The WHO classification includes 11 benign tumors, the most frequent being pleomorphic adenomas with around 50% and Warthin tumors with 25%. The ratio of benign to malignant tumors varies distinctively between the glands: 80% at the parotid gland are benign but only 10% at the sublingual gland. Besides imaging, complete excision of minor salivary glands or of the sublingual gland provides diagnostic information, whereas core needle biopsy is preferred at the submandibular and the parotid glands; incisional biopsies should not be performed. Generally, surgery of benign salivary gland tumors is much easier compared to malignancies of similar size and location or to the various inflammatory and cystic entities, which must always be considered in the differential diagnosis. For example, submandibulectomy can be performed by predominantly blunt dissection with less adherence to relevant neighboring structures, perhaps even via an intraoral approach. At the parotid gland enucleation is regarded as obsolete. Total, lateral (superficial), and partial lateral parotidectomies are established, but extracapsular dissection is nowadays usually considered the first-choice method. The latter is recommended in mobile tumors of the superficial lobe without adhesion to the facial nerve up to a diameter of 4 cm and with surgical experience in preparation of the nerve, which may ultimately become necessary. Expenditures, complications, contour deficits and scar lengths, sialoceles, Frey syndromes, temporary and permanent lesions of the facial nerve, and frequencies of recurrence differ between the respective procedures. Individual selection of the best method is impaired by the lack of prospective randomized studies.

Cemento-osseous dysplasia (COD) is the most common benign fibro-osseous lesion of the jaws and generally considered non-neoplastic and self-limited. Here, we present a 30-year old female who noticed a bilateral swelling of her posterior mandible with irregular periapical mineralization and incomplete root resorption on panoramic radiographs. A biopsy revealed florid COD and no further treatment was initiated. 9 years later, she presented with a progressive expansion of her left posterior mandible after being treated for bilateral breast cancer 4 and 8 years before. CT scans showed expansile and densely mineralized lesions in all four quadrants with the left posterior mandible showing a focal penetration of the buccal cortical bone. Biopsies revealed an osteoblastic high-grade osteosarcoma in the left and a COD in the right mandible, notably with cellular atypia in the spindle cell component. The patient underwent segmental resection of the left mandible with clear margins and adjuvant chemotherapy. Subsequent genetic testing identified a heterozygous germline TP53 mutation (p.V173G) which confirmed the clinically suspected Li-Fraumeni syndrome (LFS). 3 years after the resection, the patient is free of disease and the other foci of COD remained stable in size on follow-up imaging analyses. Our case illustrates LFS-related osteosarcoma developing within florid COD. Given the rarity of this coincidence, a causative relation between the two lesions seems unlikely but in patients with tumor predisposition syndromes it might be advisable to closely monitor even benign lesions like COD.

OBJECTIVES:Bisphosphonates (BIP) are well established in bone diseases. A serious side effect is the bisphosphonate-related osteonecrosis of the jaw (BRONJ). Among different aetiology factors, local suppression of immune functions is gaining interest. The aim of this study was to analyze the function of macrophages in BRONJ in contrast to patients with osteoradionecrosis (ORN) and secondary chronic osteomyelitis (OM) of the jaws. Samples were also taken from patients with bisphosphonate medication (BP) without signs of infection, radiation therapy (RA), and osteoporosis (OP) as controls.MATERIAL AND METHODS:One hundred five patients with surgery to the jaw were included in this study: 33 patients with BRONJ, 17 with ORN, 11 with secondary chronic OM, 8 with RA, 25 with BP medication and 11 with OP. Samples were histologically analysed and monocytes/macrophages stained using CD14 and CD68. The number of positively marked cells was counted per view (pv), and the CD68/CD14 ratio was calculated. Statistically, the Naïve-Bayes and decision-tree classifier were used.RESULTS:The number of CD14 positive cells was 10.3 cells/pv in the BRONJ-group in as compared to 5 in the ORN- and 3.8 in the OM-group respectively. The number of CD68 positive cells was 11.4/pv (BRONJ-group) as compared to 14/pv (ORN-group) and 12.7/pv (OM-group). With 0.89, the BRONJ-group showed a statistically different CD68/CD14 ratio than ORN-group with 3.39 and OM-group with 3.03.CONCLUSIONS:Our results indicate a different expression of CD14 and CD68 markers of monocytes/macrophages in BRONJ as compared to other jaw infections. This could be a sign of macrophage immunosuppression by BPs. In contrast, patients receiving BP medication without BRONJ showed no differences to other controls.CLINICAL RELEVANCE:This is the first study that clinically indicates a compromised macrophage function at BRONJ sites in contrast to ORN or secondary OM sites. The BRONJ itself could be forwarded by this effect.

PURPOSE:Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a severe and therapy-resistant disease. The present study was performed to evaluate the role of the duration of preoperative antibiotic therapy within an otherwise standardized treatment protocol of patients with BRONJ stages I and II. One group of patients received a short-term preoperative antibiotic regime (A-ST) and the other a long-term preoperative antibiotic regime (B-LT). PATIENTS AND METHODS:A retrospective chart review was used to analyze 46 patients with BRONJ from 2004 to 2009 who were treated with the same surgical technique and the same postoperative antibiotic treatment. Ten patients were classified as stage I, and 37 as stage II. All patients had intravenous bisphosphonate therapy in their case histories. Surgical treatment included an extended surgical procedure with sequestrectomy, bone smoothing, tension-free tissue covering, and drainage, with attention to neighboring teeth. After surgery, antibiotics were given (median) for 7 days intravenously and orally for another 10 to 12 days. Only patients who fulfilled these criteria were included in the retrospective chart review. In group A-ST 16 patients with 17 operations received antibiotics for 1 to 8 days before operation, whereas in group B-LT 30 patients had preoperative therapy of 23 to 54 days. Postoperative clinical examination followed a standardized protocol. Complete healing with intact soft tissue coverage was regarded as a success. RESULTS:The mean follow-up in both groups was 17.4 months (median, 11.5 months). Within the overall observation period, only 35% of patients in group A-ST and 70% in group B-LT showed complete healing, but at the time of the last clinical examination, 53% in group A-ST and 87% in group B-LT were free of soft tissue dehiscence. A certain number of soft tissue dehiscences within the observation period could clearly be related to later tooth extractions or pressure sores of dentures; excluding these interfering problems, 47% in group A-ST and 87% in group B-LT were treated successfully. Differences between these groups were significant. CONCLUSIONS:This study indicates that surgical treatment in patients with stage I BRONJ and especially in those with stage II BRONJ in combination with a long-term preoperative antibiotic treatment can lead to a complete healing in 70% to 87% of cases in contrast to 35% to 53% with a short-term regime. The higher success rate after prolonged preoperative antibiotic therapy may be linked to an infectious role in BRONJ etiology requiring adequate treatment. Antibiotics may effectively treat neighboring lightly infected bone, whereas surgery removes the irreversibly infected and necrotic bone. To achieve complete healing, an extended surgical procedure in combination with local mouth rinses and prolonged antibiotic therapy can be recommended for treatment of BRONJ.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a serious side effect of bisphosphonate (BP) medication. Tooth extractions are the most frequent causes for BRONJ. In some cases BRONJ is observed spontaneously, with some anatomic sites carrying a higher risk. Sunitinib, a tyrosine kinase inhibitor, is established in renal cell carcinoma and is known to lead to oral mucositis as a side effect, which in BP patients may additionally raise the risk of BRONJ.We present 3 patients with renal cell carcinoma under BP medication who developed BRONJ during and after sunitinib medication.In 2 patients, BRONJ was linked to the occurrence of mucositis after sunitinib intake. The third patient showed relapse of completely healed BRONJ lesions shortly after resumption of a sunitinib therapy.Oral mucositis during chemotherapy may raise the risk of BRONJ in cancer patients with BP medication. Especially in renal cell carcinoma patients under sunitinib therapy and intravenous BP medication, oral mucositis should be observed closely because it could be a risk factor for BRONJ.

The aim of this study was to evaluate a possible role of microcracks in the pathogenesis of bisphosphonate-related osteonecrosis of the jaw (ONJ) and to discuss an etiological model. Bone samples from 35 patients with ONJ were analyzed. Control samples were taken from five patients with osteomyelitis (OM), ten patients with osteoradionecrosis, seven patients with osteoporosis and bisphosphonate medication without signs of ONJ, and six osteoporotic elderly patients. Samples were examined using scanning electron microscopy. In 54% of the bone samples of patients with ONJ, microcracks were seen. Inflammatory and connective tissue reactions within the microcracks were evident in 82% of the cases, indicating that these cracks were not artificial. In contrast, only 29% of samples from patients with oral bisphosphonate medication without ONJ, no sample from patients with OM, none of the osteoradionecrosis group, and only 17% from patients with osteoporosis showed microcracks. Statistically significant differences could be found between the ONJ group and the group after irradiation and the group with OM, respectively. The evidence of microcracks could be a first step in the pathogenesis of bisphosphonate-related ONJ. The accumulation of these microcracks leads to a situation that could be named "non-symptomatic ONJ". Disruptions of the mucosal integrity may then allow bacterial invasion, leading to jawbone infection with exposed bone, fistulas, and pain. This state could be called "symptomatic ONJ". Furthermore, an assumed local immunosuppression as indicated by various studies could explain the severe courses of therapy-resistant ONJ as regularly observed.

We report on a male infant with extensive, bilateral cystic and solid lung lesions who presented postnatally with respiratory distress caused by bilateral cystic lung lesions. Parenchyma-sparing resections were performed. Histology revealed the presence of neuroglial cell-lined cysts and glial nodules. In addition, a neural element containing palatinal teratoma was detected and excised. Based on previously published cases, the pathogenesis and clinical features of pulmonary neuroglial heterotopia are discussed.

The incidence of Frey's syndrome after parotidectomy greatly varies in the literature. The aim of this study was to analyse the incidence with the help of a new series of patients and to discuss and review the results.372 patients (age: 50.7+/-11.6 yrs) underwent unilateral parotidectomy. In 203 subjects the insertion of a sternocleidomastoideus flap in the parotid area was performed intraoperatively.Patients were followed-up concerning the clinical presence of gustatory sweating and flushing after secretory stimulation, and were questioned about suffering in everyday life.86 patients (23.5%) developed Frey's syndrome after an average of 12 months (12.3+/-9.9 months) following parotidectomy. Only 44% of the patients with Frey's syndrome were symptomatic. No benefit concerning Frey's syndrome following application of a sternocleidomastoideus flap was seen.Gustatory sweating after parotidectomy must still be regarded as an unpleasant and common complication. Nevertheless, it is more the subjective suffering of the patients than the incidence that makes prevention important.

Introduction: A 16-year-old Arab boy had suffered from a severe head injury including an intracranial haematoma. Despite replantation of the bone flap later on, the cosmetic result was very unfavourable due to partial resorption of the reinserted bone and atrophy of the right temporalis muscle. Aim: For contour reconstruction of both soft and hard tissues the boy was transferred from Saudi Arabia. Method: A spiral CT was obtained and the contour was reconstructed using a new algorithm for surface generation. Result: The resulting titanium implant was inserted without complications or the need for revision. The cosmetic result was good and corresponded to the preoperative digital planning. Conclusion: Techniques of computer-assisted implant prefabrication and surgery may include special algorithms for considering soft tissues including contour deficits of the temporalis muscle. (c) 2007 European Association for Cranio-Maxillofacial Surgery.

Malignant melanoma of the oral cavity is a rare disease with high lethality, rapid progression and frequently seen lymph node metastases. The clinical appearance of the mucosal melanoma is mostly irregular in shape and dark blue, brown or black in colour. During early stages the lesions are painless with a tendency to spontaneous bleeding. Mucosal melanoma shows expansive and infiltrative growth into neighbouring structures, with the result of bone destruction and loss of teeth. We present a case of a female patient with a primary mucosal melanoma. A local infiltration and invasion of a tooth could be seen. Although many publications deal with oral mucosal melanoma with local destruction of bone, there are no reports on an infiltration into dental roots. Aspects of this unusual infiltration of hard tissues are discussed.

Malignant melanoma of the oral cavity is a rare disease with high lethality, rapid progression and frequently seen lymph node metastases. The clinical appearance of the mucosal melanoma is mostly irregular in shape and dark blue, brown or black in colour. During early stages the lesions are painless with a tendency to spontaneous bleeding. Mucosal melanoma shows expansive and infiltrative growth into neighbouring structures, with the result of bone destruction and loss of teeth. We present a case of a female patient with a primary mucosal melanoma. A local infiltration and invasion of a tooth could be seen. Although many publications deal with oral mucosal melanoma with local destruction of bone, there are no reports on an infiltration into dental roots. Aspects of this unusual infiltration of hard tissues are discussed.

Objective The TICC (Tomography, Image processing, CAD, CAM) processing chain developed at the Ruhr-University Bochum in Germany has already been established since several years for the reconstruction of large pre-existing posttraumatic skull defects with individual prefabricated implants made of pure titanium. So far, more than 500 titanium implants have been inserted with great success at more than 60 clinical centres worldwide. The aim of our study was to evaluate all implants inserted between 1994 and 2000. Materials and Methods The study describes the clinical experience with 166 patients receiving 169 skull implants between 1994 and 2000. All 169 implants were measured and categorized in the CAD system in terms of size and anatomical localization. The surgical and radiological reports of the patients were evaluated. Sixty patients operated at the university hospital in Bochum and nearby were clinically reviewed describing scars, position of the implants and cosmetic results. Questionnaires of 131 patients were analyzed regarding the postoperative quality of life distinctly. Results The study shows constantly good to excellent results intraoperatively as well as postoperatively regarding complications, fit of the implants and the clinical follow-up. In particular the enquiry of the patients shows that titanium skull implants improve quality of life. Conclusion High precision and easy handling as well as a low complication rate and the high contentedness of the patients make the individual titanium skull implants valuable for cranioplasty, especially in complicated applications with very large defects, multiple previous operations and additional irradiations. Even in these difficult cases predictable results are possible.

Biodegradable functionally graded skull implants on the basis of polylactides and calcium phosphate/calcium carbonate were prepared in an individual mould using a combination of different processing techniques. A geometrically corresponding resection template was designed to enable a craniectomy and cranioplasty with the prepared implant in the same operation. After various preliminary experiments concerning degradation kinetics, pH evolution during degradation, micromorphology, biocompatibility tests in human osteoblast cell cultures and surgery of cadaver heads, a new large-animal model was developed for long-term in vivo studies. In eight 12-months-old sheep, the surgical templates were used to create 4.5×5cm2 calvarial defects which were then filled with the corresponding degradable implants in the same operation. The animals were sacrificed after 2, 9, 12 and 18 months, and the implants and the surrounding tissues were analysed by computer tomography (CT), macroscopic examination and microscopy. The new animal model proved to be reliable and very suitable for large individual craniectomies and cranioplasties. The formation of new bone from the dural layer of the meninges corresponded well to the degradation of the porous inner layer of the implants whereas the skull contour was stabilised by the compact outer layer over the follow-up period.