The influence of dexamethasone on postoperative swelling and neurosensory disturbances after orthognathic surgery: a randomized controlled clinical trial.

BACKGROUND: Orthognathic surgery is associated with considerable swelling and neurosensory disturbances. Serious swelling can lead to great physical and psychological strain. A randomized, prospective, controlled clinical trial was realized in order to evaluate the effect of a preoperative intravenous dexamethasone injection of 40 mg on postoperative swelling and neurosensory disturbances after orthognathic surgery. METHODS: Thirty-eight patients (27 male and 11 female) patients, all with the indication for an orthognathic surgery, were enrolled in this study (mean age: 27.63 years, range: 16-61 years) and randomly divided into two groups (study group/ control group). Both groups underwent either maxillary and/or mandibular osteotomies, resulting in three subgroups according to surgical technique (A: LeFort I osteotomy, B: bilateral sagittal split osteotomy (BSSO), C: bimaxillary osteotomy). The study group received a single preoperative intravenous injection of 40 mg dexamethasone. Facial edema was measured by 3D surface scans on the 1st, 2nd, 5th, 14th and 90th postoperative day. Furthermore, neurosensory disturbances on the 2nd, 5th, 14th and 90th postoperative day were investigated by thermal stimulation. RESULTS: Facial edema after LeFort I osteotomy, BSSO and bimaxillary osteotomy showed a significant decrease in the study group compared to the control group (P = 0.048, P = 0.045, P < 0.001). The influence of dexamethasone on neurosensory disturbances was not significant for the inferior alveolar nerve (P = 0.746) or the infraorbital nerve (P = 0.465). CONCLUSIONS: Patients undergoing orthognathic surgery should receive a preoperative injection of dexamethasone in order to control and reduce edema. However, there was no influence of dexamethasone on reduction of neurosensory disturbances. TRIAL REGISTRATION: DRKS00009033 .

Magnetic resonance imaging: a useful tool to distinguish between keratocystic odontogenic tumours and odontogenic cysts.

In contrast to odontogenic cysts, keratocystic odontogenic tumours often recur and require more aggressive surgical treatment, so we tried to find features that distinguished between them on magnetic resonance imaging (MRI). Without knowing the diagnosis, two radiologists reviewed intensity (low, intermediate, or high) and homogeneity (homogeneous or heterogeneous) of signals in short-tau-inversion-recovery (STIR), T1- and T2-weighted, and fat-suppressed, contrast-enhanced MRI in 20 consecutive patients with oval, radiolucent lesions of the mandible on panoramic radiography, and who were subsequently confirmed histopathologically to have either an odontogenic cyst or a keratocystic odontogenic tumour (n=10 in each group). Fisher's exact test was statistically significant at p<0.05. Delineation of a contrast-enhanced wall of a cyst with high signal intensity distinguished odontogenic cysts (9/10 and 8/10, respectively) from keratocystic odontogenic tumours (3/10, p=0.02, and 1/10, p=0.01, respectively). One radiologist found odontogenic cysts were more likely to be homogeneous on unenhanced T1-weighted images (odontogenic cysts 9/10, keratocystic odontogenic tumours 3/10, p=0.02) and one on contrast-enhanced MRI, when the cyst wall was enhanced (odontogenic cysts 7/9, keratocystic odontogenic tumours 0/3, p=0.01). There were no other significant distinguishing features on MRI. In conclusion, the signal intensity of the enhanced wall seems to be a feature on contrast-enhanced MRI that differentiates odontogenic cysts from keratocystic odontogenic tumours.

[Maxillofacial fractures: midface and internal orbit. Part 2: therapeutic options]. / Maxillofaziale Frakturen: Mittelgesicht und interne Orbita. Teil 2: Therapieoptionen.

While the state of the art of clinical assessment and imaging techniques were described in Part 1, this contribution presents a systematic review of the surgical treatment principles in the management of midface and internal orbit fractures from initial care to definitive treatment, including illustrative case examples. New developments and advances are characterized by limited versus extended surgical approaches, by standardization of osteosynthesis principles with regard to three-dimensional buttress reconstruction, by newly developed individualized implants such as titanium meshes and, especially for complex fracture patterns, by critical assessment of anatomical reconstruction through intraoperative endoscopy, as well as intraoperative and postoperative imaging. Newly developed resorbable soft tissue anchors can be used both for ligament and soft tissue resuspension in order to reduce ptosis effects in the cheeks and nasolabial area to achieve facial aesthetics similar to those prior to the injury.

[Maxillofacial fractures: midface and internal orbit : Part 1: classification and diagnosis]. / Maxillofaziale Frakturen: Mittelgesicht und interne Orbita : Teil 1: Klassifikation und Diagnostik.

Fractures of the midface and internal orbit occur isolated or in combination with other injuries. Frequently, the patients are first seen in emergency rooms responsible for the coordination of initial diagnostic procedures, followed by the transfer to specialties for further treatment. It is, therefore, important for all colleagues in traumatology to understand the basic principles of injuries to the midface. Thus, the aim of this article is the description of the anatomy and the current classification systems in use, the related clinical symptoms, and the essential diagnostic measures to obtain precise information about the injury pattern. Issues for treatment will be illustrated and discussed in "Part 2" of this article.

The use of TMJ Concepts prostheses to reconstruct patients with major temporomandibular joint and mandibular defects.

Temporomandibular joint (TMJ) reconstruction may be required in complex cases in which there are additional mandibular or zygomatic arch defects. The reconstructive options include autogenous tissue, alloplastic material, or combinations of these. The authors describe 4 cases in which TMJ reconstruction was performed with TMJ Concepts customized joint prostheses. The prosthetic components were designed to restore major defects in the zygomatic arch and the mandibular ramus and body, including one case in which the mandibular component was used to restore total mandibular continuity. The prosthetic components used in these cases provided excellent anatomical reconstruction, and were a viable treatment option in cases in which the pathological process made autogenous grafts unsuitable. The prostheses have been functioning for up to 6 years. In one case a revision operation was required because the lack of a pterygomasseteric sling resulted in the condyle dropping out of the fossa. The authors' clinical experience with these cases suggests that a customized prosthesis combined with TMJ reconstruction can be a reliable treatment alternative for bridging complex, major maxillo-mandibular defects.

Reinnervation-induced alterations in rat skeletal muscle.

Denervation-induced myofiber atrophy can be reversed by reinnervation. Growing reinnervated myofibers upregulate numerous molecules, many of which determine the muscle fiber type. In the present study we aimed at identifying factors that might contribute specifically to myofiber growth after reinnervation. The common peroneal nerve of 15 male Wistar rats was cut and resutured without delay (9 animals) or with a delay of 4 weeks (6 animals). We studied the transcriptional repertoire of intact reinnervated tibialis anterior muscle by microarray gene analysis. We assessed SC activation by immunolabeling using anti-MyoD and -myogenin antibodies. The percentage of SC expressing MyoD reached up to 50% of M-cadherin+ cells whereas the percentage of SC expressing myogenin was normal (<10%) in all muscles examined. The values of ipsi- and contralateral muscles did not differ significantly from one another between right and left leg (p<0.05). Thirteen known genes were differentially regulated after reinnervation compared with contralateral muscles. Five of them determine the slow-twitch fiber type (four and a half LIM domains 3, cardiac beta-myosin heavy chain, calsequestrin 2, troponin C (slow), and heart myosin light chain), and three of them are neurally regulated (thrombospondin 4, transferrin receptor, cardiac ankyrin repeat protein). The results strengthen the notion that reinnervaton affects the molecular repertoire of the myofibers directly, leading to fiber type transformation and partial reversal of the denervation phenotype. By contrast, SC do not appear to be affected by reinnervation directly. They can be activated both in reinnervated and contralateral muscles, and they do not fully differentiate. This makes them unlikely to contribute to myofiber growth.

[Positioning of the premaxilla in cases of bilateral cleft lip, alveolus and palate using Latham's appliance]. / Positionierung der Oberkieferelemente mit der Latham-Appartur bei Patienten mit Lippen-Kiefer-Gaumen-Spalten.

UNLABELLED: SUBJECT MATTER: In cases of bilateral cleft lip, alveolus and palate, preoperative positioning of the premaxilla using Latham's appliance has been described. This method is controversial, since it may cause growth defects. PATIENTS AND METHODS: From 1992 to 2000, Latham's appliance was inserted preoperatively into 20 patients with bilateral lip, alveolus and palate clefts with extreme premaxillary protrusion. Pin fixation ensued at the age of 3 months. After adjustment of the premaxilla, the soft palate was closed and bilateral lip adhesion as well as bilateral gingivoperiosteoplasty were performed directly after the removal of the appliance. Final lip closure took place 4-6 weeks later. At the age of 2 years, the hard palate was closed. Evaluation was based on combined face-maxilla models, standard photographs and, when available, lateral skull x-rays showing the relative position of the segments, the influence of Latham's appliance on the nasal septum and the relation of the upper jaw to the skull base and mandibula. RESULTS: In all cases, a satisfactory alveolar alignment was achieved; thickening and curvature of the nasal septum occurred but receded. Neither growth disturbances nor dental germ damage were seen. In two cases, complications arose from suture dehiscence of the lip adhesion: in one patient, a screw defect caused a loosening of the appliance and there was also a transmigration of the postpremaxillary pin. CONCLUSIONS: On the basis of our experience, the use of Latham's appliance, combined with consistent orthodontic supervision and, if necessary, treatment, represents a practical option for the treatment of bilateral cleft lip, alveolus and palate, especially in cases with extreme protrusion of the premaxilla.

Endoscopically assisted zygomatic fracture reduction and osteosynthesis revisited.

In comminuted fractures of the zygoma open reduction of the malar arch is essential for correct anatomic repair. Avoiding exposure of this landmark may result in severe functional and aesthetic impairment. Exposure of the malar arch necessitated traditionally a coronal incision. However, recently several authors reported good results in malar fracture repair with minimal incisions and endoscopic assistance. To establish this technique a cadaver study was performed. Different approaches to the malar arch, fracture reduction and internal fixation were evaluated. After establishment of a satisfactory technique 12 patients with comminution of the zygoma were treated with endoscopic assistance. Repositioning of the fragments was excellent in nine cases, minimal remaining dislocation was seen in two cases and in one case revision was necessary. Postoperatively the frontal branch of the facial nerve was intact in all patients. Scarring was minimal. In three patients plating of the malar arch on a side table resulted in arch necrosis and resorption in the long-term follow-up. Operating time was remarkably longer than in conventional procedures due to the difficult technique.

[3-dimensional image acquisition for analysis of primary, cleft-induced facial deformity with an optoelectronic surface scanner]. / Dreidimensionale Bildakquisition zur Analyse der primären, spaltbedingten Gesichtsdeformität mit einem optoelektronischen Oberflächenscanner. Erste Ergebnisse.

BACKGROUND: Anthropometric analysis of the face has been performed with direct facial measurement and photogrammetry. Both methods have disadvantages. The aim of our investigation was to create a three-dimensional image of the primary cleft nasal deformity with a video scanner and to carry out linear measurements. MATERIAL AND METHODS: Facial plaster casts of 19 patients with uni- and bilateral cleft lip and palate before primary lip repair were scanned with digital surface photogrammetry DSP 400. The width of the nose and of the nostril floor, the distance of the alar bases, the length of the ala, and the nasal tip protrusion were measured. RESULTS: Imaging was possible without problems in all models. Direct measurements of the model correlated well with the results of the three-dimensional image. Significant dimensional differences of the nasal parameters examined were noted, depending on the cleft type. DISCUSSION: A video-supported surface scanner allowed immediate three-dimensional imaging of the face. The computer software analyzed the generated surface exactly. The data measured with the presented system resembled other previously published results.

Wooden foreign bodies in facial injury: a radiological pitfall.

Foreign bodies can present a diagnostic challenge to the maxillofacial surgeon. Three patients, who suffered from a penetrating injury with a wooden foreign body, were examined and treated. Their preoperative CT and MRI scans were evaluated. In an acute case, the penetrating wooden body mimicked air bubbles. In the other two patients, the wood was retained for several months and appeared with a much higher density on CT. In MRI the wooden foreign bodies gave a low signal intensity. In all injuries removal of the foreign body was delayed, because it was initially radiologically missed or misdiagnosed. In the appropriate trauma setting a penetrating wooden body must always be considered. Its attenuation value increases with time as water is absorbed from the surrounding tissues. Although the radiological appearance may show a great variety, CT imaging is the basic diagnostic technique. MRI is the method of second choice.

External distraction of the maxilla in patients with craniofacial dysplasia.

Patients with severe maxillary hypoplasia secondary to craniofacial dysplasia present a challenge to the craniofacial surgeon. Maxillary distraction presents a promising tool to treat these patients more successfully. Fifteen patients aged 12 to 20 years with craniofacial dysplasia and maxillary retrusion were treated with two different techniques after complete Le Fort I osteotomy: one group underwent face mask protraction (2 patients), and the other group underwent rigid external distraction (13 patients). Cephalometric evaluation was performed before and after distraction. Rigid external distraction appeared to be superior to face mask protraction. Maxillary retrusion was fully corrected in this group. The path of maxillary positioning was well controlled by changing the traction force vector. Distraction osteogenesis has certainly improved treatment of these patients.

[Callus distraction of the maxilla. Supplement or alternative to advancement osteotomy]. / Kallusdistraktion im Oberkiefer. Ergänzung oder Alternative zur Umstellungsosteotomie.

Total or partial relapses after conventional surgical advancement of the maxilla following Le Fort I osteotomy in CLP patients are frequent and major complications. The aim of this investigation was to find out whether the technique of distraction osteogenesis in these patients shows more stability and whether maxillary distraction is able to replace conventional advancement. Maxillary distraction was performed in 12 patients. In two cases, a Delaire mask was used to bring the maxilla forward, ten patients were treated with the extraoral distraction device designed by Polley. In all patients, planned advancement of the maxilla could be achieved; one partial relapse occurred. The results indicate that distraction osteogenesis offers the possibility of advancement of the maxilla with the required stability. The technique presents a major improvement which is achieved with a relatively minor surgical procedure.

Three-dimensional computer morphometry of the maxilla and face in infants with Pierre Robin sequence--a comparative study.

OBJECTIVE: To analyze the morphology of the maxillary crest in infants with Pierre Robin sequence using an anthropometric coordinate system and to compare the data with those of healthy infants. SETTING: The study was performed at a craniofacial center servicing a large geographic area. PARTICIPANTS: The study involved eight infants aged 1-28 days (average, 7 days) with an established diagnosis of Pierre Robin sequence and six healthy infants aged 1-43 days (average, 22 days). MAIN OUTCOME MEASURES: Physical models of the maxilla and face obtained by alginate replication were analyzed by computer morphometry yielding the three-dimensional topology of the maxillary crest. RESULTS: The maxillary crest of children with Pierre Robin sequence shows an increased inclination relative to the transverse plane (30 +/- 3.9 degrees) as compared with that of healthy infants (20 +/- 2.9 degrees). The maxillary crest of the patients is shortened in the sagittal direction by comparison with healthy controls. CONCLUSIONS: The increased inclination of the maxilla in infants with Pierre Robin sequence may aggravate the retroposition of the mandible and may thus be a pathogenetic factor contributing to the severe respiratory problems.

Neo-osseous flaps using demineralized allogeneic bone in a rat model.

Surgical reconstruction with revascularized bone grafts can be compromised by donor tissue limitations and may be refined by prefabrication of compound neoflaps using bone substitutes. The principal suitability of demineralized allogeneic bone (DALB) slabs in fabricating neo-osseous flaps based on the inferior epigastric vascular system was studied and compared with neoflaps with autologous bone (AUB). In 45 rats, the histological pattern of bone formation in response to angiogenesis induced by vessel implantation was assessed, and characteristics of vascularization of the neoflap were studied microangiographically at 2, 4, 6, and 8 weeks. Histological techniques included decalcified and nondecalcified sections, as well as intravital polyfluorochrome labeling. Blood flow of the neoflap was also assessed quantitatively using 15-microm microspheres labeled with technetium 99-methylene diphosphate (99-MDP) 8 weeks after flap fabrication. Although the DALB neoflaps showed consistent bone formation and neovascularization, the bone regeneration process was delayed distinctly in comparison with AUB. Microangiographically, however, no differences between the two types of grafts became apparent during all time periods tested. Furthermore, the radioactivity of the DALB neoflap, which means bone blood flow per dry weight, was significantly higher than in AUB grafts and even more than that of intact iliac bone (p = 0.001). The exact meaning of elevated blood flow in DALB and similar degrees of vascularization corresponding to native AUB grafts remains to be determined, but may be a sign of ongoing bone formation resulting in a suitable DALB-containing neo-osseous flap in the long term. The authors findings support that allogeneic bone could be a potential substitute for AUB in creating a prefabricated neo-osseous flap.

[Endosseous implants after tumor resection of the face]. / Enossale Implantate nach Tumorresektion im Gesichtsbereich.

Endosteal implants after tumor surgery of the face are helpful in reconstructing facial defects. A retrospective study of our patients treated using craniofacial implants was conducted to evaluate long-term results. A total of 128 implants were inserted, 110 implants in the periorbital, 12 implants in the mastoid, and six implants in the paranasal region; 113 implants were short craniofacial Brånemark implants, and 15 implants were dental implants. The success rate for implant survival was 94.5%. Long-term results were promising and more than satisfactory, leading to a large indication for these endosteal implants.

Relevance of SCC-Ag, CEA, CA 19.9 and CA 125 for diagnosis and follow-up in oral cancer.

The prognosis of oral cavity carcinoma is limited by recurrent disease or lymph node metastasis. Secondary to surgery and radiotherapy, anatomical structures are often severely changed and make early diagnosis of renewed tumour growth by clinical and radiological examination difficult. We studied the course of serum SCC-Ag, CEA, CA 19.9 and CA 125 in 121 patients with untreated squamous cell carcinoma of the head and neck (SCCHN) before and after therapy and evaluated their relevance for diagnosis and follow-up in oral cancer. CA 19.9 and CA 125 seemed to be useless for this tumour entity. CEA resembled more the alcohol consumption and smoking habits of the patients examined than their state of disease. Only SCC-Ag correlated with the tumour burden and represented the disease course. In the event of relapse, half the patients had an exponential increase in SCC-Ag, 1-2 months prior to diagnosis.

[Effect of early fronto-orbital advancement on growth of the frontal sinus and supraorbital area]. / Einfluss von frühem frontoorbitalem Advancement auf das Wachstum von Stirnhöhle und Supraorbitalregion.

In 12 patients with craniosynostosis the influence of early fronto-orbital advancement on the growth of the frontal sinus and supraorbital region was examined. A follow-up examination at the age of 8 years showed a lack of pneumatisation of about 50%. However, there was no correlation between this score and the external contour. The frontal sinus has no dominant influence on the growth of the supraorbital region. In 9 out 12 of cases the very early operation time did not lead to disturbances of growth. A further follow-up examination of the patients after termination of growth at the age of 16 is planned.

[Craniofacial techniques in traumatology]. / Kraniofaziale Techniken in der Traumatologie.

The coronal incision is a versatile approach to midface or skull base fractures. It allows the open reduction of complex fracture sites and facilitates canthopexy, marginotomy or calvarian bone harvesting. By this method, primary treatment can be optimised and the rate of secondary corrective surgery can be reduced. All trauma patients who underwent this kind of intervention were re-examined to check functional and aesthetic results. The complication rate was low and the advantages of these techniques are evident, so that it is suggested that the indication for this operative approach should be extended.

[Using individually designed ceramic implants for secondary reconstruction of the bony orbit]. / Verwendung individuell hergestellter Keramikimplantate zur Sekundärrekonstruktion der knöchernen Orbita.

The use of autogenous transplants and the application of intraoperatively customised alloplastic materials show, in cases of secondary orbital reconstruction, a higher postoperative morbidity caused by additional approaches to the transplant donor site. On the other hand, thorough surgical exploration and fitting of the transplants or alloplastic materials greatly prolongs operating times. For these reason we designed ceramic implants (Bioverit) on the basis of stereolithography models and prefabricated them using a commercially available dental copy milling unit (Celay). In five cases up until now seven customised implants have been inserted for reconstruction of the lamina papyracea, zygomatic complex and infraorbital floor and rim. Encouraged by the good postoperative aesthetic and functional results, with significantly reduced operating times and morbidity in all cases, we will continue to take this technique into account for reconstruction after complex orbital fractures.

[New techniques in maxillofacial surgery: local injection treatment with botulinum toxin A]. / Neuerungen in der MKG-Chirurgie: Lokale Injektionsbehandlung mit Botulinumtoxin A.

Intramuscular injections of botulinum neurotoxin type A cause reversible chemodenervation and subsequent paralysis by blocking the presynaptic release of acetylcholine. Botulinum toxin type A has emerged as the most effective form of symptomatic treatment for abnormabilities in muscle movement (blepharospasm, hemifacial spasm, torticollis) and has been approved for use in these conditions. First results in the treatment of patients suffering from oromandibular dystonia, myogenic craniomandibular dysfunction and recurrent dislocation of the temporomandibular joint are presented. In most cases, therapeutic effects occurred within 1-6 days post-injection. Muscular hyperfunction was reliably reduced and involuntary activity patterns gradually ceased. No severe side effects of the local injections were noted.