Improved prediction of metastasis in tongue carcinomas, combining vascular and nuclear tumor parameters.

BACKGROUND: Predicting the presence of metastasis, based on tumor or tumor-related characteristics is of utmost importance. The authors studied the significance of tumor DNA features and tumor-related angiogenesis to predict the occurrence of metastasis in squamous cell carcinomas (SCCs) of the tongue. METHODS: Paraplast blocks from resection specimens of 20 metastasized and 20 nonmetastasized SCCs of the tongue with a minimum follow-up of 24 months were used. Tissue sections were stained with anti-CD34 monoclonal antibodies for vessel visualization, and according to Feulgen to stain DNA. Using image analysis, data from both stainings were computed for each of the 40 carcinomas. A logistic regression model to predict the presence of metastasis, based on vascular and nuclear morphology features, was developed. RESULTS: The intratumor variation of chromatin condensation and the percentage vessels smaller than 5 microm in diameter were selected for the model. The model correctly predicted metastasis in 90% of patients and excluded metastasis correctly in 75% of nonmetastasized tumors. Taking into account the prevalence of metastasis in SCC of the tongue of between 30% and 60%, this means a predictive value for a negative outcome of between 95% and 83%. CONCLUSIONS: The proposed model shows an improvement of predictive values compared with previous models with single parameters. Therefore, a multiparameter model appears to predict the multiparameter process of metastasis better.

[Stability of orthodontic-maxillofacial surgical treatment of anterior open bite deformities]]. / Stabiliteit van de orthodontisch-kaakchirurgische behandeling van de open beet in het front.

A sample of 267 patients with maxillary hyperplasia, a Class I or Class II occlusion and anterior open bite, collected from three different institutions, was analysed regarding stability after Le Fort I intrusion osteotomies or bimaxillary osteotomies. Skeletal and dento-alveolar stability of the maxilla, postional changes of the mandible and of incisors were evaluated on cephalometric radiographs. The stability of maxillary arch dimensions after correction of the open bite is measured on dental casts. Patients with anterior open bite, treated with a Le Fort I osteotomy in one-piece or in multi-segments, with or without bilateral sagittal split osteotomy exhibited good skeletal stability of the maxilla. Rigid internal fixation showed better maxillary and mandibular stability than intraosseous wire fixation. Considerable relapse of transverse dimensions, however, was measured after orthodontic and surgical expansion. The mean overbite at the 69 months follow-up was 1.24 mm and lacking of overlap between opposing incisors was present in 19%.

Incorporation of composite bone implants in the facial skeleton.

The purpose of this study was to evaluate the capacity of composite grafts consisting of either particulated cancellous or particulated cortical bone and anorganic bovine bone mineral (BBM) (Bio-Oss) to induce regeneration in standardized critical size bony defects overlying the frontal sinus. Four full thickness critical size bone defects were made in the frontal bone in each of 8 skeletally mature female goats. These defects were filled at random with composite cancellous bone/BBM grafts or composite cortical bone/BBM grafts. Control defects were not included but could be evaluated using data from a previous study in which the same experimental setting was used (Merkx et al. 1999a). Fluorochrome bone markers were injected subcutaneously 1 and 5 weeks after implantation, and 1 week before the animals were killed. Two animals were killed at 3, 6, 12 and 24 weeks after surgery respectively. The results were evaluated by histological means including fluorescence microscopy. In conclusion, composite grafts consisting of autogenous cancellous bone/BBM yield good results, combining the advantages of each material alone and reducing the disadvantages of each when used separately. Critical size defects in the maxillofacial area, overlying a paranasal sinus, filled with this material heal uneventfully within 12 weeks. Composite grafts consisting of cortical bone and BBM show less favorable results. These grafts induce osteoclasts, probably by the presence of non-functional BBM, resulting in resorption of the cortical bone chips.

[Needs for implant therapy in cancer patients; a retrospective study]. / Implantologische behandelingsbehoefte bij oncologiepatiënten. Een retrospectief onderzoek.

After cancer treatment in the head and neck area, mastication and speech are often affected. Some of the problems encountered can be solved by adequate dental rehabilitation. However, dental rehabilitation is often compromised, for various reasons. The change in anatomy due to surgery often results in lack of denture bearing mucosa. The effects of radiotherapy of the salivary glands and the mucosa result in dry oral tissues and diminished retention of removable dentures. Osseointegrated implants can help to solve these problems. Implant treatment has, so far, not been widely used in cancer patients. An analysis was made of 95 consecutive patients with a tumor in the head and neck area. The indication for treatment with osseointegrated implants was reviewed and the need for implants as experienced bij patients was evaluated. Results show that 45% did not need specific prosthetic rehabilitation, and approximately 25% of the patients could benefit from osseointegrated implants. Due to general and local contra-indications and patients' refusal, only 3% actually have been treated. For complete oral rehabilitation of this group of patients the use of osseointegrated implants should be considered at an early stage, before the initial tumor treatment.

Fractures of the frontal sinus: classification and its implications for surgical treatment.

PURPOSE: To propose a clinical classification of fractures of the frontal sinus and discuss the implications on treatment. PATIENTS AND METHODS: One hundred patients with fractures of the frontal sinus seen and operated on in two University hospital units (Leuven and Nijmegen). The majority of the patients were surgically treated according to a protocol based on the proposed classification. Fractures were classified according to their location, extent, involvement of the nasofrontal duct, and injury to the dura. Fragments were reduced and fixed, defects were reconstructed with autologous bone grafts, and the sinus cavity was drained, obliterated, or cranialized. In the latter cases, the sinus mucosa was thoroughly removed before obliteration or cranialization. RESULTS: The follow-up ranged from 6 months to 12 years. There were functional complications in 4% of patients. Minor aesthetic sequelae were noticed in 14% of the patients. CONCLUSION: A detailed classification of fractures of the frontal sinus is proposed. It has helped the authors set up a treatment protocol. Optimally, if used by clinicians, it will contribute to a more standardized method of surgical care of patients with such injuries.

Incorporation of particulated bone implants in the facial skeleton.

The purpose of this study was to compare the regenerative response of autogenous cortical and cancellous bone chips and a natural particulate resorbable bone mineral (RBM) (Bio-Oss, Geistlich-Pharma, Wolhusen, Switzerland) in standardized bony defects relating paranasal sinuses to one another and to bone blocks. On 13 skeletally mature female goats four standardized critical-sized full thickness bone defects were made in the frontal bone overlying the frontal sinus. These defects were filled at random with cortical bone chips, cancellous bone chips, spongiosa granules of a RBM or left empty. Fluorochrome bone markers were injected subcutaneously 1 and 5 weeks after transplantation, and one week before the animals were killed. The animals were killed at 3, 6, 12 and 24 weeks after surgery. Autogenous cancellous bone chips is the material of choice for bridging a bony defect in the maxillofacial area where there is no need for mechanical strength. They heal in the same way as cancellous bone blocks do. Cortical bone chips are not reliable enough to be used as a solitary bone-grafting material under these conditions. A cortical block as a solitary implant gives better results. RBM granules as solitary implant in a critical-sized defect do not stimulate osteoconduction but give rise to an extensive osteoclastic activity stimulated by the mutual loose relation. A solid block of RBM is in a similar case more reliable.

Incorporation of three types of bone block implants in the facial skeleton.

The regenerative response on autogenous cancellous and cortical bone grafts, and on a commercial available xenogenous resorbable bone mineral (RBM) (Bio-Oss, Geistlich-Pharma, Wolhusen, Switzerland) was compared in standardized bony defects related to a paranasal sinus. On 15 skeletally mature goats four critical sized full thickness bone defects were trephined in the frontal bone. These defects were filled at random with a cortical bone plug, a cancellous bone plug, a plug of spongious RBM cut into shape or left empty. Fluorochrome bone markers were injected subcutaneously 1 and 5 weeks after transplantation, and one week before the animals were killed. The animals were killed at 3, 6, 12 and 24 weeks after surgery. Histological evaluation showed that autogenous bone grafts were all accepted and incorporated in a similar way as in calvarial defects. RBM was only osteoconductive. New bone was formed at the margins of the defects, and only little of the RBM was incorporated. Most of the RBM was gradually resorbed by multinucleated osteoclast-like cells.

Transalar sphenoidal encephalocele and respiratory distress in a neonate: a case report.

We present a full-term newborn infant who suffered from immediate postpartum severe respiratory distress. The infant had an inspiratory stridor as a result of a swelling of the soft palate, extending from the roof of the nasopharynx. Transoral endotracheal intubation resulted in normal saturation levels. Histologic examination after an open biopsy showed mature neuroglial tissue. Radiology demonstrated the presence of a right parapharyngeal process obstructing the nasopharynx and oropharynx and extending to the right middle and posterior fossa, via the foramen ovale. After transoral debulking, the infant was extubated successfully. After an uneventful period of 5 months, the patient was readmitted at our hospital for treatment of meningitis. Subsequently, the inspiratory stridor recurred, and staged surgery was performed. First, a transcranial approach was used to remove a large intradural part of the process and close the defect at Meckel's cave. Two weeks later the retro- and parapharyngeal part of the process were removed transorally. Given the site of the defect of the skull base and the intradural location of the process, the diagnosis is a transalar sphenoidal encephalocele. This is a rare type of basal encephalocele, and has never been reported in an infant nor known to present with respiratory distress. The pathogenesis, clinical presentation, pathology, and therapeutic implications of basal encephaloceles are discussed.

[Syndromes 9. Hemifacial microsomia]. / Syndromen 9. Dysostosis otomandibularis.

Hemifacial microsomia is also known under quite a number of synonyms. Pathognomonic for these usually sporadic cases are: marked three dimensional asymmetry of the mandible, the ear, the maxilla, the zygoma and the orbit. The more distal the structure, the more marked the asymmetry. Many other optional symptoms are described. The differential diagnosis is almost never a problem in this aspecific complex of symptoms. Surgical therapy asks for expert treatment. The treatment contains usually several operations of which one to three are really major. Even then, very good results are mainly obtained in the less pronounced cases only.

[Syndromes 11. Treacher collins syndrome]. / Syndromen 11. Syndroom van Treacher Collins.

Treacher Collins syndrome is seen once in 10.000 births. Inheritance is autosomal dominant with variable expressivity. The most prominent symptoms are antimongoloid slant of the eyelids, hypo- or even aplasia of the zygomata, very hypoplastic mandible with receding chin, deformed ear lobes and conductive hearing loss. With two to three operations a considerable improvement can be achieved. The correction of the eyelids is often the most difficult problem.

[Syndromes 7. Hypertelorism (Greig syndrome)]. / Syndromen 7. Hypertelorisme (Greig-syndroom).

Hypertelorism is an increased distance between the orbits. Most evident symptom is the increased intercanthal distance. It can be caused by congenital deformities (facial clefts, encephaloceles, enlarged ethmoïds) and by trauma. Three degrees are differentiated. Grade one and two can be corrected with a small risk for complications. If there is vertical orbital dystopia it has to be corrected by a transcranial procedure, as is necessary in grade 3.

Psychologic implications of surgical-orthodontic treatment in patients with anterior open bite.

Two hundred eighty-two patients who received surgical-orthodontic treatment to correct anterior open bite were retrospectively evaluated by interview and questionnaires to determine the motivation and expectations before treatment, experience during treatment, psychosocial impact, functional and esthetic results, and satisfaction. All patients underwent a Le Fort I osteotomy, and 126 patients also received a bilateral sagittal split advancement osteotomy. The mean follow-up was 6 years. The most important reasons for treatment, as cited by the patients, were biting and chewing problems (28%), dissatisfaction with facial appearance (26%), and symptoms of temporomandibular joint (TMJ) dysfunction (21%). Patients with anterior open bite had a critical attitude toward facial appearance; therefore, esthetic aspects should be taken seriously. The expectations on chewing ability, phonetics, nasal passage, and facial appearance were met by the treatment; however, expectations on TMJ function, interincisal relationship, and biting ability were not completely fulfilled. There was a subjective improvement of TMJ sounds in 27% and a worsening in 14% of the patients. Dysesthesia of the infraorbital nerve was noticed in 4% of patients and of the mental or inferior alveolar nerve in 23% of the patients. Chewing and biting abilities improved in 53% and 73%, respectively. Facial appearance, self-confidence, and social interaction had improved. Patients had expected more information before and psychologic support after treatment. Despite the relapse of open bite in 20% of the patients, 75% were satisfied with the dental and 85% with the facial appearance.

Successful surgical repair of progressive exophthalmos caused by a meningocele in a patient with neurofibromatosis Type 1. Case report.

A case of surgical repair of progressive exophthalmos of the right eye in a 43-year-old woman with neurofibromatosis Type 1 (NF1) is presented. Preoperatively, the patient's ocular movements and visual fields were intact. Visual acuity was 20/30 on the right side and 20/20 on the left. Computerized tomography scanning demonstrated complete absence of the superolateral orbital wall on the right side with a large meningocele protruding into the right orbit. Intraoperatively, a new superolateral wall was constructed using the inner table of the left frontal bone as a bone transplant. A free galeoperiosteum flap was used for water-tight dural reconstruction. A few weeks postoperatively the patient's exophthalmos showed remarkable resolution. Her ocular movements, visual acuity, and visual fields remained unchanged. In conclusion, reconstruction of the superolateral wall and repair of a meningocele in a patient with NF1 is worthwhile and can be followed by excellent cosmetic results. More important, the patient's visual functions remain preserved.

Open bite deformity in amelogenesis imperfecta. Part 2: Le Fort I osteotomies and treatment results.

Functional conditions, skeletal and dento-alveolar stability and condylar changes in 15 patients with mandibular hypoplasia, anterior open bite (AOB) and amelogenesis imperfecta (AI), who had undergone a Le Fort I osteotomy, were analysed after a mean follow-up of 5 years. Two patients underwent a one-piece Le Fort I intrusion osteotomy and 13 patients a multi-segment Le Fort I osteotomy. In three of these patients, an additional bilateral sagittal split osteotomy was performed. Thirteen patients underwent a genioplasty. Surgery was followed by prosthetic rehabilitation in 10 patients. Skeletal and dento-alveolar stability were analysed on lateral cephalometric radiographs and condylar changes on orthopantomographic radiographs. Transverse stability of the dental arches was analysed on dental casts. The treatment results in this group were compared with patients with similar skeletal features but without amelogenesis imperfecta. The harmony of the long faces was restored and a reasonable vertical stability of the maxilla was achieved, however, a slight open bite and tongue interposition was still present. The transverse stability of dental arches (60%) was disappointing. Rigid internal fixation produced better transverse stability. Progressive condylar resorption was seen in two patients (13%). Less occlusal stability could be achieved in patients with AI, but resulted neither in less skeletal stability nor in more susceptibility to morphological condylar changes.

Open bite deformity in amelogenesis imperfecta. Part 1: An analysis of contributory factors and implications for treatment.

Anterior open bite (AOB) is often seen in patients with amelogenesis imperfecta (AI). The skeletal and dental components were analysed in 15 patients with AI and AOB. Measurements on cephalometric radiographs and dental models were compared with those of 130 patients with AOB but without enamel anomalies. Skeletal components in the AI and non-AI group were comparable. The AI group showed omega-shaped dental arches and a reversed mandibular curve of Spee. Orthodontic treatment options are limited because of the conical form of the teeth, tight contacts in the posterior regions and the condition of enamel resulting in difficulties in bonding brackets. Fixation problems encountered during surgery are discussed. A multidisciplinary treatment is outlined consisting of a multi-segment Le Fort I osteotomy followed by prosthetic rehabilitation to stabilize occlusion for at least one year postoperatively.

Treatment of the edentulous mandible with a vestibuloplasty combined with Intramobil Zylinder implants: a 5-year follow-up.

The long-term success of endosseous implants is related to healthy peri-implant tissues. Attached keratinized mucosa does not seem important for the prevention of soft tissue complications. Prevention of muscle attachment near the implants, however, seems more decisive for maintaining a favourable peri-implant environment. We treated 150 patients from 1990-91 with two Intramobil Zylinder implants and modified vestibuloplasty, 65 of whom were randomly selected for evaluation at 1 year; 48 of the 65 were also seen at 5 years. The vestibuloplasty was done by the technique of Pichler and Trauner, to prevent muscle pull and to create a thin layer of mucosa around the implants, and endosseous osseointegrated implants were inserted. The results show an adequately depended vestibulum with no muscle pull around the implants and significantly lower pocket depth after 5 years of follow-up compared with similar studies.

An image analysis study on nuclear morphology in metastasized and non-metastasized squamous cell carcinomas of the tongue.

In a retrospective case-control study on 46 metastasized and 34 non-metastasized primary tongue carcinomas, the nuclear morphology and chromatin pattern were assessed in 3 microns thick, formalin-fixed, paraffin-embedded, and Feulgen-stained tissue sections of surgical resection specimens, by means of high-resolution computer-assisted image analysis. The aim of this study was to disclose differences in karyometric features, such as nuclear size-, shape-, and chromatin-pattern features, between these groups, with a view to developing a discriminant function that can predict the occurrence of metastasis for the individual patient. In addition, the lymph node metastases of 31 patients and the normal tongue epithelium of 21 patients were also assessed, to study the possible differences between these two groups and primary tumours. In the metastasized tumours, the chromatin was significantly more condensed (P = 0.01) and exhibited significantly less variation in chromatin condensation (P < 0.001) than in the group of non-metastasized carcinomas. Comparison of lymph node metastases with their primary tumours disclosed only minor differences in chromatin pattern. These findings suggest that only minor genetic differences exist between primary tongue carcinomas and their metastases. Tumour cells of tongue carcinomas showed highly significant differences from cells of normal tongue mucosa for most karyometric features. Logistic regression analysis resulted in a classifier, based on the circularity of the nucleus (CIRC) and the standard deviation of the chromatin condensation (SD COND), to predict the occurrence of lymph node metastases. After cross-validation, the percentages of correct classifications in the group of metastasized and non-metastasized tumours were 72 and 62 per cent, respectively. These results are comparable to the classification results obtained from a classifier based on the clinical T-stage, but our karyometric classification results show a much more equal distribution between the sensitivity and specificity. Karyometric features appeared to be more appropriate to predict metastases than biomarkers such as p53, bcl-2, and Ki-67.

Reproducibility of aimed-at profiles.

Would a surgeon always draw the same aimed-at profile when planning the correction of a face with evidently malpositioned jaws? The same 10 profile lines were given to seven maxillofacial surgeons on two occasions at intervals of 6 months. The differences in absolute and proportional vertical measurements were compared. It is shown that the variations between first and second drawing were quite large for individual values. However, even the mean differences per measurement vary between surgeons from 0 to 10%. The drawings for the whole group corresponded reasonably well with the ratios given by Farkas and Munro (1987) but were rather divergent from the 'golden dimensions' proposed by Brons and Mulié (1993). Considering the sometimes significant differences, one is advised not to draw profiles 'off the cuff' but to use a construction system for planning osteotomies.

Condylar remodelling and resorption after Le Fort I and bimaxillary osteotomies in patients with anterior open bite. A clinical and radiological study.

A sample of 259 patients with vertical maxillary hyperplasia, mandibular hypoplasia and anterior vertical open bite, collected from three different institutions, was analysed regarding temporomandibular joint (TMJ) sounds, condylar remodelling, and condylar resorption. All patients underwent Le Fort I osteotomies, and bilateral sagittal split advancement osteotomies were performed in 117 patients. Intraosseous wire fixation was used in 149 and rigid internal fixation in 110 patients. Cephalometric and orthopantomographic radiographs were available before surgery, immediately after surgery, one year postoperatively and at the latest follow up. The mean follow up was 69 months (range 20-210 months). The number of patients with TMJ sounds decreased from 38% to 31%. At the latest follow up 23.6% of the patients showed condylar remodelling, 7.7% unilateral condylar resorption and 7.7% bilateral condylar resorption. Condylar contours, as assessed on orthopantomographic radiographs, were classified as five different types. Condyles with preexisting radiological signs of osteoarthrosis or having a posterior inclination were at high risk for progressive resorption. Female patients with severe anterior open bite, high mandibular plane angle and a low posterior-to-anterior facial height ratio, who underwent a bimaxillary osteotomy, were prone to condylar resorption. Bone loss was predominantly found at the anterior site of the condyle. The incidence of condylar resorption was significantly higher after bimaxillary osteotomies (23%) than after only Le Fort I intrusion osteotomies (9%). Avoidance of intermaxillary fixation by using rigid internal fixation tended to reduce condylar changes, in particular in patients who underwent only a Le Fort I osteotomy. Rigid internal fixation in bimaxillary osteotomies resulted in condylar remodelling in 30% and progressive condylar resorption in 19% of the patients. Condylar changes were not significantly different after using either miniplate osteosynthesis or positional screws in bilateral sagittal split osteotomy procedures.

Randomized prospective clinical trial of two implant systems for overdenture treatment: a comparison of the 2-year and 5-year results using the clinical implant performance scale.

In a prospective randomized clinical trial, edentulous patients were treated with dental implants and overdentures. The results of treatment with two IMZ implants connected by a Dolderbar, and a transmandibular implant (TMI) were compared. By using the clinical implant performance scale, the clinical and radiographic data were evaluated and compared after a two-year and five-year follow up. After the five-year follow up, significantly less problems and complications were recorded in the IMZ group than in the TMI group (Wilcoxon, P=0.03). When compared to the two-year follow up, there was, however, a gradual increase of scores on the clinical implant performance scale in the IMZ group, while in the TMI group only a slight increase was recorded.