[Secondary posttraumatic correction of the face]

Any part of the face may present residual deviations in form and/or function after trauma, even if primary treatment has been executed optimally. Secondary corrections may be indicated as a consequence. The techniques are usually the same as for primary treatment. However since secondary corrections quite often are a consequence of complicated primary problems, it does not surprise, that frequently complex deformities present for secondary surgery. Depending on the nature of the lesion percentages of success between 60 and almost a 100% may be expected. This indicates that additional treatment after primary care may be a way out for quite a number of residual deformities.

Profiloplasty: variations in personal views

There is sometimes controversy among colleagues over treatment plans in orthognathic surgery. This is because there are differing ideas about which part of the facial skeleton should be moved to give an optimal result. A study was therefore set up to obtain insight into the differences between surgeons. Ten unbalanced profile drawings were given to seven experienced surgeons with the request that they draw the profile line which they would like to give these patients. It was acceptable either to draw the profiles 'artistically' off the cuff or to use additional construction lines as long as this was not the profile planning according to Brons and Mulié (1993). The evaluation showed that some surgeons drew profiles which resembled each other to some extent in proportions and inclinations, while others produced variations without any evident regularity and basic concept. The variability per profile was very important in almost all cases. Such discrepancies are not acceptable in a teaching centre.

Tooth eruption through autogenous and xenogenous bone transplants: a histological and radiographic evaluation in beagle dogs

The effect of implanting autogenous and xenogenous (Bio-Oss) bone transplants into metabolically active sites within beagle dog mandibles during permanent premolar tooth eruption was examined. Ten 14-week-old beagles were used. Before commencing the radiographic experiments, metal bone markers were placed in the caudal margin of the mandible at the age of 10 weeks. The deciduous first and third molar teeth were extracted and their sockets over the permanent second and fourth premolars were implanted with autogenous particulate enchondral iliac crest bone, autogenous particulate membraneous mandibular body bone, xenogenous bovine anorganic bone mineral spongiosa granules (1-2mm3) (Bio-Oss, Geistlich Pharma, Switzerland) of left empty. The third premolar served as control site. Standardized oblique lateral radiographs were taken once a week. A number of coordinates of defined points and structures were determined by means of a coordinate digitizing system. Animals were killed 4, 10 and 16 weeks after bone transplantation for histological examination of the transplantation sites. All premolars showed no delay in eruption or disruption of crown and root development. On histology, the Bio-Oss particles were not resorbed or integrated in the alveolar bone but were pushed forward into the gingiva. We have demonstrated that there is on difference in the eruption curve of the permanent premolars in the four groups (ANOVA P > 0.5) and that bone transplantation has no inhibitory effect on eruption (ANOVA P > 0.3) and crown development of the underlying permanent premolar but that Bio-Oss does not have the same resorbable or integrating capability as autogenous bone grafts.

Ectodermal dysplasia, cleft lip/palate, and severe cutaneous and osseous syndactyly in a mentally retarded girl: a new multiple malformation syndrome

A 13-year-old mentally retarded girl with severe cutaneous and osseous syndactyly of the hands and feet, cleft lip/palate, and ectodermal dysplasia is presented. We conclude that the pattern of malformations described represents a new multiple malformation syndrome. A comparison with Zlotogora-Ogür syndrome is presented.

Two-dimensional cephalometric analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats

The feasibility and possible effects of palatal soft-tissue expansion in palatal repair were studied. A prospective longitudinal animal experiment was performed in 75 growing cats assigned to 5 groups. In 31 cats, a midline defect was made, and bipediced flaps were raised at the age of 8 weeks (stimulated Langenbeck operation) in order to create palatal scars. At the age of 14 weeks, custom-made tissue expanders were inserted palatally in 61 animals. Tissue expansion was performed by weekly inflation in 33 cats (16 without and 17 with scars) for an 8-week period. The remaining 28 cats (14 without and 14 with scars) served as sham groups. A control group was formed by 14 animals (without scars and without tissue expanders). Soft-tissue gain and its effects on maxillofacial growth and development were measured in the midsagittal plane on tracings from standardized lateral radiographs. The effects of the experimental interventions were evaluated for 8 weeks after removal of the tissue expanders. Not all the cats yielded results at all time periods. This study showed that soft-tissue expansion of palatal mucoperiosteum is feasible. The surgically induced scars did not cause significant differences between the different groups in the midsagittal plane, and the data from both expansion and sham groups could be pooled. Significant soft-tissue gain was achieved by the tissue-expansion technique. Iatrogenic side effects were significant anteroposterior growth retardation at the level of the bony palate and an increase in vertical growth of the anterior nasomaxillary height and the posterior skull height during active tissue expansion. After removal of the tissue expanders, some accelerated growth was found in the tissue expansion in the scarred tissue group, with initial correction of the abnormal growth at the cranial base level. It is concluded that palatal soft-tissue expansion is possible in growing cats. This technique, however, impaired maxillofacial growth and development.

Skeletal and dento-alveolar stability of Le Fort I intrusion osteotomies and bimaxillary osteotomies in anterior open bite deformities. A retrospective three-centre study

A sample of 267 patients with maxillary hyperplasia, a Class I or Class II/I occlusion and anterior vertical open bites, collected from three different institutions, was analysed regarding stability after surgical corrections. Skeletal and dento-alveolar stability of the maxilla, and positional changes of the mandible and of the incisors were evaluated. All patients underwent Le Fort I intrusion osteotomies and in 92 patients segmentation of the maxillae was performed. An additional bilateral sagittal split advancement osteotomy was performed in 123 patients. Intraosseous wire fixation was used in 153 patients and rigid internal fixation in 114 patients. Cephalometric radiographs were collected before orthodontic treatment, before surgery, immediately after surgery, one year postoperatively and at the latest follow up. The mean follow up was 69 months (range 20-210 months). It can be concluded that patients with anterior open bites, treated with a Le Fort I osteotomy in one-piece or in multi-segments, with or without bilateral sagittal split osteotomy, exhibited good skeletal stability of the maxilla. Rigid internal fixation produced the best maxillary and mandibular stability. The mean overbite at the longest follow up was 1.24 mm and a lack of overlap between opposing incisors was present in 19%. The overbite did not differ significantly between the different treatment procedures, probably due to compensatory movements of the mandibular and maxillary incisors.

Osseointegrated oral implants in head and neck cancer patients

After cancer treatment in the head and neck area, mastication and speech are often affected. Some of the problems encountered can be solved by adequate dental rehabilitation. However, dental rehabilitation is often compromised for various reasons. The change in anatomy due to surgery often results in lack of denture-bearing mucosa. The effects of radiotherapy on the salivary glands and the mucosa result in dry oral tissue and diminished retention of removable dentures. Osseointegrated oral implants can help to solve these problems. Although implant treatment for patients with cancer of the head and neck is covered by the Dutch national health insurance, and there is therefore no financial obstacle, implants have not, so far, been widely used with these patients. In order to establish the possible reasons for this, an analysis was performed. Retrospective data on 95 consecutive patients were collected from records. The indication for the use of oral osseointegrated implants was reviewed. Analysis of the data showed that 45% did not need specific prosthetic rehabilitation. An indication for the use of osseointegrated implants was found in 25% of the patients. For various reasons, only 3% actually received implants. In striving to completely rehabilitate a cancer patient, the possible use of osseointegrated oral implants should be evaluated before the initial oncological treatment begins. The insertion of implants during the initial surgical procedure should be considered more often, with a view to reducing the number of surgical procedures.

Variations in the correction of Treacher Collins syndrome

A new combination of basically known techniques is described for the correction of Treacher Collins syndrome. The patients are treated in two to three operative sessions beginning early in the second decade of life. The main components are a chin advancement simultaneously with malar osteotomies in a first operation. In the second operation, the chin prominence is moved further forward by a simultaneous vertical movement of the maxilla, sagittal split osteotomy and body osteotomy of the mandible, together with a further chin advancement. Additional finishing touches may ask for a third intervention. Since there is a large variability of expression of the different signs, the techniques have to allow for a good deal of flexibility. The study of 10 patients reflects the considerable variations in the condition at the outset and the adequacy of the basic treatment protocol. The results of malar osteotomies are better than those of pure onlay augmentation. Despite the complexity of the maxillomandibular osteotomies, occlusal results are reasonably stable, and aesthetic improvement is considerable. The adaptation of the treatment to the individual patient resulted in modifications of direction of movement for different segments but also in omission of parts of the standard osteotomies. As a consequence, a modified treatment plan will be used as often as the standard program. The causes for the two not satisfying results are explained, and they demonstrate the limitations of the concept.

Improvement in oral function following tumour surgery by a combination of tongue plasty by the Steinhäuser technique and osseointegrated implants

Oral functions such as speaking, chewing and swallowing are often reduced after ablative tumour surgery in the mouth and oropharynx. For restoration of at least a part of these functions, stable dentures and satisfactory mobility of the tongue are necessary. Dental implants can be used to achieve stable dentures. Pre-implant surgery, however, is often needed to reduce the amount of bulky tissue when myocutaneous flaps have been used for reconstruction, and to achieve adequate mobility of the tongue. A combination of tongueplasty by the Steinhäuser technique and osseointegrated implants will be described and discussed. Twelve patients have been treated by this technique between 1992 and 1995, with a mean follow up of 11.6 months. All patients reported an improved tongue mobility and ability to chew. Tongueplasty by the Steinhäuser technique with secondary epithelialization, in combination with osseointegrated implants, is a simple and effective means of improving oral function.

Three-dimensional morphometric analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats

A prospective longitudinal study in 75 growing cats was conducted to evaluate palatal soft-tissue expansion in cleft lip and palate surgery. In 31 cats, palatal scars were induced by simulated Langenbeck surgery at the age of 8 weeks. At the age of 14 weeks, custom-made tissue expanders were inserted in 61 animals. Tissue expansion was performed by weekly inflation in 33 cats (16 without and 17 with scars) for an 8-week period. The remaining 28 cats (14 without and 14 with scars) served as sham groups. A control group was formed by 14 animals (without scars and without tissue expander). The effects of the experimental interventions were evaluated on a series of dental casts during the inflation period and until 8 weeks after removal of the tissue expander. The results indicate that soft-tissue expansion of the palatal mucoperiosteum is feasible. Until 20 weeks of age, no differences were found between both expansion and sham groups. Thereafter, significant soft-tissue surface-area gain was quantified in relation to the base surface and base diameter of the tissue expander. Iatrogenic side-effects of active tissue expansion consisted of significant transversal growth retardation in the anterior part of the bony palate and dentoalveolar structures. After removal of the tissue expanders, some accelerated growth in the tissue-expansion, scarred-tissue group was seen. It is concluded that palatal soft-tissue expansion is possible in growing cats, with and without the presence of palatal scars; however, this technique, like other kinds of palatal surgery, impairs dentomaxillary growth and development.

Transmandibular implant versus intramobile cylinder implants: a randomized, prospective clinical trial

A randomized, controlled clinical trial was conducted to compare two different implant treatment modalities for edentulous patients with severely resorbed mandibles. In one modality (the IMZ group), two intramobile cylinder implants were placed, connected by a Dolder bar and provided with an overdenture, and in the other (the TMI group), a transmandibular implant with a triple bar and cantilever extensions was placed, likewise provided with an overdenture. The conditions of the overdentures, the peri-implant tissues, and the implants were evaluated. Orthopantomograms were taken for radiologic evaluation. An overall complication scale which took account of all aspects was devised to compare the results. The follow-up period was 2-4 years, with a mean follow-up of 3 years. The condition of dentures and oral hygiene aspects were comparable for both groups. The complication rate in the TMI group was significantly higher than that in the IMZ group. The scores on the complication scale resulted in a significant difference between the TMI and the IMZ groups (Wilcoxon, P = 0.0044).

Supraperiosteal flap technique versus mucoperiosteal flap technique in cleft palate surgery

Recent animal experiments have shown that palatal repair without denudation of bone leads to a superior dento-alveolar development. The aim of this clinical study was to evaluate the peri- and postoperative course and the dento-alveolar development of the deciduous dentition in Japanese ULCP, and CP patients up to 5 years after two different types of palatal repair. One of the methods, the Kohama (1991) supraperiosteal flap technique, is performed without denudation of the bony palate, while the other, the Wardill (1937) push-back technique, results in areas of denuded bone. It was concluded that the supraperiosteal technique can be performed successfully in approximately the same amount of time as the push-back technique. Re-epithelialization of the wound areas after supraperiosteal repair takes about 1 week, which is one third of the time associated with healing after the push-back technique. Arch depth of the deciduous dentition after the supraperiosteal technique is superior compared to the push-back technique. The question of whether or not the supraperiosteal technique produces more favorable dento-alveolar development than the mucoperiosteal technique in the permanent dentition in humans has to be elucidated in future research.

Neurofibroma in the articular disc of the temporomandibular joint: a case report

In classical Von Recklinghausen neurofibromatosis (Type I), skeletal defects occur as a result of abnormalities of derivatives of the neuroectoderm and mesoderm. Temporomandibular joint (TMJ) disorders caused by neurofibroma in the joint capsule or disc have not been reported previously in the English language literature. A case of neurofibroma in the TMJ articular disc in a 29-year-old woman with neurofibromatosis Type I is presented.

Palatal mucoperiosteal expansion as an adjunct to palatal fistula repair: case report and review of the literature

Case report of conventional palatal soft-tissue expansion in an attempt at cleft palate fistula closure with a standard tissue expander. This technique may be an alternative to a tongue flap to promote closure of persistent oronasal fistula.

[Skull roof reconstruction in infants]

In this article an introduction into craniofacial surgery in children is given based on the case histories of two patients (cleido-cranial dysplasia and cranio-synostosis).

Occlusal and functional conditions after surgical correction of anterior open bite deformities

The dental occlusion and alterations in orofacial muscles were studied in 267 patients whose severe anterior open bite had been treated with a Le Fort 1 intrusion osteotomy with or without an advancement sagittal split osteotomy about 6 years ago. Only 17% of those patients showed anterior contact, and 20% had no vertical overlap of mandibular and maxillary central incisors at all. Tongue position, activity of masticatory muscles, lip competence, lip-incisor relationship, and breathing mode were assessed. Statistically significant correlations were found between tongue positions and occlusion in both the anterior and the posterior regions. In addition, the activity of the masticatory muscles, habitual mouth posture, and interlabial distance were each significantly correlated to overbite, open bite, and overjet. The interlabial distance was also significantly correlated with both breathing mode and mentalis muscle activity. The activity of the masticatory muscles was negatively correlated with tongue position.

Palatal surgery without denudation of bone favours dentoalveolar development in dogs

The present study compared the dentoalveolar development in beagle dogs after palatal repair according to the partially split flap technique and the von Langenbeck method. It was concluded that palatal surgery according to the partially split flap technique resulted in significantly wider transverse distances of the maxillary dental arch than after the von Langenbeck procedure and that its final outcome closely resembled that of the control group.

Effectiveness of primary correction of traumatic telecanthus

To assess the aesthetic and functional results of primary treatment of telecanthus in patients with naso-orbito-ethmoidal fractures, the results in 36 patients were evaluated in a retrospective study. Twenty had double-sided telecanthus: 13 required an indirect technique of canthopexy and seven a direct technique. Sixteen had unilateral telecanthus, of whom six were treated by the indirect and 10 by the direct technique. The intercanthal distance (ICD) was measured directly postoperatively and more than 12 months after reconstruction. The late ICD after application of the direct technique was nearly 3 mm smaller (ANOVA, P < or = 0.02, mean 34.3 mm) and yielded 2 mm less relapse (ANOVA, P < or = 0.02) as compared with the indirect technique. Delayed or late-primary treatment showed a significantly higher frequency of epiphora (chi-square test, P < or = 0.05). Early primary treatment of traumatic telecanthus produced the best aesthetic and functional result.

Reversing segmental osteotomies of the upper jaw

Three patients are presented in whom retropositioning of the anterior upper teeth resulted in accelerated aging of the face. Two basically different approaches to correct these bad results are illustrated. It is shown that onlaying of the maxillary base is insufficient but can be the only solution possible. Reversing the primary procedure seems much more effective. The technique, however, can be very demanding.

Effectiveness of secondary post-traumatic periorbital reconstruction

In a 12-year period, 56 consecutive patients have undergone secondary periorbital reconstruction after trauma. To evaluate the overall results and the need for further correction, three diagnostic groups were formed. These were: malar bone (n = 16), midface (n = 16) and fronto-orbital fractures (n = 24). Also, in order to judge the reliability of the procedures used most frequently, all osteotomies of the zygoma (n = 32 in 30 patients), canthopexies (n = 26 in 19 patients) and corrections of the bony nasal skeleton (n = 26) were assessed as separate groups. After malar fractures, poor results were found in two cases while after midface fractures the results were quite satisfactory with only one poor result. The outcome after fronto-orbital fractures was also generally satisfactory. However, after a considerable number of later corrections there were still four poor results. Unfortunately, osteotomy of the zygoma left a rather high percentage of unsatisfactory results (19%), but canthopexies scored high and further corrections after secondary surgery of the nasal skeleton eliminated all but one poor result. It is concluded that 7% of our trauma patients undergo secondary and further periorbital corrections. The techniques have become routine. The final outcome was assessed as good in 60% and poor in 20% of patients.

Fracture of costochondral graft in temporomandibular joint reconstructive surgery: an unexpected complication

The case of a 35-year-old woman with a history of several temporomandibular joint (TMJ) operations, including condylectomy, is reported. She presented with myofacial pain and partial fibrous ankylosis of her right TMJ. The ankylosis was released and an autogenous costochondral graft was used to restore the vertical dimension of the ramus. About 3 months after surgery, a fracture of the graft occurred during physical therapy. The cause of this complication is discussed with reference to the literature.

[Is segmental osteotomy of the jaws outdated?]

In earlier days segmental osteotomies had a broad field of indications. In the era of combined surgical-orthodontic treatments, they are pushed far into the background. This article shows that this development is unjust. If carefully indicated, segmental osteotomies still have a well-defined place in our armory of surgical interventions. With their elegance and the compulsion to respect detail they are not only of marked didactic value, but they also fill a gap, especially in the treatment options for the lower jaw. Far from being obsolete, they should still belong to the routine options when orthognathic surgery is considered.

Radiologic analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats

Palatal soft-tissue expansion might be appropriate for use in cleft palate surgery. Seventy-five cats were divided into four different experimental groups and one control group. Intraoral tissue expansion was started at the age of 14 weeks in normal or scarred mucoperiosteum. The experiment lasted until 24 weeks of age. Serial standardized lateral cephalograms from each animal were digitized, and the results were statistically analyzed. The results indicate that the effects are independent of the presence of scarred tissue, that sagittal growth is impaired by tissue expansion, and that the tissue expander induced resorption of palatal bone.

Autogenous transplantation of third molars in irradiated jaws--a preliminary report

Our experience with third molar autotransplants in 2 patients, into an area irradiated at an early age, is described and discussed. It is shown that such autotransplantations are possible.