Botulinum toxin as a therapeutic agent to prevent relapse in deep bite patients.

INTRODUCTION: The etiology of deep bite is multifactorial. One of the causes is increased muscular activity. This makes the treatment of deep bite malocclusions difficult and often results in relapse in many cases. In this work we compared patients with surgical orthognathic treatment only and surgical orthognathic treatment with additional injections of botulinum toxin after mandibular advancement for class II division 2 malocclusion. MATERIAL AND METHODS: This is a prospective study. Adult patients were assessed pretreatment (T1), posttreatment (T2), and long-term after 1 year (T3). In total, 32 patients (mean age, 30.7 years; 23 women and 9 men) reached the study end point (T3); 24 patients were treated without botulinum toxin and 8 patients received preoperative injections of botulinum toxin. RESULTS: Significant differences between both groups were observed, with a more stable result for the experimental group treated with botulinum toxin. DISCUSSION: In a selective group of adult patients with a class II division II incisor relationship and with a class II skeletal base, botulinum toxin injections can effectively prevent relapse. This may present an alternative to a conventional myotomy.

The role of mylohyoid flap in the treatment of bisphosphonate-related osteonecrosis of the jaws.

INTRODUCTION: Surgical treatment of bisphosphonate-related osteonecrosis of the jaws (BRONJ) combines excision of adequate damaged bone and watertight coverage by appropriate vascularized tissue. Local tissues are preferred when possible. This study compares local mucoperiosteal flaps with mylohyoid flaps with special emphasis on their influence on wound healing. MATERIAL AND METHODS: A total of 195 patients with BRONJ in the mandible were included in this prospective study. The control group (n = 169) were treated with a mucoperiosteal flap, whereas patients of the study group (n = 26) received a mylohyoid flap. RESULTS: Recurrence of BRONJ was significantly reduced (p = 0.023) as was extent of necrosis (p = 0.001) in patients with mylohyoid flaps. DISCUSSION: This study demonstrates the importance of a sufficient mucosal coverage in surgical treatment of BRONJ. The mylohyoid flap provides an additional tissue coverage, which seems to account for the significantly reduced rate of disease recurrence. CONCLUSION: The vascularized mylohyoid flap is an important tool in the complex and challenging surgical care of BRONJ.

Effect of neoadjuvant treatment in the management of osteosarcomas of the head and neck.

PURPOSE: Osteosarcomas of the craniomaxillofacial region in adults are rare malignant tumors with many sites of origin. The purpose of this study was to analyze the outcome of adult patients suffering from osteosarcomas and investigate whether neoadjuvant chemotherapy would be beneficial to overall outcome. PATIENTS AND METHODS: The medical records of 36 patients treated during 2002-2012 were reviewed. All patients suffered from primary osteosarcomas of the craniomaxillofacial region. RESULTS: The mean survival of patients was 64.49 ± 23.52 months. The 2- and 5-year overall survival rates in the neoadjuvant treatment group were 100 and 66.7 %; in the surgery only group, the overall survival rates were 66.7 and 41.7 %, respectively. The neoadjuvant treatment (p = 0.017), tumor size (p = 0.004), tumor location (p = 0.02), and age (p < 0.0001) were significant parameters influencing survival, whereas other tumor-related or demographic factors had no significant influence on survival. CONCLUSIONS: Early identification of osteosarcoma of the craniomaxillofacial region and combined treatment by neoadjuvant chemotherapy with radical surgery are the most important strategies in dealing with these sarcomas. If possible, this treatment option should be followed unless contraindicated by other factors.

Experimental analysis of tensile force of individualized stents for microvascular anastomoses.

The aim of this project was to investigate the fundamental idea of the possibility of anastomosing small blood vessels in microvascular transplant procedures by an individualized stent known from coronary angioplasty. We investigated the influence of length, dilation and differences in fabrication of the newly developed balloon-expandable stent on the tensile force of stented anastomoses. Various gripping devices were tested and validated to investigate how the length, dilatation and differences in fabrication of the newly developed stent influence the tensile force of the stented anastomosis. Overall, 66 arteries of thiel-fixed human cadavers were investigated, divided into 11 groups. The median tensile force in sutured anastomoses was 2.96 N. The stented anastomoses with 24 mm stents and Ø 3.5 mm dilation attained approximately two-thirds of F(max)-values compared with conventional sutured anastomoses. If the stent was less dilated or had a shorter length, the maximum tensile force of the anastomosis was lower. Recent developments with an inversely oriented stent structure are expected to achieve even higher tensile force values. Further research in stent design to reduce leakage is necessary. A reduction of stent and catheter dimension is also needed to enhance the implantation method.

Maxillary reconstruction using microvascular free flaps.

OBJECTIVE: Loss of all or part of the maxilla as a result of tumor ablation has both functional and aesthetic consequences. Reconstruction of the maxilla remains a challenge despite the availability of several flaps and the skills of the prosthodontist. We have analyzed a series of maxillary resections that underwent flap reconstruction to guide planning of the rehabilitation of patients with such defects. STUDY DESIGN: The authors present 83 patients with various types of maxillary defects that were reconstructed with different microvascular free flaps. All clinical data, including data on the functional and aesthetic outcome, are analyzed. RESULTS: Flap transfer was successful in 80 of 83 patients who underwent maxillary reconstruction. Separation of the oral and nasal cavities was achieved in all cases. Flap compromise occurred in 6 cases, which made revision necessary. Three of these flaps were salvaged and 3 flaps failed. In 10 of 28 patients with transferred bone, osseointegrated implants were inserted and dentally rehabilitated with excellent functional and aesthetic results. CONCLUSION: Various types of maxillary defects can be reconstructed successfully using different microvascular free flaps. This procedure is challenging because of the anatomical site of reconstruction creating a steep learning curve. If the reconstruction is successful, both facial appearance and oral function can be improved. Microvascular flaps containing bone of the fibula, scapula, or iliac crest facilitate complete dental rehabilitation.

Sticky platelet syndrome as a possible cause for free flap failure--a case report.

We report a case of a patient who developed clinical symptoms of sticky platelet syndrome (SPS) during free microvascular flap transplantation, following resection of an oral tumor. Multiple arterial thromboses of two free tissue transfers occurred as a probable result of SPS. Diagnosis and treatment of the various forms of SPS are described.

Impact of nonhybrid 99mTc-MDP-SPECT/CT image fusion in diagnostic and treatment of oromaxillofacial malignancies.

PURPOSE: The aim of this study was to prospectively investigate the clinical impact of image fusion of computed tomography (CT) and single photon emission computed tomography (SPECT) diagnostics in head and neck cancer adjacent or fixed to bony maxillofacial structures. PROCEDURES: Computer-based manual image fusion has been applied in 74 patients with suspected malignancies in the oromaxillofacial region following CT and SPECT. Afterward, image fusion was compared to separate evaluation of CT and SPECT and visual coregistration with histopathological results serving as control. RESULTS: In nine out of 74 patients, image fusion achieved more precise anatomical findings regarding tumor dimension than simultaneous evaluation of CT and SPECT, but there was no improvement of identification of bone infiltration. CONCLUSION: Manual image fusion of CT and SPECT does not improve identification of bone infiltration compared to simultaneous evaluation. Though particularly in complex anatomical regions, a fixed preoperative diagnostic algorithm in image registration lead to a more precise evaluation and treatment of head and neck malignancies.

Repair of oronasal fistulas with human amniotic membrane in minipigs.

We evaluated the use of multilayer human amniotic membrane (HAM) as a grafting material for the repair of mid-palate oronasal fistulas in seven Berlin minipigs. After two weeks, three animals had the fistulas repaired with multilayered HAM grafts, three had them repaired with a collagen-based dermal substitute (INTEGRA((R)), Integra Life Sciences, Plainsboro, NJ, USA), and one fistula was left untreated to serve as a control. Grafts were interposed between the oral and nasal mucosa, traversing the fistulas. After healing for 40 days, the pigs were killed for clinical, histological, and immunohistochemical examination. Two of the three fistulas closed with HAM were successful, the diameter of the third was reduced in size, and there was no change in the diameter of the fistula in the control. This study shows successful closure of oronasal fistulas in minipigs using interposed grafts of cryopreserved HAM, and offers promise as a simple and effective technique for tension-free closure of such fistulas.

Reconstruction of the maxilla and midface--surgical management, outcome, and prognostic factors.

Loss of the maxilla due to tumor ablation has both functional and aesthetic consequences. Even small defects become obvious because of missing bone and soft tissue. Reconstruction of the maxilla and midface in these patients presents a challenge to the surgeon although several possibilities are available for this purpose. The long term benefit to patients of the different modalities remains unclear due to wide individual variation. One hundred and twenty-one patients with maxillary oral squamous cell carcinoma were treated with curative intent. One hundred and five patients were surgically reconstructed using local or free microsurgical flaps. All parameters were collected from case records. Kaplan-Meier plots and univariate log-rank test and multivariate Cox proportional hazards regression models were used to determine the association between possible predictor variables and survival time of patients suffering from oral squamous cell carcinomas. After controlling for age, resection margins, nodal stage, and surgical management, which were independent and dependent predictors of survival, the type of reconstruction and involvement of surgical margins were associated with survival (HR=0.50, p=0.044, 95% CI, 0.25-0.98 and HR=3.16, p=0.007, 95% CI, 1.38-7.25). Various types of maxillary defects can be reconstructed successfully using different reconstructive techniques. The size and complexity of defects does not correlate with prognosis in oral squamous cell carcinoma patients. The criteria for reconstruction with a free flap were based on extensive defects in which local flaps were insufficient, on medical co-morbidities, and previous treatment.

Results of esophagogastroduodenoscopy in patients with oral squamous cell carcinoma--value of endoscopic screening: 10-year experience.

PURPOSE: Oral squamous cell carcinoma (OSCC) represents more than 90% of oral malignancies. Risk factors such as smoking and alcohol abuse can result in additional diseases, particularly of the upper gastrointestinal tract. The aim of the present study was to assess the synchronous pathologic changes of the upper gastrointestinal tract using endoscopy at the diagnosis of OSCC using a retrospective cohort study design. PATIENTS AND METHODS: The clinical records of 806 patients with OSCC from 1997 to 2007 were reviewed. Of the 806 patients, 570 (188 females and 382 males) with primary OSCC were identified. All patients underwent esophagogastroduodenoscopy at the initial tumor staging. The tumor stage was defined according to the International Union Against Cancer classification for head and neck malignancies. The clinical and histologic data were analyzed for probability using univariate and multivariate analyses. RESULTS: Of the 570 patients, 289 had limited and 281 advanced disease. A statistically significant association was found between the advanced and limited tumor stage for Barrett's esophagus with an odds ratio of 4.986 (95% confidence interval 1.370 to 27.360, P = .0061). Pathologic findings were observed in 169 patients. Additional risk factors for the development of secondary upper aerodigestive tract cancers were found in 103 patients. CONCLUSIONS: Esophagogastroduodenoscopy provides the opportunity to identify second malignancies, precancerous lesions, and risk factors and to obtain biopsies using one procedure. The results can be immediately integrated into the therapeutic concept of the primary disease. Although new imaging techniques have been available, esophagogastroduodenoscopy still plays a decisive role in the routine staging of OSCC.

A bioartificial surgical patch from multilayered human amniotic membrane-In vivo investigations in a rat model.

The study was performed to evaluate the suitability of glycerol-cryopreserved human amniotic membrane (HAM) as a surgical patch, far from its common use in ophthalmic surgery. In vivo experiments in rat models were performed to study the degradation patterns, biocompatibility, postoperative tissue formation and its suitability for abdominal wall closure. Degradation and thickness of the membranes were assessed over a period of 60 days after subdermal implantation of monolayer and multilayer HAM in 96 immunocompetent and immunosuppressed rats. The tissue response was mild, and histological analysis evaluated that multilayer application and immunosuppression prolonged graft survival significantly. In a second rat model, another 18 animals were monitored over a period of 28 days after abdominal wall reconstruction with multilayered HAM. Polypropylene mesh (Prolene) and polyglactin910/polydioxanon patches (Ethisorb) served as controls. Gross examination and histological analysis proved that multilayer HAM was a sufficient material for abdominal wall closure in comparison with the polypropylene mesh and was superior to the polyglactin910/polydioxanon patch. Additionally, significantly reduced postoperative intraabdominal adhesions were observed when compared to the polyglactin910/polydioxanon patch. This study demonstrates that HAM is a biocompatible, resorbable surgical patch in a rat xenotransplantation model and serves as a mechanically sufficient material for abdominal wall closure in a small animal model. These findings are encouraging and justify further research for the use of cryopreserved human amniotic membrane in soft tissue repair.

Expression profile of human beta-defensin 3 in oral squamous cell carcinoma.

Although it is known that innate immunity is important for protecting the body against foreign agents such as bacteria, little is known about elements of the innate immune system that have antitumor activity. This prospective study was designed to investigate the function of human beta-defensin 3 (hBD-3), an important component of the innate immune response, in oral squamous cell carcinoma (OSCC). Paired cancerous and noncancerous specimens of 45 patients who underwent surgical treatment for OSCC were examined for hBD-3 expression on protein and mRNA. Clinical and pathological features such as age, gender, tumor and lymph node status, UICC stage, and histological grading were correlated. hBD-3 was significantly overexpressed in tumors in comparison to healthy tissue examined with real-time quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) analysis (p = .004). Immunohistochemical stain for hBD-3 was much more pronounced in tumors than in corresponding healthy mucosa. The results illustrate that hBD-3 is frequently overexpressed in oral squamous cell carcinomas and seems to be related to oncogenesis. Increased expression of hBD-3 in oral squamous cell carcinomas suggests its potential role in the pathogenesis of oral cancer. This might be a starting point for novel pharmacological/molecular treatment modalities.

Bronchoscopy screening in primary oral squamous cell carcinoma: a 10-year experience.

Squamous cell carcinoma (SCC) in the head and neck is associated with synchronous or metachronous carcinomas of the lung. Preoperative pulmonary screening is advocated and may be done by bronchoscopy, thoracic radiograph, computed tomography (CT), or positron emission tomography (PET) with CT (PET/CT fusion). We evaluated the role of bronchoscopy in patients with primary oral SCC to ascertain the incidence of synchronous malignancies of the lung. We retrospectively reviewed a decade's experience of screening by bronchoscopy in 570 pathologically confirmed and previously untreated patients with oral SCC (188 female, 382 male). Univariate and multivariate analyses were done after evaluating the incidence of synchronous lesions and the clinical and histological features of the index tumour. Investigation by bronchoscopy showed disease in 166 patients, and malignancy of the lung in 9 (2%). The Union International contre le Cancer (UICC) stages I and II oral SCC were significantly associated with a synchronous malignancy of the lung (p=0.038). We recommend the use of bronchoscopy even in early tumour stages. Some patients had their treatment altered because of its use, including upstaging, diagnosis of distant and unresectable disease, and investigation of second primary malignancies.

Cryopreserved human amniotic membrane for soft tissue repair in rats.

Fresh amniotic membrane has been used in medicine since 1910. The reconstruction of immunologic privileged ocular surfaces with cryopreserved amniotic membrane was introduced in the 1990s. The aim of this study was to analyze the use of cryopreserved human amniotic membrane (HAM) as a surgical patch in immunologic unprivileged anatomic sites. In part I of the investigation, the abdominal wall muscle of 36 rats was covered with mono- and multilayered HAM. After 3, 14, and 28 days, respectively, these grafts were evaluated macro- and microscopically. Multilayer samples displayed slower degradation and less inflammation compared with monolayer coverage. In part II of the study, abdominal wall closure with multilayer HAM and with polypropylene mesh was conducted in 20 rats. All rats showed sufficient closure after 21 days, but significantly lower intraabdominal adhesion formation was observed in the HAM rats. The results of this study might pave the way for the use of cryopreserved HAM as graft material in reconstructive surgery.

[Image fusion of bone SPECT and CT - a specific diagnostic method in oral and maxillofacial surgery]. / Bildfusion von SPECT und CT als präzisierende Diagnostik von malignen Tumoren im Mund-Kiefer-Gesichtsbereich.

OBJECTIVE: The aim of this study was to evaluate the benefit of image fusion of CT (computertomography) and bone SPECT (single photon emission computed tomography) in diagnosis of head and neck cancer. METHODS AND PATIENTS: Computer based image fusion has been applied in 39 patients with suspected cancer in the oromaxillofacial region following CT and SPECT without any further hazard for the patients. Afterwards image fusion was set in comparision to simultaneously evaluation of CT and SPECT and histological findings. RESULTS: In 5 out of 39 patients SPECT/CT image fusion obtained more precise anatomical findings in tumour expansion than simultaneously evaluation of CT and SPECT. CONCLUSION: For planning of surgical and radiation therapy of oral and maxillofacial cancer, image fusion of CT/SPECT provides efficient and plastical diagnostic imaging. Particularly in complex anatomical regions like maxilla or base of the skull image fusion could be an additional device, if simultaneous evaluation of CT and SPECT is not clear.

Male breast cancer metastasis presenting as submandibular swelling.

This case report deals with the case of an 86-year-old man who was admitted to our hospital with an submandibular swelling after mastectomy for breast cancer one and a half year ago. Histopathological examination after surgical resection evaluated metastasis of a mixed-type breast carcinoma. Further treatment was palliative chemotherapy. This is the first description of a male breast carcinoma metastasis located in the submandibular region.

Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry.

BACKGROUND: Early identification of flap failure is an indispensable prerequisite for flap salvage. Although many methods of free flap monitoring are available, there is still no single reliable non-invasive technique for early recognition of flap failure and for differentiation between arterial occlusion and venous congestion. The aim of this study was to investigate the benefits of the tissue oxygen analysis system O(2)C for monitoring patients undergoing maxillofacial reconstruction with fasciocutaneous radial forearm flaps. MATERIAL AND METHODS: In a prospective clinical study the microcirculatory parameters of blood flow, flow velocity, haemoglobin concentration (AU, Arbitrary Units) and oxygen saturation (%) were assessed by clinical means, by laser Doppler flowmetry and tissue spectrophotometry in 61 patients intraoperatively. Measurements were carried out before flap harvest, in the separated radial forearm flap, immediately after anastomoses and up to 14 days after reconstruction. RESULTS: Following anastomosis, blood flow and flow velocity exceeded the level before flap elevation and reached significant differences by the third postoperative day (p<0.05). Oxygen saturation decreased significantly by the third postoperative day and haemoglobin oxygenation showed stable values after performing anastomosis. Simultaneous, non-invasive laser-Doppler flowmetry and tissue spectrophotometry detected vascular complications in all cases with no false positive or false negative results and prior to clinical assessment. CONCLUSION: For the first time this new device allows reliable prediction of venous congestion by an increase of haemoglobin-concentration, and of arterial occlusion by a decrease in blood flow parameters and oxygen saturation. It can thus differentiate the mechanisms of flap failure before clinical assessment.