Bony Margins Research Articles

Imaging features of iBalance, a new high tibial osteotomy: what the radiologist needs to know.

To describe the post-surgical imaging appearance and complications of high tibial osteotomy in patients with the iBalance implant system (iHTO; Arthrex, Naples, FL, USA). Retrospective, institutional review board-approved, Health Insurance Portability and Accountability Act-compliant review of imaging after 24 iBalance procedures was performed with attention to: correction of varus malalignment, healing at the osteotomy site, resorption of the osteoinductive compound, and complications. Immediate correction of the varus deformity was present in all cases. Lobular radiolucency was present in all cases, more pronounced on the lateral knee radiograph, simulating infection or erosive disease. Four radiographic signs of healing were observed: blurring at the opposing osteotomy bony margins and at the osteoinductive compound and the adjacent bone interface, callus formation, and resorption of the osteoinductive compound. Complications were present in 33% of cases, including fracture through the lateral tibial cortex (21%), genu varum recurrence (8%), painful exuberant bone formation (4%), persistent pain, requiring total knee arthroplasty (4%), and non-union (after >6months' follow-up), with suspected infection (4%). Radiologists should be aware of the normal radiographic appearance following iBalance high tibial osteotomy, which may be confused with infection. Radiologists should also be aware of potential post-operative complications and compare all post-operative radiographs with the immediate post-operative examination to detect collapse of the osteotomy site and recurrence of varus angulation.

Can the inferior alveolar nerve be used as a marker in frozen section for free margin control after segmental mandibulectomy in tumour ablation?

This study critically assessed the possibility of tumour spread along the inferior alveolar nerve (IAN) and its sensitivity as an intraoperative marker for clear bony margin control in frozen section during segmental mandibulectomy. Fifteen patients with oral squamous cell carcinoma (OSCC) involving the mandible and requiring a segmental mandibulectomy were included in this prospective trial. The ends of the IAN were analyzed using quick section analysis and the results compared with those of the definite pathological report. Nerve tissue could be identified in 25 of the 27 specimens collected. No specimen revealed tumour invasion. All histological diagnoses were finally confirmed. Three positive bony margins with microscopic carcinoma infiltrates were found, whereas corresponding nerve tissue did not confirm tumour invasion. This study supports the assumption that the pattern of tumour invasion is rarely primarily along the IAN in OSCC involving the mandible. Quick section analysis of the nerve tissue alone is therefore not a valid marker for intraoperative bony margin control. However, it can be used as an additional intraoperative diagnostic tool combined with other methods in rare cases of primary tumour spread along the IAN. A review of current knowledge regarding bony margin control published in the literature is provided.

Stent technique for endoscopic dacryocystorhinostomy – Our expertise

Abstract BACKGROUND. Endoscopic dacryocystorhinostomy is known to be the ideal treatment for saccal and postsaccal stenosis of the lacrimal apparatus. Following this surgery, an important inconvenient would be the stenosis of the created ostium with consecutive epiphora. MATERIAL AND METHODS. 20 patients with chronic unilateral lacrimal duct obstruction were operated in “Prof. Dr. D. Hociota” Institute of Phono-Audiology and Functional ENT Surgery, Department I, between January 2015 and July 2015. After creating the dacryocystorhinostoma, a stent was inserted transnasally to the bottom edge of the lacrimal sac and positioned to the bony margin of the ostium. Stents used varied in size from 1 to 3 mm in diameter. We followed-up our patients at 2 weeks and 1, 3, 6 months, assessing the symptoms of the lacrimal apparatus, especially the epiphora. RESULTS. The mean age of patients varied between 31 and 65. Most of our patients were women (n=14). In a total number of 16 patients epiphora disappeared, it decreased in 2 patients, and persisted in 2 patients. There were two patients with no changes who have spontaneously eliminated the stent 2 or 3 days after the surgery. The most widely used stent size was 3 mm diameter, with a success rate of 90%. CONCLUSION. The endoscopic approach may be an effective procedure in patients with pathologies of the lacrimal apparatus. In order to achieve an efficient result, both a preoperative rigorous preparation and also postoperative medical care are necessary. In conclusion, ostium stenting represents a better way to ensure a longer period of maintaining the permeability of the lacrimal apparatus.

What Is the Expected Learning Curve in Computer-assisted Navigation for Bone Tumor Resection?

Computer navigation during surgery can help oncologic surgeons perform more accurate resections. However, some navigation studies suggest that this tool may result in unique intraoperative problems and increased surgical time. The degree to which these problems might diminish with experience-the learning curve-has not, to our knowledge, been evaluated for navigation-assisted tumor resections. (1) What intraoperative technical problems were observed during the first 2years using navigation? (2) What was the mean time for navigation procedures and the time improvement during the learning curve? (3) Have there been any differences in the accuracy of the registration technique that occurred over time? (4) Did navigation achieve the goal of achieving a wide bone margin? All patients who underwent preoperative virtual planning for tumor bone resections and operated on with navigation assistance from 2010 to 2012 were prospectively collected. Two surgeons (GLF, LAA-T) performed the intraoperative navigation assistance. Both surgeons had more than 5years of experience in orthopaedic oncology with more than 60 oncology cases per year per surgeon. This study includes from the very first patients performed with navigation. Although they did not take any formal training in orthopaedic oncology navigation, both surgeons were trained in navigation for knee prostheses. Between 2010 and 2012, we performed 124 bone tumor resections; of these, 78 (63%) cases were resected using intraoperative navigation assistance. During this period, our general indications for use of navigation included pelvic and sacral tumors and those tumors that were reconstructed with massive bone allografts to obtain precise matching of the host and allograft osteotomies. Seventy-eight patients treated with this technology were included in the study. Technical problems (crashes) and time for the navigation procedure were reported after surgery. Accuracy of the registration technique was defined and the surgical margins of the removed specimen were determined by an experienced bone pathologist after the surgical procedure as intralesional, marginal, or wide margins. To obtain these data, we performed a chart review and review of operative notes. In four patients (of 78 [5%]), the navigation was not completed as a result of technical problems; all occurred during the first 20 cases of the utilization of this technology. The mean time for navigation procedures during the operation was 31 minutes (range, 11-61 minutes), and the early navigations took more time (the regression analysis shielded R2=0.35 with p<0.001). The median registration error was 0.6mm (range, 0.3-1.1mm). Registration did not improve over time (the regression analysis slope estimate is -0.014, with R2=0.026 and p=0.15). Histological examinations of all specimens showed a wide bone tumor margin in all patients. However, soft tissue margins were wide in 58 cases and marginal in 20. We conclude that navigation may be useful in achieving negative bony margins, but we cannot state that it is more effective than other means for achieving this goal. Technical difficulty precluded the use of navigation in 5% of cases in this series. Navigation time decreased with more experience in the procedure but with the numbers available, we did not improve the registration error over time. Given these observations and the increased time and expense of using navigation, larger studies are needed to substantiate the value of this technology for routine use. Level IV, therapeutic study.

Magnetic resonance imaging-based measures of atlas position: Relationship to canine atlantooccipital overlapping, syringomyelia and clinical signs

Canine atlantooccipital overlapping (AOO) is characterized by a decreased distance between the dorsal arch of the atlas and the supraoccipital bone. Current diagnostic criteria for this condition are subjective and clinician-dependent; objective criteria are needed to allow a reliable and reproducible diagnosis in clinical and research settings and assess clinical significance. We propose four standardized MRI-based measurements to objectively assess the proximity of the atlas to the foramen magnum. Inclusion criteria for dogs in this study were bodyweight <15 kg, age >5 months, and availability of a complete MRI study performed with the craniocervical junction in extension. Exclusion criteria were space-occupying lesions and poor image quality (i.e. unclear bony margins). Measurements also included blinded determinations of skull type, presence of craniocervical junction anomalies and presence and severity of syringomyelia. Clinical status at the time of imaging was noted.Measurements were obtained in 271 dogs; these were reproducible and reliable. Findings varied by skull type: dolichocephalic dogs had smaller foramen magnum, whereas brachycephalic dogs had more cranially and dorsally positioned atlas bodies in comparison to the other skull types. Measurements also increased with increases in bodyweight. This study demonstrated a close association between AOO, syringomyelia and clinical signs. Toy and small breed dogs (including Cavalier King Charles spaniels) showed higher than previously reported prevalence of AOO; its occurrence was also associated with lower bodyweights within the study population of <15 kg toy/small breed dogs.

Horizontally Impacted Mandibular Third Molar

Clinical Presentation: A 35 year old female presented to the Department of Dentistry and Faciomaxillary Surgery complaining of discomfort in the right mandibular third molar region (fourth quadrant). General health examination revealed that the patient was conscious, oriented, afebrile and vitals were stable. On intraoral clinical examination, partially clinically exposed right mandibular third molar was present along with pericoronitis, halitosis, pain, swelling and gingival bleeding (Figure 1). Patient stated that the discomfort has been present since a week. The pain increased in intensity during mastication. Radiographically, horizontaly impacted right mandibular third molar was seen in radiovisiogram (RVG) (Figure 2). Treatment procedure included planned surgical removal of the specific tooth under local anaesthesia with 1:2,00,000 adrenaline. After placement of mouth prop, Fraser suction in place, topical local anesthetic applied, inferior alveolar nerve block was administered , incision placed with the no.3 and no.11 Bard Parker surgical handle and blade, mucoperiosteal flap raised with the help of periosteal elevator, overlying bone and the impacted tooth clinically seen (Figure 3). The flap was retracted with the help of Austins retractor whereas the tongue by tongue depressor. With the help of micromotor handpiece apparatus which includes, high speed sharp carbide burs, no.557/703 fissure burs, no.8 round bur, excess bone coverage was trimmed so that the horizontally placed tooth was surgically uplifted by wedging with the help of Couplands elevator in the fulcrum region which lies between distal surface of right mandibular second molar and the mesial coronal surface of the impacted tooth. To reduce the heat production during bone cutting, 18 gauge needle and 10 ml syringe were used for saline irrigation. After removal of the impacted tooth in full portion with the help of lower molar forceps (Figure 4), the socket was curetted for fresh bleeding (Figure 5), bony margin were trimmed by bone rongeur, bone smoothening done by bone file, mucoperiosteal flap replaced, soft tissue held by Adson forceps and 3-0 black silk sutures placed (Figure 6) with the help of needle holder along with cutting edge suture needle and excess suture material was removed by Metzenbaum scissors. After a week of review, the sutures were removed with an evidence of excellent intraoral healing.

Two-part interlocking plate for reconstruction of large orbital fractures

econstruction of the orbital floor and wall can be challengng for many reasons, and it is important to access large efects and to restore normal bony anatomy and orbital volme without compromising cosmesis. We present a case eries of combined fractures of the orbital floor and wall that ere repaired with a custom-made, two-part, interlocking itanium plate inserted through a standard transconjunctival r lower blepharoplasty incision, without disruption to the anthi. To construct the titanium plates we mark the fracture line nd the normal bony margins on a stereolithic model prouced at our hospital (Fig. 1). Fabrication of the plate in wo halves (Fig. 2) allows each one to be inserted separately

The anatomy and function of the obturator externus.

There is limited knowledge regarding the anatomic relationships and functional anatomy of the Obturator Externus muscle (OE). It is described as a muscle which originates from the external bony margin of the obturator foramen with a cylindrical tendon which passes like a sling under the femoral neck and inserts in the trochanteric fossa. The primary aim of this study is to describe the OE morphology and its anatomic relationship to the acetabulum. A secondary aim is to postulate its action. Eighteen fresh human cadaveric hips were dissected to investigate the anatomy of the OE. A plastic model of the pelvis and femur was used to create a string model based on a technique previously described by Beck et al. The plastic model was used to determine the function of the OE.We conclude that the Obturator externus muscle helps to stabilise the head of the femur in the socket. The mechanical model demonstrated that the primary action of the obturator externus muscle was to externally rotate the femur when the hip was in neutral position and flexed at 90°. Its secondary function was as an adductor when the hip was in flexion.

Morphogenesis of the compartmentalizing bone around the molar primordia in the mouse mandible during dental developmental stages between lamina, bell-stage, and root formation (E13–P20)

Despite increasing knowledge of the basic molecular aspects of bone formation and its regulation, the mechanisms of bone morphogenesis leading to a topologically specific shape remain unknown. The formation of the alveolar bone, which houses the dental primordia and later, the dental roots, may serve as a model to understand the formation of bone form in general. Thirty-eight heads of mice (C57 Bl/6J) ranging from stages E13–P20 were used to prepare histological serial sections. For each stage, virtual 3D-reconstructions were made in order to study the morphogenesis of the mandibular molar primordia concomitantly with their surrounding bone. Special focus was given to recording the remodeling pattern.It has been shown that, in early stages (E13, E14), bone formation is characterized by apposition only. In stage E15, the bony crypt around the dental primordia is remodeled mostly by resorption of bone. In stage E18, the bone remodeling pattern shows resorption all along the bony gutter, which houses the molar primordia. The medial and lateral margins are characterized by apposition. At birth (stage P0), a bony septum has begun to form between the primordium m1 and of m2, arising from both sides and characterized by pure apposition of bone. In stage P4, the crypts of m1 and m2, and also that of m3, show bone resorption inside, while the medial and lateral bony margins show apposition of bone throughout. Generally, during development, the bone gradually encapsulates the dental primordia, in such a way that the bone reaches over the dental primordia and leaves only a continuous longish opening of about 200μm width. The opening at the occlusal surface of m1, at the time of eruption, starting at stage P14, appears to have increased in size again. The distance between bone and dental primordium undergoes change during development. In erupted molars, it is around 100μm, during early developmental stages, it may be as less as 20μm. These data show the inevitability of bone remodeling.

Gingival fenestration defect in the maxillary anterior region treated with coronally positioned flap using platelet-rich fibrin membrane

This report describes the management of gingival fenestration of maxillary right lateral incisor using platelet-rich fibrin (PRF) and coronally repositioned flap procedure. Earlier reports have been documented where fenestration defects around implants are treated with PRF. To the best of our knowledge, this is the first case reported with PRF and chronic renal failure in gingival fenestration around natural tooth. Initial oblique incisions were placed on either side of the defect at the level of the cementoenamel junction #12, followed by vertical incisions extending beyond the mucogingival junction into the alveolar mucosa. After flap elevation, recontouring of the irregular prominent bony margin was performed. Thorough root planing was done; freshly prepared PRF was placed over the root surface and sutured; overlying flap was coronally repositioned and sutured with 5-0 silk sutures. The results of the case demonstrated satisfactory healing of the gingival fenestration defect with excellent color, texture match with the surrounding area along with the keratinized tissue formation emphasizing the importance of using PRF as a membrane in esthetically demanding areas. CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY PRF could be a good option in treating fenestration which provides good healing and color match especially in esthetically demanding areas.

Super Odontoma – A Destructive Swarm Entity

Odontoma is a common benign odontogenic tumor seen mostly in permanent dentition. This case report presents the management of a 5-year-old child who had impacted primary maxillary canine associated with a compound composite odontome with multiple denticles – a rare entity. Odontomas are usually asymptomatic but can cause problems like disturbances in the eruption of teeth such as impaction or delayed eruption, retention of primary teeth or abnormalities in position of teeth such as tipping or displacement of adjacent teeth [1]. Panoramic radiography can be used in the detection of odontomas. But it cannot give enough information to management and treatment planning [2]. Cone Beam Computed Tomography is the best diagnostic imaging method currently available; it provides higher resolution for hard tissues, determines accurate location of retained teeth and their relationship to adjacent tissues and minimizes patient radiation exposure [3]. Conservative surgical excision of odontomas is the treatment of choice as these are well encapsulated and can be easily enucleated from surrounding bone and there is little possibility of recurrence. In the present case the unerupted primary maxillary canine was with the odontomas so surgical removal along with the odontomes was done. A 5-year-old boy came with the chief complaint of decayed teeth. On intraoral examination, there were multiple carious teeth and a missing primary maxillary right canine which was associated with slight swelling labially but asymptomatic. On palpation, it was bony hard in consistency. Panoramic radiograph showed numerous radiopaque masses adjacent to the roots of the first primary molar arranged in a flower pattern of 2 x 2cm in diameter [Table/Fig-1]. Based on the clinical and radiographic evaluation, the diagnosis of early childhood caries and impacted primary canine due to compound composite odontoma was made. A differential diagnosis of ameloblastic fibroodontoma and odontoameloblastoma was made. They show a great resemblance to common odontomas, especially in the radiographic examination. [Table/Fig-1]: Panoramic radiograph revealing numerous radiopaque masses adjacent to the roots of the first primary molar The enucleation of the entire lesion was planned under local anesthesia. A sulcular incision was placed buccally and a mucoperiosteal flap was raised from distal aspect of maxillary lateral incisor to mesial aspect of second primary molar. Bone was removed with a bur to expose the calcified mass [Table/Fig-2]. The mass was removed and followed by curettage of lining to remove any remnants. The tissue was sent for histopathological examination. The sharp bony margins were rounded and irrigated with povidone iodine. After adequate hemostasis suturing was done with 3 – 0 black silk sutures. The retrieved specimen revealed few tooth like structures and few were fused total of 25 with well differentiated dental tissues [Table/Fig-3]. The postoperative period was uneventful. [Table/Fig-2]: Surgical exposure of odontome [Table/Fig-3]: Multiple denticles (25)

Influence of bony resection margins and surgicopathological factors on outcomes in limb-sparing surgery for extremity osteosarcoma.

Limb-sparing surgery for osteosarcoma requires taking wide bony resection margins while maximizing preservation of native bone and joint. However, the optimal bony margin and factors associated with recurrence and survival outcomes in these patients are not well established. We conducted a retrospective review of outcomes in children and adolescents with newly diagnosed osteosarcoma from 1986 to 2012, where bony resection margins for limb-sparing surgeries were decreased serially from 5 to 1.5 cm. The association between bony margins and other surgicopathological factors with survival and recurrence outcomes was determined. In 181 limb-sparing surgeries in 173 patients, planned and actual bony resection margins were not significantly associated with local recurrence-free survival (LRFS), event-free survival (EFS), and overall survival (OS)-at median 5.8 years follow-up, decreasing planned bony resection margins from 5 to 1.5 cm did not significantly decrease survival outcomes. Multivariable analysis showed that the presence of distant metastases at diagnosis was associated with decreased LRFS, EFS, and OS (P = 0.002, 0.005, and <0.0001, respectively). Post-chemotherapy tumor necrosis ≤90% was associated with decreased EFS and OS (P = 0.001 and 0.022, respectively). Earlier years of treatment and pathologic fractures were associated with decreased OS only (P = 0.018 and 0.008, respectively); previous cancer history and male gender were associated with decreased EFS only (P = 0.043 and 0.023, respectively). We did not observe significant increase in adverse survival outcomes with reduction of longitudinal bony resection margins to 1.5 cm. Established prognostic factors, particularly histologic response to chemotherapy and metastases at diagnosis, remain relevant in limb-sparing patients. Pediatr Blood Cancer 2015;62:246-251. © 2014 Wiley Periodicals, Inc.

Description of a New Species ofAspidoras(Siluriformes, Callichthyidae) from the Serra dos Carajás, Lower Tocantins River Basin, Brazil

A new species of Aspidoras (Corydoradinae) is described from the Serra dos Carajas, lower Tocantins River basin, representing the northernmost record of the genus at the edge of the Brazilian Shield into the Amazon basin. Aspidoras gabrieli is easily distinguished from all congeners by having the rays and interradial membranes of the dorsal and pectoral fins entirely and densely pigmented, the inner bony margin of the pectoral spine expanded as a narrow laminar shelf with edge smooth or scarcely serrated; lateral-line canal posterior to the two anterior lateral-line ossicles absent (also in A. taurus), naked predorsal region (also in A. velites and A. psammatides), large brown oval spots on the flank and caudal peduncle that sometimes merge to form irregular patches (also in A. maculosus, A. albater, A. lakoi, and A. depinnai), and several additional morphometric distinguishing features. Comments on generic allocation and interspecific relationships are presented. Uma nova especie de Aspidoras (Corydoradi...

Locating the center of resistance in individual teeth via two- and three-dimensional radiographic data

The preferred reference point to describe the force-moment system exerted upon a tooth is its center of resistance (CR). Morphological data on the dentoalveolar complex can be used to locate this point either three-dimensionally (3D) with the finite element (FE) method, or two-dimensionally (2D) with a mathematical method calculating the centroid of the projected dental root. This study aimed to compare and appraise these two methods with regard to their accuracy and time requirements. Three radiological datasets with permanent teeth were included. Each single 3D dataset was used in each of these patients to derive both a 3D and 2D morphological model of the upper right central incisor. CR levels were evaluated in percent, indicating the relative height as measured from the (averaged levels of the mesial and distal) bony ridge margin to the tooth's apex. Mean CR levels of 42.8% for distalization and 56.5% for lingual movement were obtained from the 3D FE simulations of initial tooth movement. The 2D mathematical model yielded a mean CR level of 44.5%. Compared to this mathematical approach, the 3D FE simulations were around 15 times more time-consuming, with an interactive requirement of around 15h. Because they contain so much more morphological information, 3D FE simulations should offer superior predictability. In addition, they are the only method offering detailed CR identification for specific directions of tooth movement. Before this method can be used in clinical practice, however, there is still a major need to reduce time requirements via further automation of process steps and to investigate how it should be applied to different tooth types.

Image guided radiofrequency thermo-ablation therapy of chondroblastomas: should it replace surgery?

To assess the safety and effectiveness of image-guided radiofrequency ablation (RF ablation) in the treatment of chondroblastomas as an alternative to surgery. Twelve patients with histologically proven chondroblastoma at our institution from 2003 to date. We reviewed the indications, recurrences and complications in patients who underwent RF ablation. Twelve patients were diagnosed with chondroblastoma. Out of these, 8 patients (6 male, 2 female, mean age 17 years) with chondroblastoma (mean size 2.7 cm) underwent RF ablation. Multitine expandable electrodes were used in all patients. The number of probe positions needed varied from 1 to 4 and lesions were ablated at 90 °C for 5 min at each probe position. The tumours were successfully treated and all patients became asymptomatic. There were no recurrences. There were 2 patients with knee complications, 1 with minor asymptomatic infraction of the subchondral bone and a second patient with osteonecrosis/chondrolysis. Radiofrequency ablation appears to be a safe and effective alternative to surgical treatment with a low risk of recurrence and complications for most chondroblastomas. RF ablation is probably superior to surgery when chondroblastomas are small (less than 2.5 cm) with an intact bony margin with subchondral bone and in areas of difficult surgical access.

Cholesterol granuloma of the orbit: An atypical presentation

Cholesterol granuloma is a rare, well-defined lesion of the orbit. In the orbit, diploe of the frontal bone is involved almost exclusively. We report an atypical case of cholesterol granuloma involving superomedial quadrant of orbit. A 42-year-old male presented with progressive, painless, proptosis with infero-temporal displacement of left eye. A large mass was felt beneath the bony orbital margin in the superomedial quadrant of the left orbit. Computerized tomography (CT) scan revealed an extraconal superomedial, heterogeneous enhancing mass which was isodense with brain and pushing the globe inferolaterally and anteriorly. Excision biopsy of the tumor revealed the typical features of a cholesterol granuloma without any epithelial elements. Cholesterol granuloma of the orbit is a rare entity, but it can be diagnosed and differentiated from other lesions of the superior orbit by its characteristic clinical, radiological and histopathological features. An appropriate intervention in time carries a good prognosis with almost no recurrence.

Extent of Decompression and Incidence of Postoperative Epidural Hematoma Among Different Techniques of Spinal Decompression in Degenerative Lumbar Spinal Stenosis

Prospective radiographic cohort study. To study the extent of bony decompression and dural sac expansion after laminectomy (including subtotal laminectomy and laminotomy with midline resection), bilateral fenestration, and unilateral fenestration with contralateral undercutting in lumbar spinal canal stenosis. Further, to investigate differences of incidence and extent of early postoperative epidural hematoma in these approaches. There are different techniques of decompression in lumbar spinal stenosis. An overall good clinical outcome has been reported with different biomechanical consequences, but no morphometric comparative reports exist on these approaches. Using the data of a previous prospective study of 30 patients, who underwent lumbar decompression for degenerative stenosis, 49 levels treated with 3 different kinds of surgical approaches were analyzed: (1) laminectomy (including subtotal laminectomy, laminotomy with midline resection); (2) bilateral fenestration; and (3) unilateral fenestration with contralateral undercutting. In all 3 groups, the cross-sectional area of the maximum bony stenosis and dural sac compression (bony margins and dural sac expansion) were measured in each operated level before and after the operation. Occurrence of epidural hematoma and its size were noted in the 3 groups. Median postoperative bony stenosis was not significantly different in the groups, being 330 mm(2), 333.5 mm(2), and 261.5 mm(2), respectively, in groups 1, 2, and 3. There was no statistically significant difference between the median postoperative extension of dural sac areas in the 3 groups, measuring 125 mm(2), 123 mm(2), and 137 mm(2). The incidence of epidural hematoma was similar in the 3 groups. Levels where postoperative epidural hematoma was detected had larger bony decompression independent of the surgical approach compared with the whole group. Unilateral and bilateral approaches achieve a similar amount of dural sac extension by a lesser extent of bony resection in comparison with the laminectomy approach. There is a tendency of increased postoperative hematoma in approaches with greater bony decompression area.

An easy access to retrieve dental implants displaced into the maxillary sinus: the bony window technique

To present the authors' experience concerning the removal of dental implants displaced in the maxillary sinus via an intraoral approach consisting of the creation of a bony window pedicled to the maxillary sinus membrane. Thirty-six systemically healthy patients, presenting with oral implants displaced into the maxillary sinus, but with no signs of acute or chronic sinusitis, were consecutively treated between 2002 and 2012 via an intraoral approach with the bony window technique. Removal of oral implants from the maxillary sinus was achieved in all patients, and postoperative recovery was uneventful in all of them. Computed tomographies performed after surgery showed no signs of residual sinus infection in all patients and a complete ossification of the bony window margins. Twelve of the 36 treated patients were treated with a sinus grafting procedure 12-18 months after in the same areas previously treated with the bone lid technique. Seventeen implants were placed in the grafted areas 6-9 months later and, after a further waiting period needed for osseointegration, the treated patients were rehabilitated with implant-supported prostheses. The survival rate of implants was 100%, and no complications related to the sinuses and implants were recorded. Results from this study seem to demonstrate that the bony window technique is a safe and easy way to remove oral implants from the maxillary sinus under local anesthesia. The surgical access is hardly visible 6-12 months after surgery, and maxillary sinuses appeared free from residual pathology in all treated patients. Finally, this procedure allows a second-stage sinus grafting procedure via a lateral approach as in a previously untreated maxillary sinus, thus allowing an implant-supported prosthetic restoration.

Oromandibular Reconstruction Using 3D Planned Triple Template Method

Reconstruction of an oromandibular defect remains one of the most formidable surgical challenges faced by the reconstructive head and neck surgeon. The purpose of this study was to illustrate the added value of 3D imaging and planning in oromandibular reconstruction. A 41-year-old dentate male patient with T2N0M0 osteosarcoma of the mandible required segmental resection of the lateral mandible. In a virtual environment, the bony resection and reconstruction were planned preoperatively based on computed tomographic data of the head and neck and lower leg. Three custom-made templates designed in a computer-assisted design and manufacturing software package and materialized by a selective laser sintering process (DuraForm PA, 3D Worknet, Ede, Netherlands) were used to transfer this planning to the operating theater. During the operative procedure, the 3 templates allowed for a rapid and accurate execution of the different surgical steps, ie, establishing the bony surgical margins and resection of the mandible (first template), cutting of the fibula while being pedicled to the leg (second template), and placement of the fibula to the donor site (third template). Computer-aided surgery and planning using the 3-template method lead to an accurate and oncologically safe reconstruction of the mandibular geometry by eliminating intraoperative decision making, shortening ischemic time of the fibular graft, and shortening overall operative time.

The Composite Mucosal Cartilaginous Septal Flap for Endoscopic Skull Base Reconstruction

Introduction: The nasoseptal flap has revolutionized endoscopic skull base surgery; however, adequate closure of large dural defects remains technically challenging. The use of a rigid component to form a gasket-seal around the bony defect margin may prove useful in reducing the rate of CSF fistula. Here we describe a modification of the nasoseptal flap, which allows the harvest of cartilage with its blood supply along with mucosa for a stronger repair of large skull base defects.