Accuracy of the CAD/CAM technique compared with the conventional technique used for stand-alone genioplasty

The benefit of the computer-aided design and manufacturing (CAD/CAM) technique for stand-alone genioplasty remains uncertain and was evaluated in this study. Patients who underwent a conventional genioplasty (n = 20) or genioplasty with the CAD/CAM technique (n = 20), and for whom cephalometry and photogrammetry were performed before and 6 months after surgery, were included. Deviations from predictions of the soft tissue pogonion (Pg'), lip inferior point to aesthetic line (Li-Esth), facial convexity angle (FCA), mentolabial angle (MLA), and ratios of soft to hard tissue movements were calculated. No significant deviation was observed for Pg' in either the conventional group (3.85 ± 4.36 mm; 1.91 ± 1.11 mm) or CAD/CAM group (1.28 ± 1.16 mm; 2.81 ± 3.08 mm), for horizontal and vertical movements, respectively. However, for forward movement, deviation from the prediction of Pg´ in the CAD/CAM group was significantly lower than that in the conventional group (P = 0.015). Deviations of Li-Esth, MLA, and FCA did not differ significantly between the groups. No definite preference for the CAD/CAM technique could be established, because deviations from predictions were not significant in either of the technique groups and lay within the clinically acceptable range.

Limits and chances in an unfortunate course of recurrent orbital rhabdomyosarcoma

BACKGROUND

Orbital rhabdomyosarcoma (RMS) in childhood has an excellent survival rate after chemotherapy and radiation, and mutilating surgery can often be avoided.

CASE REPORT

As a rarity we present an unfortunate disease course in a child suffering from orbital embryonal RMS which did not enduringly respond to multimodal therapy including local excision and exenteration orbitae. After short intervals and despite tumor-free margins, orbital RMS recurred twice and led to an extended exenteration orbitae including the bony margins. Because of the lack of standards for adjuvant therapy in cases of recurrences after exenteration orbitae, therapy had to be restricted to a wait- and- see strategy as the only chance of tumor control.

CONCLUSION

Although survival rates of orbital RMS are high, the possibility of recurrence should not be underestimated. In cases of refractory RMS, new concepts are needed to offer further chances for survival.

Snoring in cleft patients with velopharyngoplasty

Some patients with cleft lip/palate or isolated cleft palate seem to develop snoring as one possible symptom of an obstructive sleep apnoea syndrome after velopharyngoplasty (VPP). The aim of this paper was to determine whether there was a difference in the posterior airway space (PAS) between patients with a VPP who snored and those who did not. Four standard parameters were measured in lateral cephalograms of 20 patients with cleft lip/palate and isolated cleft palate, without diagnosis of further syndromes (e.g. Pierre Robin sequence), having undergone VPP, to examine the dimensions of the PAS. Data were set in correlation to the symptom of snoring, and compared with those of 40 patients without cleft undergoing orthodontic treatment and with 20 patients with cleft lip/palate or isolated cleft palate but not VPP. Metric parameters were significantly different after VPP in patients with clefting and snoring compared to the group of cleft patients without snoring. All patients with clefts exhibited at least in one dimension a constriction when compared to patients without clefting. In conclusion, cleft lip/palate and isolated cleft palate patients tend to have constrictions of the PAS. VPP may induce snoring and further narrowing. Recall and analysis for obstructive sleep apnoea syndrome should be mandatory.

Patients’ knowledge and expectations regarding dental implants: assessment by questionnaire

Today, modern implant dentistry appeals to a wide population, but the decision for and the success of implants depend on the knowledge and expectations of patients. The aim of this study was, with the help of a questionnaire, to evaluate the level of patient knowledge before a professional consultation was performed, and hence to be better prepared in the interests of patient awareness. Fifty-eight percent of 315 patients questioned thought that implants require the same care as natural teeth, 61% expected an additional payment of 2000 Euro or less, 80% held the function of an implant-supported overdenture as very important and 54% attached great importance to the aesthetics. The expectations that patients have for an implant-supported set are high in contrast to their willingness to make additional payments. There are still misconceptions regarding costs, and these must be resolved individually in practice.

[Experiences with surgical management of facial basal cell carcinoma and procedures for plastic reconstruction]

BACKGROUND

No recurrences and optimal aesthetic outcomes after R0 resection and plastic reconstruction of the face are the goals in the surgical treatment of basal cell carcinoma. The aim of this study was to evaluate recurrence rates and to evaluate different reconstructive techniques.

PATIENTS AND METHODS

This study included 205 follow-up patients undergoing R0 resection of primary basal cell carcinoma and facial skin reconstruction between 1998 and 2002; data were analyzed retrospectively.

RESULTS

The most frequent locations of basal cell carcinoma were the nasal (40.5%) and orbital (22.9%) regions. The rate of recurrence after 2.5 years (6 months-5 years) was 7.3%. Local flaps, full-thickness skin grafts, and sliding flaps were usually performed; indications for split-thickness skin grafts were rare. Disturbances of sensation were found in only 3.6% of the sliding flaps and in 11.7% of the local flaps, but 22.7% in full-thickness and 38.7% in split-thickness skin grafts. The aesthetic outcome, evaluated by clinical inspection and a patient satisfaction score, was classified as "unobtrusive" and "good or excellent" for 88.4% of local flaps, 92.6% of sliding flaps, but only for 66.4% of full-thickness and 54% of split-thickness skin grafts.

CONCLUSION

Local flaps and sliding flaps result in better aesthetic and neurological outcomes after reconstruction of facial skin regions. Skin grafts have their indications as an alternative procedure in cases of critical indications for flaps.

Outcomes after surgical treatment of facial skin basal cell carcinomas

BACKGROUND

Missing recurrences and the aesthetic outcomes after reconstructions of the face are preoccupations in the surgical treatment of basal cell carcinomas. Hence, the different reconstructive techniques in particular and the rate of recurrence are evaluated in this study.

PATIENTS

205 patients receiving resections of basal cell carcinomas and facial skin reconstructions were included and data were analyzed.

RESULTS

The rate of recurrence was 7.3% after follow-up at an average of 2.5 years (0.5-5 years). Local flaps, full-thickness skin grafts and skin extension closures were carried out most often; indications for split-thickness skin grafts were rare. Sensitivity disturbances occurred in only 3.6% of skin extension closures and in 11.7% of local flaps, but in 22.7% of full-thickness skin grafts and in 38.7% of split-thickness skin grafts. The aesthetic outcomes were evaluated through clinical inspection and by using patients' scale. They were classified as "unobtrusive" and "excellent or good" in 88.4% of local flaps and in 92.6% of skin extension closures, but in only 66.4% of full-thickness skin grafts and in 54% of split-thickness skin grafts.

CONCLUSION

Local flaps and skin extension closures provide better aesthetic and neurological outcomes after facial skin reconstructions. However, skin grafts are alternative procedures for critical indications of local flaps.

Pierre-Robin-Sequenz — postoperative Komplikationen nach Gaumenspaltverschluss

BACKGROUND

In a 25-year retrospective review of 1976-2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied.

PATIENTS AND METHODS

The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life.

RESULTS

A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.

[Foreign body in paranasal sinuses]

AIMS

All cases of the last 5 years requiring foreign bodies to be removed from the paranasal sinuses were investigated as to causes, special aspects in diagnostics and therapy, occurrence of pathologic germs and possible sequels.

PATIENTS

68 cases were evaluated: 43 patients were male, 25 female. Average age was 29 years in males and 37 years in females.

RESULTS

In our patients foreign bodies in the paranasal sinuses were in more than 60% the result of medical or dental procedures followed by industrial accidents (25%). The maxillary sinus was affected in 75%, the frontal sinus in about 18%. Involvement of the ethmoid or sphenoid sinus was rare. The spectrum of pathologic microbes was dominated by mixed infections, the share of actinomyces and aspergillus was unexpected high. Most important acute complications were bleeding, compression of the optic nerve and liquorrhoe. Late complications consisted mainly of pain--often associated with disturbances of sensibility- and infections.

CONCLUSIONS

A smear should be taken whenever the foreign body remained in the sinus for more than 4 days. Foreign bodies jammed in the posterior wall of the sinus require a sufficiently open view since the risk of heavy bleeding is especially high.

Reasons for patients' discontent and litigation

INTRODUCTION

Discontent and litigation among patients is a problem which increasingly preoccupies the medical profession.

AIM

We aim to analyse the origin of discontent and litigation and to help avoiding these claims.

MATERIAL

One hundred and seventy-eight medical expert opinions were evaluated, all made following examination of the complainant.

METHODS

Depending on the results of the clinical examination and the study of the files it was determined whether there was either a case of malpractice or insufficient informed consent, or no fault at all in a legal sense. In addition the patient and the surgeon were questioned as to their point of view regarding the procedure and their communication and relationship before and after treatment.

RESULTS

Frequent complaints were pain (either during treatment or afterwards), major swelling or bleeding, disturbances of trigeminal or facial nerve function, poor scar formation, loss of teeth or fixtures, faulty occlusion and discrepancies between the expected and the actual result of treatment. In 26 cases actual faults made during medical treatment were discovered. In 49 further cases, poor explanation of the proposed procedure was the reason for complaint. In the majority of remaining cases, neither faulty treatment nor insufficient information given to the patient lead to the complaint but the patient's expectations were unrealistically high.

CONCLUSION

A considerable proportion of lawsuits originate from misunderstandings, and not treatment errors: The surgeons often concentrate on the legal requirements of informed consent and neglect to explain the practical consequences of the operation; the patients in turn tend not to ask about possible complications.

[Melanotic neuroectodermal tumor of infancy]

BACKGROUND

The melanotic neuroectodermal tumor of infancy is a rare and so far as being classified neoplasm with a high rate of recurrence for one year after diagnosis. Since Krompecher described 1918 the tumor at first, only about 200 cases are reported until today, mostly with manifestation in the maxillary region.

CASE-REPORTS

The authors present two infants at the age of six and eight weeks with first clinical manifestation of the tumor in the maxillary region. Although there were no other common signs, the tumor destroyed wide areas of the mid-face. In spite of a treatment with radical surgery, recurrences occur rapidly in the first living year.

CONCLUSIONS

Our clinical and histological findings show characteristics of local malignant growth. For these facts the radical resections of the primary tumor and its recurrences are individually the therapeutical consequences. A follow up of seven years of one infant shows a hypoplasm of the mid-face as a result of the inhibition of further growth by the loss of germs after maxillary hemisection.

[Frey syndrome]

AIMS

The incidence of Frey's syndrome after parotidectomy as cited in the literature varies distinctively. Strategies for successful treatment are also assessed differently.

PATIENTS

Between 1980 and 1994 a total of 372 parotidectomies were performed in 364 patients at the Bochum University Hospital.

RESULTS

After an average of 18 months following parotidectomy, 86 patients (23.5%) developed Frey's syndrome. Thirty-five patients were treated with scopolamine ointment. The symptoms improved in nine cases after an average of 25 months of therapy. Of the patients receiving no treatment (n = 20), seven improved after an average follow-up of 20 months. Therapy with scopolamine ointment did not elicit significantly better results compared to no treatment at all.

CONCLUSION

Gustatory sweating after parotidectomy still has to be regarded as an unpleasant complication which is difficult to cure.

[Associated anomalies in lip-maxillopalatal clefts]

BACKGROUND

Retrospective studies of cleft lip and palate patients suggest a multifactorial aetiology for this condition. Many patients exhibit multiple defects, often removed from the orofacial region. The frequency and location of such coexistent abnormalities vary between studies.

PATIENTS

A retrospective case-note study of 1,737 individuals with orofacial cleft, treated between 1974 and 1998 at our centre, was undertaken to assess the frequency of associated malformations and syndromes.

RESULTS

Associated malformations were found to be present in 33% of all cases investigated. In nearly one half of these individuals (48%), defects could be attributed to recognisable syndromes. Patients with isolated palatal clefts (45.6%) and those with bilateral clefts of the lip and palate (35.3%) were particularly well-represented. The following problems were observed relatively frequently: Cerebral anomalies (16%), facial anomalies (14%), heart malformations (15%), anomalies of the extremities (9%) and urogenital tract abnormalities (8%). In contrast, endocrine aberrations were identified sporadically (0.5%). A partial situs inversus was found only in one case.

CONCLUSION

As clefts of the lip and palate are frequently associated with additional malformations, the importance of thorough interdisciplinary neonatal screening cannot be over emphasised.

Amplification of the mdr1-gene is uncommon in recurrent ovarian carcinomas

Ovarian carcinomas are known to rapidly develop drug resistance against chemotherapeutic agents. This phenomenon is often associated with the expression of pl70-glycoprotein. A high rate of transcription of the corresponding mdr1-gene in resistant tumors is reported. Amplification of the mdr1-gene has been observed in tumor cell lines exposed to cytotoxic drugs; however, significant information is lacking as to whether this holds true in clinical carcinomas. To fill this gap, we investigated the rate of gene amplification of the mdr1-gene in 63 recurrent ovarian carcinomas and we determined the resistance pattern of these cells using an ex vivo assay. The tumors showed varying ex vivo resistance patterns which did not correlate to clinical parameters. Amplification of the mdr1-gene was not observed in any of the cancer specimens. Therefore, we conclude that mdr1-gene amplification is not a common pathway for the development of chemoresistance in clinical ovarian carcinomas.

[20 years geriatric rehabilitation at the Hannover at the Henrietta Foundation]

This report includes the historical formation of the institution in regard to the background of the development of the German Society of Gerontology. A description of the newly formed clinic and its special institute for geriatric rehabilitation is supposed to provide a survey about the conditions of clinical work as well as the special courses and training possibilities. This is followed by the presentation of treatment methods and results.

[Organization and implementation of clinical rehabilitation at a special hospital]

This contribution offers guidance in the planning, organization, and operation of a clinical gerontological rehabilitation unit. The first part outlines the important requirements of a geriatric rehabilitation clinic and considerations for medical and non-medical staffs (with recommendations showing keynumbers), as well as the structure and equipment for the clinical buildings and recommendations for room area and amount of beds. The general requirement for clinical geriatric rehabilitation beds in Germany is mentioned and training for geriatric rehabilitation is considered. The second part deals with the organization and operation of clinical rehabilitation, in particular, regarding directions and responses of rehabilitation teams, and especially their priority to use collected data as a management function. The contribution concludes with an example of an inpatient rehabilitation at the Klinik für medizinische Rehabilitation und Geriatrie, Henriettenstiftung Hannover, FRG.

[Treatment of sleep disorders in the elderly]

The physiological and pathophysiological peculiarities of the aging organism require to be observed in the treatment of sleep disorders. After eliminating extracerebral causes one has to consider changes of cerebral blood flow as a reason for impaired sleep, for instance resulting from cardial insufficiency or pathological changes of blood pressure. In using sleeping drugs one should keep in mind type and severeness of the sleep disorders and prescribe with care, since the elimination potential in the aged is mostly reduced and the quote of side effects is increased.

[Intervention possibilities in the geriatric rehabilitation clinic]

Aged people often are incapable to get on with their homes, for instance with the use of the bathroom, WC, and the kitchen, especially after illness. The author listet the most important localities of problems and difficulties, and proved the therapeutical ways suitable for geriatrical and reha-hospitals to make aged people fit for living at home. The outcome of these researches and the results of working on this base during one year are reported.

[Quantitative investigation of the amino acid levels in putrefying liver (author's transl)]

To elucidate the post-mortem proteolysis we investigated the behaviour of the free amino acids in rotting liver homogenates by means of two-dimensional thin-layer chromatography and reflection densitometry. The post-mortem alterations of the amino acid levels are characterized mostly by a two-phase increase with maxima at the end of the first and after the third week. A few amino acids showed only little changes hardly above the physiological intra-cellular levels. Anaerobic rat experiments and experiences with antibiotic treatment give rise to the supposition that increasing amino acid concentrations indicate a predominance of proteolytic activities over aminoacid catabolism. In the beginning autoenzymes are prevalent, while afterwards bacterial proteases probably predominate. The transient regression about the second and thrid week is interpreted as the effect of a temporarily intensified amino acid degradation by foreign enzymes (maximal bacterial growth).