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The presence of ticks inside human constructions was evaluated in two localities from Colon province (Charco La Piedra and Espinar) and one from Panama province (Ancon, City of Panama). In two of houses, eight people from Charco La Piedra and one from Ancón reported “insect bites,” which produced blisters for several weeks. The investigation resulted in the collection of argasid ticks, which were identified by morphology and sequencing the 16 s ribosomal RNA gene, and later evaluated for the presence of relapsing fever Borrelia DNA. All ticks were identified as Ornithodoros puertoricensis . While spirochetal DNA was not detected by PCR in the ticks, our report highlights the potential for relapsing fever borreliosis in rural and urban localities in Panama. [ABSTRACT FROM AUTHOR]

Cluster headache (CH) is a debilitating, severe form of headache. A novel non-systemic therapy has been developed that produces therapeutic electrical stimulation to the sphenopalatine ganglion (SPG). A transoral surgical technique for inserting the Pulsante SPG Microstimulator into the pterygopalatine fossa (PPF) is presented herein. Technical aspects include detailed descriptions of the preoperative planning using computed tomography or cone beam computed tomography scans for presurgical digital microstimulator insertion into the patient-specific anatomy and intraoperative verification of microstimulator placement. Surgical aspects include techniques to insert the microstimulator into the proper midface location atraumatically. During the Pathway CH-1 and Pathway R-1 studies, 99 CH patients received an SPG microstimulator. Ninety-six had a microstimulator placed within the PPF during their initial procedure. Perioperative surgical sequelae included sensory disturbances, pain, and swelling. Follow-up procedures included placement of a second microstimulator on the opposite side ( n = 2), adjustment of the microstimulator lead location ( n = 13), re-placement after initial unsuccessful placement ( n = 1), and removal ( n = 5). This SPG microstimulator insertion procedure has sequelae comparable to other oral cavity procedures including tooth extractions, sinus surgery, and dental implant placement. Twenty-five of 29 subjects (86%) completing a self-assessment questionnaire indicated that the surgical effects were tolerable and 90% would make the same decision again. [ABSTRACT FROM AUTHOR]

Introduction The objective of this study was to determine whether postoperative control of the neurostimulator placement within the pterygopalatine fossa (PPF) by means of 3-dimensional (3D) cone beam computed tomography (CBCT) was of therapeutic relevance compared to intraoperative CBCT imaging alone. Material and methods Immediately after implantation of the sphenopalatine ganglion (SPG) neurostimulator, intraoperative CBCT datasets were generated in order to visualize the position of the probe within the PPF. Postoperatively, all patients received a CBCT for comparison with intraoperatively acquired radiographs. Results Twenty-four patients with cluster headache (CH) received an SPG neurostimulator. In 4 patients, postoperative CBCT images detected misplacement not found in intraoperative CBCT. In 3 cases, electrode tips were misplaced into the maxillary sinus and in 1 case into the apex of the PPF superior to the suspected location of the SPG. Immediate revision with successful repositioning within 3 days was done in 2 patients and a deferred reimplantation in 1 patient within 6 months. One patient declined revision. Conclusion We were able to demonstrate the clinical value of postoperative dental CBCT imaging with a wide region of interest (ROI) due to a superior image quality compared with that achieved with intraoperative medical CBCT. Although intraoperative 3D CBCT imaging of electrode placement is helpful in the acute surgical setting, resolution is, at present, too low to safely exclude misplacement, especially in the maxillary sinus. High-resolution postoperative dental CBCT allows rapid detection and revision of electrode misplacement, thereby avoiding readmission and recurrent tissue trauma. [ABSTRACT FROM AUTHOR]

Objective: To determine the diagnostic and predictive value of ultrasound and radioisotope scans of the thyroid, alone and in combination, during a single visit after initial referral by the screening laboratory with thyroid-stimulating hormone (TSH) elevation. Study design: Retrospective blind review of ultrasound and radioisotope images followed by final diagnosis based on clinical features, biochemistry, imaging, and molecular genetic study. Results: Infants (n = 97; 61 female) with median birthweight 3.38 kg (range 2.04-4.86) and gestation 40 weeks (range 33-42), underwent successful dual thyroid ultrasound and technetium-99m pertechnetate radioisotope scan in a single center. Combined scanning at the initial visit resulted in a correct final diagnosis in 79 of 97 (81%) cases. One patient was misdiagnosed initially as having athyreosis as the result of delayed radioisotope scan and the diagnosis of ectopia made later on diagnostic challenge. The specificity/sensitivity for radioisotope scan and for ultrasound was as follows: 100%/97% and 100%/55% for ectopia (n = 39); 81%/100% and 54%/100% for athyreosis (n = 18); and 89%/90% and 80%/95% for dyshormonogenesis (n = 20). Neither modality, alone or in combination, predicted final diagnosis in eutopic glands due to hypoplasia (n = 4), transient TSH elevation (n = 12), and status still uncertain (n = 4). Conclusion: More than 80% of newborn infants with TSH elevation can be diagnosed correctly on initial imaging with combined radioisotope scan and ultrasound. Ultrasound cannot reliably detect thyroid ectopia. Radioisotope scan, especially if performed late, may show no uptake despite the presence of a eutopic gland. [Copyright &y& Elsevier]

Abstract: Mortality is a rare but disastrous complication of microvascular head and neck reconstruction. The investigators attempt to identify the procedure-related mortality cases and analyse the causes of death. A retrospective analysis of 804 consecutive free flap procedures during a 19-year period was performed and fatal cases were identified (n =42 deaths). Multivariate logistic regression was employed to determine the association of in-hospital mortality with patient-related characteristics. The 30-day post-operative mortality rate was 1% (8 out of 804 patients), and the in-hospital mortality rate (post-operative deaths in-hospital before or after the 30th post-operative day without discharge) was 5.2% (42 out of 804 patients). Cancer recurrence and metastases related pneumonia were the most common causes of death (n =26, 62%), followed by cardiac, pulmonary, infectious and hepatic/renal aetiologies. Logistic regression analysis revealed that patients with stage IV disease and an operation time of >9h were significantly associated with post-operative mortality. Malignancy-related conditions were the most common causes of death following free flap transfer for head and neck reconstruction. For patients with stage IV head and neck cancer, this aggressive surgical approach should be cautiously justified due to its association with post-operative mortality. To shorten the operation time, experienced microsurgical operation teams are necessary. [Copyright &y& Elsevier]

Hyperthyrotropinaemia [mildly elevated thyrotropin (TSH) with normal thyroxine (T4) levels] demands a full assessment, including clinical examination, thyroid imaging and, where indicated, molecular genetic investigations. A male infant, both of whose parents were on T4 treatment, was referred at age 57 days with mild but persistent TSH elevation (12.7 mU/L) and normal free T4 (19.6 pmol/L), following notification by the screening laboratory of a capillary TSH of 10.7 mU/L (reference range, 1.7-9.1 mU/L) on day 8. Assessment showed a venous free T4 level of 15 pmol/L, venous TSH of 20.9 mU/L, serum thyroglobulin of 63 μg/L (reference range, <50 μg/L), and negative thyroglobulin and thyroid peroxidase antibodies. Thyroid ultrasound showed a eutopic, slightly small gland with heterogeneous texture; however, there was no uptake on radioisotope scan. Molecular genetic studies demonstrated a novel missense heterozygous mutation in the TSH receptor ( TSHR) gene (c.1169G>T;p.Cys390Phe) in the child, mother and maternal grandmother, but not in the father. The infant was treated with T4 but this was discontinued at age 3 years when repeat testing showed a free T4 of 16.7 pmol/L (reference range, 9-23 pmol/L) and TSH of 8.5 mU/L (reference range, 0.3-5.5 mU/L). A heterozygous TSHR mutation should be considered in the context of hyperthyrotropinaemia and reduced/absent uptake on radioisotope scan. Detection of this mutation has allowed our patient to discontinue T4 treatment for the moment, with a view to staying off treatment in the long-term. [ABSTRACT FROM AUTHOR]

Abstract: Quantitative analysis of surface modifications due to wear tests of a diamond-like carbon (DLC)-coated cylindrical steel test sample was carried out by atomic force microscopy and confocal microscopy. In order to get a reliable metrics for the quantitative assessment of surface modifications due to nano-wear, different surface texture parameters like arithmetic average roughness Sa, surface kurtosis Sku, surface skewness Ssk, and core roughness depth Sk were analysed. The results show that, after application of a Gaussian filter to reduce the influence of the underlying longer-range surface topography variations, the surface skewness parameter Ssk was the most sensitive and reliable parameter to indicate the very small wear modifications of the DLC-coated surface. Further studies were carried out to investigate the influence of pixel sampling distance, scanning area and scanning tip dimensions. [Copyright &y& Elsevier]

A 10-year old child born to consanguineous parents presented with an extremely large goiter, a low free T4 level and free T4 index, and normal TSH concentration. The findings of undetectable thyroglobulin (TG) and low free T4, and an elevated free T3/free T4 ratio suggested the possibility of a defect in TG synthesis. Noteworthy aspects of this case were the extremely elevated thyroidal radioiodide uptake despite a normal TSH concentration and the fact that the reduction in the size of her goiter only occurred when her TSH was suppressed below the normal range. Gene sequencing revealed that the patient was homozygous for a donor splice site mutation in intron 30 (IVS30+1G>C). Isolation of RNA obtained from the thyroid gland by fine needle aspiration and sequencing of the TG cDNA confirmed the prediction that exon 30 was skipped, resulting in an in-frame loss of 46 amino acids. [ABSTRACT FROM AUTHOR]

Abstract: This study analyzed the surgical outcome and complications of 1000 microvascular free flaps performed at the authors’ institution in Germany, between 1987 and 2010. 972 patients underwent reconstruction with 1000 flaps: 28% latissimus dorsi flaps, 27% radial forearm flaps, 20% iliac crest flaps, 12% fibula flaps, 6% jejunal flaps, 2% anterolateral thigh flaps, and 5% other flaps. 130 failures (7.6%) were encountered, including 58 complete flap failures (44.6%) and 72 partial free-flap failures (55.4%). This study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck, but it is essential that complications be recognized and addressed early in their course to prevent or minimize devastating consequences. Owing to the large number of possible errors in flap transplantation, microsurgeons should always check everything for themselves. The on-duty doctors and nursing staff should not be trusted blindly. Venous thrombosis and cervical haematoma are the most common complications at the recipient site and are mainly responsible for flap failure, while complications occurring at the donor site may result from dehiscence and graft necrosis. When a compromised flap is identified, surgical re-exploration should not be deferred. [Copyright &y& Elsevier]

Background: Pseudohypoparathyroidism (PHP) is characterized by hypocalcemia and hyperphosphatemia in association with an increased secretion of parathyroid hormone (PTH) due to decreased target tissue responsiveness to PTH. Patients with PHP type Ia are not only resistant to PTH, but also to other hormones that bind to receptors coupled to stimulatory G protein (Gsα). PHP Ia and Albright hereditary osteodystrophy (AHO) are caused by a reduced activity of the Gsα protein. Heterozygous inactivating Gs alpha ( GNAS) gene mutations have been identified in these patients. Methods: We studied a boy with PHP Ia. During follow-up the patient developed elevated liver enzyme serum levels and abdominal discomfort. Gsα activity was measured in erythrocyte membranes from the patient and the GNAS coding region of Gsα sequenced. Results: Gsα activity was reduced (62%) and molecular analysis revealed a new heterozygous GNAS gene mutation (D196N). Gallstones were diagnosed and cholecystectomy was performed. Biochemical analysis revealed cholesterol stones, a condition that was not reported before in PHP Ia. Conclusions: Cholesterol gallstones may rarely be associated with PHP Ia and should be taken into account. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: This study aimed to evaluate the use of intraoperative cone-beam computed tomography (CBCT) in monitoring the results of repositioning and osteosynthesis of condylar process and head (capitulum) fractures of the mandible to see if CBCT is beneficial for these patients. Patients and methods: Sixty patients (22 females and 38 males, age range 16–17 years, average 36.5 years) with condylar process and head fractures according to the classification of Spiessl and Schroll were treated during the study period. Thirty-four of the 60 patients received a CBCT scan immediately after surgical treatment under aseptic conditions. Results: In all 34 cases, intraoperative CBCT provided high-quality imaging of the condylar process in all three planes. In four patients (11.8%), unsatisfactory reposition or unexpected complications were detected which could immediately be corrected with a surgical revision. Conclusion: Intraoperative use of CBCT enables optimization of the surgical outcome for fractures of the condylar process and head of the mandible, reduces postoperative complications, and spares patients from repeated intervention. In addition, intraoperative CBCT enables safer treatment with minimally invasive approaches. [Copyright &y& Elsevier]

Summary: Purpose: The virtual environment of the Voxel-Man simulator that was originally designed for virtual surgical procedures of the middle ear has been adapted to intraoral procedures. To assess application of the simulator to dentistry, virtual apicectomies were chosen as the pilot-test model. Methods: A group of 53 dental students provided their impressions after virtual simulation of apicectomies in the Voxel-Man simulator. Results: Fifty-one of the 53 students recommended the virtual simulation as an additional modality in dental education. The students indicated that the force feedback (e.g. simulation of haptic pressure), spatial 3D perception, and image resolution of the simulator were sufficient for virtual training of dental surgical procedures. Conclusion: The feedback from dental students involved in this pilot-test has encouraged our interdisciplinary group to continue further development of the simulator with the goal of creating new training strategies in dental and medical education. [Copyright &y& Elsevier]

Hypothyroidism was documented by cordocentesis at 19 weeks in a fetus with non-immune goiter. Intra-amniotic thyroxine was injected at 25 weeks when amniotic fluid volume increased. Psychomotor outcome was normal. We argue that intra-amniotic thyroxine should not be used to treat the hypothyroidism but only to correct the development of polyhydramnios. [Copyright &y& Elsevier]

Malignant tumors in the oral cavity are relatively rare. About 5% of all malignant growths in the body are localized in the oral cavity. The vast majority of oral malignancies are primary tumors with squamous cell carcinoma being the most frequent and sarcomas occurring very seldom. Secondary tumors caused by hematogenous spread arising from a tumor localized elsewhere in the body are extremely rare. About 1% of all oral cancers are metastases to the jawbones and the surrounding soft tissues. Metastases to the jaws are mainly caused by malignant tumors of the breast, lung, kidney, bone, and colon. They occur in the late state of the disease and are regularly detected by staging examinations including scintigraphy. Even more rare are metastases into odontogenic cysts. Odontogenic cysts include dentigerous cysts, periapical or radicular cysts, and the keratocysts—nowadays declared as keratocystic odontogenic tumor. The incidence of odontogenic cysts is about 10% to 15% of all oral biopsies and therefore general dentists are frequently faced with these types of lesions. The aim of this study was to review the literature regarding metastasis into odontogenic cysts and to further highlight this rare entity with the help of a clinical case. [Copyright &y& Elsevier]

Purpose: The surgical approaches for the open treatment of condylar process fractures have been controversial. In our study, we evaluated the morbidity of the transparotid approach during 2 years of follow-up. Patients and Methods: A total of 48 patients with condylar process Class II and IV fractures according to classification of Spiessl and Schroll, were included in the present study. Of the 48 patients, 16 were female and 32 male. The patient age range was 16 to 79 years (average 36.52). All patients were treated using the transparotid approach, with rigid internal fixation using miniplates. Follow-up examinations were performed for a minimum of 6.5 months and a maximum of 25 months (average 12.16) after surgical treatment. At the follow-up examination, the patients completed the Mandibular Function Impairment Questionnaire, and the examiner completed the Helkimo index. X-rays taken before, directly after, and 6 months after surgery were compared. Results: None of our patients had problems with wound healing; 2 patients developed a fistula of the parotid gland; and 4 patients developed palsy of the facial nerve that was completely reversible after 6 weeks. The results of the Mandibular Function Impairment Questionnaire and the Helkimo index revealed only a few subjective and objective problems after 6 months. Conclusions: The transparotid approach to condylar process fractures is most appropriate for strongly displaced Class II fractures. Especially for very old patients with dementia, for whom maxillomandibular fixation is contraindicated, this approach is very appropriate. Another benefit to this type of patient is the short operating time, with an average of 45 minutes. [Copyright &y& Elsevier]

Summary: Purpose: The results of primary bone grafting in terms of initial cleft width, existence or absence of a lateral incisor and scar formation in the donor area are compared. Methods: After primary osteoplasty with calvarian bone at an average age of 24 months (4–56 months) radiographic assessment was carried out in 31 patients with 40 alveolar clefts. The bone formation in the grafted area was assessed using dental radiographs taken at 66 months on average (13–114 months) after primary bone grafting. According to the Abyholm classification patients were assigned to 4 groups (indices I–IV) with indices I and II being rated as a success. Results: We observed success (indices I and II) in 76% and poor results (index IV) in 14%. The causes for the poor results were an alveolar cleft width of 11–12mm in three cases, an extraction of a decayed deciduous tooth 17 months after bone grafting in one case and a traumatic transplant loss in another case. The non-existence of a lateral incisor and a broad cleft are related to poor results. Conclusion: Based on the results presented, primary bone grafting using calvarial bone seems to be a promising alternative in bridging narrow alveolar defects. This method allows early intervention at an age in which children do not recognize themselves as cleft patients. The preservation of the deciduous teeth is equally important regarding their functional stimulus for bone development. [Copyright &y& Elsevier]

The article highlights congenital hypothyroidism in Turkey, where it has a prevalence of one in 2,736 newborns that is caused by the dysgenesis of the thyroid gland. A defect in thyroid peroxidase (TPO) is seen in most dyshormonogenesis, which has 60 known different mutations. In the study conducted by the authors of three Turkish families, they found that there are two different mutations of the TPO gene and a later genotyping of the polymorphic markers revealed that the families share a common haplotype.

Abstract: Esophageal cancer related gene 1 (ECRG1) is a novel candidate tumor suppressor gene in human esophageal squamous cells. Overexpression of ECRG1 protein inhibits tumor cell proliferation. Genetic polymorphisms in coding sequences of the gene may cause functional alterations of the gene product and be associated with higher cancer risk and disease phenotypes. A single nucleotide polymorphism (SNP) (Arg290Gln) found in the coding region of ECRG1 might play a role in susceptibility to esophageal squamous cell carcinoma. This study examined SNPs in ECRG1 in a similar tumor type (oral squamous cell carcinoma; OSCC) and investigated the relationship between SNPs in ECRG1 and the clinical outcome of patients with OSCC. DNA samples of 137 OSCC patients were analyzed for SNP genotypes Arg/Arg, Arg/Gln and Gln/Gln in the coding region (exon 8) of ECRG1. SNP genotypes Arg/Arg were found in 70 (51%), Arg/Gln in 60 (43%) and Gln/Gln in 7 (5%) patients. There was no significant association between genotypes and survival (p =0.77) or relapse free survival (p =0.32). The Gln/Gln genotype had the best survival (not significant) probably due to rare cases of SNP Gln/Gln genotype. Genotype Arg/Arg might be a potential negative prognostic marker in OSCC, but more studies with higher patient numbers are required. [Copyright &y& Elsevier]

Summary: Purpose: The improvement of the ischaemic tolerance of myocutaneous flaps is of clinical importance and hence the subject of numerous investigations. Methods: In an attempt to increase the ischaemic tolerance, 20 myocutaneous flaps (rectus abdominis muscle) in pigs were elevated and perfused with various, established solutions prior to the onset of ischaemia. The flaps were elevated, utilizing the superior epigastric vessels as the pedicle. Ten flaps were flushed with the University of Wisconsin solution, five with the Euro-Collins solution and the last five with a Ringer-Lactate solution, prior to the 6h long, normothermic ischaemia. On the day of operation, the first, third, fifth, seventh and tenth postoperative day clincical examinations and thermography were performed as well as biopsies. Additionally, on the tenth postoperative day, the rate of necrosis was determined morphometrically as the average of three measurements. Results: Ten days after surgery, the flaps pretreated with the University of Wisconsin solution displayed a vital surface area of 89%, the Euro-Collins solution 23% and the Ringer-Lactate solution 14%. Histologically, muscle tissue proved to be more susceptible to ischaemia than skin. Conclusion: Regarding the rectus abdominis flap in a pig model, the University of Wisconsin solution proved superior in the prevention of ischaemic injury compared with the Euro-Collins solution and Ringer Lactate. In accordance with the literature, muscle tissue proved to be more susceptible to ischaemia than skin in our study. [Copyright &y& Elsevier]

Purpose: To describe the first clinical applications of intraoperative cone-beam computed tomography with an integrated flat-panel detector in oral and maxillofacial surgery after surgical treatment of zygomaticomaxillary complex fractures Patients and Methods: Nine cone-beam computed tomography datasets of patients with zygomaticomaxillary complex fractures were intraoperatively acquired using a mobile isocentric C-arm (PowerMobil; Siemens Medical Solutions, Erlangen, Germany), including a flat-panel detector. Datasets based on 400, 200, and 100 fluoroscopic images were performed with different tube currents (4.6 mA, 3.3 mA, 2.3 mA, 1.2 mA, and 0.5 mA) and a current tube voltage of 100 kV. Postprocessing resulted in 15 different datasets available for comparison with corresponding preoperative computed tomography datasets. Four oral and maxillofacial surgeons and 2 experienced radiologists evaluated each dataset regarding noise, transition, and the delimitation of landmarks. Results: All examinations were successfully performed. Reconstructed datasets showed high-resolution images of all midfacial osseous structures in near-computed tomography quality. Regarding high-contrast structures, detailed analyses of datasets acquired in this study suggest that the parameters 400 projections, 1.2 mA, and 100 kV are sufficient. In terms of soft-tissue visualization, a higher level of mA seems preferable. Conclusions: The tested prototype predicts a new era in cone-beam computed tomography imaging. The integration of a flat-panel detector will overcome the limitations of current available systems. The size of the field of view is increased allowing regularly the visualization of the whole facial skeleton. Particularly in cases of open reduction of unilateral fractures, the assessment of symmetry is of clinical value. [Copyright &y& Elsevier]

The article presents the results of a study on a German girl with congenital hypothyroidism due to a mutation in the thyroid peroxidase (TPO) gene who had elevated serum levels of thyroglobulin (Tg) during periods of hyperthyrotropinemia. The patient was found to have a novel homozygous mutation in the TPO gene which was sequenced directly from genomic DNA. The study concluded that the measurement of serum Tg level is helpful to differentiate developmental defects the thyroid gland from cases of thyroid dyshormonogenesis.

Purpose: This study investigated 3-dimensional (3D) imaging with intraoperative cone beam computed tomography (CBCT) in major mandibular reconstruction procedures. Patients and Methods: The study group was comprised of 125 patients (83 males, 42 females) admitted for surgical treatment of the mandible. The patients ranged in age from 3 months to 91 years (average age, 40.72 ± 22.843 years). Surgical procedures of the mandible were subdivided into repair of body fractures (17 patients), angle fractures (21 patients), condylar fractures (14 patients), and multiple fractures (30 patient). In addition, the study group included 21 patients undergoing orthognatic surgery and 22 undergoing reconstructive surgery on the mandible. Intraoperatively, 3D images were generated with a mobile CBCT scanner (Arcadis Orbic 3D; Siemens Medical Solutions, Erlangen, Germany). Results: During open reduction of mandibular fractures, not all fracture sites can be readily exposed for direct visual control. For example, the lingual cortical bone of the mandible is difficult to assess intraoperatively. This structure and others can be effectively visualized using the 3D mode of CBCT. Furthermore, screw placement can be evaluated, specifically in insertions near the alveolar nerve. The intraoperative acquisition of the data sets is uncomplicated, and the image quality is sufficient to allow evaluation of the postoperative result in all cases. Conclusion: Intraoperative CBCT has proven to be a reliable imaging technique for providing visual control during major mandibular procedures. [Copyright &y& Elsevier]

Purpose: Since the first harvesting of a microsurgical fibula in 1974 by Ueba and in 1975 by Taylor, using the fibula for osseous reconstruction has proven to be a valuable approach. The harvesting technique, which has been refined by subsequent investigators, has become increasingly standardized, today providing a clear, reproducible method. The procedure involves elevating the fibular graft from lateral, choosing the shortest route to reach the fibula. One disadvantage of this approach is that the bone often obstructs visualization of the vascular pedicle, which lies medially, promoting unintentional injury. In addition, this method is associated with some donor site morbidity, prompting further investigations into accessing the fibula. Here we present an alternative approach for harvesting the fibula and highlight the pros and cons of each approach. Patients and Methods: Between 1999 and 2006, a total of 38 microsurgical (23 for the mandible, 9 for the extremities, and 6 for the maxilla) fibula grafts were harvested through the medial approach. Results: In all cases, the patency of the posterior tibial, peroneal vessels, and the tibial nerve could be visualized. Two flaps failed (both mandible, for a success rate of 94.7%). No ischemic or wound healing complications of the lower limb were observed. Conclusions: The medial approach for harvesting the fibula is a feasible alternative to the lateral approach and provides the surgeon with a comparable likelihood of success. If for some reason access from the lateral approach is contraindicated, then the medial route should be considered. [Copyright &y& Elsevier]

Abstract: The use of a combination of intraoperative cone-beam computed tomography (CBCT) and a navigation system via a spinal software platform for the navigated implantation of oral implants after microsurgical bone transfer is described. Intraoperative data sets were generated using Arcadis Orbic 3D (Siemens, Medical Solutions, Erlangen, Germany) and immediately transferred to the VectorVision2 navigation system (BrainLAB, Feldkirchen, Germany) via the NaviLink interface. In two patients who underwent microsurgical bone transfer for midfacial reconstruction, implants were placed using intraoperatively acquired CBCT data sets for planning and navigated insertion. In both cases, successful realization of the planned implant sites was achieved by the guidance of the drill, leading to rehabilitation of both patients. CBCT data generated by mobile systems are sufficient for the planning of implant position, and can be used for navigated insertion using tools originally developed for spinal surgery. [Copyright &y& Elsevier]

Objective: The aim of this study was to evaluate soft tissue image quality of a mobile cone-beam computed tomography (CBCT) scanner with an integrated flat-panel detector. Study design: Eight fresh human cadavers were used in this study. For evaluation of soft tissue visualization, CBCT data sets and corresponding computed tomography (CT) and magnetic resonance imaging (MRI) data sets were acquired. Evaluation was performed with the help of 10 defined cervical anatomical structures. Results: The statistical analysis of the scoring results of 3 examiners revealed the CBCT images to be of inferior quality regarding the visualization of most of the predefined structures. Visualization without a significant difference was found regarding the demarcation of the vertebral bodies and the pyramidal cartilages, the arteriosclerosis of the carotids (compared with CT), and the laryngeal skeleton (compared with MRI). Regarding arteriosclerosis of the carotids compared with MRI, CBCT proved to be superior. Conclusions: The integration of a flat-panel detector improves soft tissue visualization using a mobile CBCT scanner. [Copyright &y& Elsevier]

Summary: Introduction: This retrospective study was intended to determine the incidence and causes of postoperative complications in patients following head and neck reconstruction using microvascular free flaps. Patients and methods: A total of 202 consecutive microvascular free flaps were performed for reconstruction of the head and neck by the same surgeon, 85% of the defects arose following the treatment of malignancies. Flap donor sites included latissimus-dorsi flap (n=83), radial forearm (n=35), fibula (n=31), iliac crest (n=36), TRAM flap (n=3), groin flap (n=l), jejunal flap (n=13). The incidence of postoperative complications and patient-related characteristics (age, sex, diagnosis, comorbidity level, operation duration, defect site, history of radiotherapy/chemotherapy) were retrospectively analyzed. Results: Free flaps proved to be extremely reliable, with a 2.9% incidence of free flap failure. Postoperative medical complications occurred in 11.4% of cases, with cardiac, pulmonary and infectious complications predominating. Conclusion: The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of postoperative complications is related to the preoperative comorbidity. [Copyright &y& Elsevier]

Summary: Mammary tumour samples (11 surgical and five post-mortem) from 16 adult European hedgehogs submitted between 1980 and 2004 were examined. Histologically, the tumours were classified as simple tubulo-papillary carcinomas with local invasive growth. In six cases, tumour cell emboli were present in blood vessels or lymphatic vessels, or both. However, metastasis to regional lymph nodes was found only in one hedgehog. Malignant neoplastic epithelial cells were immunolabelled by antibodies specific for various cytokeratins (CKs), including CK1–8, 10, 13–16, 19 and 20. CK expression did not differ from that in normal mammary gland tissue. CK20 was expressed in the mammary tissue of hedgehogs, in contrast to that of dogs and cats; CK7 immunolabelling, however, which commonly occurs in mammary epithelial cells, was negative. CK20 expression, together with the lack of CK7 as determined by a protein-specific antibody, represented an important difference from the CK profile shown by mammary epithelial cells of other mammalian species, including the dog and cat. [Copyright &y& Elsevier]

Abstract: The aim of this study was to test a previously described training tool for ultrasound for use as a first-line imaging modality. Navigated sonography was performed in 10 patients with midfacial fractures diagnosed using computed tomography (CT). One examiner ranked his sonographic findings regarding the presence of a fracture on six predefined anatomic landmarks on a scale from 1 to 5. These results were correlated with CT findings by displaying fused images. In all but three patients fractures were correctly identified using sonography. In the remaining three patients the examiner was unable to determine whether a fracture was present or not. Normally, these patients would have been subjected to conventional radiographs. Ultrasound proved to be a reliable first-line imaging modality for the investigation of suspected midfacial fractures in daily clinical practice, resulting in decreased radiation exposure since conventional radiographs are omitted. According to this algorithm, patients with sonographically confirmed midfacial fractures are examined for surgical planning using cone-beam CT. [Copyright &y& Elsevier]

Abstract: Selective reduction of bone without collateral damage (nerves, teeth) is essential in apicectomy. To test whether skills acquired on a virtual apicectomy simulator (VOXEL-MAN system with integrated force-feedback) are transferable from virtual to physical reality, two groups of trainees were compared. Group 1 received computer-based virtual surgical training before performing an apicectomy in a pig cadaver model. The probability of preserving vital neighboring structures was improved significantly, i.e. six-fold, after virtual surgical training (P <0.001). The average volume of the bony defects created by the trainees of Group 2 (mean: 0.47ml) was significantly (P <0.001) larger than by the trainees of Group 1 (mean: 0.25ml). Most importantly, the ability to objectively self-assess performance was significantly improved after virtual training. Training with a virtual apicectomy simulator appears to be effective, and the skills acquired are transferable to physical reality. [Copyright &y& Elsevier]

Objectives: Intraoperative cone-beam computerized tomography (CBCT) imaging has been introduced in oral and maxillofacial surgery. Using midfacial fractures as the pioneer model, this study describes the spectrum of further promising clinical indications for intraoperative CBCT and a clinical combination with intraoperative navigation. Study design: One hundred seventy-nine patients admitted for surgical treatment of the facial skeleton were included in the study. Intraoperatively, 3-dimensional images were generated with the mobile CBCT scanner Arcadis Orbic 3D, obtained from Siemens Medical Solutions, in a variety of indications. Results: The acquisition of the data sets was uncomplicated, and image quality was sufficient to assess the postoperative result in all cases. In the example of a facial gunshot injury, a navigation system for intraoperative localization of the metal foreign bodies was used. [Copyright &y& Elsevier]

PURPOSE: This retrospective study was performed to compare the bone resorption rates of revascularized free fibular flaps with those of avascular fibular bone grafts. Special attention was drawn to horizontal bone resorption. PATIENTS AND METHODS: One hundred twelve patients who had received fibular grafts for reconstruction of the mandible were included in this study. Surgery was performed between 1991 and 2004, leading to a follow-up of 12 to 140 months. In 7 cases, microvascular onlay grafts (group A), and in 61 cases, microvascular reconstruction of segmental defects (group B) were performed. Avascular onlay grafts were applied (group C) in 41 patients and avascular reconstruction of segmental defects (group D) was performed in 7 patients. Bone heights were measured on panoramic views at 1, 3, and 7 years postoperatively. RESULTS: Most of the resorption in group B occurred during the first postoperative year, at an average rate of 16% (range, 3% to 30%). After the first year, transplants became almost stable, and an average of 80% of bone height was maintained after 7 years. Conversely, bone resorption continued regularly in group C, and up to an average of 51% (range, 5% to 80%) of bone height was lost after 7 years postoperatively. CONCLUSION: After mandibular reconstruction with fibular transplants, resorption occurs among both microsurgical and free grafts; however, the bone resorption rate was higher among avascular grafts. In group A and B patients, fibular grafts became stable after 1 year, but bone resorption continued at a regular rate in groups C and D.Copyright © 2007 by the American Association of Oral and Maxillofacial Surgeons [ABSTRACT FROM AUTHOR]