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The purpose of this proof-of-principle study was to develop a rapid and approachable method to analyse bone resection margins in patients with oral squamous cell carcinoma (OSCC) in an intraoperative setting, similar to assessing frozen sections of soft tissue. Bone excision and risk of remaining tumour cells could be minimised, thus improving reconstruction measures and facilitating convalescence. Frozen, sawed wafers of porcine bone artificially combined with porcine skin (simulating OSCC properties) were used to develop and evaluate a new molecular method: protein transfer from non-decalcified, sawed wafers onto a membrane stained by immunofluorescence (Tissue-ProtTrans). Tissue-ProtTrans was based on the detection of keratin 5/6 as a marker of tumour cells. The results were compared to standard immunohistochemistry (IHC) and H&E results of the same wafers after decalcification. Tissue-ProtTrans resulted in a total assay time of 3.5 h using the Trans-Blot ® Turbo™ Transfer System (Bio-Rad) for protein transfer. Amersham Protran ® Premium Nitrocellulose Membranes 0.2 µm (GE Healthcare) were stained with a primary antibody to keratin 5/6 (Dako Agilent) and a secondary antibody labelled with IRDye ® 800CW (LI-COR). Visualisation was performed with an infrared laser scanner (Odyssey). Upon comparison, five independent experiments on porcine specimens processed with the Tissue-ProtTrans showed similar results to standard IHC and H&E analysis. In comparison to standard IHC results (requiring several days due to decalcification) Tissue-ProtTrans provided similar results, but was much faster (3.5 h). This highly promising method has good potential for further time reduction and will be suitable for intraoperative assessment.

Purpose: The adequate perioperative antibiotic prophylaxis in maxillofacial surgery is still under discussion due to the wide range of hard and soft tissue procedures as well as contaminated, semi-contaminated and clean surgical sides. Perioperative antibiosis is an easy applicable tool that can be used to decrease nosocomial morbidity and mortality by reducing the rate of infections. We compared strictly perioperative antibiosis with an extended postoperative prophylactic antibiosis., Materials and Methods: In this study, 901 consecutive patients, from a tertiary care maxillofacial surgery department were included and distributed into two groups: The first group received peri- and postoperative antibiotic prophylaxis (PP; n = 365) from the day of operation until the fifth day postoperatively. The second group was treated with single shot prophylaxis with intraoperative repetition as needed (SSP; n = 536) only. Furthermore, the patients were grouped according to their main diagnosis and surgical procedure. For comparison, general anamnestic data, cultured bacteria and resistances, number of surgical site infections and duration of hospitalization were compared., Results: There were no statistically significant differences in general diseases or extent of surgery between the groups. There was no statistical difference in the surgical site infections between the groups regardless of their diagnosis. There were significant correlations between tracheotomised patients (p < 0.001) as well as patients with a higher BMI (p = 0.009) and the incidence of surgical site infections. Most common cultured bacteria were staphylococci., Conclusion: Based on the findings of the study, we believe that a perioperative antibiosis delivers a sufficient prophylaxis for patients undergoing maxillofacial surgery procedures.

Numerous in vivo, in vitro and clinical studies report on beneficial effects of strontium with respect to increased bone growth. Based on this knowledge the aim of this study was to evaluate early and late osseointegration stages of functionalized titanium implants showing sustained release of strontium (Sr) and further investigate its potential systemic effect. Strontium functionalized (Ti-Sr-O) and Grade 4 (Control) titanium implants were inserted in the femoral condyle of New Zealand White rabbits. The Ti-Sr-O coating was characterized using Scanning Electron Microscopy (SEM) and Energy Dispersive X-ray Spectrometry (EDX) for structure, coating thickness and chemical composition. Inductively Coupled Plasma Atomic Emission Spectrometry (ICP-AES) was used to evaluate released strontium in vitro while Atomic Absorption Spectrometry (AAS) was utilized to monitor serum levels of strontium and calcium. Additionally, histological and tomographic analysis of bone-to-implant contact (BIC%) and bone formation (BF%) was performed, following implantation periods of two or twelve weeks, respectively. Median values for BIC% for Ti-Sr-O revealed significant differences within the two- and twelve-week observation periods, while exceeding BF% was discovered especially after twelve weeks when performing the histological evaluation. The results from the micro-computed tomography (µ-CT) showed no significant differences, when comparing the experimental groups. AAS measurements did not indicate a systemic effect by the local strontium release. Within the limitations of the study, it was shown that a Ti-Sr-O coating with sustained release characteristics of strontium, accelerates bone apposition and represents a potential potent surface modification for endosseous medical implant devices., Statement of Significance: This study presents first data with respect to early and late in vivo response on a strontium functionalized titanium surface comprising a nanotopography manufactured by a magnetron sputtering process. We investigated different osseointegration stages of screw-shaped implants with dental implant geometries in a rabbit femur model observing beneficial effects of the functionalized surface on bone-to-implant contact and bone formation caused by tailored release of the bone anabolic strontium. Histomorphometrical data revealed that a functionalized titanium surface with controlled liberation of strontium accelerates osseointegration while spectrometry measurements did not indicate a potential systemic effect of this osteoinductive agent and could thus have impact on modifications of medical implant devices., (Copyright © 2018 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Aim: Frequently general anaesthesia (GA) is used to treat noncompliant children. Especially in children with morbid diseases general anaesthesia can be a challenging procedure for anaesthetists. The aim of this paper was to evaluate the risks and adverse reactions with a special focus on the impact of existing medication conditions and syndromes., Materials and Methods: and methods Records of children up to 10 years of age, who were admitted for paediatric dentistry procedures under GA from January 2011 to December 2016 at the University Hospital of the University of Aachen (Germany), were reviewed. A special attention was paid to the intra- and perioperative critical adverse reactions and concomitant systemic conditions and their impact on treatment outcome., Results: Two hundred and twenty patients were admitted for dental restorations. Critical adverse reactions occurred in 4% of the treated patients and they were statistically significantly (p=0.004) related to the ASA classification above II. The use of a laryngeal mask airway was significantly associated (p<0.001) with a shorter duration of surgery. Most common concomitant medical conditions were congenital heart disease, mental retardation and inherited syndromes., Conclusion: Although the administration of general anaesthesia in infants and children can be regarded as a safe procedure, clinically significant adverse reactions can occur, especially in patients with an existing medical condition.

Introduction: Tracheotomy is a frequent procedure in extended head and neck cancer surgery and known to be a risk factor for prolonged hospitalization. The authors hypothesized that the clinical course and delayed decannulation of patients are not only influenced by airway narrowing, but also by a compromised postoperative swallowing function., Material and Methods: The investigators implemented a retrospective cohort study. The sample was composed of a tertiary care center patients who underwent major head and neck cancer surgery, each receiving a tracheostomy. Data collected include general clinical data as well as endoscopical evaluation of swallowing function and aspiration rate. Descriptive and bivariate statistics were computed and the P value was set at.05., Results: The sample was composed of 96 patients with an average age of 64.2 and sex ratio of 1.4:1 (m:f). There was a strong statistically significant relation between swallowing function and timing of decannulation (P < 0.001) and duration of hospitalization (P < 0.001). Age (P = 0.55), sex (P = 0.54), tumor size (P = 0.12), general diseases (P = 0.24), distant metastases (P = 0.15), or extent of neck dissection (P = 0.15) were not significantly associated to swallowing function. Permanent cannulation was significantly correlated to a primary cancer of the soft palate or base of the tonge (P < 0.001)., Conclusion: The results of this study confirm the importance of the evaluation of swallowing function before the removal of the tracheotomy cannula in head and neck cancer patients.

Background: Alveolar cleft repair is performed via bone grafting procedure to restore the dental arch continuity. A suitable bone substitute materials should possess osteoinductive and osteoconductive properties, to promote new bone formation, along with a slowly resorbable scaffold that is subsequently replaced with functionally viable bone. Calcium phosphate biomaterials have long proved their efficacy as bone replacement materials. Dentin in several forms has also demonstrated its possibility to be used as bone graft replacement material in several studies. The purpose of this study was to evaluate bone regeneration pattern and quantify bone formation after grafting pre-established experimental alveolar clefts defects model in rabbits using composite xenogenic dentin and β-TCP in comparison to β-TCP alone., Methods: Unilateral alveolar cleft defects were created in 16 New Zealand rabbits according to previously described methodology. Alveolar clefts were allowed 8 weeks healing period. 8 defects were filled with β-TCP, whereas 8 defects filled with composite xenogenic dentin with β-TCP. Bone regeneration of the healed defects was compared at the 8 weeks after intervention. Quantification of bone formation was analyzed using micro-computed tomography (µCT) and histomorphometric analysis., Results: µCT and histomorphometric analysis revealed that defects filled with composite dentin/β-TCP showed statistically higher bone volume fraction, bone mineral density and percentage residual graft volume when compared to β-TCP alone. An improved surgical handling of the composite dentin/β-TCP graft was also noted., Conclusions: Composite xenogenic dentin/β-TCP putty expresses enhanced bone regeneration compared to β-TCP alone in the reconstruction of rabbit alveolar clefts defects.

Background: Chronic alcohol consumption is a known limiting factor for bone healing. One promising strategy to improve bone augmentation techniques with Bio-Oss ® in oral and maxillofacial surgery might be the supportive application of platelet-concentrated biomaterials as platelet-released growth factor (PRGF). To address this matter, we performed an in vitro study investigating the protective effects of PRGF and Bio-Oss ® in ethanol (EtOH) treated osteoblasts., Methods: The SAOS-2 osteosarcoma cell line, with and without EtOH pretreatment was used. The cell viability, proliferation and alkali phosphatase activity (ALP) after application of 0%, 5% and 10% PRGF and Bio-Oss ® were assessed., Results: The application of PRGF and Bio-Oss ® in EtOH impaired osteoblasts showed a significant beneficial influence increasing the viability of the osteoblasts in cell culture. The synergistic effect of Bio-Oss ® and 5% PRGF on the proliferation of osteoblasts was also demonstrated. Bio-Oss ® only in combination with PRGF increases the alkaline phosphatase (ALP) activity in EtOH pretreated cells., Conclusions: These results indicate that the simultaneous application of PRGF and Bio-Oss ® inhibits EtOH induced bone healing impairment. Furthermore, in the cells, PRGF induced a protective mechanism which might promote bone regeneration., (Copyright © 2017 Elsevier GmbH. All rights reserved.)

Objectives: The adequate perioperative antibiotic prophylaxis in head and neck cancer surgery is an important and easy applicable tool to decrease nosocomial morbidity and mortality by reducing the rate of infections. In the study a strictly perioperative antibiosis is compared with an extended postoperative prophylactic antibiosis. We aim to clarify the value of postoperative prophylactic antibiosis for the recovery and clinical course of patients., Material and Methods: In this prospective study 75 consecutive patients, who underwent major oncological head and neck surgery were included and divided in three groups, each containing 25 patients. The first group received peri- and postoperative antibiotic prophylaxis (POAP) from the day of operation until the fifth day postoperatively. The second group was treated with perioperative antibiotic prophylaxis (PEAP) only. The third group received perioperative antibiotic prophylaxis and increased local antiseptic care (PAPAC). General anamnestic data was collected, as well as duration of hospitalisation, stay on intensive care unit, rate and type of infections, surgical closure of the tracheostomy, and postoperative blood parameters., Results: There were no statistically significant differences in general diseases or extent of surgery between the groups. There were statistically significant fewer patients suffering from surgical site infections in subjects with POAP (n = 1) in comparison to PEAP (n = 9; p = 0.011) and PAPAC (n = 9; p = 0.011). In contrast, other nosocomial infections (pneumonia, urinary tract infection, sepsis) did not decrease under a prolonged antibiotic prophylaxis., Conclusion: Based on findings of the study, we recommend an extended postoperative antibiotic prophylaxis for patients undergoing major oncological head and neck surgery., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The anterior lateral thigh flap (ALT) has become increasingly important in reconstructive surgery in the head and neck region. To cope with the problem of anatomical variability in the supplying blood vessels, preoperative evaluation is desirable. Purpose of the study is to compare the most commonly used Doppler devices Handheld Doppler (HD) and Color Doppler Ultrasonography (CDU) for their clinical reliability., Methods: Forty five consecutive head and neck cancer patients (mean age 66.0 ± 11.2 years) were included in the study. They all underwent a reconstruction via ALT flap for a defect in the head and neck area. Study period ranged from May 2014 to August 2015. We preoperatively conducted HD and CDU on the lateral thigh and compared the intraoperative findings by measuring presence of the perforator and distance to the estimated position., Results: There were 95 perforators identified in 45 patients. The sensitivity and positive predictive value (PPV) were calculated as 97.9% and 100% for CDU and 90.5% and 80.4% for HD, respectively. Accuracy was significantly greater with the HD compared to the CDU device (P < 0.001) and was strongly associated with body mass index (BMI) (P < 0.001). This effect was stronger in HD than in CDU (r = 0.800; P < 0.001 versus r = 0.673; P < 0.001)., Conclusions: Our results indicate CDU is more precise and reliable than HD with respect to detecting the anatomical position of perforating arteries. © 2017 Wiley Periodicals, Inc. Microsurgery 37:388-393, 2017., (© 2017 Wiley Periodicals, Inc.)

Objectives: The purpose of the present study was to develop an animal model for creating alveolar cleft defects with properly simulated clinical defect environment for tissue-engineered bone-substitute materials testing without compromising the health of the animal. Cleft creation surgery was aimed at creating a complete alveolar cleft with a wide bone defect with an epithelial lining (oral mucosa) overlying the cleft defect., Methods: A postmortem skull of a New Zealand White (NZW) rabbit skull (Oryctolagus cuniculus) underwent an osteological and imaging survey. A pilot postmortem surgery was conducted to confirm the feasability of a surgical procedure and the defect was also radiologically confirmed and illustrated with micro-computed tomography. Then, a surgical in vivo model was tested and evaluated in 16 (n = 16) 8-week-old NZW rabbits to create in vivo alveolar cleft creation surgery., Results: Clinical examination and imaging analysis 8 weeks after cleft creation surgery revealed the establishment of a wide skeletal defect extending to the nasal mucosa simulating alveolar clefts in all of the rabbits., Conclusions: Our surgical technique was successful in creating a sizable and predictable model for bone grafting material testing. The model allows for simulating the cleft site environment and can be used to evaluate various bone grafting materials in regard to efficacy of osteogenesis and healing potential without compromising the health of the animal.

Objective: Patient specific implants have been used for the reconstruction of large skull bone defects. Several therapeutic effects have been suggested in current literature but were never objectified. The aim of the current study was to evaluate the change in quality of life, pain, aesthetics, and the surgical and medical outcomes after reconstruction of large skull bone defects with titanium or polyetheretherketone (PEEK) implants., Methods: We retrospectively evaluated 29 consecutive patients receiving a patient specific skull implant between November 2004 and December 2015. Twenty-one patients received PEEK implants and eight received titanium implants. Data was acquired regarding quality of life, aesthetics, pain, demographics and complications. Quality of life was measured using the Glasgow Benefit Inventory (GBI). Additional questions were asked concerning pain, satisfaction and aesthetics., Results: The mean total GBI-score was +26.1 (95%CI 16.8-35.4, p < 0.001). Headache complaints or pain in the operation site improved in 75.0% and 77.8% of these patients, respectively. In 8.0% an increase was seen with regard to both variables., Conclusion: Reconstruction of skull bone defects with PEEK and titanium patient specific implants gave a statistically significant improvement in quality of life. Furthermore, it decreased pain and headaches and gave aesthetically good results., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: In this study is investigated if bundling of two scanners leads to better accuracy in recording faces than a standard face-scanning device., Material and Methods: In a group of 28 volunteers, two test specimens were attached to their faces: one on their forehead and one turned 90° on their cheek. Each volunteer was scanned by FaceScan3D ® and two bundled Artec EVA ® scanners. The scans were aligned to a three-dimensional model of the test specimen, and the mean error was recorded. Length, width and angles between the test specimen's planes were compared., Results: The mean deviation is significantly lower for the cheek test specimen in alignment (P < 0.001), length and width (P < 0.001) but not for the forehead test specimen in alignment and length and width (P > 0.05) using FaceScan3D ® . The aberration from the original angle between two sides of the test specimen is significantly lower measured with Artec EVA ® for the angle between the front and the bottom plane of both test specimens (P < 0.01). Besides the angle between the right plane and the bottom plane as well as the top plane of the test specimen mounted to the cheek, the deviation of the angle between the other side planes to each other is significantly lower (P > 0.05) scanned with Artec EVA ® ., Conclusions: Compared to FaceScan3D ® , two bundled Artec EVA ® scanners provide different accuracies depending on the location of the measured parameters. The accuracy measured for both scanners is inside the range found in the literature.

The anterolateral thigh flap (ALT) is often used to reconstruct the head and neck and depends on one or more skin perforators, which often present with variable anatomy. The aim of this study was to localise and evaluate the precise position of these perforators preoperatively with colour Doppler duplex ultrasound scanning (US). We detected 74 perforators in 30 patients. The mean duration of examination with colour Doppler was 29 (range 13-51) minutes. Adequate perforators and their anatomical course could be detected preoperatively extremely accurately (p<0.001). The mean difference between the preoperatively marked, and the real, positions was 6.3 (range 0-16) mm. There was a highly significant correlation between the accuracy of the prediction and the body mass index of the patient (0.75; p<0.001). Neither the age nor the sex of the patient correlated with the accuracy of the prediction. Colour Doppler duplex US used preoperatively to localise perforators in ALT flaps is reliable and could be adopted as standard procedure., (Copyright © 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: Numerous three-dimensional (3D) facial scanners have emerged on the market; however, publications evaluating their accuracies are sparse. In this study, the accuracy of two 3D scanners used in facial scanning was evaluated., Materials and Methods: A test specimen was attached at the right cheek and the forehead of 41 volunteers. These volunteers were scanned with Artec EVA ® and FaceScan3D ® . The acquired data were aligned to a 3D model of the test specimen for comparing the mean error, original length and width and angles to the measured values., Results: The mean error in Best Fit alignment is significantly lower using Artec EVA (p < 0.001) for both test specimens. The deviation from the original length and width is significantly lower for the test specimens (p < 0.01) when measured with Artec EVA. The aberration of the angles measured between the front plane and the side plane is significantly lower when measured with Artec EVA (p < 0.001). Captured with Artec EVA the discrepancy between the original angle and the angle measured between the side planes to each other is significantly lower (p < 0.01)., Conclusions: Scanning with Artec EVA leads to more accurate 3D models as compared to scanning with FaceScan3D. The exactness achieved by both scanners is comparable to other scanners mentioned in literature., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The necessary extent of cervical dissection in oral squamous cell carcinoma (OSCC) is still under discussion. Due to its anatomical properties Robins level IIb has a special role in neck dissection. This study focuses on the lymph node metastatic behaviour of OSCC in level IIb and evaluates its worth of dissection. 183 consecutive patients with OSCC were retrospectively screened for age, gender, TNM classification, cancer stage (after UICC), tumour localization, tumour infiltrations depth, and affected cervical lymph node levels. Associations between lymph node metastases and the above-mentioned characteristics were evaluated using Pearson's chi square test and Spearman's rho correlation analyses. Metastases in level IIb were seen in only 3.3% of all patients, and none of these metastases were an exclusive metastasis. Lymph node metastases most likely occurred in levels I and IIa at ipsilateral sites, and metastases were significantly related to tumour size (p < 0.01) and the infiltration of lymph vessels (p < 0.001). The locations of primary cancer sites in metastatic disease were the soft palate, alveolar crest of the lower jaw and buccal mucosa. Lymph node metastases of OSCC in level IIb remain rare, especially as exclusive metastases and in clinically N-negative necks. The findings of our study support the hypothesis of sparing neck dissection in level IIb in cases of clinically negative necks., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Unlabelled: This study aimed to improve bone regeneration using a timed-release system for periosteal expansion osteogenesis (TIME-PEO) using a shape memory alloy (SMA) mesh device and absorbable thread in a rabbit model., Materials and Methods: Twelve rabbits were used in this study. The device was inserted under the periosteum at the forehead, then pushed, bent, and attached to the bone surface and fixed with an absorbable thread. Rabbits were divided into groups C1 (5 weeks postoperatively without dynamic elevation), C2 (8 weeks postoperatively without dynamic elevation), T1 (5 weeks postoperatively from TIME-PEO), and T2 (8 weeks postoperatively from TIME-PEO). Newly formed bone was evaluated histologically and radiographically., Results: The newly formed bone volume to elevated bone volume ratio was 6.1% in C1, 21.9% in T1 15.5% in C2 and 36.0% in T2. These quantitative data indicate that TIME-PEO group had a significantly higher volume than that of the control group (P < 0.05). Histologically, multiple dome-shaped bones, outlined by thin and scattered trabeculae, over the original bone surface were evident in the T group., Conclusion: This technique appears to be a promising clinical alternative for alveolar bone augmentation and introduces the new concept of "dynamic guided bone regeneration" for atrophic alveolar bone., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Polyetherketoneketone (PEKK) a high performance thermoplastic polymer that is FDA-approved for cranio- and maxillo-facial as well as spineal surgery. We studied the viability, growth and osteogenic differentiation of bone marrow-derived human and sheep mesenchymal stem cells (MSC) in combination with a 3D scaffold made of PEKK using different cell-based assays. To investigate if autologous MSC, either undifferentiated or osteogenically pre-differentiated, augmented bone formation after implantation, we implanted cell-seeded 3D PEKK scaffolds into calvarial defects in sheep for 12 weeks. The volume and quality of newly formed bone were investigated using micro-computer tomography (micro-CT) and histological stainings. Our results show that the 3D PEKK scaffolds were cyto- and bio-compatible. They allowed for adherence, growth and osteogenic differentiation of human and ovine MSC. However, bone healing seemed unaffected by whether the scaffolds were seeded with MSC. Considerable amounts of newly formed bone were found in all PEKK treated groups, but a fibrous capsule was formed around the implants regardless of cell seeding with MSC., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The goal of this study was to determine a combination of screw and transplantation type that offers optimal primary stability for reconstructive surgery. Fibular, iliac crest, and scapular transplants were tested along with artificial bone substrate. Six different kinds of bone screws (Medartis(©)) were compared, each type utilized with one of six specimens from human transplants (n = 6). Controlled screw-in-tests were performed and the required torque was protocolled. Subsequently, pull-out-tests were executed to determine the retention forces. The artificial bone substitute material showed significantly higher retention forces than real bone samples. The self-drilling screws achieved the significantly highest retention values in the synthetic bone substitute material. Cancellous screws achieved the highest retention in the fibular transplants, while self-drilling and cancellous screws demonstrated better retention than cortical screws in the iliac crest. In the scapular graft, no significant differences were found between the screw types. In comparison to the human transplant types, the cortical screws showed the significantly highest values in the fibula and the lowest values in the iliac crest. The best retention was found in the combination of cancellous screws with fibular graft (514.8 N + -252.3 N). For the flat bones (i.e., scapular and illiac crest) we recommend the cancellous screws., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The aim of this retrospective study was to test the diagnostic performance of ultrasound guided fine-needle aspiration cytology (USFNAC) in comparison to ultrasound (US) and magnetic resonance imaging (MRI) for detecting lymph node metastases in patients with squamous cell carcinoma of the oral and oropharyngeal region. 143 patients with oral cavity and oropharyngeal squamous cell carcinoma were included in the study. US, USFNAC and MRI were routinely performed prior to neck dissection. The results of the imaging studies were compared to histopathology. The sensitivity of MRI was highest at 83%, followed by USFNAC and US at 81% and 73%, respectively. The specificity was highest for FNAC at 100%, followed by MRI and US at 76% and 45%, respectively. Positive predictive value was highest for USFNAC 100%, US 57%, MRI 75% and negative predictive value was 77%, 69% and 84%, respectively. In our patient group with oral and oropharyngeal carcinoma, MRI had a higher sensitivity than USFNAC and US alone. USFNAC provided additional staging information. Especially in an uncertain lymph node situation it can facilitate and optimize preoperative planning with a specificity of 100% regarding tissue entity of cervical lymph nodes., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

There are many possibilities for the use of three-dimensional (3D) scanners in maxillofacial surgery. This study aimed to investigate whether the bundling and syncing of two 3D scanners has advantages over single-scanner acquisition in terms of scan quality and the time required to scan an object. Therefore, the speed and precision of 3D data acquisition with one scanner versus two synced scanners was measured in 30 subjects. This was done by analyzing the results obtained by scanning test objects attached to the forehead and cheeks of the subjects. Statistical methods included the Student t test for paired samples. Single-scanner recording resulted in significantly lower mean error of measurement than synced recording with two scanners for length (P < 0.001), all frontal/lateral plane angles (P = 0.034, P < 0.001, P = 0.002, P = 0.003), and side/side plane angles (P = 0.014, P < 0.001, P = 0.015, P = 0.011) of the test object on the cheek. Likewise, the single-scanner method resulted in a significantly lowermean error of measurement than the two-scanner method for frontal/lower plane angles (P < 0.001), right/lower plane angles (P < 0.001), and left/lower plane angles (P = 0.002). Conversely, synced recording of data with two scanners resulted in a significant reduction of scanning time (P < 0.001). Compared to data acquisition with a single 3D scanner, the bundling of two 3D scanners resulted in faster scanning times but lower scan quality.

Purpose: Sinus floor elevation via the lateral window approach represents a reliable technique for bone augmentation in the atrophic posterior maxilla. It is known that sinus membrane elevation leads to new bone formation. This prospective clinical study compared a specific technique in sinus membrane elevation with a conventional sinus floor augmentation (xenogenous/autogenous bone) in a human split mouth model., Methods: Five edentulous patients with highly atrophic posterior maxillae were included in this study. On one maxillary side a degradable PDLLA-membrane was placed to create a space underneath the sinus membrane. Contralateral a mixture of autogenous and xenogenous bone was used for sinus floor augmentation. A two-stage procedure was carried out. The following variables were assessed: bone regeneration on cone-beam computed tomography (cone-beam CT), implant success, prosthetic comfort and patient satisfaction. Bone biopsies were taken with simultaneous implant placement. The samples were histologically analyzed., Results: Cone-beam CTs revealed new bone formation on both sides. Thirty implants were placed, 15 in the augmented region and 15 in the non-augmented side. Thirty bone biopsies were taken and evaluated. Vital new bone was detected on the experimental side (osteoinductivity). On the conventional side a mixture of autogenous and residual bone substitute material was seen (osteoconductivity). Implant survival was 100% so far. Patient's satisfaction was high and prosthetic complications were not encountered., Conclusion: As it provides the highest rate of bone formation, autogenous bone in combination with bone substitute material can be considered as a very reliable standard procedure in sinus floor augmentation. The specific sinus membrane elevation technique as presented here showed satisfying results and might be a suitable alternative for maxillary sinus augmentation., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Unlabelled: Different options exist for the reconstruction of craniectomy defects following interval cranioplasty. The standard procedure is still based on the re-implantation of autogenous bone specimen which can be stored in the abdominal wall or be cryopreserved. Alternatively patient-specific implants (PSIs) can be used. We conducted a retrospective study based on 50 consecutive patients with skull bone defects of 100 cm(2) or more being operated on by the same team of surgeons. Thirty-three patients agreed to take part in the study. Seventeen patients who underwent reconstruction with PSIs (titanium and polyether ether ketone, PEEK) (follow-up, 43 months [range, 3-93]) were compared with 16 control subjects who had autogenous bone grafts re-implanted (follow-up, 32 months [range, 5-92]). Criteria analyzed were the success and complication rates, operation time, duration of hospitalization and the treatment costs. Complication rate and the rate of reoperation were significantly lower, and the hospital stay was shorter in the PSI group. The treatment costs for reconstruction with autogenous bone were considerably lower than skull bone reconstruction based on PSIs (average costs: 10849.91 €/patient versus 15532.08 €/patient with PSI). Due to biological reasons some of the autogenous bone implants fail due to infection and resorption and the patients have to undergo another operation with implantation of a PSI in a secondary attempt. For those patients the highest overall treatment costs must be calculated (average costs: 26086.06 €/patient with secondary stage PSI versus 15532.08 €/patient with primary stage PSI)., Conclusion: High success rates and reliability of PSIs may change the treatment strategy in patients undergoing interval cranioplasty., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: The main goal of the present study was to compare the biomechanical stability of locking plates and conventional miniplate combinations in human mandibles reconstructed with fibular grafts., Materials and Methods: A specially developed and well-proven testing device reproduced the in vivo loading conditions on the mandible. Cadaveric human mandibles (n = 12) reconstructed with harvested human fibular bone grafts were divided into two groups, and different osteosynthesis systems were applied using two lines of plates per osteotomy. On the test apparatus, the specimens were stressed to failure, and interfragmentary movement was monitored and quantified with a contact-free optical measurement system., Results: The relevant interfragmentary movement results from a Euclidean summary calculation which considered all three spatial angles around the axes. Using values up to a maximum load of 300 N, the conventional six-hole miniplates (profile 1.0) had an average value of 7.45° ± 1.46°, and the locking six-hole plates (profile 1.3) had an average value of 12.16° ± 2.37° for rotational interfragmentary movement. The miniplate system exhibited a significantly superior performance in fixation compared to the fixed-angle system (p < 0.05)., Conclusion: According to these biomechanical experiments, both osteosynthesis devices provided sufficient stabilization at loads of up to 300 N. The six-hole miniplate system provided better stabilization of the osteotomy gap for mandibles reconstructed with fibular grafts., Clinical Relevance: The osteosynthesis system is essential for primary stability and the avoidance of pseudarthrosis formation. This study demonstrates that the miniplates provide sufficient stabilization and offers a method to improve fixation in reconstructed mandibles.

Interval cranioplasty after craniectomy carries the risk of infection and failure. There is no consensus regarding the choice of reconstruction technique. In addition to the replacement of the stored autogenous bone graft, the use of patient-specific implants (PSIs) has become popular. We conducted a retrospective study comparing 17 patients who underwent reconstruction with PSIs (titanium and polyether ether ketone) (follow-up, 43 months [range, 3-93]) with 16 control subjects who had their stored bone grafts reimplanted (follow-up, 32 months [range, 5-92]) based on success rate, complication rate, operative time, and duration of hospitalization. Complication rate and the rate of necessary reoperation were significantly lower, and the hospital stay was shorter in the PSI group. We did not find any significant differences concerning operative time. In our patient groups, interval reconstruction after craniectomy with a PSI was a safer procedure based on complication and success rates than reconstruction with stored autogenous bone grafts. In patients with interval cranioplasty who have a higher risk for complication or failure, the use of PSIs should be the treatment of choice.

Objective: The purpose of this paper was to find a correlation between laser doppler flowmetry (LDF) and the bone mineral density quotient (BMDQ) to evaluate irradiated bone quality preoperatively., Materials and Methods: Premolars and molars were extracted from six minipigs. After a three-month healing period, three animals received irradiation at a total dose of 24 Gy. Three months after irradiation, quantitative computed tomography was performed using a calibration bone phantom to determine the 120-position BMDQ in the alveolar bone. A drill template was created to define the exact location for measurement. LDF was then recorded after osteotomy of the residual alveolar ridge. The correlation between the BMDQ and LDF was investigated., Results: There was a linear negative correlation between LDF and BMDQ in non-irradiated bone (r = -0.435, P = 0.001) and less pronounced also in irradiated bone (r = -0.309, P = 0.017). In both non-irradiated and irradiated bone, we found distinct differences between the maxilla and mandible with respect to BMDQ. However, a clear difference in mandibular and maxillary vascularity was only seen in non-irradiated bone., Conclusion: In non-irradiated bone, LDF and BMDQ were inversely correlated. In irradiated bone, the BMDQ alone is not an adequate preoperative tool for evaluating bone quality because it was not correlated with bone perfusion., (© 2012 John Wiley & Sons A/S.)

The present study evaluated the use of this self-activated shape memory alloy (SMA) device, with a focus on its effects in the region under the periosteum. Twelve Japanese white rabbits were used in this study. The device was inserted under the periosteum at the forehead. In the experimental group, the device was pushed, bent, and attached to the bone surface and fixed with a titanium screw. In control group, the device was only inserted under the periosteum. After 14 days, the screw was removed and the mesh was activated in the experimental group. Rabbits were sacrificed 5 and 8 weeks after the operation and newly formed bone was histologically and radiographically evaluated. The quantitative data by the area and the occupation of newly formed bone indicated that the experimental group had a higher volume of new bone than the control group at each consolidation period. Histologically, some newly formed bone was observed and most of the subperiosteal space underneath the device was filled with fibrous tissue, and a thin layer of immature bone was observed in the control group. In the experimental group, multiple dome-shaped bones, outlined by thin and scattered trabeculae, were clearly observed under the SMA mesh device. The use of self-activated devices for the periosteal expansion technique may make it possible to avoid donor site morbidity, trans-skin activation rods, any bone-cutting procedure, and the following intermittent activation procedure., (Copyright © 2013 Wiley Periodicals, Inc.)

Although implant placement is regarded as a safe procedure, some reports about displacement or migration to the maxillary cavity have been published. Further migration to other paranasal cavities and spontaneous loss are rare events. A case is reported of a migration to the inferior nasal meatus, which is documented by cone-beam CT, with subsequent spontaneous loss. Mucociliary clearance in combination with a local osteolytic inflammatory process likely caused this unusual migration.

Background: Irradiation results in impaired bone healing. Thus, osteosynthesis procedures are afflicted with increased failure rates. To improve osseointegration bone morphogenetic protein-2 (BMP-2) immobilized on nanocrystalline diamond (NCD)-coated implant surfaces might be 1 solution., Methods: By 4 weeks after irradiation of pig's mandible with a dose of 60 Gy a fracture was accomplished. Osteosynthesis was performed either with titanium osteosynthesis screws or NCD-coated screws with immobilized BMP-2. Nonirradiated animals served as control. After 1, 2, 4, and 8 weeks screws were evaluated histologically. Bone biopsies were gained to extract mesenchymal stem or precursor cells (MSCs)., Results: MSCs after irradiation demonstrated a behavior comparable to that of unirradiated cells. Consequently, immobilized BMP-2 resulted in an initial increased bone contact ratio (p = .014) but demonstrated no sustainable effect compared with osseointegration in nonirradiated bone (p = .08)., Conclusion: Immobilized BMP-2 demonstrates an osteoinductive effect in irradiated bone. MSCs as effector cells possess protective mechanisms to overcome the destructive effect of irradiation., (Copyright © 2012 Wiley Periodicals, Inc.)

Orthopedic implants including engineered bone tissue are commonly tested in sheep. To avoid rejection of heterologous or xenogeneic cells, autologous cells are preferably used, that is, ovine mesenchymal stem cells (oMSC). Unlike human MSC, ovine MSC are not well studied regarding isolation, expansion, and characterization. Here we investigated the impact of culture media composition on growth characteristics, differentiation, and surface antigen expression of oMSC. The culture media varied in fetal calf serum (FCS) content and in the addition of supplements and/or additional epidermal growth factor (EGF). We found that FCS strongly influenced oMSC proliferation and that specific combinations of supplemental factors (MCDB-201, ITS-plus, dexamethasone, and L-ascorbic acid) determined the expression of surface epitopes. We compared two published protocols for oMSC differentiation towards the osteogenic, adipogenic, and chondrogenic fate and found (i) considerable donor to donor variations, (ii) protocol-dependent variations, and (iii) variations resulting from the preculture medium composition. Our results indicate that the isolation and culture of oMSC in different growth media are highly variable regarding oMSC phenotype and behaviour. Furthermore, variations from donor to donor critically influence growth rate, surface marker expression, and differentiation.

Galectins,β-galactoside binding proteins, function in several physiological and pathological processes. The further evaluation of these processes as well as possible applications of galectins in diagnosis and therapy has raised high scientific interest. Therefore, easy and reliable test systems are necessary. Here we present the simple and cost-efficient production of recombinant human galectins as fusion proteins with SNAP-tag and fluorescent proteins. These constructs show binding specificities and oligomerisation properties generally comparable to recombinant galectins. Their direct fluorescence signal was utilised by ELISA-type assay and flow cytometry analysis with human and ovine mesenchymal stem cells (MSC). Flow cytometry demonstrated glycan mediated binding of His6-SNAP-YFP-Gal- 3 to both MSC types, which was specifically inhibited by lactose. Moreover, directed immobilisation by SNAP-tag technology onto benzylguanine- activated sepharose was utilised to prepare galectin affinity columns for glycoprotein analysis and purification. The SNAPtag directed coupling yielded up to three-fold higher binding capacities for the glycoprotein standard asialofetuin compared to nondirected coupled galectin suggesting improved functionality following directed coupling.

Background: This case report is about a patient with 2 synchronous bilateral cervical schwannomas., Patients and Methods: A 59-year-old white man presented a 6-month history of painless bilateral cervical swelling. Magnetic resonance imaging revealed 2 tumors in the carotid sheath. Both tumors, which derived from the cervical sympathetic chain, were surgically removed., Results: Histopathologically, both tumors were diagnosed as schwannomas., Conclusions: Commonly, a bilateral cervical swelling is not caused by 2 schwannomas. It is unusual for 2 schwannomas to appear in a patient synchronously without any evidence of neurofibromatosis or schwannomatosis. Differential diagnosis of a bilateral cervical swelling includes malignancy, carotid body tumor, and chronic infection., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Severe skeletal relapse is one of the most difficult problems after mandibular advancement, and the management to overcome such problems tends to require more compromised methods and longer treatment period. We described that mandibular backward distraction osteogenesis with maxillomandibular fixation at an appropriate occlusion. Furthermore, to avoid inappropriate distraction vector, the distal plates of the distraction device were fixed with 1 screw to work as a pivot after the manipulation of the condyle to the glenoid fossa at the end of distraction activation. This technique was applied to 3 female patients with mandibular deficiency. The intraoral distractors were set on the lateral surface of the mandibular body; the fixation of the distal plate was fixed with 1 monocortical screw to make the proximal segment including the condyle manipulating at the end of the distraction phase by releasing the maxillomandibular fixation. The distraction rate was 1 mm/d, and the latency period was 7 days. The follow-up period after mandibular backward distraction osteogenesis ranged from 26 to 56 months. No specific complication, such as broken device, severe infection, or bony nonunion, occurred. Postoperative relapse was not observed during the follow-up period. This technique might become 1 choice to apply for mandibular deficiency in a patient with high risk for relapse.

Large skull defects as a result of craniectomies due to cerebral insults, trauma, or tumors create functional and aesthetic disturbances for the patient. Cranioplasty with implants in these cases are an alternative to autogenous bone transplantation. In our clinic, customized titanium or optima poly-ether-ether ketone (PEEK) implants are used to reconstruct craniectomy defects. To compare the two materials we investigated the structural changes of the implants fixed to a sintered polyamide skull model under mechanical stress in four simplified models. In a standard testing machine, the models were subjected to a load under a quasi-static loading rate of 1.925 mm/min. Fractures of the PEEK implants occurred at a force of 24.2 and 24.5 kN with a displacement of 8.4 and 8 mm. The titanium implants showed no deformation, but extensive damage was seen in the polyamide skull models. The highest pressures achieved were 45.8 and 50.9 kN. In a simplified model with quasi-static loading, both implants withstood forces that were higher than those capable of causing skull fractures. It seems that the mechanical properties of PEEK could provide better protection when used for cranioplasty in patients after craniectomy if reconstruction with autogenous bone is not possible.

Objectives: The aim of this study was to evaluate the use of model mandibles made preoperatively by additive manufacturing, which were used to prebend reconstruction plates prior to mandibular resection and reconstruction with microvascular bony flaps., Materials and Methods: Computer Tomography (CT) or Cone Beam Tomography (CBT) scans acquired preoperatively were used to obtain DICOM data sets to produce a model of the mandible using rapid prototyping. This model was used as a template to prebend and then sterilize a 2.3 or 2.7 reconstruction plate, which was used to reconstruct the mandible with a microvascular bony flap. This technique was used in 20 consecutive patients who required mandibular resection and reconstruction because of a tumour or osteoradionecrosis., Results: The prebent plate was used in all patients intraoperatively without the need for any further bending. The average time to bend a plate on a nonsterile model was 0.42 h (range 0.25-0.68 h). This is felt to represent the minimum amount of time saved during the operation. Additive manufacture of the mandible prior to resection and reconstruction with a microvascular flap is a useful technique which reduces the operating time., (Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Large skull bone defects resulting from craniotomies due to cerebral insults, trauma or tumours create functional and aesthetic disturbances to the patient. The reconstruction of large osseous defects is still challenging. A treatment algorithm is presented based on the close interaction of radiologists, computer engineers and cranio-maxillofacial surgeons. From 2004 until today twelve consecutive patients have been operated on successfully according to this treatment plan. Titanium and polyetheretherketone (PEEK) were used to manufacture the implants. The treatment algorithm is proved to be reliable. No corrections had to be performed either to the skull bone or to the implant. Short operations and hospitalization periods are essential prerequisites for treatment success and justify the high expenses., (Copyright © 2010 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: The aim of this prospective cohort study was to determine the 5-year implant survival and success rates associated with early loading (6 weeks after nonsubmerged placement) of sandblasted and acid-etched (SLA) Straumann implants in the edentulous mandible. A secondary objective was to determine the peri-implant tissue response and measure alterations in peri-implant crestal bone levels., Materials and Methods: SLA implants were placed and primarily loaded 6 weeks later with 35 Ncm during abutment placement. The peri-implant bone and mucosal conditions of the participants were monitored radiographically and clinically over a 5-year period., Results: Fourteen patients received 60 implants. Thirteen patients and 54 implants were examined at the 5-year appointment. Two of 60 implants failed during the healing period, and four implants were lost during follow-up and considered as dropouts. The remaining implants showed favorable clinical and radiographic findings and were considered successfully integrated at the 5-year examination. The mean loss of crestal bone height after 5 years was 0.77 mm (SEM 0.09). This resulted in a 5-year cumulative success rate of 96.7%., Conclusion: In this prospective study, the early loading of Straumann implants with the SLA surface in the edentulous mandible after a healing time of 6 weeks provided successful osseointegration with high predictability. Successful integration was maintained for 5 years.

Objective: This study investigated a new technique for the bilateral sagittal split osteotomy (BSSO) by adding a new osteotomy line at the inferior border of the mandible in the Obwegeser-Dal Pont operation., Material and Methods: For this purpose a test system was designed and 100 pig mandibles were split to assess the test's reliability, to compare the torque necessary to split the mandible in both techniques and to record the fracture lines. The splitting technique was standardized, avoiding any contact with the inferior alveolar nerve. All outcomes were statistically examined by paired t-tests., Results: By using the new technique, we demonstrated a decrease in the torque force required to split the mandible of 29.7% (t(69)=-12.68; p<0.05, paired t-test) compared to the Obwegeser-Dal Pont technique. The fracture lines were close to ideal., Conclusion: The additional osteotomy facilitates the BSSO technique and it reduces the likelihood of bad splits and damage to the inferior alveolar nerve in pig mandibles., (Copyright © 2010 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Anaplastology is the discipline devoted to the construction of epithesis. An epithesis is a prosthesis that replaces soft tissue. This offers a solution for patients with a facial defect., Case Description: A 78-year-old woman, who had undergone ablative surgical treatment for a squamous cell carcinoma of the left ear, was left with a large defect in the mastoid region. This defect had a severe impact on her psychosocial functioning. For this patient an episthesis was constructed to replace the left ear. After this, her psychosocial problems were greatly improved., Conclusion: A nearly-realistic episthesis can reduce the negative psychosocial effects of facial mutilation. The construction requires multidisciplinary treatment. In order to achieve the optimal result, an anaplastologist must have well developed artistic capacities. Feeling for detail, form and colour are essential. Modern 3D technology contributes to a more precise, quicker and cosmetically high-quality result.

Due to its osteoinductive potential, the periosteum plays a crucial role in the process of neoosteogenesis. Therefore, periosteal elevation can lead to new bone formation in an artificially created space. In this study, we compared dynamic periosteal elevation with static shielding in an animal experiment. Different elevation/shielding heights of 5, 10, and 15 mm were tested with regard to various consolidation periods. Histological analysis, histomorphometry, and microradiography were used to measure the quantity and quality of the newly formed bone. No significant differences regarding bone quantity or quality were found between the two techniques. The cumulative results for the bone regeneration in the space created by distraction/elevation were about 66% in the dynamic and 67% in static procedure. The main advantages of both techniques are minimal invasion and low morbidity. In terms of clinical applications, periosteal elevation could be applied in cranio-maxillofacial surgery, in pre-implant augmentation and in reconstructive surgery.

Purpose: The histological differences between the defect and contact areas of the implant surface to bone were tested in 35 New Zealand White rabbits in a standardized model. Microwave plasma chemical vapor-coated implant probes were tested in control and uncoated materials., Material and Methods: In each femur of 35 rabbits, cylindrical implant rods with a planed side were inserted. Three groups, divided in coated and uncoated material at half, were observed 42, 84 and 168 days. The probes were examined histologically for bone-implant contact in the curved and plane (defect area) sides., Results: Generally the bone-implant contact seems to be nearly constant in time in the curved area of coated and uncoated probes. Here the implant was inserted in the press-fit mode. Diamond-coated probes showed similar bone-implant contact (51.9% (42 days), 62.5% (84 days), 56.1% (168 days)) compared to uncoated material (56.2%, 65.4%, 62.9%). The defect area (plane side) had no bone-implant contact at the time of insertion and showed increasing values on longer observation times with only significant differences in the 42-day group between coated (17.85%, 35.2%, 47.7%) and uncoated materials (35.5%, 40.55%, 51.81%)., Conclusion: The evaluation of the curved side of the implant probe showed no great variation of bone-implant contact within the described observation times. This model simulates the usual implant insertion situation. The diamond-coated material becomes osseointegrated at a later time point. The bone-implant contact was only statistically relevant in one group in comparison to uncoated material.

Background: Fibular osteocutaneous free tissue transfer represents the work horse procedure in the reconstruction of large oromandibular defects. Before the fibula is harvested the blood supply of the lower leg and foot should be examined, as the perfusion may be based predominantly on the peroneal artery and venae comitantes. To avoid postoperative ischaemia of the lower leg, adequate perfusion must be guaranteed before sacrificing the peroneal vessels. Anatomical variations and peripheral arterial occlusive disease add to the risk of ischaemia. Various methods of evaluating the blood supply have been described., Material and Methods: Fifty-two consecutive cases of fibular flaps were evaluated to study the arterial blood supply of the lower extremity. For angiography, the right femoral artery was punctured using the Seldinger technique and a total of 20-25 ml contrast medium (Imeron 300) was infused and images required at a rate of 0.5/sec., Results: A patent three-vessel supply to both feet could only be detected in 21 patients. Thirty-one angiograms revealed anatomic and/or arteriosclerotic alterations. Angiography provided accurate information in all patients and allowed successful fibular transfer in those patients who were found preoperatively to have regular conditions., Conclusion: Preoperative assessment of the blood supply of the lower extremity is important before fibular osteocutaneous free tissue transfer. We advocate angiography as interpretation is not examiner dependent., (Copyright 2001 European Association for Cranio-Maxillofacial Surgery.)