International Poster Journal of Dentistry and Oral Medicine, Supplement DGMKG/2015

Osteopetrosis (marble bone disease, Albers-Schönberg disease) is in the majority of the cases an inherited disorder, which is caused by a considerably decreased function of bone resorbing cells (osteoclasts). Through constant accumulation of bone tissues, the microarchitecture of the bony structures get highly impaired, whereby the mechanical stability of the bone declines, leading to frequent bone fractures. Different variations of autosomal dominant and autosomal recessive inherited disorders are distinguishable, which are highly distinctive in their onset, their clinical manifestation and in the progression of the disease. A 58-year-old patient, who was referred to our clinics after unsuccessful treatment at a hospital in Libya, is presented. Following an existing osteopetrosis this patient developed a massive osteomyelitis in the maxilla and mandible with abscess, extra-oral fistula, and a widespread impairment of the soft tissues. After clinical examination of the soft tissue, vast osseous lesions in terms of acute osteomyelitis were diagnosed, based on the computer tomography (CT) and the digital volume tomography (DVT) findings. Major parts of the maxilla and the mandible and both zygomatic bones were affected. Phlegmonous involvement of all surrounding soft tissues was present. As additional findings characteristic signs of an autosomal dominant inherited osteopetrosis were found in parts of the craniofacial bone as well as the cervical spine ("rugger-jersey-spine"). Laboratory-chemical results showed a characteristic decrease of the Calcium level. The surgical rehabilitation based on a removal of the diseased tissues proved to be challenging due to the broad extension. In some parts centimetre-sized sequesters including the teeth were extracted. The reduced healing tendency of the osseous structure led to a difficult and prolonged progression of the disease. With several surgical interventions and intensive medical adjunctive therapy the wounds could finally heal, however, extreme mandibular and mid-facial defect sites were still present. An Osteomyelitis resulting from an osteopetrosis is usually not as characteristic symptom or complication of this disease. However, if it develops,it may make the surgical treatment and management extremely difficult. The knowledge of the pathogenesis of the underlying disease is an important prerequisite for an adequate planning of the therapy and for the conduct of a successful treatment of the operative steps. Keywords: Osteopetrosis, Osteomyelitis, Albers-Schönberg Disease

Chondrosarcomas are a rare disease of the bone and the soft tissue, which often impress in the area of the facial bones as a painless swelling. They speak very poorly to a radiotherapy or chemotherapy. Radical surgical resection with the greatest possible safety margins is the treatment of the first choice. We present a case of a 34-year-old patients with the upper jaw chondrosarcoma. Preoperative MRI and CT-diagnostics showed a pronounced tumor growth with intraorbital, ethmoidal, nasal expansion and involvement of the skull base. The tumor diameter was up to 7 cm. In the clinical examination, an extreme displacement of the eyeball was manifested anteriorly and superiorly, as well as a facial swelling and disturbed vision at the right side. After presentation of the patients in our tumor conference, we chose a tumor resection with preservation of eyeball and a postoperative adjuvant heavy ion therapy. The tumor resection was done over a transfacial access under microscope- and navigation-guided surgery with preservation of the eyeball. The reconstruction of the orbital floor and the maxillary sinus was made with a titanium mesh. The special challenge was to prevent the correct position of the previously extremely repressed eyeball. The post-operative course was uneventful and the cosmetic and functional results were very satisfactory. Also the visual disturbances have been significantly improved. Due to the extensive tumor size and the small safety distances in the skull base and the bulb, adjuvant radiotherapy was carried out with heavy ion radiation. With navigation and microscope-guided surgical techniques also extremely large and the bulb displacing chondrosarcoma can be operated with good functional and aesthetic results. Keywords: Chondrosarcoma, Maxillary bone tumor

Aim: To evaluate the Ti-Epiplating System (MEDICON®) for implant supported nasal epitheses after nasal ablation. Method: Indication for the use of the Ti-Epiplating System were patients who received nasal ablation because of malignancies and who had only poor bony conditions to place other kinds of implants to anchor a nasal epithesis. Intraoperative handling was determined. All kinds of complications such as infection, wound dehiscence, screw loosening and implant fracture were evaluated. Results: Three patients were treated using the Ti-Epiplating Systems. The intraoperative handling was judged as simple. After a mean follow-up of 18 months no complications such as infection, wound dehiscence, screw loosening or implant fracture occurred. Sufficient anchoring of nasal epithesis was possible in all patients. Conclusions: The Ti-Epiplating System consists of multiple small screws and one plate. Therefore it is favourable in patients with reduced bony conditions for sufficient anchoring of nasal epitheses. Keywords: nasal epithesis, bony anchoring, implant

Procedures and workflow for the digital setup and planning for precision and cost-optimized navigated implantation with the aid of CTV Systems. Keywords: navigated implantation, minimally invasive, economical process, digital setup

The documentation of postoperative wound infections by means of indicator operations within the surveillance system of postoperative wound infections of the National Reference Centre for the Surveillance of Nosocomial Infections is established. Until know there is no indicator operation for the Oral and Maxillofacial Surgery available. In the period of 2009-2013 every orthognathic surgery of the mandible, which was performed at the Department of Oral and Maxillofacial Surgery of the University Medical Centre of Mainz (Germany), was used as indicator operation without an official participation. In none of the 258 orthognathic surgeries of the mandible an infection could be detected. If an operation without wound infection should be used as indicator operation is questionable. Keywords: indicator operation, oral- and maxillofacial surgery, orthognathic surgery of the mandible, Op-Kiss, clean-kontaminated

There is increasing evidence of 11β-hydroxysteroid dehydrogenase (11β-HSD) isoforms playing a pivotal role in the pathogenesis of various metabolic, systemic and inflammatory diseases such as diabetes mellitus or ischemic and coronary heart disease. Additionally, bone affecting diseases such as rheumatoid arthritis or osteoporosis correlate with altered 11β-HSD expression patterns and glucocorticoid (GC)-action as described earlier. Interestingly, the pathogenesis of periodontitis is indeed frequently accompanied by the aforementioned systemic inflammatory comorbidities. The genomic response to inflammatory stimuli relies, besides on other mechanisms, on the activation of the glucocorticoid receptor (GR), which in turn represses or stimulates expression of diverse pro- and anti-inflammatory genes in order to regulate stress and inflammatory responses. To avoid or dampen unwanted systemic effects of GCs (e.g. cortisone, cortisol), this mechanism depends upon tissue-specific fine-tuning. Thus, transformation of GCs is mediated by specialised enzymes, which convert steroid hormones from their inactive to their active forms and vice versa. A key role is played by the two isoforms of 11β-HSD which catalyse the interconversion of active cortisol and inactive cortisone. The interaction and expression of both 11β-HSD isoforms is highly dynamic in various types of tissues, as they individually equilibrate local and systemic GC-concentrations and hence control transcription patterns under different physiological conditions. However, most studies targeting the expression patterns of 11β-HSD isoforms and GC-action in the clinical picture of periodontitis are restricted to mouse models. For the first time, the present study examines human gingival tissue of periodontitis patients and healthy controls with the use of quantitative Real-Time PCR (qRT-PCR) in order to test whether tissue-specific dysregulation of 11β-HSD isoforms contributes to the progression of periodontal disease. On the mRNA level, our results do not indicate dysregulation of 11β-HSD isoforms in cases and controls. However, regulation patterns of 11β-HSD isoforms in the clinical picture of peri-implantitis remain to be investigated in future studies as these enzymes constitute promising pharmaceutical targets to ameliorate disease progression and medical conditions of the oral cavity. Keywords: Periodontitis, 11beta-hydroxysteroid dehydrogenase type 1, 11beta-hydroxysteroid dehydrogenase type 2, inflammation, glucocorticoids, cortisone

Objectives: For mandibular reconstruction after continuity resection locking reconstruction plates are mostly used. Aim of the study was the investigation of reconstruction accuracy (RA) of 4 different mandibular reconstruction plate systems. Methods: The systems (1) Medartis Modus Reco 2.5, (2) Synthes Compact 2.4 UniLock, (3) Synthes MatrixMANDIBLE Recon 2.4 and (4) Stryker Leibinger Universal Mandible Recon were compared. Per system 10 mandibular models were provided. Each model was marked with 4 measuring points (MP) on both sides of the condyles and mandibular rami. For evaluation of the RA the distances between the 4 MP were measured before and after the simulation of the reconstruction. Results: The absolute values of system (1) showed with 0.78mm the largest deviation from the initial value. The other systems showed nearly identical deviations ((2)=0.57mm, (3)=0.48mm, (4)=0.52mm). The difference between system (1) and the others is significant. Between the other systems there are no significant differences. Concerning the signed values, system (2) showed a distance reduction of -0.57mm, which indicates a narrowing between the rami and condyles. The other systems showed an increase of the distances ((1)=+0.42mm, (3)=+0.27mm, (4)=+0.40mm), which implies an enlargement in the rami- and condyle region. Only the difference between system (2) and the others is significant. Conclusion: The tested systems are showing differences concerning their reconstruction accuracy, which are partially statistically significant. However, with median deviations below 1 mm, it can be assumed, that all investigated systems have a high RA. No relevant differences can be expected concerning the clinical outcome. Keywords: mandibular reconstruction, mandibular reconstruction plates, mandibular models, rapid prototyping, mandible reconstruction plates, locking plates, mandibular reconstruction accuracy, angular-stable mandibular reconstruction plates

Background and Aim: The activation of platelets by thrombin, apoptosis and mechanical stress results in the release of small membrane vesicles from the platelet surface, so-called microparticles (MPs). MPs interact in various ways with their environment. Experimental data suggest that MP play an integral role in modulating innate and adaptive immunity, hemostasis, angiogenesis and bone-forming cell activation. Thus, MP application represents a promising method for enhancing the regeneration of peri-implant defects. This study aimed to evaluate the healing of peri-implant defects grafted with microparticles (MPs). Material and Methods: Six domestic pigs received nine standardized defects at the calvaria, and an implant was inserted in the middle of each defect. The space between the implant and lateral bone portion was filled with thrombocytes +MP (n=18) or MP (n=18) or left unfilled (n=18). After 14 and 28 days, three animals were sacrificed and specimens removed for further processing. Samples were microradiographically and histologically analyzed. In addition, we immunohistochemically stained for anti-vWF as a marker of angiogenesis. Results: In the case of bone regeneration and vessel formation, the null hypothesis can be partially rejected. After 14 and 28 days, no significant difference was observed within groups regarding de novo bone formation and osseointegration. However, superior vessel formation was found at both time points. Conclusion: MPs represent a promising treatment option to accelerate peri-implant vessel formation. Further studies are needed to investigate the regenerative properties of MPs more precisely. Keywords: Microparticles, Dental implant, Bone regeneration, Histology, Immunohistochemistry, Animal Model

The Oral Squamous Cell Carcinoma (OSCC) frequently metastasizes lymphogenously. Haematogenous dissemination is less common. This report describes a rare case of a metastatic OSCC of the floor of the mouth to the patients' left upper arm. This is the first case described in literature as far as we know. Twelve months after R0 tumor resection surgery, including microvascular reconstruction of the lower jaw and followed by adjuvant radiotherapy, the patient was admitted for osteosynthesis plates removal. During clinical examination a tumor situated at his left upper arm was detected. According to the patient the tumor has demonstrated a rapid growth. Macroscopic appearance and conventional imaging led to the differential diagnosis of an abscess. MR-imaging could not differentiate between a tumor of soft tissue origin and a metastasis. A biopsy was taken and the pathological examination confirmed the diagnosis of an OSCC metastasis. The postoperative interdisciplinary tumor board recommended radiation therapy. Due to the fact that patients with regional lymph node metastases have a higher probability to develop distant metastasis a more detailed screening might be considered - especially when hemangiosis carcinomatosa was found histologically or macroscopically. Keywords: Mouth neoplasms, Neoplasm metastasis, Upper arm metastasis, Soft-tissue metastasis, Metastatic OSCC

Background: A prevalent modality to increase the amount of available bone prior to implantation is grafting of the maxillary sinus. Multiple factors such as the surgical technique, moment of implant placement as well as grafting materials and membranes are known to affect implant survival. However, the role of different factor combinations and associated reciprocal effects remain unclear. Conventional statistical methods do not consider inconsistency of study designs and do not take covariables into account. Hence, a systematic research and meta-analysis was conducted to investigate the influence of various treatment modalities on implant survival in the grafted maxillary sinus. Materials and Methods: A meta-analysis was conducted according to the PRISMA guidelines. Articles published from 1980 through January 2013 were electronically and manually searched in MEDLINE (Ovid), the Cochrane Register of Controlled Trials, the Database of Abstracts of Effects, and the Cochrane Database of Systematic Reviews. Clinical reports on single intervention sinus augmentation with root-form implants, a minimum of 10 patients and 6 months of loading were eligible for inclusion if implant survival was stated or calculable. Results were calculated by non-parametric univariate Kaplan-Meier analysis and Bayesian multivariate interval-censored Cox regression. Results: A total of 122 publications on 16268 endosseous implants placed in grafted maxillary sinus were included. The treatment parameters surgical approach, grafting material and implant type showed no selective preference. However, application of membranes showed a significantly reduced hazard-ratio, independent of other co-factors. Conclusions: The use of membranes is the most significant factor to achieve long-term implant survival in sinus augmentation procedures. More data exceeding 3 years follow-up are needed to address prospective confounding and improve clinical evidence. Keywords: Sinuslift, Sinus augmentation, alveolar ridge, Membrane, Dental implants, Long-Term Survival

Computer aided virtual planning to correct defect and in malposition consolidated fractures helps to obtain esthetic and functional results. The case shown in the presentation describes the work flow of this technique. Keywords: Virtual planning, post traumatic defects and malpositions

Background: Rheumatoid Arthritis (RA) is the most common inflammatory disease of the joints, affecting various joints. It is observed predominantly in women in the age of 35 and 45 years. Therapy consists of various medications, ranging from anti-inflammatory drugs to immunsuppressant agents and surgical therapy. Materials and Methods: The presented poster reports the case of a 66 year old female patient with RA and permanent immunosuppressive therapy by Retuximab and Denosumab. Due to increased craniomandibular dysorders the patient has been treated with a condylar prosthesis of the right temporomandibular joint and dental implants in the upper molar region. Results: The reported patient presented with longlasting suffering from head- and neck- pain of unclear origin. After clinical and radiological examination a severe craniomanibular dysfunction with arthritis of the temporomandibular joint as a consequence of RA could be diagnosed. In 2008 arthroscopy, followed by arthroplasty with an interponate of the fascia of the musculus temporalis was performed. Due to recurring pain and mouth opening restriction removal of the condyle and implantation of a condyle prothesis was performed in 2014. Simultaneously insertion of dental implants placed in the upper molar region (regio 24 and 26) was performed by internal sinus floor elevation. Discussion: In case of a severe RA significant improvement of craniomandibular disorders could be achieved by arthroscopy, arthroplasty and implantation of a condylar prosthesis. Thereby improvement of mouth opening could be achieved. Further, simultaneous insertion of dental implants in the upper molar region was performed to competely restore oral function. The presented implantologic treatment presents under specific, complicating circumstances such as RA and immunosuppressive medication a limiting case of implant rehabilitation. Keywords: Rheumatoid Arthritis, Condylar Prothesis, Dental Implantat, Craniomandibular Dysfunction

A segmental resection of the mandible is usually required for a reliable removal of a mandibular ameloblastoma. Especially in the mental regionthe three-dimensional reconstruction of the soft and hard tissues is a particular challenge. On the basis of two case presentations, the specific features of a clinical approach will be illustrated. Two patients aged 57 and 59 years were diagnosed with a mandibular ameloblastoma with each showing a similar baseline status. The different follow-up times of 3 and 13 years allow presentable medium-term and long-term results and make a comparison possible. Regular clinical and radiographical follow-up controls took place. The segmental resection in the regions 31 - 34 and 34-36 led to complex defect situations of the bone, teeth and the soft tissues in the affected areas in each case. A staged surgical reconstruction was performed with the microsurgical neurolysis and decompression of the mental nerve, autologous hip bone transplantation with osteosynthesis as well as a delayed dental implant placement with three implants. A vestibuloplasty using a free mucosal graft from the palate and the individualised prosthetic supraconstruction resulted in a favourable revonstructive outcome. After 3 and 13 years after surgery good osseointegration of the implants and favourable results of the hard and soft tissue-recontructions relating function as well as aesthetics, without any limitation of the neural function has been accomplished. This staged reconstructive approach we describe, is a complex procedure but seems to be a reliable method for a functional and aesthetic rehabilitation of these cases. Favourable clinical and radiological results were persistingly observed at three years post interventionem as well as after the long-term observation time of 13 years. Keywords: ameloblastoma, bone defect, augmentation, implant, autologous bone transplantation, segmental resection, soft tissue reconstruction

Most of the cases of a periapical radiolucency are caused by a periapical granuloma or a radicular cyst. However, differential diagnoses exist, which require a modified approach. The following case presentation demonstrates a rare differential diagnosis of a periapical radiolucency. Per incidental finding, multiple apical osteolysis were detected on the panoramic radiograph taken by a 65-year-old female patient. Until the very first clinical examination, there were no complaints of the affected teeth present. The vitality test taken showed all teeth being positive. Following the CT Scan osteolysis around the teeth 33, 35, 36 and 41 and a vestibular distension on 36 were found, which were clinically manifest as well. The histologic examination of the samples taken from the regions 36 and 41 revealed an ossifying fibroma. Following root canal treatment of the affected teeth 33, 35, 36 and 41, a surgical resection of the fibroma based on a microscope-based surgery and a neurolysis of the mental and alveolar inferior nerve were carried out. An apecectomy was performed on several teeth. The defects were drilled out and the soft and fibrous tissues were removed completely. Collagen was placed in the bony defects. The one-year postoperative clinical and radiologic examination revealed no recurrence of the ossifying fibroma. The treatment of the ossifying fibroma consists of the exstirpation and curettage in toto. All structures affected from the lesion should be removed as well. Following a total resection of the tumoral tissues, it can be claimed to have a good prognosis. Even asymptomatic incidental findings should be examined using further diagnostic investigations such as a CT-Scan, and where applicable, samples should be taken for a histologic clarification, so that a reliable diagnosis can be evaluated. Keywords: Ossifying Fibroma, Periapical Radiolucency

Introduction: Dento-alveolar defects with vertical maxillary bone loss may be caused by tumor- resection, trauma or cystectomy. Reconstruction of such bone-defects with a cortico-cancellous iliac bone graft is a well established augmentation-method, suited to create a sufficient recipient area for dental implants. This approach is accepted for restoration of masticatory function and therefore oral rehabilitation of such patients and produces reliably good results. In extreme cases, however, the soft tissue coverage may become the limiting factor: Common methods of soft tissue coverage of the bone graft then fail and taking of a bone-graft altogether might fail. By demonstrating difficult clinical cases with extreme defects we suggest how to solve this problem. Methods: Intraoral examination in all these patients showed a pronounced vertical maxillary bone defect of the posterior maxilla with very difficult soft tissue conditions. By choosing a special type of buccal incision, we succeeded to cover our bone grafts by pedicled flaps form the palate, even though, we temporarily lost the buccal vestibule. Each of the iliac bone grafts had been fixed by two osteosynthesis-screws. Six months after graft-healing, dental implants were inserted without any further soft tissue reconstruction. After osseointegration of the dental implants vestibuloplasty was used to recreate the buccal vestibule, and, additionally a free palatal mucosal graft reconstructed the attached gingiva. Results: After successful healing of the bone-grafts, good osseointegration of the dental implants was also achieved. The oral vestibule was successfully reconstructed, and a keratinized gingiva was recreated successfully. Conclusion: With a special clinical approach and technique of soft tissue management it is possible to achieve coverage and healing of bone-grafts in vast vertical bone augmentation cases in the maxilla. The disadvantage of the temporary loss of the vestibule can be completely reversed in second step. Keywords: Alveolar ridge defect, Vertical augmentation, Soft tissue management

Introduction: Oligodontia is defined by a lack of at least six teeth. Most commonly, this is a concomitant symptom on the grounds of a syndromic disease. The non-syndromic oligodontia is much less common. The aetiology has not been fully clarified yet, however a genetic predisposition may play an important role. Due to the dental agenesis and missing function, there is an enormous alveolar ridge resorption, and the rehabilitation of these patients can evolve into a major task. Methods: A 20-year-old woman with non-syndromic oligodontia is being presented. The examination revealed agenesis of 17 teeth in the maxilla and mandible, and the family history showed that the patient's father and two sisters were on record with similar conditions of oligodontia. As the retained deciduos teeth were affected by generalized root resorption, they had to be extracted. Following a healing time of 12 weeks, bone augmentation with corticocancellous grafts from the iliac crest was conducted under general anaesthesia. After 6 months of healing, dental implant placement of 12 implants was performed, and after another 3 months, the uncovering of the implants and soft tissue management took place. The final restoration was delivered after 4 months of uneventful healing. Since then, a regular recall for maintenance therapy took place. The panoramic radiograph obtained after 7 years revealed good stability of the peri-implant levels, meeting an essential requirement for a long-term functional and aesthetical success. Conclusion: Even large horizontal defect sites in non-syndromic oligodontia patients can be treated with autologous bone harvested from the iliac crest. This approach was successfully utilized in the case presented to restore the horizontal dimension and the vertical height of the buccal bone wall; both factors are keys to aesthetic and functional success. Keywords: Non-Syndromic Oligodontia, bone augmentation, corticocancellous grafts, iliac crest

Background. Microcystic adnexal carcinomas (MACs) are slow-growing and often asymptomatic, malignant skin tumours that usually develop on the facial skin and may reach considerable size. We present a case of MAC arising on the hair-bearing scalp and discuss our experiences and considerations. To our knowledge, it is the first report of a MAC developing in this area. Case report. A 58-year-old female was admitted with a histopathologically secured diagnosis of MAC of the temporal and occipital regions that had expanded to 10 × 12 cm. Magnetic resonance imaging revealed an infiltration of the skin and the subcutaneous adipose tissue. No lymphatic or haematogenic metastases were detected. Therapy consisted of resecting the tumour and reconstructing the area by applying an anterolateral thigh (ALT) flap. Histopathological evaluation revealed clear, 1 cm margins and a tumour-free periosteum. One-year postoperative follow-ups showed no evidence of recurrence, while the outcome was aesthetically pleasing. Conclusion. When screening for skin cancer, careful attention must be paid to the scalp. Resection of MAC with clear margins is mandatory to minimize the risk of recurrence. In this case, applying an ALT perforator flap to a large defect of the hair-bearing scalp led to a very satisfying result; it should be considered in comparable cases. Keywords: Skin cancer, Microcystic adnexal carcinoma, Anterolateral thigh flap, Magnetic resonance imaging, Skin cancer screening

We present the medical history of a 61 year old male patient with a many years persiting swelling in the depth of the left cheek anteior of m. masseter that was actually growing slowly without pain. The patient could not remember any accident or surgery in this area. A possible systemic inflammatory cause was also not present. Presurgical performed MRI-scan and OPTG were even more not able to give hints to etiology. Under suspicion of a chronic sialadenitis of a small salivary gland the mass was removed by an transoral approach after splinting Stenon duct. The histopathologigal reprocessing revealed a high-grade fibrosis with particular xanthogranulomatous inflammation and herotopic ossifcation. Salivary gland tissue or mykobacterial inflammation components were not detectable. Further wound healing of the patient was within normal limits. The presented case shows that not only frequent beningn lesions but also rare lesions of the cheek have to be considered in differential diagnosis. Like in this case sometimes etiology stays indeterminate and diagnosis emerges by exclusion. Keywords: xanthogranulomaous inflammation, heterotopic ossification, swelling of the cheek with unknown etiology

Background: Entities of lacrimal gland lesions comprise almost inflammatory and lymphoproliferative processes as well as benign and malign tumors and usually cannot be differentiated by magnetic resonance imaging (MRI) exclusively. Hence, representative tissue samples are needed to arrive at sufficient histopathological diagnosis for further treatment decisions. Case report: Three women aged between 18 and 67 years were admitted to our centre with clinical signs of a space-occupying mass in the lacrimal fossa. MRI revealed a circumscribed lacrimal gland lesion in all three cases. The orbital lobe was resected through a lateral orbitotomy approach for histopathological evaluation. Findings confirmed the diagnoses of pleomorphic adenoma, dacryoadenitis and low-grade B-cell non-Hodgkin's lymphoma. Further surgery was not necessary. No recurrence or symptoms of 'dry eye' were observed over the course of a 1-year follow-up. Conclusion: In cases of non-specific masses in the lacrimal gland on MRI, histopathological diagnoses are vital and can be sufficiently provided by resection of the orbital lobe. Symptoms of 'dry eye' are uncommon and secondary surgical intervention can be avoided in cases of the presented entities. Further studies with larger patient cohorts are warranted to confirm these findings. Keywords: lacrimal gland, orbital lobe, dry eye, orbitotomy, MRI, dacryoadenitis

Introduction: A sagittal split of the mandible is a well established surgical procedure nowadays. A sagittal split however that is performed in a previously reconstructed mandible is a rare procedure. Case Report: A 37 years old patient presented with an odontogenic keratozystic tumor of the mandible. After surgical treatment - preserving the inferior alveolar nerve- reconstruction was achieved with a cortical iliac crest bone graft. After this surgery, however, a unilateral mandibular prognathia developed. Clinically the patient presented with a class III occlusion on the right side and a lateral shift of the dental midline of 3 mm to the left, as well as an edge to edge bite on the left. Therefore, eight months after the initial resection of the tumor and the reconstruction, we carried out a unilateral mandibular split in the reconstructed bone with as little bone denudation as possible. The osteotomy was fixed with two mini-plates. Wound healing was uneventful. A stable clinical result with class I occlusion was achieved. X-rays showed neither an atrophy nor an osteolysis of the grafted area. Six months later screws and plates were removed and three dental implants were inserted. After osseointegration of the implants masticatory rehabilitation was achieved by a prosthetic dental suprastructure of three single-crowns. Conclusion: Sagittal split ostetotomy in the angular region of the mandible is possible even in reconstructed bone after free bone grafting from the iliac crest, if excessive bone denudation is avoided. In this case the graft lost none of its original dimensions. Keywords: sagittal split osteotomy, unilateral, iliac crest bone graft

Introduction: The diffuse sclerosing osteomyelitis (DSO) of the mandible is characterized by recurrent pain of the jaw and swelling of the surrounding soft tissues. The final understanding of the etiology of this disease is still unclear. The symptoms seem often to be recurrent. During the last years some promising reports and small series about effective therapy of the DSO with oral or intravenous bisphosphonates have been published.1-5 Case report: We report about a 66 years old patient suffering from DSO in the lower jaw for 5 years. Conservative treatment with antibiotic and hyperbaric oxygen therapy showed no reduction of his complaints or improvement of the radiological findings. We decided to administer the patient a single shot of 4g zolendronate (Zometa®) intravenously. Within 2 days the patient appeared completely free of pain and the long lasting pain medication could be discontinued. Discussion: Bisphosphonates seem to be a promising option to reduce the progress of DSO and to control the clinical symptoms. However, longtime evaluation und follow up of larger case numbers are still necessary to proof the evidence of this treatment approach. Apart from the promising positive aspects of bisphosphonate treatment in patients with DSO, the undesirable side effects, especially the risk of development a bisphosphonate related osteonecrosis of the jaw have to be taken under account. Therefore, intensive information of the patients about this possible risk and the off-label use of the drug are mandatory. References: 1. Urade M, Noguchi K, Takaoka K, Moridera K, Kishimoto H. (2012) Diffuse sclerosing osteomyelitis of the mandible successfully treated with pamidronate: a long-term follow-up report. Oral Surg Oral Med Oral Pathol Oral Radiol. 114(4):e9-12. 2. Kuijpers SC, de Jong E, Hamdy NA, van Merkesteyn JP. (2011) Initial results of the treatment of diffuse sclerosing osteomyelitis of the mandible with bisphosphonates.J Craniomaxillofac Surg.39(1):65-68. 3. Hatano H, Shigeishi H, Higashikawa K, Shimasue H, Nishi H, Oiwa H, Shindo H, Takechi M, Ohge H, Kamata N. (2012) A case of SAPHO syndrome with diffuse sclerosing osteomyelitis of the mandible treated successfully with prednisolone and bisphosphonate J Oral Maxillofac Surg. 2012 Mar;70(3):626-631 4. Hino S, Murase R, Terakado N, Shintani S, Hamakawa H. (2005) Response of diffuse sclerosing osteomyelitis of the mandible to alendronate: follow-up study by 99mTc scintigraphy. Int J Oral Maxillofac Surg. 34(5):576-578. 5- Soubrier M, Dubost JJ, Ristori JM, Sauvezie B, Bussière JL. (2001) Pamidronate in the treatment of diffuse sclerosing osteomyelitis of the mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 92(6):637-640. Keywords: Diffuse sclerosing osteomyelitis, DSO, mandible, bisphosphonates, zolendronate

Introduction Immunocompromised patients have a predisposition to infections because of their weakened immune system. Thus,a fungal infection in the head area with entry points of the sinuses can induce massive destruction of the surrounding tissue, as in the case described below. Case report As part of a chemotherapeutic treatment of acute lymphocytic leukemia a 3½ year old boy developed a fungal infection of the paranasal sinuses. In addition, there was a Trisomy 21. initially he showed clinical an incipient necrosis in the area of the right nostril. In a nasal swab Aspergillus could be detected. Despite a supportive antifungal therapy, there was a progress of fungal disease with an invasive and destructive growth component. After regeneration of the blood formation and improvement of the general condition of the patient was a radiological diagnosis and surgical intervention possible. An MRI of the head and neck showed a necrosis of the septum and the tip of the nose to the right lateral nasal wall. Similarly, there was a necrosis of the hard palate and anterior alveolar ridge right in front. The neck and lungs could not be found pathological findings. In an interdisciplinary approach of the maxillofacial and ENT clinics the necrotic nose, the anterior maxilla including parts of the paanasal sinuses had be resected. The Defect of the palate was supplied by inserting a tampon and covered with a plate. Afterwards the defect in the nose area was supplied with an epihesis the of nose. Conclusion The dramatic developments of the case shows that the benefit of chemotherapy for acute lymphoblastic leukemia can have a high price. This may take up to a massive tissue loss in functional and aesthetically important regions of the face. As the benefit of chemotherapy unquestionable is, knowledge of such potential complications is important in order through early intervention. Keywords: Leukemia, fungal infection, necrosis, tissue loss nose and jaw

Occult metastasis of the lymph nodes of the neck occurs in up to 20-40 % of all oral squamos cell carcinoma (OSCC). Elective neck dissection of levels I - III is still recommended even in a clinically unsuspicious lymph node staging of the neck (cN0), regardless of the size of the primary tumor. Sentinel lymph node biopsy is not a common standard in the therapy of the primary stage of OSCC (cT1-2, cN0). Even if the method is not yet evidence based, several studies have already shown good results that suggest that the SLNB is an alternative procedure for the standard elective neck dissection in these cases. These studies also showed difficulties in the practical performance of the SLNB. Reasons for this were the close relationship between the sentinel lymph nodes to each other and to the primary tumor. Furthermore, the specific SLNs were difficult to find intraoperatively in a complex soft tissue anatomy of the neck. A new system for SLNB now offers the chance for an intraoperative 3D-SPECT of the radioactive SLNs with a 3D visualization of these structures. The marked SLNs are therefore superimposed on a live image of the patient's neck. This method should enable the surgeon to identify the SLNs more accurately. For a secure resection of these nodes, an additional computer navigated γ-probe is used as well. This navigation allows for the determination of direction and distance from the probe tip to the radioactive focus (SLN). After tumor and SLNs resection, a detection of the remaining radioactive tissue with a final 3D-SEPCT scan is also possible. Remaining lymph nodes can be visualized and resected before the completion of the operation. Even though this method offers promising possibilities in intraoperative visualization and soft tissue navigation, the procedure showed deficits in clinical use. The intra-OP 3D-SEPCT proved itself to be a time-consuming process in practice. The navigation within the soft tissue of the neck in order to find the SLNs proved itself to be imprecise. Possible reasons for this might be inaccurate registration and the soft tissue. The SLNs could often be detected properly only by the use of the acoustic feedback of the γ-probe. For this reason, this expensive and time-consuming procedure has to be evaluated critically from a clinical point of view. This method showed the greatest advantage in intraoperative 3D-SPECT scanning in order to evaluate the complete removal of all radioactive structures (SLNs and tumor) before completing the operation. Keywords: sentinel lymphnode, intraoperative navigation, computer assisted surgery, augmented reality