Distraction osteogenesis in secondary microsurgical mandible reconstruction: report of seven cases.

INTRODUCTION: Fibula, ilium and scapula are the preferred donor areas for vascularised bone grafts. For secondary mandibular reconstruction, however, compromises often have to be made as a result of the poor quality of the covering soft tissue and recipient vessels especially in irradiated patients. Callus distraction osteogenesis is a complementary method for optimising the intermaxillary relationship and the facial profile from an aesthetic point of view. MATERIALS AND METHODS: Thirteen distractions were performed in seven patients following microsurgical mandibular reconstruction over a period of 4 years, all by the same surgeon. Intra-oral distraction devices were predominantly applied. After a 7-day healing period, the callus distraction was begun, involving two advisements per day of 0.5mm each. The distraction devices were removed after a consolidation phase of 4-5 months. RESULTS: Ten of the 13 distractions were uneventful with an average bone lengthening of 20mm, retained after a follow-up time of 6-47 months (average 27 months). The intermaxillary relationship and the facial profile were improved in all cases. Distraction plate fractures, screw loosening or absence of new bone formation were the complications encountered in the other three patients. CONCLUSION: Regarding the high complication rate, a successful outcome cannot be expected with greater certainty. Thus the indication should be stringent when including this procedure within the possible treatment alternatives available to the clinician.

Mechanical aspects of a multidirectional, angular stable osteosynthesis system and comparison with four conventional systems.

BACKGROUND: Following open reduction, internal fixation of fractures of the mandible is predominantly achieved using plates and screws. Today, a multitude of osteosynthesis systems are available on the market. One therapy modality, primarily developed for orthopaedic surgery, is using angular stable osteosynthesis plate systems. The dominating principle of these is the bond between screw and plate following insertion. This principle of an "internal fixateur" results in a more stable fixation of the fragments associated with less compression of the bone surfaces. MATERIAL: A new multidirectional osteosynthesis system (TiFix=Smartlock, Hamburg - Germany) was modified to fit the maxillofacial region and compared with four other well established osteosynthesis systems developed by Mondial, Medicon, Synthes, Leibinger-Stryker, one of these (Unilock by Synthes) being also angular stable. The resistance to deformation in varying directions was investigated following fixation in four different materials. RESULTS: The TiFix system proved more resistant to deformation even when mounted with fewer screws than the non-angular stable systems. CONCLUSION: This system results in greater stability even when fewer screws are used. For the clinician this means smaller access incisions, less soft tissue trauma, better aesthetic results, decreased duration of operation and a reduction of costs.

Clinical implementation of a multidirectional, angular stable osteosynthesis system in maxillofacial traumatology.

AIM: To investigate whether a multidirectional, angular stable osteosynthesis system is suitable for the treatment of mandibular fractures and to compare it with well established available systems. MATERIAL AND METHODS: Following preliminary testing in an animal model, the multidirectional angular stable system TiFix 2.3 obtained from Litos (Hamburg, Germany) was utilised for internal fixation of 39 mandibular fractures. These involved four symphyseal fractures, 17 parasymphyseal, 16 of the angle of the mandible and two comminuted fractures. The surgical and postoperative course was closely scrutinised. Radiographs were taken after 6 months and all plates removed under local anaesthesia. Photographs were taken intraoperatively and the plates and surrounding soft tissues were salvaged for histological analysis. Additionally, these operations were compared with treatment of equivalent fractures which were treated with conventional, non-angular stable systems. The relative costs have also been evaluated. RESULTS: In 33 of the 39 fractures one TiFix plate sufficed for osteosynthesis. The plate most often used was a 2-hole plate which was applied in 25 (55.5%) fractures, followed by the 4-hole plates used in 16 (35.5%) fractures. In two comminuted fractures, four 6-hole plates were used (9%). In 17 patients the operation lasted less than 30 min, in 20 patients less than 60 min, in two less than 120 min. In all cases, the operations were shorter, and due to the plates' dimensions fewer screws had to be used, thus reducing the costs. DISCUSSION: This angular stable system enabled reduction of the amount of the implant material. Also reduced were the operation time and the cost of the procedure. Furthermore, in the future it will allow smaller access incisions and better preservation of the soft tissue integrity.

Major mandibular surgical procedures as an indication for intraoperative imaging.

PURPOSE: This study investigated 3-dimensional (3D) imaging with intraoperative cone beam computed tomography (CBCT) in major mandibular reconstruction procedures. PATIENTS AND METHODS: The study group was comprised of 125 patients (83 males, 42 females) admitted for surgical treatment of the mandible. The patients ranged in age from 3 months to 91 years (average age, 40.72 +/- 22.843 years). Surgical procedures of the mandible were subdivided into repair of body fractures (17 patients), angle fractures (21 patients), condylar fractures (14 patients), and multiple fractures (30 patient). In addition, the study group included 21 patients undergoing orthognatic surgery and 22 undergoing reconstructive surgery on the mandible. Intraoperatively, 3D images were generated with a mobile CBCT scanner (Arcadis Orbic 3D; Siemens Medical Solutions, Erlangen, Germany). RESULTS: During open reduction of mandibular fractures, not all fracture sites can be readily exposed for direct visual control. For example, the lingual cortical bone of the mandible is difficult to assess intraoperatively. This structure and others can be effectively visualized using the 3D mode of CBCT. Furthermore, screw placement can be evaluated, specifically in insertions near the alveolar nerve. The intraoperative acquisition of the data sets is uncomplicated, and the image quality is sufficient to allow evaluation of the postoperative result in all cases. CONCLUSION: Intraoperative CBCT has proven to be a reliable imaging technique for providing visual control during major mandibular procedures.

Retrospective assessment of the peri-implant mucosa of implants inserted in reanastomosed or free bone grafts from the fibula or iliac crest.

PURPOSE: To investigate the susceptibility of implants to inflammation following autogenous bone transplantation and to evaluate whether various factors affect outcomes. MATERIALS AND METHODS: This retrospective cross-sectional clinical investigation involved patients who were treated between the years 1994 and 1996. The donor site, mode of transplantation, primary disease, gender, smoking habits, and age were evaluated with respect to outcomes. Clinical and radiologic assessments were the basis for the classification into 3 categories: (1) no inflammation, (2) mucositis, and (3) peri-implantitis. Lost implants were also noted. The data were evaluated statistically to determine whether significant differences existed. RESULTS: Forty-three patients (23 men and 20 women) were involved in this retrospective study. These patients received a total of 216 oral implants over a follow-up time of 8 to 10 years. Depending on the type of reconstruction, rates of peri-implant inflammation between 9% and 38% were observed. For mucositis, rates of 16.3% to 24.1% were seen, and 30% to 70.9% of sites showed no inflammation. CONCLUSION: High rates of soft tissue inflammation adjacent to implants were observed. The choice of donor site in conjunction with the mode of transplantation seemed to influence the development of peri-implant inflammation. The microsurgically reanastomosed fibula seemed most resistant to inflammatory processes, followed by the microsurgically reanastomosed iliac crest, free iliac crest, and free fibula. No significant differences could be observed for primary disease. These findings should be taken into consideration prior to surgery and when establishing individual recall systems.

Long-term results of jaw reconstruction with microsurgical fibula grafts and dental implants.

PURPOSE: The aim of this retrospective study was to evaluate the long-term utility of the free fibula flap for the reconstruction of the maxilla and mandible and to investigate its suitability for prosthetic rehabilitation with dental implants focusing on implant survival and implant-related morbidity. MATERIALS AND METHODS: Thirty patients who underwent microsurgical reconstruction of the upper or lower jaw after resection from 1992 to 1994 and were available for follow-up examination were included in the investigation. The primary afflictions were malignant tumors, alveolar atrophy, or osteomyelitis. Clinical and radiologic findings were gathered and evaluated with emphasis on the radiologic follow-up as well as clinical investigations disclosing implant-related complications. RESULTS: The fibula proved very suitable for the reconstruction of the upper and lower jaw, allowing rehabilitation with dental implants in all cases. Additionally, the peri-implant bone resorption and the overall complication rate proved to be low. In 93 of 128 implants, probing depths ranged from 2 to 3 mm. In 20 implants, probing depths of 4 to 6 mm were observed. In 4 implants, probing depths of greater than 7 mm were observed. These values corresponded with the radiologically assessed values. CONCLUSION: The reconstruction of the upper and lower jaw with a microsurgically reanastomosed fibula flap, in combination with dental implants, leads to satisfactory functional and esthetic results. The fibula flap seems resistant to peri-implantary resorption processes and is capable of withstanding the masticatory forces that develop during functional loading. In conjunction with the new prosthetic attachments, like the titanium magnetic inserts, the fixation of cover dentures and the oral hygiene is simplified and improved.

Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency with inadvertent caries in infants.

BACKGROUND: Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) is a rare systemic disease that is associated with early tooth decay. CASE REPORT: This report describes the case of a 3-year-old boy suffering from LCHADD. At the time of referral, extensive carious lesions of the subject's maxillary dentition necessitated the surgical removal of eight teeth. Preventive treatment for LCHADD involves a regular oral intake of glucose that is vital for the survival of the affected individual. In young infants, the glucose solution needs to be administered as often as every 3 h in order to prevent hypoglycaemia, leading to a local environment similar to that experienced in nursing bottle syndrome. While nursing bottle syndrome can be resolved by eliminating the sugar substrate and curtailing the feeding sessions, these alternatives are not available in cases of LCHADD. CONCLUSION: This report highlights this rare disease and emphasizes its dire consequences for the dentition. Prophylactic recommendations for high-risk children are reviewed. Familiarity with LCHADD allows this high-risk group of patients to be identified, and thus, ensures diligent prophylactic action.

The acute orbit: etiology, diagnosis, and therapy.

PURPOSE: Extension of dental abscesses to distant areas of the head and neck has been repeatedly reported in the medical literature. Subsequent involvement of the orbit still remains a rarity, resulting in protracted onset of therapy because of inaccurate diagnosis. Considering the possible lasting damage that can result from insufficient therapy, like blindness or even death, the need to extensively educate practicing physicians becomes evident. MATERIALS AND METHODS: With the help of a comprehensive review of the medical literature underlined with a clinical case, the etiology, diagnosis, and therapy of the acute orbit are highlighted with emphasis on the new imaging modalities as well as the broad spectrum antibiotics currently available on the market. RESULTS: Orbital infections of odontogenic origin are the rarest sequelae, with a prevalence of 1.3%. Correct diagnosis, adequate antibiotic therapy, and surgical drainage are the keys to success. CONCLUSION: The acute orbit continues to be a medical challenge. With the proposed diagnostic and therapy guidelines, this affliction can be identified and contained with a high degree of certainty.