Berthold Hell

Experience with AO reconstruction plates after partial mandibular resection involving its continuity

A report is presented on experience with the use of 54 plates, without primary bone grafts, after resections for malignant tumours involving the continuity of the mandible, in 52 patients. There were complications in 27 cases: postoperative infection or soft tissue dehiscence occurred 20 times, chronic soft tissue perforation once, screw loosening twice, and plate fracture four times. Adjuvant radiotherapy and/or chemotherapy had no effect on the incidence of the complications. Seventeen of the plates (a good 30%) had to be removed prematurely due to the complications. Major deformity did not always occur if relative stabilization had developed through cicatrix formation. Thirty-seven plates (barely 70%) remained: in 19 cases until the death of the patient, in 3 cases until recurrence, in 12 cases until bone grafting, and in 3 cases they were still in situ up to 65 months. In principle, reconstruction plates have proven themselves. However, application and soft tissue coverage need great care and a great deal of experience.

Regeneration of intraoral defects after tumor resection with a bioengineered human dermal replacement (Dermagraft).

&NA; The experiences of seven patients with squamous cell carcinomas of the oral cavity who underwent reconstruction with a bioengineered human dermal replacement (Dermagraft) are examined. The human dermal replacement consists of fibroblasts seeded onto a three‐dimensional polymer scaffold to create a living dermal structure. In this setting, the fibroblasts secrete a mixture of growth factors and matrix proteins in physiological concentration that is essential for wound healing and epithelization. The fibroblast tissue remains metabolically active after cryopreservation and can be used as an off‐the‐shelf tissue to cover medium‐sized defects and avoid donor‐site morbidity. In the first series of patients treated with this tissue, defect closure was achieved without functional problems, allowing optimal postoperative monitoring for tumor recurrence. (Plast. Reconstr. Surg. 109: 889, 2002.)

The infrahyoid flap : A technique for defect closure in the floor of the mouth, the tongue, the buccal mucosa, and the lateral pharyngeal wall

The surgical technique, indications, and results of the infrahyoid muscle flap are presented. This flap is fed by the superior thyroid vessels and innervated by the ansa cervicalis. The flap is indicated in case of medium-sized defects in the floor of the mouth, the tongue, the buccal mucosa, and the lateral pharyngeal wall. The advantages of the technique presented include the rapid flap elevation close to the original operating field, the ability to use the motor capability of the flap, and the ability to combine it with other local flaps--for example, the platysma flap. This technique appeared to render excellent function for swallowing and speech. Safe flap grafting is possible only if the internal jugular vein is preserved.

Resorption of microsurgically vascularized bone grafts after augmentation of the mandible

Vascularized bone grafts taken from the iliac crest to augment the extremely atrophied mandible are valued for their ability to maintain their contour. Reliable data on long-term performance, however, is not yet available. The purpose of this study was to investigate the long-term results of this method, evaluating the radiological documentation (lateral cephalograms, orthopantomograms) of six patients. The mean follow-up period was 7.3 years. Dental implants were not inserted into the bone grafts. The average increase in ridge height immediately after surgery was 17.8 mm in the symphyseal area, 17.1 mm above the mental foramen and 13.9 mm in the molar region. In the first postoperative year, the average vertical loss was 3.0 mm in the symphyseal, 2.0 mm in the premolar and 2.9 mm in the molar regions. After that the mean yearly rate of vertical resorption dropped to 0.24 mm in the symphyseal, 0.27 mm in the premolar and 0.34 mm in the molar regions, which corresponded to the physiological loss in ridge height due to aging. The fact that graft resorption was so slight portends a good long-term prognosis with this procedure. However, indication is restricted by the high operative burden for the patient and by the availability of alternative rehabilitation methods.

B-scan sonography in maxillo-facial surgery

Ultrasonography is a relatively new diagnostic aid in maxillo-facial surgery. The method is useful in examining tumours, swellings, cysts and similar processes in the soft tissues of the cervico-facial region. Some examples are given, and some details of the technique are outlined. The ultrasound examination may easily be repeated as often as necessary.

Computed tomographic study of bone availability for facial prosthesis-bearing endosteal implants

In a computed tomographic study, 56 patients with facial defects were examined to assess the availability of bone for extraoral Brånemark implants (3 or 4 mm long, 3.75 mm diameter) to bear facial prostheses. Bone depths were determined in the auriculotemporal (2-8 mm), infraorbital (0-10 mm), lateroorbital (8-14 mm), supraorbital (1-14 mm) and medioorbital (1-6 mm) areas as well as at the base of the nasal skeleton (1-5 mm). The low values for the supraorbital and infraorbital areas were determined at the points closest to the frontal- and maxillary sinuses, respectively. Implantation in these areas would be permissible only under certain conditions. The very thin osseous structures of the nasal region also present problems for implants. In the auriculotemporal region, the bone width is always sufficient, but at the orbital margin it can vary from 3 to 8 mm. The three-year success rates for implant survival were found to be 100% and 85.8% respectively for auricular and orbital defects. No serious skin complications were seen. Six patients (10.7%) required secondary corrective surgery in a total of 13 implant areas.

Lower lip carcinoma: Infiltration of the mandible along the mental nerve

In general, carcinoma of the lower lip has a good prognosis after radical surgery. In rare cases, however, recurrences may be seen because of spread of the tumour along the mental nerve into the mandible. The earliest symptom of this is pain in the mandible and radiological evidence of widening of the mental foramen. Large resections and reconstructive procedures will be necessary. Three cases are presented.

Otoplasty: a combined approach to different structures of the auricle

A technique for otoplasty is presented, which combines the advantages of different methods. The procedure includes a dorsal skin excision, a cartilage incision at the border between the concha and scapha, scoring of the crus superior on the anterior side, and if necessary a reduction of the conchal height and modification of the position of the cauda helicis by cartilage excision. The results of the treatment of 526 ears in 312 patients are retrospectively analysed by a patient questionnaire and a chart review.

Long-term peri-implant bone level changes of non-vascularized fibula bone grafted edentulous patients

Long-term results of reconstructions and prosthetic rehabilitation of patients presenting severely atrophied edentulous ridges remains a challenge for clinicians. Among the various available augmentation materials there is evidence that avascular fibula bone grafts possess a reliable resistance against resorption and may thus provide a valuable source to reduce the loss of vertical bone height after reconstruction of the severely atrophied mandible and maxilla. The purpose of the present study was to assess long-term crestal bone level stability in avascular fibula bone grafts. 8 edentulous female patients (average age 70.6 years) with Class-VI-atrophy and less than 5 mm residual bone volume received onlay-grafting with avascular fibula bone grafts and were monitored with a mean observation time of 133.7 months (121-186). A total of 39 implants were placed in the maxilla and mandible. Three patients received immediate and five patients delayed implant placement 3 months after grafting. All patients were provided with bar-retained dentures. Postoperative evaluation included clinical implant success (Buser) and radiographic examinations (orthopantomogram) to quantify crestal bone resorption. Grafting was successfully performed in all patients with no regrafting necessary. All implants but one, lost 2 years after abutment connection, remained successfully integrated and fulfilled the Buser criteria, rendering to a success rate of 97%. Mean bone resorption after 10 years was mesial 1.4 mm and distal 1.4 mm at each implant-site. Maximum bone resorption occurred between postoperative and first year, thereafter no significant resorption was measured in re-examinations up to 15 years. Avascular fibula grafts are a reliable bone graft for augmentation procedures in atrophied edentulous ridges. Dental implants that integrated in the autogenous fibular bone grafts showed a stable crestal peri-implant bone level up to 15 years after implant placement.

Camouflage in head and neck region – a non-invasive option for skin lesions

The technique of camouflage, a non-invasive procedure to correct flaws in the texture and colour of the facial skin, is presented. The acceptance and use of camouflaging by 52 patients with different diagnoses are presented. The advantages of camouflaging are discussed in comparison to medical tattooing.