Toxina botulínica A para el tratamiento de síndromes de cefalea y síndromes de dolor pericraneal / Botulinum toxin A in the treatment of headache syndromes and pericranial pain syndromes

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[Botulinum toxin A for the treatment of headache disorders and pericranial pain syndromes]. / Botulinum-Toxin A in der Therapie von Kopfschmerzerkrankungen und perikranialen Schmerzsyndromen.

For 20 years botulinum toxin A has been used for the treatment of a variety of disorders characterised by pathologically increased muscle contraction. Recently, treatment of tension headache, migraine, cluster headache, and myofascial pain syndromes of neck, shoulder girdle, and back with botulinum toxin A has become a rapidly expanding new field of research. Several modes of action are discussed for these indications. The blockade of cholinergic innervation reduces muscular hyperactivity for 3 to 6 months. Degenerative changes in the musculoskeletal system of the head and neck are prevented. Nociceptive afferences and blood vessels of the pericranial muscles are decompressed and muscular trigger points and tender points are resolved. The normalisation of muscle spindle activity leads to a normalisation of muscle tone and central control mechanisms of muscle activity. Oromandibular dysfunction is eliminated and muscular stress removed. However, the effect of botulinum toxin A cannot be explained by muscular actions only. Its retrograde uptake into the central nervous system modulates the expression of substance P and enkephalins in the spinal cord and nucleus raphe. Recent findings suggest an inhibition of sterile inflammation which may lead to a blockade of the neurogenic inflammation believed to be the pathophysiological substrate of primary headache disorders. The efficacy of botulinum toxin A in the treatment of pain disorders is being investigated in several studies at the moment. The results and experiences obtained so far present new alternatives in the treatment of chronic pain disorders. The practical use of botulinum toxin A is demonstrated.

[Need for transfusions in orthognathic surgery. No general indication for preoperative autologous blood donation]. / Transfusionsbedarf bei Dysgnathieoperationen. Keine generelle Indikation für die präoperative Eigenblutspende.

The use of deposited autologous blood instead of allogenic blood is recommended in cases of elective maxillofacial operations if the blood transfusion probability is more than 10%. As an alternative, the controlled intraoperative normovolemic hemodilution and the preoperative use of EPO (Erytropoetin) should be considered. In a retrospective study, we analyzed 438 patients who underwent orthognathic surgery. The perioperative blood loss was determined in order to calculate the transfusion probability in case of the acceptance of 7.5 g/dl hemoglobin as the critical value in patients without cardiac failures. Only four patients undergoing Le Fort I osteotomy (1.55%) or bimaxillary osteotomy (3.03%) had to be transfused. Therefore, the statistical transfusion need was clearly below 10%. Due to this, there was no general need for autologous blood donation. However, in individual cases with low hemoglobin and/or low blood volume, a transfusion need can be predicted. In those few cases, autologous blood donation may be indicated. However, in case of a more conservative indication to transfusion (hemoglobin 10 g/dl), more than 10% of the patients with bimaxillary osteotomies would have been transfused. Autologous blood donation is then indicated according to the German regulations for transfusion. If low hemoglobin values are accepted, the exact individual blood demand should be calculated, a blood saving operation technique should be used, adequate postoperative warding is necessary, and compatible allogenic red cell concentrates should be quickly available.

Functional reconstruction of the TM joint in cases of severely displaced fractures and fracture dislocation.

In a clinical and axiographic study the outcome of patients with severely displaced fractures and fracture dislocations of the mandibular condyle was evaluated. Two operation methods were compared one via an intraoral approach without joint revision and another via a preauricular approach with open reduction of the joint. In the group with joint revision, resorbable material was used for osteosynthesis. Twenty-eight patients (32 joints) treated without revision of the joint and 26 patients (29 joints) with open reduction of the joint were evaluated. The mean observation time following surgery was 3 years and 10 months (range 1-7.5 years). Clinical examination utilized the Helkimo-index, while the electronic axiographical results were evaluated by using a five point scheme of joint-mobility. Concerning clinical evaluation, 20 out of 28 patients (71%) without joint revision and 23 out of 26 (89%) patients with joint revision had none or only slight dysfunction of the stomatognathic system. When focusing on arthralgia and pain in motion (part D and E of Helkimo's-index) significantly better results were achieved by open joint revision (Helkimo D: p< or =0.007; Helkimo E: p = 0.0029). No patient exhibited severe dysfunction (group D3). In axiographic evaluation optimal results (group A1) were achieved in seven joints (24%) with revision and four joints (12%) without revision. Twelve out of 29 joints with revision (41%) and six out of 32 joints without revision (19%) were classified as group A2 with a slightly shortened condylar excursion. Revision of joints with disc reduction and reconstruction of ligaments in cases of severely displaced or dislocated fractures resulted in better mobility and less pain. This was seen clinically and in the axiographic results. Looking at the long-term outcome of patients better mobility of the joint without internal derangement due to surgical repair also protects the contralateral (nonoperated) joint. When managing severe TMJ-trauma we suggest that both, bony and soft tissue structures should be reconstructed if there are any signs of internal derangement. However, the limits between bony reconstruction with or without joint revision are still not defined. Our results appear to be promising concerning mobility and absence of pain of the joints after open reduction. Further research comparing the two operative treatment regimes in a randomized controlled clinical trial will be necessary.

[Implants in avascular iliac crest bone transplants. Prospective study of 176 implants]. / Implantate in avaskulären Beckenknochentransplantaten. Prospektive Studie über 176 Implantate.

Total and subtotal defects of the upper and lower alveolar ridge require bone grafts to make masticatory rehabilitation possible using alloplastic dental implants. The aim of this study was to establish the survival rate of dental implants inserted in avascular iliac bone grafts. Furthermore, we aimed to discover whether the prognosis of implants can be influenced by choosing one-stage or a two-stage procedure. In a prospective study, jaw defects in 40 patients were treated with avascular mono- or bicortical bone transplants taken from the right iliac wing. A total of 134 of 176 dental implants were inserted into an onlay osteoplasty. In 19 cases, 95 implants could have been inserted in a one-stage procedure, while in the other 13 cases 39 implants have been inserted in a two-stage procedure. One-stage insertion of implants was done in cases of definite primary stability only; otherwise, the two-stage method was preferred. After treatment, all patients were examined at least once every year. Both the rate of loss of implants and the time-dependent crestal bone loss were recorded. Of the 134 implants, 88% (i.e., 118 implants) were still in situ 6.8 years after abutment connection, and after 8.5 years 78% (i.e., 104 implants) were in situ. The interval of confidence was 95%. Projected over 8 years, 83 implants inserted in a one-stage procedure (i.e., 87%) were still functioning, while differently only 26 of the implants inserted in a two-stage procedure (i.e., 66%) were still functioning. The probability that implants stay in situ for a particular time corresponds to the results of former studies. The results of other studies with regard to one-stage or two-stage procedures could not be confirmed. The probability of total retention time for implants inserted in a two-stage procedure is lower than for those inserted in a one-stage procedure. The unfavorable starting point with the lack of primary stability of the implants in local bone within the two-stage procedure might be a reason for this.

[Function and morphology of the temporomandibular joint after mandibular translocation osteotomies with and without positioning plates]. / Kiefergelenkfunktion und -morphologie nach Unterkieferumstellungsosteotomien mit und ohne Positionierungsplatten.

Positioning devices are commonly used to avoid the malpositioning of the proximal segments in bilateral, sagittal split osteotomies and to make sure the preoperative fossa condyle relation is reproduced. The aim of our prospective study, with random selection of 24 patients, was to compare the morphological and functional outcome of the TMJs. The proximal segments in half of the patients had been positioned using devices, in the other half without devices. The segments were fixed by transoral bicortical miniscrew fixation. The evaluation of function is based on pre- and postoperative clinical and electronic axiographic investigations. To study the TMJ morphology, we performed MRI and X-ray investigations preoperatively and 6 months postoperatively. Preoperatively, 12 patients showed slight dysfunction, six patients moderate, and six patients severe dysfunction. Postoperatively, no patient was symptomless. Slight dysfunction was presented in 15 cases, moderate dysfunction in five and severe dysfunction in four cases. Evaluating the axiographic investigations preoperatively, 22 patients showed no mobility disturbances of the TMJ. Two patients showed severe mobility disturbances. Postoperatively, a significant increase in TMJ mobility disturbances could be seen. The MRI investigations of both groups showed both worsening and improvement in the disk positions. No significant differences could be determined between the two groups, however. Regarding the X-ray investigation, three patients from the group with positioning devices showed dislocated condyles; in the group without positioning devices four cases of condyle dislocation were seen. All dislocations were transversal except for one case in the group without positioning devices. Positioning devices do not seem to improve the functional and morphological outcome of the TMJ after BSSO.

[TMJ-function and -morphology after mandibular translocation-osteotomies with and without positioning plates]. / Kiefergelenkfunktion und -morphologie nach Unterkieferumstellungsosteotomien mit und ohne Positionierungsplatten.

Positioning devices are commonly used to avoid the malpositioning of the proximal segments in bilateral, sagittal split osteotomies and to make sure the preoperative fossa condyle relation is reproduced. The aim of our prospective study, with random selection of 24 patients, was to compare the morphological and functional outcome of the TMJs. The proximal segments in half of the patients had been positioned using devices, in the other half without devices. The segments were fixed by transoral bicortical miniscrew fixation. The evaluation of function is based on pre- and postoperative clinical and electronic axiographic investigations. To study the TMJ morphology, we performed MRI and X-ray investigations preoperatively and 6 months postoperatively. Preoperatively, 12 patients showed slight dysfunction, six patients moderate, and six patients severe dysfunction. Postoperatively, no patient was symptomless. Slight dysfunction was presented in 15 cases, moderate dysfunction in five and severe dysfunction in four cases. Evaluating the axiographic investigations preoperatively, 22 patients showed no mobility disturbances of the TMJ. Two patients showed severe mobility disturbances. Postoperatively, a significant increase in TMJ mobility disturbances could be seen. The MRI investigations of both groups showed both worsening and improvement in the disk positions. No significant differences could be determined between the two groups, however. Regarding the X-ray investigation, three patients from the group with positioning devices showed dislocated condyles; in the group without positioning devices four cases of condyle dislocation were seen. All dislocations were transversal except for one case in the group without positioning devices. Positioning devices do not seem to improve the functional and morphological outcome of the TMJ after BSSO.

Resorbable dowels for osteosynthesis of noncongruent bone fragments.

Dowels, in contrast to screws, offer the great advantage in osteosynthesis that no pressure peaks occur by functional loading rectangular to the screw axis; consequently, there is no bone resorption and no loosening of the fixation because of the even contact of dowel and bony surface. However, dowels must be made of resorbable materials because they cannot be removed. We developed double-spreading dowels with a slotted tube whose outside is cylindric and the inside conical at both ends. Two conical screws in the core of the dowel moved toward each other cause symmetric expansion of the outer surface. Dowel material consisted of polylactic acid with an inherent viscosity > 7 dl/g (Resomer 214, Böhringer Ingelheim). A model simulating retromolar sagittal split osteotomy was chosen for experimental research because, in this case, noncongruent bone segments have to be osteosynthesized to regenerate in the sense of distance osteogenesis. Two segments of synthetic material were synthesized like proximal and distal segments after retromolar sagittal split osteotomy fixed by two or three dowels without coherent contact. The synthesized segments underwent a continuous jiggling stress test comparable with the physiologic stress of a jaw for about 4 weeks. Dowel fixation proved to be nearly as stable as position-screw fixation. Resorbable dowel fixation yields experimentally the required stability for the time needed for bony regeneration.

[Does velopharyngoplasty as a speech-improving measure in cleft palates lead to obstructive sleep apnea?]. / Führt die Velopharyngoplastik als sprachverbessernde Massnahme bei Gaumenspalten zur obstruktiven Schlafapnoe?

Velopharyngoplasty performed to correct velopharyngeal insufficiency in cleft palate patients may cause obstructive sleep apnea in individual cases. The aim of this study was to answer the question, following velopharyngoplasty to what extent and with what frequency can signs of breathing disturbances during sleep be observed. Following the recommendations of the German Sleep Society, a step-by-step procedure was adopted. In 25 patients, in some cases before the operation and in all cases following surgery, nightly oxygen saturation, heart rate, and snoring were recorded. When observable pathological signs surfaced, a cardiorespiratory polygraph was taken. Up to this point only quickly passing signs of sleep related breathing disturbances have been observed. In not a single case could lasting sleep related breathing disturbances as a result of velopharyngoplasty be proven. Nevertheless, the call for pulse oximetric monitoring in the immediate postoperative phase together with corresponding pre-operative observation is legitimate. Even if at this point the danger of sleep related breathing disturbances following velopharyngoplasty appears to be minimal, these preliminary results should be polysomnographically studied within the framework of a much larger test study in order to reach still more reliable conclusions and in order to intercede if necessary with counter measures in the rare individual case of breathing disturbance during sleep following velopharyngoplasty.

Long-term results after maxillary advancement in patients with clefts.

In order to evaluate relapse tendencies after maxillary advancement, 31 patients were examined preoperatively, postoperatively, and 1 year postoperatively; 14 of whom had clefts of the lip, alveolus, and palate. Patients with maxillary deficiency were selected in a method that mere sagittal displacement was planned. Any patients with major vertical or transverse changes or additional mandibular surgery were excluded. Treatment consisted of maxillary advancement by Le Fort I osteotomy and miniplate fixation. Besides clinical examination, skeletal and dental changes were assessed cephalometrically. Results revealed a certain relapse tendency of the displacement in the noncleft group that compared favorably to the cleft group. This relapse is dependent on the amount of advancement. Despite minor differences, the two groups did not differ significantly based on maxillary advancement, so besides advancement surgery there must be another factor, cleft, to explain the different relapse tendencies between patients with and without clefts.

The one-stage repair of bilateral cleft lip.

Twenty children with broad, complete clefts of lip, alveolus, and palate were studied. For functional restoration of the lip in complete bilateral clefts we advocate a one-stage modification of the Millard procedure even if the clefts are broad. Orthodontic treatment is done first to achieve maximal maxillary growth. Reconstruction of the lip is done at the age of 5 to 6 months. Our method of lip restoration is described with special attention to the muscle reconstruction. The lengthening of the columella, which is done at the age of 4 years, is still a problem.

Presurgical orthopaedic treatment using hard plates.

Our concept in the treatment of unilateral clefts of lip, alveolus and palate includes early maxillary orthopaedic treatment starting immediately after birth until the end of the first year of life and the surgical closure of the lip at three months and of the soft palate at twelve months. Hard palate and alveolus are closed after three years by secondary osteoplasty in the alveolar region. The appliance is made of hard acrylic resin and is adjusted monthly to allow for growth. It thus encourages passive orthopaedic guidance of maxillary growth. The local compatibility of the plate was excellent and the acceptance by the children created no problems until tooth eruption. Follow-up studies were conducted on twenty children treated in this way until three years of age. After the first year results show a good and harmonious arch alignment without any collapse of the alveolar segments. The cleft narrows and the steepness of the palatal slope flattens. This maxillary development is arrested after suspension of orthopaedic treatment, and a slight collapse of the alveolar segments is observed.