Jens Bodem

Influence of Lower Third Molar Anatomic Position on Postoperative Inflammatory Complications

PURPOSE Postoperative inflammatory conditions, including alveolar osteitis, surgical site infections, and abscess, are frequent complications after surgical removal of impacted mandibular third molars and multiple associated risk factors have been identified. However, few studies have evaluated the influence of extraction difficulty according to anatomic variables on postoperative inflammatory complications. PATIENTS AND METHODS A retrospective study was performed of 585 surgically removed lower third molars. All molars were classified by a difficulty score (range 3 to 10) according to the anatomic parameters. RESULTS For 109 third molars (19%), the extraction difficulty was rated noncomplex (score 3 to 4); for 341 (58%), moderate (score 5 to 7); and for 135 (23%), difficult (score 8 to 10). Molars rated as moderate or difficult for extraction were more often accompanied by postoperative infection than molars rated noncomplex (odds ratio 5.3 and 3.9, respectively, P < .0001). CONCLUSIONS The results from the present study revealed a highly significant correlation between the level of difficulty for surgical removal of lower third molars (predicted by the anatomic variables) and postoperative inflammatory complications.

Surgical management of bisphosphonate-related osteonecrosis of the jaw stages II and III.

OBJECTIVE The value of surgery in advanced stages of bisphosphonate-related osteonecrosis of the jaw (BRONJ) is still controversial. Hence, we evaluated the effect of surgical therapy in BRONJ stages II and III in combination with a standardized perioperative adjuvant treatment. STUDY DESIGN We included 39 patients who presented with BRONJ in a total of 47 locations and stages II (n = 23) and III (n = 24). All patients had exclusively received a monthly intravenous application of zoledronic acid. Surgical therapy consisted of complete removal of the necrotic jaw, accompanied by a standardized perioperative adjuvant treatment including intravenous antibiotic prophylaxis, gastric feeding, and an antimicrobiologic mouth rinsing. RESULTS Overall, 35 (74.5%) of the 47 BRONJ sites were treated successfully, with success defined as complete mucosal healing of the exposed jaw (n = 24) or as relative healing when surgical therapy downscaled BRONJ II or III to asymptomatic BRONJ stage I (n = 11). Interestingly, perioperative adjuvant treatment or bisphosphonate therapy parameters showed no statistical effect on the treatment outcome. CONCLUSIONS The results of the present study prove the effectiveness of surgical therapy for BRONJ stage II or III.

Mandibular reconstruction with a prefabricated free vascularized fibula and implant-supported prosthesis based on fully three-dimensional virtual planning.

AbstractBecause optimal reconstruction of maxillofacial defects requires functional rehabilitation, the current study demonstrates the successful secondary reconstruction of a large mandibular continuity defect using a fully digitally planned prefabricated free vascularized fibula with immediate implant-supported prosthodontic restoration.A 56-year-old man presented with a large mandibular continuity defect after resection of an enlarged squamous cell carcinoma arising from the floor of the mouth. For secondary reconstruction, the shape of the neomandible and implant position for support of the lower prosthesis were planned virtually. The combined cutting and drilling guide was printed in 3 dimensions.In a 2-step surgical approach, first, the implants were inserted into the fibula and covered with a split-thickness skin graft to form a neogingiva. In a second operation, the fibula was harvested, osteotomized, and fixed with the denture on the preinserted implants. The fibula was placed to its final position guided by the occlusion.Using three-dimensional virtual backward planning, it was feasible to perform a mandibular reconstruction with immediate prosthetic rehabilitation.

Value of nonsurgical therapeutic management of stage I bisphosphonate-related osteonecrosis of the jaw.

There is still controversy about the best treatment strategy for patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ) stage I. Therefore, the aim of the present study was to analyse the effect of a nonsurgical treatment protocol in patients with BRONJ stage I. During the study period we included 17 patients (11 male; 6 female) who presented with a total of 24 separate areas of BRONJ, stage I. All patients were exclusively treated with a monthly intravenous regime of zoledronic acid due to an underlying malignant disease. All patients were treated using a standardized nonsurgical protocol consisting of antimicrobial mouth rinsing with chlorhexidine (CHX) (0.12%) three times a day, and daily CHX gel application. In 11 patients (45.8%) the surface area of the exposed jawbone was completely healed by nonsurgical treatment. In seven patients (29.2%), nonsurgical treatment reduced the size of the exposed bone area by a mean of 64.7% (range 20.0-96.8%). None of the patients showed an increase in size of the area of exposed jawbone, or a worsening of the BRONJ from stage I to stages II or III. However, the duration of nonsurgical treatment or the duration of intravenous bisphosphonate therapy did not significantly influence the treatment outcome (p = 0.6628, p = 0.6077, respectively). The results of the present study support the beneficial role of nonsurgical treatment in patients presenting with BRONJ stage I. Surgical therapy of BRONJ should be restricted to patients with advanced stages with clinical symptoms and local signs of infection.

The Incidence of Complications Associated With Molding Helmet Therapy: An Avoidable Risk in the Treatment of Positional Head Deformities?

AbstractMolding helmet therapy using an individual head orthosis presents a widely accepted treatment option for children with positional head deformities; however, studies addressing the incidence of complications during helmet therapy are rare.The current study evaluates the incidence of complications in 205 children with positional head deformity undergoing molding helmet therapy. Children were classified according to the severity of their deformity as presented by the Cranial Vault Asymmetry Index (CVAI) and the Cephalic Index (CI).Fifty-nine (28.8%) of our patients presented a moderate and 146 (71.2%) a severe form of a positional head deformity. Of these children, 166 (81.0%) were diagnosed for plagiocephaly, 19 (9.3%) were brachycephalic, and 20 (9.7%) showed a combination of plagiocephaly and brachycephaly.Overall, 54 children (26.3%) showed minor complications during their helmet molding including pressure sores (13.7%), ethanol erythema (2.9%), skin erosions/skin infections (4.3%), or deficient fitting (5.4%). Children with a combination of plagiocephaly and brachycephaly (n = 20) showed the highest risk for complications, which was significantly higher compared with children with plagiocephaly (50% vs 22.3%; P = 0.012). Irrespective of the type of positional head deformity, no statistical difference was revealed between the moderate and the severe form.Minor complications are a relatively frequent event during helmet molding therapy. Especially children with a combination of plagiocephaly-brachycephaly are at high risk for complications. A reduction of this rate might be reached by a close follow-up for a short period between helmet manufacturing adjustments.

Reconstruction of a near-total nasal defect using a precontoured titanium mesh with a converse scalping flap.

The reconstruction in case of large nasal defects, especially affecting the cartilaginous portion, is a surgical and aesthetic challenge. The result has to fulfill functional and aesthetic aspects concerning shape, texture, and nasal breathing, which requires accurate reproduction of nasal lining, support, and coverage. Here, we describe nasal reconstruction in a 36-year-old woman after near-total nasal resection due to a malignant peripheral nerve sheath tumor in the glabellar and nasal regions. After tumor resection, the cartilaginous and bone structures were reconstructed using a dynamic titanium mesh, which was precontoured on a three-dimensional-print model of the preoperative situation. Soft tissue defects were covered as a 2-stage procedure using a Converse scalp flap. We achieved an adequate long-term functional and aesthetic and oncological result. Titanium mesh in combination with Converse flap proved to be an alternative in extensive composite midfacial defects.

The value of tranexamic acid during fronto-orbital advancement in isolated metopic craniosynostosis.

Craniofacial surgery in infants still harbors the risk of significant blood loss and the need for red blood cell (RBC) transfusion. Hence, the aim of the present study was to investigate the antifibrinolytic effect of tranexamic acid (TXA) on intraoperative blood loss and RBC transfusion rates during fronto-orbital advancement (FOA) in isolated metopic synostosis. A total of 33 children with metopic synostosis were operated on using standardized FOA, of which 16 patients (48.5%) were treated without intraoperative TXA (non-TXA group) and 17 patients (51.5%) received TXA intraoperatively (TXA group). To accurately evaluate the calculated blood loss (CBL) we analyzed the values for pre- and postoperative hematocrit and the volume of the RBC transfusion. The mean CBL and the mean weight-adjusted CBL was significantly lower for patients receiving TXA compared with the non-TXA group (158.8 ml vs. 198.5 ml, p = 0.0001; and 19.1 ml/kg vs. 22.3 ml/kg, p = 0.0293, respectively). In addition, the mean RBC transfusion and the mean weight-adjusted RBC transfusion was significantly lower for the TXA group (252.2 ml vs. 280.0 ml, p = 0.0001; and 27.9 ml/kg vs. 31.3 ml/kg, p = 0.0345, respectively). The mean duration of the surgical procedure did not differ statistically between the groups (132 min vs. 136 min, p = 0.4081), hence the lower CBL in the TXA-group was not related to a shorter cutting-suture time. As the use of intraoperative TXA minimizes blood transfusion volumes in children who undergo FOA, antifibrinolytics, such as TXA, should be considered for routine use in pediatric craniofacial surgery.

Role of neck dissection in the treatment of melanoma of the head and neck.

AbstractDespite numerous studies, specific guidelines for cervical lymph node surgery in cutaneous malignant melanoma of the head and neck are still missing.In a retrospective study, the modalities of neck dissection (ND), the histologic results, and the outcome in 59 patients with cutaneous malignant melanoma of the head and neck were evaluated to verify the benefit of this therapy.Patients with proven lymph node metastasis often benefit from complete ND because about 50% of the patients showed more metastases in their ND specimen than before surgery. In addition, suspicious but not surely malignant lymph nodes often proved to be benign.This study reveals that patients with proven lymph node metastasis often benefit from complete ND because the number of infiltrated nodes is often higher than suspected; nevertheless, when planning the surgical therapy, the overall prognosis has to be kept in mind.

Outcome of heavily pretreated recurrent oral squamous cell carcinoma after salvage resection: A monocentric retrospective analysis

PURPOSE The goals of the present study were to analyze survival data of patients who received salvage surgery due to recurrent oral squamous cell carcinoma (OSCC) of the oral cavity with curative intent, and to investigate the feasibility of microvascular flap reconstruction in a heavily pretreated patient cohort. MATERIAL AND METHODS A total of 32 patients who received salvage surgery due to recurrent OSCC were included. The cohort was analyzed in regard to relevant clinical and pathological features. Survival was estimated by using Kaplan-Meier analysis and verified in a multivariate Cox regression model. RESULTS All patients recovered well from surgery. The most common severe complication was free flap failure in 7 patients (24.1%). R0-resection was achieved in 16 patients (50%). Univariate Kaplan-Meier analysis showed that the estimated overall survival and disease-free survival of all patients after 24 months were 37.8% and 30.9%, respectively. Multivariate testing identified R1-resection was the only independent predictor of treatment failure. CONCLUSION Salvage surgery is the only potential curative treatment option in recurrent OSCC. Microvascular reconstruction is feasible in heavily pretreated patients, but it is associated with a higher free flap failure rate. Recurrent OSCC in heavily pretreated patients shows different biological behavior. Further prospective clinical and molecular studies are needed to develop a better molecular understanding of recurrent OSCC and the best and safest individual therapeutic strategy.