Midfacial Advancement Line-A Comparative Evaluation of a New Measurement Method in Orthognathic Surgery.

PURPOSE: In planning intraoral quadrangular Le Fort II osteotomy (IQLFIIO), simulation of hard and soft tissue changes will be important at the infraorbital, Le Fort I, and incisor level. The aim of our study was to evaluate a new method for visualization and quantification. MATERIALS AND METHODS: Three different methods of quantification were compared: the point-to-point (PTP) measurement, which has been viewed as the reference standard; part comparison analysis (PCA); and a new method, the midfacial advancement line (MFAL) measurement. We performed a measurement comparison study using the Bland-Altman method to measure agreement and enrolled patients with midfacial deficiency and Class III malocclusion who had undergone IQLFIIO. The primary predictor variable was the method of measurement. The primary outcome variable was the amount of midfacial advancement. We also investigated the time required, visualization quality, and interobserver agreement. RESULTS: The sample included 12 subjects with a mean age of 21.6 years; 7 patients were male. The PTP and MFAL showed no significant observer dependence. The advancement measured with PTP and MFAL showed no significant differences. However, the advancement measured using MFAL and PCA showed a significant difference. The highest rating of visualization was found for MFAL. The time requirements were similar for all 3 methods. CONCLUSIONS: Our results have shown that the MFAL is a suitable method for visualization and quantification of soft and hard tissue changes at all 3 face levels in 1 image. It could be a valuable tool for virtual planning of midfacial advancement surgery.

Expression of inhibitors of apoptosis proteins in salivary gland adenoid cystic carcinoma: XIAP is an independent marker of impaired cause-specific survival.

OBJECTIVES: Inhibitors of apoptosis proteins are crucial to carcinogenesis since their expression results in evasion of apoptosis. Overexpression of inhibitors of apoptosis has repeatedly been associated with resistance to treatment and poor prognosis in various cancers. The role of inhibitors of apoptosis in adenoid cystic carcinoma of the salivary gland is still unclear. The aim of this study was to investigate the expression of inhibitors of apoptosis and their potential prognostic value in adenoid cystic carcinoma. DESIGN, SETTING AND PARTICIPANTS: Forty-nine patients, diagnosed with adenoid cystic carcinoma of the salivary gland between 1996 and 2016, were retrospectively included in this study. The expression of cIAP1, cIAP2, XIAP, Birc6, Livin and Survivin was assessed using immunohistochemistry, and their association of survival and prognosis was evaluated during a median follow-up of 6.4 years. MAIN OUTCOME MEASURE: Cause-specific survival and recurrence-free survival rates. RESULTS: XIAP, cIAP2, Livin and nuclear Survivin showed high expression levels in adenoid cystic carcinoma in most patients. There was no significant association of cIAP1, cIAP2, Livin, Birc6 and Survivin with outcome. However, high XIAP expression was associated with worse cause-specific survival and worse response to radiotherapy and proved to be an independent marker in multivariable analysis. CONCLUSION: Our data indicate that high expression of XIAP may be used as a prognosticator for poor survival and poor response to radiotherapy in adenoid cystic carcinoma patients.

Soft Tissue Changes in Patients Undergoing Intraoral Quadrangular Le Fort II Osteotomy Versus Conventional Le Fort I Osteotomy.

PURPOSE: The aim of this study was to evaluate soft tissue changes after intraoral quadrangular Le Fort II osteotomy (IOQLFII) and correlate those changes to underlying osseous changes. MATERIALS AND METHODS: Twenty-six non-growing patients with midfacial deficiency and Class III malocclusion were analyzed. A study group of 13 patients who underwent IOQLFII was compared with 13 patients who underwent conventional Le Fort I osteotomy (LFI). After fusion of pre- and postoperative computed tomograms, each patient's hard and corresponding soft tissue changes were measured. Measurement points were defined at 3 levels in the IOQLFII group (infraorbital rim [IR], sinus floor [SF], and lateral incisor tip [LI]) and at 2 levels in the LFI group (SF and LI). Linear models were created to test for correlations between hard and soft tissues. RESULTS: The slope (a1 coefficient) between anteroposterior hard and soft tissue changes was found to be highly significant at each measurement point for all groups. In the IOQLFII group, soft tissue advancement was 69% (confidence interval [CI], 62 to 77%) of the hard tissue advancement at the IR, 90% (CI, 84 to 96%) at the SF, and 73% (CI, 64 to 82%) at the LI. In the LFI group, the corresponding percentages were 90% (83 to 97%) at SF and 84% (77 to 90%) at LI. CONCLUSION: IOQLFII results in predictable correction of midfacial deficiency. At the IR, bony advancement always resulted in markedly less soft tissue advancement than at the SF level. These results indicate that the planned infraorbital advancement should not be too conservative because soft tissue changes are smaller in this region.

Technical Modifications for Intraoral Quadrangular Le Fort II Osteotomy.

PURPOSE: The intraoral quadrangular Le Fort II osteotomy (IQLFIIO) represents a reliable surgical method in cases of midfacial deficiency with good functional, esthetic, and stable long-term results. PATIENTS AND METHODS: In this technical note, we present 3 surgical modifications to previous reports: 1) inferior orbital rim osteotomy by angulated piezosurgical instruments, thereby avoiding the use of chisels in the orbital region; 2) osteosynthetic fixation only laterally at the zygomatic buttress with 2 L-shaped miniplates, thus avoiding paranasal osteosynthesis; and 3) advancement step camouflage in the lateral infraorbital region with a compound mass of autologous bone chips and fibrin glue with the intention to reduce bone block-associated side effects. RESULTS: Thirteen consecutive patients presenting with midfacial deficiency and Class III malocclusion were treated by IQLFIIO and mandibular osteotomy. In all cases, osteotomy and consecutive down fracture could be conducted as planned using the piezotome. No atypical fractures were encountered. No cases of infraorbital nerve anesthesia developed. Midfacial hypesthesia was found in 54% of the operated sides after 3 months, in 23% after 6 months, and in 13% after 12 months. The 5-month postoperative 3-dimensional scans revealed osseous healing at the infraorbital advancement step. CONCLUSIONS: Our results suggest that IQLFIIO can be conducted fully without chisels in the orbital region. Implementation of piezosurgery in IQLFIIO allows for safe bone cutting in the orbital region. Two miniplates and step camouflage with fibrin glue-stabilized bone chips were sufficient for osseous healing. Future studies will focus on quantitative soft to hard tissue changes that occur with IQLFIIO advancement.

Antibiofilm Activity of Low-Amperage Continuous and Intermittent Direct Electrical Current.

Bacterial biofilms are difficult to treat using available antimicrobial agents, so new antibiofilm strategies are needed. We previously showed that 20, 200, and 2,000 µA of electrical current reduced bacterial biofilms of Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa. Here, we tested continuous direct current at lower amperages, intermittent direct current, and combinations of surface materials (Teflon or titanium) and electrode compositions (stainless steel, graphite, titanium, or platinum) against S. aureus, S. epidermidis, and P. aeruginosa biofilms. In addition, we tested 200 or 2,000 µA for 1 and 4 days against biofilms of 33 strains representing 13 species of microorganisms. The logarithmic reduction factor was used to measure treatment effects. Using continuous current delivery, the lowest active amperage was 2 µA for 1, 4, or 7 days against P. aeruginosa and 5 µA for 7 days against S. epidermidis and S. aureus biofilms. Delivery of 200 µA for 4 h a day over 4 days reduced P. aeruginosa, S. aureus, and S. epidermidis biofilms on Teflon or titanium discs. A reduction of P. aeruginosa, S. aureus, and S. epidermidis biofilms was measured for 23 of 24 combinations of surface materials and electrode compositions tested. Four days of direct current delivery reduced biofilms of 25 of 33 strains studied. In conclusion, low-amperage current or 4 h a day of intermittent current delivered using a variety of electrode compositions reduced P. aeruginosa, S. aureus, and S. epidermidis biofilms on a variety of surface materials. The electricidal effect was observed against a majority of bacterial species studied.

Esthetic Outcomes for Immediate Implant Placement with Immediate Provisionalization in the Anterior Maxilla with Buccal Dehiscence: Results of a Comparative Pilot Study.

PURPOSE: The aim of this pilot exploratory cohort study was to assess the value of buccal augmentation in immediate implant placement and immediate restoration of anterior teeth in maxillae with missing buccal lamellar bone with regard to esthetic parameters, as well as soft and hard tissue level changes. MATERIALS AND METHODS: This study compared three groups of 10 patients each with immediate implant placement and immediate restoration in the anterior maxilla: (1) patients with partially to totally missing buccal bone with simultaneous augmentation with bovine collagen (test group augmented [TGA]); (2) patients with partially to totally missing buccal bone without augmentation (test group nonaugmented [TNA]); and (3) patients with intact buccal lamellar bone (control group [CG]). The pink esthetic score (PES) and the course of the peri-implant bone level after 1, 3, and 12 months were used as assessment criteria. RESULTS: After 12 months, the PES in the TGA was assessed as being better than it was preoperatively (mean ± SD: 8 ± 3.09 vs 9.25 ± 3.01, respectively, P = .8243), while it remained almost identical in the other two groups (TNA = 8.75 ± 2.7 vs 8.6 ± 3.3, P = .4098; CG = 10.6 ± 2.41 vs 10.6 ± 2.22, P = .7085). A significant difference among the PES values of the three groups was not observed at any point in time (preoperative: P = .118, 12 months: P = .383). In total, the TNA and CG showed an improvement in 3 out of 7 parameters of the PES after 12 months, while this was the case in 5 out of 7 parameters in the TGA. No significant difference among the three groups could be seen at any time point regarding peri-implant bone level. In the CG and TGA patients, a nonsignificant improvement in peri-implant bone level was seen after 12 months (respectively: 1.6 mm to 0.99 mm; P = .08068; 1.89 mm to 1.73 mm; P = .5866). In contrast, TNA patients showed a nonsignificant deterioration vs the postoperative situation (1.16 mm to 1.45 mm; P = .08208). CONCLUSION: Within the limitations of this pilot study, it can be concluded that a missing buccal lamellar bone appears to be no contraindication for immediate implant placement and immediate restoration, provided the baseline esthetic situation is accepted. As compared to the nonaugmented defect group or the group with intact lamellar bone, neither the esthetic nor the radiologic results could be improved significantly by augmentation with bovine collagen.

Comparison of feasibility, time consumption and costs of three virtual planning systems for surgical correction of midfacial deficiency.

BACKGROUND: Today virtual surgical planning (VSP) is a standard method in maxillofacial corrective surgery and is the key to reach satisfactory esthetic outcomes. The purpose of this study was to evaluate usability of three established virtual surgical planning software applications by comparing feasibility, time consumption, and costs in a standardized workflow for a modified intraoral quadrangular Le Fort II osteotomy (IQLFIIO). RESULTS: A cross-sectional study was performed based on retrospective and re-planned data of patients with midfacial deficiency treated by modified IQLFIIO, using three software applications: IPS Case Designer ®, Dolphin Imaging ®, and ProPlan CMF ®. Feasibility: All evaluated steps of the VSP procedure could be successfully performed in all three evaluated applications. In all software packages, it was possible to design the surgical splints with CAD/CAM technology. Working time: The mean value of time needed was IPS Case Designer ®, 36.5 min; Dolphin Imaging ®, 33.6 min; ProPlan CMF ®, 45.5 min. We found statistical significant difference between ProPlan CMF ® and Dolphin Imaging ® (p value, 0.02). COSTS: Asset costs for acquiring the software, license fee, license possibilities, paying for support services, and service contracts were evaluated and are found in similar ranges. CONCLUSION: All three tested software applications are usable for virtual planning of an IQLFIIO and splint production by CAD/CAM technology. Successful movement of bone segments and overlaying soft tissues proved feasibility. Time consumption and costs were found in similar ranges.

Accuracy of Soft Tissue Prediction of 2 Virtual Planning Systems in Patients Undergoing Intraoral Quadrangular Le Fort II Osteotomy.

Virtual surgical planning (VSP) is state of the art in routine clinical work. Visualization of soft tissue changes adds important information for surgical planning. The aim of this study was to evaluate accuracy of soft tissue prediction of 2 VSP systems in patients undergoing an intraoral quadrangular Le Fort II osteotomy. METHODS: VSP was performed with the software application IPS Case Designer (IPS) and Dolphin Imaging 11.95 (DOL) in bone and soft tissue structure. Distances were measured at the 3 levels of the face at the infraorbital rim, the sinus floor, and the lateral incisor level with 2 VSP systems (DOL and IPS). RESULTS: A convenience sample of 19 patients was included in the study with a mean age of 21.9 years. From cranial to caudal, mean differences between simulation and postintervention data were as follows: infraorbital rim level: DOL and ST0: mean difference: 2.90 mm; IPS and ST0: 1.70 mm; sinus floor level: DOL and ST0: mean difference: 3.57 mm; IPS and ST0: 1.34 mm; and lateral incisor level: DOL and ST0: mean difference: 2.48 mm; IPS and ST0: 2.25 mm. CONCLUSIONS: Generally, both VSP systems are suitable for planning an intraoral quadrangular Le Fort II osteotomy. Especially in the infraorbital region, improvement of the algorithm is required for trustworthy prediction of soft tissue changes.

AF1q Expression Associates with CD44 and STAT3 and Impairs Overall Survival in Adenoid Cystic Carcinoma of the Head and Neck.

Salivary gland malignancies of the head and neck form a heterogeneous group. Adenoid cystic carcinomas are an aggressive entity of salivary gland malignancies characterized by frequent distant metastases and poor response to radio- and chemotherapy. AF1Q is a MLL fusion partner, which can activate Wnt and STAT3 signaling. Recently, overexpression of AF1q has been identified as a poor prognosticator in patients of different malignancies. A total of 46 patients with adenoid cystic carcinoma were immunohistochemically evaluated for expression of AF1q and clinical outcome was analyzed in this context. Additionally, STAT3 and the Wnt downstream target CD44 were investigated and correlated with AF1q. AF1q was overexpressed in 52.2%. Overexpression of AF1q was associated with poorer overall survival (p = 0.03). Additionally, lymph node metastases and solid tumor parts were more frequently observed in AF1qhigh patients (p = 0.07 and 0.05, respectively). AF1q did not influence the occurrence of distant metastases. Expression of AF1q was associated with higher levels of STAT3 and CD44 (p = 0.003 and 0.006, respectively). AF1q is a novel prognostic marker for poor overall survival in adenoid cystic carcinoma patients. The deleterious effects on survival may be a result of promotion of the STAT3 and Wnt pathway.

Pretreatment assessment of hematologic and inflammatory markers in adenoid cystic carcinoma: neutrophil/lymphocyte ratio is associated with multiple recurrences.

OBJECTIVE: Adenoid cystic carcinoma (ACC) is a rare entity of salivary gland cancer. Inflammatory and hematologic markers and their prognostic and predictive value have been intensively studied in several cancer entities. The aim of this study was to investigate the role of such markers in patients with ACC. STUDY DESIGN: This retrospective analysis investigated hematologic and inflammatory markers in patients with ACC in the period between the years 1996 and 2016. We assessed the preoperative neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, cross-reactive protein and fibrinogen levels. A total of 28 to 31 patients were included, depending on the examined parameter. All markers were evaluated for their effects on outcome and prognostic value. RESULTS: Patients with an elevated preoperative NLR (>2) had a significantly higher multiple recurrence rate (44.4% vs 8.3%; P = .049). Other hematologic markers showed no significant effects on outcome. CONCLUSIONS: This study showed that the NLR may serve as a useful prognosticator for a high risk of multiple recurrences in patients with ACC.