Intravenous ibuprofen versus diclofenac plus orphenadrine in orthognathic surgery: a prospective, randomized, double-blind, controlled clinical study.

OBJECTIVES: The aim of this prospective, randomized, double-blind, controlled clinical study was to evaluate the analgesic effect of ibuprofen versus diclofenac plus orphenadrine on postoperative pain in orthognathic surgery. MATERIAL AND METHODS: Patients who underwent orthognathic surgery were randomized into two groups to receive intravenously either 600 mg of ibuprofen (I-group) or 75 mg diclofenac plus 30 mg orphenadrine (D-group), both of which were given twice daily. Additionally, both groups were given metamizole 500 mg. Rescue pain medication consisted of acetaminophen 1000 mg and piritramide 7.5 mg as needed. To assess the pain intensity, the primary end point was the numeric rating scale (NRS) recorded over the course of the hospital stay three times daily for 3 days. RESULTS: One hundred nine patients were enrolled (age range, 18 to 61 years) between May 2019 and November 2020. Forty-eight bilateral sagittal split osteotomies (BSSO) and 51 bimaxillary osteotomies (BIMAX) were performed. Surgical subgroup analysis found a significant higher mean NRS (2.73 vs.1.23) in the BIMAX D-group vs. I-group (p = 0.015) on the third postoperative day. Additionally, as the patient's body mass index (BMI) increased, the mean NRS (r = 0.517, p = 0.001) also increased. No differences were found between age, gender, length of hospital stay, weight, operating times, number of patients with complete pain relief, acetaminophen or piritramide intake, and NRS values. No adverse events were observed. CONCLUSION: The results of this study demonstrate that ibuprofen administration and lower BMI were associated with less pain for patients who underwent bimaxillary osteotomy on the third postoperative day. Therefore, surgeons may prefer ibuprofen for more effective pain relief after orthognathic surgery. CLINICAL RELEVANCE: Ibuprofen differs from diclofenac plus orphenadrine in class and is a powerful analgetic after orthognathic surgery.

Facial scars resulting from a transbuccal approach during osteosynthesis of a sagittal split osteotomy: A retrospective study.

The purpose of the current study was to assess the quality of facial linear scars. The Stony Brook Scar Evaluation Scale (SBSES) was developed and validated as a tool to assess postoperative scars. Postoperative facial scars were rated using high-quality macrophotographs and SBSES by three independent raters at baseline and three months thereafter. Percentage agreement (PA) and intraclass correlation coefficient (ICC) were used to measure interrater and intrarater reliability. Scar outcomes ranging from 0 (worst) to 5 (best) were evaluated against age and gender. One-hundred-sixty-six patients with a mean age of 30.6 years (range of 17-59) were included in this study. Forty-four were male (26.5%), and 122 were female (73.5%). Mean total SBSES scores were 4.63 (range of 4.56-4.76) at baseline and 4.60 (range of 4.54-4.72) at three months. As patient's age increased, mean total SBSES scores also decreased significantly (r = -0.216, p = 0.005). Gender did not significantly affect raters' perception of scar cosmesis (p = 0.847). Interrater reliability showed an ICC of 0.675 (95% CI, 0.609-0.731) and a PA of 65.4% at baseline, and an ICC of 0.655 (95% CI, 0.585-0.715) and a PA of 64.2% at three months. Intrarater reliability found ICCs ranging from 0.988 to 0.990 and a PA of 96.8% with 3 separate raters. Within the limitations of the study it seems that the transbuccal approach during osteosynthesis of a sagittal split osteotomy seems still to be acceptable when the patient gives his or her informed consent and advanced instruments like an angled screwdriver are not available.

Growth Factor Release within Liquid and Solid PRF.

Aim: The purpose of this study was to obtain data concerning growth factor release within liquid and solid platelet-rich fibrin (PRF) matrices and to estimate the amount of potential interindividual variations as a basis for further preclinical and clinical trials. Therefore, we aimed to determine possible differences in the release of growth factors between liquid and solid PRF. Materials and Methods: Blood samples obtained from four subjects were processed to both liquid and solid PRF matrices using a standard centrifugation protocol. Five growth factors (vascular endothelial growth factor, VEGF; epidermal growth factor, EGF; platelet-derived growth factor-BB, PDGF-BB; transforming growth factor-ß1, TGF-ß1; and matrix metallopeptidase 9, MMP-9) have been evaluated at six time points by ELISA over a total observation period of 10 days (1 h, 7 h, 1 d, 2 d, 7 d, and 10 d). Results: Growth factor release could be measured in all samples at each time point. Comparing liquid and solid PRF matrices, no significant differences were detected (p > 0.05). The mean release of VEGF, TGFß-1, PDGF-BB, and MMP-9 raised to a peak at time point five (day 7) in both liquid and solid PRF matrices. VEGF release was lower in liquid PRF than in solid PRF, whereas those of PDGF-BB and MMP-9 were higher in liquid PRF than in solid PRF at all time points. EGF had its peak release already at time point two after 7 h in liquid and solid matrices (hour 7 EGF solid: mean = 180 pg/mL, SD = 81; EGF liquid: mean = 218 pg/mL, SD = 64), declined rapidly until day 2, and had a second slight peak on day 7 in both groups (day 7 EGF solid: mean = 182 pg/mL, SD = 189; EGF liquid: mean = 81 pg/mL, SD = 70). Conclusions: This study detected growth factor release within liquid and solid PRF matrices with little variations. Further preclinical trials are needed to precisely analyze the growth factor release in larger samples and to better understand their effects on wound healing in different clinical indications.

Complex Mandibular Reconstruction for Head and Neck Squamous Cell Carcinoma-The Ongoing Challenge in Reconstruction and Rehabilitation.

Large head and neck squamous cell carcinoma (HNSCC) tumors affecting the mandible require a versatile reconstruction to maintain form, function, and quality of life. Large defect reconstruction of soft and hard tissue in the head and neck necessitates, at best, one vascular system including various tissues by large dimensions. The subscapular flap system seems to meet these standards. A retrospective study was conducted focusing on clinical data, including an analysis of the quality of life with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires, (QLQ-C30 and QLQ-H&N43). A total of 154 patients (122 males, 32 females; age range: 31-71 years, mean: 54.5 years) treated at our department from 1983 through to 2019 were included. Of the subscapular system free flaps (SFFs), 147 were based on the angular artery branch of the thoracodorsal pedicle (95.45%), and the remaining seven cases (4.55%) were lateral scapular border flaps. Mean mandible defect length was 7.3 cm. The mean skin paddle dimension was 86.8 cm2. The most common recipient artery was the thyroid superior artery (79.22%). Major postoperative complications occurred in 13 patients (8.44%). This study confirms that SFFs offer excellent soft and hard tissue quality, component independence, a large arc of rotation length, and a large gauge of pedicle, making them the gold standard for the reconstruction of large composite defects of mandibular HNSCC tumors.

Weight gain in infants with Pierre Robin sequence.

OBJECTIVE: To determine weight gain during treatment with the modified palatal plate (MPP) in infants with isolated and syndromic Pierre Robin Sequence (PRS) suffering from micrognathia, upper airway obstruction (UAO), and failure to thrive (FTT), the authors conducted a retrospective study of infants treated with the MPP. METHODS: The main outcome measure was infant weight (g) for up to three months after birth. Demographic and outcome data (associated syndromes, comorbidities, presence of cleft lip or palate, intubation attempts, tracheotomy and cleft repair) were collected. RESULTS: 14 children born January 2010 - December 2019 were included. The majority (86%) of infants showed highly significant weight gain (p < 0.001) within a 3-month period (mean pretreatment weight 3147 g with a SD of 425 g vs mean weight at three months 4435 g with a SD of 635 g). Syndromic PRS was found in 7% of infants. 43% of nonsyndromic PRS patients were found to have other congenital anomalies. Genetic testing showed normal karyotypes in 93% of infants and a microdeletion in 7% of infants. 21% of infants required tracheotomy, but no patients required mandibular distraction (MDO) or tongue-lip adhesion (TLA) to relieve UAO. CONCLUSION: PRS infants treated with the MPP showed highly significant weight gain within a 3-month period and did not require mandibular surgery for early airway management, but faster gain of weight might have implications for strategies to perform surgery at an earlier point in time.

PRF in dentistry ­ a short synopsis about implementation and workflow / PRF in der Zahnmedizin

Platelet-rich fibrin (PRF) is a blood concentrate system derived from human peripheral blood. A solid and a liquid PRF-based matrix can be obtained by centrifugation in accordance with specific centrifugation protocols without the addition of anticoagulants or external chemicals. In dentistry, oral- and cranio-maxillo-facial surgery, PRF-based matrices are used on different subjects. The healing benefits of platelet-rich preparations together with the low risk profile and disposability of a simple preparation procedure should encourage more clinicians to incorporate PRF as a treatment option in their practice to accelerate healing, reduce adverse events, and improve patient outcomes.

In vivo Implantation of a Bovine-Derived Collagen Membrane Leads to Changes in the Physiological Cellular Pattern of Wound Healing by the Induction of Multinucleated Giant Cells: An Adverse Reaction?

The present study evaluated the tissue response toward a resorbable collagen membrane derived from bovine achilles tendon (test group) in comparison to physiological wound healing (control group). After subcutaneous implantation in Wistar rats over 30 days, histochemical and immunohistochemical methods elucidated the cellular inflammatory response, vascularization pattern, membrane protein and cell absorbance capacity. After 30 days, the test-group induced two different inflammatory patterns. On the membrane surface, multinucleated giant cells (MNGCs) were formed after the accumulation of CD-68-positive cells (macrophages), whereas only mononuclear cells (MNCs) were found within the membrane central region. Peri-implant vascularization was significantly enhanced after the formation of MNGCs. No vessels were found within the central region of the membrane. Physiological wound healing revealed no MNGCs at any time point. These dynamic changes in the cellular reaction and vascularization within the test-group are related typical indications of a foreign body reaction. Due to the membrane-specific porosity, mononuclear cells migrated into the central region, and the membrane maintained its integrity over 30 days by showing no breakdown or disintegration. The ex vivo investigation analyzed the interaction between the membrane and a blood concentrate system, liquid platelet-rich fibrin (liquid PRF), derived from human peripheral blood and consisting of platelets, leukocytes and fibrin. PRF penetrated the membrane after just 15 min. The data question the role of biomaterial-induced MNGCs as a pathological reaction and whether this is acceptable to trigger vascularization or should be considered as an adverse reaction. Therefore, further pre-clinical and clinical studies are needed to identify the types of MNGCs that are induced by clinically approved biomaterials.

Assessment of tumor margins in head and neck cancer using a 3D-navigation system based on PET/CT image-fusion - A pilot study.

OBJECTIVES: Determination of tumor margins in patients with squamous cell carcinoma of the head and neck (SCCHN) is mostly based on preoperative magnetic resonance imaging (MRI) or computed tomography scans (CT). Local recurrence of disease is often correlated with the presence of positive resection margins after surgical treatment. Positron emission tomography/computed tomography (PET/CT) imaging plays a crucial role in the assessment of patients with SCCHN. The purpose of this study was to determine whether PET/CT could predict tumor extension. METHODS: In 12 patients who underwent surgical treatment of primary SCCHN (Stage III-IV) F18-FDG PET/CT image-fusion was performed on a 3D navigation-system based workstation. Image-guided needle biopsies were obtained from four different, color-coded metabolic areas within the tumor. The histopathological findings were correlated with findings on corresponding PET/CT scans. RESULTS: 81.3% of biopsies from the central area were positive. Specimens taken from the outer metabolic zone were positive in 66.7% of the patients. The highest incidence of positive biopsies was found in the zone adjacent to the outermost area. There was a statistically significant difference in positive tumor histopathology when comparing the various metabolic zones (p = 0.03). CONCLUSION: Exact determination of tumor is an important research topic, although results remain controversial. The results of this study suggest that in some cases PET scans may overestimate tumor extension.

Early detection of pulp necrosis and dental vitality after traumatic dental injuries in children and adolescents by 3-Tesla magnetic resonance imaging.

OBJECTIVES: More than 50% of all children suffer a traumatic dental injury (TDI) during childhood. In many cases, dentists apply root canal treatment (RCT), which is performed on an average of 7-10 days after replantation. Our aim was to evaluate whether RCT is necessary in many cases, and whether revitalization of affected teeth is possible and measurable by visualization using 3T magnetic resonance imaging (MRI). MATERIAL AND METHODS: Seven healthy children with TDI were treated by repositioning of the affected teeth and reduction of alveolar process fractures followed by splinting. Two weeks after initial treatment, splints were removed. After 6 weeks, all children received 3-Tesla (3T), three-dimensional, high-resolution MRI with a 20-channel standard head and neck coil. The mean age of the children (male/female = 5:2) was 10.8 years (range, 8-17 years). In addition, all children received conventional dental examination for tooth vitality and dental sensitivity to cold and tenderness on percussion. RESULTS: 3T MRI provided excellent images that allowed fine discrimination between dental pulp and adjacent tooth. Using four in-house optimized, non-contrast-enhanced sequences, including panoramic reconstruction, the assessment and analysis of the dental pulp was sufficiently feasible. We could demonstrate reperfusion and thus vitality of the affected teeth in 11 sites. In one child, MRI was able to detect nonreperfusion after TDI of the affected tooth. MRI results were confirmed by clinical examination in all cases. As a consequence of this expectant management and proof of reperfusion and tooth vitality by 3T MRI, only one child had to be treated by RCT. CONCLUSION: 3T MRI is a very promising tool for visualization and detection in the field of dental and oromaxillofacial diseases. By using new 3T MRI sequences in children with TDI, we could demonstrate that RCT are not necessary in every case, and thus could prevent unnecessary treatment of children in the future. Larger studies should follow to confirm the potential benefit in clinical practice.

Intraindividual comparison of preoperative (99m)Tc-MDP SPECT/CT and intraoperative and histopathological findings in patients with bisphosphonate- or denosumab-related osteonecrosis of the jaw.

PURPOSE: Bisphosphonate- or denosumab-related osteonecrosis of the jaw (BRONJ/DRONJ) requires reliable preoperative assessment of the extent of disease for surgical planning. The aim of this study was to compare the extent of BRONJ/DRONJ as detected by Tc-99m-methylene diphosphonate (MDP) bone scintigraphy with intraoperative and histopathological findings, and to assess the additional value of hybrid single photon emission computed tomography/computed tomography (SPECT/CT) for evaluation of disease. MATERIAL AND METHODS: Twenty-one patients with BRONJ/DRONJ underwent three-phase bone scintigraphy including SPECT/CT. The diagnostic certainty using conventional SPECT or fused SPECT/CT imaging was compared. Location and extent of disease on scintigraphic imaging and pre- and intra-operative clinical assessment were compared. Intraoperative and histopathological findings served as reference standard. RESULTS: A total of 29 sites of BRONJ/DRONJ were histopathologically confirmed in 21 patients. Bone scintigraphy demonstrated increased perfusion in 57.1% of patients, increased blood pool in 76.2%, and increased tracer accumulation at the metabolic phase in all patients. The intensity of tracer accumulation at the metabolic phase correlated significantly with clinical stage of disease (rs = 0.47, p = 0.03). Clinical examination (p < 0.0001), but not SPECT (p = 0.19), underestimated the extent of disease as determined by surgical evaluation. SPECT/CT offered a significantly higher diagnostic certainty (p < 0.0001). CONCLUSION: In patients with BRONJ/DRONJ, the true extent of osseous lesions as determined by surgery is significantly underestimated by clinical examination. Tc-99m-MDP bone scintigraphy can reliably predict the extent of disease. Hybrid SPECT/CT may significantly increase the diagnostic certainty of anatomical localization.

Intraoperative efficiency of fluorescence imaging by Visually Enhanced Lesion Scope (VELscope) in patients with bisphosphonate related osteonecrosis of the jaw (BRONJ).

OBJECTIVES: The purpose of this study was to determine the potential of tissue fluorescence imaging by using Visually Enhanced Lesion Scope (VELscope) for the detection of osteonecrosis of the jaw induced by bisphosphonates (BRONJ). METHODS: We investigated 20 patients (11 females and 9 males; mean age 74 years, standard deviation ± 6.4 years), over a period of 18 month with the diagnosis of BRONJ in this prospective cohort study. All patients received doxycycline as a fluorescending marker for osseous structures. VELscope has been used intraoperatively using the loss of fluorescence to detect presence of osteonecrosis. Osseous biopsies were taken to confirm definite histopathological diagnosis of BRONJ in each case. RESULTS: Diagnosis of BRONJ was confirmed for every patient. In all patients except one, VELscope was sufficient to differentiate between healthy and necrotic bone by visual fluorescence retention (VFR) and visual fluorescence loss (VFL). 19 cases out of a total of 20 showed no signs of recurrence of BRONJ during follow-up (mean 12 months, range 4-18 months). CONCLUSION: VELscope examination is a suitable tool to visualize necrotic areas of the bone in patients with bisphosphonate related osteonecrosis of the jaw. Loss of fluorescence in necrotic bone areas is useful intraoperatively as a tool for fluorescence-guided bone resection with relevant clinical interpretation.

Pseudoepitheliomatous hyperplasia associated with bisphosphonate-related osteonecrosis of the jaw.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a well-characterized oral complication of systemic therapy with bisphosphonates. Pseudoepitheliomatous hyperplasia was observed in some of the lesions. Because podoplanin expression has been linked to malignant lesions of the oral mucosa, we aimed to investigate podoplanin expression in the pseudoepitheliomatous hyperplasia. We analyzed archival paraffin- and plastic-embedded specimens from BRONJ using both conventional and immunohistochemical (AE1/AE3, D2-40) staining methods. Eleven out of seventeen BRONJ cases showed pseudoepitheliomatous hyperplasia. All these cases were positive for AE1/AE3 and pseudoepitheliomatous hyperplasia displayed a strong basal and parabasal reaction against podoplanin. The podoplanin expression in pseudoepitheliomatous hyperplasia in BRONJ specimens should not be considered a sign of malignancy. We discuss the current and possible future roles of surgical pathologists in diagnosing morphological changes associated with the development and therapy of BRONJ lesions.

Prevalence of Stafne's bone cavity--retrospective analysis of 14,005 panoramic views.

AIM: Stafne's bone cavity (SBC) is a very rare defect, affecting only selected parts of the mandibular bone. Its etiology is unknown. On two-dimensional images, it appears as a narrowed cavity and might be interpreted as a space-occupying process inside the bone. The aim of the present study was to investigate the prevalence of SBC on panoramic views, and compare these results to published reports. MATERIALS AND METHODS: A total of 14,005 panoramic views were examined retrospectively with regard to the presence of SBC. All images were analyzed regarding typical characteristics as originally described by Stafne. RESULTS: A total of 11 cases fulfilled diagnostic criteria of SBC (0.08%). All patients were men (100%), at a mean age of 58.1 years (range=38-75 years). Eight patients (72.7%) had SBC on the left side, three patients on the right side (27.3%). In eight cases, SBC was found in the mandibular corpus (72.7%), and in three cases in the mandibular angle (27.3%). Correlating with published results, SBC was found at a relative frequency of 0.13%. CONCLUSION: SBC on panoramic views or other imaging modalities should alert the clinician to exclude other potential pathologies. In doubtful cases, surgical procedures might be necessary to verify the diagnosis.

Evaluation of four different optimized magnetic-resonance-imaging sequences for visualization of dental and maxillo-mandibular structures at 3 T.

OBJECTIVES: The purpose of this study was to evaluate four in-house optimized, non-contrast enhanced sequences for MRI-investigation of maxillo-mandibular and dental structures by use of 3 T. METHODS: 12 volunteers with different dental status were examined by using a 3 T MRI with a 20-channel standard head-and-neck coil. All images performed were evaluated by using 3D-techniques, with different slice-thicknesses, in 3D T1- and T2-weighted sequences, as well as by using new techniques of image depictions. In addition phantom measurements were performed to estimate the extent of image artefacts caused by retainers and metal implants. RESULTS: Mean age of the participants was 33 years (range, 25.5-62.75 years), and the sex ratio was 5 females to 7 males. We identified different techniques to improve osseous and dental structures, despite problems caused by dental implants, tooth crowns or braces. CONCLUSION: The sequences evaluated offered excellent visualization in 2D and 3D of osseous and dental structures. Anatomical, osseous and dental structures were described at their ROI, in relation to patients with dental and head and neck pathologies. The ability to detect and distinguish pathological processes as soon as possible in 3D with excellent image quality avoiding ionizing radiation remains a challenging domain.

Numb chin syndrome: a rare and often overlooked symptom.

Numb chin syndrome (NCS) describes a sensory neuropathy characterized by numbness in the distribution of the terminal branch of the mandibular division of the trigeminal nerve. Benign as well as malignant diseases are known to cause NCS. This is often misdiagnosed, and in some cases the symptom may lead to a late detection of malignancy. Reports of 10 cases in which NCS was the presenting and isolated symptom, caused by extracranial malignancies, drugs, or dental/surgical interventions, are presented. This article outlines the symptoms and the diagnostic approaches taken, provides a short review of the etiology and pathogenesis, and proposes diagnostic criteria and treatment of NCS. Both medical practitioners and dentists need to be aware of the relationship between malignancies and paresthesia of the chin or complete loss of sensation in partial segments of the jaw. In addition, dentists should be aware of the diagnostic limitations of an orthopantomogram to detect underlying diseases beyond localized dental disorders.