Demineralized bone bandeau in a patient with kleeblattschädel skull deformity.

Management of complex craniofacial deformities in the neonatal setting can pose daunting reconstructive challenges due to the limited supply of autogenous bone. We present a patient who was born with idiopathic nonsyndromal pansynostosis and the associated kleeblattschädel skull deformity. In this setting the patient's initial evaluation was suggestive of raised intracranial pressure and, as such, an emergent decompression was required. The native bone was unsuitable for reconstruction. Therefore, an allogenic demineralized perforated cortical iliac bone graft was used as the cornerstone of the reconstruction. Subsequent 2-year follow-up utilizing both clinical and microscopic evaluation revealed excellent osseous integration of the demineralized bone implant with near-total transformation into living bone. This clinical success has encouraged us to increase our utilization of this bone substitute in the neonatal setting.

Distraction osteogenesis of costochondral neomandibles: a clinical experience.

Distraction osteogenesis quickly has become a mainstay in the treatment of craniofacial syndromes with mandibular hypoplasia. We report on a series of eight patients undergoing distraction osteogenesis of neomandibles constructed with costochondral grafts. The length of distraction, resting phase between distraction and device removal, and complication rate were significantly greater in the rib-graft distraction group when compared with our series of native mandibular distraction patients (n = 21 devices). Most complications were minor, including pintrack infection and hardware failure; however, major complications included fibrous union and facial nerve praxia. Secondary procedures have been able to be performed successfully on previously distracted rib grafts as well.

Long-term outcome of extensive skull reconstruction using demineralized perforated bone in Siamese twins joined at the skull vertex.

The successful use of cortical demineralized perforated bone in the treatment of extensive skeletal defects in children is exemplified by this case involving Siamese twins joined at the skull vertex. Four years following extensive skull reconstruction using demineralized perforated bone, an examination revealed successful calvarial reconstruction in one twin. The other twin required additional implants of demineralized perforated bone to fill in defects. However, a histologic examination taken following this additional procedure revealed that these implants neither caused tissue reaction over a 4-year period, nor showed signs of resorption. Bony remodeling and new bone formation were in progress. Compared with other bone substitutes, demineralized perforated bone has proven to be effective in the treatment of large skull defects in children.

Cranioplasty in the growing canine skull using demineralized perforated bone.

This study was designed to test the hypothesis that demineralized perforated bone matrix implant from canine skull and tibia induces new bone formation within the calvarial defect comparable with the bone induced by autogenous graft. We also were interested in determining whether demineralized perforated bone matrix implants from membranous bone have greater osseoinductive capacity in the calvarial area than demineralized perforated bone matrix implants from endochondral bone. Forty 12-week-old purebred beagles were used. Group I consisted of animals with unrepaired surgically created calvarial defects healed by secondary intention (n = 10). Group II consisted of animals with surgically created calvarial defects in which the bone was removed and replaced with an autograft (n = 10). Group III consisted of animals with surgically created calvarial defects in which the bony defect was closed with a demineralized perforated bone matrix implant obtained from beagle calvaria (n = 10). Group IV consisted of animals with surgically created calvarial defects in which the bony defect was closed with a demineralized perforated bone matrix implant obtained from beagle tibia (n = 10). The two control groups (I and II) allowed us to isolate the inductive capacity of demineralized perforated bone matrix implants and compare it with the healing of the bone defects left unrepaired or repaired with calvarial autografts. Animals were sacrificed after 8 and 12 weeks. In the present study we were able to verify that demineralized perforated bone matrix implants are well accepted in the calvarial defects with little tissue reaction and remarkably little osteoclastic activity.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of lip repair with and without soft-tissue undermining and delayed palate repair on maxillary growth: an experimental study in beagles.

Undermining of the soft tissue on the surface of the maxilla at the time of cleft lip repair remains a controversial issue in cleft management. Using 64 eight-week-old beagles, we tested the hypothesis that lip repair with soft-tissue undermining contributes more to maxillofacial growth aberrations than lip repair without these additional procedures. Animals were assigned to four groups: unoperated controls, unrepaired controls, and two experimental groups (with and without undermining). Defects simulating cleft of the lip, alveolus, and palate were surgically created in the unrepaired and experimental animals. At 36 weeks of age, 11 measurements were made directly on the cleaned maxillae. Analysis revealed that all groups with surgically created defects were significantly different from normal; however, animals with undermining exhibited the greatest group deviation from normal. These findings reaffirm our earlier conclusions that undermining of the soft tissue on the surface of the maxilla is detrimental to maxillofacial growth.

Malar augmentation using lamellar split osteotomy.

Lamellar split osteotomy technique, when used in malar-zygomatic complex, presents a new and effective way of changing facial contour to obtain lateral or anterior projection and to improve facial aesthetics. This technique, an original invention of the author, provides new elements in the surgical correction of skeletal deformities. In contrast to classic osteotomies, this technique transforms the outer table into a maneuverable bone segment, the contour of which can be changed by bending, sliding, or rotation. In separating the outer from the inner table, the outer table becomes movable, whereas the inner table remains in place. A basic advantage of this technique is that the contour can be changed without using additional biological or nonbiological implants. Screws fix the outer table in its changed shape and position. During the last 6 years, 44 lamellar split osteotomies were performed; 22 were for advancement of the malar-zygomatic complex. Follow-up spanned from 6 months to 6 years. No resorption of bone or change of contour was observed at follow-up, which indicates that the outer table maintains its new contour and position during childhood and adolescent growth.

A comparative study of the effects of biodegradable and titanium plating systems on cranial growth and structure: experimental study in beagles.

An experimental study was conducted in beagles to assess the effects of biodegradable and titanium plating systems on cranial growth and structure. Forty-eight 9-week-old purebred beagles were used in this study. To avoid any effects of sexual dimorphism, we used only female beagles. The animals were divided in three groups: sham-operated controls, n = 16; beagles implanted with commercially available titanium plates and screws, n = 16; and beagles implanted with biodegradable plates and screws, n = 16. The biodegradable plating system developed by Storz Instrument Company (St. Louis, Mo.) for use in the craniofacial skeleton does not require another procedure to remove plates and screws once the healing process is completed. To assess the dynamics of changes in cranial growth under the influence of two different plating systems, we conducted two identical studies during two different time periods: 6 weeks and 12 weeks. Using two different time frames allowed us to assess changes in the biodegradable material and in the bone and soft tissue surrounding this material. Statistical analysis revealed no significant differences in the gross cranial structure among the three groups. This finding suggests that the biodegradable plating system has no adverse effect on cranial growth. The material does resorb and/or disintegrate between 6 and 12 weeks after insertion. The rate of resorption is approximately 5.3 microns per day. The bone and soft tissue surrounding the biodegradable implant exhibited very limited inflammation and foreign body reaction. Bony overgrowth was frequently found over the plating system.

Relationship between the sequence of lip and palate repair and maxillary growth: an experimental study in beagles.

The present study was designed to evaluate the relationship between varying sequences of lip and palate repair and maxillary growth. To investigate this problem, an experimental study using beagles was conducted to assess the influence of three different sequences of lip and palate repair. The first sequence constitutes the commonly accepted approach of lip repair first, palate repair second. The second sequence was reversed: palate repair first, lip repair second. The third sequence consisted of simultaneous lip and palate repair. Using 70 eight-week-old beagles, we tested the following hypothesis: The sequence of lip repair first and palate repair second is less detrimental to maxillary growth than the other two sequences. The animals were assigned to two control groups (unoperated and unrepaired animals) and three experimental groups, in which three different sequences of repair were executed. Upon sacrifice, 11 maxillary variables were measured directly from cleaned skulls and analyzed by univariate and multivariate techniques. The most important finding from this analysis is that the commonly accepted sequence of cleft lip and palate repair (lip first, palate second) is less detrimental to maxillary growth than repairing the palate first and the lip second or simultaneous closure of both defects.

Craniofacial neurosurgical approach for extensive hyperostotic meningioma.

We present a patient with a craniofacial meningioma that had been considered inoperable for 8 years but has now been successfully treated using the combined neurosurgical and craniomaxillofacial approach. The tumor extensively involved the meninges, skull, face, left orbit, and maxilla. Vision and mild proptosis of the left eye had worsened over the last several years. Computed tomography and magnetic resonance imaging scans revealed an extensive intraosseous meningioma with intracranial and extracranial extension. An angiogram revealed an intensely vascularized mass supplied by a markedly enlarged ophthalmic artery. The tumor was approached through a bicoronal incision. The meningioma that extended into the dura was removed entirely from the brain. The left orbital roof and the lateral and medial walls were resected along with the meningioma, which extended through the orbit into the maxilla. The defect in the dura was closed with a pericranial flap. Split parietal bone and lyophilized cartilage were used for reconstruction of the cranial and orbital defects. Three and a half months after the initial surgery, further reconstruction was performed using calvarial, rib, and iliac bone and lyophilized cartilage. A methylmethacrylate implant was inserted but then removed due to chronic wound drainage. It was substituted with demineralized perforated bone implants from Pacific Coast Tissue Bank. Seventeen months after the initial surgery, there was no evidence of the tumor.

A comparative study of facial growth following lip and palate repair performed in sequence and simultaneously: an experimental study in beagles.

This study was designed to assess the effects of the commonly accepted sequence of cleft lip and palate repair on subsequent maxillofacial growth and to compare these effects with those resulting from simultaneous lip and palate repair. Using 62 eight-week-old normal beagles, we tested the hypothesis that sequential repair (lip first, palate second) of surgically induced lip and palate defects is less detrimental to maxillofacial growth than simultaneous repair of both surgically created defects. Animals were assigned to one of four groups: two control groups (unoperated and unrepaired) and two experimental groups. Defects simulating cleft of the lip, alveolus, and palate were surgically created in the unrepaired controls and in the experimental animals. In one experimental group, the lip and palate defects were repaired immediately and simultaneously. In the other experimental group--simulating current clinical practice--the lip defect was repaired first at the time that it was created, while closure of the palatal defect was delayed 4 weeks. After the animals were killed at 36 weeks of age, 11 maxillary variables were measured directly from cleaned skulls and analyzed by using univariate and multivariate techniques. Animals that had lip and palate defects closed in sequence had less severe maxillofacial aberrations than animals with simultaneously closed defects. Sequential closure of the defects also had identifiable effects on maxillofacial form. The growth aberrations observed among animals with sequential closure, however, are primarily attributable to surgical creation of the defects and not to the surgical repair. Delaying palate repair is less traumatic to the subsequent growth of the maxillary complex than simultaneous repair of lip and palate defects.

Early and late treatment of unilateral cleft nasal deformity.

Surgical techniques have been developed to correct nasal deformity associated with unilateral cleft lip, alveolus, and palate. This deformity can be significantly corrected during the primary cleft lip repair, as performed by the technique described by the author. Secondary corrective procedures focus mostly on skeletal support and lining distortions as well as on rearrangements of lower lateral cartilages. At the final stage, esthetic appearance can be significantly improved by contour remodeling with the addition of cartilage and/or bony implants. Choice of surgical technique depends upon the severity of the deformity and the experience and proficiency of the surgeon. At the present time, correction of the nasal deformity associated with a unilateral cleft is an integral part of primary cleft lip repair and part of multidisciplinary management of cleft deformities.

Demineralized perforated bone implants in craniofacial surgery.

Between July 1990 and September 1991, demineralized perforated allogeneic bone implants (Pacific Coast Tissue Bank, Los Angeles, CA) were placed in 72 patients. Because many patients received more than one implant, a total of 248 implants were used in 80 procedures. The technology of processing demineralized bone implants is described in detail. All patients were operated on by one surgeon (K.E.S.) at the Humana Craniofacial Institute in Dallas, Texas. Forty-one patients had craniofacial deformities, 16 had secondary deformities following cleft lip and palate repair, 8 had bony defects following removal of tumors, and 10 had various skeletal deformities following trauma. Of the 72 patients, 6 had two surgical procedures during which additional implants were inserted. Implants placed in the cranial vault and the maxillary complex, including alveolar grafts, were inlay grafts, whereas implants placed in the orbital, nasal, paranasal, temporal, and malar areas were onlay grafts used for contouring, augmentation, or both. Complications were limited to delayed wound healing in 6 patients. According to our observations, demineralized perforated bone implants represent an encouraging alternative to autogenous bone grafting. Further clinical and experimental studies are necessary to obtain more information about this material.

Growth status of children treated for unilateral cleft lip and palate.

Cephalometric distances, angles, and proportions were evaluated for 32 children 5 to 8 years of age treated for unilateral cleft lip and palate. The children were age and sex matched with untreated controls with normal skeletal relationships. The unilateral cleft lip and palate sample was treated by the same surgeon and orthodontist using the same techniques and appliances. Measures of overall facial proportions, facial convexity, and prognathism were not significantly different between the two groups. The primary group differences pertain to the posterior aspect of the maxilla, which is vertically short in the unilateral cleft lip and palate sample. Horizontally, the maxilla of the unilateral cleft lip and palate children was significantly longer, producing a steeper palatal plane. In addition, the zygoma and orbits of unilateral cleft lip and palate children were somewhat retruded; the posterior cranial base and total mandibular length also were longer in the unilateral cleft lip and palate children.

Lamellar split osteotomy: a new craniofacial technique.

Craniofacial osteotomies have by convention been bilamellar translocations of the entire substance of the dysmorphic bone. This approach limits the surgeon by reducing the stable bone mass available for fixation, creating dependence on concave surfaces. Most important, it changes the bony topography that determines the preoperative plan. This paper presents a new craniofacial concept and technique used in 26 patients with various dysmorphic syndromes who were reconstructed by performing a lamellar split osteotomy. This technique maintains the internal lamella in its native position, thereby allowing it to act as a reference for the bony topography and providing a stable facial framework for rigid fixation. This interlamellar osteotomy has led to improved aesthetic results in the orthomorphic reconstructions of congenital and other deformities. It can be used in any aesthetic patient in whom contour changes or augmentation of form is desired. It is recommended as a preferred method for achieving quantitative contour improvement in patients over 3 years of age.

Bandeau--the focal point of frontocranial remodeling.

Reconstructing the proper balance and harmony of the face begins with the manipulation and positioning of the bandeau. The bandeau or brow is the key architectural component of craniofacial reconstruction. Advancement of the supraorbital bar and forehead can result in functional improvements. This article details the historical development of the surgical procedures available for use in recontouring the forehead. Specific surgical procedures are described and evaluated including the method of removing an unsuitable, unusable bandeau, fashioning a new one from a strip of parietal cranial bone, and repositioning it. The advantages of the bilateral lamellar split bandeau are discussed.

Porous hydroxyapatite as an onlay bone-graft substitute for maxillofacial surgery.

This paper chronicles 3 years of a continuing study comparing porous hydroxyapatite to autogenous bone grafts as onlays in maxillofacial surgery. Twenty-five patients, seen from June of 1984 to May of 1985, underwent onlay augmentation on various maxillary and mandibular locations. A total of 68 onlay augmentation sites comparing Interpore porous hydroxyapatite and autogenous bone were followed for 2 years or more. This long-term study compares these substances in radiologic longevity, histologic incorporation, clinical function, and aesthetic appearance.

Effects of craniofacial deformity in infancy on the quality of mother-infant interactions.

Self-report and behavioral observation procedures were used to assess the quality of mothers' interactions with facially deformed infants. This assessment strategy also provided an opportunity to evaluate the hypothesis that parents of facially deformed infants may deny or be unaware of deficits in their relationships with these children. 10 mothers, 5 with unattractive/craniofacially deformed infants and 5 with normal infants, completed self-report measures of stress, social support, satisfaction with parenting, and general life satisfaction. Mother-infant interactions were videotaped and rated on discrete and global behavioral measures. Results revealed that mothers of deformed infants rated their parental satisfaction and current life satisfaction more positively than did mothers of normal infants. However, these same mothers were observed to behave in a consistently less nurturant manner than mothers of normal children. These results suggest that infant facial deformity/unattractiveness may affect the quality of infant-caregiver interactions without parental awareness.