Oral & Maxillofacial Surgery

The Oral and Maxillofacial Surgery clinic covers four odontologic specialist units - maxillofacial surgery, maxillofacial orthopedics, maxillofacial x-ray and hospital odontology. The units all conduct research within the research area oral and maxillofacial surgery.  

Within our research, we develop methods for prevention of injuries in the jaw, improvement of survival, and improvement of chewing function. Congenital defects are treated, as well as injuries caused by diseases or trauma, such as cleft lip, jaw and palate or defects after cancer operations. The resarch is conducted in close collaboration and in many parts together with research areas Plastic Surgery and Otolaryngology and Head & Neck Surgery

Cranio-Maxillofacial Surgery   

The objective of this cross-clinic project is to create a platform from which to develop treatment of diseases of the jaw, facial skeleton and cranium. This platform will rest on a foundation of (a) virtual planning prior to tumor-trauma reconstruction and surgical treatment of congenital malformations; (b) an operating room of the future with computer-assisted surgery, for increased precision, reliability, and speed, as well as reduced morbidity; (c) expanded opportunities for basic research within a collaborative network composed of national and international participants as well as improved educational opportunities; (d) testing and development of biomaterials for reconstructive surgery; and (e) qualitative and quantitative evaluation of care from the perspective of the patient, family and health care personnel. 

Multidisciplinary approach to congenital and acquired cranio-maxillofacial defects

Oral Cancer – tobacco, virus, alcohol and malignant cell transformation

Aetiology, intervention

Lifestyle aspects, tobacco, alcohol, infections, diet and oral hygiene comprise risk factors for developing oral cancer. We are developing methods to help tobacco users, both those who are healthy and those who are sick and are being treated in the hospital for their acquired problems, to quit. Once patients have quit using tobacco an increased risk for developing malignancy remains among those who continue to use nicotine. We know that tobacco use increases the risk of developing oral cancer and even human papilloma virus (HPV) infection. A sharp increase has been noted in the number of tumours containing HPV. In cases where the virus can be demonstrated, the prognosis is usually better and more treatment options are available. We are attempting to clarify the various biological processes associated with tobacco and alcohol-induced tumors as well as those due to viral manifestation by studying molecular changes in the development of cancer, which are still essentially unknown.

Oncogenic HPV codes for the early E6 and E7 proteins that inactivate tumor suppressors pRB (E7) and p53 (E6) and inhibit apoptosis, which is significant in the tumor development process, in contrast to tobacco and alcohol-associated tumors that cause mutation of tumor suppressor genes. Since lifestyle plays an important role, researchers are studying changes in the oral mucosa of smokers and smokeless tobacco users with various diagnoses and differing degrees of cellular changes who come from regions in Asia, Africa and Scandinavia, regions covering the spectrum from low to high socioeconomic standards. The overall aim is to study clinical, immunological and genetic parameters of importance for malignant cell transformation.

 Aetiology of oral cancer

Virtual planning, computer-assisted surgery and customized implants

Reconstruction and rehabilitation

Each year a large number of people are involved in serious accidents in which they sustain severe head and facial injuries, while others develop cancer of the head and neck region, or are born with craniofacial malformations. The severe problems that result can often be alleviated by reconstructive surgery.

Despite extensive evidence that rehabilitation can be improved through meticulous planning and the use of new, patient-specific biomaterials, in most cases surgery is still carried out based solely on the knowledge and experience of the surgeon. To prepare for complicated surgeries, we are working on creating an integrated functional solution based on visualization of 3D images and haptics, in which a robotic hand can work within the image to practice and plan in detail prior to surgery. This approach makes it possible to design and adapt bone grafts, biomaterials needed for the procedure and transmit electronic data for production of materials such as patient-specific titanium plates to be used for fixation of bone segments. Inserting screws for fixation or installation of dental implants the intention is to be able to evaluate in advance of surgery the biomechanical stability possible to achieve.

A unique technology, additive manufacturing which involves electron beam melting of titanium powder or alternative material, is used to manufacture implants with various properties. The surgical plan can be converted to real time with patient-specific guides or to computer-assisted surgery and in the future even to robotic surgery.

The project group is working to develop a new generation of guides and patient-specific biomaterials that can be more quickly and efficiently integrated into both soft and hard tissues, and with biomechanical properties that meet the load requirements demanded by the situation.

Visualisation of 3-D images and virtual haptic surgical planning

Our project includes studies of bone formation and incorporation of modified implants. The new technologies will be evaluated in extensive preclinical in vivo studies using molecular methods and PET/CT to assess how bone reacts, after which they will be tested in actual surgery. We want to achieve a fully usable commercial system for clinical use in the treatment of complicated congenital or acquired conditions involving the face, jaw and cranium.

We propose to implement a haptic surgery planning system that will facilitate shaping and fitting of bone replacement, design of customized biomaterials, and fixation devices such as plates and screws to restore bone structure in patients with congenital or acquired facial deformities, using a virtual model derived from, casts or scanning of areas of interest, and the patient’s CT and MRI data. Unlike vision and hearing, haptics provides bi-directional communication between an individual and his/her environment. The great challenge in haptic research is to build a device that can engage the entire hand, i.e., a system that allows simulation of touch to the fingertips and force feedback to the joints of the fingers and wrist.

The depiction above illustrates cranio-maxillofacial surgery planning which requires manipulation of both bone and soft tissue which makes it a good bench-mark for the developed technology. The system will allow a surgeon to plan and practice complicated reconstructive surgical procedures prior to surgery.
 

Bone regeneration and osseointegrated implants

Rehabilitation   

Surgical interventions and the use of biomaterials that result in positive gain for the patient needs to be evaluated both in the clinic and the laboratory. This is done in our project in collaboration with national and international co-workers from the industry and academic sciences. The day-to-day clinical reality is very often about ordinary dental reconstruction and augmentation of bone and surrounding tissues. We connect experimental immunological models with surgical procedures that aim for reconstructing the bone around dental implants and bone replacement therapies in connection with congenital and acquired defects after tumor surgery or trauma.

The project group is working to develop a new generation of guides and patient-specific biomaterials produced with varying techniques that can be more quickly and efficiently integrated into both soft and hard tissues, and with biomechanical properties that meet the load requirements demanded by the situation. One of our major partners is the Mid Sweden University that uses the electron beam melting technique for production of patient specific solutions. Our project includes studies of bone formation and incorporation of the modified implants. The new technologies will be evaluated in extensive preclinical in vivo studies using molecular methods and PET/CT alongside the use of radiology and histology for studying biomaterials to assess how bone reacts, after which they will be tested in actual surgery.

The two slides show the pre-treatment situation (top) with a bone deficient situation not allowing for installation of implants. The bottom picture show bone formation 6 months after a space filled with blood was created in the maxillary sinus cavity. 

pre op

post op
 

Functional outcome, quality of life 

The face is a crucial and complex part of the human body that is the centre of a host of important functions with great implications for the direct and indirect survival of the individual. Facial fractures are common in conjunction with motor vehicle accidents, abuse, sports-related accidents and accidents at work. These injuries run the gamut from minor fractures with no or negligible implications, to multiple injuries that damage several vital facial functions resulting in extensive functional impairment.

Each year in Sweden, many people are severely injured in motor vehicle accidents and require hospital care. Among motor vehicle accident survivors, 50–70% sustains facial injuries. In order to restore function and aesthetics and preserve quality of life for these individuals, carefully planned surgery is required and must be carried out with high-level precision. The aim is to conduct in-depth analyses of skull and facial fractures and their ramifications and to create a structure for research and quality assurance in a field with high potential for further development, using a framework of multidisciplinary collaboration between the University Hospital in Uppsala, Sweden, and the University Hospital in Basel, Switzerland.

The project uses newly developed computerized fracture classification systems that define fractures in great detail to facilitate documentation and web-based communication between the involved parties. In addition to classification, function and quality of life are assessed. An important component in surgery planning is to be able to accurately measure the extent of certain anatomical structures. Of particular interest in CMF surgery are the shape and volume of the orbits (eye sockets) comparing the left and right side. These properties can be measured in CT images of the skull, but this requires the orbits to be extracted from the rest of the image, a process called segmentation. Segmentation is usually performed by manual tracing of the orbit in a large number of slices of the CT image. This task is very time consuming, and sensitive to operator errors.

Semi-automatic segmentation methods could reduce the required operator time significantly. A part of the project was to develop and evaluate a semi-automatic system for segmenting the orbit in CT images which has been completed and now applied in evaluation of outcome in a collaborative project. The expected final outcome of the project is a working prototype of such a segmentation system.  


 

Telemedicine as a supplement in the daily practice of dentistry

In odontology, specialist consultation is of great importance with regard to pathological changes in the oral cavity and bordering regions. To find a new, more efficient and cost-effective approach, a telemedicine network has been developed for the maxillofacial surgery clinics at the Akademiska Sjukhuset in Uppsala and the outpatient dental and medical clinics in Uppsala County. The project is part of the EU HEALTH OPTIMUM project (HEALTHcare delivery OPTIMization throUgh teleMedicine) aimed at exploring how new technology and new processes increase quality of care within medical and odontological specialties.

For patients, this translates to fast and competent handling of their problems at regular clinics. They are able to be absent from their regular routines for shorter periods, while avoiding travel and travel expenses. For the profession, this means that certain issues can be handled through the network with specialist support, which reduces the pressure on specialist clinics and provides more equal access to care.

Our pilot area involved changes of the oral mucosa, either exogenous or endogenous in origin. For instance, skin diseases often manifest in the mouth and patients with internal medicine disease, both benign and malignant, often present with problems in the oral cavity related to underlying disease; similarly, tumors and tumor-like conditions are not uncommon. Changes in the oral mucosa present with a highly variable clinical picture, which requires significant experience for proper management. Many people have mild problems, yet require expert management.

Regular consultations and discussions between primary care/general dentistry and specialists convey substantial amounts of knowledge, which in the long term increases the quality of care and reduces the need for specialist consultation. Our work will continue with an assessment of the broader impact of telemedicine on patient management.

Live telemedicine round

Members of the group 

Senior investigators
Jan-Michaél Hirsch, Professor emeritus, LDS, PhD
Andreas Thor, Associate Professor, DDS, PhD
Lars Sand, Associate Professor, MD, DDS, PhD

Post-doc
Jamshid Jalouli, M.Sci, B.Sci, PhD
Mats Wallström, Assistant Professor, PhD, DDS
Erika Reiser, Assistant Professor, DDS

PhD-students
Petter Gavelin, Assistant Professor, DDS
Miranda Jalouli, Medical Nurse, B.Sci.
Anders-Petter Carlsson, DDS
Christopher Riben, DDS
Björn Lindell, DDS
Amela Trbakovic, DDS
Johanna Nilsson, DDS
Maria Erkapers, DDS 
Bent Williger, MD DDS
Christina Klee, MD DDS
Jani Talvilahti, DDS

Collaborations

Ingela Nyström, Professor, Centre for Image Analysis Uppsala University

Ewert Bengtsson, Professor, Centre for Image Analysis Uppsala University

Ingrid Carlbom, Professor, Centre for Image Analysis Uppsala University

Peter Thomsen, Professor, Director of BIOMATCELL, Gothenburg University

Lars-Erik Rännar, Associate Professor, PhD in Technology, Sports technology, Mid Sweden University

Mikael Bäckström, Associate Professor, PhD in Technology, Sports technology, Mid Sweden University

Jaan Hong, Associate Professor, Department: Immunology, Genetics and Pathology , Uppsala University

Jöns Hilborn, Professor, Polymer Chemistry, Uppsala University

Thomas Engstrand, PhD, Karolinska Institute

Håkan Engquist, Professor, Ångström Laboratory, Dept. of Engineering Sciences, Uppsala University

Gunnar Antoni, PET-centre Uppsala university

Jens Sörensen, PET-centre Uppsala university

Bengt Magnusson, Professor, Oral Medicine and Pathology, Sahlgrenska Academy, Gothenburg University

Bengt Hasséus, Associate Professor, Oral Medicine and Pathology, Sahlgrenska Academy, Gothenburg University

Daniel Nowinski, Associate Professor, MD, PhD Dept. of Surgical Sciences, Plastic Surgery, Uppsala University

Hans-Florian Zeilhofer, Professor, Dep. of Cranio-Maxillofacial Surgery, University Hospital Basel, Switzerland 

Christoph Leiggener, Professor, Dep. of Cranio-Maxillofacial Surgery, University Hospital Basel, Switzerland

Philipp Jürgens, Professor, Dep. of Cranio-Maxillofacial Surgery, University Hospital Basel, Switzerland

Salah Ibrahim, Associate Professor, Faculty of Medicine and Odontology Dept. of Biomedicine,The University of Bergen, Norway, avd. för Biomedicin Universitet i Bergen Norge, University of Khartoum, The Toombak Research Centre and Oral Cancer Campaign, Sudan 

Lukas Kamer, DDS, MD, AO-Research Institute, Davos, Switzerland

Dissertations 

Jamshid Jalouli 2010
Mats Wallström 2010
Erika Reiser 2011

Publications 2012-2014

  1. Andlin-Sobocki A, Tehrani D, Skoog V. Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery. 2012;46(3-4):229-234.
  2. Blomstrand L, Sand L P, Gullbrandsson L, Eklund B, Kildal M, Hirsch J. Telemedicine: a complement to traditional referrals in oral medicine. Telemedicine journal and e-health. 2012;18(7):549-553.
  3. Dasmah A, Thor A, Ekestubbe A, Sennerby L, Rasmusson L. Particulate vs. block bone grafts: Three-dimensional changes in graft volume after reconstruction of the atrophic maxilla, a 2-year radiographic follow-up. Journal of Cranio-Maxillofacial Surgery. 2012;40(8):654-659.
  4. Edman K, Ohrn K, Holmlund A, Nordstrom B, Hedin M, Hellberg D. Comparison of oral status in an adult population 35-75 year of age in the county of Dalarna, Sweden in 1983 and 2008. Swedish Dental Journal. 2012;36(2):61-70.
  5. Hillbertz N S, Hirsch J, Jalouli J, Jalouli M M, Sand L. Viral and Molecular Aspects of Oral Cancer. Anticancer Research. 2012;32(10):4201-4212.
  6. Hirsch J, Wallström M, Carlsson A, Sand L P. Oral cancer in Swedish snuff dippers. Anticancer Research. 2012;32(8):3327-3330.
  7. Jalouli J, Jalouli M M, Sapkota D, Ibrahim S O, Larsson P, Sand L. Human Papilloma Virus, Herpes Simplex Virus and Epstein Barr Virus in Oral Squamous Cell Carcinoma from Eight Different Countries. Anticancer Research. 2012;32(2):571-580.
  8. Lekerud A, Sand L P, Englund A, Hirsch J. Treatment of sleep apnoea using a mandibular advancement splint : an open prospective study. In Vivo. 2012;26(5):841-845.
  9. Rasmusson L, Thor A, Sennerby L. Stability Evaluation of Implants Integrated in Grafted and Nongrafted Maxillary Bone: a Clinical Study from Implant Placement to Abutment Connection. Clinical Implant Dentistry and Related Research. 2012;14(1):61-66.
  10. Riben C, Thor A. The Maxillary Sinus Membrane Elevation Procedure: Augmentation of Bone around Dental Implants without Grafts - A Review of a Surgical Technique. International journal of dentistry. 2012;2012:105483-.
  11. Rizell S, Barrenas M --L, Andlin-Sobocki A, Stecksen-Blicks C, Kjellberg H. Turner syndrome isochromosome karyotype correlates with decreased dental crown width. European Journal of Orthodontics. 2012;34(2):213-218.
  12. Saiepour D, Messo E, Hedlund A J, Nowinski D J. Radiologic and Long-Term Clinical Outcome From Treatment of Isolated Medial Orbital Wall Blowout Fractures. The Journal of craniofacial surgery (Print). 2012;23(5):1252-1255.
  13. Sand L, Jalouli J, Jalouli M, Ibrahim S, Larsson P --A, Hirsch J --M. Virus, genetic alterations and tobacco use in premalignant and malignant oral lesions. International Journal of Molecular Medicine. 2012;30(S1):S9-S9.
  14. Sand L, Jalouli M M, Jalouli J, Sapkota D, Ibrahim S O. p53 Codon 72 polymorphism in oral exfoliated cells in a Sudanese population. In Vivo. 2012;26(1):59-62.
  15. Sand L, Lekerud A, Wallström M, Hirsch J M. Local Tolerance of a Sublingual Nicotine Tablet: an Open Single-centre Study. In Vivo. 2012;26(3):463-468.
  16. Dasmah A, Thor A, Ekestubbe A, Sennerby L, Rasmusson L. Marginal Bone-Level Alterations at Implants Installed in Block versus Particulate Onlay Bone Grafts Mixed with Platelet-Rich Plasma in Atrophic Maxilla : A Prospective 5-Year Follow-Up Study of 15 Patients. Clinical Implant Dentistry and Related Research. 2013;15(1):7-14.
  17. Hammarfjord O, Roslund J, Abrahamsson P, Nilsson P, Thor A, Magnusson M, et al. Surgical treatment of recurring ameloblastoma, are there options? British Journal of Oral & Maxillofacial Surgery. 2013;51(8):762-766.
  18. Hong J, Kurt S, Thor A. A Hydrophilic Dental Implant Surface Exhibit Thrombogenic Properties In Vitro. Clinical Implant Dentistry and Related Research. 2013;15(1):105-112.
  19. Jawert F, Hasseus B, Kjeller G, Magnusson B, Sand L, Larsson L. Loss of 5-Hydroxymethylcytosine and TET2 in Oral Squamous Cell Carcinoma. Anticancer Research. 2013;33(10):4325-4328.
  20. Khonsari R H, Friess M, Nysjö J, Odri G, Malmberg F, Nyström I, et al. Shape and volume of craniofacial cavities in intentional skull deformations. American Journal of Physical Anthropology. 2013;151(1):110-119.
  21. Klobas L. The Manifestations and the Treatment of Temporomandibular Disorders in Patients with Chronic Whiplash-associated Disorders Grades 2 and 3. [Thesis]. Uppsala: Acta Universitatis Upsaliensis; 2013. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, 900.
  22. Klobas L. The precipitation of symptoms of temporomandibular disorders (TMD) in patients with chronic whiplash-associated disorders (WAD). 2013;
  23. Klobas L. Stabilization appliance therapy has an equally extensive alleviating effect on jaw pain and frontal headache in patients with myogenous temporomandibular disorders (TMD), with or without chronic whiplash-associated disorders (WAD) grades 2 and 3. 2013;
  24. Mani M, Reiser E, Andlin-Sobocki A, Skoog V, Holmström M. Factors Related to Quality of Life and Satisfaction with Nasal Appearance in Patients Treated for Unilateral Cleft Lip and Palate. The Cleft Palate-Craniofacial Journal. 2013;50(4):432-439.
  25. Olsson P, Nysjö F, Hirsch J, Carlbom I B. A haptics-assisted cranio-maxillofacial surgery planning system for restoring skeletal anatomy in complex trauma cases. International Journal of Computer Assisted Radiology and Surgery. 2013;8(6):887-894.
  26. Olsson P, Nysjö F, Hirsch J, Carlbom I B. Snap-to-fit, a Haptic 6 DOF Alignment Tool for Virtual Assembly. In: Proc. World Haptics (WHC), 2013 IEEE: IEEE World Haptics Conference (WHC), 14-18 April, 2013, Daejeon, SOUTH KOREA. 2013. p. 205-210.
  27. Reiser E, Skoog V, Andlin-Sobocki A. Early dimensional changes in maxillary cleft size and arch dimensions of children with cleft lip and palate and cleft palate. The Cleft Palate-Craniofacial Journal. 2013;50(4):481-490.
  28. Rizell S, Barrenas M, Andlin-Sobocki A, Stecksen-Blicks C, Kjellberg H. Palatal height and dental arch dimensions in Turner syndrome karyotypes. European Journal of Orthodontics. 2013;35(6):841-847.
  29. Rizell S, Barrenäs M, Andlin-Sobocki A, Stecksén-Blicks C, Kjellberg H. 45,X/46,XX karyotype mitigates the aberrant craniofacial morphology in Turner syndrome. European Journal of Orthodontics. 2013;35(4):467-474.
  30. Thor A. Porous Titanium Granules and Blood for Bone Regeneration around Dental Implants: Report of Four Cases and Review of the Literature. Case Reports in Dentistry. 2013;2013:410515-.
  31. Thor A L, Hong J, Kjeller G, Sennerby L, Rasmusson L. Correlation of Platelet Growth Factor Release in Jawbone Defect Repair : A Study in the Dog Mandible. Clinical Implant Dentistry and Related Research. 2013;15(5):759-768.
  32. Cedstromer A, Ahlqwist M, Andlin-Sobocki A, Berntson L, Hedenberg-Magnusson B, Dahlstrom L. Temporomandibular condylar alterations in juvenile idiopathic arthritis most common in longitudinally severe disease despite medical treatment. Pediatric Rheumatology. 2014;12:43-.
  33. Dasmah A, Kashani H, Thor A, Rasmusson L. Integration of fluoridated implants in onlay autogenous bone grafts: An experimental study in the rabbit tibia. Journal of Cranio-Maxillofacial Surgery. 2014;42(6):796-800.
  34. Huo J, Hirsch J, Rännar L, Dérand III P, Gamstedt E K. Finite element investigation of the in-vivo failure of a titanium alloy human jaw implant. In: 10 International Bernd-Spiessl-Symposium. 2014.
  35. Huo J, Hirsch J, Deránd P, Rännar L, Gamstedt E K. Finite Element Investigation of the In - Vivo Failure of a Titanium Alloy HumanJaw Implant.  In: 10 International Bernd-Spiessl-Symposium. 2014.
  36. Jabbari F, Skoog V, Reiser E, Hakelius M, Nowinski D. Optimization of Dental Status Improves Long-Term Outcome After Alveolar Bone Grafting in Unilateral Cleft Lip and Palate. The Cleft palate-craniofacial journal: official publication of the American Cleft Palate-Craniofacial Association. 2014;
  37. Kharazmi M, Carlsson A, Hallberg P, Modig M, Bjornstad L, Hirsch J. Surgical approach to snus-induced injury of the oral mucosa. Journal of Oral Science. 2014;56(1):91-94.
  38. Kharazmi M, Carlsson A, Hallberg P, Modig M, Björnstad L, Hirsch J. Surgical approach to snus-induced injury of the oral mucosa. Journal of Oral Science. 2014;56(1):91-94.
  39. Leiggener C S, Krol Z, Gawelin P, Buitrago-Téllez C H, Zeilhofer H, Hirsch J. A computer-based comparative quantitative analysis of surgical outcome of mandibular reconstructions with free fibula microvascular flaps. Journal of Plastic Surgery and Hand Surgery. 2014:1-7.
  40. Nysjö F, Olsson P, Hirsch J, Carlbom I B. Custom Mandibular Implant Design with Deformable Models and Haptics. In: Proc. Computer Assisted Radiology and Surgery (CARS). Fukuoka, Japan, June 25-28: CARS 2014, Computer Assisted Radiology and Surgery, Computed Maxillofacial Imaging for Dental Implantology, 28th International Congress and Exhibition Fukuoka, Japan, June 25-28, 2014. Springer Berlin/Heidelberg; 2014. p. 246-247.
  41. Ramadhan A, Gavelin P, Hirsch J M, Sand L. A retrospective study of patients with mandibular fractures treated at a Swedish University Hospital 1999-2008. Annals of maxillofacial surgery. 2014;4(2):178-81.
  42. Rodriguez-Lorenzo A, Rydevik Mani M, Thor A, Gudjonsson O, Marklund N, Olerud C, et al. Fibula osteo-adipofascial flap for reconstruction of a cervical spine and posterior pharyngeal wall defect. Microsurgery. 2014;34(4):314-318.
  43. Sand L, Jalouli J. Viruses and oral cancer. Is there a link? Microbes and infection. 2014;16(5):371-378.
  44. Sand L, Wallström M, Hirsch J. Smokeless tobacco, viruses and oral cancer. Oral health and dental management. 2014;13(2):372-378.
  45. Thor A, Ekstrand K, Baer R A, Toljanic J A. Three-year Follow-up of Immediately Loaded Implants in the Edentulous Atrophic Maxilla : A Study in Patients with Poor Bone Quantity and Quality. International Journal of Oral & Maxillofacial Implants. 2014;29(3):642-649.