Journal of Cranio-Maxillofacial Surgery

Editorial Board

2010-04-01

Orthodontic characteristics of maxillary arch deficiency in 5-year-old patients undergoing unilateral cleft lip and palate repair with and without early gingivoplasty

2009-05-18

Summary: The purpose of this study was to compare the maxillary arch morphology in 5-year-old children treated for unilateral cleft lip and palate (UCLP) with early gingivoplasty (EGP) and without this procedure (non-EGP). Three-dimensional (3-D) imaging was used to verify which measurements and to what degree specific orthodontic parameters differ in both groups.The study included 120 non-syndromic 4.5–5.5-year-old children treated surgically at the age of 6–18 months. Fifty-six children underwent EGP utilising a Skoog-type of technique. The (non-EGP) group consisted of 64 patients. Patients in both groups were treated without nasoalveolar moulding prior to cleft lip repair. The maxillary arch models were obtained and subjected to the 3-D computer-aided imaging procedure and metric analysis. Ten selected orthodontic measurements were calculated based on imaging landmarks.The computed data derived from models in both (EGP and non-EGP) groups were compared. The differences between groups were statistically analysed using Student's test.Five orthodontic measurements: the angle of the lesser segment inclination, dental arch radius of this segment, anterior palatal depth, palatal surface and length of dental arch demonstrate more severe maxillary underdevelopment in patients with previous EGP. The results reaffirm the negative impact of EGP with wide undermining of periosteal flaps on maxillary development and suggest that these five parameters may be the most sensitive early indicators of growth alteration.

Osteogenic uni- or bilateral form of the guided rapid maxillary expansion

K. Al-Ouf, C. Krenkel, M.Y. Hajeer, S. Sakka — 2009-05-18

Summary: Surgically assisted rapid palatal expansion is an important treatment procedure in patients with constricted maxillae. Several surgical methods have been proposed to expand the maxilla bilaterally. A new technique was developed for performing a symmetric or asymmetric maxillary expansion guided by the stability of the mid-palatal area employing two osteotomy cuts on either side of mid-palatal suture. A Hyrax-type expansion device was used post-operatively. Seventeen patients were included in the study (9 males, 8 females) with a mean age of 30.7 years. Inter-canine and inter-molar widths were evaluated at three assessment intervals: before treatment (T1), immediately after appliance removal (T2) and at six months follow-up (T3). Between T1 and T2, a mean expansion of 7.1 and 9.9mm was achieved at the canine and molar areas, respectively. The amount of relapse measured between T2 and T3 was minimal (a mean value of 0.35 and 0.8mm at the canine and molar areas, respectively). Asymmetric expansion was performed in 6 patients who exhibited unilateral skeletal constriction at the initial assessment and these cases appeared stable at T3. The surgical approach described in the current study enabled rapid maxillary expansion of unilateral and bilateral skeletal constriction cases effectively and with good stability.

A systematic review of the effects of bone-borne surgical assisted rapid maxillary expansion

2009-08-07

Summary: Introduction: A systematic literature review was conducted to find out if bone-borne maxillary expansion with corticotomies is an effective and secure orthodontic/orthopaedic treatment modality, eliminating orthodontic and periodontal side effects of tooth-borne maxillary expansion with corticotomies.Material and methods: Randomized controlled trials (RCT), controlled clinical trials (CCT) and case series with a sample size≥5 were electronically searched in PubMED, MEDLINE, EMBASE Excerpta Medica, CINAHL, Biological Abstracts and CENTRAL till June 2008. Data were extracted by 2 observers.Results: Ten studies fulfilled the inclusion criteria, of which 9 were prospective and 1 was a retrospective case series.Conclusion: No RCT's or CCT's were published on bone-borne surgically assisted rapid maxillary expansion (SARME). For expected advantages compared to tooth-borne SARME, only weak evidence was found for less buccal tipping of the teeth used as anchor teeth in tooth-borne expansion. The heterogeneity of the retrieved publications and the wide variety of outcome variables posed serious restrictions on the review of the literature in a quantitative systematic manner. There is a need for well designed clinical trials research on the effects of tooth-borne and bone-borne SARME.

Long term effects of surgically assisted rapid maxillary expansion without performing osteotomy of the pterygoid plates

Robin Seeberger, Wolfgang Kater, Rolf Davids, Oliver C. Thiele — 2009-08-06

Summary: Purpose: Surgically assisted rapid maxillary expansions (SARME) are commonly used to widen the maxilla. This study evaluates long term stability of surgically assisted rapid palatal expansion without performing osteotomy of the pterygoid plates and its effects on nasal airway volume.Materials and methods: 13 patients (mean age 31, 23±6, 11) with a maxillary transverse deficit of at least 5mm were examined 1 month before and on average 63 months after a mean palatal distraction of 8.29±1.68mm by acoustic rhinometry. Profiles of the nasal airway volumes were collected. A cast model analysis was performed. The data were evaluated using Wilcoxon signed rank test.Results: A V-shaped movement of the segments was observed. The gain for total nasal volume was 23.25%. Findings indicate a significant enhancement of nasal volume in all patients (P<0.01) as result of the maxillary expansion. No relapse occurred in the study group.Conclusion: SARME provides a long term stable orthodontic bite correction and permanently enhances the nasal airways. A transverse shift of the segments can be achieved over the whole bony palate even when no osteotomy of the pterygo-maxillary suture is performed.

Functional results after condylectomy in active laterognathia

Roberto Brusati, Marco Pedrazzoli, Giacomo Colletti — 2009-06-08

Summary: Introduction: Mandibular asymmetry due to overgrowth has two main forms, hemimandibular hyperplasia and hemimandibular elongation. It is necessary to distinguish between inactive and active forms, since surgical treatment of the latter, with a solely morphological aim, could lead to recurrence of further condylar growth. In these cases orthognathic surgery is performed in association with high condylectomy to interrupt the hyperactivity of the condyle. Condylectomy alone in growing patients stops the progression of deformities and sometimes achieves facial symmetry at the end of growth. Some authors have viewed condylectomy as a dangerous procedure, with the possibility of compromising articular function. We aimed to verify immediate and long-term results of condylar function after high condylectomy.Materials and methods: Between 1998 and 2007, 15 patients underwent high condylectomy for active laterognathia. All but one patient underwent postoperative Delaire functional rehabilitation. Long-term articular function was evaluated using subjective and objective criteria.Results: In 14 patients, articular function was subjectively satisfactory. In one case, this did not occur because the patient refused postoperative functional rehabilitation.Discussion and conclusions: Some authors have advised against condylectomy because of the possibility of temporomandibular joint dysfunction. High condylectomy in active laterognathia seems to be the procedure of choice in both adults and growing patients. In our experience, functional alterations of practical relevance are rare if the operation is followed by successful functional rehabilitation.

Early Secondary Gingivo-Alveolo-Plasty in the treatment of unilateral cleft lip and palate patients: 20 years experience

2009-07-10

Summary: Since 1988, the Milano surgical protocol has included lip, nose and soft palate repair at 6–9 months of age and closure of the hard palate at 18–36 months together with an Early Secondary Gingivo-Alveolo-Plasty (ESGAP). Prior to 1988 the alveolar cleft was repaired in a third step by bone grafting at 9–11 years of age. The goal of this study was to evaluate the long-term maxillary growth in unilateral cleft lip and palate (UCLP) patients who have undergone ESGAP. Alveolar ossification after ESGAP was also studied in the permanent dentition. Growth assessment was carried out comparing lateral X-ray cephalograms of a UCLP ESGAP sample (15 consecutive patients with a mean age of 18.2 ±1.2 years) and of the UCLP bone graft sample (10 consecutive patients with a mean age of 18.7 ±1.1 years) and a sample from the Oslo cleft lip and palate (CLP) centre sample (15 patients with a mean age of 18.1 ±0.8 years). Alveolar ossification in the sample which had undergone ESGAP was evaluated through a sample of panoramic X-rays of UCLP in the permanent dentition. Alveolar bridging was assessed using a modified Bergland's scoring system. From the results it seems that ESGAP allows for an excellent alveolar ossification, but patients show an inhibition of maxillary growth compared with the secondary bone graft group and with the Oslo group. Although ESGAP allows for early repair of the alveolus together with palate repair, thus eliminating in all patients the need for secondary bone grafting, it seems to have an inhibiting influence on maxillary growth which increases the need for Le Fort I osteotomies. It is however fair to recall, that, even with an adjunctive Le Fort I osteotomy, ESGAP enables the total number of operations to be reduced to three, instead of most European protocols (4–5 procedures).

A 4-year retrospective study of facial fractures on Jeju, Korea

Jung Hoon Lee, Byung Ki Cho, Woo Jin Park — 2009-07-06

Summary: A number of researchers from various regions have reported statistical and clinical studies of facial fractures. The results of those studies show slight differences depending on regional, cultural, social and economic backgrounds. This report presents a statistical analysis of facial fractures occurring over 4 years on Jeju, Korea. The statistics come from the 318 patients who presented to Cheju National University Hospital for facial fractures, and ours is a retrospective study analyzing patient ages, gender, fracture etiology, alcohol involvement and the anatomical site of the fracture. The most common cause of facial fractures on Jeju was violence (40.9%), followed by traffic accidents (17%). The most frequently fractured site was the nasal bone (42.5%). According to the Jeju Statistics Agency, the people of Jeju are highly dependent on alcohol and previous research has reported the close relationship between alcohol consumption and violence. We paid close attention to violence as a primary cause for facial fractures in the cultural and social context of Jeju. Data analysis regarding facial fractures may provide crucial information for recognition of causes and planning for prevention.

Treatment of orbital floor fracture using a periosteum–polymer complex

2009-08-03

Summary: Various materials for the reconstruction of bone defects in orbital floor fractures have been developed and applied clinically. Recently, reconstruction using polymers, in place of autologous bone and artificial materials, has been actively introduced, but there are problems, such as the size of reconstructable bone defects and the decomposition rate of polymers.A basic study was performed on bone regeneration using a periosteum–polymer complex produced by attaching periosteum to a biodegradable polymer sheet.In this study, patients with orbital floor fractures were evaluated clinically who had undergone reconstruction of orbital floor defects of the using a periosteum–polymer complex produced by applying periosteum to an Hydroxyapatite-[poly (l-lactide–ɛ-caprolactone)](HA-P (CL/LA)) sheet and the ilium in the previous 3 years.A bone defect of less than 2.5cm2 area was defined as small, that of 2.5–4cm2 as intermediate, and that of more than 4cm2 as a large bone defect. For small bone defects, hypoaesthesia in the infraorbital nerve was observed in one patient each of the periosteum–polymer complex and ilium groups. Regarding intermediate bone defects, diplopia and hypoaesthesia in the infraorbital nerve were observed in one patient in each of the two groups. For large bone defects, diplopia was observed in one patient each for the periosteum–polymer complex and ilium groups, and hypoaesthesia of the infraorbital nerve was only detected in one patient of the former group. Not more than 2mm of enophthalmos was detected in any patient. The anatomical eyeball position and eyeball movement were normal after surgical treatment using the periosteum–polymer complex, just as in reconstruction using autologous bone.

En bloc resection of the lateral orbital rim to reduce exophthalmos in patients with Graves' disease

Heidrun Schaaf, Gregor Santo, Michael Gräf, Hans-Peter Howaldt — 2009-05-25

Summary: Introduction: Today, elective surgical procedures are performed on patients with thyroid-associated orbitopathy for aesthetic and “quality-of-life” reasons and only rarely in emergency cases to prevent blindness. The surgical methods should have minimal adverse effects and reliable outcomes.Patients and methods: En bloc resection of the lateral orbital rim and part of the orbital floor was performed on 44 patients over a 7-year period. An osteotomy was made in the inferolateral wall of the orbit via a subciliary incision and the periorbital tissues were resected. Exophthalmos reduction, postoperative changes in strabismus and extraocular muscle function, visual acuity and follow-on operations were analysed.Results: Most patients underwent surgery for exophthalmos, conjunctival and corneal symptoms. The average exophthalmos reduction was 3.8±1.5mm (range 1.5–7.5mm, p<0.01). No loss of vision was noted. Overall, a reduction in diplopia was achieved, although new strabismus appeared after surgery in one patient. Nineteen patients required additional lid surgery.Conclusion: The procedure for exophthalmos reduction is as effective as other two-wall expansion methods and it features low risks for loss of vision, new-onset diplopia and other disturbances of extraocular motility.

An easy and cheap way of staining the arterial supply of the face: A preclinical study of visualization of facial vascular territories in human cadavers

2009-05-18

Summary: Introduction: A cadaver study in preparation of a facial allograft transplantation in humans requires accurate dissection of the arterial, venous and nerve pedicles. A simple and cheap method for the use of arterial tree mapping in cadaver soft tissue is presented.Materials and methods: Eight fresh cadavers aged 55–89 years at the time of death were studied. Five were female and three were male. All injections were performed within four post-mortem days.Results: Our method determined the perfusion territories of the human face without risk of spillage of the dye from capillary structures and showed the arteries very clearly. Vascular patterns of the face were interpreted after dyed gel mixture injection.Conclusion: This study confirms the current reconstructive procedures on the face, but also helps and allows the anatomical dissection to be carried out in an effective and safe manner. The dyed gel mixture represents a valid, cheap and alternative tool for delineating the vascular structures, without leakage and spillage during the anatomical dissection.

Reproducibility of osseous landmarks used for computed tomography based three-dimensional cephalometric analyses

Raphael Olszewski, Olivier Tanesy, Guy Cosnard, Francis Zech, Hervé Reychler — 2009-07-03

Summary: Purpose: The aim of this paper was to measure the reproducibility of osseous landmark identification from two recently described three-dimensional (3D) cephalometric analyses: 3D-ACRO and 3D-Swennen analyses. The study population consisted of 13 patients examined with spiral 3D computed tomography (CT). We used a previously validated low-dose CT protocol. For each analysis, 22 cephalometric reference landmarks were identified on 3D CT surface renderings. Forty-four reference landmarks were identified per patient. Two series of identifications were performed by two independent observers. In total, 3432 imaging measurements were completed. The intra-observer reconstructed mean log was 1.210±1.042mm for the 3D-ACRO analysis, and 1.311±1.042mm for 3D-Swennen analysis (comparison: p=0.17 NS). The inter-observer reconstructed mean log was 1.799±1.037mm for the 3D-ACRO analysis, and 2.465±1.036mm for 3D-Swennen analysis (comparison: p=0.000000002). The difference between the intra- and inter-observer reconstructed mean logs were 1.486±1.057mm for 3D-ACRO and 1.880±1.056mm for 3D-Swennen analysis. In conclusions: 3D-ACRO analysis was significantly more reproducible than 3D-Swennen analysis (p=0.0027) due to the use of a majority of highly reproducible cephalometric landmarks. Finally, we propose a classification scheme and exclusion criteria for reference landmarks used in 3D cephalometrics, based on inter-observer reproducibility and anatomical reality.

Clinical, histological and histomorphometric evaluation of the healing of mandibular ramus bone block grafts for alveolar ridge augmentation before implant placement

Alessandro Acocella, Roberto Bertolai, Maurizio Colafranceschi, Roberto Sacco — 2009-08-03

Summary: Background: Localized bone defects in the maxilla are commonly reconstructed with autologous mono-cortical bone blocks prior to the placement of dental implants. This study presents a clinical, histological and histomorphometric analysis on the use of mandibular ramus block grafts for ridge augmentation.Materials and Methods: mono-cortical bone blocks from the mandibular ramus were grafted in 15 patients. The bone grafts were left to heal for period varying from 3 to 9 months. Afterwards, 30 implants were inserted and bone samples were removed for subsequent histological analysis.Results: All the bone grafts were successful and resorption was minimal. There were no implant failures. At graft placement, mean lateral augmentation was 4.6±0.73mm, which, later, at the time of implant insertion, reduced to 4±0.77mm. Histological evaluation indicated signs of active remodelling in all specimens. However, the grafted bone contained substantial amounts of non-vital bone (NVB) and generally weak neo-vascularization regardless of the time of biopsies.Conclusions: The outcome of the study suggests that the larger part of osteocytes in mono-cortical bone do not survive grafting and neo-vascularization of non-vital grafted bone is difficult because of the slow remodelling process into new vital.

Comparative audiometric evaluation of temporomandibular disorder patients with otological symptoms

Gurel Pekkan, Songul Aksoy, Canan HekImoglu, Fatih Oghan — 2009-08-05

Summary: Objectives: The purpose of this study was to assess the audiological status of temporomandibular disorder (TMD) patients with otological symptoms and to make comparisons with that of a control group of subjects without TMD and otological symptoms.Methods: 25 TMD patients with otological symptoms and 20 age and gender matched controls, 45 subjects in total, were included in the study. All subjects underwent a series of audiological tests that included pure-tone audiometry, impedance test and reflex tympanometry. The audiological parameters recorded in the two groups were compared statistically by means of unpaired t tests and corrected according to Bonferroni in the case of repeated tests.Results: The pure-tone thresholds at frequencies 125, 250, 500Hz, and 6kHz showed significant differences between the TMD patients and control subjects after the Bonferroni correction (p<0.007). Compliance peaks demonstrated significant differences when the TMD and control groups were compared (p<0.05).Conclusions: The findings indicate that TMD patients with otological complaints have hearing impairment at low frequencies and also perhaps, at high frequencies.

EACMFS Prizes and Awards

2010-04-01

The Council of EACMFS wishes to ensure that all members of the Association are aware of the current awards and prizes that are available. These are designed to provide educational support and also to allow the opportunity for trainees and those who have recently achieved specialist status to visit units outside their own departments.

Announcements

2010-04-01

Dear Colleagues, As the Education and Training Officer of the European Association for Cranio-Maxillofacial Surgery, I would like to draw your attention to the forthcoming educational activities. Courses included in the Rolling Programme of the Association are linked to the EBOMS examination curriculum and cover all aspects related to our specialty and are open to all colleagues working in our field. Trainees are especially invited to attend these Courses. A refund of Euro 150 is available for each EACMFS Trainee Member attending a Course of this Programme.