European Association For Cranio-Maxillofacial Surgery Research Articles

Microsurgical reconstruction of the head and neck – Current concepts of maxillofacial surgery in Europe

IntroductionMicrovascular surgery following tumour resection has become an important field of oral maxillofacial surgery (OMFS). This paper aims to evaluate current microsurgical practice in Europe. MethodsThe questionnaire of the DOESAK collaborative group for Microsurgical Reconstruction was translated into English, transformed into an online based survey and distributed to 200 OMFS units with the aid of the European Association for Cranio-Maxillo-Facial Surgery (EACMFS). Results65 complete and 72 incomplete questionnaires were returned. Hospitals from the United Kingdom, France, Italy, the Netherlands, Spain, Belgium, Greece, Slovenia and Lithuania participated. 71% of contributing centres were university hospitals, 87% out of these perform microvascular tumour surgery at least on a two-weekly base. Overall complication rate was at around five percent. Most frequently used transplants were the radial forearm flap and the fibular flap. The perioperative management varied widely. Success factors for flap survival, however, were uniformly rated, with the surgical skill being the most important factor, followed by the quality of postoperative management. Medication seems to play a less important role. ConclusionWithin Europe microvascular surgery is a common and safe procedure for maxillofacial reconstructive surgery in the field of OMFS. While there is a major accordance for the surgical procedure itself and the most frequently used flaps, perioperative management shows a wide variety of protocols with low presumed impact on surgical outcome.

Mandibular cortical shape index in non-standardised panoramic radiographs for identifying patients with osteoporosis as defined by the German Osteology Organization.

The aim of this prospective controlled study was to determine the validity of the mandibular cortical shape index (CI) on panoramic radiographs in distinguishing patients with osteoporosis as defined by the German Osteology Organization (Dachverbands der Deutschsprachigen Osteologischen Fachgesellschaften, DVO). The study group contained 50 patients (33 female, 17 male, mean age: 74.9 years), who had a high risk of osteoporosis. 50 young patients (33 female, 17 male, mean age: 37.9 years) with no anamnestic evidence of osteoporosis served as control. Three blinded observers evaluated panoramic views of the study and the control group in a mixed manner regarding the mandibular cortical shape index. The study group underwent bone mineral density measurement using dual energy X-ray absorptiometry and received a diagnosis according to the Organization’s guidelines (normal, osteopenia, osteoporosis). The CI showed a high sensitivity of 72.2% and a high specificity of 93.9% with a highly significant predictive value (Chi-square ¼ 22.96, p < 0.001), while the observer’s agreement was moderate (kappa ¼ 0.47). We concluded that patients with a cortical shape index of the category assessed as “severe” on non-standardised panoramic radiographs have a higher risk of suffering systemic osteoporosis. The CI in panoramic radiographs is a good screening tool, which could be implemented in the routine assessment of panoramic radiographs in elder patients. Crown Copyright 2013 Published by Elsevier Ltd on behalf of European Association for Cranio-MaxilloFacial Surgery. All rights reserved.

My Trip to the XXI Congress of the European Association for Cranio-Maxillo-Facial Surgery

My Trip to the XXI Congress of the European Association for Cranio-Maxillo-Facial Surgery

O.363 Angiogenesis is enhanced by high frequency distraction

Conference abstract (The XIXth Congress of the European Association for Cranio-Maxillofacial Surgery)

O.206 The role of maxillo-mandibular advancement in surgical treatment of patients with OSAS

Background and objective: Anthropometric measurements, described and assessed in Part I of this article were applied in dysgnathic patients. Diagnosis, surgical planning and follow-up were performed and soft tissue ratios quantified. Material and methods: One hundred and seventy-five anthropometric measurements and 146 cephalograms of 100 patients were included. Forty-five patients were analysed before and after surgery. Ten randomly selected patients were re-measured directly by two investigators for reliability and validity assessment. Results: Manoeuvres that expanded the facial skeleton such as maxillary or mandibular advancements or maxillary elongations generally had a greater soft tissue impact than setbacks or maxillary impactions. A 1.4% intra–observer and a 2.6% inter-observer error was apparent with anthropometry. Concordance of anthropometry with roentgenocephalometry (p<0.04) was found by paired t -test. Conclusion: The anthropometry allowed reliable and objective, independent calculation of cranial bone relations and soft tissue projection. It is also sensitive to facial asymmetry. Easy application, versatility and an economic price for the assessment of facial proportions, soft tissue ratios, operation planning and follow-up were obvious. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Apoptotic epithelial cell death: a prerequisite for palatal fusion. An in vivo study in rabbits

The aim of the present study was to investigate stage-specific changes in medial edge epithelium during in vivo fusion of embryonic palatal shelves in 25 Russian rabbits. Material and Methods: The embryos were dissected following Caesarian section at day 18. Palatal shelves of specific developmental steps (approximation, contact, fusion) were examined by light microscopy, immunohistochemistry and transmission electron microscopy. Results: Light microscopy revealed that the superfical peridermal cells underwent apoptosis prior to contact of the basal epithelial cells. Following contact, an epithelial monolayer was left on each shelf with an intact basement membrane. Apoptosis of the epithelial cells was followed by discontinuity of the basement membrane. Islands of epithelial cells remained. Conclusion: This paper presents new data on palatal development in vivo. The results support our theory that apoptotic medial edge epithelial cell death is a precondition for palatal fusion. There were no indications of epithelial mesenchymal transformation or migration. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Preliminary results of standardized occipital advancement in the treatment of lambdoid synostosis

Introduction: Lambdoid synostosis can be found unilaterally, bilaterally or in combination with other forms of craniosynostosis. Based on the concept of frontoorbital advancement, we used the occipital advancement in order to correct unilateral or bilateral lambdoid synostosis. Methods: The standardized technique consists of transverse osteotomies, removal, remodelling and advancement of the occipital region. Results: Standardized occipital advancement was performed in 21 patients at a multidisciplinary craniofacial centre. The surgery was carried out for patients between 5 and 28 months of age. Aesthetically satisfactory skull shape and normalization of the intracranial pressure could be achieved. A major complication in the form of a life-threatening intraoperative haemorrhage occurred in one case. Other complications like infections have not been experienced. Conclusion: Standardized occipital advancement allows precise, reproducible and predictable positioning of the segments. Artificial ‘sutures’ are created as a result of the osteotomy. Remodelling leads to a well-proportioned skull shape and posterior advancement leads to an increase in intracranial volume. Copyright 2002 Published by Elsevier Science Ltd. On behalf of European Association for Cranio-Maxillofacial Surgery.

Three-dimensional facial morphology, following primary cleft lip repair using the triangular flap with or without rotation advancement

Introduction: There are numerous methods of repairing a cleft lip. In our institution, two methods have been used for primary lip repair, the triangular flap method, and the rotation-advancement plus small triangular flap method. The purpose of this study was to compare postsurgical anthropometric results following these two surgical methods. Patients: Twenty children with a unilateral complete cleft lip, alveolus and palate (UCLAP) were selected for this study. Ten underwent primary lip repair by the triangular flap method (Triangular Group), and the other 10 underwent repair by the rotation-advancement plus small triangular flap method (Rotation Group). Method: They were documented with a three-dimensional optical scanner, and analysed with computer-aided anthropometric method reported previously (Comput. Methods Programs 58: 159–173, 1999a; J. Cranio-Maxillofac Surg 27: 345–353, 1999b). Results: The shapes of the nose and nostril were a little better in the Rotation Group. However, in the Rotation Group, differences between good and poor cases were more extreme than in the Triangular Group. The shape of Cupid's bow was good shortly after surgery in the Triangular Group. A good shape of Cupid's bow was also obtained in the Rotation Group, but the improvement was more delayed. On the non-cleft side, the length of Cupid's bow was more extended in the Triangular Group. Certain deformities were common to both groups, such as deviation of the columella and a flattened ala on the cleft side. Conclusion: Rotation-advancement plus the small triangular flap method was thought to produce somewhat better results, however, further improvements in the technique are needed. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Histology of surgically removed overgrown osteochondral rib grafts

Introduction: Osteochondral rib grafts are most commonly used for mandibular condylar replacements. However, when used in growing patients, unpredictable growth of the constructed condyle/ramus is a common complication. Clinically two types of overgrowth, linear or exuberant, have been described. Purpose: In order to investigate growth disorders associated with osteochondral rib grafts in children, overgrown grafts were examined histologically. Patients and Methods: The material consisted of seven samples (six patients) of osteochondral rib grafts, that had been removed due to overgrowth. Results: Examination revealed that the clinical type of overgrowth was not related to any specific microarchitecture, which in itself, showed considerable variation. In three of the samples, a typical endochondral ossification zone was seen and in two others, signs of metaplasia, i.e. a gradual transformation of the cartilage cells into osteocytes, were noted. Conclusions: The study reveals that the clinical type of overgrowth, linear or exuberant, cannot be related to any typical histological finding. Furthermore, the findings suggest that local factors, such as mandibular movements and loading of the reconstructed condyle may have an effect on the structure of the osteochondral rib graft, and eventually on its growth. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Tuberous sclerosis: clinicopathologic features and review of the literature

Introduction: Tuberous sclerosis is a hamartoneoplastic syndrome, which may involve multiple organ systems. Oral hard tissue manifestations of the syndrome have been described in the literature only as recently as 1955. Patients who presented with clinical manifestations of tuberous sclerosis did not routinely undergo oral surveys to rule out ‘lesions’, and consequently data on ‘lesions’ in the maxillofacial complex is scant. Ten cases have been found in the English language literature, which describe maxillofacial ‘lesions’, which may be tumours, new growths, neoplasms or overgrowths occurring in patients diagnosed with tuberous sclerosis. Purpose: To review the literature for all maxillofacial lesions associated with tuberous sclerosis and to present an eleventh case of a patient with a maxillofacial lesion diagnosed as having tuberous sclerosis. Results: Eleven cases were found with maxillofacial fibroblastic lesions associated with tuberous sclerosis. These lesions were all fibrous benign neoplasms found in the maxillofacial bony complex. Conclusions: Maxillofacial fibroblastic lesions in tuberous sclerosis have various histopathological presentations, some of which may be difficult to differentiate. Consequently, close microscopic examination of these lesions is necessary so that adequate surgical treatment is provided. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

A pilot study of the effects of transpalatal maxillary advancement on velopharyngeal closure in cleft palate patients

Background and Aims: Impaired velopharyngeal closure function is sometimes a complication of a standard Le Fort I maxillary advancement in cleft palate patients. The transpalatal Le Fort I osteotomy has been suggested as an alternative technique that may avoid this problem. The aim of this pilot study was to examine the effects of the transpalatal approach on velopharyngeal function in a series of cleft palate patients. Patients: Sixteen consecutive patients with a history of cleft palate exhibiting maxillary hypoplasia who underwent a transpalatal Le Fort I osteotomy. Methods: All patients had a simultaneous audio/video speech recording and nasopharyngoscopy examination prior to maxillary advancement, followed by a repeat of the same examinations at least 1 year post-operatively. Velopharyngeal function was measured in two ways: by direct observation using nasopharyngoscopy, and indirectly by means of perceptual assessment. Reliability studies of the two measures were performed with satisfactory results. Results: No statistically significant difference was found between the pre- and post-operative data in either the perceptual speech assessment or nasopharyngoscopy examination. Conclusion: These results indicate that maxillary advancement by transpalatal Le Fort I osteotomy does not adversely affect velopharyngeal closure function. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Functional rehabilitation following resection of the floor of the mouth: the nasolabial flap revisited

Introduction: The aim of this study was to analyse the results of treatment following reconstruction of intraoral soft tissue using a nasolabial flap, with particular consideration of functional aspects. Material and Methods: In 26 patients (over a period of 10 years), the intraoral repair of the defect was carried out in the anterior floor of the mouth, 19 have received a unilateral and seven a bilateral nasolabial flap. The defects were caused by resection of squamous cell carcinomas (T1–T2) of the intraoral mucosa in 24 cases and osteoradionecrosis with soft tissue loss in two cases. Results: Complications of local wound healing were observed in three cases. In 23 patients the subsequent prosthetic rehabilitation was successful and allowed a return of masticatory function. In the other three cases, a secondary operation for flap remodelling would have been preferred, but the patients declined these operations. Conclusion: The nasolabial flap for replacement of soft tissue in the floor of the mouth represents a functional and aesthetically satisfactory alternative to reconstruction by microsurgically anastomosed flaps in cases with defects of up to 5×5 cm in size, especially in older, medically compromised patients who are therefore of poorer surgical risk. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Effects of streptomycin on the rat infraorbital nerve

Introduction: It has been reported that streptomycin can have anti-neuralgic effects. However, the mode of action is unknown. This article was intended to investigate eventual neurolytic effects of streptomycin on peripheral nerves when applied topically. Material and Method: The rat infraorbital nerve, used as the experimental model, was treated with 0.01 ml of streptomycin sulphate dissolved either in distilled water or in lidocaine via an infraorbital perineural injection. Saline was used in control animals. Results: Cross-sections of the nerve, a week following treatment with streptomycin, revealed damaged axons with disintegration of both heavily and thinly myelinated fibres. Signs of regeneration were detected from the fourth postoperative week on. In control rats no damage was observed. Conclusion: Streptomycin can cause peripheral nerve damage when injected perineurally. These morphological changes may be responsible for anti-neuralgic effects of streptomycin. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Neurosensory alterations of the inferior alveolar and mental nerve after genioplasty alone or associated with sagittal osteotomy of the mandibular ramus.

The purpose of our protocol is to study neurosensory disturbances following genioplasty, sagittal split mandibular osteotomy, or both procedures in combination. Many authors assessed the incidence and degree of neurosensory disturbances of the inferior alveolar nerve following orthognathic surgery but often results are difficult to interpret and compare due to a lack of standardization of methods. Fifty patients (24 males and 26 females) were tested with qualitative (touch sensation, sharp/blunt test, cold sensation and hot sensation) and quantitative methods (localization test, two point static and dynamic test) at least 1 year after orthognathic surgery. The patients were divided into the following groups: 10 patients in group 1 (controls); 12 patients in group 2 (genioplasty alone or in association with maxillary osteotomy or vertical mandibular ramus osteotomy); 10 patients in group 3 (sagittal split osteotomy alone); 18 patients in group 4 (sagittal split osteotomy with concomitant genioplasty). On both sides four areas were tested: centre of chin and lip (cutaneous and mucosal sides), 2 cm lateral to the chin centre (cutaneous and mucosal sides), 3 cm lateral to the chin centre i.e. approximately at the mental foramen (cutaneous and mucosal sides) and vermilion. Tests were always performed by the same person. All patients were also asked to indicate whether the altered sensation was considered subjectively as being disabling. None of the patients showed persistent anaesthesia in the tested areas according to the qualitative tests. In group 2 the quantitative sensory tests revealed normal or slight hypoaesthesia (17%) in all areas tested; in 30% of the patients of group 3, minimal quantitative sensory disturbances were noted, while the incidence of objective sensory deficits increased in patients who had undergone a concomitant genioplasty (40% among group 4). Among the tested areas the vermilion and oral commissure were affected most often in all groups. Statistical analysis (using STATA 6.0) revealed that these differences were significant (p<0.05). There were also significant differences between group 1 and groups 3 and 4 for tactile sensitivity, location tests and sharp-blunt discrimination, while two point discrimination (quantitative test) showed statistically significant differences between group 1 and all other groups (2-4). No statistically significant differences among the four groups were found for thermal sensation (hot and cold). The combination of genioplasty and sagittal split osteotomy seems to be more detrimental for the lip sensibility than genioplasty or sagittal split alone. Thermal sensation is less affected than tactile sensation, location and two point discrimination tests (static and dynamic). Despite that, sensory deficit was never considered as disabling by the patients subjectively.

Maxillary ameloblastomas: a review of the literature and of a 15-year database

Introduction: Cases of maxillary ameloblastomas from 15-year database (1986–2000) collected in the Department of Cranio-Maxillofacial Surgery of the University Hospital of Zurich were evaluated. Patients: Twenty-six patients suffering from ameloblastoma had been collected. Five of them, had a maxillary ameloblastoma, three females and two males. Methods: A clinical retrospective study was performed. In addition a review of the literature was undertaken and the findings have been compared and contrasted. Patients: The overall incidence of ameloblastoma within the mandible (21) was four times higher than in the maxilla (5). In 69 per cent of the cases (18) it occurred in men, in 31 percent (8) in women. The sex ratio differed with the maxillary ameloblastomas: 40 percent male (2) and 60 per cent female (3). Although slow growing and nearly painless, it can reach a considerable size within the mid-face involving such highly specialized structures as the orbit, skull-base and brain. Wide resections with a safety margin of healthy bone to prevent local recurrence were undertaken. Nevertheless, recurrence was frequent due to invasion of the adjacent bone. Conclusion: On the one hand, a recurrence was found after a simple curettage of a ‘dental cyst’. On the other hand, extensive bone destruction, involvement of the nasal cavity, the ethmoidal and sphenoidal sinuses, infiltration of the skull-base and distant metastasis were observed. The current treatment of choice is partial maxillectomy with a 10–15mm safety margin of healthy bone including the alveolar ridge, the hard palate, the mucosa of the maxillary sinus and the lateral nasal wall. For the removal of tumours close to or invading the retromaxillary space the temporal approach gives ample access. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved

The great auricular nerve; does it penetrate the parotid gland? An anatomical and microscopical study

Conflicting opinions exist in the literature regarding the exact anatomical course of the great auricular nerve. The aim of this work was to study the pathway of its anterior branch and endings in relation to the parotid gland. Material and Methods: Thirty-seven specimens were dissected from 19 fresh adult cadavers and studied including the parotid gland at the region of the termination of the anterior branch of the nerve. The causes of death were not due to pathology in the parotid region. All the specimens were fixed in formaldehyde, serially cut, stained by haematoxylin and eosin, and examined by light microscope. Results: In most of the glands (21/37=57%), there was no evidence of well-organized nerve fibres of the great auricular nerve inside the parotid gland. In a few (5/37=13%), nerve fibers were seen to penetrate the interlobular septa and in 30% of the cases (11/37) nerve bundles were found deep in the gland along side small ducts and close to thin-walled blood vessels. Conclusion: These findings prove that there are anatomical variations of the endings of the anterior branch of the great auricular nerve. The significance of nerve bundles deep in the gland along ducts and near vessels remains to be explored. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Vertical distraction osteogenesis of fibula transplants for mandibular reconstruction – a preliminary study

Introduction: When reconstructing the mandible after tumour resection with a fibular graft, the mandible is often vertically deficient, making placement of dental implants impossible. Patients: Segmental vertical distraction of the reconstructed mandible was performed in nine patients following tumour surgery between February 1998 and 2001. Their age was 14–65 years (average 46.3); all underwent radiotherapy with a dose of up to 55.6 Gy prior to tumour resection. Mandibular discontinuity was repaired with a microvascular fibular bone graft. All grafts had a vertical bone deficit ranging from 9 to 12 mm when compared with the non-resected part of the mandibles. Methods: All patients underwent segmental vertical distraction of the transplants. The distraction devices were applied intraorally. Distraction of 1.0 mm/day was performed using a Martin ® distractor (TRACK 1.5) followed by 12 weeks retention time. Results: The increase of vertical bone height was stable and enabled placement of dental implants without any complications. Conclusion: Vertical distraction osteogenesis may become a common procedure in the treatment of alveolar ridge deficiency resulting from transplanting fibulae for mandibular reconstruction following tumour surgery. Copyright Published by Elsevier Science Ltd. on behalf of European Association for Cranio-Maxillofacial Surgery

Distraction osteogenesis of the mandible: evaluation of callus distraction by B-scan ultrasonography

Introduction: Distraction osteogenesis is a new and reliable technique for lengthening of hard and soft tissue in cranio-maxillofacial surgery. Since its first applications, X-rays were often the preferred diagnostic method to monitor this treatment. Apart from adding an additional radiation dose, analysis cannot detect and follow the osteogenic process in the distraction gap on the one hand, nor can it evaluate the soft tissue around the distracted area. In this paper, the authors report their experience with B-scan imaging to control mandibular distraction and to overcome the shortcomings of X-rays analysis. Method: Comparison of B-scanning with the traditional X-ray methods was performed in 12 patients. Results: B-scan evaluation appeared to be a precise technique in monitoring the different phases of distraction. It is easy to repeat whenever necessary. Early and late complications of soft tissue healing, movements of the bone segment, as well as the osteogenesis were easily detectable. Conclusion: In the authors' opinion B-scan evaluation can play an important role in monitoring distraction osteogenesis. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Function of the great auricular nerve following surgery for benign parotid disorders

Introduction: The main concern in benign parotid surgery is complete removal of the lesion whilst avoiding any harm to the facial nerve. Some time ago, surgeons also began to spare other structures including the great auricular nerve. The purpose of this paper was to study these procedures prospectively and to evaluate the sensory recovery of this nerve. Material: Fourteen patients undergoing parotid surgery with preservation of the great auricular nerve (group A) have been studied and compared with 10 patients whose operations involved sacrificing the nerve (group B). Methods: The function of the great auricular nerve has been tested (qualitatively and quantitatively) before the operation, and postoperatively during the first few days and at 3, 6, 9 and 12 months. Results: Twelve months postoperatively, no area of anaesthesia was found in group A, whilst all patients in group B had some degree of sensory loss. In group A, the qualitative and quantitative tests documented complete recovery of various types of surface sensitivity in 80% of cases, with the remaining 20% showing only a moderate reduction in comparison with the unoperated side. Conclusion: From this study, it seems reasonable to spare the great auricular nerve during parotid surgery for benign disease because the procedure takes very little time, but guarantees a major improvement of postoperative sensitivity of the region innervated by the great auricular nerve. Copyright 2002 Published by Elsevier Science Ltd. on behalf of European Association for Cranio-Maxillofacial Surgery.

Modification of the Hunsuck sagittal split osteotomy using a nerve hook. Technical note

A modification of the Hunsuck mandibular sagittal split osteotomy is described by which a nerve hook is used to facilitate the optimum placement of the medial bone cut. The simple technique assists with the location of the lingula, protects the inferior alveolar nerve as it enters the mandibular foramen, and enables a bone cut to be placed into the mandibular foramen itself. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.