Cranio-Maxillofacial Surgery

Scaffold implantation in the omentum majus of rabbits for new bone formation Publication date: Available online 3 June 2019 Source: Journal of Cranio-Maxillofacial Surgery Author(s): Falk Birkenfeld, Andre Sengebusch, Chiara Völschow, Björn Möller, Hendrik Naujokat, Jörg Wiltfang Abstract Restoration of the mandible after defects caused by ablative surgery remains challenging. Microvascular free flaps from the scapula, fibula or iliac crest remain the 'gold standard'. A drawback of these methods is donor-side morbidity, availability and the shape of the bone. Former cases have shown that prefabrication of a customized bone flap in the latissimus dorsi muscle may be successful; however, this method is still associated with high donor-side morbidity. Osteogenesis in the omentum majus of rabbits by wrapping the periosteum into it was confirmed recently and is particularly interesting for bone endocultivation. Twelve adult male New Zealand white rabbits were used. In each, two hydroxyapatite blocks were implanted in the greater omentum with autologous bone or autologous bone+rhBMP-2. Bone density measurements were performed by CT scans. Fluorochrome labelling was used for new bone formation detection. The animals were sacrificed at week 10, and the specimens were harvested for histological and histomorphometric analysis. In histological and fluorescence microscopic analysis, new bone formation could be found, as well as new blood vessels and connective tissue. No significant differences were found regarding the histological analysis and bone density measurements between the groups. It could be demonstrated that the omentum majus is a practical way to use one's own body as a bioreactor for prefabrication of tissue-engineered bony constructs. Regarding the influence and exact dose of rhBMP-2, further research is necessary. To establish and improve this method, further large-animal experimental studies are also necessary.

Microdialysis in postoperative monitoring of microvascular free flaps: experiences with a decision algorithm Publication date: Available online 28 May 2019 Source: Journal of Cranio-Maxillofacial Surgery Author(s): Falk Birkenfeld, Hendrik Naujokat, Ann-Kristin Helmers Nicolai Purcz, Björn Möller, Jörg Wiltfang Abstract Background Reconstruction with free flaps has become a usual practice in maxillofacial surgery. Clinical monitoring is still the standard approach for postoperative follow-up, but can be difficult or impossible with intraorally situated or buried flaps. Microdialysis is a sampling technique that offers the possibility to monitor the metabolism of flaps continuously. It is a reliable method for early diagnosis of ischemia. Materials and methods 48 microvascular free flaps applied following oral cancer resection were monitored with a microdialysis (MD) catheter, placed in the flap. Glucose, lactate, and lactate/pyruvate ratio were monitored using a bedside analyser for 5 days. 48 free flaps served as controls and were assessed (refill, flap temperature, and color) by clinical monitoring (CM). Results 12 flaps monitored by MD showed abnormal metabolism and underwent revision. Eight flaps were saved and four were lost within the first 5 days postoperatively. In addition, two flaps were lost at days 15 and 30 postoperatively, without previous complications. Four flaps assessed by CM developed complications, underwent revision, and were saved. In addition, five flaps were lost between the 8th and 23rd days postoperatively, without revision, due to missing previous clinical signs. Conclusion Postoperative monitoring of free flaps using a microdialysis decision algorithm allows early diagnosis of anastomotic complications. It is a clinically feasible and sensitive monitoring method for microvascular flaps, allowing surgical revision to be undertaken before clinical alteration takes place.

Computed tomography visualizing alterations in the upper airway after orthognathic surgery Publication date: Available online 10 May 2019 Source: Journal of Cranio-Maxillofacial Surgery Author(s): Luis Fernando Azambuja Alcalde, Paulo Esteves Pinto Faria, Renato Luiz Maia Nogueira, Letícia Chihara, Eduardo Sant'Ana Abstract Three-dimensional (3D) software has revolutionized planning in orthognathic surgery. This technology allows the simulation of surgical movements and evaluation of the volume and area of the pharyngeal airway space (PAS), which are not possible with two-dimensional (2D) software. Many patients undergo orthognathic surgery to improve occlusion and facial profile. The PAS may increase or decrease depending on the surgical movements. This study aimed to evaluate the changes in the area and volume of the PAS in patients having bimaxillary movement in orthognathic surgery. The minimum axial area and volume of the PAS (preoperative (T0) and postoperative (T1) air volumes) of 68 patients (26 male and 42 female, mean age 36.6 ± 12.1 years) were analyzed. Evaluations were conducted using cone-beam computed tomography in the Nemoceph 3D-OS program. A paired t-test was used to compare pre- and postoperative volume data, and the Wilcoxon test was used to compare pre- and postoperative data of the minimal axial area. All the tests were performed with Statistica software (StatSoft Inc., Tulsa, OK, USA), and a significance level of 5% was adopted. In the study of the method error, no casual or systematic error was found between the first and second measurements of the variables (p > 0.05 in all measurements). Bimaxillary surgery presented a mean of 70.46% in volume and a median increase of 61.27% in the minimum axial area, which varied from −22.50% to 659.06%. The results demonstrated that bimaxillary advancement significantly increased the volume and minimum axial area of the upper airway; however, the increase was not homogeneous in all the patients.

Association Between Gender, Estrogen Receptors Genes and Anxiety Levels In Patients Undergoing Orthognathic Surgery Publication date: Available online 10 May 2019 Source: Journal of Cranio-Maxillofacial Surgery Author(s): Rafaela Scariot, Camila Oliveira Tomaz, Robson Diego Calixto, Jennifer Tsi Gerber, Maria Fernanda Pivetta Petinati, Rafael Correia Cavalcante, Erika Calvano Küchler, Delson João da Costa Abstract Orthognathic surgery is a procedure that is performed for the correction of dentofacial deformities and can lead to a change in an individual's anxiety levels. Anxiety is a multifactorial condition in which hormones and genes play an important role. This study aimed to evaluate if gender and genetic polymorphisms in estrogen receptor alpha (ESR1) and beta (ESR2) are associated with anxiety levels in patients undergoing orthognathic surgery. In this longitudinal observational study, 44 patients were included. Anxiety level assessments were performed at three time periods: 2 days before the surgical procedure and 1 and 6 months postoperatively, using the State-Trait Anxiety Inventory Scale. Gender, age, and facial profile were also evaluated. Additionally, a saliva sample from each individual was collected for the genotypic evaluation of ESR1 (rs2234693 and rs9340799) and ESR2 (rs1256049 and rs4986938) using real time polymerase chain reaction. Data were analyzed with a significance level of 0.05. There was a decrease in trait-anxiety and state-anxiety when comparing the preoperative measurements with those obtained 1 and 6 months postoperatively (p < 0.05). Females were more anxious than males at each time point during the study (p < 0.05). The genetic polymorphism rs9340799 in ESR1 was associated with state-anxiety during the preoperative period (p = 0.046). In conclusion, an individual's gender and genetic polymorphism in ESR1 are associated with anxiety in orthognathic surgery patients.

Epidemiological Analysis Of Management Of Severe Odontogenic Infections Before Referral To The Emergency Department Publication date: Available online 10 May 2019 Source: Journal of Cranio-Maxillofacial Surgery Author(s): Konstantinos Katoumas, Dimitrios Anterriotis, Maria Fyrgiola, Violetta Lianou, Dimitrios Triantafylou, Ioannis Dimopoulos Summary Purpose The aims of the present study are to present the epidemiology and management of patients hospitalized with odontogenic infections in a major Greek hospital from 2015 to 2016 and to find out whether the basic principles of management of odontogenic infections were followed before referral to the emergency department of the Oral and Maxillofacial Surgery Clinic (OMFSED). Methods A retrospetive study of the patients hospitalized with odontogenic infections was performed, including management both prior and after referral to the OMFSED. Results During the two-year period from 2015 to 2016, 102 patients, 54 men (52.9%) and 48 women (47.1%) were hospitalized with severe odontogenic infections. The most common space involved in severe odontogenic infections was the submandibular (52.9%), and in 31.4% of the patients multiple spaces were involved. The lower third molars were the most common cause (36.5%). In 83 patients (81.4%) the tooth causing the infection had not received any treatment whatsoever and in all cases (100%) no decision for early incision and drainage prior to the referral to the OMFSED was made. Conclusion The data presented reveal that the basic principles of management of odontogenic infections are not followed before referral of the patients to the OMFSED.

In vitro proinflammatory gene expression changes in human whole blood after contact with plasma-treated implant surfaces Publication date: Available online 9 May 2019 Source: Journal of Cranio-Maxillofacial Surgery Author(s): Merlind Becker, Susanne Quabius, Thorben Kewitz, Luka Hansen, Gesa Becker, Matthias Kern, Holger Kersten, Sönke Harder Summary Background The aim of this in vitro study was to identify changes in gene expression of proinflammatory cytokines in human whole blood after contact with titanium implant surfaces after plasma treatment. Materials and methods Grade 4 titanium dental implants were conditioned with low-pressure plasma (LPP) and atmospheric-pressure plasma (APP) and submerged in human whole blood in vitro. Unconditioned implants and blood samples without implants served as control and negative control groups, respectively. Sampling was performed at 1, 8, and 24 h. Changes in mRNA expression levels of interleukin 1-beta (IL1-β) and tumor necrosis factor-alpha (TNF-α) were assessed using RT-qPCR. Results In the control group, significant increases in IL1-β and TNF-α expression were observed. Significant decreases in the expression of IL1-β and TNF-α were identified in blood with implants after plasma treatment. Conclusion Differences in gene expression of proinflammatory cytokines after implantation of plasma-conditioned titanium implants can be assessed using human whole blood. The results of the present study indicate that plasma treatment (APP and LPP) of titanium dental implants leads to downregulation of proinflammatory cytokine gene expression, which might be beneficial in early osseointegration.

Impact of orthognathic surgery on quality of life: predisposing clinical and genetic factors Publication date: Available online 9 May 2019 Source: Journal of Cranio-Maxillofacial Surgery Author(s): Marilisa Gabardo, João Zielak, Gabriela Tórtora, Jennifer Gerber, Michelle Meger, Nelson Rebellato, Erika Küchler, Rafaela Scariot Summary Introduction Dentofacial deformities have an impact on quality of life (QOL). Many factors can influence this perception, including genetic aspects. ANKK1 and DRD2 genes are associated with dopaminergic system and could modulate behavioral dysfunction. Purpose The impact of orthognathic surgery and associated factors on QOL of adults was ealuated. Material and Methods The abbreviated World Health Organization Quality of Life questionnaire (WHOQOL-BREF) was applied to patients from two surgery services one week before (T0) and six months after surgery (T1). The independent variables were age, sex, race, facial pattern, presence of jaw asymmetry and vertical deformities, and polymorphisms associated with ANKK1 and DRD2 genes. Descriptive and bivariate analyses were performed. Results There was improvement in the perception of QOL from T0 to T1 in the general score, in the physical and psychological domains, and in the quality of life and general health perception (QOLGHP) (p < 0.001). In this interval, individuals aged ≥ 30 years reported positive impacts on all outcomes (p < 0.05), whereas in women this improvement did not occur only for the physical domain (p = 0.136). There was an association between the polymorphisms associated with the ANKK1 gene (rs1800497) and the perception of QOL in the social relationship's domain (p = 0.021) and QOLGHP (p = 0.042). The other clinical conditions were not associated with outcomes (p > 0.05). Conclusion Perception of QOL of patients improved following orthognathic surgery in physical, psychological, and QOLGHP domains. Aged ≥30 years, being women and polymorphisms associated with the ANKK1 gene were related to positive impacts.

Single-step surgical treatment of odontogenic maxillary sinusitis: A retrospective study of 98 cases Publication date: Available online 4 May 2019 Source: Journal of Cranio-Maxillofacial Surgery Author(s): Fabio Costa, Enzo Emanuelli, Leonardo Franz, Alessandro Tel, Massimo Robiony Abstract Purpose The aim of this study was to review clinical and radiological presentation, surgery, and results of treatment in patients with chronic odontogenic maxillary sinusitis (OMS) treated with a single surgical procedure, including endoscopic sinus surgery (ESS) and oral surgical approaches to treat the odontogenic source of infection. Materials and methods A retrospective case series analysis of 98 patients was performed. All the patients received ESS. 88 patients required oral surgical approaches. Results Nasal symptoms were present in 58 patients (59.2%). Nasal endoscopy was positive in 65 patients (66.3%). A positive nasal endoscopy was significantly associated with nasal symptoms (p < 0.05). 60 patients (61.2%) had OMS of iatrogenic origin. Total opacification of the maxillary sinus was the most common radiological presentation (74.5%) and was significantly associated with nasal symptoms (p < 0.05). 91 patients (92.9%) had complete clinical and radiological resolution of the OMS. Conclusions Iatrogenic origin, sinonasal symptoms and positive clinical endoscopy are common in patients with OMS. Nasal symptoms were significantly associated with total maxillary sinus opacification and positive endoscopic clinical examination. Combining treatment of the odontogenic source of infection via an oral surgical approach and of the sinus inflammation by ESS appears to be sufficient for successfully treating patients with OMS.

Functional and aesthetic treatment outcomes after immediate jaw reconstruction using a fibula flap and dental implants Publication date: May 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 5 Author(s): Sameh Attia, Jörg Wiltfang, Philipp Streckbein, Jan-Falco Wilbrand, Thaqif El Khassawna, Katharina Mausbach, Hans-Peter Howaldt, Heidrun Schaaf Abstract 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.

Catching condyle – Endoscopic-assisted transoral open reduction and rigid fixation of condylar process fractures using an auto reposition and fixation osteosynthesis plate Publication date: May 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 5 Author(s): Philipp Poxleitner, Pit Jacob Voss, David Steybe, Stefan Schlager, Steffen Schwarz, Marc Anton Fuessinger, Rainer Schmelzeisen, Marc Metzger Abstract Introduction Fractures of the mandibular condyle are reported to account for 9 %–45 % of all mandibular fractures. There has been a long lasting controversy on the superiority of different treatment options with endoscopic-assisted transoral approaches gaining increasing attention in recent years. In this article, we report the application of a newly developed osteosynthesis plate for an auto reposition, reconstruction and rigid fixation of condylar process fractures. Material and methods We present 6 cases of uni- or bilateral fractures of the condylar process treated with a transoral open reduction and rigid fixation using an auto reposition plate. Via a transoral endoscopic assisted approach the proximal condyle fragment is captured using an anatomical defined clinch of the cranial part of the plate. The reposition of the condyle is facilitated with the distal bridge of the plate ranging around the posterior part of the ascending ramus. Results The results show a sufficient reposition, rigid fixation and no facial nerve palsy or postoperative long-term occlusal disturbances. The mean operating time was 86 min. Conclusion Transoral endoscopic-assisted surgery with application of an auto reposition, reconstruction and fixation plate offers a quick and convenient way for open reconstruction and rigid fixation of condylar process fractures.

Alexandros Sfakianakis
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alsfakia@gmail.com