Using dental implants in the prosthetic rehabilitation of patients with cleft defect type II.

A dental implant may be used in prosthetic tooth reconstruction in cleft patients. There are three main indications for this approach: substitution of a missing single tooth, an abutment for the framework, and an abutment for a fixed dental prosthesis (we designate these as defect types I, II, and III). A clinical report about prosthetic rehabilitation using dental implants instead of a fixed or removable partial prosthesis is presented. A patient with a unilateral cleft defect was treated at the University Hospital in Prague, Czech Republic. Together with a missing lateral incisor, the defect was associated with agenesis of the two upper canines and three second premolars. The treatment was completed by prosthetic dental reconstruction using the framework with a dental implant as an abutment. This approach allowed minimizing the preparation of adjacent teeth to a single tooth functioning as the second abutment. If classical fixed prosthodontics had been performed, the preparation would have involved a larger group of intact teeth with the risk of their viability loss. The procedure had no complications. The outcome was of high quality and brought satisfaction to the patient.

Skin aging: the dermal perspective.

The world population of adults aged 60 years or more is increasing globally, and this development can impact skin disease morbidity and mortality, as well as being reflected in the health care system organization. There is substantial evidence that the burden from a remarkable number of skin nonmalignant and malignant conditions is greater in the elderly. Dermatologic research and clinical education in dermatology should focus on both challenges and opportunities created by aging. Skin aging due to intrinsic and extrinsic factors can alter significantly epidermal and dermal structure and functions. Dermal aging can be linked to a great number of complications in routine dermatologic conditions, with slow healing as an example of a severe complication in the elderly. This may be attributed to aged dermal fibroblasts modifying the tissue microenvironment via a shift in their soluble factors and extracellular matrix repertoire. This senescence-associated secretory phenotype can explain the particular proclivity of aged skin to develop malignancies.

Bone reconstruction of the maxillary alveolus for subsequent insertion of a dental implant in patients with cleft lip and palate.

Bone grafting of maxillary alveolus cleft defect followed by insertion of dental implant may be a good alternative to conventional prosthetic treatment. The principle is the formation of stable alveolar crest with a sufficient three-dimensional volume. The problems are lack and quality of mucoperiosteum for the reconstruction of shell and bone gap characteristics for bone graft intake. The procedure was carried out by a single surgeon (MD) in 45 patients between 29 August 2001 and 30 June 2006, with an 86.7% success rate. The success was defined as completed process with dental implant insertion and its loading by a prosthetic suprastructure without a failure for at least 15 months from that last step. The success rate mainly depends on 1) good alveolar arch flow of maxilla segments in both horizontal and vertical planes; 2) the height of osseous poles of at least 12 mm and onlay augmentation of built-up section does not work; 3) adequate volume of cancellous bone graft, 3.7 cm on average. On the basis of histologic verification and clinical findings, the bone graft is matured enough to ensure a primary stability of a fixture in 12.5 weeks after reconstruction. Early load may prevent bone resorption. Prediction of complications are as follows: 1) graft resorption increases according to gap size and low possibility of revascularization; 2) a higher number of complications are linked to presence of oronasal fistula and to scarring of soft tissues; 3) because of more gracile skeleton and female metabolism, the risk is higher in women.

Localization of the sentinel node of the upper outer breast quadrant in the axillary quadrants.

BACKGROUND: Sentinel node (SN) biopsy is associated with much less morbidity than axillary dissection. In patients with early breast cancer, lymphatic mapping and SN biopsy accurately stage the axillary nodes. Both currently available lymphatic mapping agents, radiocolloid and blue dye, have some limitations that may make perioperative or preoperative SN identification difficult. In such cases, exact knowledge of the topography of the axilla and the most probable location of the SN may be crucial. METHODS: In 12 fresh female cadavers with no history of breast carcinoma, injections of patent blue dye were used to visualize the SNs in the axillary quadrants and their lymphatic collectors from the upper outer quadrant of the breast, which is the most common location of breast cancer. The axilla was divided into quadrants with regard to the intersection of the thoracoepigastric vein and the third intercostobrachial nerve. RESULTS: All SNs were located within a circle of 2-cm radius of this intersection in the fatty tissue at the clavipectoral fascia. In most cases, the SN was located in the fatty tissue near the clavipectoral fascia in the lower ventral quadrant of the axilla (n = 14, 58%). In seven cases (29%), the SN was located in the upper ventral quadrant, in two cases (8%) in the upper dorsal quadrant, and in one case in the lower dorsal quadrant. CONCLUSIONS: The results of this anatomical study may facilitate SN biopsy in patients with breast cancer.

Moustache reconstruction in patients with cleft lip: (final aesthetic touches in clefts-part ii).

Men with clefts often have limited or even missing moustache growth in scar areas or in the upper lip prolabium. However the histological testing showed the absence or at least the inactive form of androgenic receptor in hair follicle of cleft site, transplantation of autologous grafts harvested from hair was successful in all six cases either into scars or the prolabium. A more natural effect was achieved by using micrografts. The positive reaction of patients proved there is a need for detailed treatment in highly outgoing individuals.

Scar flap for extension of the nasal and lip soft tissue shell in secondary cleft deformities: final aesthetic touches in clefts-part iii.

A scar flap is formed with the pedicle at the lateral part of the columella base at the cleft side, that is, in the center of the affected region. It enables flap placement according to individual need. A prospective evaluation was performed in a group of 76 patients with cleft lip and palate, all operated on by the same plastic surgeon. The flap was used to improve the height of the columella and the extent of nasal mucosa on the frontal septum and on the nostril base in the vestibule. In the lip, the flap raised its height and improved proportionality. The average area of flap used in a unilateral deformity was 42 mm. Both flaps in a bilateral deformity were 77 mm. The average follow-up was 22.4 months. Neither local nor general complications were noted apart from a recurrence of the deformity of the nasal septum in 7.9% of patients. The nasal passage was improved in 59.9% of patients and normalized in 19.6% upon follow-up rhinomanometry, but nevertheless, only one third of patients overcame their dynamic stereotype of breathing by the mouth. Anthropometric measurements showed an absence of statistically significant differences between patients after surgery and healthy individuals in crucial parameters (nasal tip projection, length of columella, nasolabial angle, nasal angle, and lip angle). The loss of the stigmatizing deformity is based on rotation of the nasolabial angle in relation to the aesthetic axis of the face. Direct examination proved aesthetic and functional improvement as statistically significant in 92.1% of patients.

The anthropometric verification of corrective surgery outcome in cleft secondary deformities.

An anthropometric measurement serves as both an objective assessment and a description of shape and size. Gypsum casts were used for the measurement, along with a statistical evaluation of results, to compare the appearance of patients with a complete unilateral or bilateral cleft lip and palate prior to corrective surgery of their secondary deformity and following this intervention. The evaluated approach was our own modification of rhinoplasty and lip correction, using the remodeling and extension of soft tissues envelope by a skin flap. That is formed from a lip scar after primary reconstruction. Both data of the studied group (n = 49), pre- and postoperative, were compared to a control group of healthy individuals (k = 19), thereby allowing the original severity of the deformity and the morphologic change after surgery to be objectively assessed. Upon correlation to healthy volunteers, we proved that the effect of surgery shifted the monitored parameters into a range found in the normal population. An anthropometric measurement on gypsum casts appeared to be simple, easy to perform, precise, easy to repeat, inexpensive, and yet of a three-dimensional nature with no burden for the patient. It is suitable for verifying the effects of new therapeutic procedures.

Guided tissue regeneration, barrier membranes and reconstruction of the cleft maxillary alveolus.

The use of barrier membranes for bone regeneration is especially beneficial in the case of severely affected soft tissue. One useful indication may be the formation of an effective shell for bone grafts in maxilla cleft defect reconstruction. When selecting a proper material for clinical use, one must consider the safety record, the resorption time and route of elimination, the time of the maintained barrier function, the necessary time of mechanical strength, and costs. Two resorbable collagen membranes, one of single-layer and one of double-layer material, were tested in vitro and in vivo. The tested single-layer membrane is less expensive, but it is also less handling than the double-layer membrane. In vitro, samples were incubated in simulated surgical wound. A complete unambiguous picture of disintegration was not proved histologically in either material in six investigation terms (1-6 weeks). In vivo the effect of the assessed membranes was verified on a group of patients (N = 45) with a cleft. Materials were applied in the reconstruction of the alveolar defect by cancellous bone grafts. The influence on the course of healing was not stated as statistically significant. However, with respect to the costs of double layer membrane, this material was used in the most severe cases.

Augmentation by autologous adipose tissue in cleft lip and nose. Final esthetic touches in clefts: part I.

Although patients with a cleft lip and palate undergo many surgeries and other therapeutic procedures in the course of their treatment, many are still deeply concerned with their handicap and continue searching for perfection in their appearance. Augmentation using the subject's own fat cells involves minor invasion, is readily available, is an unpretentious method regarding time and cost, and has no contraindications. This method can serve to supplement a hypotrophic scarred upper lip and nasal columella, and by improving the volume, it induces a more natural contour, which reduces the stigmatizing deformity as well as the visibility of externally apparent scars. Using this approach, five patients with a complete cleft have been treated. The median follow-up interval is 22 months (through January 2003). The procedure and postoperative course had a pleasing outcome and were without any complications. The disadvantage was the temporary effect of the outcome, which necessitated repeated application every 7 months on average.

Bioactive glass-ceramics in facial skeleton contouring.

The removal of certain facial-bone defects is a prerequisite to restoration of function, stability, and appearance. Synthetic bone substitutes are beneficial in cases where other operative techniques would be an unacceptable burden for a patient. Satisfactory results can be achieved in one surgical intervention with low costs and low demand on technical equipment. Osteoconductive, biocompatible, non-resorbable glass-ceramic implants based on oxyfluoroapatite and wollastonite permit osteointegration--a direct physical and chemical bond between live bone tissue and the implant without formation of a fibrous capsule. They display better stress durability in simulated body fluid than hydroxyapatite implants do. This material was used for facial skeletal framework, contour restoration in 44 cases under conditions where other solutions were doubtful. Patients were observed for 24.8 months. Immediate healing occurred without any adverse reaction. The main problem was extrusion, observed in 20.45% cases over a 2-3 month period after the implantation. All cases, with one exception, were solved with a satisfactory final result by reoperation, implant size reduction, and increased soft tissue cover. This approach was found to be a suitable technique, especially for patients exhausted by prior incompetent treatment but still dissatisfied with their appearance. Successful reconstruction with a bone substitute may remarkably increase quality of life for affected persons and, at the same time, reduce surgery-related time and costs.