C. P. Cornelius

Orbital reconstruction with individually copy-milled ceramic implants

Diagnostic advances such as computed tomography and new surgical techniques have dramatically improved both the functional and aesthetic outcome of orbital reconstructions. Taking a further approach, we designed ceramic implants (Bioverit) on the basis of stereolithographic models. After copy milling a resin template with a commercially available dental unit (Celay), the prefabricated implants were inserted for reconstruction of the lamina papyracea (n = 1), zygomatic complex (n = 2), infraorbital floor (n = 5), and rim (n = 3). Intraoperatively, only slight modifications of the implants had to be performed. The results were encouraging, as all cases showed a good aesthetic and functional postoperative outcome. Preoperative evaluation of the osseous defect and prefabrication of the required implant reduced operating time and patient morbidity significantly.

Relevance of SCC-Ag, CEA, CA 19.9 and CA 125 for diagnosis and follow-up in oral cancer

The prognosis of oral cavity carcinoma is limited by recurrent disease or lymph node metastasis. Secondary to surgery and radiotherapy, anatomical structures are often severely changed and make early diagnosis of renewed tumour growth by clinical and radiological examination difficult. We studied the course of serum SCC-Ag, CEA, CA 19.9 and CA 125 in 121 patients with untreated squamous cell carcinoma of the head and neck (SCCHN) before and after therapy and evaluated their relevance for diagnosis and follow-up in oral cancer. CA 19.9 and CA 125 seemed to be useless for this tumour entity. CEA resembled more the alcohol consumption and smoking habits of the patients examined than their state of disease. Only SCC-Ag correlated with the tumour burden and represented the disease course. In the event of relapse, half the patients had an exponential increase in SCC-Ag, 1-2 months prior to diagnosis.

The use of flash visual evoked potentials in the early diagnosis of suspected optic nerve lesions due to craniofacial trauma

Craniofacial trauma encroaching on the orbital apex and optic canal can result in direct or indirect optic nerve lesions, leading to visual impairment or blindness. Early diagnosis of a visual loss and immediate therapy are generally considered crucial for a successful restoration of vision in indirect trauma. However, in comatose or sedated patients the assessment of optic nerve function by testing pupillary reactivity may be severely compromised or impossible because of tensely swollen eyelids, conjunctival oedema, concussion of the ciliary muscle or pharmacological effects. In the event that clinical ophthalmic examination, computer tomography or nuclear magnetic resonance scanning fail to clarify the state of the optic nerve, visual evoked potentials (VEPs) to flash stimulation appear to provide reliable information on function within the visual pathway. On this basis, treatment with corticosteroids and/or surgical decompression can be rapidly initiated. Our results in a preliminary patient series confirm the value of acutely monitored VEPs as an objective test of optic nerve function in cases of suspected optic nerve injury immediately after admission to the emergency care unit. The imaging techniques usually applied may be complemented by VEPs to show the functional significance of structural abnormalities found in the vicinity of the optic nerve.

Neo-osseous flaps using demineralized allogeneic bone in a rat model.

&NA; Surgical reconstruction with revascularized bone grafts can be compromised by donor tissue limitations and may be refined by prefabrication of compound neoflaps using bone substitutes. The principal suitability of demineralized allogeneic bone (DALB) slabs in fabricating neo‐osseous flaps based on the inferior epigastric vascular system was studied and compared with neoflaps with autologous bone (AUB). In 45 rats, the histological pattern of bone formation in response to angiogenesis induced by vessel implantation was assessed, and characteristics of vascularization of the neoflap were studied microangiographically at 2, 4, 6, and 8 weeks. Histological techniques included decalcified and nondecalcified sections, as well as intravital polyfluorochrome labeling. Blood flow of the neoflap was also assessed quantitatively using 15‐&mgr;m microspheres labeled with technetium 99‐methylene diphosphate (99‐MDP) 8 weeks after flap fabrication. Although the DALB neoflaps showed consistent bone formation and neovascularization, the bone regeneration process was delayed distinctly in comparison with AUB. Microangio‐graphically, however, no differences between the two types of grafts became apparent during all time periods tested. Furthermore, the radioactivity of the DALB neoflap, which means bone blood flow per dry weight, was significantly higher than in AUB grafts and even more than that of intact iliac bone (p = 0.001). The exact meaning of elevated blood flow in DALB and similar degrees of vascularization corresponding to native AUB grafts remains to be determined, but may be a sign of ongoing bone formation resulting in a suitable DALB‐containing neo‐osseous flap in the long term. The authors findings support that allogeneic bone could be a potential substitute for AUB in creating a prefabricated neo‐osseous flap. Lee J‐H, Cornelius CP, Schwenzer N. Neo‐osseous flaps using demineralized allogeneic bone in a rat model. Ann Plast Surg 2000;44:195‐204

Mikroneurale Wiederherstellung nach iatrogenen Läsionen des N. lingualis und des N. alveolaris inferior

As microneural repair techniques of the sensory mandibular branches enter the third decade of their clinical use, there are but a few long-term investigations into the value of these procedures in the treatment of iatrogenic injury to the lingual (LN), inferior alveolar (IAN) or mental (MN) nerve. To establish the efficacy of microneural repair in lesions of the LN, IAN or MN with loss of continuity, the outcome of sensory recovery was evaluated in a series of 92 patients (LN: direct coaptationn=39, coaptation+sural nerve graftingn=23; IAN: direct coaptationn=11 coaptation+sural nerve graftingn=10; MN: direct coaptationn=11). The minimum duration of follow-up was 14 months postoperatively. The persistent sensory deficit was assessed using standardized neurosensory testing and gustometric stimuli. In addition the patients answered a multiple-choice questionnaire containing a list of complaints. To obtain a numeric estimate for interindividual and intergroup comparison the information from clinical measurements and patient reports was condensed into a ‘neurological score’ and a ‘complaint score’, respectively. Furthermore, adequate items from both scores were combined to affirm or deny the return of sensory function in terms of protective and discriminative sensation. The overall results show a broad range of variation in the scores, sometimes reflecting severe degrees of persistent sensory impairment. The lowest scores, corresponding to the best regeneration, were found after direct coaptation of the LN, IAN and NM, but even the best results did not provide sensory recovery to a preinjury level. After direct coaptation of LN 69% of the patients exhibited protective sensation and 41% regained discriminative function. In contrast, LN grafting was ensued from restoration of protective function in 39% and discriminative function in 17% of the patients. More striking differences were found between coaptation and grafting of the IAN (IAN coaptation: 91% protective function, 18% discriminative function; IAN grafting: 60% protective function, 0% discriminative function). In the LN coaptation group low scores and improved taste perception were convincingly associated with short periods since injury (i.e. timing of repair). In conclusion, we feel there is sufficient justification to optimize the potential results of microneural repair by immediate (LN/MN) or early (IAN) reexposure of the injured site in order to clarify the precise nature of the underlying nerve damage and prevent delay, if patients present with complete loss of sensory function subsequent to dentoalveolar or oral surgery. However, clinical and electrophysiologic findings suggesting impairment or partial loss of sensory function are considered a contraindication to microneural intervention, in view of the limited propects of sensory recovery after surgical repair.Fragestellung: Welche Erfolgsaussichten haben mikroneurale Rekonstruktionen des N. lingualis (NL), des N. alveolaris inferior (NAI) oder N. mentalis (NM) nach iatrogenen Kontinuitätstrennungen? Patienten: Das neurologische Restdefizit und persistierende Beschwerden wurden mit Hilfe eines Befund- bzw. Selbstbeurteilungs-Scores in einer Untersuchungsreihe von 92 Patienten (LN: direkte Koaptation n=39, Suralisinterponat n=23; NAI: direkte Koaptation n=11, Suralisinterponat n=10; NM: direkte Koaptation n=11) dargestellt. Ergebnisse: Erwartungsgemäß fanden sich bei keinem Patienten eine vollständige sensible und/oder sensorische (Geschmacksempfinden) Restitution, sondern vielfach erhebliche neurologische Ausfalls- und Reizerscheinungen ohne Wiederkehr einer Schutzsensibilität. Nervenersatzplastiken mit Suralisinterponaten erwiesen sich weniger aussichtsreich als die direkte Nervenkoaptation. Bei Nervenkoaptationen des N. lingualis ist der Zeitraum zwischen Schädigung und Durchführung der mikroneuralen Rekonstruktion offenbar prognosebestimmend. Innerhalb einer Zeitgrenze von ca. 3 Wochen bis zur Wiederherstellungsoperation waren hier die günstigsten Regenerationsergebnisse anzutreffen. Schlußfolgerungen: Unsere aktualisierten Ergebnisse bekräftigen das Votum zur frühzeitigen Indikationsstellung mikroneuraler Eingriffe bei mechanischen Läsionen der sensiblen Mandibularisäste und lassen im Fall eines kompletten Funktionsausfalls nach iatrogenen Nervenschädigungen von einer monatelangen abwartenden Haltung abraten. Da die Aussichten auf eine Funktionsrückkehr a priori begrenzt sind, sehen wir in Nerventeilläsionen mit entsprechender klinischer Symptomatik eine Kontraindikation zur operativen Intervention. As microneural repair techniques of the sensory mandibular branches enter the third decade of their clinical use, there are but a few long-term investigations into the value of these procedures in the treatment of iatrogenic injury to the lingual (LN), inferior alveolar (IAN) or mental (MN) nerve. To establish the efficacy of microneural repair in lesions of the LN, IAN or MN with loss of continuity, the outcome of sensory recovery was evaluated in a series of 92 patients (LN: direct coaptationn=39, coaptation+sural nerve graftingn=23; IAN: direct coaptationn=11 coaptation+sural nerve graftingn=10; MN: direct coaptationn=11). The minimum duration of follow-up was 14 months postoperatively. The persistent sensory deficit was assessed using standardized neurosensory testing and gustometric stimuli. In addition the patients answered a multiple-choice questionnaire containing a list of complaints. To obtain a numeric estimate for interindividual and intergroup comparison the information from clinical measurements and patient reports was condensed into a ‘neurological score’ and a ‘complaint score’, respectively. Furthermore, adequate items from both scores were combined to affirm or deny the return of sensory function in terms of protective and discriminative sensation. The overall results show a broad range of variation in the scores, sometimes reflecting severe degrees of persistent sensory impairment. The lowest scores, corresponding to the best regeneration, were found after direct coaptation of the LN, IAN and NM, but even the best results did not provide sensory recovery to a preinjury level. After direct coaptation of LN 69% of the patients exhibited protective sensation and 41% regained discriminative function. In contrast, LN grafting was ensued from restoration of protective function in 39% and discriminative function in 17% of the patients. More striking differences were found between coaptation and grafting of the IAN (IAN coaptation: 91% protective function, 18% discriminative function; IAN grafting: 60% protective function, 0% discriminative function). In the LN coaptation group low scores and improved taste perception were convincingly associated with short periods since injury (i.e. timing of repair). In conclusion, we feel there is sufficient justification to optimize the potential results of microneural repair by immediate (LN/MN) or early (IAN) reexposure of the injured site in order to clarify the precise nature of the underlying nerve damage and prevent delay, if patients present with complete loss of sensory function subsequent to dentoalveolar or oral surgery. However, clinical and electrophysiologic findings suggesting impairment or partial loss of sensory function are considered a contraindication to microneural intervention, in view of the limited propects of sensory recovery after surgical repair.

Dreidimensionale Bildakquisition zur Analyse der primären, spaltbedingten Gesichtsdeformität mit einem optoelektronischen Oberflächenscanner

Hintergrund. Die anthropometrische Analyse des Gesichts erfolgte bisher mit den Methoden der direkten Gesichtsvermessung und der Fotogrammetrie. Beide Methoden haben Nachteile. Ziel unserer Studie war, die primäre spaltbedingte Nasendeformität mit einem videogestützten Oberflächenscanner aufzunehmen und dieses dreidimensionale Bild zu vermessen. Patienten und Methode. Aus Gesichtsabdrücken hergestellte Modelle von 19 Patienten mit uni- und bilateraler Lippen-Kiefer-Gaumen-Spalte vor dem Lippenverschluss wurden mit dem 3D-Oberflächenscanner DSP 400 aufgenommen. Die Breite der Nasenwurzel, der Abstand der Nasenflügel und der Nasenflügelbasen, die Breite des Naseneingangs, die Protrusion der Nasenspitze und die Nasenflügellänge wurden anschließend vermessen. Ergebnisse. Die Aufnahme war bei allen Gesichtsmodellen problemlos möglich. Vergleichende Messungen am Gipskopf und 3D-Bild korrelierten sehr gut miteinander. Es konnten damit deutliche Dimensionsunterschiede für die untersuchten Nasenparameter in Abhängigkeit von der Spaltform bestimmt werden. Schlussfolgerung. Der vorgestellte videogestützter Oberflächenscanner erlaubte die dreidimensionale Aufnahme des Gesichts ohne Zeitverzögerung. Mit Hilfe entsprechender Software konnte die geschaffene Oberfläche exakt vermessen werden. Mit dem vorgestellten System konnten Messergebnisse erzielt werden, die mit der bekannten Literatur übereinstimmten. Background. Anthropometric analysis of the face has been performed with direct facial measurement and photogrammetry. Both methods have disadvantages. The aim of our investigation was to create a three-dimensional image of the primary cleft nasal deformity with a video scanner and to carry out linear measurements. Material and methods. Facial plaster casts of 19 patients with uni- and bilateral cleft lip and palate before primary lip repair were scanned with digital surface photogrammetry DSP 400. The width of the nose and of the nostril floor, the distance of the alar bases, the length of the ala, and the nasal tip protrusion were measured. Results. Imaging was possible without problems in all models. Direct measurements of the model correlated well with the results of the three-dimensional image. Significant dimensional differences of the nasal parameters examined were noted, depending on the cleft type. Discussion. A video-supported surface scanner allowed immediate three-dimensional imaging of the face. The computer software analyzed the generated surface exactly. The data measured with the presented system resembled other previously published results.

Orale, faziale und kraniale Manifestationen der Neurofibromatose von Recklinghausen (NF)

19 patients with neurofibromatosis (NF) type 1 were evaluated retrospectively. Many patients presented not only with orocraniofacial neurofibromas but also with cranial skeletal deformities--involving skullbase, skull, orbit, midface and mandibula--and ophthalmological and dental symptoms, as well as neurological disorders. Malignant transformation of NF was observed in 1 case. Severe manifestations of NF were associated with the plexiform growth type. Due to the nature of NF surgical treatment most often is only palliative.Es wurden retrospektiv die Befunde von 19 Patienten mit Neurofibromatose von Recklinghausen (NF) ausgewertet. Neben orokraniofazialen Neurofibromen wurden bei vielen Patienten sowohl Deformitäten des Schädelskeletts — Schädelbasis, Kalotte, Orbita, Mittelgesicht und Mandibula betreffend — als auch ophthalmologische, neurologische und dentale Symptome festgestellt. Eine maligne Transformation zu einem Neurofibrosarkom wurde bei 1 Patienten beobachtet. Die Tumoren monströsen Ausmaßes waren meist vom plexiformen Wachstumstyp. Gemäß der Natur der NF handelte es sich bei den Operationen in der Regel nicht um kurative, sondern um palliative Eingriffe. 19 patients with neurofibromatosis (NF) type 1 were evaluated retrospectively. Many patients presented not only with orocraniofacial neurofibromas but also with cranial skeletal deformities — involving skullbase, skull, orbit, midface and mandibula — and ophthalmological and dental symptoms, as well as neurological disorders. Malignant transformation of NF was observed in 1 case. Severe manifestations of NF were associated with the plexiform growth type. Due to the nature of NF surgical treatment most often is only palliative.

Verwendung individuell hergestellter Keramikimplantate zur Sekundärrekonstruktion der knöchernen Orbita

Sowohl die Verwendung autologer Transplantate als auch der Einsatz alloplastischer Materialien zeigen bei der Rekonstruktion der knöchernen Orbita Nachteile, die sich im wesentlichen durch die zusätzliche Entnahmemorbidität, aber auch durch verlängerte Operationszeiten ergeben. Aus diesem Grund haben wir bei ausgesuchten Fällen mit extremer Bulbusdystopie traumatischer oder kongenitaler Genese Bioveritglaskeramikimplantate auf der Basis von Stereolithographiemodellen hergestellt. Bei 5 Patienten wurden bislang insgesamt 7 Keramikimplantate im Orbitabereich inseriert, die jeweils komplikationslos einheilten und nach subjektiver und objektiver Beurteilung eine deutliche funktionelle und ästhetische Verbesserung ergaben. Damit zeigt sich hier eine Alternative zu konventionellen rekonstruktiven Verfahren, da trotz des hohen Material- und Personalaufwands dieser Technik bei nur kurzer stationärer Behandlungsdauer eine frühe Rehabilitation der betroffenen Patienten erfolgen kann. The use of autogenous transplants and the application of intraoperatively customised alloplastic materials show, in cases of secondary orbital reconstruction, a higher postoperative morbidity caused by additional approaches to the transplant donor site. On the other hand, thorough surgical exploration and fitting of the transplants or alloplastic materials greatly prolongs operating times. For these reasons we designed ceramic implants (Bioverit) on the basis of stereolithography models and prefabricated them using a commercially available dental copy milling unit (Celay). In five cases up until now seven customised implants have been inserted for reconstruction of the lamina papyracea, zygomatic complex and infraorbital floor and rim. Encouraged by the good postoperative aesthetic and functional results, with significantly reduced operating times and morbidity in all cases, we will continue to take this technique into account for reconstruction after complex orbital fractures.The use of autogenous transplants and the application of intraoperatively customised alloplastic materials show, in cases of secondary orbital reconstruction, a higher postoperative morbidity caused by additional approaches to the transplant donor site. On the other hand, thorough surgical exploration and fitting of the transplants or alloplastic materials greatly prolongs operating times. For these reason we designed ceramic implants (Bioverit) on the basis of stereolithography models and prefabricated them using a commercially available dental copy milling unit (Celay). In five cases up until now seven customised implants have been inserted for reconstruction of the lamina papyracea, zygomatic complex and infraorbital floor and rim. Encouraged by the good postoperative aesthetic and functional results, with significantly reduced operating times and morbidity in all cases, we will continue to take this technique into account for reconstruction after complex orbital fractures.The use of autogenous transplants and the application of intraoperatively customised alloplastic materials show, in cases of secondary orbital reconstruction, a higher postoperative morbidity caused by additional approaches to the transplant donor site. On the other hand, thorough surgical exploration and fitting of the transplants or alloplastic materials greatly prolongs operating times. For these reasons we designed ceramic implants (Bioverit) on the basis of stereolithography models and prefabricated them using a commercially available dental copy milling unit (Celay). In five cases up until now seven customised implants have been inserted for reconstruction of the lamina papyracea, zygomatic complex and infraorbital floor and rim. Encouraged by the good postoperative aesthetic and functional results, with significantly reduced operating times and morbidity in all cases, we will continue to take this technique into account for reconstruction after complex orbital fractures.

Enossale Implantate nach Tumorresektion im Gesichtsbereich

Zusammenfassung Enossale Implantate, die nach Tumorresektion im Gesichtsbereich inseriert werden, können entscheidend zur Deckung von Defekten an Auge, Nase, Ohr und komplexen Gesichtsdefekten beitragen. Inseriert wurden insgesamt 128 Implantate. 110 Implantate wurden im Bereich der Orbita, 12 Implantate ins Mastoid und 6 Implantate paranasal inseriert. Bei den Implantattypen handelte es sich um 113 kraniofaziale Brånemark-Implantate und 15 lange dentale Implantate. Die Langzeitergebnisse dieser Implantate sollten anhand einer in regelmäßigen Abständen durchgeführten Nachuntersuchung unserer Patienten eruiert werden. Bei einer hohen Erfolgsrate der Implantate von 94,5% während eines langen Untersuchungszeitraums kann von einer sehr guten Langzeitprognose ausgegangen werden. Der Einsatz enossaler Implantate im Gesichtsbereich sollte ausgeweitet und die Indikation großzügiger gestellt werden. Summary Endosteal implants after tumor surgery of the face are helpful in reconstructing facial defects. A retrospective study of our patients treated using craniofacial implants was conducted to evaluate long-term results. A total of 128 implants were inserted, 110 implants in the periorbital, 12 implants in the mastoid, and six implants in the paranasal region; 113 implants were short craniofacial Brånemark implants, and 15 implants were dental implants. The success rate for implant survival was 94.5%. Long-term results were promising and more than satisfactory, leading to a large indication for these endosteal implants.Endosteal implants after tumor surgery of the face are helpful in reconstructing facial defects. A retrospective study of our patients treated using craniofacial implants was conducted to evaluate long-term results. A total of 128 implants were inserted, 110 implants in the periorbital, 12 implants in the mastoid, and six implants in the paranasal region; 113 implants were short craniofacial Brånemark implants, and 15 implants were dental implants. The success rate for implant survival was 94.5%. Long-term results were promising and more than satisfactory, leading to a large indication for these endosteal implants.

Kallusdistraktion im Oberkiefer

Total or partial relapses after conventional surgical advancement of the maxilla following Le Fort I osteotomy in CLP patients are frequent and major complications. The aim of this investigation was to find out whether the technique of distraction osteogenesis in these patients shows more stability and whether maxillary distraction is able to replace conventional advancement. Maxillary distraction was performed in 12 patients. In two cases, a Delaire mask was used to bring the maxilla forward, ten patients were treated with the extraoral distraction device designed by Polley. In all patients, planned advancement of the maxilla could be achieved; one partial relapse occurred. The results indicate that distraction osteogenesis offers the possibility of advancement of the maxilla with the required stability. The technique presents a major improvement which is achieved with a relatively minor surgical procedure.Die Kallusdistraktion bietet die Möglichkeit einer protrahierten Segmenteinstellung im Oberkiefer bei gleichzeitiger Weichgewebedehnung. Sagittale Defizite können bereits im Wachstumsalter behandelt werden, sodass keine dentalen Kompensationen auftreten und frühzeitig morphologisch und funktionell physiologische Verhältnisse hergestellt werden. Ausgeprägte sagittale Missverhältnisse, die mit herkömmlichen Techniken kaum therapierbar sind, können durch Distraktion sicher und zuverlässig im Rahmen kurzer Hospitalisationszeiten behandelt werden. Abschließend kann festgehalten werden, dass die vorgestellten Techniken zur Distraktionsosteogenese im Oberkiefer derzeit eine sinnvolle und Gewinn bringende Ergänzung zu den gängigen Umstellungsosteotomien darstellen. Es wird jedoch nach u. E. auch weiterhin klare Indikationen für konventionelle Behandlungsmethoden auch bei Patienten aus den genannten Indikationsbereichen geben. Total or partial relapses after conventional surgical advancement of the maxilla following Le Fort I osteotomy in CLP patients are frequent and major complications. The aim of this investigation was to find out whether the technique of distraction osteogenesis in these patients shows more stability and whether maxillary distraction is able to replace conventional advancement. Maxillary distraction was performed in 12 patients. In two cases, a Delaire mask was used to bring the maxilla forward, ten patients were treated with the extraoral distraction device designed by Polley. In all patients, planned advancement of the maxilla could be achieved; one partial relapse occurred. The results indicate that distraction osteogenesis offers the possibility of advancement of the maxilla with the required stability. The technique presents a major improvement which is achieved with a relatively minor surgical procedure.