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Necrotizing fasciitis of the head and neck is a rare, very severe disease, which, in most cases, originates from odontogenic infections and frequently ends with the death of the patient. Rapid surgical intervention in combination with a preferably pathogen-specific antibiotic therapy can ensure patients' survival. The question arises concerning which pathogens are causative for the necrotizing course of odontogenic inflammations. Experimental 16S-rRNA gene analysis with next-generation sequencing and bioinformatics was used to identify the microbiome of patients treated with an odontogenic necrotizing infection and compared to the result of the routine culture. Three of four patients survived the severe infection, and one patient died due to septic multiorgan failure. Microbiome determination revealed findings comparable to typical odontogenic abscesses. A specific pathogen which could be causative for the necrotizing course could not be identified. Early diagnosis and rapid surgical intervention and a preferably pathogen-specific antibiotic therapy, also covering the anaerobic spectrum of odontogenic infections, are the treatments of choice. The 16S-rRNA gene analysis detected significantly more bacteria than conventional methods; therefore, molecular methods should become a part of routine diagnostics in medical microbiology.

Odontogenic abscesses are usually caused by bacteria of the oral microbiome. However, the diagnostic culture of these bacteria is often prone to errors and sometimes fails completely due to the fastidiousness of the relevant bacterial species. The question arises whether additional pathogen diagnostics using molecular methods provide additional benefits for diagnostics and therapy. Experimental 16S rRNA gene analysis with next-generation sequencing (NGS) and bioinformatics was used to identify the microbiome of the pus in patients with severe odontogenic infections and was compared to the result of standard diagnostic culture. The pus microbiome was determined in 48 hospitalized patients with a severe odontogenic abscess in addition to standard cultural pathogen detection. Cultural detection was possible in 41 (85.42%) of 48 patients, while a pus-microbiome could be determined in all cases. The microbiomes showed polymicrobial infections in 46 (95.83%) cases, while the picture of a mono-infection occurred only twice (4.17%). In most cases, a predominantly anaerobic spectrum with an abundance of bacteria was found in the pus-microbiome, while culture detected mainly Streptococcus , Staphylococcus, and Prevotella spp. The determination of the microbiome of odontogenic abscesses clearly shows a higher number of bacteria and a significantly higher proportion of anaerobes than classical cultural methods. The 16S rRNA gene analysis detects considerably more bacteria than conventional cultural methods, even in culture-negative samples. Molecular methods should be implemented as standards in medical microbiology diagnostics, particularly for the detection of polymicrobial infections with a predominance of anaerobic bacteria.

Craniofacial anomaly including deformational plagiocephaly as a result of deformities in head and facial bones evolution is a serious health problem in newbies. The impact of such condition on the affected infants is profound from both medical and social viewpoint. Indeed, timely diagnosing through different medical examinations like anthropometric measurements of the skull or even Computer Tomography (CT) image modality followed by a periodical screening and monitoring plays a vital role in treatment phase. In this paper, a classification model for detecting and monitoring deformational plagiocephaly in affected infants is presented. The presented model is based on a deep learning network architecture. The given model achieves high accuracy of 99.01% with other classification parameters. The input to the model are the images captured by commonly used smartphone cameras which waives the requirement to sophisticated medical imaging modalities. The method is deployed into a mobile application which enables the parents/caregivers and non-clinical experts to monitor and report the treatment progress at home., (© 2021. The Author(s).)

Severe odontogenic abscesses are regularly caused by bacteria of the physiological oral microbiome. However, the culture of these bacteria is often prone to errors and sometimes does not result in any bacterial growth. Furthermore, various authors found completely different bacterial spectra in odontogenic abscesses. Experimental 16S rRNA gene next-generation sequencing analysis was used to identify the microbiome of the saliva and the pus in patients with a severe odontogenic infection. The microbiome of the saliva and the pus was determined for 50 patients with a severe odontogenic abscess. Perimandibular and submandibular abscesses were the most commonly observed diseases at 15 (30%) patients each. Polymicrobial infections were observed in 48 (96%) cases, while the picture of a mono-infection only occurred twice (4%). On average, 31.44 (±12.09) bacterial genera were detected in the pus and 41.32 (±9.00) in the saliva. In most cases, a predominantly anaerobic bacterial spectrum was found in the pus, while saliva showed a similar oral microbiome to healthy individuals. In the majority of cases, odontogenic infections are polymicrobial. Our results indicate that these are mainly caused by anaerobic bacterial strains and that aerobic and facultative anaerobe bacteria seem to play a more minor role than previously described by other authors. The 16S rRNA gene analysis detects significantly more bacteria than conventional methods and molecular methods should therefore become a part of routine diagnostics in medical microbiology.

Delayed-onset infections are rare postoperative complications of lower third molar extractions. This article presents a case of a chronic combined hard and soft tissue infection after the extraction of a third molar, where the causative organisms could only be elucidated by molecular methods. Experimental 16S-rRNA gene analysis with next-generation sequencing and bioinformatics was used to identify the bacterial spectrum of the infection. 16S-rRNA gene analysis delivered the microbiome of the abscessing inflammation while standard culture and laboratory examinations were all sterile. The microbiome showed a mixed bacterial infection with a dominance of Delftia and Alcanivorax (spp.) besides other bacteria of the normal oral flora. Using 16S-rRNA-gene analysis, next-generation sequencing, and bioinformatics, a new type of chronic wound infection after wisdom tooth extraction was found. The property of Delftia and Alcanivorax (spp.) as water-affine environmental bacteria raises suspicion of infection from contaminated water from a dental unit. Thus, osteotomies of teeth should only be done with sterile cooling water. The 16S-rRNA gene analysis should become a part of the routine diagnostics in medical microbiology.

Introduction: Serious abscesses of an odontogenic origin occur frequently in the oral and maxillofacial surgery departments. Rapid surgical incision and drainage constitutes the most important therapeutic action. However, additional surgical therapy and supplementary administration of antibiotics is often carried out, such that the efficiency of this supplementary therapeutic option has been questioned., Methods: All patients with severe odontogenic infections who received surgical treatment under general anaesthesia were recruited to this retrospective study. We determined whether they received additional antibiotic therapy on the ward and if it was possible to improve therapeutic outcomes using this option., Results: A total of 258 patients with a severe odontogenic infection between January 2008 and August 2014 were included. The most frequent infection observed was a submandibular abscess (56%), followed by a perimandibular abscess (18%) and a submental abscess (9%). About 65% of the patients were treated with antibiotics in addition to surgery. The median CRP level prior to surgical treatment was 87.8 mg/l (Q 1 : 40.3 mg/l; Q 3 : 143.5 mg/l) in patients who were administered an additional antibiotic and 83.8 mg/l (Q 1 : 37.3 mg/l; Q 3 : 135.0 mg/l) in those who received no antibiotic treatment after surgery. The postoperative median CRP levels were 116.5 mg/l (Q 1 : 52.1 mg/l; Q 3 : 159.3 mg/l) and 106.5 mg/l (Q 1 : 40.6 mg/l; Q 3 : 152.6 mg/l), respectively. Neither the preoperative CRP level (p = 0.546) nor the postoperative CRP level (p = 0.450) differed significantly between the groups. But patients who received additional antibiotic therapy had a significantly longer hospital stay (median: 6 days; range: 1-22 days) than patients who had no additional antibiotic therapy (median: 4 days; range: 1-19 days) (p = 0.002)., Conclusions: This study did not show an improvement in the therapeutic outcome with administration of supplementary antibiotics in addition to surgery. Thus, surgically incising an abscess is the most important therapeutic action and administration of antibiotics must be critically scrutinised., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Precise fitting and immobilisation of bone transplants at the recipient site is of utmost importance for the healing process. With the help of the standardised Osseo Transfer System, the recipient site is adjusted to the graft, rather than vice versa as it is typically done. The aim of this study was to analyse donor-site morbidity after harvesting cylindrical bone grafts from the retromolar region using the Osseo Transfer System. The patient satisfaction with the surgical procedures was also evaluated. All patients treated with this standardised reconstruction method between 2006 and 2013 at the Department of Cranio-Maxillofacial Surgery, University Hospital Giessen, were included in this study. Complications were recorded and evaluated. Bone graft success and patient satisfaction were documented with a questionnaire, and then confirmed by clinical and radiological follow-up examinations. Fifty-four patients were treated and 64 harvested cylindrical autologous bone grafts were transplanted. In all cases, dental implants could be inserted after bone healing. One patient lost an implant, associated with failure of the bone graft. Six patients who were examined continued to show neurological disorders in locally limited areas. No complete or long-term damage of the inferior alveolar nerve occurred. More than 94% (n = 52) of the patients were 'very satisfied' or 'satisfied' with the results and would recommend this surgical treatment to other patients. The standardised Osseo Transfer was an effective treatment option for small and mid-sized alveolar ridge augmentations. A low donor-site morbidity rate and a high transplant success rate were verified. The Osseo Transfer System demonstrated to be a reliable surgical technique without major complications. We highly recommend this surgical augmentation procedure as a surgical treatment for local bone defects.

The implant surface must withstand high insertion torque during implant insertion. The aim of this study was to investigate the damage to implant surfaces caused by two different insertion protocols in vitro. Fifteen titanium implants per group were inserted in standardized polyurethane foam models, group 1 according to a non-threaded surgical protocol and group 2 according to a threaded surgical protocol. Before and after insertion, the surfaces were visualized by scanning electron microscopy (SEM) and non-contact laser profilometry. Different surface area parameters were evaluated and maximum torque during insertion was determined. SEM detected topographical changes such as deposition of the test block and smoothening of the surface in the region of the thread crests in both groups. The laser profilometry analysis revealed significant changes in the surface topography of the implants in both groups, but no differences between the groups. Insertion torque was significantly decreased in the threaded group. Both types of surgical intervention resulted in surface damage. Less damage was detected to the thread crests with the use of a thread cutter, and most of the surface was not visibly affected by the surgical protocol at the microscopic level. The surgical protocol seems to have a minor influence on preservation of the implant surface., (Copyright © 2018 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Dental aplasia is an anomaly in which the number of teeth is reduced. It is the most commonly occurring dental anomaly during tooth development. Treatment management of patients with dental aplasia is challenging., Objectives: The aim of this retrospective clinical study was to analyze the survival and success rates of dental implants placed in hypodontic patients, rated with different criteria., Methods: Forty-three patients were diagnosed with dental aplasia and treated with dental implants between November 2000 and February 2016. The variables assessed included the plaque level, bleeding on probing, probing depth, implant mobility, implant stability, and implant loss. To analyze the peri-implant bone level, a panoramic X-ray of each patient was taken. The results were compared with X-rays taken immediately after implantation., Results: Thirty-seven patients (16 males; 21 females) participated in this study. In total, 155 implants (86 maxillary; 69 mandibular) were inserted. Two of the 155 implants failed; the in situ survival rate was 98.7%. The success rate according to the criteria of Buser et al. was 96.8%, and that according to the criteria of Albrektsson et al. was 88.4%., Conclusion: The survival and success rates of dental implants in patients with congenitally absent teeth were very high and did not differ significantly from results achieved in an unaffected population. Dental implants are a reliable therapy for patients with dental aplasia.

Purpose: Microvascular fibula flap surgery is a reliable and effective procedure for reconstructing the jaws after tumour surgery. This procedure allows the placement of dental implants after bone consolidation. This study was designed to evaluate the oral, functional, and aesthetic rehabilitation of tumour patients with immediate fibula transfer and dental implants and included assessment of diet, speech, and aesthetics., Materials and Methods: The study included 34 patients who underwent ablative tumour surgery and immediate jaw reconstruction using a fibula free flap with consecutive rehabilitation by dental implants. In total, 134 implants were inserted into the transferred fibula. The functional and aesthetic results were assessed using a questionnaire. Implant loss and oral excursion were compared with diet type, speech ability, functionality, and patient satisfaction., Results: Of the 34 patients included in this study, 33 completed the questionnaire. Twenty-six patients (76%) could eat normally without the limitation of a hard or soft diet, 73% could speak intelligibly, and 31 rated the aesthetic result from good to excellent., Conclusion: The fibula flap with the early application of endosseous implants allowed primary immediate reconstruction of the jaw, significantly leading to functional and aesthetic satisfaction in patients who underwent ablative tumour surgery., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Ablative oncological surgery to treat head-and-neck cancer often triggers a requirement for jaw reconstruction. Modern surgical procedures using free microvascular flaps afford acceptable outcomes in terms of restoration of bony and soft tissue defects. A fibula free flap is often the preferred flap, as the bone length is considerable and a two-surgeon approach is possible. Dental implants play important roles in functional rehabilitation. Our aim was to evaluate the survival of dental implants placed in reconstructed areas after transfer of fibula tissue to the jaw., Materials and Methods: We retrospectively studied 34 patients who underwent ablative tumour surgery and jaw reconstruction using osteocutaneous fibula free flaps and who then received dental implants. We evaluated implant survival and success, survival of the fibula flap, and clinical and radiographic data., Results: We included 34 patients, 23 of whom were diagnosed with squamous cell carcinoma. In total, 134 dental implants were inserted in transferred fibula bone. The cumulative implant survival rate was 81%. The survival rate of the 34 fibula flaps transplanted after surgical reconstruction was 97%., Conclusion: The insertion of endosseous implants after jaw reconstruction using vascularised fibula tissue yields successful dental rehabilitation in patients with oral cancers., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Resection of posteriorly located oral squamous cell carcinomas (OSCCs) remains challenging for head and neck surgeons. However, several surgical techniques, such as lip and mandibular splitting, as well as submental "visor drop-down" of intraoral soft tissues, have been proposed for this purpose. Merrick et al. suggested that a pedicled genial drop-down surgical approach should be used to resect dorsally located OSCCs. Our study investigated patient outcomes following this surgical procedure, as no previous study has analyzed long-term follow-up data., Material and Methods: All patients who underwent surgery using the pedicled genial "visor drop-down" approach at the Maxillofacial Department of the University Hospital Giessen in Germany between 1995 and 2010 were included in this study. In addition, our study required that patients diagnosed with OSCC had no history of other intraoral malignancy or any other form of malignancy. A preliminary questionnaire was completed for each patient based on retrospective analysis of available data from medical reports., Results: A total of 51 patients fulfilled all inclusion and exclusion criteria and were evaluated retrospectively. In total, 32 patients were excluded from the study due to OSCC recurrence or acquisition of a different type of malignancy. The male to female distribution of patients in our study was 30 to 21 (58.8%-41.2%), and the mean ages of female and male patients were 57.7 (SD 14.3) and 55.7 (SD 14.4) years, respectively. Approximately 76.5% of tumors were located along the dorsal aspect of the tongue, 17.6% were along the floor of the mouth, 3.9% were in the dorsal mandibular region, and 1.9% were in the dorsal palatal region. The mean overall operation time was 6.25 h, and 28 patients received microvascular flaps for reconstruction. Results of final histopathological examination suggested primary in-sano resection of the tumor in 84.3% of patients. Overall, the 5-year postoperative survival rate was 52.9%; 31.3% of the patient cohort was not followed up for the full 5-year period. In addition, 15.7% of the patients included in our study died during the study period. Unimpaired functional outcomes in terms of swallowing and speech were observed in 86.3% of patients., Conclusion: The pedicled genial "visor drop-down" approach, also known as the ex corpore linguae, is a suitable method for the radical resection of dorsally located OSCCs, with a promising 5-year survival rate and satisfactory postoperative oral function., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: An accurate preoperative assessment of cervical lymph node status is a prerequisite for individually tailored cancer therapies in patients with oral squamous cell carcinoma. The detection of malignant spread and its treatment crucially influence the prognosis. The aim of the present study was to analyze the different staging modalities used among patients with a diagnosis of primary oral squamous cell carcinoma between 2008 and 2015., Material and Methods: An analysis of preoperative staging findings, collected by clinical palpation, ultrasound, and computed tomography (CT), was performed. The results obtained were compared with the results of the final histopathological findings of the neck dissection specimens. A statistical analysis using McNemar's test was performed., Results: The sensitivity of CT for the detection of malignant cervical tumor spread was 74.5%. The ultrasound obtained a sensitivity of 60.8%. Both CT and ultrasound demonstrated significantly enhanced sensitivity compared to the clinical palpation with a sensitivity of 37.1%. No significant difference was observed between CT and ultrasound. A combination of different staging modalities increased the sensitivity significantly compared with ultrasound staging alone. No significant difference in sensitivity was found between the combined use of different staging modalities and CT staging alone. The highest sensitivity, of 80.0%, was obtained by a combination of all three staging modalities: clinical palpation, ultrasound and CT., Conclusions: The present study indicates that CT has an essential role in the preoperative staging of patients with oral squamous cell carcinoma. Its use not only significantly increases the sensitivity of cervical lymph node metastasis detection but also offers a preoperative assessment of local tumor spread and resection borders. An additional non-invasive cervical lymph node examination increases the sensitivity of the tumor staging process and reduces the risk of occult metastasis., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Premature craniosynostosis of the lambdoid suture is rare. The use of differential diagnosis to rule out positional occipital plagiocephaly is crucial. Nevertheless, once diagnosed, lambdoid craniosynostosis requires corrective surgery to prevent intracranial harm and aesthetic stigma by significant dyscrania. Operative correction of the lambdoid fusion is often performed by suturectomy and helmet therapy, total occipital remodeling interventions, transposition of occipital bone flaps, or occipital advancement procedures either with or without distraction osteogenesis. We present a simple surgical maneuver to potentially correct the occipital and suboccipital constriction caused by unilateral lambdoid craniosynostosis., Materials and Methods: Three patients with true unilateral lambdoid synostosis underwent surgery. A straight-line skin incision was created, beginning at the caudal pole of the ipsilateral mastoideal bulge. The incision ran cranially and corresponded to the course of the lambdoid suture up to the posterior fontanel. The periosteum was incised and the contralateral (potent) lambdoid suture was identified at its origin. One burr-hole was created to separate the dura from the intern tabula. Afterwards, a square meander-shaped craniotomy was performed along the assumed course of the lambdoid suture. The squares were then forced apart to form the occipital and suboccipital area into a more rounded shape. The squares were fixed in those positions with resorbable plates or sutures. Pre- and postoperative three-dimensional (3D) photoscans were performed and analyzed with special software to follow the perioperative course of the cranial shape., Results: This new approach minimized the operative time and degree of blood-loss, and rounding of the occipital area was accomplished with only one unilateral intervention. In terms of the available photogrammetric data of two of the patients, the cranial vault asymmetry index, posterior symmetry ratio, and posterior/anterior skull volume ratio were improved but not normalized completely. The measurement outcome, as determined by an automated analysis of the photoscans, however, indicated clear flaws with regard to repeatability., Conclusion: A unilateral approach using a square meander-shaped craniotomy and subsequent inclination may be a suitable surgical method for correcting assorted cases of lambdoid craniosynostosis. Transposition of the occipital bone flaps, subtotal craniectomies of the occipital area, and occipital advancements with or without distraction devices may not be essential in all cases of lambdoid synostosis. However, the reliability of the automated analysis of three-dimensional photoscans must be determined., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Positional head deformity in early childhood is asserted to be a benign and in some cases spontaneously correcting entity encountered in craniofacial surgery. Although many authors have stated that helmet therapy is indicated in moderate and severe cases of deformational plagiocephaly and brachycephaly; others have reported resolution of these conditions within the first 2 to 3 years of life. A recent randomized controlled trial found that helmet therapy does not have beneficial effects for patients with positional head deformity., Methods: The authors evaluated the clinical course of positional cranial deformation during a period of 5 years and compared the anthropometric parameters of orthotically treated versus untreated children within this timeframe., Results: Although the patients were matched with respect to their cranial deformation at baseline, there were significant differences in the cranial vault asymmetry (CVA), cranial vault asymmetry index (CVAI), and oblique cranial length ratio (OCLR) between Groups 1 and 2 at the initial point (P < 0.05). The mean CVA was 0.95 cm in Group 1 (no helmet) and 1.74 cm in Group 2 (helmet). The mean CVAI at baseline was 7.25 for Group 1 and 13.77 for Group 2. Approximately 5 years after the first examination, the authors found clear improvement in the mean CVA in Group 2 (ΔCVA 1.35 cm) compared with Group 1 (ΔCVA 0.01 cm) and the mean CVAI., Conclusions: In contrast to recently published studies, the authors found clear improvement in nonsynostotic head deformity treated with an individual molding helmet and no clear evidence of improvement of absolute measurements in untreated cranial deformity within a 5-year follow-up period.

The increased number of adolescents and young adults with unknown or inaccurately given date of birth is a current issue in justice and legal medicine. The objective of this study was to determine the extent to which third molar calcification stages assessed on panoramic X-rays could be useful as additional criteria for forensic age estimation in living individuals, focusing on the legally important ages 17 and 18. In a retrospective multi-center study, the developmental stage of each individual's third molar was analyzed using Demirjian's scale in 2360 cases. Additionally, sex, age and ancestry were assessed. Individuals with the lowest calcification stage of all present molars in stage H were ≥18 years with a likelihood of ≥99.05% in the female (n=388), and ≥99.24% in the male (n=482) population. The lowest calcification stage of all present third molars proved to be useful as an additional reliable criterion for the determination of an age ≥18 years., (Copyright © 2014 Forensic Science Society. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective : To photogrammetrically objectify changes in nonsynostotic craniofacial deformity in orthotically treated versus untreated infants. Design : A statistical retrospective pairwise comparison of two respective three-dimensional (3D) photo scans of 80 children performed in a 6-month time lag. Patients : Two comparable samples of children (40 treated, 40 untreated) with nonsynostotic cranial deformity. Interventions : Respective 3D photo scans were matched using Cranioform Analytics 4.0 software. Main Outcome Measures : Median change of 30° Cranial Vault Asymmetry Index (CVAI), modified CVAI (CVAImod), Cranial Index (CI), and posterior symmetry ratio (PSR). Results : We found an improvement in Δ30° CVAI by 3.3% (treated) and by 1.31% (untreated), respectively. CVAImod improved by 3.46% in the treated group and by 1.55% in the untreated group. CI improved by 4.41% in the treated group and by 3.68% in the untreated group, and PSR improved by 0.71 in the treated group and 0.49 in the untreated group. Although improvement of cranial asymmetry was higher in those children treated with an individual molding orthosis, we could not document a statistically significant difference between the two groups. Conclusions : Helmet therapy may be less appropriate for the correction of brachycephaly than for cranial asymmetry. Nonsynostotic cranial deformity shows some spontaneous correction. Photogrammetry presents an accurate method to objectify craniofacial changes in early infancy.

Context: Bisphosphonates are common drugs used in the management of bone metabolic diseases. Because of their recently increased use, their adverse effects, especially bisphosphonate-related osteonecrosis of the jaw (BRONJ), are monitored more frequently. BRONJ is a critical challenge in craniofacial surgery and is difficult to treat. Its occurrence is either spontaneous or follows dentoalveolar surgery. Typical complications of BRONJ are painful exposed bone, pathological fractures, extra-oral fistula, and local infections., Objective: The aim of this paper is to report a rare case of bacterial embolism in the internal jugular vein after a BRONJ-induced submandibular abscess resulting in bacterial sepsis, multi-organ failure syndrome, and death., Case Illustration: A 59-year-old female patient developed severe BRONJ (stage II) with recurrent abscesses after oral osteoporosis therapy with alendronic acid. A subsequent submandibular abscess led to bacterial embolism of the left internal jugular vein, causing sepsis and death., Discussion: Prevention, early detection and management of BRONJ remain a crucial challenge in craniofacial clinical practice. Despite several therapeutic approaches described in the current literature, none have undergone bedside application., Conclusion: Considering this report of death after recurrent abscesses following BRONJ, the use of bisphosphonates should be carefully monitored in order to prevent such severe complications., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Perioperative assessment of craniosynostosis is based mostly on subjective scores. In this study, we sought to find an objective method to assess cranial deformation based on normative craniofacial percentiles. Anthropometric datasets from 104 (79 males, 25 females) patients with craniosynostoses were included. Anthropometric data were compared with normative age-dependent percentiles. Deviations above the 90th or below the 10th percentile were defined as significant cranial deformation. The cohort comprised 69 children with sagittal, 22 metopic, nine coronal, two bicoronal, one lambdoid, and one with coronal + lambdoid craniosynostosis. Most children with sagittal synostosis were above the 90th percentile for cranial circumference and length, whereas only 27.9% were below the 10th percentile for cranial width. Most (83%) children with scaphocephaly had cranial indices below the 10th percentile. For trigonocephaly, we found normal cranial circumference values in most patients (10th-90th percentile), 40.9% were above the 90th percentile for cranial length, and 63.1% and 57.9% were above the 90th percentiles for sagittal and transverse circumferences. For unicoronal synostosis transverse circumference was above the 90th percentile in 83.3% of children. Matching of anthropometric data of craniosynostosis patients with craniofacial norms could be useful in grading the clinical picture and potentially adapting the operative procedure., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: The use of autologous block bone grafts for horizontal alveolar ridge augmentation in dental implantology is a common surgical procedure. Typically, bone grafts are individually moulded., Objective: The aim of this paper is to introduce an innovative procedure in lateral bone augmentation, where the recipient side is adjusted to the graft, not vice versa as in common procedures. Our initial clinical experience of twenty-five consecutive cases is presented., Materials and Methods: Adjusted trephine drills were used to harvest partly cylindrical grafts from the retromolar region of the mandible. After preparing the recipient site with accurately fitting grinding drills, the bone grafts were transplanted., Results: The horizontally compromised alveolar ridges were successfully augmented and treated with dental implants. No major complication occurred during transplantation, the healing period, and subsequent implant therapy in our experimental setting with 25 patients and 38 augmentation procedures. One out of twenty-five patients presented with temporary dysaesthesia of the inferior alveolar nerve., Conclusion: The new method presented is an effective treatment option for horizontal alveolar ridge augmentation prior to single implant installation. Further studies should evaluate the donor site morbidity and long-term outcome on a larger population., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

In patients with bony defects, autologous bone grafts are the "gold standard" for reconstruction. In children, autologous bone harvesting is limited but tissue engineering offers an alternative. Next to bone marrow, adipose tissue is a source of mesenchymal stromal cells, and adipose-derived stromal cells (ADSC) can differentiate into osteocytes. The aim of this study was to evaluate the efficacy of bioactive implants (ADSC in fibrin glue) for repair of critical-size mandibular defects in athymic rats. Human adult ADSC embedded in fibrin glue were implanted into a critical-size defect in the rat mandible and their efficacy was compared to those of protected bone healing (pbh), autologous bone graft, and an empty defect. The newly formed bone was quantified using high-resolution flat-panel volumetric CT (fpvCT) during different observation times. After eight weeks, the specimens were assessed histologically and by micro-computed tomography (μ-CT). The radiographic examination demonstrated a significantly higher level of ossified defect area in the ADSC side compared with the pbh side. The autologous bone graft side showed significantly enhanced bone formation compared to the empty defect. The histological findings in the specimens with ADSC showed bony bridging of the defect. ADSC were capable of defect reconstruction under our experimental conditions., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: To evaluate the impact of stretching exercises versus available bedding pillows on positional head deformities., Study Design: Fifty children aged 5 months or younger with positional head deformity were included in this prospective clinical trial (n=20 plagiocephaly, n=10 brachycephaly, n=20 combination). A random distribution was performed for treatment with the bedding pillow alone (n=25) or with stretching exercises (n=25) for 6 weeks. Anthropometric caliper measurements were done before and after that interval. Cranial vault asymmetry index (CVAI) and cranial index (CI) were calculated and analyzed using a descriptive statistical general linear model., Results: ΔCVAI in the stretching group was 2.09% for plagiocephaly and 2.34% for combined head deformities. Using the bedding pillow, ΔCVAI was 3.01% in plagiocephal children and 2.86% for combined head deformity. The ΔCI in the stretching group was 0.94% for isolated brachycephal children and 2.24% for combined head deformity. ΔCI in the pillow group was 3.63% for brachycephaly and 3.23% in children with combined head deformities, respectively., Conclusions: Bedding pillows and stretching exercises both resulted in improvements in positional cranial deformation. For children with combined plagiocephaly and brachycephaly, improvement in cranial asymmetry was slightly greater when using bedding pillows versus stretching., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: Based on a pilot study including >400 children and a comprehensive database analysis of >2500 children, we sought to define the craniofacial norm and to objectify the categorization of positional head deformity., Study Design: A database was created containing clinical information on children assessed for nonsynostotic cranial deformity. The findings of standardized anthropometric measurements were compared with data from a group of 401 healthy children with a normal head shape collected in terms of a prospective pilot study. Using a statistical analysis of all anthropometric craniofacial measurements, cut-off percentiles for discriminating different groups of deformation and severity classes were generated., Results: Normative percentiles for all dimensions in cranial vault anthropometric measurements during the first year of life were calculated. Children with definite nonsynostotic head deformity could be clearly allocated into 3 different groups: positional plagiocephaly (abnormal Cranial Vault Asymmetry Index), positional brachycephaly (abnormal Cranial Index), and combined positional plagiocephaly and brachycephaly (abnormal Cranial Vault Asymmetry Index and Cranial Index). Additionally, a reliable 3-level severity categorization (mild, moderate, and severe) for each group of cranial deformation could be obtained according to age and sex., Conclusions: Our results allow a meaningful and reliable classification of nonsynostotic early childhood cranial deformity., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Micro-gaps and osseous overload in the implant-abutment connection are the most common causes of peri-implant bone resorption and implant failure. These undesirable events can be visualized on standardized three-dimensional finite element models and by radiographic methods. The present study investigated the influence of 7 available implant systems (Ankylos, Astra, Bego, Brånemark, Camlog, Straumann, and Xive) with different implant-abutment connections on bone overload and the appearance of micro-gaps in vitro. The individual geometries of the implants were transferred to three-dimensional finite element models. In a non-linear analysis considering the pre-loading of the occlusion screw, friction between the implant and abutment, the influence of the cone angle on bone strain, and the appearance of micro-gaps were determined. Increased bone strains were correlated with small (< 15°) cone angles. Conical implant-abutment connections efficiently avoided micro-gaps but had a negative effect on peri-implant bone strain. Bone strain was reduced in implants with greater wall thickness (Ankylos) or a smaller cone angle (Bego). The results of our in silico study provide a solid basis for the reduction of peri-implant bone strain and micro-gaps in the implant-abutment connection to improve long-term stability.

Purpose: Correction of craniosynostosis is necessary in predominant cases. Surgical planning usually requires a preoperative CT to estimate the bony and intracerebral structures. A postoperative CT scan would involve a significant dose of radiation, which carries an elevated risk of malignant tumor development in later life. This study was performed to demonstrate the quality of three-dimensional (3D) photogrammetry when objectifying perioperative changes in craniofacial surgery., Patients and Methods: Twenty-eight patients with different premature craniosynostoses were analyzed photogrammetrically before and after surgical correction. 3D changes in cranial distances, symmetry and volumes were evaluated. A statistical covariance analysis excluded changes in cranial shape caused by physiological head growth., Results: The Cephalic Index in Scaphocephaly changed from 75.1% to a median value of 77.4%. The anterior symmetry ratio for coronal synostoses improved from 0.943 to 0.949 (a value of 1.0 represents perfect symmetry). The posterior symmetry ratio improved from 0.733 to 0.808 postoperatively in one single lambdoidal synostosis. In trigonocephaly, the median anterior skull volume rose from 528 to 601 ml., Conclusions: 3D photogrammetry has great potential to track and objectify the clinical course of surgical correction of craniosynostoses. Craniofacial changes become highly reproducible and demonstrate clinical utility based on this technology., (Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Pediatric scurvy is a rare condition characterized by perifollicular petechiae and bruising, hemorrhagic gingivitis and musculoskeletal symptoms, all assumed to be predominantly related to abnormal collagen structure. We report on a 9-year-old autistic boy with vitamin C deficiency due to a highly limited food range presenting with multiple petechiae, gum bleeding and debilitating bone pain, in whom platelet aggregometry revealed a distinctly reduced thrombocyte aggregation, normalizing after vitamin C supplementation. This observation indicates that platelet dysfunction may additionally contribute to the hemorrhagic diathesis in scurvy, and demonstrates that ascorbic acid deficiency should be considered in children with an otherwise unexplained acquired thrombocytopathy., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Helmet therapy is an established method to correct positional head deformity in early infancy. Side effects such as skin erythema or pressure sores are well known for helmet therapy, but not yet adequately discussed in current literature., Patients and Methods: Retrospectively, all patient-sheets of infants treated by individual orthotic therapy in the years 2007 and 2008 were sighted and complications were noted. Complications were classified and sorted by their frequency and descriptive statistics was performed. The treatment to cure complications was recorded and success in complication control was analysed., Results: Altogether, 410 patients fit the inclusion criteria for this investigation. Complications were apportioned into pressure sores, local ethanol erythema, unsatisfying fit of the helmet or loss of the helmet, skin infection, failed correction of head deformity, and subcutaneous abscess in one case. Non-compliance is to be noticed in a high number, but mainly occurred towards the end of the treatment period., Conclusion: Helmet therapy represents a safe therapeutic tool for the correction of positional cranial deformity. Complications have to be clear in number and severity for parental elucidation. Most complications can easily be avoided or eliminated by proper instruction of the parents., (Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The coronal incision is a standard surgical approach in craniofacial surgery. For pediatric patients, it holds a certain risk for unbeneficial aesthetic outcome due to a broadening of the scar in the fast-growing infant skull., Methods: We readopted the coronal approach over the last decade and developed a sinusoidal type of incision based on the “stealth incision” by Munro and Fearon. We present a calculative standardization of our approach., Results: The sinusoidal coronal approach assures superior aesthetical results with equivalent skeletal exposure. The surgical procedure is simplified and standardized. Even in the fast-growing infant skull, broadening of the scar or vertical divergence is avoided.

Introduction: Embolia cutis medicamentosa (Nicolau syndrome) is a rare iatrogenic event of tissue necrosis after intramuscular or intraarticular application of cristalloid suspensions. Clinically, it presents as a livid discoloration of the skin, local pain, and signs of inflammation., Methods: This article presents the first case of Nicolau syndrome after the endodontic application of calcium hydroxide paste into the distal root canal of tooth 18. The patient presented to the Department for Maxillofacial Surgery and hospitalized for several days., Results: The application of calcium hydroxide paste led to a thrombosis of the inferior alveolar artery and various branches of the maxillary artery. A definite necrosis of the left-side infraorbital skin area and concomitant hypaesthesia of the infraorbital nerve and of the mental nerve were observed., Conclusions: Calcium hydroxide paste is appropriate for the medicamentous treatment of root canals, but is not suitable to stanch bleeding from periapical arteries., (Copyright © 2011 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Objectives: Treating mandibular angle fractures is common in maxillofacial surgery. The aim of this study was to compare lag screw fixation and miniplates., Study Design: This retrospective investigation compared patients treated with miniplates (n = 24) and with lag screws (n = 21). Inclusion criteria were a solitary angle fracture without comminution or other reasons for load-bearing osteosynthesis. The main parameters for the outcome analysis were fracture gaps at 4 defined measuring points on postoperative radiography. Postsurgical complications were recorded., Results: Fracture gaps measured in panoramic radiographs differed significantly between the lag-screw (average 0.56 mm) group and the group using 1 miniplate (average 0.85 mm) and 2 miniplates (1.40 mm). Miniplate fixation resulted in a wider fracture gap, especially in the region of the lower margin of the mandible., Conclusion: Lag-screw fixation demonstrated smaller fracture gaps compared with miniplate fixation., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Objectives: Since the "back to sleep" campaign initiated by the American Pediatric Society in 1992, an increasing incidence of positional cranial deformity in early infancy has been widely observed. Anthropometric caliper measurements present the most practical tool for diagnosis and decision making although their value is being controversially discussed in literature., Patients and Methods: Our study included 30 randomly chosen infants who had been diagnosed with plagiocephaly, brachycephaly, or a combination of both conditions. The 10 patients in each group were then measured anthropometrically by three examiners. The following parameters were measured six times in a standard manner and with a standard head position by each examiner: circumference, length, width, and oblique distance from the fronto-temporal area (ft) to the lambdoid suture on each side of the head (ld). Inter- and intra-observer variabilities for every value were statistically evaluated by a variance components estimation procedure., Results: Both inter- and intra-observer agreement had very low variability. Overall, mean inter-observer variability was lower than 0.182mm(2), and mean intra-observer variability was lower than 1.131mm(2). Altogether, interobserver variability as well as intraobserver variability had a maximum of about 2 mm measurement variance., Conclusions: Standardized measurements are highly reproducible to quantify early childhood head deformity. Standard head position is indispensable for reliable measurement. Repeatability of anthropometric measurements is essential to define diagnoses and severity codes and to develop treatment concepts., (Copyright © 2010 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Cranial asymmetries due to nonsynostotic deformation of the skull have been reported with increasing frequency during the last decade. Conservative approaches using helmets and physiotherapy have been shown to be effective in their treatment. Traditionally, documentation has been carried out using anthropometric caliper measurements. The present study evaluates the use of a new three-dimensional photographic system in the improved validation of changes in head deformities. This prospective analysis introduces a new technique for digital anthropometric measurement. The study series comprised 181 children with nonsynostotic head deformities. Three-dimensional photographs were obtained before and after treatment with an orthotic helmet device. The oblique head diagonals and head width and length were measured from three-dimensional photographs using 3dMD customer software. The cranial vault asymmetry index, cranial vault asymmetry, and cranial index were compared before and after treatment. The measurements obtained on three-dimensional images were able to demonstrate significant improvement in early infant cranial deformity after treatment with an orthotic helmet. The cranial vault asymmetry index in plagiocephaly was reduced by 7.16%, and cranial vault asymmetry was reduced by 0.86 cm. The cranial index in brachycephaly decreased by 7.32%. In children with combined plagiocephaly and brachycephaly, the cranial vault asymmetry index improved by 5.77%, cranial vault asymmetry improved by 0.71 cm, whereas the cranial index changed by 5.48%. Three-dimensional photogrammetry can support treatment control in patients with deformational plagiocephaly. This new technology offers several advantages such as easy acquisition of images, detection of landmarks without patient movement, repeatable measurements without patient discomfort, and the opportunity for unbiased evaluation.

Objective: Anthropometric landmarks of the skull have traditionally been used to describe cranial deformities resulting from nonsynostotic plagiocephaly or brachycephaly. Recently, digital photography has become an important tool for characterizing facial and cranial pathologies. The purpose of this study was to compare standard anthropometric cranial measurements with measurements taken from cranial photographs., Patients: Standardized digital images in the supracranial view and cranial anthropometric measurements were obtained from 122 children between the ages of 3 and 15 months. The photographs were assessed using Quick Ceph® software. The cephalic index and cranial vault asymmetry index were used to indicate the degree of cranial deformity. Children were classified into plagiocephaly, brachycephaly, and the combination of both. To determine interobserver variability, two clinicians separately measured the cephalic index and cranial vault asymmetry index from digital photographs in 70 infants of the plagiocephalic group., Results: To compare interassay reliability for these methods of obtaining the cephalic index and cranial vault asymmetry index, the differences between photographically and anthropometrically derived values were plotted against anthropometrically derived values alone (Bland-Altman plots). The photographic method satisfied the limits of agreement (cephalic index, 7.51%; cranial vault asymmetry index, 6.57%) and showed slightly lower values represented by the respective bias (cephalic index, 1.79%; cranial vault asymmetry index, 3.03%). Comparison between observers revealed excellent agreement, detected by the intraclass correlation coefficient of .982 for the cephalic index and .946 for the cranial vault asymmetry index., Conclusion: Our results demonstrate that digital photography is a reliable tool for quantifying cranial deformities. Furthermore, it is rapid, noninvasive, and reproducible. However, we continue to use both methods in clinical practice.

Objective: Given the increasing incidence of deformational plagiocephaly due to infants' supine sleeping position to prevent sudden infant death syndrome, reliable anthropometric diagnostics are needed. Besides the traditional method of measuring landmarks with callipers, three-dimensional (3D) photography has great potential. In this investigation the accuracy of 3D photogrammetry is studied., Methods: The study included 100 randomly chosen children between the ages of 4 and 20 months with a non-synostotic cranial deformity in a retrospective analysis. Measurements of diagonals A and B on the infant's head were obtained once using callipers. 3D photographs of these children were measured 5 times by 5 clinicians separately., Results: The inter- and intra-rater agreements of the 3D measurements had low variability in the variance component analysis. The standard deviations for reproducibility and repeatability were 0.117-0.283 cm for diagonals A and B. The intra-class correlation coefficients for the inter-rater reliability resulted in excellent agreement (0.97 for plagiocephaly, 0.98 for brachycephaly, 0.96 for combined deformity). The comparison of the 3D photographic and callipers measurements showed that 3D photography resulted in a slight over-estimation., Conclusion: 3D photogrammetry is potentially a reliable tool for treatment planning and follow-up of abnormal head shapes in infancy.