colonies in biopsy material from BRIOJ patients. The aim of this study was to analyze current knowledge concerning the impact of Actinomyces on the pathogenesis of this condition and to present data from our own patients. METHODS: Data from 51 patients with histopathological diagnoses of BRIOJ were retrospectively analyzed. In addition, a systematic literature search for studies describing the presence of Actinomyces was performed. RESULTS: Actinomyces was present in 86% of our cases and 63.3% of 371 cases presented in the literature. All of our patients and 85% of patients described in the literature had a clearly defined local focus in association with osteopathology. A clear picture of whether Actinomyces colonizes the previously necrotic bone or contributes to inflammation causing subsequent bone necrosis is lacking in the literature. CONCLUSION: The pathogenesis of BRIOJ remains unknown; however, there seems to be a role for Actinomyces, and possibly other pathogens, in the development of osteopathology of the jaws, which is not exclusive to bisphosphonate therapy. This study supports the hypothesis that an infectious component is of utmost importance for the pathogenesis of BRIOJ.

Craniomaxillofacial fibrous dysplasia: a 10-year database 1996-2006.

Fibrous dysplasia is a rare bone disease caused by an abnormal proliferation of fibrous tissue in bone. We retrospectively evaluated eight patients (female to male ratio 3:1, mean age 22.5 years, range 10-32) with a monostotic form who were treated between 1996 and 2006. Two each were affected in the lower jaw, the upper jaw, the midface, and the frontoparietal region. Most patients were referred because of a painless swelling. Biopsy specimens from two patients were examined, six patients had modelling osteotomies, two of whom had further operations because of progressive enlargement. There was no visual impairment or malignant transformation. Fibrous dysplasia should be treated as conservatively as possible, but in cases of functional disturbance that results from malignant transformation, or from the involvement of the optic foramen or the foramen magnum, an immediate operation is needed. Disfigurement can be another reason for operation. When there is a risk of malignant transformation, follow-up of patients is recommended.

Jaw osteonecrosis related to bisphosphonate therapy: a severe secondary disorder.

Bisphosphonate-related osteonecrosis of the jaws (BON), first described in 2003, is gaining importance due to the increasing indication spectrum of bisphosphonate therapy [S. Takeyama, M. Ito, H. Shinoda, A novel bisphosphonate, TRK-530, for periodontitis, Bone 38 (2006) 31-31; M. Tagil, A. W-Dahl, J. Astrand, D. Little, S. Toksvig-Larsen, Decreasing the catabolic response by a single bisphosphonate infusion shortens the healing time in hemicallotasis operations, Bone 38 (2006) 84-85; E. Rodriguez, M.C. Duran, L.M. Rodriguez, R. Ros, M.R. Aleman, M. Rodriguez-Gaspar, A.M. Lopez, E. Garcia-Valdecasas, F. Santolaria, Intravenous (IV) bisphosphonates for osteopenic cancer survivor women: an alternative treatment, Bone 38 (2006) 72-73; D.G. Little, K. Ward, P. Kiely, M.C. Bellemore, J. Briody, C.T. Cowell, Bisphosphonate rescue in distraction osteogenesis: a case series, Bone 38 (2006) 80-80; R. Marx, Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic, J. Oral Maxillofac. Surg. 61 (2003) 1115-1118]. BON patients suffering from varying bony defects and symptoms are extremely restricted in their quality of life. Due to a limited knowledge of the aetiology of BON efficient evidence-based treatment strategies are lacking. Until now 23 patients with bisphosphonate-related osteonecrosis have been admitted to the Department of Cranio-Maxillofacial Surgery of the University of Zurich. A complete history has been recorded. All patients underwent clinical and radiographic examination. CT scans and MRI have been performed in selected cases. All patients had in common that, before signs of BON were observed, a local traumatic incidence had occurred. All patients showed signs of infection which could be remarkably reduced by antibacterial treatment. Furthermore, the period of bisphosphonate treatment was found to be one of the significant factors causing bisphosphonate-related osteonecrosis of the jaws. The aetiology of BON appears to depend on multiple factors: period and type of bisphosphonate therapy and trauma paving the way for an invasion of pathogens. Because evidence based therapy protocols for complete remodelling of bone defect are still missing, prevention in bisphosphonate-treated patients seems to be of utmost importance. A close interdisciplinary collaboration is required.

Clinical experiences with bisphopsphonate induced osteochemonecrosis of the jaws.

QUESTION: Bisphosphonates are frequently used drugs in the adjuvant therapy of bone metastases and tumour-induced hypercalcaemia, but also for osteoporosis or Pagets disease. Several publications within the last three years considered osteonecrosis of the jaws to be connected with bisphosphonate therapy. Until today possible treatment strategies contain antibiotics, hyperbaric therapy and operative treatment. The tendency of healing however seems to be extremely poor. All clinicians should be aware of this new kind of side effect of bisphosphonate therapy. METHODS: 14 patients with this new kind of osteonecrosis were admitted to the department of Cranio-Maxillofacial Surgery of the University Hospital of Zurich. 8 men and 6 women all received bisphosphonates for cancer therapy. A complete analysis of patients' data was performed. RESULTS: Of 14 patients in 7 the underlying disease disease was multiple myeloma. In one patient it was prostate cancer and in all female patients it was breast cancer. All of them had prior dental treatment and showed inflammatory signs and bacterial colonisation with localisation in the upper or lower jaw or in both. CONCLUSION: The infectious part of the bisphosphonate-induced osteonecrosis (ONJ) is considered to be more important than thought before. We presume that antimicrobial treatment is of utmost importance in the treatment of this kind of osteonecrosis. Patients with current or previous bisphosphonate therapy should be treated multidisciplinary to assure ideal prevention and treatment.

The galea fascia flap in orbital reconstruction: innovative harvest technique.

AIM: To report the treatment of a recurrent adenoid-cystic carcinoma of the lacrimal gland required orbital exenteration with an en bloc resection of the lateral orbital rim and wall and an anterior portion of the temporal muscle. Reconstruction was planned with both the objectives of a shortened healing time for faster epithetic reconstruction and no visible scars. METHOD: After a cranially extended temporal approach, the dissection of the superficial galea layer was connected with the subcutaneous dissection of the upper and lower eyelid after subciliary incisions. RESULTS: Ample exposure of the temporal, frontal and orbital region was obtained, facilitating the orbital exenteration with en bloc resection of the lateral orbital rim and wall and the anterior portion of the temporal muscle. The epithelialization of the eye socket covered with the galea fascia flap was accelerated, providing faster epithetic reconstruction, without visible scars. CONCLUSIONS: Healing time is accelerated, providing faster epithetic rehabilitation without visible scars, which is important in the postoperative rehabilitation ladder after eye exenteration for both patient and surgeon. Further more ablative surgery within this region gets safer and easier due to the ample exposure of this innovative surgical technique. Further evaluation of the effectiveness and safety of this new approach is advisable.

[Condylar metastasis. Review of the literature and report of a case]. / Die kondyläre Metastasierung. Literaturrecherche und ein Fallbericht.

BACKGROUND: Metastases in the mandibular condyle are rare. A survey of the literature showed that only 23 of 69 selected cases qualified under the criteria of Meyer and Shklar. REPORT OF A CASE: A 48-year-old white male suffering from a previously operated lung carcinoma was referred due to pain and discomfort in the left TMJ. A solitary condylar metastasis of the mandible was revealed. Because of diffuse tumorous infiltration into periarticular tissue, irradiation treatment was performed. During the long-term follow-up growth of additional skeletal metastases occurred. DISCUSSION: The course of condylar metastases in general is similar to other metastases involving the jaw. Breast cancer as the primary tumor is most frequent, followed by lung cancer. There are no specific clinical or radiological parameters leading to diagnosis. The clinician should take a potential metastasis into account when dealing with TMJ complaints, radiological oddities, and medical history of malignant tumors. For proper treatment planning, diagnosis should be based on histology. Since the diagnosis of metastasis is usually made at an advanced stage of disease, therapy will be mainly intended as palliative.

[Solitary abscessing osteomyelitis of the mandibular condyle. A rarity]. / Die solitäre abszedierende Osteomyelitis des Kieferköpfchens. Eine Rarität.

CASE REPORT: We report on a rare case of secondary chronic osteomyelitis of the left condyle. Haemophilus aphrophilus could be isolated from the abscess material. The condyle was resected and reconstructed with an endoprosthesis in the same operation. DISCUSSION: Possible causes of the rare location of secondary chronic osteomyelitis are assembled in a review of the literature and compared with the actual case. CONCLUSION: We suggest the inoculation of microorganisms through the needle of a local anesthetic injection, bacterial contamination during the tooth extraction, or bacteremia following the dental extraction to be possible causes for the infection.

Tratamiento conservador de las fracturas del cóndilo: evaluación radiológica y clínica / Conservative treatment of condyle fractures: radiological and clinical evaluation

Las ventajas del tratamiento quirúrgico de las fracturas del procesocondilar hasta la fecha han despertado controversia en la literatura.El tratamiento conservador es el método de elección en nuestra clínica,por lo tanto, el propósito de este estudio es evaluar los resultados obtenidosen un grupo de nuestros pacientes, seleccionados y aleatorizados,que recibieron un tratamiento conservador de fracturas del proceso condilar.Se evaluaron las intervenciones terapéuticas entre 1997 y 2000 en 30 pacientes(18 varones, 12 mujeres, edad media de 25 años) con fracturas del cóndiloy un tiempo de seguimiento medio de 12 meses. Se incluyó un totalde 35 fracturas del cóndilo en este estudio. El tratamiento utilizado fue lafijación maxilomandibular (FMM), que se aplicó durante 2 semanas en lasfracturas unilaterales y durante 3 a 4 semanas en las fracturas bilaterales.Se realizó una evaluación radiológica inicial del ángulo del proceso condilarfracturado y del acortamiento de la rama ascendente. Se evaluaronlas exploraciones clínicas y radiológicas a intervalos regulares (6 semanasy 3, 6 y 12 meses).Cinco pacientes presentaron fracturas bilaterales; todos con luxación anterior.En el grupo de las fracturas unilaterales, 12 pacientes presentaron luxaciónanterior (valor medio 23°) en la radiografía panorámica. Trece pacientespresentaron luxación posterior (valor medio 10°). En la proyección posteroanteriorse observó la luxación medial en 12 fracturas (valor medio 14°)y luxación lateral en 4 fracturas (valor medio 6°). El acortamiento de la ramaascendente alcanzó un valor medio de 5,40 mm. Se logró una funcionalidady movilidad satisfactorias en todos los pacientes tratados. Las secuelaspostraumáticas fueron el chasquido de la articulación temporomandibular(ATM) (5 de 29), la desviación de la boca al abrirse (14 de 27), la reducción de los movimientos laterales y de la protrusión (15 de 29) y finalmenteun rango de apertura de la boca de 30 a 60 mm.Para concluir, el tratamiento conservador de las fracturas del proceso condilares un método de tratamiento seguro que evita la cirugía y producefiablemente buenos resultados. El grado de desplazamiento o de acortamientode la rama ascendente no precluyó obtener buenos resultados eneste estudio

Benefits of surgical treatment for condylar fractures areto date discussed controversially in the literature. As conservativetreatment is the method of choice in our clinic, the purpose of thisstudy is to evaluate the outcomes of a randomised selected groupof our patients who received conservative treatment for condylarfractures.The acts of 30 patients (18 males, 12 females, mean age of 25years) treatment for condylar fractures between 1997 and 2000with a mean follow up time of 12 months have been assessed. Atotal of 35 condyle fractures were included in this study. Thetreatment applied was maxillo-mandibular fixation (MMF) for 2weeks on unilateral fractures, and 3 - 4 weeks on bilateral fractures.Initial radiological evaluation of the broken condyles angulationsand shortening of the ascending ramus was performed. Clinical andradiological examinations were assessed in regular intervals (6weeks, 3, 6 and 12 months).5 patients presented bilateral fractures; all of them had anteriordislocation. In the unilateral fracture group 12 presented anteriordislocations (mean value of 23°) on the panoramic x-ray. 13 casespresented posterior dislocation (mean value of 10°). On the (PA)projections 12 fractures presented medial dislocation (mean valueof 14°), 4 presented lateral dislocation (mean value of 6°). Ascendingramus shortening reached a mean value of 5.40 mm. Satisfactoryfunction and mobility were observed in all the treated cases.Posttraumatic sequels as TMJ clicking (5 of 29), deviation by mouthopening (14 of 27), reduction of lateral movements and protrusion(in 15 of 29) and finally mouth opening ranged 30 to 60 mm.In conclusion, conservative treatment of condylar fractures is a safetreatment method avoiding surgery with predictable good results.Degree of the displacement or ascending ramus shortening didn’tprevent obtaining good results in this study

Impact of whole body positron emission tomography on initial staging and therapy in patients with squamous cell carcinoma of the oral cavity.

The aim of this study is to evaluate the additional clinical information provided by whole body positron emission tomography (PET) with fluorodeoxyglucose (FDG) for initial staging of patients with squamous cell carcinoma (SCC) of the oral cavity. PET scans from the head to the pelvic floor of 34 consecutive patients (22 male, 12 female; mean age 71 years) with histologically confirmed SCC of the oral cavity were retrospectively evaluated. Clinical information including CT of the head and neck and chest X-Ray or chest CT was compared with information on nodal involvement and distant metastases or secondary tumours obtained with PET. The primary tumour was identified with PET in 33 of 34 patients (97%). In 27 Patients (81%) the clinical N-stage was confirmed with PET. In two Patients (6%) additional pathologic loco-regional lymph nodes were found. In five patients more lymph nodes were identified with CT. Distant lesions were seen with PET imaging in bone, lung, mediastinum, liver and colon. In three patients (6%) distant metastases were correctly identified. In another four patients (12%) a secondary cancer was detected. One false positive finding was described with PET. In five of 34 patients (15%) the additional findings as revealed with PET lead to a change of treatment. Whole body PET provides relevant additional information to a standard clinical staging procedure in patients with oral cavity SCC. The detection of distant metastases and secondary primary tumours can have a great impact on patient management.

Surgical removal of a dislocated lower third molar from the condyle region: case report.

INTRODUCTION: Migration of dislocated lower third molar into the condylar region is quite rare. Attention should be taken to avoid condyle fracture. METHODS: 49-year-old patient had an ectopic lower left third molal in the condylar region, suffered from a submandibular and masseter space abscess. Removal of the molar via intraoral approach was chosen avoiding facial nerve branches and unnecessary scar formation. Coronoid process is removed, the tooth is separated and removed. The defect is filled with iliac cancellous bone. The coronoid process was fixed as a cover with a resorbable plate and screws (BIONX). RESULTS: Removal via intraoral approach is possible. Hypesthesia existed postoperatively, became normal later. CONCLUSION: Annual observation is strongly recommended. Intraoral approach is superior to the extraoral approach. Removal of the coronoid process minimizes the masticator forces. Separation of the tooth is essential. Filling the defect with cancellous bone accelerates the healing.

Laser-induced temperature changes in dentine.

OBJECTIVE: The purpose of this work is to study the temperature rise and potential thermal damage caused during ablation of human dentine using a super pulsed carbon dioxide laser of 9.6-microm wavelength, equipped with a water-cooling spray and scanner system. BACKGROUND DATA: There have been no reports on thermal effects of super pulsed CO2 laser of 9.6 microm wavelength on human dentine recently. MATERIALS AND METHODS: Two different types of samples were investigated to yield data most consistent with a typical clinical situation. Human dentine slices and crown segments were studied at a drilling depth of 1.0 +/- 0.1 mm and 2.5 +/- 0.5 mm, respectively. A control group treated with a conventional hand piece was compared to four laser groups with settings varying from 2 to 8 W. RESULTS: In the laser group demonstrating the highest elevation in temperature of the four studied, dentine slices lased at 2 W for 15 sec showed a mean temperature rise of less than 1.68 degrees C at an ablation rate of 0.86 +/- 0.08 mm. Conventional drilling with a comparable ablation rate of 0.76 +/- 0.59 mm resulted in a mean rise of 2.87 degrees C. The laser groups of crown segments revealed a constant decrease in temperature. SEM observations were lacking the typical morphological changes seen in earlier studies, specifically extensive melting, charring or cracking. CONCLUSION: A maximum rise of mean temperature to 1.68 degrees C in closest vicinity to the pulpal chamber and the morphological unaltered dentine surfaces demonstrate the safe and tissue preserving character of the superpulsed 9.6 microm CO2 laser. The laser caused an even lower temperature rise than conventional drilling. Moreover, the laser showed acceptable efficacy with ablation rates that did not significantly differ from the conventional dental drill.

Slow and continuous application of human recombinant bone morphogenetic protein via biodegradable poly(lactide-co-glycolide) foamspheres.

Bone morphogenetic proteins (BMPs) are multifunctional cytokines that were originally identified as molecules that induce bone and cartilage formation in vivo. In order to increase the efficacy of this potent protein for application in medicine, a carrier system is needed to retain the BMP at the preferred site. Here we present and characterize a slow-release carrier system for pure human recombinant (rh)BMP. The large porous microspheres, called 'foamspheres', are biodegradable, because they consist of poly(lactide-co-glycolide) acids and release loaded rhBMP slowly and continuously. In vivo studies in rodents revealed that rhBMP-loaded foamspheres increased the thickness of the calvarial bone of rats by 222%. When the same amount of rhBMP was applied via a gelatine-based hydrogel, the increase in bone height was only 66%. Thus, the carrier system for rhBMP is an important factor for the efficacy of BMPs.

Disulfide bridge conformers of mature BMP are inhibitors for heterotopic ossification.

Heterotopic ossification is a frequent complication in patients who have suffered head and neck traumas or undergone total hip replacement. Heterotopic ossification occurs when osteogenic precursor cells present at the ectopic site receive the necessary signal(s) to differentiate into osteoblasts. At the protein level, the key factors in differentiation of cells to the osteogenic lineage are BMPs. Stable BMP variants derived from the identical amino acid sequence but with different disulfide bridge configurations have been investigated and found to be capable of inhibiting ossification in vitro and in vivo in rodents. These findings provide a concept for the straightforward development of a novel class of BMP antagonists that could lead to new treatments for traumatically and genetically induced heterotopic ossification and also, possibly, for disorders in which other members of the TGF-beta superfamily are involved.

Temperature mapping of magnetic resonance-guided laser interstitial thermal therapy (LITT) in lymphangiomas of the head and neck.

BACKGROUND AND OBJECTIVE: Lymphangiomas of the tongue and neck are uncommon benign congenital lymphatic tumors. These vascular lesions are difficult to treat, frequently recur, and can cause patients significant morbidity. Treatment may also be complicated by adjacent vital anatomic structures. Magnetic resonance (MR)-controlled laser-induced interstitial thermotherapy (LITT) has been proven to be a noninvasive safe treatment. Real-time monitoring of tissue temperature with thermosensitive sequences allows controlled coagulation necrosis. STUDY DESIGN/MATERIALS AND METHODS: LITT was performed in a lymphangioma specimen ex vivo. In four patients (eight procedures) with lymphangiomas of the tongue and neck, MR-guided LITT was performed with a percutaneous approach in a multiapplicator technique. The laser system consisted of a titanium catheter and a protective catheter. The dome of the fiber end had a diameter of 1.4 mm with an active length of 20 mm. Temperature sensitive sequences were used in a 0.5 T open-configured MR scanner with the proton frequency shift technique to map the spatial and temporal distribution of Nd:YAG laser effects (7 Watts, 30 pulses per second, 10 minutes/location). Postoperative MR follow-up was performed at 1 week and at 3 months. In three patients, partial resection of the tumor was performed 6 months after LITT. RESULTS: In three patients, MR clearly showed a diminished tumor volume. All four patients reported subjective amelioration and in three patients former functional problems, such as speech and swallowing were improved. MR thermometry allowed accurate demarcation of changes by heat and distinction of affected tumor volume (3.0 cm +/- 0.3 cm). The histology of the patients 6 months after LITT showed laser-induced fibrosis of former lymphatic tissue. CONCLUSION: The results suggest that LITT can be performed safely with tissue preserving of vital structures and can be effective in the treatment of deep tumors, such as lymphangiomas. However, given the nature of the lesion, the potential for recurrence exists no matter what modality is chosen.

The Le Fort I osteotomy as a surgical approach for removal of tumours of the midface.

Tumours of the midface and maxillary sinuses have been removed via multiple approaches. The most common approaches are those using incisions in the facial skin, especially in the case of malignant tumours. The Le Fort I procedure via an intraoral incision as described by Sailer in 1986 is a versatile alternative. Combined with a coronal approach and various osteotomies of the upper face it also allows removal of tumours extending into the orbits, the nasoethmoidal complex and the skull base. The versatility of the Le Fort I osteotomy as a surgical approach was analysed in 17 cases. This method is reliable and gives excellent access. Further advantages are the wide surgical exposure and the clear visibility of the resection margins, the absence of visible scars, the feasibility of combining this approach with reconstruction using the buccal fat pad and the possibility of simultaneous placement of bone grafts, insertion of endosseous implants or other preprosthetic procedures via the same incision.

Frontal sinus fractures: computed tomography evaluation of sinus obliteration with lyophilized cartilage.

Allogenic lyophilized cartilage has been proven clinically to be a reliable material for obliteration of the frontal sinus without the limitations of donor site morbidity and the prolongation of the operation time produced by autogenic grafting. The long-term behaviour of the implanted material is of paramount importance for the success of the obliterative technique. This survey included 51 trauma patients on whom obliteration of the frontal sinus with lyophilized cartilage was performed. The fate of the lyophilized cartilage graft was evaluated from computed tomography imaging of the obliterated frontal sinus. No radiological sign of mucocele formation or inflammatory disease was noted. Bone density measurement of the obliterated sinus and the adjacent trabecular bone was calculated. The patient population was distributed into four groups (0-2, 2-4, 4-6, > 6 years) according the postobliterative time. The bone density of the implanted lyophilized cartilage was accentuated from group 1 to group 4 when compared with the bone density of the trabecular bone. This shows the long-term tendency of lyophilized cartilage graft to osseous substitution.