Hermann F. Sailer

A new method of inserting endosseous implants in totally atrophic maxillae

A new method is described (Sailer, 1988) whereby endosseous implants are inserted in the totally atrophic maxilla, the intermaxillary relationship and vertical dimension corrected and a vestibuloplasty performed during one surgical procedure. The method can also be used to treat minor degrees of maxillary alveolar atrophy. The procedure enables 20 mm-long Titanium screws to be used in totally atrophic maxillae. The following surgical procedures are carried out during one operation: A Le Fort I osteotomy, removal of the mucous membrane of the sinus floor, obturation of the denuded maxillary sinus floor by autologous bone grafts from the iliac crest, simultaneous insertion of Titanium screws, fixation of the down-fractured maxilla by miniplates, and a modified submucous vestibuloplasty. Intermaxillary relationship and vertical dimension can be normalized, and the aesthetic results are excellent. To date 35 implants of which none has been lost, have been placed in 5 patients.

Should titanium miniplates be removed after bone healing is complete

A prospective study of 32 patients was performed to analyze black pigmentation in the soft tissue covering titanium miniplates. This soft tissue was compared with the soft tissue covering Champy stainless steel plates. All plates were removed 8 months after application. Macroscopically visible pigmentation was found in 25.6% of the soft tissue covering titanium miniplates and in none of the soft tissue covering Champy stainless steel plates. Microscopically visible pigmentation was found in 71.8% of the soft tissue covering titanium miniplates and in 65.3% of the soft tissue covering Champy stainless steel plates. Energy-dispersive x-ray analysis of the soft tissue covering titanium miniplates revealed only the presence of titanium dioxide. In the soft tissue near Champy stainless steel plates, chromium, nickel, iron, and molybdenum were found. Electron microscopy showed titanium dioxide to be mainly deposited between the collagen fibers, whereas stainless steel particles were mainly found in giant cells.

Seven years clinical experience with mandibular distraction in children

Mandibular distraction was performed on 14 children, between September 1991 and December 1997. Their average age was 6.9 years, ranging from 1.5 to 13.5 years. All patients had severe hypoplastic mandibles with retromandibulism. Seven of the children (50%) had respiratory distress due to obstruction of the upper airway before distraction. This resolved in every case. Five patients underwent unilateral and nine bilateral distraction. A total of 23 distractors were used, 15 were applied extraorally and 8 endorally. The average latency time after operation was 2.8 days, but for the past 2 years, distraction was started beginning with the operation. The distraction was increased twice daily for an average of 5.5 weeks, by 0.4 or 0.5 mm each time, depending on the distractor. Computed tomography and ultrasound were used to follow the ossification process in the distraction gap and to measure the lengthening achieved. Subsequent retention time averaged 2.4 weeks. The mandibles were elongated by up to 18 mm (average 9.3 mm) and the respiratory distress symptoms resolved in all patients. Several minor complications which are reported occurred. Six patients were followed up for periods between 3 and 7 years. During this time further growth of the distracted mandibles was recorded.

Application of purified bone morphogenetic protein (BMP) in cranio-maxillo-facial surgery: BMP in compromised surgical reconstructions using titanium implants

After a review of the clinically relevant literature on early modified whole bone products (demineralized bone; AAA bone (Urist et al., 1975))--predecessors of purified bone morphogenetic protein (BMP)--and a summary of the only published clinical experience with purified human BMP (in orthopedic surgery; from the group of Urist; Johnson et al., 1988-1992), an introductory overview of our experience with our own preparations of BMP from bovine bone in 271 procedures on the face and cranium in 145 patients is presented. In this first article of a series of three, major preprosthetic reconstructions using iliac bone grafts and titanium screw implants are described. All patients are examples of compromised bone and/or soft tissue conditions and cannot be considered routine indications for the operations performed. The most endangered implants became osseointegrated after 6 to 8 1/2 months as judged from clinical examination and CT imaging. These results demonstrate the efficacy of purified, concentrated BMP preparations, able unequivocally to induce bone even in areas with seemingly lost implants.

Biodegradable polylactide plates and screws in orthognathic surgery: technical note

In orthognathic surgery, the bone fragments are usually fixed with metallic plates and screws. Metallic devices other than titanium plates are usually removed after the osteotomy has consolidated, which often requires general anaesthesia. Titanium plates, supposed to be biotolerable, have been introduced in order to overcome this need for secondary intervention. However, due to corrosion, titanium particles have been found in scar tissue covering these plates and in locoregional lymph nodes. Therefore, their removal is also advocated. Self-reinforced poly (L-lactide) homopolymer (PLLA) and poly (L/D-lactide) stereocopolymers with a L/D molar ratio up to 85/15 have sufficient strength to overcome the need for additional support for the fixation of fractures. The plates can be bent at room temperature. The surgical technique and early results of a case of bimaxillary surgery and genioplasty fixed with bioresorbable material without postoperative rigid maxillomandibular fixation are reported.

Frontal sinus fractures : principles of treatment and long term results after sinus obliteration with the use of lyophilized cartilage

The most commonly used techniques for frontal sinus obliteration involve the implantation of an autogenous tissue graft: either fat, muscle or bone. Lyophilized allogenic cartilage due to its unique properties, such as the tendency to ossification and resistance to volume reduction, can be used as the material of choice for sinus obliteration. A clinical and radiological study of 66 patients operated on for frontal sinus fractures, between January 1 1988 through December 31 1995 was undertaken. Variables recorded included the aetiological factors, the clinical and radiological fracture features with the corresponding treatment modality, the association of frontal sinus fractures with intracranial involvement, the early and late postsurgical complications and the correlation between pre- and postoperative radiological findings. Obliteration of the frontal sinus with lyophilized cartilage chips was performed in 51 (77.3%) patients. The postsurgical evaluation showed no major complications. Revision of the frontal sinus was only required in one patient. The radiological findings verified the progressive calcification of the obliterated sinus. Allogenic lyophilized cartilage implantation offers distinct advantages in cases of severe frontal sinus trauma: 1. There is nearly unlimited availability of the material. 2. There is no need for a second operation field with the associated potential donor site morbidity. 3. The operation time is reduced due to the avoidance of a second operation on the donor site.

Application of purified bone morphogenetic protein (BMP) preparations in cranio-maxillo-facial surgery. Reconstruction in craniofacial malformations and post-traumatic or operative defects of the skull with lyophilized cartilage and BMP.

New ways of craniofacial reconstruction in old post-traumatic or fresh donor site craniectomy defects and in congenital malformations (Aperts and Crouzons syndromes) are described. In all instances a stacked composite of lyophilized cartilage strips interspersed with BMP layers was applied to fill the defects and indentations or used in combination with autologous bone struts to rebuild the cranium completely in synostotic malformations. The stratified implants interlaced with BMP induced early bone formation, and in addition were rigid enough from the beginning to serve as bridging elements over and between autologous bone struts in the cage-like forehead reconstructions. The reconstructed areas became clinically solid after a few months. CT images taken in 4 cases showed progressive calcification starting in the BMP layers, sometimes already visible after a few weeks. These results indicate that the usual slow process of calcification/ossification of lyocartilage alone is considerably accelerated by the combination with BMP. From intermediate term observations (more than one year) we conclude that complete consolidation of the whole implants, so far without signs of resorption, will consistently be the final outcome of this type of reconstruction.

Temperature mapping of magnetic resonance-guided laser interstitial thermal therapy (LITT) in lymphangiomas of the head and neck.

Lymphangiomas of the tongue and neck are uncommon benign congenital lymphatic tumors. These vascular lesions are difficult to treat, frequently recur, and can cause patients significant morbidity. Treatment may also be complicated by adjacent vital anatomic structures. Magnetic resonance (MR)‐controlled laser‐induced interstitial thermotherapy (LITT) has been proven to be a noninvasive safe treatment. Real‐time monitoring of tissue temperature with thermosensitive sequences allows controlled coagulation necrosis.

Mandibular resorption due to systemic sclerosis: Case report of surgical correction of a secondary open bite deformity

Systemic sclerosis (SSc) is a connective-tissue disorder of unknown origin causing a multisystem disease. While erosions of the distal phalanges are commonly described, resorption of the mandible has been considered an unusual finding. However, systematic radiographic screening of different groups of patients suffering from SSc revealed a resorption incidence of 20-33% of the examined mandibles. Women especially seem to be affected, and the male/female ratio is 1/7. Bilateral condylysis due to SSc has been described in seven cases, or 13.7% of the reported cases. To the best of our knowledge, this is the fourth report of surgical correction of secondary dysgnathia due to systemic sclerosis and the first with a 2-year follow-up period.

Another way of treating fractures of the atrophic edentulous mandible

Summary The treatment of fractures of the edentulous, atrophic mandible with the usual surgical methods has proved unsatisfactory in our hands. We have therefore, searched for a more successful procedure and believe we have found a method utilizing autogenous or deep frozen rib grafts to immobilize the fragments. The grafts are placed around the mandibular ridge to include the fracture sites and are maintained and stabilized with at least two circum-mandibular wires for each fragment. With the use of autogenous bone, as described in this procedure, the fracture can be stabilized and at the same time the alveolar ridge augmented and shaped for prosthetic purposes. The treatment of 5 cases is presented: one includes an extensive bilateral nonunion of the edentulous mandible, the defect of which was bridged by a circular autogenous iliac crest graft. In the remaining 4 cases autogenous or deep frozen bank rib grafts were used. On the basis of the presented cases, the ideal treatment and possible errors are discussed.