Timing of facial osteotomies. A consensus conference

A concensus conference on the timing of facial osteotomies was held in Jönköping, Sweden. Seven teams consisting of a maxillofacial surgeon and an orthodontist representing five countries discussed treatment planning for young patients with maxillomandibular deformities with special emphasis on timing. Patients with severe syndromic facial deformities were not considered. Consensus was reached that for most deformities it is best advised to wait until growth has ceased, as determined by longitudinal cephalometric data. This rule is less tight for Angle Class II than for Class III cases. For asymmetries often there is still not enough scientific evidence to obtain well-founded uniform agreement.

[Corrections after facial trauma. Experiences with secondary periorbital corrections]

Corrective surgery after primary treatment of periorbital trauma is indicated for functional as well as aesthetical reasons. These indications and the over-all results will be discussed, based on 56 cases. Surgical techniques such as osteotomy of the malar bone or correction of the nose will be presented. It is concluded that 60% of the cases achieve a good, final result. In another 30% considerable improvements have been realized.

Facial growth in patients with bilateral cleft lip and palate: a cephalometric study

In this study, sagittal facial growth of bilateral cleft lip and palate (BCLP) patients between 6 and 20 years of age is analyzed. The data of Nijmegen were derived from 131 lateral cephalograms taken in 21 BCLP patients who were treated in the Cleft Lip and Palate Center of the University Hospital of Nijmegen. Reported data of 90 BCLP patients treated at the Center of Oslo were used as a reference for comparison. Results of this investigation showed mandibular growth to be similar in both centers. In the premaxillary region some differences were found: The Nijmegen patients presented a more protrusive premaxilla than those at Oslo. The upper front teeth and hence, the premaxilla, were more retroclined in the Nijmegen sample. There were also statistically significant differences in the soft tissue profile. The mean z-score was positive for the nasolabial angle and negative for the angle N'-Sn-Pg'. At 18 years of age, these differences are still apparent. In comparison with Broadbent's values of normal individuals, the SNPg-angle was smaller and the mandibular angle greater in Nijmegen and Oslo. The profiles of the BCLP patients are more convex in Nijmegen and more concave in Oslo than in the noncleft group. Finally, the different treatment strategies of the Cleft Lip and Palate Centers of Nijmegen and Oslo are compared and discussed in terms of their long-term results.

[The appearance after osteotomy of the jaw]

A patient undergoing orthognathic surgery wants to know in advance what he will look like after the treatment. For this purpose a prediction tracing may be used. The value i.e. precision of such a tracing is discussed. Several factors seem to limit the reliability of the prediction, such as 1. the surgery is not always executed as planned; 2. a (partial) relapse influences the final result; 3. rotational movements cannot yet be integrated with precision in the prognosis; 4. the ratios used in the planning are not absolutely reliable. Nevertheless, the prediction tracing is useful if one is aware of its shortcomings.

Timing and transplant materials for closure of alveolar clefts. A clinical comparison of 296 cases

A retrospective study of bone grafting of 296 clefts (165 unilateral and 131 bilateral was required) to answer questions about the most favourable timing and the most appropriate bone graft material. The results as such are not exceptional in comparison with earlier publications by the same or other authors, but it is of special interest that operations with different graft materials applied at different times in development, in (usually) a sufficient number of cases, can be compared together. The patients have been operated on during a period of 11 years, by the same surgeons, applying the same principles and techniques. It is shown that early secondary grafting, before the eruption of the canine, results in by far, the highest success rate. Similarly, chin bone is considerably better than any other type of transplant. Aspects of general planning, timing, technique and failures are extensively discussed. Besides the afore-mentioned most significant findings, it is also concluded that the results of grafting during osteotomies are better than they appear; that tertiary grafting is extremely difficult, and requires special surgical skill; that rib grafts score as high as iliac crest grafts and that materials other than these three types of bone should be avoided.

Fractures of the frontal sinus: a rationale of treatment

There is still controversy on the management of frontal sinus fractures, as the optimal method of treatment has not been developed yet. Based on experience with 71 patients we formed a protocol, the basic principles of which are outlined here. In cases of posterior wall fractures the sinus was either cranialised or it was obliterated down to the nasofrontal duct. Anterior table fractures were reduced, defects were reconstructed and the sinus was drained via the nose for 4-6 weeks. Autologous graft material was always used for all reconstructive purposes. Meningitis occurred directly after the operation in 2 patients and a mucopyocele of the sinus with osteomyelitis of the frontal bone 1.5 years postoperatively in another. No further early or long term sequelae originating from the sinus were seen.

An orthodontic and cephalometric study on the results of the combined surgical-orthodontic approach of the protruded premaxilla in bilateral clefts

The anatomical aberration of the premaxilla in bilateral cleft lip and palate (BCLP) gives rise to many problems. Orthodontic and orthopaedic treatment alone often fail to correct this deformity. In this study, the results of a combined surgical-orthodontic approach were analysed. 22 BCLP-patients, who had undergone an osteotomy of the premaxilla in combination with secondary or tertiary bone grafting, were involved in this study. Two cephalograms were analysed from each patient, one prior to and one after osteotomy. Dental casts were made prior to orthodontic treatment, prior and after osteotomy of the premaxilla and after final orthodontic treatment. As a control group, BCLP-patients treated by the cleft palate centre, Oslo were used. Treatment planning of these two teams is comparable, except for the fact that in Oslo surgical repositioning of the premaxilla is never performed. Cephalometric values before and after osteotomy of the premaxilla were calculated. These values were corrected for growth by means of the Oslo-data. Differences before and after osteotomy were tested statistically with a paired t-test. After osteotomy, good arch form was achieved, the premaxilla was positioned more superiorly and normal inclination of incisors was achieved. It was not possible, however, to lower a high-positioned premaxilla to a normal vertical relationship.

[Treatment of syndromes with abnormalities of the face]

A standard method of treating syndromes with anomalies in the face does not exist. Not only are the differences between the symptoms of different syndromes very important. Also within one syndrome variations can be marked. A team of specialists supports the cranio-facial surgeon in his central role when treating these patients. Type of treatment, sequence, timing, et cetera, follow certain rules, which may be in part the same as for the treatment of 'ordinary' maxillo-mandibular disharmonies, but sometimes differ significantly from it. The most important aspects of treatment of three rather frequently seen cranio-facial syndromes are given. Incidence, symptoms, therapeutical possibilities and timing, and results are discussed as well as the necessity of this kind of surgery.

Long-term results on the quadrangular osteotomy

The results of a follow-up study of 17 patients who underwent a quadrangular osteotomy, are presented. The indication for a quadrangular osteotomy includes a hypoplastic maxilla with retruded infra-orbital rims and infra-orbital area, but with normal nose projection. Almost all patients were satisfied with the result. Relapse in a horizontal direction appeared to be approximately 12%; however, considerable relapse was seen in the vertical direction (61.7%-158%). A major problem during operation appeared to be the high rate of fractures of the infra-orbital wing. Sensory loss in the area of the infra-orbital nerve occurred in 79% of the operated sides. Four patients needed surgical correction of conditions that should be considered complications resulting from the osteotomy, including a case of partial ischaemic necrosis of the premaxilla in a BCLP patient.

Disturbances of smell and taste after high central midface fractures

Estimation of the senses of smell and taste in patients who had suffered a high central midface fracture between 1979 and 1989 was carried out. 180 of these patients were operated on for repositioning and fixation of their fractures. A written questionnaire was sent to 165 living patients, 109 individuals responded, a response rate of 66%. Of these patients, 38% claimed to suffer impaired ability to smell and 23% not to taste well. 64% mentioned unconsciousness after the trauma. With rising seriousness of the trauma, more disturbances of smell are found: from 25% of the nasal fractures, to 80% of the fronto-nasal-Le Fort fractures. In more than half of the cases of disturbance of smell, a simultaneous impairment of taste was reported. It can be concluded that disturbance of smell most often appears after fronto-maxillary and fronto-nasal fractures. However, the higher and more extensive the fracture is, the more frequently is unconsciousness reported. Consequently, impairment of smell can be attributed to the fracture itself, but also to a cerebral lesion located more proximally.

The chin as a donor site in early secondary osteoplasty: a retrospective clinical and radiological evaluation

26 unilateral cleft palate patients received an autogenous bicortical chin bone graft for early reconstruction of the alveolar process. In the evaluation of the donor site, 4% of the anterior teeth showed a negative pulpal sensibility, less than 1% a peri-apical granuloma and 12% pulp canal obliteration. The tooth buds of the canines showed developmental disturbances in 6%. Exposure of unerupted canines should be avoided, and a 5 mm safety margin is advised. Based on its architecture, topographic accessibility, minimal post-operative morbidity and absence of visible scars, the chin can be considered to be a very useful donor site in bone grafting procedures.

Cranio-maxillo-facial tissue expansion, experimentally based or clinically empiric? A review of the literature

The literature over 10 years covering tissue expansion in cranio-maxillo-facial surgery is reviewed. Since 1981, an evolving set of indications for application of the soft-tissue expansion technique has been published. However, it seems to be based much more on clinical experience (empiricism) than on the results of thorough experimental research. The direction of future research should be aimed at effects on bone, cartilage and mucosa at a microscopical level, and at the influence on growth and development of cranio-maxillo-facial structures.

Restricted opening of the mouth with an extra-articular cause in children

Restricted opening of the mouth with an extra-articular cause (ROMEC) can have very different aetiologies. A series of 6 children, who have been operated on under 4 different diagnoses, are presented. Excluded are common problems such as recent trauma and posttraumatic scarring, craniomandibular dysfunction or elongated coronoid process, and also tumours. Problems of establishing the diagnosis, surgical treatment, postoperative physiotherapy and timing are discussed. It is shown that none of the cases is a perfect result, some outcomes are even very disappointing. It is therefore concluded that absolute trismus should be treated independently of age. The result expected will be mediocre. For final correction it is suggested that the operator should wait preferably until the second growth spurt has passed. The same goes for children presenting primarily with a mouth opening greater than 20 mm.

A modified sagittal step osteotomy of the mandibular body. Technical note

A modification of the osteotomy of the body of the mandible for elongation and rotation of its anterior part is presented. It allows these movements without the necessity for bone grafting, with a reduced risk of damage to the alveolar nerve and increased stability.

Early secondary osteotomy-stabilization of the premaxilla in bilateral clefts

Using the same arguments as for early bone grafting of the alveolar process in unilateral clefts, the cleft team of the University of Nijmegen started about 10 years ago to apply early osteotomy-stabilization of the premaxilla to bilateral clefts. A series of 13 cases with a minimum follow-up of 15 months is presented. The patients were operated on at the age of 8 2/12 to 12 5/12 years. The results are considerably better than when doing the same operation in the adult. More than 90% are successful. In comparison with adults we additionally register more favourable eruption of the canine, the possibility of closing the dental arch without prosthetic appliances and in some cases also the elimination of a psychological handicap. The inhibition of growth by this operation seems not to be important. If need be, Le Fort I osteotomies are possible after completion of growth. They will be in one piece which is technically easier than the usual three-segment Le Fort I. In conclusion we prefer early secondary osteotomy and stabilization of the premaxilla to the tertiary operation.

[Transposition of the temporal muscle in the surgical treatment of cleft palate]

The use of the temporalis muscle flap presents a great interest for the surgical repair of cleft palate. The simplicity of the technical procedure, the absence of cosmetic and functional sequelae, and the excellent morphological results lead us to affirm its efficacy in the reconstructive surgery of the palatine region. The Authors report a clinical case and describe the surgical procedures utilized.

Four-step mandibular lengthening to correct a bird face deformity. A case report

A technique for extreme lengthening of the mandible is presented. In one operation it combines several procedures already known, modifying some of them. Its advantage is that the movement is subdivided in 4 steps. Thereby the need for grafting is reduced or even absent and the amount of relapse is probably less important than if fewer but bigger movements were applied.

Sensibility and cutaneous reinnervation of pectoralis major myocutaneous island flaps. A preliminary clinical report

The cutaneous sensibility of 13 pectoralis major cutaneous island flaps has been investigated retrospectively. Although in raising the pectoralis major myocutaneous island flap sensory denervation of the skin is produced, after a mean follow-up period of 29 months (range 5 to 71 months), 68% of the cutaneous portion of the flap revealed sensibility to touch, suggesting a reinnervation from the surrounding intact oral mucosa or skin. The rate of reinnervation was found to be related to the sensibility present in the surrounding tissue.

Early secondary bone grafting of alveolar cleft defects. A comparison between chin and rib grafts

Since 1981 in cleft lip and palate patients a combined surgical-orthodontic procedure has been performed to eliminate the residual alveolar cleft. For early secondary bone grafting (before the eruption of the canine tooth) initially the graft tissue of choice was rib. Since 1984 chin bone has also been used. Sixty one patients with complete unilateral clefts were reviewed (mean age 9.5 years). 15.7% of the rib graft cases showed resorption of the graft of 50% and more. Such resorption was not found in any of the chin graft cases. No complications such as wound dehiscence, sequestration, excessive resorption of bone or recurrence of an oro-nasal fistula were found in the chin graft group. This leads to the conclusion that if enough bone is available in the chin region to bridge the defect, this graft is preferable to a rib graft.

Early secondary osteoplastic closure of the residual alveolar cleft in combination with orthodontic treatment

In 84 early secondary bone graftings, rib and chin transplants were used. While good overall results are obtained, comparison of the two types of graft show that the cases with bone from the chin clearly do better.

Stability after osteotomy of the edentulous maxilla

The results after advancement and lowering of the edentulous maxilla after a mean follow-up of 21 months are presented. Eight cases were stabilized with wire osteosyntheses, eight others with miniplates. In contrast to earlier reports considerable variation of the results after a longer follow-up was found, although the means of the whole group do not differ very much from other series. It is concluded that the Le Fort-I operation is more reliable for the augmentation of the edentulous maxilla than onlay grafting. Better results are achieved after stabilization with miniplates than with wiring.

Replacement of the damaged interarticular disc of the TMJ

Meniscectomy should be abandoned and the removed, damaged disc of the TMJ should be replaced in patients suffering from internal derangement of the TMJ. In seventeen patients the disc which was removed, was replaced with fresh autogenous auricular cartilage. The follow-up period ranged from one to six years with a mean of almost three years. From the analysis of the results we concluded that all patients showed a postoperative improvement in their symptoms and joint function and that the use of intermaxillary fixation for a short period postoperatively had a significant effect on the subsequent increase in mouth opening.

Secondary post-traumatic periorbital surgery. Incidence and results

Over a 6 year period 20 patients presented for secondary corrections of the periorbital region after trauma. Corrections after isolated fracture of the zygoma were necessary in 6 cases, mainly comprising re-osteotomies and contour corrections. A tertiary correction was needed only once (17%). Secondary treatment was indicated in 6 patients after fracture of the midface, necessitating mainly re-osteotomies of the zygoma, corrections of the nose and canthopexies. Tertiary corrections were performed in 3 cases (50%). In 8 patients the results of treatment of fronto-orbito-nasal fractures required further improvement. Again, osteotomies of the zygoma, corrections of the nose as well as corrections of scars and bony contours were often indicated. Four cases (50%) needed tertiary surgery. It is concluded that the more serious the primary trauma the greater the necessity for further secondary surgery. Independently of the kind of primary trauma the indication for secondary treatment was, in most cases, aesthetic. Not only was the number of re-osteotomies and nasal corrections high, but also the number of tertiary revisions. While this might not be very surprising for the nose, it is for the zygoma and proves the difficulties which arise for perfect positioning when there are no clear landmarks. Forty percent of all patients underwent tertiary and one patient needs a quaternary correction.

Sagittal sliding osteotomy of the alveolar process of the mandible. A modification of Hofer's osteotomy

A modification of Hofer's (1942) osteotomy of the alveolar process of the lower jaw is described. Under certain circumstances it is possible to cut the alveolar process sagittally. Thereby a gap in the alveolar process is avoided and there is no need for bone grafting normal alveolar ridge height being maintained nevertheless.