Frank Wilde

Intraoperative Imaging With a 3D C-Arm System After Zygomatico-Orbital Complex Fracture Reduction

PURPOSE During the repair of zygomatico-orbital complex (ZMC) fractures, the lateral orbital wall and/or the orbital floor is often reduced by merely reducing the zygoma. Intraoperative 3D imaging can help surgeons decide whether the orbit must be reconstructed as well. The purpose of this study was therefore to assess the usefulness of intraoperative 3D C-arm imaging in evaluating the adequacy of fracture reduction. METHODS A total of 21 patients with unilateral ZMC fractures were enrolled in this retrospective study. Four fractures were treated with a closed reduction technique. Seventeen fractures were repaired with open reduction and internal fixation of the zygomaticomaxillary buttress area. Intraoperative 3D C-arm imaging was performed in all cases. All patients underwent postoperative computed tomography and a clinical examination no earlier than 5 months after the procedure. RESULTS After reduction of the ZMC fractures, intraoperative 3D scans showed inadequate repair of the orbital floor in 2 patients and inadequate repair of the lateral orbit in 1 patient. Zygoma and zygomatic arch fracture reduction had to be corrected in 1 further case. The other 17 patients did not need an additional procedure. Postoperative imaging showed that no patient required a secondary operation. No postoperative diplopia or enophthalmos developed in any patient. CONCLUSIONS Intraoperative 3D C-arm imaging appears to be an effective tool for evaluating ZMC fracture reduction. It helps avoid additional procedures and thus helps reduce morbidity. In addition, there appears to be no need for postoperative imaging.

Prevalence of cone beam computed tomography imaging findings according to the clinical stage of bisphosphonate-related osteonecrosis of the jaw

OBJECTIVES Investigations of cone beam computed tomography (CBCT) for bisphosphonate-related osteonecrosis of the jaw (BRONJ) imaging are rare. The purpose of this study was to investigate the prevalence of typical radiological findings of BRONJ in CBCT. METHODS Twenty-seven CBCTs of BRONJ sites were assessed on the basis of the radiological findings (cancellous bone destruction, cortical bone erosion, sequestration, osteosclerosis, and periostal bone formation) and put in relation to the severity of the BRONJ sites. RESULTS Cancellous bone destruction and cortical bone erosion were the most common findings. Occurrence seems to decrease with decreasing BRONJ severity. Sequestration and osteosclerosis were less frequent and could be seen across all stages. Periosteal bone formation occurred in high-stage BRONJ only. CONCLUSION Cancellous bone destruction, cortical bone erosion, sequestration, and osteosclerosis can be seen across all stages and prevalence seems to decrease with decreasing severity of BRONJ. The occurrence of periosteal new bone formation seems to start in high-stage BRONJ.

A prospective multicenter study to compare the precision of posttraumatic internal orbital reconstruction with standard preformed and individualized orbital implants

PURPOSE A variety of implants are available for orbital reconstruction. Titanium orbital mesh plates are available either as standard preformed implants or able to be individualized for the patient. The aim of this study was to analyze whether individualized orbital implants allow a more precise reconstruction of the orbit than standard preformed implants. MATERIALS AND METHODS A total of 195 patients treated between 2010 and 2014 were followed up to 12 weeks after surgery. Of the patients, 100 had received standardized preformed and 95 individualized implants. The precision of orbital reconstruction with the different implants was determined by comparing the variances in the volume difference between the reconstructed and the contralateral orbit on the postoperative computed tomographic scans. Clinical volume-related parameters including globe position, vision, motility, and diplopia and surgical details including approach, timing and technique of implant modification, use of navigation, duration of surgery, as well as adverse events were documented. RESULTS Orbital reconstruction was significantly more precise when individualized implants were used. The same was seen with intraoperative navigation. An overlap in the use of individualized implants and navigation makes it difficult to attribute the improved precision to a single factor. CONCLUSION This study demonstrated that individualization and navigation provide clinical benefit.

Intraoperative imaging in orbital and midface reconstruction.

The orbit is very often affected by injuries which can leave patients not only with esthetic deficits, but also with functional impairments if reconstruction is inadequate. Computer-assisted surgery helps to achieve predictable outcomes in reconstruction. Today, intraoperative three-dimensional (3D) imaging is an important element in the workflow of computer-assisted orbital surgery. Clinical and radiological diagnosis by means of computed tomography is followed by preoperative computer-assisted planning to define and simulate the desired outcome of reconstruction. In difficult cases, intraoperative navigation helps in the implementation of procedure plans at the site of surgery. Intraoperative 3D imaging then allows an intraoperative final control to be made and the outcome of the surgery to be validated. Today, this is preferably done using 3D C-arm devices based on cone beam computed tomography. They help to avoid malpositioning of bone fragments and/or inserted implants assuring the quality of complex operations and reducing the number of secondary interventions necessary.

Patient-specific reconstruction plates are the missing link in computer-assisted mandibular reconstruction: A showcase for technical description

INTRODUCTION Preoperative planning of mandibular reconstruction has moved from mechanical simulation by dental model casts or stereolithographic models into an almost completely virtual environment. CAD/CAM applications allow a high level of accuracy by providing a custom template-assisted contouring approach for bone flaps. However, the clinical accuracy of CAD reconstruction is limited by the use of prebent reconstruction plates, an analogue step in an otherwise digital workstream. TECHNICAL REPORT In this paper the integration of computerized, numerically-controlled (CNC) milled, patient-specific mandibular plates (PSMP) within the virtual workflow of computer-assisted mandibular free fibula flap reconstruction is illustrated in a clinical case. Intraoperatively, the bone segments as well as the plate arms showed a very good fit. Postoperative CT imaging demonstrated close approximation of the PSMP and fibular segments, and good alignment of native mandible and fibular segments and intersegmentally. Over a follow-up period of 12 months, there was an uneventful course of healing with good bony consolidation. CONCLUSION The virtual design and automated fabrication of patient-specific mandibular reconstruction plates provide the missing link in the virtual workflow of computer-assisted mandibular free fibula flap reconstruction.

Die computergestützte Gesichtsschädelrekonstruktion

Injury to the facial skeleton may result not only in aesthetic but also functional deficits. Computer-assisted surgery promises predictable reconstructive results. In clinical routine the authors use the combination of preoperative planning, intraoperative navigation and intraoperative imaging to treat complex facial trauma. With preoperative planning the intended reconstructive results can be precisely preplanned and guided intraoperatively using navigational surgery. Intraoperative imaging achieves the final intraoperative validation. Using computer-assisted surgery dislocation and malformation of fragments and transplants can be avoided in facial reconstruction. This means reliable quality control of surgical outcome and the number of further surgeries can be reduced in this complex reconstructive surgery.ZusammenfassungVerletzungen des Gesichtsschädels können neben ästhetischen insbesondere funktionelle Defizite bei den Betroffenen hinterlassen. Die computerassistierte Rekonstruktion ermöglicht ein vorhersagbares Rekonstruktionsergebnis des knöchernen Gesichtsschädels. Die Kombination aus virtueller präoperativer Planung, intraoperativer Instrumentennavigation und intraoperativer Bildgebung wird routinemäßig an der Autorenklinik bei komplexen Verletzungen des Gesichtsschädels eingesetzt. Mithilfe der präoperativen Planung kann das erstrebte Rekonstruktionsergebnis millimetergenau vorgeplant und durch intraoperative Instrumentennavigation umgesetzt werden. Die intraoperative Bildgebung erlaubt die intraoperative Endkontrolle des Operationsergebnisses. Durch die Anwendung der computerassistierten Chirurgie bei der Gesichtsschädelrekonstruktion können intraoperative Fehlpositionierungen und Fehlkonturierungen der knöchernen Fragmente und der eingebrachten Transplantate verhindert werden. Dies ist ein herausragender Beitrag zur Qualitätssicherung bei diesen komplexen Operationen und senkt damit die Zahl notwendiger Folgeeingriffe.AbstractInjury to the facial skeleton may result not only in aesthetic but also functional deficits. Computer-assisted surgery promises predictable reconstructive results. In clinical routine the authors use the combination of preoperative planning, intraoperative navigation and intraoperative imaging to treat complex facial trauma. With preoperative planning the intended reconstructive results can be precisely preplanned and guided intraoperatively using navigational surgery. Intraoperative imaging achieves the final intraoperative validation. Using computer-assisted surgery dislocation and malformation of fragments and transplants can be avoided in facial reconstruction. This means reliable quality control of surgical outcome and the number of further surgeries can be reduced in this complex reconstructive surgery.

Bone Regeneration Without Bone Grafting After Resection of a Segment of the Mandible to Treat Bisphosphonate-Related Osteonecrosis of the Jaw

o p B t In 2003, Marx first described an association of exposed necrotic bone of the jaw with long-term application of bisphosphonates (BPh). Bisphosphonaterelated osteonecrosis of the jaw (BRONJ) seems to be resistant to customary dental anti-infective treatment, for example, antimicrobiological rinsing (chlorhexidine, peroxide, etc), curettage of the exposed bone followed by simple closure of the mucosa, or open wound management with regular changing of a gauze wick. Often the severity and stage of the BRONJ is worsened by these procedures. Several articles in the recent literature deal with the question of the most

[Computer-assisted reconstruction of the facial skeleton].

Injury to the facial skeleton may result not only in aesthetic but also functional deficits. Computer-assisted surgery promises predictable reconstructive results. In clinical routine the authors use the combination of preoperative planning, intraoperative navigation and intraoperative imaging to treat complex facial trauma. With preoperative planning the intended reconstructive results can be precisely preplanned and guided intraoperatively using navigational surgery. Intraoperative imaging achieves the final intraoperative validation. Using computer-assisted surgery dislocation and malformation of fragments and transplants can be avoided in facial reconstruction. This means reliable quality control of surgical outcome and the number of further surgeries can be reduced in this complex reconstructive surgery.ZusammenfassungVerletzungen des Gesichtsschädels können neben ästhetischen insbesondere funktionelle Defizite bei den Betroffenen hinterlassen. Die computerassistierte Rekonstruktion ermöglicht ein vorhersagbares Rekonstruktionsergebnis des knöchernen Gesichtsschädels. Die Kombination aus virtueller präoperativer Planung, intraoperativer Instrumentennavigation und intraoperativer Bildgebung wird routinemäßig an der Autorenklinik bei komplexen Verletzungen des Gesichtsschädels eingesetzt. Mithilfe der präoperativen Planung kann das erstrebte Rekonstruktionsergebnis millimetergenau vorgeplant und durch intraoperative Instrumentennavigation umgesetzt werden. Die intraoperative Bildgebung erlaubt die intraoperative Endkontrolle des Operationsergebnisses. Durch die Anwendung der computerassistierten Chirurgie bei der Gesichtsschädelrekonstruktion können intraoperative Fehlpositionierungen und Fehlkonturierungen der knöchernen Fragmente und der eingebrachten Transplantate verhindert werden. Dies ist ein herausragender Beitrag zur Qualitätssicherung bei diesen komplexen Operationen und senkt damit die Zahl notwendiger Folgeeingriffe.AbstractInjury to the facial skeleton may result not only in aesthetic but also functional deficits. Computer-assisted surgery promises predictable reconstructive results. In clinical routine the authors use the combination of preoperative planning, intraoperative navigation and intraoperative imaging to treat complex facial trauma. With preoperative planning the intended reconstructive results can be precisely preplanned and guided intraoperatively using navigational surgery. Intraoperative imaging achieves the final intraoperative validation. Using computer-assisted surgery dislocation and malformation of fragments and transplants can be avoided in facial reconstruction. This means reliable quality control of surgical outcome and the number of further surgeries can be reduced in this complex reconstructive surgery.

Nasal meatus plasty: a contribution to plastic reconstruction of the nasal valve during midfacial degloving.

Midfacial degloving is a proven method for easily accessing the midface, the nasal pyramid, the maxillary and ethmoidal sinuses, the orbits, as well as the anterior skull base. Indications for this method of access mainly include tumour resections in the area of the midface, the septum, the maxillary sinus, the paranasal to the sphenoidal sinus as well as the clivus. In addition, this method of access allows for the exposure of the bony structures of the midface in the event of extensive fractures. In general, this method of access combines an incision in the oral vestibule and circular incisions in the nasal vestibule area in order to release the nasal pyramid. After removing the facial wall of the maxillary sinus, extensive exposure of the surgical site is possible. One disadvantage of this method of access is the difficult reconstruction of the nasal valve area, which often leads to cicatricial stenoses and difficulties with breathing through the nose. Furthermore, wound healing problems and osteoradionecrosis in the area of the lateral margin of the anterior nasal aperture after replantation of the facial wall of the maxillary sinus have been described, because in this area sufficient soft tissue coverage cannot be ensured when a conventional technique is used. We describe a soft tissue flap pedicled in the cranial and caudal directions in the nasal valve area which makes both the reconstruction of the nasal vestibule and sufficient soft tissue coverage of the anterior nasal aperture possible.

Improving the quality of life of parotid surgery patients through a modified facelift incision and great auricular nerve preservation.

Postoperative quality of life after parotidectomy depends not only on surgical outcomes, such as the complete removal of a tumour, non-recurrence and the preservation of facial nerve function, but also on scar satisfaction and the degree of sensory dysfunction in the upper cervical area and at the ear lobe. Especially young patients and women consider the scar in the infra-auricular area and in the neck region to be distressing and even disfiguring. Resection of the great auricular nerve leads to paraesthesia and hypoesthesia, which leads to discomfort in many patients especially when using the telephone, shaving or wearing earrings. A modified approach to the parotid gland via a facelift incision and the careful exposure of the great auricular nerve can reduce the aforementioned problems considerably and improve postoperative quality of life. We present our experiences with the modified approach at our institution.