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OBJECTIVE: To compare the diagnostic quality of 2-dimensional panoramic views generated from imaging data acquired by a newly developed cone beam machine with the diagnostic quality of conventional digital orthopantomograms (OPTs). METHOD AND MATERIALS: Thirty panoramic views reconstructed from digital volume tomograms (DVT) obtained by the pre-retail version of Galileos (Sirona Dental Systems), a newly developed compact cone beam device, were compared with 30 OPT images acquired by Orthophos XG Plus (Sirona Dental Systems). Diagnostic quality was assessed by 3 observers on criteria regarding detection of diagnosis-related findings, image quality, and visualization of anatomic structures in the maxillomandibular area. Wilcoxon rank sum test was applied for paired comparison. RESULTS: Statistical analysis showed no significant difference in diagnostic quality between both imaging modes using a calculation model based on 10 weighted criteria (P = .629). There was especially no statistically significant difference in the assessment of diagnosis-related findings detection (P = .163). Image quality of DVT panoramic views was significantly lower than that of OPT. Except for mandibular canal and alveolar ridge gingiva, all evaluated anatomic structures were visualized better by DVT. Intraclass correlation coefficients were consistently higher in the DVT group for all criteria but 2, although the difference was not statistically significant (P = .374). CONCLUSIONS: DVT panoramic views perform better in diagnosis of specific lesions, whereas OPTs provide a better image quality for a general overview of the maxillomandibular area. The diagnostic quality of both imaging modes is, however, equal. [ABSTRACT FROM AUTHOR]

The article presents a study according to which patients, who were treated with radiochemotherapy (RCT) followed by neck dissection, only showed a partial histopathological response. It mentions an observation that planned neck dissection should be performed in cases of equivocal 18F-fluorodeoxyglucose (FDG) uptake in the cervical lymph nodes. It states that association between cervical lymph node metastases and Squamous cell carcinoma of the head and neck region (HNSCC).

Objectives In advanced oral squamous cell carcinoma ( OSCC), tumour regression after neoadjuvant radiochemotherapy seems to be an important prognostic factor. In this study, we intended to compare regression grading according to two previously described regression models and to analyse the association of tumour regression and other tumour characteristics with patients' characteristics and overall survival. Methods The retrospective study included 63 treatment-naive patients with primary OSCC of stages II- IV, who were treated with a concomitant neoadjuvant radiochemotherapy followed by radical surgery. Assessment of histopathological features was performed, there under regression grading according to two previously described regression models. Results Both tumour regression models provided comparable results in terms of distribution of different regression grades. In univariate analysis regression gradings ( P = 0.003 and P = 0.007), yp T-stage, yp N-stage and status of resection margins ( P < 0.001) were significantly associated with the 5-year overall survival ( OS). None of the pretreatment clinicopathological parameters showed association with histopathological tumour regression. Multivariate analysis revealed the status of resection margins and of lymph node metastasis as statistically significant features for OS ( P = 0.020 and P = 0.003, respectively). Conclusion Tumour regression grading, nodal stage and status of resection margins predict prognosis in patients after neoadjuvant treatment. Currently, there are no pretreatment clinicopathological parameters, which predicting good tumour response to therapy. Thus, identifying non-responding patients, which might benefit from an intensified systemic therapy, requires surgical resection and consecutive histopathological assessment. Therefore, further investigation and validation of new, especially, molecular predictors of tumour response to radiochemotherapy remains an unmet, future clinical need. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study was to compare the performance of cone-beam computerized tomography (CBCT) with multislice CT (MSCT) and single photon emission CT (SPECT) in the detection of bone invasion from oral malignancies. STUDY DESIGN: In this prospective investigation, 77 patients with histologically proven malignancy of the oral cavity received MSCT, CBCT, and SPECT imaging of the head presurgically. Radiologic evaluations were compared with histopathologic examinations of the resected tumor specimens. Receiver operating characteristic (ROC) analysis as well as the sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value for MSCT were 0.8, 1.0, 1.0, and 0.75, respectively; for CBCT 0.92, 0.965, 0.98, and 0.875; and for SPECT 0.91, 0.4, 0.7, and 0.75. ROC analysis showed area under the curve values of 0.894 (95% confidence interval [CI] 0.806-0.982) for MSCT; 0.931 (95% CI 0.835-1.000) for CBCT, and 0.716 (95% CI 0.566-0.866) for SPECT. CONCLUSION: CBCT is accurate in predicting malignancies' bone involvement and can compete with MSCT and SPECT in detecting bone invasion in patients with oral malignancies. [ABSTRACT FROM AUTHOR]

When bone is limited, short, ultra-short, or narrow implants help to restore oral rehabilitation with an acceptable long-term outcome. This becomes more difficult with severe vertical bone loss. Guided bone regeneration, onlay block transplantation, or sandwich osteotomy have been established to build up these defects. The alternative to the alveolar distraction osteogenesis (ADO) has only been established in some centers, with a standardized protocol. On the one hand, ADO is a biological procedure that allows almost a "restitutio ad integrum" when building up hard and soft tissue. On the other hand, there are clear indications, limitations, and complications of the procedure in the literature. In addition to the literature, concept of Tissue Regeneration by Alveolar Callusdistraction Cologne (TRACC), which has been practiced successfully for over two decades, will be presented for different indications., (© 2023 The Authors. Periodontology 2000 published by John Wiley & Sons Ltd.)

The aim of the study was to evaluate prophylactic removal of titanium osteosynthesis miniplates in patients after midface fractures. Complaints after fracture treatment and complications after plate removal were analyzed, retrospectively. A total of 205 patients were included. Plate removal was performed in 99 cases. Complaints related to the osteosynthesis material resulted in more frequent plate removal (p < 0.001). Complications were noted in 22 patients after plate removal. Duration of plate removal did not correlate with postoperative complications. In 69 patients, plates were removed without previous symptoms. Of these patients, postoperative complications were recorded in 15 cases. In patients with complaints after osteosynthesis, complications after plate removal occurred in seven (23.3%) patients. Ectropia developed significantly more often with increasing age (p < 0.05). CONCLUSION: Within the limitations of the study it seems that prophylactic plate removal is a treatment option that is not associated with an increased complication rate., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: Procedures in oral and maxillofacial surgery bear a high risk of nerve damage. Three-dimensional imaging techniques can optimize surgical planning and help to spare nerves. The aim of this study was to investigate the diagnostic value of a 1.5 T magnetic resonance imaging (MRI) scanner with a dedicated dental signal amplification coil for the assessment of nerves in the oral cavity as compared with cone beam computed tomography (CBCT)., Methods: Based on 6 predefined criteria, the assessability of the inferior alveolar and nasopalatine nerves in CBCT and MRI with a dedicated 4-channel dental coil were compared in 24 patients., Results: Compared with CBCT, MRI with the dental coil showed significantly better evaluability of the inferior alveolar nerve in the sagittal and axial plane and the nasopalatine nerve in the axial plane. In the sagittal plane; however, the assessability of the nasopalatine nerve was significantly better in CBCT as compared with MRI. Yet, pertaining to overall assessability, no significant differences between modalities were found., Conclusions: In this pilot study, it can be reported that 1.5- T MRI with a dedicated dental coil is at least equivalent, if not superior, to CBCT in imaging nerve structures of the stomatognathic system., Clinical Relevance: Preoperative, 3-dimensional images are known to simplify and refine the planning and execution of operations in maxillofacial surgery. In contrast to computed tomography and CBCT, MRI does not cause radiation exposure while enabling visualization of all relevant hard and soft tissues and, therefore, holds an advantage over well-established techniques., Competing Interests: N.G.H. is a speaker at the bureau of Philips Healthcare; received research support from Philips Healthcare; and consultancy for Bristol-Myers Squibb. The remaining authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Purpose: This study analyzes postoperative airway management, tracheotomy strategies, and airway-associated complications in patients with oral squamous cell carcinoma in a tertiary care university hospital setting., Material and Methods: After institutional approval, airway-associated complications, tracheotomy, length of hospital stay (LOHS), and length of intensive care unit stay were retrospectively recorded. Patients were subdivided in primarily tracheotomized and not-primarily tracheotomized. Subgroup analyses dichotomized the not-primarily tracheotomized patients into secondary tracheotomized and never tracheotomized. Associations were calculated using regression analyses. A multivariate regression model was used to determine risk factors for secondary tracheotomy., Results: A total of 207 patients were included. One hundred fifty-three patients (73.9%) were primarily tracheotomized. Primarily tracheotomized patients showed longer LOHS [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07, P =0.008] but decreased need for reventilation within the intensive care unit stay (OR 0.39, 95% CI 0.15-0.99, P =0.05) compared with not-primarily tracheotomized patients. Within the not-primarily tracheotomized patients, secondary tracheotomized during the hospital stay was needed in 15 of 54 patients (27.8%). In secondary tracheotomized patients, airway management due to respiratory failure was required in 6/15 (40%) patients resulting in critical airway situations in 3/6 (50%) patients. Multivariate regression model showed secondary tracheotomy-associated with bilateral neck dissection (OR 5.93, 95% CI 1.22-28.95, P =0.03) and pneumonia (OR 16.81, 95% CI 2.31-122.51, P =0.005)., Conclusion: Primary tracheotomy was associated with extended LOHS, whereas secondary tracheotomy was associated with increased complications rates resulting in extended length of intensive care unit stay. Especially in not-primarily tracheotomized patients, careful individualized patient evaluation and critical re-evaluation during intensive care unit stay is necessary to avoid critical airway events., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

This study was conducted to reveal the relevant risk factors for surgical site infections (SSI) of the tracheostomy in ICU tracheostomy patients with oncologic history. Retrospectively, medical and ICU records of patients who received open tracheostomy in a uniform manner were investigated. Of 187 consecutive patients in total, patients with a peri/post-operative antibiotic prophylaxis (POABP) experienced significantly more Organ-Space SSI, whereas patients with a POABP developed less Superficial Incisional SSI and Deep Incisional SSI. Neck Dissection (p = 0.025), especially the more levels are included, and POABP (p = 0.005) have a significant impact on the occurrence of an SSI of the tracheostomy. Deep incisional SSI significantly prolonged a patient's dependency on a ventilator (p = 0.045, M = 3.92, SD = 4.718). The difference between Superficial Incisional, Deep Incisional and Organ-Space SSI should be taken in consideration regarding risk evaluation and treatment. Furthermore, a gram-negative facultative anaerobic biofilm should be taken into consideration in treatment options and thus an escalation regarding antibiotic treatment as a POABP. For fulminant SSI of the tracheostomy the use of piperacillin/tazobactam or 3rd generation cephalosporines or carbapenems is recommendable., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2022 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: Screw-retained restoration of implants is advantageous for biological and esthetic reasons. Due to buccal concavities, however, this preferred type of restoration can only be used in about half of the anterior indications. Based on case series, an optimized method for the treatment of such indications is to be described; the clinical reliability is to be ascertained by means of measurements (before and after augmentation) and assigned to the current literature., Material and Methods: A case series of seven cases with buccal concavities of the anterior alveolar ridge were treated with optimized method, which is presented step-by-step until the prosthetic restoration. The depths of the bone concavities were measured and related to the bone gain after augmentation procedure respectively after implantation., Results: Linear measurements of the buccal concavities showed an average undercut of 4 mm [SD ± 1.13]. After healing period of six months, the buccal concavities could be compensated bony to such an extent that implants could be inserted in correct position and angulation. On average, there was a horizontal bone gain of 3.7 mm [SD ± 0.59]. Even after implantation and another six months of healing, stable bone dimensions could be assumed with an average of 4.3 [SD ± 0.83] mm of bone gain compared to baseline. In six of the seven cases, the favorite screw-retained, one-piece full-ceramic restoration could be fixed on the implants. Due to the implant axis, one case had to be treated with a cemented two-part full-ceramic system., Conclusions: With the described optimized method the most favorable screw-retained restoration can also be used in situations with unfavorable concavities of buccal bone. Especially for this indication, a special form of the horizontal deficit, the customized bone regeneration with titanium meshes is highly reliable in terms of healing and extent of augmentation. However, long-term results and a study/control group are required to evaluate the effectiveness of the presented protocol., Clinical Relevance: Since these situations require an augmentation that is up to 5 mm thick and a procedure that is as minimally invasive as possible appears to be necessary in the visible area, an optimized method is described in this publication., (© 2022. The Author(s).)

Purpose: The transoral approach (TRA) to subcondylar fractures without any endoscopic or transbuccal assistance is not a common technique. The purpose of this study was to measure and compare the quality of open reduction and internal fixation (ORIF) between the TRA and the retromandibular approach (RMB), including types and frequencies of postoperative complications., Methods: In our retrospective cohort study, we enrolled a sample of patients with displaced subcondylar mandible fractures treated by ORIF. The predictor was the approach mode: TRA or RMB. In postoperative computed tomography (CT) data sets, we measured the angles of the condylar process in relation to references: 1) midline, 2) lateral ramus border, and 3) posterior ramus border. The primary outcome variable was the reduction outcome, which was calculated as the difference between the total of all angles of the operated side and the non-affected side. Secondary outcomes were postoperative complications extracted from patients' files. Other variables were age, gender, number of plates, operation time and a modified AO trauma score. In bivariate analysis, we compared the outcome between both groups., Results: Sixty-four patients were included in total, with TRA performed in 50%. Patients with TRA were younger (31 vs 41, P = .003), and the trauma score was lower (1.9 vs 3.3, P < .001). Reduction outcome remained comparable between both techniques (mean 3.7° for both, P = .92). Complication rates were similar, although facial nerve palsy was absent for TRA (0 vs 4, P = .039)., Conclusion: We suggest TRA for selected patients with displaced, single fragmented subcondylar fractures. Reduction outcome shows a comparable exactness to RMB, while TRA is safer for the facial nerve., (Copyright © 2021 The American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Abstract: This study was conducted to provide diametric and volumetric data of mandibular condyles from patients with Angle class 2 and 3 malocclusions by semiautomatic segmentation based upon cone-beam computed tomography.Cone-beam computed tomography images of 79 patients were analyzed. By using the open-source software "ITK-SNAP", diametric and volumetric measurements of 158 mandibular condyles were performed. Descriptive statistics were calculated for all normally distributed variables. Correlations between patients with Angle class 2 and 3 were calculated with the independent Student t test. P values P < 0.05 were considered significant.Irrespective of the side, patients with class 2 malocclusion showed smaller mandibular condyles (right: 1.128 ± 0.504 cm3; left: 1.222 ± 0.596 cm3) than patients with class 3 (right: 1.504 ± 0.361 cm3; left: 1.493 ± 0.335 cm3). These results were reproducible also in accordance with the diametric measurement (class 2 right: 16.75 ± 2.72 mm; left: 17.04 ± 3.01 mm) (class 3 right: 18.24 ± 2.54 mm; left: 18.32 ± 2.13 mm). However, volumetric differences were highly statistically significant (right: P = 0.001; left: P = 0.018) while diametric differences were slightly significant for the right and not significant for the left side (right: P = 0.042; left: P = 0.053).Diametric and volumetric analyses offer important additional information based on 3D images of cone-beam computed tomography technology. Significant differences in diameter and volume of mandibular condyles could be assessed between different classes of malocclusion., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Purpose: Our study aimed to provide volumetric data relating to fibro-osseous lesions of the craniofacial skeleton, in order to highlight risk factors due to the different entities, and to guide clinical decisions for jeopardized patients., Methods: Volumetric measurements of osteomas and ossifying fibromas were performed by applying the open-source software ITK-Snap to cone-beam computed tomography images. DICOM datasets were imported, identified, and delineated using semiautomatic segmentation; this was then verified using manual segmentation. The volumes of the lesions were computed automatically in cubic millimeters using the program. For statistical investigations, descriptive statistics and independent Student t-tests were performed. Additionally, Pearson's correlation was applied as a bivariate analysis. Values of p < 0.05 were considered significant., Results: 45 patients (11 male and 34 female) were included in this study. The mean volumes were 10.02 ± 18.79 cm 3 for osteomas and 4.80 ± 5.71 cm 3 for ossifying fibromas (p = 0.016). Males (12.81 ± 20.38 cm 3 ) presented significantly larger volumes than females (5.43 ± 10.32 cm 3 ) (p = 0.042). With regard to shape, morphology, and affection of surrounding anatomical structures, irregular shape (p = 0.001; p = 0.037), multilocular morphology (p = 0.001; p = 0.037), nerve affection (p = 0.001; p = 0.002), tooth affection (p = 0.001; p = 0.594), cortical bone exceedance (p = 0.033; p = 0.001), and clinically visible symptoms (p = 0.004; p = 0.001) were statistically significantly associated with a larger volume of both entities., Conclusion: Volumetric analysis revealed that osteomas significantly exceeded the mean size of ossifying fibromas, supporting the argument that special attention should be paid to this entity. In cases of difficult histopathological examination, lesions with irregular shape, multilocular morphology, nerve and tooth affection, cortical bone exceedance, and clinically visible symptoms should be considered for close clinico-radiological follow-up, irrespective of the entity., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Cone beam computed tomography (CBCT) is considered both reliable and safe and provides reproducible results in guided dental implant planning procedures. However, it has weaknesses in soft tissue contrast and is associated with radiation exposure. Recent studies showed promising results with magnetic resonance imaging (MRI) as a possible noninvasive, radiation-free, alternative imaging modality for dental indications. The purpose of this study was to evaluate the quality of 1.5 T MRI with a dedicated dental signal-amplification coil in comparison to CBCT for dental implant planning procedures., Materials and Methods: Sixteen subjects undergoing preoperative MRI (3D HR T1w TSE and 3D HR T1w FFE) and CBCT were included in this prospective study. All imaging data were used for dental implant planning procedures using commercially available software. Two experts scored the planning as "ideal," "improvable," or "unacceptable." Furthermore, quantitative distances according to EuCC recommendations were collected. Finally, discrepancies between CBCT and 3D HR T1w TSE were analyzed. Statistical analysis was performed using the Mann-Whitney U test and analysis of variance (ANOVA)., Results: The dental implant planning procedure was technically feasibly using all imaging data. CBCT allowed for "ideal" placement in all cases. Ratings for 3D HR T1w TSE and 3D HR T1w FFE were 81.9%, 18.1%, and 0% and 54.2%, 30.0%, and 15.3% for ideal, improvable, and unacceptable, respectively, identifying 3D HR T1w TSE as superior compared with 3D HR T1w FFE. Head-to-head comparison between CBCT and 3D HR T1w TSE revealed no significant differences regarding the apical position of the implant of 1.2 ± 0.7 mm and 1.3 ± 0.5 mm coronally, respectively (P = .287). The deviation of the planed angle was 3.0 ± 1.2 degrees. In these merged data sets, the distance to the mandibular canal was significantly higher with 1.3 ± 0.8 mm, indicating better utilization of the existing bone., Conclusion: Within the limits of this pilot study, it can be reported that the dental image planning procedure is feasible using 1.5 T MRI with a dedicated dental coil and specific MRI sequences.

Purpose: Retrobulbar hematoma (RBH) is a rare but serious vision threatening emergency. We analyze the relationship between hematoma volume, visual impairment and outcome., Methods: Fifty-four patients with RBH receiving orbital decompression were retrospectively included. Volumetric analysis of RBH was performed by semi-automatic segmentation based on preoperative CT scans using ITK-SNAP software. Best corrected visual acuity (BCVA) measurements were obtained and correlated in 2 groups (no light perception (NLP), severe visual impairment) with the hematoma volume., Results: NLP was documented preoperatively in 5/28 and postoperatively in 9/43 patients. Preoperative NLP was significantly associated with a larger hematoma volume (P = .03) and higher hematoma/orbital volume ratio (P = .03). Postoperative severe visual impairment showed significant associations with a larger hematoma volume (P = .02) as well as higher hematoma/orbital volume ratio (P = .02)., Conclusion: Eyes with severe visual impairment and large hematoma volumes preoperatively are at high risk of permanent vision loss. Hematoma volume calculation might represent an additional prognostic parameter for visual outcome after RBH., (Copyright © 2021 The American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Abstract: With the introduction of an e-scooter-sharing system in Germany, standing electric scooters became popular modes of transportation in many urban areas. But the increase in popularity has resulted in an increase in traumatic injuries associated with e-scooter accidents. The purpose of this investigation was to determine the common fracture pattern of patients with mandible fractures as a result of an electric scooter accident. The authors performed a retrospective investigation of 52 patients who were admitted to the trauma unit of an oral and maxillofacial department from June until November 2019 with a fracture of the mandible. Our study investigated the first 6 months of e-scooter sharing system in a major city with more than 1 million inhabitants. Our cohort consists of 52 patients, 38 males, and 14 females with a mean age of 37 years. E-scooter related mandible fractures were with 21% the third biggest group, after physical assault and falls. 45% of these patients were intoxicated by alcohol. Furthermore, the majority of e-scooter patients presented more than one fracture of the mandible (73%). For our cohort, a typical combination of a symphysis or body fracture and bilateral affected ramus and/or condyle was the prevalent recorded fracture combination (55%) of e-scooter related traumata. Small scooter wheels, a speed of 15 miles or 20 kilometers per hour and the individual clinging to the handlebar falling predestinate these vehicles for accidents with craniofacial trauma. Among all cranio-facial traumas mandible fractures were mostly documented for e-scooter accidents. The severity of e-scooter related mandible fractures and their fracture pattern should be recognized by trauma units., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

The purpose of this investigation was to analyze the volume of medication-related osteonecrosis of the jaw (MRONJ) lesions by semi-automatic segmentation of cone-beam computed tomography images, and correlate the results with the underlying diseases and applied medication. MRONJ lesions detected in cone-beam computed tomography images were assessed. The open-source software ITK-Snap enabled volumetric measurements of MRONJ lesions based on semi-automatic segmentation. Results were analyzed according to necrosis volume, localization, and gender. In addition, the underlying disease and the type of application of antiresorptive medication were investigated. Cone-beam computed tomography images of 66 patients were studied. 34 male and 32 female patients were included, with ages ranging from 50 to 93 years at the time of diagnosis. The mean volume was 993.24 ± 620.94 mm 3 : 484.73 ± 230.97 mm 3 for the upper jaw and 1084.04 ± 625.74 mm 3 for the lower jaw. The results indicated statistically significant differences between lesions of the upper and lower jaw, regardless of gender (p = 0.003). The analysis of differences between males and females did not show any significant results (p = 0.464), although males presented slightly larger lesions than females. With regard to the underlying disease, patients with osteoporosis presented larger volumes, whereas patients with malignant tumors presented smaller volumes. Nevertheless, no statistically significant differences according to the underlying disease (p = 0.313) were detected. However, patients with intravenous (iv) application showed statistically significantly larger lesions than patients who underwent oral or subcutaneous (s.c.) applications (p = 0.004). It seems that the osteonecrosis volume correlates with the applied antiresorptive agents. Larger MRONJ lesions should be expected in patients who receive intravenous antiresorptive therapy., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Precise perforator mapping of the epifascial and subcutaneous course of the perforator flaps, including the precise detection of the skin point, is mandatory for successful preoperative flap design and planning of supramicrosurgery. We investigated the effectiveness of contrast-enhanced B-flow (BCEUS) imaging for perforator mapping and preoperative perforator flap planning and compared it with B-flow ultrasound, contrast-enhanced ultrasound, and color Doppler ultrasound. Sixteen patients who received an individualized perforator flap reconstruction were included in the study. Preoperative perforator mapping includes the following structures: subfascial course of the pedicle, fascial penetration point, subcutaneous course (epifascial and subcutaneous), and perforator skin point. The precision of the preoperative perforator mapping was analyzed for color Doppler ultrasound, contrast-enhanced ultrasound, B-flow ultrasound, and BCEUS. Each technique was able to precisely display the subfascial course of the vascular pedicle, including the fascial penetration point. However, only BCEUS enabled precise mapping of the epifascial and subcutaneous (suprafascial) course, including the skin point of the perforators with a clear delineation. Precise knowledge of the suprafascial course of the perforators is mandatory for successful supermicrosurgery and perforator flap planning. BCEUS imaging facilitates full perforator mapping, which improves the safety of flap harvesting. However, BCEUS is technically demanding and requires an experienced sonographer., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Objective: Open surgical tracheotomy performed beside (STB) is a standardized procedure in critical ill patients. The aim of the study was to evaluate perioperative complications and the safety of STB in a tertiary care university hospital setting., Materials and Methods: Intra- and postoperative complications were retrospectively recorded and associations based on the evaluation of clinical and laboratory parameters were studied using regression analyses., Results: A total of 562 patients were included. Early tracheotomy shortened ventilation time after tracheotomy (ventilation before STB ≤ 5 days: mean 9.2 ± 9.1 days; ventilation before STB ≥ 6 days: mean 11.5 ± 10.5 days, p = 0.0001). Overall complications were found in 30/562 cases (5.3%), major complications in 12/562 cases (2.1%). Significant risk factors for overall tracheotomy related complications were higher body mass index (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.07, p = 0.02), lower CRP (OR 0.99, CI 0.99-1.00, p = 0.03), higher INR (OR 5.67, CI 1.27-25.34, p = 0.02), longer duration of operation (OR 1.03, CI 1.00-1.06, p = 0.04) and tracheotomy during extracorporeal membrane oxygenation (ECMO) support (OR 6.26, CI 1.21-32.44, p = 0.03)., Conclusion: STB represents a safe surgical procedure, also suitable for patients with an increased risk profile. Careful evaluation of individual risk factors should be favored to reduce procedure related complications., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: To identify the clinicopathological parameters that influence survival in patients with oral squamous cell carcinoma, in order to allow for the development of individualized surveillance programmes and reduce the delay in diagnosis of recurrence., Materials and Methods: Retrospective chart review of 553 patients with a treatment-naïve primary oral squamous cell carcinoma, who underwent primarily curative intended surgery. Exclusion criteria were neoadjuvant radio(chemo)therapy, follow-up < 1 year, perioperative death, inoperable disease, synchronous multiple malignancies and inadequate information on clinicopathological parameters., Results: The clinicopathological factors that influence overall survival, disease-free survival and locoregional control were calculated. In the multivariate survival analysis, the occurrence of recurrence, presence of extracapsular spread, T- and N-classification were shown to be independent risk factors for overall survival., Conclusion: The identification of these risk factors can lead to the development of individualized follow-up programmes based on risk stratification. This allows for the earliest possible diagnosis of relapse which is essential to offer the patient a realistic second treatment chance and to improve survival rates., (© 2020 The Authors. Oral Diseases published by John Wiley & Sons Ltd.)

The aim of this study was to provide volumetric data of the pterygopalatine fossa by semiautomatic segmentation based upon cone beam computed tomography.Cone beam computed tomography (CBCT) images of 100 patients were analyzed. By using the open source software "ITK-Snap," the volumetric measurements of 200 pterygopalatine fossae were performed. For statistical investigations paired t test, and independent Student t test were performed. Also, the Pearsons chi-square test was applied. P values P < 0.05 were considered significant.The mean volume was 578.376 mm for the right and 560.979 mm for the left side. The results indicated statistically significant differences according to the right and the left pterygopalatine fossa, regardless of gender (P < 0.05). The analysis of differences between males and females did not show any significant results (P > 0.05), although males present a slightly larger volume than females. According to the median age (59 years), younger patients presented smaller volumes, whereas older patients presented larger volumes. Nevertheless, no statistically significant differences according to age (χ = 3.520; P > 0.05) could be found.Clinical intervention with the application of local anesthetics into the complex and vulnerable anatomy of the pterygopalatine fossa makes a thorough knowledge about the volumetric capacity indispensable. Therefore, the semiautomatic segmentation of CBCT images provides a useful, available and validated tool. Our results show that a final injected anesthetic volume larger than 1 ml exceeds the pterygopalatine fossa capacity considerably and could cause complications. To prevent this, volumetric analysis of this region can provide further information and enables an individualized patients' treatment.

Purpose: Single photon emission computed tomography (SPECT) has been commonly used as an additional method to assess mandibular bone invasion in patients with oral squamous cell carcinoma (OSCC). In the present study, we measured the diagnostic validity of SPECT findings compared with the histologic findings., Patients and Methods: We implemented a retrospective cross-sectional study and enrolled a sample of patients with OSCC adjacent to the mandible. The staging examinations included magnetic resonance imaging (MRI) and/or computed tomography (CT) and additional SPECT. The patients' medical records and imaging data were reviewed by 2 readers, and bone invasion was classified as positive or negative for each diagnostic method. The predictor was bone invasion found on CT and/or MRI compared with the combination of CT and/or MRI with either positive or negative SPECT results. The primary outcome variable was histologic bone invasion. Other variables of interest were clinicopathologic data, type of mandibular resection, and resection margin status. Bivariate tests were used to compare the diagnostic specificity, sensitivity, and accuracy of each imaging modality., Results: The study enrolled 122 patients, with a mean age of 67 years (55% male; study period, January 2010 to December 2017). In 60 patients (49%), segmental mandibular resection was performed. The sensitivity and specificity for bone invasion were 100% and 39% for SPECT and 84% and 75% for CT and/or MRI. The negative results for bone invasion using SPECT did not match the false-positive CT and/or MRI results in 5% (n = 6 of 122). Positive SPECT findings, in addition to positive CT and/or MRI findings increased the sensitivity to 100% but decreased the specificity to 29% (P < .001). Considering only negative SPECT findings increased the specificity to 85% (P = .03), sensitivity remaining unaffected. The accuracy of CT and/or MRI alone was 80% and was 84% when combining CT and/or MRI and negative SPECT findings (P = .03)., Conclusions: In oncologic staging with CT and/or MRI, the addition of SPECT provided only small benefits. Only negative SPECT results allowed for greater specificity and accuracy. The use of SPECT could be considered to rule out bone invasion in cases of radiologic uncertainty of positive CT or MRI findings., (Copyright © 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: This study was designed to assess the influence of peri/post-operative antibiotic prophylaxis (POABP) and the reconstructive graft itself on recipient sites infections in head and neck surgery., Materials and Methods: In this retrospective cohort study, 322 consecutive patients with reconstructive surgery were investigated. The primary objective was to analyze the differences of commonly applied reconstructive grafts on the occurrence of oral recipient site infections. Moreover, differences of POABP regimes (namely: ampicillin/sulbactam, 2 nd generation cephalosporins, clindamycin) and antibiotic alternatives were investigated. In addition, patients' length of in-hospital stay was analyzed in regard to reconstructive graft and POABP regime., Results: The free radial forearm flap and split-thickness skin graft presented significantly less recipient site infections and shorter length of in-hospital stays (LOS) in comparison to further six reconstructive technique with pedicled tissue transfer or bone transfers. LOS was significantly shorter for patients with ampicillin/sulbactam than with 2 nd generation cephalosporins as POABP. 91% of the harvested pathogens (n=193) were susceptible to the combination of 2 nd and 3 rd generation cephalosporins. Secondly, 92 out 113 (81%) harvested pathogens presented susceptibility to moxifloxacin., Conclusion: Smaller tissue transfers are less prone to infections of the recipient site and present low LOS. For an POABP regime, the combination of 2 nd and 3 rd generation cephalosporins presents substantial results in recipient site infections. In cases of allergy, potential pathogens show adequate susceptibility to moxifloxacin., Clinical Relevance: A combination of 2 nd and 3 rd generation cephalosporins may be used to prevent recipient sites in head and neck surgery.

The pterygopalatine fossa (PPF) is a complex and paired anatomical structure located at the skull base. A clinically and surgically relevant structure located in the pterygopalatine fossa is the sphenopalatine ganglion. Electrical stimulation of the sphenopalatine ganglion is one possible method of treating cluster headache. The pterygomaxillary fissure (PMF) defines the pterygopalatine fossa laterally and determines the surgical approach. As part of preoperative surgical planning, each patient undergoes a preoperative head computed tomography or a cone beam computed tomography. In our study cone beam computed tomography images of 90 male and 110 female PMF were analyzed. Generally, males have a wider fissure than females. Moreover, a significant inter-subject difference could be shown between males and females. The analysis of the right and left PMF according to gender and age does not show any significant intra-subject differences. Following an established protocol for high-resolution CT images the measurements were classified into four fissure types and also analyzed according to gender and age. Fissure type I is significantly more often present in males, whereas the smaller fissure types (II, III, and IV) are significantly more often found in females. Older patients presented statistically significant more often with type I, whereas the younger patients showed more often the narrower types II and IV. Due to the fact that narrow fissures smaller than 2 mm could limit the insertion of neurostimulator implants in the PPF, special attention should be paid to females and younger patients during preoperative planning.

Purpose: The aim of this study was to evaluate the impact of extubation time on postoperative complications in patients undergoing bimaxillary orthognathic surgery. We therefore retrospectively compared the effect of early extubating (EE) in the operating room versus delayed extubating (LE) on the intensive care unit (ICU) regarding postoperative complications and length of ICU/hospital stay (LOICUS/LOHS). Furthermore, we analyzed the influence of the PAS change on postoperative complications., Methods: The clinical data of 117 patients were retrospective analyzed regarding postoperative complications using Clavian-Dindo Classification. Volumetric calculations of the pre- and postoperative PAS were conducted using ITK-SNAP software. The Fisher's exact test was performed to evaluate the significance of differences between categorical variables. Continuous variables were analyzed using the Mann-Whitney U-Test or the Kruskal-Wallis one-way analysis of variance. Regression analysis was used estimating predictors for postoperative complications., Results: EE led to significant shortening of LOICUS (p < 0.001) and LOHS (p = 0.023). In total, we recorded 38 complications (minor n = 30; major n = 8) within the hospital stay. Complication rates were without significant differences with respect to the postoperative ventilation strategy. Large changes in PAS volume led to an increase in the major complication rates (p = 0.031). Increase or decrease of PAS was independent from postoperative complication rates (p = 1.000). Higher body mass index (p = 0.04) and a higher ASA PS score (p = 0.016) were associated with increased major complication rates., Conclusion: Early extubation after surgery is a safe procedure and is associated with a reduced LOICUS and LOHS. Complications seem to occur more frequently in marked changes of the PAS and should be considered in perioperative risk stratification., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: The purpose of this study was to evaluate potential differences in volumes of areas of osteolysis caused by medication-related osteonecrosis of the jaw (MRONJ) between the upper and lower jaw. We aim to analyze the clinical relevance of volumetric measurement of osteolytic lesions for surgical planning of MRONJ patients., Methods: Sixty-seven patients who were clinically and histopathologically diagnosed with MRONJ were retrospectively included in this study. Cone beam computed tomography (CBCT) images were evaluated according to localization, affected anatomical structures, and volumetric measurement of osteolytic lesions caused by MRONJ in appliance of CBCT datasets by using ITK-SNAP., Results: The most frequently affected localization is the mandible, whereas female patients show significantly more often lesions of the maxilla. The cortical bone was predominantly affected. Furthermore, the affection of teeth, sinus floor, inferior alveolar nerve canal, or even a pathological fracture of the mandible are infrequently existing. The volumetric measurements revealed a statistically significant greater absolute osteolysis volume in males., Conclusions: Image analysis and volumetric measurements of osteolytic lesions of MRONJ patients is a helpful tool to further understand the clinical appearance and identify compromised anatomic landmarks. Volumetric analysis aids in pre-surgical planning and visualizes the individual extent of the disease for each patient.

Objective: Magnetic resonance imaging (MRI) shows excellent image quality for the depiction of soft tissues and is therefore an important imaging technique in medical diagnostics. However, the practical simultaneous presentation of hard and soft tissue structures of the mouth, jaw and facial area is not fully satisfactory at this time. We investigated the image quality of 1.5 T MRI using a dedicated signal amplifying coil for the application in the oral and maxillofacial field of and compared it with cone beam computed tomography (CBCT). We hypothesized that imaging quality for growth disorders of the facial skull does not differ significantly between the two imaging techniques., Materials and Methods: 12 patients were consecutively enrolled into this study between 01/2016 and 12/2017. Patients received diagnostic imaging for clinical indications using 1,5 T MRI using a dedicated head and neck coil for signal amplification as well as an CBCT. For each patient 5 different MRI sequences and one CBCT protocol were assessed. Images were evaluated by a radiologist and a dentist in consensus. On the basis of 51 anatomical structures and orthodontic, cephalometric reference points, the five datasets were subjectively rated and compared to the CBCT dataset., Results: Patient age was in the range of 19-78 years. 2614 (69.8%) out of 3744 possible valuations were assessable. Compared to CBCT, MRI images were rated to have a superior image quality of presentation for 42 out of 51 anatomic structures (p < 0.05). Notably, 5 out of 51 structures were not assessable due to missing values. T1-weighted MRI images were rated superiorly to T2-weighted images in displaying anatomically relevant landmarks in the oral and maxillofacial field. MRI datasets were inferior in imaging cephalometric and orthodontic reference points in comparison to CBCT images., Conclusion: In conclusion, this pilot study demonstrates that radiation-free dental MRI enables a reliable detection of important anatomical structures. Thus, the signal amplified MRI presents a radiation-free imaging alternative to established CBCT in craniofacial growth disorders protocols. However, imaging quality in MRI datasets remains inferior to CBCT images for cephalometric and orthodontic reference points., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

For horizontal bone deficiency alveolar ridge osteotomy is considered an option for augmentation. Major advantages are the option for a one-stage approach and the absence of donor site morbidity. However, the conventional technique is associated with complications such as perforations and fractures of the cortical bone. A case using a 3D based modified, full-guided alveolar ridge expansion is described to explain the technique step by step. Main features of modified technique: successive application of surgical guides for ridge osteotomy and expansion - implementation of virtually determined splitting vector, which allows guided bone splitting along a guide surface of template in an ideal direction - osteotomy as deep as implant length. The example shows that the 3D based modified alveolar ridge osteotomy is a suitable alternative to the conventional technique as it has several advantages such as fewer fractures and perforations of the cortical vestibular bone. The individualized preoperative planning helps to minimize complications. However, long-term outcomes and a study, conducted on a study group, is needed to evaluate the benefits of our presented treatment protocol., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: Tumor invasion into blood and/or lymphatic vessels, perineural invasion, and histopathological grading are evaluated to assess the biological aggressiveness of oral squamous cell carcinoma (OSCC). We aim to assess the prognostic impact of a novel scoring system, based upon the aforementioned histological parameters., Materials and Methods: Retrospective chart review of 334 patients with treatment-naive squamous cell carcinoma of the oral cavity. Statistical analysis was performed using univariate and multivariate analysis. Histological grade G1 or G2 were assigned 0 points and G3 or G4 1 point. Invasion of the lymphatic vessels, blood vessels, or perineural space was given 1 point. Zero points were given, when invasion was not detectable. The final score was conducted through addition of each parameter. Therefore, our scoring system ranged between 0 and 4 points., Results: T-classification (p < 0.001), N-classification (p < 0.001), UICC stage (p < 0.001), extracapsular spread (p < 0.001), locoregional recurrence (p < 0.001), and overall survival (p < 0.001) were significantly associated with the OSCC-Histoscore. In multivariate analysis, T-classification (p = 0.001), N-classification (p = 0.039), resection margins (p = 0.038), and OSCC-Histoscore (p < 0.001) were independent prognostic markers for overall survival rate., Conclusion: Our presented OSCC-Histoscore serves as a strong independent prognostic parameter for 5-year overall survival (OS) and predicts OS better than T-classification, N-classification, and resection margins., Clinical Relevance: Our presented histoscore improves prediction of the overall survival of patients with OSCC.

Purpose: The purpose of this retrospective study was to evaluate perioperative risk factors concerning difficult airway management, primary tracheostomy, and need for intensive care unit (ICU) admission in severe odontogenic space infections., Methods: Perioperative risk factors were retrospectively analyzed in 499 cases. Fisher's exact test and analysis of variance were performed to analyze associations between categorical and continuous variables. Univariate regression analysis was used for estimating predictors for ICU admission. A risk model for ICU admission was performed using multivariate regression analysis. Area-under-the-curve (AUC) was calculated by receiver-operating-characteristic (ROC) curve., Results: Airway securing in patients with restricted mouth opening led to significant use of the video laryngoscope (p < 0.001) or fiberoptic bronchoscope (p < 0.001). The use of fiberoptic bronchoscopy was significantly increased in patients with dysphagia (p = 0.005) and dyspnea (p = 0.04). Four patients (0.8%) needed primary tracheostomy. ICU admission was significantly associated with higher levels of C-reactive protein (CRP, p = 2.78 × 10 -5 ), white blood cell count (WBC, p = 0.003), dyspnea (p = 9.95 × 10 -6 ), and higher body mass index (BMI, p = 0.0003). American Society of Anesthesiologists physical status (ASA PS) class III patients (p = 0.04) and the need for the use of a video laryngoscopy (p = 0.003) or fiberoptic bronchoscopy (p = 6.58 × 10 -5 ) resulted in a more frequent ICU admission. The AUC of the model was 0.897., Conclusion: Difficult airway management was mainly dependent on limited mouth opening and elevated CRP. Elevated CRP, BMI, ASA PS III, and dyspnea were important risk factors for ICU admission. These predictors should be considered preoperatively for proper planning and preparation.

Objectives: Tumour relapse remains one of the major problems in managing oral squamous cell carcinoma (OSCC) with mortality rates of up to 92%. Early recurrences have a worse prognosis than late relapses. However, few has been written about the influence of clinicopathological parameters on the timing of recurrence and the patient survival., Materials and Methods: Retrospective chart review of 159 patients with an OSCC recurrent disease. Exclusion criteria were neoadjuvant chemoradiotherapy, follow-up <6 weeks, perioperative death, second primaries and inadequate information on clinicopathological parameters. Statistical analysis was performed using univariate and multivariate analysis., Results: A significant correlation was found in the χ2-analysis between the timing of recurrence and the margin status (p = 0.020), lymph node ratio (p = 0.030) and grading (p = 0.003) of the primary tumour. In the multivariate survival analysis, the timing of recurrence (p < 0.001), margin status of the primary tumour (p = 0.023), presence of extracapsular spread in the primary tumour (p = 0.003) and performance of a salvage treatment (p < 0.001) were shown to be independent risk factors for overall survival., Conclusion: For patients with a recurrent OSCC, the time to recurrence, margin status, extracapsular spread and the performance of a salvage treatment are independent prognostic factors for overall survival. Furthermore, a significant association exists between the moment of recurrence and the lymph node ratio, the margin status and grading of the primary tumour. This knowledge can allow for the development of individualised surveillance programs and like this, an earlier diagnosis and better second treatment chance in the case of a recurrence., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: Published data on procalcitonin (PCT) levels after microsurgical interventions are very scarce, although infection within these patients is not only associated with severe morbidity but also significantly higher mortality rates., Material and Methods: Retrospective study on 20 patients, who were operated on by a single experienced plastic and reconstructive surgeon within one year (June 2017-June 2018). The authors included all patients, who received microvascular transplants for reconstruction of soft tissue defects. Furthermore, age above 18 years and appropriate documentation allowing sufficient data collection were defined as inclusion criteria. The authors excluded all patients with perioperative systemic inflammation and transplant loss, as our aim was to solely determine and evaluate potential alterations of serological PCT levels after microsurgical interventions., Results: The PCT cutoff level to differentiate physiological and pathological levels was defined as 0.1 μg/L. There was no detectable increase in procalcitonin in all of our 20 patients, for whom the authors performed microvascular transplantation to reconstruct soft tissue defects., Conclusion: Serological PCT levels remain stable after the considered surgical interventions and therefore PCT levels might be utilized to identify systemic inflammation, thus helping to reduce severe complications by early individualized antiinfective treatment strategies.

Objectives: A central role of infections in the treatment of MRONJ patients is widely accepted. An investigation of the MRONJ lesions' biofilms as potential pathogens seems logical., Materials and Methods: We investigated the clinical data of our MRONJ patients who received surgery in advanced stage of the disease. Special attention was granted to the local colonizers harvested from osseous MRONJ specimens and submucosal putrid infections., Results: Eleven out of 71 patients presented a spontaneous onset of the disease and for 60 out of 71 patients a trigger was detected. Breast cancer (29.6%) and prostate cancer (22.5%) were the most frequent underlying disease for prescription of an antiresorptive therapy, mostly zoledronate. Submucosal soft tissue biofilms significantly differed from biofilms harvested from the MRONJ lesions bottom, yet the most frequent bacteria were equally present in both groups: Streptococcus species (spp.), Prevotella spp., Actinomyces spp., Veillonella spp., and Parvimonas micra. The cephalosporins, cefuroxime and cefotaxime, and ß-lactam antibiotics with ß-lactamase inhibitor revealed the greatest susceptibility for the detected bacteria., Conclusion: The bacteria from the submucosal areas and the bottom of the infected bone presented comparable susceptibility to the common antibiotics regimes. Streptococcus spp., Prevotella spp., and Veillonella spp. present a high abundance in MRONJ lesions beside Actinomyces spp. The MRONJ lesions bottom is in many cases not infected by Actinomyces spp., Clinical Relevance: The removal of the necrotic bone reduces the variety of bacteria found in MRONJ lesions, in particular at the bottom of the lesion.

Introduction: Purpose of this study was to evaluate a probable risk of frontal sinus size for traumatic depressed anterior table fractures in patients with similar forehead trauma., Methods: We conducted a retrospective case-control study with a case group of consecutive treated patients with displaced frontal sinus anterior table fractures. The control group was randomly sampled from patients who presented with a blunt forehead trauma in our institution's emergency unit. In computed tomography data sets, all patients' frontal sinus size was categorized by Guerram's classification that is defined as aplasia, hypoplasia, medium-size and hyperplasia. Odds for prevalence of the sinus types as well as sinus total width and height were compared between both groups., Results: In total, 47 cases and 93 controls were identified. Hyperplasia in the case group had an odds ratio of 46:1 (p < 0.001) compared to the controls. Mean sinus width (73 mm vs. 46 mm; p < 0.001) and sinus height (30 mm vs. 15 mm; p < 0.001) were larger in the case group., Conclusion: Depressed traumatic fractures of the anterior table are an injury with a high risk specific for enlarged frontal sinus sizes. Anatomy is the predictive factor for this mode of craniofacial trauma., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Intraoperative navigation to assess anatomic reduction is the general trend in maxillofacial trauma surgery. The aim of this study was to evaluate the closed reduction outcome of isolated zygomatic arch fractures using ultrasound compared with palpation control., Materials and Methods: In this case-and-control study, the authors identified consecutively treated patients who underwent closed reduction of isolated zygomatic arch fractures using the Volkmann reposition hook with intraoperative ultrasound. Controls were patients with the same diagnosis and surgical procedure without ultrasound imaging. Pre- and postoperative radiographic datasets were geometrically analyzed. The outcome variables postoperative cortical step, persistent postoperative displacement, and overall grade of reduction were compared in the 2 study groups. Subgroups of fracture patterns were classified as M-shaped or variable. Statistical analysis was performed using t test for continuous variables and 2-sided χ 2 test for categorical variables, with a P value less than .05 defined as significant., Results: Sixteen cases with intraoperative ultrasound and 60 controls were identified from the institution's database. The angle of postoperative displacement was significantly decreased in the ultrasound group for all fractures (2.4° vs 5.3°; P = .004) and the variable fracture type (1.6° vs 8.1°; P = .005). Overall grade of reduction was improved in the ultrasound group for all fractures (P = .03) but with no difference solely for M-shaped fractures (P = .37)., Conclusions: Although reduction control using palpation and probing using the Volkmann hook showed satisfactory results for M-shaped fractures, additional intraoperative ultrasound imaging showed promise for increasing success rates for the variable type of zygomatic arch fracture., (Copyright © 2018 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this prospective work was to examine oral leukoplakia for their podoplanin expression to determine whether podoplanin expression is associated with the degree of dysplasia., Materials and Methods: We took biopsy samples from 50 patients with oral leukoplakia in 2013. The preparations studied by immunohistochemistry were analyzed in correlation with the degree of dysplasia and other clinicopathological variables., Results: The Chi-square test showed a significant correlation between podoplanin expression and the degree of dysplasia according to the squamous intraepithelial neoplasia (SIN) classification (p = 0.033). Also, a significant association between age grouping and podoplanin expression was found. We were able to show that the distribution is the same for both age groups in relation to the score of podoplanin expression (p = 0.003)., Conclusion: In a comparable retrospective work of our working group, it could be shown that podoplanin is a reliable predictive marker for the assessment of the risk of malignant transformation. The present work was able to substantiate the assumption that podoplanin not only plays an important role in the context of malignant degeneration but also exerts a major influence in advance., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Cone beam computed tomography (CBCT) in orthodontics is increasingly used for detecting impacted or ectopic teeth or for orthognathic and cleft lip and palate treatment. Incidental findings (IFs) are frequently encountered and often relevant. The aim of this study was to detect the prevalence of relevant pathologies on CBCT scans of orthodontic patients., Methods: Over a 6-year period, incidental imaging findings were analyzed in 345 CBCT scans (181 men; 164 women; age 16.3 ± 8.4 years), and subdivided into dental (Group 1), skeletal (Group 2), sinunasal (Group 3), and infrequent other pathologies (Group 4)., Results: A total of 502 IFs were detected in 345 patients (1.4 IFs per patient, on average). Most IFs were found in Group 1 (358 IFs; 71.3%), followed by Group 2 (129 IFs; 25.7%), Group 3 (14 IFs; 2.8%), and Group 4 (1 IF; 0.2%). There were 119 (34.5%) patients with a missing wisdom tooth, 94 (27.3%) with dental aplasia, 71 (20.6%) with dislocations, 33 (9.6%) with partial opacifications, and 27 (7.8%) with signs of sinusitis., Conclusions: This study found that IFs in orthodontic CBCT scans are frequently encountered, even in younger orthodontic patients. When interpreting CBCT scans, orthodontists should be aware of potential relevant IFs that may require further investigation, change patients' treatment or affect their quality of life.

Purpose: The frontal sinus shows a wide range of morphologic variations. The aim of this study was to evaluate the influence of frontal sinus size on fracture characteristics in frontal bone trauma., Materials and Methods: In this cross-sectional study, data from patients with traumatic fractures of the frontal bone were retrospectively collected from the institution's database. Radiometric analysis of computed tomography and cone-beam computed tomography datasets was performed. Frontal sinus size was measured as variables of height, width, and depth. The secondary predictor was morphologic sinus type according to Guerram's classification: hyperplasia, medium size, hypoplasia, or aplasia of the frontal sinus. To determine outcomes, we classified fractures into the following categories: fracture isolated to the anterior table, combined fractures of the anterior and posterior tables, fracture isolated to the posterior table, and frontal bone fracture without sinus involvement. Further study variables were patients' demographic characteristics, combined midfacial fractures, orbital rim involvement, fracture displacement, and surgical approach. For statistical analysis, fracture types were assessed for frontal sinus metric size and morphologic type using bivariate tests with P < .05 defined as significant., Results: We enrolled 53 consecutive patients with a mean age of 35 years; male patients comprised 91%. Fracture types differed significantly in sinus width and height (both P < .001), as well as depth (P = .002). Frontal sinus morphology was hyperplastic in 66%, medium in 30.2%, and hypoplastic in 3.8%. Patients with a hyperplastic frontal sinus had an increased likelihood of isolated anterior table fractures (odds ratio, 6.0; P = .007) compared with medium-sized types. Fractures without sinus involvement were more likely in hypoplastic and medium types (P < .001)., Conclusions: The morphology of the frontal sinus determines the probability of fracture types from craniofacial trauma. Thus the frontal sinus size appears to be a major factor for frontal bone resistance to traumatic force impingement., (Copyright © 2018 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study aims at investigating the prognostic significance of lymph node ratio (LNR) in a cohort of patients with oral squamous cell carcinomas (OSCC), treated with neoadjuvant radiochemotherapy followed by radical surgery., Methods: The study included 171 treatment-naive patients with biopsy-proven primary OSCC, being reviewed retrospectively. All patients received a concomitant neoadjuvant radiochemotherapy (RCT) followed by radical surgery of the primary tumor and neck dissection based on the pretreatment staging results. The Kaplan-Meier survival analysis method was used to estimate the events of interest for overall survival (OS). Prognostic factors were identified through univariate and multivariate analysis., Results: The 5-year overall survival rate for all patients was 48 %. In univariate analysis, patient's age and data compiled from the histopathological examination as margin status, extracapsular spread, ypT, ypN, ypUICC, number of positive lymph nodes and lymph node ratio (LNR) had a statistically significant impact on overall survival. Multivariate analysis revealed an independent significant impact of patient age, ypT, margin status and LNR on OS. ypN showed no statistical significant impact on OS., Conclusion: Our results show that LNR is an important predictor for OS in patients with OSCC that were treated with neoadjuvant radiochemotherapy and radical surgery., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: In the field of reconstructive head and neck surgery, surgical site infections (SSI) are commonly investigated for the recipient site of various reconstructive procedures. Data about SSI of the donor site of different flaps raised for reconstruction are rare., Material and Methods: With regard to the bacterial donor site infections, we retrospectively investigated the medical data, surgical reports and wound management protocols of 267 patients who received reconstruction of the head and neck after ablative surgery. All patients underwent reconstruction with one of the following flaps: free fasciocutaneous radial forearm flap (RFFF), free fasciocutaneous anterolateral thigh flap (ALTFF), pedicled myocutaneous latissimus dorsi flap (PLDF), pedicled myocutaneous pectoralis major flap (PPMF), free osteocutaneous fibula flap (FFF). Follow-up was conducted for 12 months., Results: The lowest detection ratio (DR: number of infected sites/flaps raised from the respective donor site) was calculated for the radial forearm, 0.087. Pedicled flaps presented a moderate DR (PLDF: 0.27, PMMF:0.35). Donor sites of the leg possessed the highest DR (ALTFF:0.61, FFF: 045). Mainly gram-positive facultative anaerobic bacteria (n = 41) were detected and gram-negative bacteria (aerobe/anaerobe) were present in 27 cases. The most frequently detected bacteria were Staphylococcus spp., Viridans Streptococci, Pseudomonas aeruginosa and Escheria coli. Continuous wound management for in-hospital patients was able to prevent any local spreading or a prolonged length of in-hospital stay., Conclusion: Overall, gram-positive facultative anaerobic bacteria, mainly Staphylococcus spp., are the predominant bacteria detected in donor site wounds. For wound care management, an infection with gram-negative pathogens should not be neglected., (Copyright © 2018. Published by Elsevier Ltd.)

Customized implants have simplified surgical procedures and have improved patient outcome in craniomaxillofacial surgery. Traditionally, patient-specific data is gathered by conventional computed tomography (CT). However, cone-beam CT (CBCT) can generate a 3D reconstruction of the area of interest with a lower dose of radiation at reduced cost. In this study, we investigated the feasibility of using CBCT data to design and generate customized implants for patients requiring craniomaxillofacial reconstruction. We used CBCT to generate 62 implants for 51 consecutive patients admitted to our department between January 2015 and December 2017. The indications for reconstruction and types of reconstruction were very variable. In all cases, the implants were well fitted and no implant-related complications were detected. Pre-surgical planning was faster and more efficient as we did not have to consult a radiologist. Although CBCT data is more difficult to process than conventional CT data for the implant provider, the clinical advantages are pronounced and we now use CBCT as standard in our department. In conclusion, we have shown that using CBCT to design and manufacture customized implants for reconstruction of the craniomaxillofacial area is feasible and recommend this approach to other departments., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Although different proposals have been made to categorize isolated zygomatic arch fractures (ZAF), an investigation about fracture type and clinical outcome has not been published. In this study, we analyzed the geometric fracture morphology in isolated ZAF and provide a survey of reduction outcomes in accordance with 4 independent classifications., Materials and Methods: Geometric measurements were performed in radiologic images of 94 patients with isolated ZAF, which were consecutively treated by closed reduction over transbuccal approach. Fracture types were allocated to the classifications of Rowe and Williams, Honig and Merten, Yamamoto et al., and Ozyazgan et al. The odds of achieving a satisfactory outcome were calculated for all categories., Results: Wide preoperative dislocation angles of more than 22° presented in M-type fractures (77.1%) more frequently compared to 2 fragments without the M-shape (33.3%) and one fragment (14.8%, p < 0.001). Favorable reduction outcome was significantly higher for M-shaped fractures than for differently configured fractures (83.3% vs. 30.4%, odds ratio 11.43, confidence interval 4.27-30.61). The rate of reduction in 100%-75% was most frequent for the Honig and Merten type I as well as Ozyazgan type IBV (both 85.4%, p < 0.001) and Yamamoto type II (84.2%, p < 0.001)., Conclusion: The classifications of Honig and Merten, Yamamoto et al., and Ozyazgan were quite applicable, and subgroups showed significant increments in reduction outcome. Our analysis emphasizes that the differentiation of two clinical relevant groups, M-shaped and variable arch fractures, is feasible to manage and efficient to determine the odds of reduction outcome., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Fractures of the orbital floor and orbital rim are frequently treated in maxillofacial departments. Various approaches to the orbital floor are described in the literature. We present an investigation of a modified subciliary approach (laterocaudal approach) with respect to its feasibility and clinical outcome., Materials and Methods: Our retrospective study investigated 130 well-documented cases of patients with orbital floor fractures who received surgical reconstruction using a laterocaudal approach, and compared the results with the current literature, with a focus on subciliary and transconjunctival approaches., Results: 111 patients (85.4%) presented a Vancouver scar scale (VSS) of 0.14 patients (10.8%) had a VSS score of 1. No patients had a VSS of 2. Just five patients (3.8%) had a slight ectropium and therefore a VSS score of 3., Conclusion: The laterocaudal approach can be safely performed and presents advantages over comparable techniques such as the subciliary and transconjunctival approaches if performed correctly., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Up to half of patients with oral cavity squamous cell carcinoma (OCSCC) have stage I to II disease. When adequate resection is attained, no further treatment is needed; however, re-resection or radiotherapy may be indicated for patients with positive or close margins. This multicenter study evaluated the outcomes and role of adjuvant treatment in patients with stage I to II OCSCC., Methods: Overall survival (OS), disease-specific survival, local-free survival, and disease-free survival rates were calculated with Kaplan-Meier analysis., Results: Of 1257 patients with T1-2N0M0 disease, 33 (2.6%) had positive margins, and 205 (16.3%) had close margins. The 5-year OS rate was 80% for patients with clear margins, 52% for patients with close margins, and 63% for patients with positive margins (P < .0001). In a multivariate analysis, age, depth of invasion, and margins were independent predictors of outcome. Close margins were associated with a >2-fold increase in the risk of recurrence (P < .0001). The multivariate analysis revealed that adjuvant treatment significantly improved the outcomes of patients with close/positive margins (P = .002 to .03)., Conclusions: Patients with stage I to II OCSCC and positive/close margins have poor long-term outcomes. For this population, adjuvant treatment may be associated with improved survival. Cancer 2018;124:2948-55. © 2018 American Cancer Society., (© 2018 American Cancer Society.)