Klaus-Dietrich Wolff

Osteoporosis and bisphosphonates-related osteonecrosis of the jaw: Not just a sporadic coincidence – a multi-centre study

INTRODUCTIONnBisphosphonates (BPs) are powerful drugs that inhibit bone metabolism. Adverse side effects are rare but potentially severe such as bisphosphonate-related osteonecrosis of the jaw (BRONJ). To date, research has primarily focused on the development and progression of BRONJ in cancer patients with bone metastasis, who have received high dosages of BPs intravenously. However, a potential dilemma may arise from a far larger cohort, namely the millions of osteoporosis patients on long-term oral BP therapy.nnnPATIENTS AND METHODSnThis current study assessed 470 cases of BRONJ diagnosed between 2004 and 2008 at eleven different European clinical centres and has resulted in the identification of a considerable cohort of osteoporosis patients suffering from BRONJ. Each patient was clinically examined and a detailed medical history was raised.nnnRESULTSnIn total, 37/470 cases (7.8%) were associated with oral BP therapy due to osteoporosis. The majority (57%) of affected individuals did not have any risk factors for BRONJ as defined by the American Association of Oral and Maxillofacial Surgery. The average duration of BP intake of patients without risk factors was longer and the respective patients were older compared to patients with risk factors, but no statistical significant difference was found. In 78% of patients the duration of oral BP therapy exceeded 3 years prior to BRONJ diagnosis.nnnDISCUSSIONnThe results from this study suggest that the relative frequency of osteoporosis patients on oral BPs suffering from BRONJ is higher than previously reported. There is an urgent need to substantiate epidemiological characteristics of BRONJ in large cohorts of individuals.

Advanced malignant minor salivary glands tumors of the oral cavity

OBJECTIVEnIntraoral minor salivary gland carcinomas (MSGC) are rare tumors with different frequency, distribution, and prognostic factors relating to overall survival.nnnSTUDY DESIGNnFrom 1992 to 2006, a total of 95 patients with MSGC originating in the oral cavity were analyzed by univariate and multivariate analysis using the log-rank test and Cox-regression.nnnRESULTSnFifty-four percent of all patients had a low-grade disease and 46% had a high grade disease. The 2-, 5-, and 10-year overall survivals were 82%, 73%, and 58%, respectively. The T (P = .007), N category (P = .010), UICC stage (P = .021), and resection margin status (P < .0001) statistically influenced survival, whereas the M status did not (P = .16). Salvage treatment influenced the patients overall survival significantly (P < .0001).nnnCONCLUSIONnThis study confirms that in MSGC salvage surgery and tumor stage correlates well with prognosis. More studies are necessary to confirm prognostic factors and determine the true frequency of MSGC in the oral cavity.

Raising of microvascular flaps

Raising of microvascular flaps : , Raising of microvascular flaps : , کتابخانه دیجیتال جندی شاپور اهواز

Bronchoscopy screening in primary oral squamous cell carcinoma: a 10-year experience

Squamous cell carcinoma (SCC) in the head and neck is associated with synchronous or metachronous carcinomas of the lung. Preoperative pulmonary screening is advocated and may be done by bronchoscopy, thoracic radiograph, computed tomography (CT), or positron emission tomography (PET) with CT (PET/CT fusion). We evaluated the role of bronchoscopy in patients with primary oral SCC to ascertain the incidence of synchronous malignancies of the lung. We retrospectively reviewed a decades experience of screening by bronchoscopy in 570 pathologically confirmed and previously untreated patients with oral SCC (188 female, 382 male). Univariate and multivariate analyses were done after evaluating the incidence of synchronous lesions and the clinical and histological features of the index tumour. Investigation by bronchoscopy showed disease in 166 patients, and malignancy of the lung in 9 (2%). The Union International contre le Cancer (UICC) stages I and II oral SCC were significantly associated with a synchronous malignancy of the lung (p=0.038). We recommend the use of bronchoscopy even in early tumour stages. Some patients had their treatment altered because of its use, including upstaging, diagnosis of distant and unresectable disease, and investigation of second primary malignancies.

Die Leishmaniasis – eine parasitäre Erkrankung als Differenzialdiagnose maligner Mundschleimhauterkrankungen. Fallbericht und Literaturübersicht

Zur Differenzialdiagnostik maligner Erkrankungen der Mundschleimhaut zählen auch Infektionen mit im nördlichen europäischen Raum seltenen parasitären Erregern. Durch zunehmenden Tourismus in Endemiegebieten ist auch mit einer weiteren Verbreitung von seltenen Erregern zu rechnen, die in dem hier vorliegenden Fall eine maligne Mundschleimhauterkrankung vortäuschen können und sich klinisch als Ulkus an ungewöhnlicher Lokalisation darstellen. Der hier vorgestellte Fall ist insofern eine Besonderheit, da der Patient bei bekannter chronischer Hepatitis C eine zunehmende Leberzirrhose entwickelte, die eine Lebertransplantation verlangte. Anamnestisch lag ebenfalls eine stattgehabte Leishmanien-Infektion vor, die jedoch durch ein Tropeninstitut ausbehandelt zu sein schien. Die neu entwickelten Leishmanien-Infektion stellt aufgrund der anstehenden Immunsuppression eine Kontraindikation für die Lebertransplantation dar. Unter oraler Therapie mit Miltefosin (IMPAVIDO®) konnte eine Remission erzielt werden. Die Leishmaniase gehört zu den klassischen tropenmedizinischen Infektionskrankheiten. Derzeit sind laut WHO etwa zwölf Millionen Menschen in 88 Ländern der Welt, speziell in tropischem Klima, infiziert. Wiederholt kommt es zu Infektionen im Bereich des nördlichen europäischen Raumes durch die Phleobotonus-Sandmücke. Bei der intraoralen Befunderhebung ist die Leishmaniase bei zukünftigen unklaren Effloreszenzen der Mundschleimhaut als Differenzialdiagnose zu bedenken. Although parasitel infections in northern Europe are rare, it must be considered as differential diagnosis of malignant tumours of mucous membrane. With increasing tourisms in endemic areas, infections with parasite pathogen are spreading in non-endemic areas as well. In this case axa0mucous membrane malignancy with clinical feature of ulcer on unusual location was imitated. In this reported case the patient suffers with hepatitis c, causing cirrhosis of the liver and making axa0liver transplantation necessary. In this patient axa0history of axa0leishmaniosis which had been treated successful by the tropical institute is reported, but because of axa0new actually leishmaniosis-infection axa0liver transplantation is contraindicated. Under oral therapy with Miltefosin (IMPADIVO®) axa0remission was successful. The leishmaniosis is axa0classical tropical disease. WHO reported axa0morbidity of nearly 12 million people in 88 countries around the world especially in tropical areas. Repeatedly infections in northern Europe caused by the phlebotonus-sandflies are described. Therefore leishmaniosis must be considered as differential diagnosis in suspect lesions of mucous membrane.Although parasitel infections in northern Europe are rare, it must be considered as differential diagnosis of malignant tumours of mucous membrane. With increasing tourisms in endemic areas, infections with parasite pathogen are spreading in non-endemic areas as well. In this case a mucous membrane malignancy with clinical feature of ulcer on unusual location was imitated. In this reported case the patient suffers with hepatitis c, causing cirrhosis of the liver and making a liver transplantation necessary. In this patient a history of a leishmaniosis which had been treated successful by the tropical institute is reported, but because of a new actually leishmaniosis-infection a liver transplantation is contraindicated. Under oral therapy with Miltefosin (IMPADIVO) a remission was successful. The leishmaniosis is a classical tropical disease. WHO reported a morbidity of nearly 12 million people in 88 countries around the world especially in tropical areas. Repeatedly infections in northern Europe caused by the phlebotonus-sandflies are described. Therefore leishmaniosis must be considered as differential diagnosis in suspect lesions of mucous membrane.

Radial Forearm Flap: Flap Raising Including the Cephalic Vein

Since the RFF is drained by a deep and a superficial system, there is still a debate as to which system is more reliable for anastomoses. Anatomically, the superficial system of the RFF is largely represented by the cephalic vein, which collects the blood from the dorsal venous arch and courses along the dorsolateral border of the radius toward the antecubital fossa, where it communicates with the median cubital vein, the basilic vein, and also with the deep venous system of the RFF via a perforating vein. The vein then further ascends to the deltopectoral fossa, traveling within the groove between the biceps and brachialis muscles, where it perforates the clavipectoral fascia to drain into the axillary vein. According to an anatomic dissection by Reid and Taylor [421], the cephalic vein was absent in 2 out of their 50 specimens. The average diameter of the cephalic vein is about 5 mm (1–12 mm) [270].

Radial Forearm Flap: Standard Technique

In 1978, a fasciocutaneous free flap from the volar aspect of the forearm and pedicled on the radial artery was first used in China. When this so-called “Chinese flap” was originally described by Yang et al. in 1981 [608] and Song et al. in 1982 [497], both groups already had performed more than 100 successful flap transfers. Shortly after, this technique was popularized by different European surgeons, who visited their colleagues in China. In 1981, Muhlbauer was the first to describe the advantages of the radial forearm flap (RFF) in the European literature, especially its excellent pliability, thinness, the ease of flap raising, as well as the constant anatomy and the long and high caliber vascular pedicle [377, 379]. Very soon, many authors favorized this flap for reconstructions in the head and neck region and for intraoral lining. In a number of publications, Soutar and coworkers reported on different indications of the radial forearm flap for reconstructions of the oral cavity and the hand [501–504], and Cheng used this flap for tongue reconstruction [88]. Hatoko et al. and Chen et al. favorized the forearm flap for defect coverage at the hard and soft palate and thus proposed this flap for the rehabilitation of the cleft lip and palate patient [79, 206]. Apart from a reliable closure of oroantral fistulas, they were able to resurface the alveolar ridge and build a vestibule for reliable fitting of dentures. Moreover, the forearm flap was used as a tubed flap to reestablish the ability of phonation or deglutition by inserting it in defects of the hypopharynx, trachea, or esophagus [82, 199, 606]. By including a bony segment of the radius, an osteocutaneous flap can be raised, which was proposed for mandible reconstruction [377, 504, 507]. Because of the rich vascularization, two or more isolated skin paddles can be built which are suitable for the closure of perforating defects of the oral cavity [54]. Niranjan and Watson described a technique for cheek reconstruction using the tendon of the palmaris longus muscle to elevate the denervated angle of the mouth [394]. Lip reconstructions were performed by incorporating a segment of the brachioradialis muscle into the radial flap, which than was reinnervated by a branch of the facial nerve and sutured to the ends of the resected orbicularis muscle [447, 516]. As another variation, vascularized fascial flaps from the forearm were placed into the oral cavity to allow for reepithelialization and thus to achieve a mucosal surface [332]. When covering the fascia with a skin graft prior to flap raising, ultrathin flaps can be prefabricated which show less shrinkage compared to pure fascial flaps. Moreover, the appearance of the donor site is improved by linear closure of the forearm skin, which is not used for flap raising [588]. Although sensory recovery of the radial forearm flap may be facilitated by anastomosing a branch of the antebrachial cutaneous nerve to a sensory nerve of the recipient site [556], according to clinical experience, sensation will at least partially be reestablished spontaneously after years even without neurocutaneous anastomoses, probably by nerve sprouting.

Radial Forearm Flap: Suprafascial Flap Raising

Despite the increasing development of thin perforator flaps and continuous sophistication of flap-raising techniques at nearly any donor site of the body, the RFF remains the most commonly used free flap, mostly raised as a standard fasciocutaneous flap with dissection deep to the forearm fascia [24, 495, 583]. Using this conventional approach, a number of modifications concerning the soft and hard tissue components of the flap and its design, volume, and shape are possible and open a wide range of indications [24, 455]. Nevertheless, the numerous advantages of this flap are limited by a significant incidence of donor-site morbidity, which is the major stimulus to search for alternatives to the RFF. As described above, partial loss of the skin graft, delayed healing, and tendon exposure are the most-reported complications after subfascial flap raising, and many proposals have been made to overcome these problems like oversewing the tendons with musculature [144], primary closure [350], bilobed flaps [228], Z-plasty [233], V-Y advancement flaps [75, 310, 558], and various suturing techniques to reduce the size of the donor defect [366, 495, 580]. According to wide clinical experience and retrospective studies, full-thickness skin grafts seem to have a better functional and esthetic outcome over split-thickness skin grafts [26, 75, 159, 245, 493] and negative pressure wound dressings can further improve the outcome of wound healing at the RFF donor site [12, 21–23].

Medial Sural Artery Perforator Flap

Based on the concept of myocutaneous flaps which was introduced in the late 1970s, the posterior aspect of the calf has been used as a donor site for local musculocutaneous flaps from the gastrocnemius muscle for defect coverage at the lower leg and around the knee joint [119, 142, 347, 348]. Before that, a successful local defect coverage with the lateral gastrocnemius muscle head, which was supplied by a direct branch of the popliteal artery, was reported by Pers and Medgyesi in 1973. In these first descriptions, the authors highlighted the excellent blood supply to both heads of the gastrocnemius muscle from either the medial or lateral sural artery, allowing for wide rotation of the muscle including skin to reach defects from above the patella down to the upper portion of the lower tibia and anterior lower leg. Because a substantial amount of tissue could safely be transposed into defects from a well-perfused donor site of the same leg, this technique immediately started to replace the formerly used crossleg flaps in lower-leg reconstructions. Consecutively, the muscle was transferred to the distal third of the lower leg as a free flap by Salibian et al. and Keller et al., thereby using the lesser saphenous vein as an interposition graft to elongate the sural artery [260, 452]. According to Matthes and Nahai, the muscle has a type I pattern of circulation [342].