[Sensibility changes of the infraorbital nerve after primary surgery on patients with unilateral cleft lip according to J. Delaire]. / Évaluation à long terme de la sensibilité du nerf infraorbitaire chez les patients porteurs de fente labiale unilatérale complète après traitement primaire selon la technique de J. Delaire.

OBJECTIVE: The aim was to determine the overall sensibility changes in the area of the infraorbital nerve on patients with unilateral clefts lips and unilateral clefts lips and palate who had undergone primary surgical correction according to the principles of Delaire. PATIENTS AND METHOD: Twenty patients (7-20years) with unilateral cleft lips (and palate) who had undergone surgery in infancy according to Delaire were included. Cutaneous sensibilities of the nasolabial fold and of the upper lip were tested using four cutaneous modalities. A tactil superficial sensibility light touch test, a two-point discrimination test (McKinnon-Dellon Disk-Criminator), and the determination of cold and warm detection thresholds (Quantitative Sensory Testing, Medoc Thermal Sensory Analyser). The possible difference of the sensibility between operated and controlateral sides of the face were compared. Results were finally compared to a control group of twenty healthy volunteers. RESULTS: No significant difference could be found between the operated and non-operated side of the cleft group. There was also no difference between the cleft and the control group. Specific difference of perception between nasolabial fold and lip encountered in the literature were confirmed by the experiments. CONCLUSION: The large subperiostal approach according to Delaire during the primary surgical procedure have not affected long term infraorbital sensibility of patients with unilateral complete cleft lip.

Inspiratory stridor and dysphagia in two newborn infants caused by ectopic thymus tissue.

We report two cases of ectopic cervical thymus, a solid thymic lesion, and a thymus cyst causing inspiratory stridor and mild dysphagia in the neonatal period. Because of the rarity of thymic dystopia, the two masses were initially misdiagnosed as more common entities, namely, lymph node enlargement and lymphangioma, respectively. The correct diagnosis was made only after surgical excision and histopathological examination. This case report is completed by a short review of embryogenic development, diagnostic procedures with differential diagnoses, and therapeutic outcome of ectopic thymus.

A congenital teratoma with a cleft palate: report of a case.

Teratomas are benign tumors containing cells from ectodermal, mesodermal and endodermal layers. They occur in about 1 in every 4000 births and most commonly in the sacrococcygeal region, followed by the ovaries. Congenital epignathus teratomas are rare embryological neoplasms localised in the region of head and neck. An epignathus is found in approximately 1:35,000 to 1:200,000 live births. This accounts for 2-9% of all teratomas. Size and location of the neoplasm in the oronasopharynx is variable. Teratomas are partly undiagnosed at the time of birth. They may exist with an intracranial extension or as small polyps. Large epignathi can lead to difficult management during and after birth. The case of a newborn girl with a combination of an epignathus and a cleft palate is described. The epignathus presented as a huge mass extending out of the mouth of the infant girl. On the day of birth debulking of the extraoral portion of the tumor, followed by intraoral exstirpation, was performed. The results of the histologic examination indicated a congenital epignathus. Six months later a recurrence was found.

Differences in the fatty acid composition of KB-cells and gingival keratinocytes is culture medium additive dependent.

The influence of culture medium additives foetal bovine serum (FBS), serum effective substitutes (SES) and human autologous serum on the fatty acid profile of KB-cells and human gingival keratinocytes was examined. The KB-cells were cultivated in RPMI medium added with FBS or SES and the gingival keratinocytes in D-MEM added with FBS or human autologous serum. Two days before the cells were prepared for gas chromatography (GC), the media were changed to serum- and antibiotic-free media. Whole fatty acids of the cells were analysed using GC and the fatty acid profiles were compared. KB-cells as well as gingival keratinocytes changed their fatty acid composition, according to the medium additive used. Significant differences were observed. In the case of KB-cells cultivated with SES the fatty acid changes suggest an increase of the membrane fluidity. Corresponding and significant differences were observed with gingival keratinocytes cultivated in medium added with human autologous serum: the membrane fluidity of the gingival keratinocytes was increased. It is supposed that an increased membrane fluidity caused by a different fatty acid spectrum of the host cell may relate to mechanisms of bacterial adhesion. Consequently, in vitro studies on invasion and adhesion of bacteria or virus are dependent on the medium used. Further analyses are necessary of the functional effects caused by differences in the content of specific FAs, especially with regard to the application of cultivated cells in the field of tissue engineering.

Bacterial colonization on different suture materials--a potential risk for intraoral dentoalveolar surgery.

In this in vivo and in vitro study on resorbable (Monocryl and nonresorbable (Deknalon) monofilament sutures used in intraoral dentoalveolar surgery the bacterial colonization was compared. For the in vivo study the sutures were applied in 11 patients during dental surgery. Eight days postoperative the sutures were removed and the adhered bacteria were isolated and identified by biochemistry, morphology, antibiotic susceptibility, and gas chromatography. The colonization was studied by scanning electron microscopy. Aerobic and anaerobic bacteria were isolated in nearly equal colony-forming units (cfu) on each suture. In comparison with Monocryl about 15% more aerobic and anaerobic strains were isolated on Deknalon. Regarding the pathogens only, about three times more anaerobic strains were isolated on both sutures in total. Additionally, more pathogens were found on Deknalon than on Monocryl (aerobic >40%, anaerobic >25%). The variety of bacteria correspond with purulent infections, not with normal oral flora. Intraindividual comparisons of cfu showed differences in dependence of the patient as described for subgingivale plaques. For the in vitro study the sutures were incubated with Streptococcus intermedius and Prevotella intermedia for 0.5 h. Scanning electron microscopy was performed to examine qualitatively the level of bacterial adherence. After 0.5 h the bacteria adhered very well. The colonization rate of Streptococcus intermedius on both sutures was similar. Coccoid bacteria within biofilms were seen. The growth of Prevotella intermedia was much better on Deknalon than on Monocryl. The risk of bacteremia at the time of suture removal is discussed.

Pathological mandibular fractures following third molar removal.

Seventeen patients, who presented mandibular fractures following third molar removal, were treated in the Department of Oral and Maxillofacial Surgery at the University Hospital Freiburg between 2000 and 2004. Clinical and radiological data were analysed to evaluate the possible risk of fracture following third molar removal. Our data show an increased rate of pathological mandibular fractures in males over 40 years of age, following removal of a difficult lower wisdom tooth with a high retention grade that necessitated bone removal. Fourteen out of 17 fractures occurred postoperatively. In six cases, no fracture was visible in radiographs during the primary investigation. Pathological mandibular fractures were typically located anterior to the mandibular angle (n=15). We recommend informing patients about possible risks and, in selective cases, a soft diet for up to 4 weeks after the operation. A cracking noise reported by the patient is the most important indication of a fracture. If, initially, the fracture is radiologically undetectable, we recommend the use of radiological controls.

Response of progressive fibromatosis to therapy with liposomal doxorubicin.

BACKGROUND: Patients with fibromatosis not amenable to surgery may suffer from high morbidity. Various chemotherapeutic regimens have been tried in these patients with limited success. Here, we report on the successful use of pegylated liposomal doxorubicin in the treatment of 4 patients with unresectable fibromatosis in unfavorable localizations. PATIENTS AND METHODS: 3 children and 1 adult with progressive fibromatosis were treated with 3-weekly cycles of chemotherapy with liposomal doxorubicin (dose range 20-50 mg/m2 per day every 21 days). Tumors were located at the nasal cavity, fossa infratemporalis, oral cavity, abdomen, and fossa supraclavicularis and were unresectable. 3 of the 4 patients had been heavily pretreated with various chemotherapeutic agents. Objective tumor response was monitored by magnetic resonance imaging and possible cardiotoxicity by echocardiography at regular intervals. RESULTS: A tumor response was obtained in all 4 patients. All patients showed normal cardiac function after completion of chemotherapy as evaluated by left ventricular shortening fraction. Severe neutropenia was not observed. CONCLUSION: Pegylated liposomal doxorubicin is a therapeutic option in patients with progressive unresectable fibromatosis in unfavorable localizations.

The titanium surface texture effects adherence and growth of human gingival keratinocytes and human maxillar osteoblast-like cells in vitro.

The adhesion, orientation and proliferation of human gingival epithelial cells and human maxillar osteoblast-like cells in primary and secondary culture were studied on glossy polished, sandblasted and plasma-sprayed titanium surfaces by scanning electron microscopy and in thin sections. The primary cultured explants of human gingival epithelial cells attached, spread and proliferated on all titanium surfaces with the greatest extension on the polished and the smallest extension on plasma-sprayed surfaces. In secondary suspension cultures of gingival keratinocytes, attachment spreading and growth was only observed on polished and plasma-sprayed surfaces, but not on sandblasted surfaces. Moreover, the attachment of these cells depended on the seeding concentration as well as on the coating with fetal calf serum. Cells on polished surfaces developed an extremely flat cell shape, but on sandblasted and plasma-sprayed surfaces a more cuboidal shape. In contrast human maxillar osteoblasts seeded as secondary suspension cultures attached very well to all three differently textured titanium surfaces and showed identical growth patterns independent of the titanium surface structure. These findings suggest that cell morphology, orientation, proliferation and adhesion of human gingival epithelial cells in primary or secondary culture are dependent on the texture of the titanium surface whereas no such differences were observed for maxillar osteoblast-like cells. In conclusion, the soft tissue integration and response is more influenced by the surface texture than the process of osseointegration.

Immunohistochemical study during healing of free palatal mucosa grafts on plastic-embedded samples.

This immunohistochemical study describes changes in the histology and in the distribution of the basement membrane components laminin and collagen IV as well as of the cytokeratins (CK)1/2/10/11, CK5/6, CK13, CK14, CK17, CK19 during the take of free split mucosa (epithelial and connective tissue) transplants in humans up to 36 months post-operative. Histology showed a flattening of the epithelial layer within the first 2 weeks after grafting, followed initially by an increase (25-30 layers, week 6) and later on by a decrease of cell layers in the epithelium (15-20 layers, week 20). From that time onwards, clear stratification and reteridges as signs of differentiation were present. Up to day 14 of graft take, the linear staining patterns for laminin and collagen IV were interrupted, which was not observed at any later stage. During this early interval CK5/6, CK1/2/10/11, CK14 and CK17 were expressed in all epithelial layers. The reactions for CK5/6 and CK1/2/10/11 were less intensive. At 6 weeks, CK1/2/10/11 stained the intermediate and superficial layers, being consistent with findings after longer graft take. CK5/6 reacted in the basal and intermediate cell layers, and CK13, CK14 and CK17 reacted in all layers. In the following period up to week 20, CK5/6 were found in the parabasal cells of the intermediate cell layers and the basal cells. CK14 staining was confined to these cell layers too, but also showed some reaction in the superficial layers. CK13 and CK17 were still bound to all layers. At 7 months post-operative, CK5/6 and CK14 were seen in their typical localisation in the basal cell layer and the parabasal cells of the intermediate layers, CK17 was seen mainly in the intermediate layer and CK13 was seen in focal areas of all layers. Anti-CK19 reacted only with single basal and parabasal cells up to week 20. These results suggest that during healing of mucosal autografts there is a sequence of changes in the expression of cell biological differentiation markers that may involve an epithelio-connective tissue interaction before the typical patterns for the donor side were observed again on the gingiva or mucosa of the hard palate.

[Optimized hemodilution with hydroxyethyl starch. A blood saving method in malocclusion operations]. / Optimierte Hämodilution (OHD) mit Hydroxyethylstärke. Ein Blut sparendes Verfahren bei Dysgnathieoperationen.

UNLABELLED: OPTIMIZED HEMODILUTION: To avoid blood transfusions, the method of optimized hemodilution (OHD) was developed. OHD consists of preoperative hypervolemic hemodilution with 500 ml hydroxyethyl starch (HES) and consecutive volume replacement with HES in the case of intraoperative intravasal fluid loss. This study verifies the efficacy of OHD. RESULTS: Mono- and bimaxillary operations (n = 213) performed between January 1995 and May 1999 were evaluated retrospectively with respect to reduction of blood transfusions due to application of OHD. The average blood loss in the OHD group (n = 127) was 593 ml, and no blood transfusion was required. In contrast, the control group (n = 86) showed an average blood loss of 738 ml, and 15% of these patients (n = 13) required transfusion of a total of 18 blood units. Based on our results, provision of autologous blood is only necessary for patients who do not receive OHD. The costs of fluid replacement and transfusion are increased by a factor of 5.7 when OHD is not used. DISCUSSION: OHD should be preferably used in cases of elective surgery on patients with good cardiopulmonary health. It is an easy to handle infusion regimen, which does not require additional monitoring, has no risk of infection, and results in a significant cost reduction.

The lateral upper arm free flap for intraoral reconstruction.

Twenty-three consecutive patients who were reconstructed with a lateral upper arm free flap (LUFF) were examined especially concerning functional and morphological results at the recipient and donor sites. There were 22 intraoral and one upper oesophageal reconstruction after radical laryngectomy. The LUFF rendered good functional and esthetic results except for one case of complete and one case of incomplete flap necrosis due to vascular insufficiency of the supplying vessel of the neck. There was some sensory deficit of the donor site (n=10), but no radial nerve injury or conspicuous scarring. Recipient site dehiscence occurred in two cases and a temporary orocervical fistula was seen in one case. Oral function was maintained due to the thin and pliable flap. Excellent flap adaptation to the adjacent tissue was obtained in eight cases of complete loss of lingual attached gingiva in the molar region and in four cases of loss of buccal attached gingiva. The success and functional results of LUFF were comparable to the results of 14 cases in which radial forearm free flaps (RFFF) were used. Although the length of the pedicle and the diameter of the vessels in LUFF are smaller than in RFFF, neither pedicle length nor vessel diameter proved to be a problem. Extent of scarring and risk of vascular compromise proved to be less as compared to RFFF. LUFF is, therefore, the flap of choice for intraoral soft tissue reconstruction and it is advised to reserve RFFF for cases in which LUFF fails.

Indications for computer-assisted treatment of cranio-maxillofacial tumors.

OBJECTIVE: Ablative tumor surgery requires detailed planning using computed tomography (CT) or magnetic resonance imaging (MRI). Reconstruction following tumor resection is dependent on reliable information for choosing the correct type and volume of grafts and predicting the outcome. This study evaluates the benefit of and the indications for computer-assisted surgery in the treatment of cranio-maxillofacial tumors. MATERIALS AND METHODS: Based on a CT or MRI data set, the STN Navigation System (Stryker-Leibinger) was used for preoperative planning, intraoperative navigation, and postoperative control of radical tumor resection and primary and secondary reconstruction. Tumor resection was preoperatively planned and intraoperatively navigated. Preoperatively, the required soft and hard tissue were measured using the mirrored data set of the unaffected side of the facial skeleton; the size and location of the graft were chosen virtually. Intraoperatively, contours of transplanted tissues were navigated in accordance with the preoperatively simulated reconstructive result. RESULTS: Computer-assisted treatment was successfully completed in all cases of radical tumor resection, and safety margins outlined preoperatively could be precisely controlled during tumor resection. Reconstruction was designed and performed exactly as virtually planned. CONCLUSIONS: Image-guided treatment improves preoperative planning by visualization of the individual anatomy and the intended reconstructive outcome, and by objectivation of the effect of adjuvant chemo-/radiotherapy. Intraoperative navigation makes radical tumor surgery more reliable by showing the determined safety margins, preserving vital structures, and guiding reconstruction to preplanned objectives.

[Mandibular osteomyelitis after mandibular conduction anesthesia]. / Unterkieferosteomyelitis nach Mandibularisleitungsanästhesie.

Several complications following a mandibular nerve block were reported in the literature. In some cases pterygomandibular abscess formation may be caused by mandibular needle injections. There is no report of odontogenic osteomyelitis of the ascending mandibular ramus in the literature. Here two patients with osteomyelitis of the ascending ramus following a mandibular nerve block injection are presented.

[Personality and profile-modifying operations: positive and negative markers]. / Persönlichkeit und profilverändernde Operationen: Positive und negative Merkmale.

In a prospective longitudinal study, 26 patients with facial-profile changes by surgery in the upper and/or lower jaw were evaluated concerning motivational factors and the outcome of surgery. Subjective criteria, i.e., expectations of surgery, social support and personality factors, are subject to the evaluation of the outcome. To reduce failure there should be a small amount of psychological screening in advance.

[Modifications in cultivating gingival keratinocytes]. / Modifikationen in der Kultivierung von Gingivakeratinozyten.

Gingival keratinocyte grafts are usually cultured using 3T3 mouse fibroblasts as feeder cells and fetal calf serum as growth factor. These additives entail risks due to xenogenic DNA and protein. Therefore the explant and the disperse culture technique free of feeder cells were compared, and autogenous human serum was tested. Twelve halved gingival biopsies were trypsinized and cultured as single-cell suspensions, the other halves were cultured as explants. Six halved biopsies were cultured in autogenous serum, the other halves in fetal calf serum. Growth, morphology and cell biological aspects were compared. The single-cell suspensions did not form a confluent epithelial layer, whereas all explants formed confluent primary gingival keratinocyte cultures. The keratinocytes' growth in autogenous serum was equivalent to that in fetal calf serum. Morphology and cytokeratin expression were identical. The explant technique combined with autogenous serum can be used for culturing gingival autografts as well as for individual cultures for special issues.

[Cultivation of gingival keratinocytes on permeable membranes: simulation of the function of mouth cavity epithelium]. / Kultivierung von Gingivakeratinozyten auf permeablen Membranen: Simulation der Funktion des Mundhöhlenepithels.

Cultured epithelial cells are used in in vitro studies. Gingival keratinocytes are usually grown adherent to the floor of the culture dish, whereby the basal side of the epithelium can not be approached. To be able to study barrier function and transepithelial transport processes the gingival keratinocytes were seeded on different permeable membranes as support material. Six primary keratinocyte cultures each using the explant technique were established on polycarbonate membranes with pore sizes 2-8 mm and on nylon. Secondary cultures were established accordingly as single-cell suspension. Primary cultures formed confluent epithelial cultures on all membranes tested, whereas in secondary culture confluent gingival keratinocyte epithelia were found on the polycarbonate membranes, only. Thus, gingival keratinocytes can be used to study barrier and transport functions in an in-vitro model.

[Passive and continuous temporomandibular movement--functional treatment after surgery of the temporomandibular joint (TMJ)]. / Mobilisation temporo-mandibulaire passive et continue--traitement fonctionnel après intervention sur l'articulation temporo-mandibulaire (A.T.M.).

Limited opening of the mouth after surgery of the TMA is often treated by various technical means that are often not appropriate for this function. More specifically, many devices only perform extension to ensure normal opening of the mouth. Until now we have been using the Toronto Medical automated mobilization splint in 21 patients. Passive and continuous extension of the masticatory muscles using this device is a very useful method to achieve normal opening of the mouth in patients suffering from fractures and abscesses. Although this cannot be achieved in patients with tumors and ankylosis, the distance between incisors can still be increased to four times its original value.

[Peripheral oxygen saturation during dental surgery with and without premedication]. / Periphere Sauerstoffsättigung bei zahnärztlich-chirurgischen Eingriffen mit und ohne Prämedikation.

83 adults undergoing dental surgical procedures in local anesthesia were monitored continuously with a pulse oximeter for hypoxemia. 30 patients received as premedication either a combination of a neuroleptic drug and an opiate or a benzodiazepine. There was a drop in the oxygen saturation in 80% of the patients with premedication but only in 66% of the patients without. There were statistical highly significant more periods of hypoxemia in patients with premedication compared to the others. (1548 periods versus 659 periods p less than 0.001). The kind of premedication/sedation does not influence the number of hypoxic episodes. We conclude that especially patients with premedication should only be treated by surgeons with sufficient clinical experience in coping with emergency situations.