Horst Menneking

A surgical robot system for maxillofacial surgery

In this paper, the first active surgical robot system (OTTO) in a clinical environment for maxillofacial surgery is presented. The medical application is described from a technical point of view and the requirements for a robot in this speciality are defined. The paper describes the system architecture of the robotics environment and the need for research and development. The robots hardware is based on a delta-kinematics robot system. At the current state of development, the robot can be used for inserting nonflexible catheters and for implanting bone fixtures in the skull.

Untersuchung zur Lebensqualität bei Patienten mit Gesichtsepithesen

OBJECTIVE This clinical study examined the quality of life of face-disabled patients who had received a facial prosthesis. PATIENTS AND METHODS The examination of the 58 patients was performed using different questionnaires. For the evaluation of the subjective health-related quality of life an instrument constructed by the WHO was used (WHOQOQL-Bref). The Frankfurter Scales of Body Concepts (FKKS) was chosen to measure the self-assessment of the patients own body perception. For the assessment of the present general quality of life a visual analogue scale was used (Anamnestic Comparative Self-Assessment, ACSA). Additionally an ad hoc questionnaire was used, which registers the post-therapeutic epithetic rehabilitation. The health-related quality of life of this sample was compared to a healthy one of the normal population. RESULTS The examinations showed that the quality of life of the patients is reduced in contrast to the healthy group when the acquired defects were located in the region of the eye and the nose. The evaluation of the scales of body concepts showed that the patients own body image was significantly altered. Body contact with other persons and their own sexual attraction was perceived as remarkably diminished. The patients believed that they spread an unpleasant odor. It is surprising that the wearers of a facial prosthesis indicated that they did not notice a restriction in the acceptance of their body by others. The influence of the application of camouflage did not have an impact on the quality of life. CONCLUSION To improve the restricted quality of life, to the raise the reduced well-being and to strengthen the altered body experience, psychological care should be provided besides further optimization of the surgical-epithetic therapy and the camouflage technique.

Significance of distraction osteogenesis of the craniomaxillofacial skeleton – A clinical review after 10 years of experience with the technique

INTRODUCTION Distraction osteogenesis (DO) has been applied to the field of craniomaxillofacial surgery for more than two decades. Although relevant factors for successful distraction osteogenesis are well known there are ongoing controversies about indications and limitations of the method and there is still a lack of evidence based data. Since 2003 the principle of gradual lengthening has been applied to patients affected by different types of skeletal craniomaxillofacial deficiency within individualized treatment protocols at the Campus Virchow Klinikum - Charité Universitätsmedizin Berlin - by the same surgical team. The records of these patients were reviewed in order to assess the significance of the technique within the spectrum of a craniomaxillofacial department. During 10 years DO has been applied in 80 patients representing less than 1% of all patients that have been treated since 2003. Review of the protocols showed a heterogeneous group with a wide variance of parameters, the age ranging from 2½ to 51 years. Internal distraction devices were used in all cases and individually selected with respect to optimal stability during active distraction and consolidation phase. Although distraction related complications occurred the majority of procedures ended up with the favoured result and skeletal stability. However additional reconstructive surgery was required despite successful distraction in the majority of patients. Although DO has a low significance with respect to overall patient counts the method is a powerful tool within individual therapeutic concepts for the surgical correction of craniofacial anomalies that are characterized by skeletal deficiencies and should be seen as addendum to other surgical options. Predictable and stable results can be expected if the basic principles of the method are regarded.

Incidence and management of severe odontogenic infections—A retrospective analysis from 2004 to 2011

The management of odontogenic infections is a typical part of the spectrum of maxillofacial surgery. Normally these infections can be managed in a straight forward way however under certain conditions severe and complicated courses can arise which require interdisciplinary treatment including intensive care. A retrospective analysis of all patients affected by an odontogenic infection that received surgical therapy from 2004 to 2011 under stationary conditions was performed. Surgical treatment consisted in incision and drainage of the abscess supported by additional i.v. antibiotic medication in all patients. Detailed analysis of all patients that required postoperative intensive medical care was additionally performed with respect to special risk factors. During 8 years 814 patients affected by odontogenic infections received surgical treatment under stationary conditions representing 4% of all patients that have been treated during that period (n = 18981). In 14 patients (1.7%) intensive medical therapy after surgery was required, one lethal outcome was documented (0.12%). In all of these 14 patients a history of typical risk factors was present. According to these results two patients per week affected by an odontogenic infection required stationary surgical treatment, about two patients per year were likely to require additional intensive medical care. If well-known risk factors are present in patients affected by odontogenic infection appropriate interdisciplinary management should be considered as early as possible.

Antley–Bixler-Syndrome – Staged management of craniofacial malformations from birth to adolescence – A case report

In 1975 Antley and Bixler described an unusual syndromal disorder consisting of complex craniosynostosis with midfacial hypoplasia, dysplasia of ears and nose, radiohumeral synostosis, congenital fractures of the femur and upper airway impairment in a newborn. Additional urogenital and cardiac malformations can be associated however diagnosis is based on a characteristic craniofacial deformity in association with humeroradial synostosis. Complex disturbance of craniofacial growth due to premature synostoses of the cranial base and vault results in a characteristic phenotype. Steroidogenesis due to intrinsic or extrinsic disturbance by maternal fluconazole ingestion during early pregnancy may be impaired. The mode of inheritance is supposed to be autosomal recessive. Mutations in the fibroblast growth factor receptor 2 (FGFR2) as well as mutations in the cytochrome P450 oxidoreductase (OR) gene have been verified. Like in other craniofacial dysostosis syndromes malformation of neuro- and viscerocranium is complex and requires a staged age- and growth-related interdisciplinary management with respect to the individual situation. This case report of a female patient born in 1994 suffering from that rare syndrome describes the interdisciplinary long-term management in one craniofacial centre over 16 years from birth to adolescence.

Anaplastology in times of facial transplantation: Still a reasonable treatment option?

Optimum functional and aesthetic facial reconstruction is still a challenge in patients who suffer from inborn or acquired facial deformity. It is known that functional and aesthetic impairment can result in significant psychosocial strain, leading to the social isolation of patients who are affected by major facial deformities. Microvascular techniques and increasing experience in facial transplantation certainly contribute to better restorative outcomes. However, these technologies also have some drawbacks, limitations and unsolved problems. Extensive facial defects which include several aesthetic units and dentition can be restored by combining dental prostheses and anaplastology, thus providing an adequate functional and aesthetic outcome in selected patients without the drawbacks of major surgical procedures. Referring to some representative patient cases, it is shown how extreme facial disfigurement after oncological surgery can be palliated by combining intraoral dentures with extraoral facial prostheses using individualized treatment and without the need for major reconstructive surgery.

Frontofacial advancement by internal distraction devices. A technical modification for the management of craniofacial dysostosis in early childhood

Normal craniofacial growth is characterized by a different growth pattern of neuro- and viscerocranium. In craniofacial dysostosis (CFD) syndromes there is complex disturbance of this physiological growth pattern. Modern surgical management of CFD is staged with respect to the severity of the deformity, the age and the development of the patient. Early single stage management of anterior cranial vault deformity and midfacial retrusion in children affected by syndromic craniosynostosis is possible when anterior cranial vault remodelling is performed together with gradual Le Fort III midfacial advancement. One pair of internal distraction devices, placed in accordance with the midfacial growth vector after initial cranial vault remodelling, can be sufficient for this purpose. Technical aspects of this modified frontofacial advancement procedure are presented and discussed based on a case report with a postoperative follow up time of 50 months.

Necrotizing soft tissue infection of the scalp after fronto-facial advancement by internal distraction in a 7-year old girl with Gorlin–Chaudhry–Moss syndrome – A case report

In 1960, Gorlin, Chaudhry and Moss described a syndrome consisting of craniofacial dysostosis in association with hypertrichosis, cardiac, genital, dental and ocular anomalies. Diagnosis is based on typical clinical findings and cannot be performed by molecular genetic analysis until now. There is little in the clinical literature concerning this rare craniofacial syndrome. For functional and psychosocial reasons, surgical correction of the complex craniofacial malformation in a 7-year old Hungarian girl with Gorlin-Chaudhry-Moss syndrome was performed by fronto-facial advancement using internal distraction devices. Postoperatively necrotizing soft tissue infection of the scalp developed leading to termination of the distraction process ahead of schedule and requiring aggressive surgical management. Typical physiological and clinical characteristics were observed both during the initial craniofacial correction as well as during the management of the infectious complication suggesting that the linking of different conditions (surgical trauma plus the selection of toxic microorganisms) has caused tissue destruction rather than the syndromal disorder or the surgical technique of distraction osteogenesis. Although skeletal improvement was achieved residual damage from the infectious complication must be considered as severe.

Transpalatal distraction – State of the art for the individual management of transverse maxillary deficiency – A review of 50 consecutive cases

Transpalatal distraction has been established as a technique for surgical assisted rapid palatal/maxillary expansion (SARPE/SARME) in order to correct transverse maxillary deficiency. From 2007 until 2013 bone borne transpalatal distraction devices have been inserted in 50 patients affected by transverse maxillary deficiency and transpalatal distraction has been performed by the same surgical team. Patient records were retrospectively evaluated after ending of the active distraction phase with respect to indication, achieved expansion, additional procedures and side effects. In all cases the existing transverse maxillary deficiency was corrected by means of transpalatal distraction according to the individual needs. No complications were observed that interfered with that therapeutic aim. Evaluation of the records showed a wide variance of parameters which impedes evidence based statements. According to that series transpalatal distraction is a safe, powerful and reliable procedure and can be recommended as a state of the art procedure for the individually adapted correction of transverse maxillary deficiency if well known parameters of distraction are respected.

The oculo-auriculo-fronto-nasal syndrome (OAFNS) - description of a rare and complex craniofacial deformity and its interdisciplinary management before school age.

Craniofacial clefts are certainly among the most challenging congenital malformations with respect to functional, aesthetic and psychosocial consequences. The aetiology is still under discussion, recent molecular genetic findings suggest defects in the ciliary function of neural crest cells during facial development. The severity of craniofacial clefting is known to be extremely variable. Different classifications have been proposed however nomenclature is not uniform. If vertical, median craniofacial clefting of fronto-naso-maxillary structures is accompanied by auriculo-mandibular malformations the term oculo-auriculo-fronto-nasal syndrome (OAFNS) has been proposed. Extreme craniofacial abnormalities have to be expected in this rare disorder. Adequate correction is a surgical challenge and interventions have to be adapted individually to patients needs with respect to general condition, age and growth. This case report describes both the underlying pathology as well as the interdisciplinary management of a female patient from birth to 6 years of age affected by this rare combination of vertical craniofacial clefting and bilateral auriculo-mandibular dysplasia.