Dysgnathia, orthognathic surgery and spinal posture.

The aim of this study was to evaluate the spine by video rasterstereography before and after orthognathic surgery. Twenty-nine patients (17 patients with a skeletal class III, 7 patients with a skeletal class II, and 5 patients with mandibular asymmetry) were evaluated preoperatively and 1 year postoperatively. Video rasterstereography is a method of back surface measurement and shape analysis using the moire topography. Orthognathic surgery in cases of class III and asymmetry did not lead to significant changes in body posture. In class II patients it led to some changes in body posture, but without orthopaedic consequences. It is concluded that orthognathic surgery causes minimal or no change in body posture.

Pedicled sandwich plasty: a variation on alveolar distraction for vertical augmentation of the atrophic mandible.

We describe a method of vertical augmentation of an edentulous mandible that causes minimal weakening of bone and disturbance of sensation.

Preprosthetic vertical distraction osteogenesis of the mandible using an L-shaped osteotomy and titanium membranes for guided bone regeneration.

PURPOSE: Vertical osteodistraction is a new alternative method for alveolar ridge augmentation of the mandible. The purpose of this article is describe a technique using an L-shaped osteotomy and titanium membranes for guided bone regeneration (GBR) in the distraction gap. PATIENTS AND METHODS: Ten patients with severe atrophy of the edentulous molar region of the mandible underwent vertical callus distraction in 13 sites using intraoral microplate distractors. An L-shaped osteotomy with a short vertical part mesially and a longer horizontal part ending in the retromolar region was made, and the osteotomized segment was fixed to the mandibular ramus at its distal edge by a microplate, which became the center of rotation when distraction began. In this way, more callus generation could be achieved mesially than in the distal molar region. Follow-up computed tomography (CT) scans reconstructed axially to the axis of the mandible revealed semilunar excavations of the generated bone buccally in the distraction gap in the first cases. Clinical inspection on removal of the distractors showed fibrous connective tissue in the gap. Therefore, to prevent this from happening, titanium membranes covering the distraction gap were applied in subsequent cases. RESULTS: Ten patients (13 sites) were treated by vertical callus distraction. In 4 cases, GBR was achieved using titanium membranes. In all cases, the increase in alveolar height was sufficient to make dental implantation possible. In 1 patient, a fracture of the distractor occurred, and dehiscence was observed in 2 cases. These complications did not change the plan of therapy nor did they influence the results. The CT scans showed a homogenous surface on the regenerated mandible in the cases of GBR application. CONCLUSION: Both an L-shaped osteotomy and the application of titanium membranes for GBR in the distraction gap are of great value for mandibular augmentation, producing a physiologically shaped alveolar ridge.

The L-shaped osteotomy for vertical callus distraction in the molar region of the mandible: a technical note.

The following report refers to a well described surgical procedure using a prototype vertical distractor developed in Cologne in cooperation with Martin Medizintechnik GmbH. The surgical technique has been refined by an L-shaped osteotomy stabilized posteriorly by a miniplate to limit the amount of callus regeneration in the molar region where no increase in vertical height is required. The surgical technique with its advantages and one complication is described as used in four patients undergoing six distraction treatments.

Reconstruction of the floor of the mouth with a fascial radial forearm flap, prelaminated with autologous mucosa.

To circumvent the disadvantages of extraoral skin within the oral cavity and to cover mucosal defects by mucosa, we successfully prelaminated the radial forearm flap by insertion of buccal mucosa in ten patients. In a first-step operation, free grafts of buccal mucosa were fixed to the forearm fascia and covered with an alloplastic sheet, separating the mucosa grafts and the dissected fascia between and around the grafts from the overlaying subcutaneous tissue. The dimension of the alloplastic sheet in the subcutaneous pocket was chosen according to the size of the desired flap. Underneath the alloplastic sheet, the mucosal grafts merged and the mucosal surface increased by advancing of epithelial cells under in vivo culture conditions. After two months, mucosal prelamination of the distal radial forearm fascia had led to thin, pliable and resistant fasciomucosal flaps with a mucosal surface up to 7x4 cm, allowing physiological intraoral reconstruction. The preservation of skin and subcutaneous tissue of the forearm also enabled primary wound closure, reducing donor-site morbidity.

Mucosal prelamination of a radial forearm flap for intraoral reconstruction.

For reconstruction of intraoral soft-tissue defects after radical resection of squamous-cell carcinomas, the microvascular jejunal patch has been a reconstructive graft option of first choice. in addition to other advantages, these jejunal grafts are able to produce mucus. In cases in which the use of jejunal grafts is contraindicated, the fasciocutaneous radial forearm flap has enlarged the spectrum of reconstructive options. A disadvantage is that mucus production will be absent, because mucosal and lining reconstruction is performed with tissue lacking mucus-providing qualities. The authors successfully prelaminated a distal radial forearm flap with buccal mucosa in five patients. Mucosal prelamination of the distal radial forearm flap enables a physiologic reconstruction with resultant mucus production, in combination with the provision of thin, pliable, and resistant flaps. The technique lowers donor-site morbidity because of the preservation of skin and subcutaneous tissue. Reconstruction with fasciomucosal, osteomyomucosal, and myomucosal flaps by this method seems feasible.

Solitary plasmocytoma of the mandible--a combined approach for treatment and reconstruction.

A 44-year-old man presented with a solitary plasmocytoma in the left mandible. After neoadjuvant radiation therapy and chemotherapy, a bone marrow biopsy was taken for cryopreservation. In simulation surgery, tumour resection and primary reconstruction were planned on an individual stereolithographic 3-D skull model. Radical tumour resection and primary reconstruction using a microvascular iliac crest bone graft was performed. In case of extensive osteolysis and/or mandibular asymmetry due to tumourous bone enlargement, preoperative model planning has proved to be a useful tool for primary reconstruction. In the three-year follow up, the patient showed no recurrence of disease.

Mucosal prelaminated flaps for physiological reconstruction of intraoral defects after tumour resection.

In order to provide vascularised mucosa for reconstruction of intraoral defects after radical tumour resection, 5 distal radial forearm flaps and 1 fibula flap were prelaminated. Prelamination was performed by fixing small, full thickness mucosa pieces onto the fascia and covering the mucosa with an alloplastic sheet as large as the future flap. The alloplastic material was a silicone sheet (n = 2), a Gore-tex sheet (n = 3) or a titanium sheet (n = 1). The mucosa and the alloplastic material were covered by the skin and subcutaneous tissue which had been elevated to expose the fascia. With the silicone and titanium sheets, the mucosa spread on the fascia and the final flaps were thin, pliable, mucus-producing and larger than the original mucosa pieces. With the Gore-tex sheets, extension of the mucosa was prevented by adhesions and the area of mucosa on the final flap was the same size as the original graft. The six prelaminated flaps were harvested after 8-10 weeks. During this time the patients had radiotherapy and chemotherapy. Preserving the skin and subcutaneous tissue reduced donor site morbidity. Six patients had intraoral defects successfully reconstructed with mucus-producing prelaminated flaps.

Extensive facial vascular malformations and haemangiomas: a review of the literature and case reports.

We present 6 selected cases of extensive facial vascular anomalies extending to the skull base or actually involving it. These patients are compared with other cases in the literature. The spontaneous course of these vascular lesions is different and so variable treatment modalities are suggested depending on the age of the patient and the type of lesion. In young children, haemangiomas are common and spontaneous involution is characteristic. Conservative treatment in the sense of a wait-and-see approach is thereby favoured if there is no urgent indication such as involvement of essential structures, e.g. blockage of an orifice as demonstrated in one case or complications such as excessive bleeding. Vascular malformations most commonly appear in adults, there is no tendency to spontaneous involution and resection is usually necessary, especially in arteriovenous malformations. Nowadays, preoperative superselective embolization is recommended to minimize intraoperative blood loss. Superselective embolization is the treatment of choice in cases of a-v fistulae. Proximal ligation of the supplying arteries should be avoided because this may make embolization more difficult, and may be responsible for the common occurrence of rapid revascularization.

Posterior ischemic optic neuropathy following bilateral radical neck dissection.

A patient is presented with posterior ischemic optic neuropathy (PION) after bilateral radical neck dissection, probably caused by hemodynamic hypotension, combined with other factors. A postmortem histologic study of the optic nerve was performed to analyze the pathogenic mechanism of blindness. To prevent this complication, one should favor a two-stage procedure, avoiding drug-induced hypotension, overtransfusion, and anemia. During the postoperative period, visual acuity should be monitored regularly, and proper positioning of the patient's head is necessary.

[Evaluation of long-term results and donor site defects following transposition of connective tissue flaps]. / Evaluierung der Langzeitergebnisse und Hebedefekte nach Transposition des subpektoralen Gleitgewebslappens.

Nine patients suffering from chronic pain after surgery for thoracic outlet syndrome or after radiation therapy underwent neurolysis of the brachial plexus. To avoid a recurrence of scar formation, a pedicled subpectoral transposition flap of connective tissue, utilizing the pectoral branch of the A. thoraco-acromialis, was wrapped around the neurolyzed structures. Long-term follow-up results are presented.

Subpectoral gliding tissue flap.

By cadaver dissection, the anatomy of the connective tissue between the pectoralis major and the pectoralis minor muscle was studied. The possibility of creating a pedicled flap of gliding tissue based on the pectoral branch of the thoracoacromial artery was confirmed. The clinical relevance of this tissue was defined in nine patients. To avoid recurrent fibrosis after neurolysis of the structures of the brachial plexus in patients with recurrent pain syndromes, the envelopment of the neurolyzed nerves by a subpectoral gliding tissue flap was carried out and was successful in eight cases. After the transposition of the subpectoral gliding tissue flap, the remaining pectoralis major muscle showed only a small partial atrophy in the clavicular segment without any functional impairment; this was confirmed by physical examination and by electromyogram.

Ankylosis of the temporomandibular joint. Follow-up of thirteen patients.

We undertook a postoperative clinical study of 13 patients with ankylosis of the temporomandibular joints. The study consisted of an evaluation of the surgical concepts of resection and subsequent surgical reconstruction by osteotomy in previous height of the joint space and lining of the glenoid fossa with lyophilized dura. Early mobilization and aggressive physiotherapy are mandatory postoperative measures. According to the theory of mandibular growth as a result of functional matrix, early surgical intervention to correct ankylosis should be performed, regardless of the age of the patient, to prevent recurrence and later asymmetry or distoclusion.

[Training and conditioning in atopic patients following high altitude climate therapy]. / Training und Abhärtung bei Atopikern nach Hochgebirgsklimatherapie.

The subjective and objective values have changed after a four weeks treatment in high mountain areas under cool climatic conditions. "Terrainkuren" (mountain walking under guidance of a therapist) under cool climatic- and body temperature conditions show besides training results (in sport medicine) also favourable thermoregulatory adaptations. Improvements of the endurance training can be objectivated by means of the reduced heart frequency and the decrease in lactit acid under standardized physical exercises. The simultaneous changes of thermoregulation can be looked upon as part of the reaction of the whole body (also called inurement). Both, the improvement of the training condition and the thermoregulatory change seem to support each other. Thus patients can train more effectively under the same standardized physical training, but cooler conditions. The decrease of comfort temperature of patients is due to the thermoregulatory adaptation. There is a considerable decrease in the sensibility to cold. The training in high mountain areas causes an improvement in the well being and behaviour of the atopic patients which can still be manifested three months after the therapy.