Books

Introduction: Orbital reconstruction can be performed by using different kinds of alloplastic materials. Especially in solitary fractures of the orbital floor, the application of individual prefabricated CAD/CAM-implants represents a novel and increasingly used procedure. In this case report, we show the application of an CAD/CAM-implant in a complex nasoorbitoethmoid fracture combined with plate osteosynthesis and Polydioxanone foil. Case report: We report about the case of a 28-year-old professional football player with craniocerebral injury and a midfacial fracture due to collision in a football match. Preoperative CT-diagnostics showed a displaced and multiple fragmental fracture of the naso-ethmoidal complex involving the inferior orbital margin, medial orbital wall and orbital floor. Repositioning and osteosynthesis of the complex fracture was done over intra- and extraoral access. The reconstruction of the orbital floor was realized by using an individual CAD/CAM-implant in navigation-guided surgery. The medial orbital wall was reconstructed with a Polydioxanone foil. Results: By virtual mirroring of the opposite orbital frame in preoperative planning, it was possible to prefabricate an individual CAD/CAM-implant in order to reconstruct the fractured orbital floor. Despite the complex and difficult fracture of the naso-ethmoidal complex with multiple fragments, anatomical correct reconstruction of the displaced inferior orbital margin could be successfully done through the preoperative planned repositioning site of the CAD/CAM-implant. The accurate reconstruction of the orbital floor allowed intraoperative gain of time and and resulted in good rehabilitation of the patient. Conclusion: Individual prefabricated orbital floor CAD/CAM-implants can be successfully used in complex fractures and may be combined with other methods and materials. By correct planning, the described procedure can be advantageously in surgery and postoperative outcome. Keywords: CAD/CAM-implant, Reconstruction of the orbit, Orbital floor fracture, Nasoorbitoethmoid fracture

Infections in the mouth, jaw and face are mostly seen as infiltrates or abscesses with odontogenic cause. With little diagnostic effort we can quickly reach the desired treatment success through a causal therapy. A diagnostic and therapeutic challenge represent atypical disease process, which are located in various medical disciplines and are difficult to assign to an agent. In our case report, we represent a immunocompetent 42-year-old patient with no systemic diseases, which envisioned a massive upper lip swelling with bullous-phlegmonösem appearance. There was a detailed diagnostics and interdisciplinary investigation of the disease, which ultimately led to the diagnosis of kerion celsi. This is the maximum variation of tinea barbae, which is often accompanied by severe infiltration, pustule, abscess formation and hair loss. The disease proceeded despite intravenous and topical treatment with antivirals and antibiotics initially progressive. There were also pronounced thrombophlebitis at various intravenous access points, and an infestation on the right arm. Tropical and rheumatoid diseases were excluded as consultants. A pathology proof was not achieved despite multiple samples were taken. The disease was also assessed from different disciplines (Dermatology, Rheumatology, Internal Medicine) differently. Among systemic and topical antifungal therapy ultimately showed a regressive course and corroborated the diagnosis of kerion celsi. Kerion celsi often complicates diagnostics in oral and maxillofacial surgery. It represents the maximum variation of dermatophytosis and is often accompanied by secondary bacterial infections, and requires a long-term systemic therapy. Keywords: Vasculitis, infection, upper lip swelling, impetigo, erysipelas, pathergy phenomenon, thrombophlebitis, cellulitis, herpes zoster, kerion celsi

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

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

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 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

Purpose: For dental implants to be successful, osseointegration must occur, but it is unknown how much time must pass for osseointegration to be established. Preclinical studies suggested that titanium implants with a sandblasted and acid-etched (SLA) surface were more osteoconductive and allowed more rapid osseointegration than machined or turned implant surfaces. The hypothesis of this study was that implants with an SLA surface could be loaded in half the conventional healing time of machined-surface implants and that, after loading, the implants would be successful for 5 years. Materials and Methods: A prospective multicenter clinical study was conducted with 439 implants placed in native bone in 135 edentulous and partially edentulous patients. Abutments were attached to the implant with 35 Ncm of torque without countertorque after 6 weeks in type I to III bone and after 12 weeks in type IV bone. The patients were carefully evaluated for 5 years. Results: Most implants were placed in nonsmoking, nondiabetic patients with a mean age of 55 years (range, 21 to 82 years). Eighty percent of the implants were 10 or 12 mm long, 96% had a diameter of 4.1 mm, and 78% were placed in type II or III bone. Patients maintained good oral hygiene and were satisfied with the restorations. Four implants failed, and one implant was deemed unsuccessful between surgery and the 1-year postloading visit. No implants failed or were unsuccessful in subsequent years. The cumulative survival and success rates for 385 implants in 120 patients after 5 years were 99.1% and 98.8%, respectively. Conclusion: Implants with an SLA surface can be restored in 6 weeks for type I to III bone and 12 weeks for type IV bone. Furthermore, they can be maintained after loading for 5 years with very high success and survival rates. Keywords: clinical trial, dental implants, early loading, implant-supported prostheses, multicenter study