Paul W. Poeschl

Antibiotic susceptibility and resistance of the odontogenic microbiological spectrum and its clinical impact on severe deep space head and neck infections

OBJECTIVE The purpose of this retrospective study was to identify the major pathogens responsible for deep space head and neck infections and their current resistance to routinely used antibiotics in a university hospital setting. STUDY DESIGN A total of 206 patients suffering from odontogenic deep space infections were treated at our department by means of surgical intervention and intravenous administration of antibiotics. RESULTS The predominant bacteria were viridans group streptococci (VGS), staphylococci, Prevotella, Peptostreptococcus, and Bacteroides. In the aerobic spectrum, resistance against clindamycin was found in 18%, against macrolides in 14%, and against penicillin G in 7%. The anaerobes were resistant to clindamycin in 11%, to metronidazole in 6%, and to penicillin G in 8%. CONCLUSION The high resistance rate for clindamycin and macrolides was especially striking and may necessitate an adaptation of our antibiotic regime in the future.

Closure of oroantral communications with Bichat's buccal fat pad.

PURPOSE The aim of the present study was to evaluate the use of the pedicled buccal fat pad for the closure of oroantral communications (OACs) and to describe our experience with this surgical procedure. PATIENTS AND METHODS A retrospective review of 161 patients treated at the University Hospital for Cranio-Maxillofacial and Oral Surgery in Vienna, Austria, from 2000 to 2005, with the diagnosis of an OAC was performed. All defects were closed by application of a buccal fat pad. Data were obtained from chart review, a compiled database, and clinical follow-up and included the location of the defect, the cause of the OAC, the modality of anesthesia, intraoperative complications, any complications during the process of wound healing, and any late adverse effects. RESULTS The buccal fat pad for closure of an OAC was successfully used in 161 patients at our department. In 12 patients (7.5%), the closure of the OAC was insufficient, and a second operation was necessary. Excluding all severe and complicating cases such as tumor-related defects or previously treated cases, the overall success rate for closure of the OAC was nearly 98%. No late complications occurred, and all patients were free of pain or any limitations after the 6-month follow-up period. CONCLUSIONS According to the recommendations and anatomic limitations reported in published studies and discussed in the present report, the application of the buccal fat pad is a safe and reliable procedure for closing an OAC.

Application of platelet-rich plasma for enhanced bone regeneration in grafted sinus.

PURPOSE The present study was conducted to evaluate the effect of platelet-rich plasma (PRP) on new bone formation and remodeling after grafting of the maxillary sinus with an algae-derived hydroxyapatite AlgOss/C Graft/Algipore. MATERIALS AND METHODS Fourteen consecutive patients with severely atrophic maxillae underwent uni- or bilateral grafting of the maxillary sinus with a mixture of collected bone, algae-derived hydroxyapatite AlgOss/C Graft/Algipore (ratio 1:10), and a combined addition of PRP and thrombin (Tissucol Kit; Baxter, Vienna, Austria) to allow for fast clotting. After an average healing period of 7.1 months bone samples were retrieved. Patients from a former consecutive series treated without PRP served as control group. Statistical analysis was done by Welch 2-sample t test and mixed linear model testing. RESULTS In the coronal specimen portions, mean values for newly formed bone area, biomaterial area and marrow space of 32.2% ± 10.4%, 20.1% ± 13.0%, and 47.7% ± 8.5% were found with PRP, respectively. In the control group the corresponding values were 27.6% ± 13.4%, 20.3% ± 12.9%, and 52.1% ± 9.3%. In the apical specimen portions in the PRP group, the newly formed bone area, biomaterial area, and marrow space was 25.7% ± 15.0%, 23.4% ± 14.9%, and 50.9% ± 12.5%, respectively. The corresponding values in the control group were 17.0% ± 8.6%, 34.5% ± 11.2%, and 48.5% ± 8.5%. CONCLUSIONS Statistical evaluation of the samples proved significantly better overall resorption of algae-derived hydroxyapatite AlgOss/C Graft/Algipore and increased new bone formation when PRP was used, especially in the apical region.

Clinical Experiences With Resorbable Ultrasonic-Guided, Angle-Stable Osteosynthesis in the Panfacial Region

PURPOSE In this study we report our experiences with the treatment of midfacial fractures and various other indications in regions with low load bearing (eg, dysmorphias) using the biodegradable Osteosynthesis System (SonicWeld Rx by KLS Martin, Tuttlingen, Germany), comprising biomechanical and histological aspects. PATIENTS AND METHODS Seventy-five patients were included in this study. We describe the application of this system for the treatment of fractures of the zygomamaxillary complex, frontal bone impression fractures, surgical treatment of mukocele in the frontal sinus, isolated fractures of the orbital floor, complex midfacial trauma and bone cap fixation, craniosynostoses, and fixation of a distracted bone fragment. RESULTS The pin insertion could be finished with a total failure rate of lower than 5%. In 3 patients, soft tissue swellings in regions with less subcutaneous fat were observed 6 to 8 months postoperatively. No fracture dislocations occurred. Scanning electron micrograph of the experimentally acquired connection between the resorbable plate and 2 pins clearly demonstrates a tight and reliable fusion to bone, both at the cortical as well as at the spongy compartment. Conventional histology leads to corresponding findings as scanning electron micrography, and shows a close fusion between all components. CONCLUSION This retrospective study shows the general feasibility, sufficient mechanical stability, and efficient intraoperative handling of this angle-stable, ultrasonic-guided resorbable Osteosynthesis System (ResorbX and SonicWeld Rx) for a wide variety of indications in craniomaxillofacial surgery.

Endodontic Pathogens Causing Deep Neck Space Infections: Clinical Impact of Different Sampling Techniques and Antibiotic Susceptibility

INTRODUCTION The aims of the present study were to compare microbial populations in patients suffering from deep neck space abscesses caused by primary endodontic infections by sampling the infections with aspiration or swabbing techniques and to determine the susceptibility rates of the isolated bacteria to commonly used antibiotics. METHODS A total of 89 patients with deep neck space abscesses caused by primary endodontic infections requiring extraoral incision and drainage under general anesthesia were included. Either aspiration or swabbing was used to sample microbial pus specimens. The culture of the microbial specimens and susceptibility testing were performed following standard procedures. RESULTS A total of 142 strains were recovered from 76 patients. In 13 patients, no bacteria were found. The predominant bacteria observed were streptococci (36%), staphylococci (13%), Prevotella (8%), and Peptostreptococcus (6%). A statistically significant greater number of obligate anaerobes were found in the aspiration group. The majority of patients presented a mixed aerobic-anaerobic population of bacterial flora (62%). The antibiotic resistance rates for the predominant bacteria were 10% for penicillin G, 9% for amoxicillin, 0% for amoxicillin clavulanate, 24% for clindamycin, and 24% for erythromycin. CONCLUSIONS The results of our study indicated that a greater number of anaerobes were found when sampling using the aspiration technique. Penicillin G and aminopenicillins alone are not always sufficient for the treatment of severe deep neck space abscesses; beta-lactamase inhibitor combinations are more effective. Bacteria showed significant resistant rates to clindamycin. Thus, its single use in penicillin-allergic patients has to be carefully considered.

Impact of elective neck dissection on regional recurrence and survival in cN0 staged oral maxillary squamous cell carcinoma.

To evaluate the impact of elective neck dissection (END) on regional recurrence and survival in cN0 staged patients with maxillary squamous cell carcinoma (SCC). Eighty-six patients with maxillary SCC and clinically staged N0 cervical lymph-nodes were evaluated in this single center retrospective study. Seventy-four of 86 patients were included in this analysis, of which 36 patients were treated with END, 38 without END. Following END, pathohistologically verified regional lymph-nodes in the initially cN0 neck were found in three (8%) patients. In both the +END and non-END group regional recurrences occurred exclusively in patients with T4 primaries. The overall regional recurrence rate was 17% in the +END and 18% in the non-END group, respectively. The 5-year overall survival rate for all tumor stages combined (T1-T4) was 86% in the +END group and 82% in the -END group. Within the patients groups with T4 tumors, 5-year overall survival was 81% for the +END group and 56% for the -END group. Over all tumor stages combined (T1-T4), END did not significantly improve overall survival rates and did not prevent the rate of regional recurrence in cN0 staged patients with maxillary alveolar, gingival and palatal SCC. However, in the subgroup of patients with locally advanced T4 tumors, their seemed to be a clear tendency towards improvement of overall survival in the END group. END can therefore be recommended for these patients.

Maxillomandibular Fixation Using Intraoral Cortical Bone Screws and Specially Designed Metal Hooks (Ottenhaken) in the Conservative Treatment of Mandibular Fractures

PURPOSE The present work evaluated the success of maxillomandibular fixation (MMF) by intraoral cortical bone screws and specially designed metal hooks (Ottenhaken) in nondislocated or slightly dislocated mandibular fractures. PATIENTS AND METHODS A total of 44 patients who sustained various types of mandibular fractures were treated at the University Hospital for Craniomaxillofacial and Oral Surgery, Vienna Medical School by MMF with Ottenhaken only. The patients were evaluated by preoperative and postoperative radiography, and clinical testing was performed by thermal testing with a cold spray and by assessing the degree of tooth mobility adjacent to the inserted screws. To determine the success of the treatment, various parameters, including screw or hook fracture, screw loosening, local infection of the punctured mucosa, and iatrogenic tooth damage, were considered. RESULTS The screws and hooks were successfully inserted and MMF was engaged with tight elastics in all cases. The most frequent complication was rupturing of the elastics, necessitating replacement. In 5 patients, local infection of the mucosa around the screw led to severe pain that was treated successfully with analgesics. The screws could be left in place in all 5 cases. Hook fracture and screw loosening each occurred in 1 patient. No iatrogenic injuries of the dental roots were noted. After screw removal, all wounds healed uneventfully. CONCLUSION The use of intraoral cortical bone screws and specially designed metal hooks (Ottenhaken) for MMF is a useful, valid alternative to arch bars that carries only rare, mild complications.

Tricalcium phosphate-based biocomposites for mandibular bone regeneration--A histological study in sheep.

The present study investigated the suitability of three different absorbable biocomposites for the repair of critical sized bone defects created at the mandibular angle of adult sheep. Each biocomposite was composed of a three-dimensional individualized polylactide scaffold, containing a tricalcium phosphate biomaterial (chronOS). Either autologous bone marrow (chOS/BoneMarrow) or coagulation factor XIII (chOS/FactorXIII) was added to the biomaterial for osteopromotion. Venous whole blood (chOS/Blood) added to the biomaterial served as a control. A total of 18 adult sheep were used for implantation studies, subdivided into three groups of six animals each. After 12 weeks of observation, the animals were sacrificed and the mandibles were retrieved for qualitative and quantitative histologic assessment within three regions of interest (transitional zone, center, and periphery) throughout the biocomposites. Successful bone regeneration was defined by the absence of scaffold deformation and the presence of new bone formation within the biocomposites. In histomorphometry, only chOS/BoneMarrow showed elevated area fractions of newly formed bone in all regions of interest (transitional zone 50.7 ± 7.5, center 31.9 ± 9.3, periphery 23.1 ± 13.5). This led to preservation of the macroscopic scaffold structure in all specimens. Zero hurdle regression confirmed this by validating the factor biocomposite as significant (p < 0.001) for regeneration success. In our experiment, chOS/BoneMarrow was the only biocomposite passing the hurdle of regeneration in all three regions of interest. In contrast, bone formation was less pronounced and uniform in chOS/FactorXIII and chOS/blood-containing specimens. In these groups, scaffolds showed obvious to significant deformation. Overall, autologous bone marrow showed the most promising results in our experimental setting. As opposed to reports in the literature, we could not confirm the suitability of coagulation factor XIII to promote bone formation, since bone formation rates were comparable only to those of the control venous blood.

CROOMA, complication rates of operatively treated mandibular fractures, paramedian and body

INTRODUCTION This retrospective study comprises an exploratory analysis of 10 years of surgical treatment of symphysis (S) and parasymphysis/body (P/B). Correlations of complications, as well as dependencies of surgical concepts, are investigated. MATERIALS AND METHODS All surgically treated patients in the period of 1995 to 2005 with at least one mandibular fracture mesial to the mandibular angle were included in this study. A total of 63 patients (46 men, 17 women) with 63 symphysis fractures were included and 497 patients (369 men, 128 women) with 553 P/B were included; 99.27% (549) of these fractures were included in the study, 4 had to be dismissed because of inconclusive documentation. RESULTS Of patients with P/B, 96.04% were successfully treated with 1 open reduction, 3.76% had 2, and 0.20% had 3 surgeries. Of the surgically treated patients, 75.77% (416) were completely free of complications, whereas the other 24.23% of the P/B showed 1 or more complications. The main complication was mild nerve damage (24.8%). Osteosynthesis failure rate (OFR) was 2.4% (7 of 298) for 2 miniplates, 5.7% (3 of 53) for 1 tension screw, and 8.4% (9 of 107) for 1 miniplate. Regarding OFR, 2 miniplates showed to be superior in a Fisher exact test (P = .018, adjusted P = .132). Symphysis fractures were completely free of complications in 81.8% and showed 2 major complications, i.e., 1 severe nerve damage and 1 osteosynthesis failure. DISCUSSION This study has the limitations of a retrospective study. CONCLUSION A high success rate of open reduction and osteosynthesis with 2 miniplates can be guaranteed.