Severe osteomyelitis following immediate placement of a dental implant.

Risk factors and complications in immediate implant placement are widely discussed. The present report describes a case of severe osteomyelitis as a serious complication after the immediate placement of a dental implant into an extraction socket of a 61-year-old woman. The course leads from initial treatment of recurrent perimandibular abscesses with surgical drainage and high-dose intravenous antibiotics to a refractory osteomyelitis. Hemimandibulectomy and partial mandibular reconstruction with a free fibular flap followed.

Volume-rendered three-dimensional spiral computed tomographic angiography as a planning tool for microsurgical reconstruction in patients who have had operations or radiotherapy for oropharyngeal cancer.

Three-dimensional spiral computed tomographic angiography (3D-SCTA) is a minimally invasive method of delineating vessels in three-dimensional detail. Our aim was to evaluate the clinical usefulness of volume-rendered three-dimensional SCTA for planning microsurgical reconstruction. Eighteen patients had a spiral computed tomogram (CT) of the extracranial carotid arteries. The volume rendering technique (VRT) was used to visualise the cervical vessels, and the three-dimensional SCTA images evaluated by a staff radiologist. Radiographic and operative findings were correlated in 13 of 18 patients. The anatomical and pathological alterations of vascular anatomy identified by three-dimensional SCTA correlated exactly with operative findings and led to a successful microsurgical reconstruction. Oropharyngeal reconstruction with microvascular free flaps requires accurate evaluation of the vascular system of the carotid arteries, and improves the accuracy of diagnostic decisions. Three-dimensional SCTA enables the surgeon to establish an appropriate treatment plan.

Electrical ear acupuncture reduces histamine-induced itch (alloknesis).

In order to assess an objective measure for the outcome of ear acupuncture, we evaluated the effect of electrical ear acupuncture on areas of histamine-induced alloknesis in 32 healthy volunteers. In a first assessment 5 min after histamine application on both volar forearms, 16 subjects received right ear and 16 left ear acupuncture. Immediately before and 5 min after acupuncture, alloknesis areas on both forearms were planimetrically evaluated. A second assessment was carried out 4 weeks later with the same patients. They underwent histamine application once more, but received no acupuncture. Alloknesis areas were then compared with reference to time, assessment and therapy side. Forearms relating to ipsilateral acupuncture showed significantly reduced or even no alloknesis areas after therapy. On the contralateral sides and during the "non-acupuncture" assessment 4 weeks later, alloknesis areas were significantly enlarged compared with sides ipsilateral to right and left ear acupuncture. Hence, results verify the effects of electrical ear acupuncture by objective measures.

The anterolateral thigh as a universal donor site for soft tissue reconstruction in maxillofacial surgery.

OBJECTIVE: The experience with 191 flaps from the anterolateral thigh is described with special regard to variations of vascular anatomy and possible flap designs. PATIENTS: Since 1992, 191 flaps from the anterolateral thigh donor site were used in 187 patients. The size of the defects varied from 3 x 5 cm to 21 x 10 cm, being located in nearly all areas of the head and neck region including the skull base. METHODS: The functional and aesthetic outcome was routinely evaluated during follow-up of the patients. All complications and secondary procedures were documented during the whole follow-up period ranging from 4 weeks to 11.2 years. RESULTS: Six different patterns of variations were observed concerning the flap pedicle, but none of these resulted in failure of flap raising except for two patients, in whom no perforators could be found. Poor functional results were observed in 17 patients, and debulking procedures or scar revisions were carried out in 58 of the 187 patients. Nine flap types reaching from voluminous and large myocutaneous flaps to ultra-thin cutaneous perforator flaps were used, enabling closure of virtually any type of soft tissue defect. Twelve flaps were lost, resulting in a success rate of 93.7%. CONCLUSION: Due to the combined advantages of minimal donor site morbidity, the option of simultaneous flaps and the satisfying results, the anterolateral thigh can be considered a universal donor site which is ideally suited for soft tissue reconstruction in cranio-maxillofacial surgery.

Microscopic changes in the condyle and disc in response to distraction osteogenesis of the minipig mandible.

PURPOSE: Unilateral mandibular distraction osteogenesis (DO) has been shown to cause gross changes in the mandibular condyle and articular disc. The purpose of this study was to correlate histologic findings with these gross changes in a minipig distraction model. MATERIALS AND METHODS: Semiburied distractors were placed via submandibular incisions in 15 minipigs. Two unoperated animals served as controls. The protocol consisted of 0-day latency and rates of 1, 2, or 4 mm/day for a 12-mm gap. After the minipigs were killed (at 0, 24, or 90 days), ipsilateral and contralateral condyles and discs were harvested, decalcified, prepared for standard paraffin embedding, and evaluated to determine changes in 1) morphology and thickness of the articular cartilage and subchondral bone and 2) morphology of the disc. RESULTS: In control animals, there were no degenerative changes in the articular cartilage and underlying condylar bone; there were no significant differences in the mean articular cartilage thickness. The temporomandibular joint discs were normal. In experimental animals, distracted condyles showed increasing degenerative changes and mean articular cartilage thickness as the DO rate increased. The discs were thinner. These changes were present, but to a lesser degree, in the contralateral condyles. After 90 days, degenerative changes in the condyles and discs were reduced, after remodeling, except in the 4 mm/day DO group. CONCLUSIONS: Histologic changes in the condyles and temporomandibular joint discs in response to mandibular DO correlated with previously reported gross changes. These changes were greater at higher distraction rates and remodeling back to normal occurred in mandibular condyles distracted at 1 mm/day.

Animal bite injuries to the head: 132 cases.

We made a retrospective study of the casenotes of 132 patients with bite injuries who were treated in the departments of craniomaxillofacial surgery in Berlin and Bochum university hospitals. Dogs caused most of the injuries (n=121, 92%) and the lips were most commonly involved. Nearly half the patients had superficial injuries. More than 70% of the patients presented to the clinic within 6h after the bite, and developed fewer wound infections than the patients who presented late. A total of 71 patients were given antibiotics for prophylaxis. Patients who were given amoxycillin with clavulanic acid developed no wound infections. Surgical management included cleansing and primary closure of the wound. Infected wounds were closed primarily after insertion of a drain. Wound cultures showed mainly streptococcus. We concluded that antibiotic prophylaxis is essential for several indications and the antibiotic of first choice is amoxycillin-clavulanic acid. Primary wound closure is an approved principle even in infected wounds.

Changes in the condyle and disc in response to distraction osteogenesis of the minipig mandible.

PURPOSE: Distraction osteogenesis (DO) is a commonly used technique for mandibular lengthening, but changes in the temporomandibular joint have not been well documented. The purpose of this study was to evaluate the effect of DO, at varying rates, on the mandibular condyle and articular disc. MATERIALS AND METHODS: Semiburied distractors were placed via submandibular incisions in 15 minipigs. Two unoperated animals served as controls. The protocol consisted of 0 day latency and rates of 1, 2, or 4 mm/d for a 12-mm gap. After the animals were killed (0, 24, or 90 days), ipsilateral and contralateral condyles and discs were harvested and evaluated to determine changes in 1) condylar form and size, 2) condylar surface, and 3) the articular disc. RESULTS: Articular surfaces of the condyles in control animals were smooth, with no irregularities or erosions. In animals undergoing distraction, ipsilateral condyles showed increasing changes in morphology and AP dimension, and surface contour irregularities as the DO rate increased. These changes were present, but to a lesser degree, in the contralateral condyles. Articular discs of both ipsilateral and contralateral sides showed variable thinning at the medial aspect at end DO. After 90 days, changes in the condyles and discs were reduced by remodeling except in the 4 mm/d DO groups. CONCLUSIONS: Results of this preliminary study indicate that gross changes occur in condyles and discs after unilateral mandibular DO. These changes are more severe at faster distraction rates (4 mm/d) and tend to resolve during neutral fixation when a rate of 1 mm/d is used.

Use of ultrasound to assess healing of a mandibular distraction wound.

PURPOSE: A standardized, noninvasive technique to assess healing of the mandibular distraction wound is not available. Current methods include clinical examination, plain radiography, and computed tomography. These imaging techniques are expensive and obligate the patient to serial radiation exposure. In addition, anatomic overlap and metal artifacts may obscure the distraction gap. In contrast, ultrasound has been shown to be a noninvasive, efficient, and inexpensive way to evaluate bone healing. The purpose of this study was to test the feasibility of ultrasound to evaluate an experimental mandibular distraction osteogenesis wound. MATERIALS AND METHODS: Distraction devices were placed via a submandibular incision into 24 minipigs. The protocol consisted of 0-day latency and distraction rates of 1, 2, or 4 mm/d for a 12-mm gap. The wounds were assessed in vivo after 0, 8, 16, and 24 days of neutral fixation. Ex vivo radiographs were used to estimate bone fill using a semiquantitative score. A semiquantitative ultrasound score was assigned, and the beam penetration depth was measured in millimeters. RESULTS: In all groups, clinical stability of the distraction wound increased with the duration of fixation. Plain radiographs, taken during neutral fixation, showed that the desired distraction gap was achieved and maintained. The ultrasound score increased with fixation time, whereas beam penetration depth decreased as expected. Ex vivo radiographs showed increasing bone fill score with time and paralleled the ultrasound score. CONCLUSIONS: The results of this feasibility study indicate that ultrasound is potentially useful for the assessment of bone formation in distraction osteogenesis wounds.

Functional gliding spaces of the dorsal side of the human hand.

The clinical and functional importance of gliding spaces of the hand (e.g., their role in the spread of infection or as a consideration in reconstructive surgery) has been repeatedly emphasized. However, only a few studies have provided details regarding the connective tissue spaces in the metacarpal region of the dorsal side of the human hand. The aim of the present study was to analyze the morphology and elucidate the anatomic relation of functional gliding spaces in the metacarpal region on the dorsal side of the human hand in order to provide a better understanding of function, and of clinical disorders and their treatment. To delineate these spaces we used a plastic (Acrifix 90) injection method. Twenty fixed and unfixed cadaver hands were subcutaneously injected with Acrifix 90 (a methacrylate) into the metacarpophalangeal transitional region and into the tendon sheaths of the extensor muscles. Different colors were used to distinguish one injected plastic solution from another. The spreading pattern of the injected medium was analyzed by careful dissection. To delineate the exact bordering structures and the topography of the injected spaces, two hands were plastinated using the E12/E6 technique (von Hagens et al., Anat Embryol 1987;175:411-421), and one hand was injected and embedded in Technovit 7100 for histological investigations. Injecting the plastic into the metacarpophalangeal transitional region of fingers II-IV in a disto-proximal direction, the solution spreads along the surface of the separate extensor tendons. It then coalesces 1-2 cm proximal to the injection points to form a continuous plastic plate, which protrudes between and on top of the previous injected tendon sheaths. In no case was a communication between the paratendinous tissue and the tendon sheaths observed. Laterally, the injected solution is delimited at the radial side of the extensor tendon of the second finger and at the ulnar side of the extensor tendon of the fourth finger. Using the described technique at the fifth finger yields a plastic plate that extends from the injection point to the tendon sheath. However, in two specimens a connection between the plastic injected into the tendon sheath of the fifth finger, and the distal injected solution was observed.