Maximilian Rohde

Qualitative tissue differentiation by analysing the intensity ratios of atomic emission lines using laser induced breakdown spectroscopy (LIBS): prospects for a feedback mechanism for surgical laser systems

The research work presented in this paper focuses on qualitative tissue differentiation by monitoring the intensity ratios of atomic emissions using ‘Laser Induced Breakdown Spectroscopy’ (LIBS) on the plasma plume created during laser tissue ablation. The background of this study is to establish a real time feedback control mechanism for clinical laser surgery systems during the laser ablation process. Ex-vivo domestic pig tissue samples (muscle, fat, nerve and skin) were used in this experiment. Atomic emission intensity ratios were analyzed to find a characteristic spectral line for each tissue. The results showed characteristic elemental emission intensity ratios for the respective tissues. The spectral lines and intensity ratios of these specific elements varied among the different tissue types. The main goal of this study is to qualitatively and precisely identify different tissue types for tissue specific laser surgery. (© 2013 WILEY-VCH Verlag GmbH &Co. KGaA, Weinheim)

Laser induced breakdown spectroscopy for bone and cartilage differentiation - ex vivo study as a prospect for a laser surgery feedback mechanism

Laser surgery enables for very accurate, fast and clean modeling of tissue. The specific and controlled cutting and ablation of tissue, however, remains a central challenge in the field of clinical laser applications. The lack of information on what kind of tissue is being ablated at the bottom of the cut may lead to iatrogenic damage of structures that were meant to be preserved. One such example is the shaping or removal of diseased cartilaginous and bone tissue in the temporomandibular joint (TMJ). Diseases of the TMJ can induce deformation and perforation of the cartilaginous discus articularis, as well as alterations to the cartilaginous surface of the condyle or even the bone itself. This may result in restrictions of movement and pain. The aim of a surgical intervention ranges from specific ablation and shaping of diseased cartilage, bone or synovial tissues to extensive removal of TMJ structures. One approach to differentiate between these tissues is to use Laser Induced Breakdown Spectroscopy (LIBS). The ultimate goal is a LIBS guided feedback control system for surgical laser systems that enables real-time tissue identification for tissue specific ablation. In the presented study, the authors focused on the LIBS based differentiation between cartilage tissue and cortical bone tissue using an ex-vivo pig model.

Elevation forces and resilience of the sinus membrane during sinus floor elevation: preliminary measurements using a balloon method on ex vivo pig heads.

PURPOSE Because the maxilla and its alveolar process are prone to resorption after tooth loss, it is often necessary to perform a bone augmentation procedure to successfully carry out implant treatment in that region. The aim of this study was to determine the adhesive force between the sinus membrane and the osseous sinus floor that occurs during sinus floor elevation with a balloon lift system. MATERIALS AND METHODS Twenty-two ex vivo pig heads were used for this study. Access to the maxillary sinus was gained via the lateral sinus wall. Sinus elevation was performed using an inflatable balloon, which was consecutively filled with 3 mL of a radiopaque fluid. Pressure was monitored directly and continuously during the elevation procedure with an electronic pressure gauge. The integrity of the membrane was checked microscopically and macroscopically. RESULTS The average adhesion force of the sinus membrane was found to be 748 ± 65.56 mmHg. On microscopic and macroscopic inspection, no mucosal tearing occurred during sinus floor elevation. Underwood septa, when present, did not significantly influence the adhesion forces. CONCLUSIONS The balloon system allowed for reproducible real-time measurement of the elevation forces and soft tissue resilience of the sinus membrane during the elevation process in this animal model. No mucosal ruptures were caused with this technical setup, in which effective elevation pressure ranging from 660 to 880 mmHg was not exceeded. A possible transfer of this technical setup to clinical procedures in humans requires investigation.

Tissue Discrimination by Uncorrected Autofluorescence Spectra: A Proof-of-Principle Study for Tissue-Specific Laser Surgery

Laser surgery provides a number of advantages over conventional surgery. However, it implies large risks for sensitive tissue structures due to its characteristic non-tissue-specific ablation. The present study investigates the discrimination of nine different ex vivo tissue types by using uncorrected (raw) autofluorescence spectra for the development of a remote feedback control system for tissue-selective laser surgery. Autofluorescence spectra (excitation wavelength 377 ± 50 nm) were measured from nine different ex vivo tissue types, obtained from 15 domestic pig cadavers. For data analysis, a wavelength range between 450 nm and 650 nm was investigated. Principal Component Analysis (PCA) and Quadratic Discriminant Analysis (QDA) were used to discriminate the tissue types. ROC analysis showed that PCA, followed by QDA, could differentiate all investigated tissue types with AUC results between 1.00 and 0.97. Sensitivity reached values between 93% and 100% and specificity values between 94% and 100%. This ex vivo study shows a high differentiation potential for physiological tissue types when performing autofluorescence spectroscopy followed by PCA and QDA. The uncorrected autofluorescence spectra are suitable for reliable tissue discrimination and have a high potential to meet the challenges necessary for an optical feedback system for tissue-specific laser surgery.

Oral squamous cell carcinoma of the tongue: Prospective and objective speech evaluation of patients undergoing surgical therapy

Prospective speech intelligibility assessments lack objectivity in patients undergoing surgery for oral squamous cell carcinoma (OSCC) of the tongue.

Gender trends in authorship in oral and maxillofacial surgery literature: A 30-year analysis

The aim of the present study was to perform a bibliometric analysis of the gender distribution of first and senior authorships in important oral and maxillofacial journals over the 30-year period from 1980 to 2010. Articles published in three representative oral and maxillofacial surgery journals were selected. The years 1980, 1990, 2000, and 2010 were chosen as representative points in time for article selection. Original research, case reports, technical notes, and reviews were included in the analysis. Case reports and technical notes were pooled in one group. For each article, the gender of the first author as well as that of the senior author was determined, based on the inspection of their first name. The type of article was determined and the country of origin of the article was documented. A total 1412 articles were subjected to the data analysis. A significant increase in female authorship in oral and maxillofacial surgery could be identified over the chosen 30-year period. However, the number of publications by male authors was still significantly higher at all points of time, exceeding those of female authors by at least 3.8 fold in 2010. As there is a trend towards feminization of medicine and dentistry, the results of the present study may serve as the basis for further analysis of the current situation, and the identification of necessary actions to accelerate the closure of the gender gap in publishing in oral and maxillofacial surgery.

Gingival esthetics and oral health-related quality of life in patients with cleft lip and palate

While the oral health-related quality of life (OHRQoL) is known to be reduced in patients with cleft lip and palate (CLP), its inter-dependency with the soft tissue characteristics of the CLP area remains unclear. This study aimed to evaluate the soft tissue characteristics in the treated cleft area in order to investigate whether gingival esthetics correlate with OHRQoL. Thirty-six patients with unilateral or bilateral CLP (46 cleft areas) were investigated after secondary/tertiary alveolar bone grafting and orthodontic/prosthetic implant treatment using an adapted score to rate gingival esthetics (clinical esthetic score, CES). The patients OHRQoL was determined using the German short version of the Oral Health Impact Profile questionnaire (OHIP-G14). The results showed a significantly better rating in patients with their own teeth in situ (12.05±1.10) than in patients with implants (6.95±4.78) or prosthetics (4.00±3.58). The best OHRQoL values were achieved by patients with their own teeth integrated into the cleft area (1.32±2.31), followed by patients with implants (2.33±2.33) and prosthetics (3.75±5.87). A significant (P=0.017) correlation was found between OHIP-G14 and CES scores, suggesting an increased OHRQoL in cases with higher oral esthetics in the cleft area. The therapeutic strategy contributes to both gingival esthetics and OHRQoL. The patients subjective perception of OHRQoL can be attributed to objective gingival esthetic ratings.

Does Laser Surgery Interfere with Optical Nerve Identification in Maxillofacial Hard and Soft Tissue?—An Experimental Ex Vivo Study

The protection of sensitive structures (e.g., nerves) from iatrogenic damage is of major importance when performing laser surgical procedures. Especially in the head and neck area both function and esthetics can be affected to a great extent. Despite its many benefits, the surgical utilization of a laser is therefore still limited to superficial tissue ablation. A remote feedback system which guides the laser in a tissue-specific way would provide a remedy. In this context, it has been shown that nerval structures can be specifically recognized by their optical diffuse reflectance spectra both before and after laser ablation. However, for a translation of these findings to the actual laser ablation process, a nerve protection within the laser pulse is of utmost significance. Thus, it was the aim of the study to evaluate, if the process of Er:YAG laser surgery—which comes with spray water cooling, angulation of the probe (60°) and optical process emissions—interferes with optical tissue differentiation. For the first time, no stable conditions but the ongoing process of laser tissue ablation was examined. Therefore, six different tissue types (nerve, skin, muscle, fat, cortical and cancellous bone) were acquired from 15 pig heads. Measurements were performed during Er:YAG laser ablation. Diffuse reflectance spectra (4500, wavelength range: 350–650 nm) where acquired. Principal component analysis (PCA) and quadratic discriminant analysis (QDA) were calculated for classification purposes. The clinical highly relevant differentiation between nerve and bone was performed correctly with an AUC of 95.3% (cortial bone) respectively 92.4% (cancellous bone). The identification of nerve tissue against the biological very similar fat tissue yielded good results with an AUC value of 83.4% (sensitivity: 72.3%, specificity: of 82.3%). This clearly demonstrates that nerve identification by diffuse reflectance spectroscopy works reliably in the ongoing process of laser ablation in spite of the laser beam, spray water cooling and the tissue alterations entailed by tissue laser ablation. This is an essential step towards a clinical utilization.

Investigation of Laser Induced Breakdown Spectroscopy (LIBS) for the Differentiation of Nerve and Gland Tissue—A Possible Application for a Laser Surgery Feedback Control Mechanism

Laser surgery provides clean, fast and accurate modeling of tissue. However, the inability to determine what kind of tissue is being ablated at the bottom of the cut may lead to the iatrogenic damage of structures that were meant to be preserved. In this context, nerve preservation is one of the key challenges in any surgical procedure. One example is the treatment of parotid gland pathologies, where the facial nerve (N. VII) and its main branches run through and fan out inside the glands parenchyma. A feedback system that automatically stops the ablation to prevent nerve-tissue damage could greatly increase the applicability and safety of surgical laser systems. In the present study, Laser Induced Breakdown Spectroscopy (LIBS) is used to differentiate between nerve and gland tissue of an ex-vivo pig animal model. The LIBS results obtained in this preliminary experiment suggest that the measured spectra, containing atomic and molecular emissions, can be used to differentiate between the two tissue types. The measurements and differentiation were performed in open air and under normal stray light conditions.

Autofluorescence spectroscopy for nerve-sparing laser surgery of the head and neck—the influence of laser-tissue interaction

The use of remote optical feedback systems represents a promising approach for minimally invasive, nerve-sparing laser surgery. Autofluorescence properties can be exploited for a fast, robust identification of nervous tissue. With regard to the crucial step towards clinical application, the impact of laser ablation on optical properties in the vicinity of structures of the head and neck has not been investigated up to now. We acquired 24,298 autofluorescence spectra from 135 tissue samples (nine ex vivo tissue types from 15 bisected pig heads) both before and after ER:YAG laser ablation. Sensitivities, specificities, and area under curve(AUC) values for each tissue pair as well as the confusion matrix were statistically calculated for pre-ablation and post-ablation autofluorescence spectra using principal component analysis (PCA), quadratic discriminant analysis (QDA), and receiver operating characteristics (ROC). The confusion matrix indicated a highly successful tissue discrimination rate before laser exposure, with an average classification error of 5.2%. The clinically relevant tissue pairs nerve/cancellous bone and nerve/salivary gland yielded an AUC of 100% each. After laser ablation, tissue discrimination was feasible with an average classification accuracy of 92.1% (average classification error 7.9%). The identification of nerve versus cancellous bone and salivary gland performed very well with an AUC of 100 and 99%, respectively. Nerve-sparing laser surgery in the area of the head and neck by means of an autofluorescence-based feedback system is feasible even after ER-YAG laser-tissue interactions. These results represent a crucial step for the development of a clinically applicable feedback tool for laser surgery interventions in the oral and maxillofacial region.