A conceptual framework for treating jaw deformities in patients with abnormal condyles: preservation versus replacement of the glenoid fossa-disc-condyle-ramus.

This article outlines a conceptual approach to the reconstruction of jaw deformities associated with abnormalities in the mandibular condyle. The authors describe a hierarchy of reconstruction, emphasizing use of the least invasive and progressing to the most complex and invasive techniques, depending on the nature and severity of the underlying deformity, prior operations, patient age, and stage of growth. Consider joint preservation orthognathic surgical correction, followed by biological techniques for replacement of the condyle, and avoid replacing a functional temporomandibular joint based only on radiographic remodeling and concerns about potential future flare-ups of disease based on anecdotal data.

Use of a 'low and short' medial cut limits sagittal ramus osteotomy interferences.

The traditional 'high and short' medial cut of the sagittal ramus osteotomy (Hunsuck modification) is a frequent cause of lingual plate interferences in patients undergoing mandibular yaw or cant corrections. We describe how the modified 'low and short' medial cut of the sagittal ramus osteotomy reduces lingual plate interferences with improved passive alignment of the osteotomy segments.

Method of osteotomy fixation and need for removal following bimaxillary orthognathic, osseous genioplasty, and intranasal surgery: a retrospective cohort study.

The purpose of this study was to determine the incidence and causes of fixation hardware removal after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery. A retrospective study was performed, involving subjects with a bimaxillary developmental dentofacial deformity (DFD) and symptomatic chronic obstructive nasal breathing. At a minimum, subjects underwent Le Fort I osteotomy, bilateral sagittal ramus osteotomies (SROs), septoplasty, inferior turbinate reduction, and osseous genioplasty. The primary outcome variable studied was fixation hardware removal. Demographic, anatomical, and surgical predictor variables were assessed. Two hundred sixty-two subjects met the inclusion criteria. Their mean age at operation was 25 years (range 13-63 years); 134 were female (51.1%). Simultaneous removal of a third molar was performed in 39.9% of SROs. Three of 262 Le Fort I procedures (1.1%) and two of 524 SROs (0.4%) required hardware removal. There were four cases of ramus wound dehiscence, four of ramus surgical site infection (SSI), one of chin SSI, two of maxillary sinusitis, and one of lingual nerve injury; none of these subjects underwent hardware removal. A limited need for fixation hardware removal after orthognathic procedures was confirmed. There was no statistical correlation between hardware removal and patient sex, age, pattern of DFD, simultaneous removal of a third molar, or occurrence of wound dehiscence, SSI, or lingual nerve injury.

Lingual nerve injury in association with sagittal ramus osteotomy and bicortical screw fixation: a review of 523 procedures in 262 subjects.

The purpose of this study was to assess the frequency of irreversible lingual nerve (LN) injury in patients undergoing sagittal ramus osteotomies (SRO) with bicortical screw fixation. A retrospective cohort study of patients treated by a single surgeon was performed (follow-up 2-11 years). The sample consisted of a series of subjects with a bimaxillary dentofacial deformity (DFD). The SRO and bicortical screw fixation techniques were consistent. The primary outcome variable was the prevalence of irreversible LN injury. Two hundred sixty-two subjects undergoing 523 SROs with bicortical screw fixation met the inclusion criteria. Average age at operation was 25 years (range 13-63 years) and there were 134 females (51%). The majority of SROs were fixated with three bicortical screws (92%). Simultaneous third molar removal was done in 209 of the 523 SROs (40%). For primary mandibular deficiency subjects (n=40), the mean mandibular advancement was 11.0mm (range 5-17mm), with 42.5% undergoing counter-clockwise rotation. In the study group (n=523 SRO's) there was one irreversible LN injury (<1%). This study confirmed a lack of association of LN injury at the time of SRO with sex, age at operation, simultaneous removal of a third molar, use of bicortical screw fixation, pattern of DFD, and extent of mandibular advancement.

Osseous genioplasty in conjunction with bimaxillary orthognathic surgery: a review of 262 consecutive cases.

The purpose of this study was to evaluate the results of osseous genioplasty with bimaxillary orthognathic surgery. A retrospective consecutive case series of patients treated by a single surgeon between 2004 and 2013 was studied. All underwent Le Fort I, sagittal ramus osteotomies, septoplasty, inferior turbinate reduction, and osseous genioplasty. The outcome variables included the presenting chin dysmorphology, complications, and assessment of morphologic change. A Steiner analysis was completed for each subject's interval cephalogram. Two hundred sixty-two subjects met the inclusion criteria. Their mean age at operation was 25 (range 13-63) years. Chin osteotomy complications included one wound infection (0.4%), and two of the 1572 mandibular anterior teeth at risk sustained a pulpal injury. None of the subjects required revision. For subjects undergoing chin advancement, the mean change was +3.5 (range +3 to +6) mm. A majority also underwent counterclockwise rotation of the mandible (62%). For those undergoing chin lengthening, the mean change was +5 (range +3 to +12mm) mm, and for those undergoing vertical shortening, the mean change was -3.5 (range -3 to -7) mm. Osseous genioplasty is confirmed to be a safe method to reshape the chin. When osseous genioplasty is performed in conjunction with bimaxillary orthognathic surgery, only a modest horizontal change is required to achieve the preferred pogonion projection.

Occurrence of a 'bad' split and success of initial mandibular healing: a review of 524 sagittal ramus osteotomies in 262 patients.

The purpose of this study was to assess the prevalence of a 'bad' split after sagittal ramus osteotomies (SRO) and report the results of initial mandibular healing. A retrospective cohort study derived from patients treated by a single surgeon at one institution between 2004 and 2013 was performed. An index group consisting of a series of subjects with a spectrum of bimaxillary dentofacial deformities also involving the chin and symptomatic chronic obstructive nasal breathing was identified. The SRO design, bicortical screw fixation technique, and perioperative management were consistent. Outcome variables included the occurrence of a 'bad' split and the success of initial SRO healing. Two hundred sixty-two subjects undergoing 524 SROs met the inclusion criteria. Their average age was 25 years (range 13-63 years) and 134 were female (51%). Simultaneous removal of a third molar was performed during 209 of the SROs (40%). There were no 'bad' splits. All subjects achieved successful bone union, the planned occlusion, and return to a chewing diet and physical activities by 5 weeks after surgery. The presence of a third molar removed during SRO was not associated with an increased frequency of a 'bad' split or delayed mandibular healing.

Syndrome of proximal interstitial deletion 4p15: report of three cases and review of the literature.

We report on two boys and a girl with interstitial deletion in the short arm of chromosome 4 including the segment p15.2p15.33. All had normal growth with psychomotor retardation, multiple minor congenital anomalies, and a characteristic face distinct from that of the Wolf-Hirschhorn syndrome. One of the patients had congenitally enlarged penis. These patients resemble some of the previously reported patients with similar cytogenetic abnormalities and suggests the recognition of a specific clinical chromosome deletion syndrome.

Melanotic neuroectodermal tumor of infancy: clinical, radiologic, and pathologic findings in five cases.

Five pathologically proved melanotic neuroectodermal tumors of infancy are reported. These rare neoplasms of infancy exhibit a distinct predilection for the maxillary bone. Three tumors originated in the maxilla, one in the calvaria, and one in the cerebellar vermis. Those occurring in bone did not metastasize but were locally invasive, as reflected in their radiologic appearance. Bone erosion, expansion, hyperostosis, and osteogenesis can occur in the same neoplasm and were appreciated best on CT. MR imaging showed the soft-tissue component and extent of the neoplasm better than CT did. The pathologic findings from all five cases (and one possibly related melanotic tumor of the face) revealed abundant melanin. MR imaging of two melanotic tumors showed isointense T1-weighted and slightly hyperintense T2-weighted signals. This appearance is contrary to that of most melanin-containing tumors, which exhibit enhanced T1 and T2 relaxation, and indicates that variables other than the absolute amount of melanin may determine the MR signal. Clinically, rapid neoplastic growth and excessive melanin production by the tumor cells caused facial disfigurement and visible blue black discoloration. All five melanotic neuroectodermal tumors were resected and the vermian tumor was also irradiated. Four of five children were well and free from disease 1 month to 7 years after resection. The calvarial tumor was incompletely resected and involved the underlying brain, eventually causing death. The clinical, radiologic, and pathologic features of melanotic neuroectodermal tumors of infancy are reviewed. Melanotic neuroectodermal tumors of infancy that involve bone can be diagnosed from the clinical and radiologic findings. Prompt diagnosis and surgical resection are essential for cure.

Reconstruction of skull defects in children and adolescents by the use of fixed cranial bone grafts: long-term results.

This article presents the long-term results of skull defect reconstruction in a series of 27 children studied between 1986 and 1990 (mean age, 8.4 yr; range, 1-17 yr). Causes of their defects were encephalocele (six patients), trauma (seven patients), tumor (eight patients), fibrous dysplasia (two patients), postsynostectomy defects (two patients), osteomyelitis (one patient), and Reye's syndrome with bone flap loss (one patient). All patients underwent clinical and computed tomographic scan documentation of their skull defects before and immediately after surgery and at least 1 year later. The average preoperative defect surface area measured 33 cm2 (range, 2.5-114 cm2). Skull defects were reconstructed in all patients with fixed autogenous cranial bone grafts. In the initial five patients, the grafts were fixed with interosseous wires, and in the remainder, they were fixed with a combination of miniplates and microplates and screws. Follow-up ranged from 12 to 66 months (mean, 31.4 mo). Complications were minimal, with no infection, plate or graft exposure, or intracranial injuries. In 24 of 27 patients, clinical examination and computed tomographic scans showed no evidence of skull defect or appreciable irregularity of donor or recipient sites. Two patients had documented small regions of graft resorption. One skull had palpable contour irregularities but without a bony defect. All patients have resumed routine activities and sports without special head protection. Repair of skull defects in children with fixed autogenous cranial grafts is a reliable method of reconstruction with minimal morbidity. Although we prefer miniplates and microplates and screws for fixation, the grafts fixed in place with interosseous wires did equally well.

The detection and management of intracranial hypertension after initial suture release and decompression for craniofacial dysostosis syndromes.

We performed a retrospective study of 107 consecutive patients with syndromic forms of craniosynostosis (craniofacial dysostosis) seen by the craniofacial team at the Hospital for Sick Children between 1986 and 1992. There were 51 patients with Crouzon's syndrome, 33 with Apert's syndrome, 8 with Pfeiffer syndrome, 11 with Saethre-Chotzen syndrome, and 4 with kleeblättschadel anomaly. Six patients developed raised intracranial pressure (ICP) after initial suture release and decompression (Apert's syndrome, three patients; Pfeiffer syndrome, one patient; Saethre-Chotzen syndrome, two patients). Raised ICP was considered in those children who returned with a bulging fontanelle, progressive frontal bone protrusion, intermittent headaches, irritability, and vomiting. The diagnosis of raised ICP was based on papilledema (four patients), progressive macrocephaly (one patient), and ICP monitoring (one patient). No child in this group had hydrocephalus requiring cerebrospinal fluid diversion. Once raised ICP was detected in these children, a second operation was immediately performed to reduce the ICP with the intention of expanding the volume of the cranial cavity. The second procedures included: anterior cranial vault and upper orbital reshaping (four patients), posterior cranial vault reshaping (one patient), and total cranial vault reshaping (one patient). There were no perioperative complications in these patients, although one patient showed subsequent recurrence of raised ICP requiring further cranial vault re-expansion. At follow-up, ranging from 3 to 7 years, all six patients were asymptomatic without evidence of raised ICP. In our series, raised ICP occurred in 6% of the children with a craniofacial dysostosis syndrome after initial suture release and decompression.(ABSTRACT TRUNCATED AT 250 WORDS)

Cancer of the floor of the mouth and buccal cavity.

The ability of the surgeon to use the entire armamentarium of reconstructive techniques is essential in head and neck reconstruction. Each modality has its advantages and disadvantages. The decision of which technique to use is, of course, left to the individual surgeon's best judgment. Many new ideas will be explored in the future as the challenge of reconstruction awaits the perfect answer.

Craniofacial dysostosis. Staging of reconstruction and management of the midface deformity.

Crouzon's and Apert's syndromes are the most common of the craniofacial dysostosis syndromes. A team approach is required to achieve effective patient management. The team evaluation begins shortly after birth and follows the patient through infancy, childhood, and adolescence into early adulthood. The role of each team member varies according to the patient's age and individual circumstances. For example, in infancy and early childhood, constant combined reassessment by the pediatrician, neurosurgeon, ophthalmologist, neuroradiologist, and craniofacial surgeon is essential. Later in adolescence, the role of the ophthalmologist, neuroradiologist, and neurosurgeon becomes less important, whereas that of the orthodontist, speech pathologist, maxillofacial surgeon, and psychosocial team becomes more dominant. Major craniofacial centers should be encouraged to develop protocols for patient management and to follow a consistent prospective process of collecting data. Meeting these objectives allows us to learn from the past. During the past decade since the introduction of the modern era of craniofacial surgery by Tessier in 1967, craniomaxillofacial surgery has advanced in many ways: through the use of autogenous cranial bone grafts for onlay or interpositional use; refinements in bone stabilization techniques that include miniplate and microplate and screw fixation rather than direct wires; the reintroduction of creative osteotomies for the management of midface deficiency (monobloc and monobloc bipartition); the development of CT scanning techniques applied to the craniofacial skeleton for both qualitative and quantitative measurement; and the presence of the dedicated craniofacial anesthetist whose meticulous monitoring, airway management, and fluid replacement allows for the safe execution of complex total midface osteotomies. The recognition of the need for a staged surgical approach to the correction of the deformities caused by Apert's and Crouzon's syndromes has clarified reconstructive goals and allowed the surgeon to take advantage of differential craniofacial growth patterns similar to those used to help the patient with congenital cleft lip and palate defects. By continuing to define our rationale for the timing of surgical intervention--for example, using cranial vault surgery in infancy to relieve increased intracranial pressure and papilledema; total midface advancement in childhood to further increase intracranial and orbital volume, improve nasal airflow, occlusion, and body image; and orthognathic surgery in adolescence to improve occlusion, speech, and aesthetics--we can avoid unproductive surgery and select the optimal timing for surgical intervention to maximize long-term functional and aesthetic results.

The craniofacial dysostosis syndromes. Current reconstructive strategies.

The author's preferred approach to the management of the craniofacial dysostosis syndromes is to stage the reconstruction to coincide with the facial growth patterns, visceral (brain and eye) function, and psychosocial development. Recognition for the need for a staged reconstruction approach serves to clarify the objectives of each phase of treatment for the surgeon, the craniofacial team, and the family unit. By continuing to define the rationale for the timing and extent of surgical intervention, then objectively evaluating both functional and morphologic outcomes, surgeons will further improve the long-term function and facial aesthetics for patients born with these complex syndromes.

The craniofacial dysostosis syndromes. Staging of reconstruction and management of secondary deformities.

During the past several decades, since the introduction of craniofacial surgery by Dr. Tessier in 1967, craniomaxillofacial surgery has advanced in many ways. Craniosynostosis is a common craniofacial malformation and requires a thoughtful team approach to select the preferred timing and technical aspects of reconstruction. The current approach to the correction of the deformities associated with the craniofacial dysostosis syndromes is to stage the reconstruction to coincide with facial growth patterns, visceral function, and psychosocial development. Recognition of the need for a staged reconstructive approach serves to clarify the objectives of each phase of treatment both for the clinicians and family. By continuing to define our rationale for the timing, method, and extent of surgical intervention and then objectively evaluating both functional and morphologic outcomes, we will improve the outlook for patients affected by these disorders.

The treatment of secondary and residual dentofacial deformities in the cleft patient. Surgical and orthodontic therapy.

The methods described to manage secondary jay deformities, resulting malocclusion, residual oronasal fistulas, and bony defects in adolescents born with a cleft are safe and reliable when carried out by an experienced cleft surgeon and team. They enhance the patient's quality of life and well-being. They also provide a stable foundation in which final soft-tissue lip and nose revisions may be carried out.

The role of microsurgery in pediatric craniofacial reconstruction.

Great strides have been made in both microsurgery and craniofacial surgery. Situations arise in which practitioners of both disciplines must work closely together to achieve a satisfactory reconstruction for the patient. This unified approach has set the stage for a new era in the treatment of pediatric craniofacial problems.

Surgical management of temporomandibular joint ankylosis in the pediatric population.

The treatment of temporomandibular joint ankylosis requires excision of the involved structures and immediate reconstruction. This paper presents a consecutive series of nine pediatric patients (mean age 7.7 years) who underwent a standardized treatment protocol to 13 affected joints. Four patients had unilateral temporomandibular joint ankylosis, five bilateral. One child required bilateral release but only unilateral reconstruction. Radiographic evidence demonstrated bony ankylosis in a total of 13 joints. Two patients had undergone surgical intervention of the temporomandibular joint before presentation to the authors. Two patients had preoperative temporomandibular joint pain. The cause of ankylosis was primarily traumatic or congenital. Our operative protocol included excision of the involved ankylotic structures through a coronal and Risdon incision, followed by immediate costochondral grafting. Fixation with miniplates and screws allowed for early mobilization. For unilateral patients, maximal incisal opening was improved from 5.4 mm before surgery to 24.8 mm after it, and for bilateral patients, from 6.0 to 17.5 mm. Mean follow-up was 2 years; only one patient was followed for less than 1 year. Pain symptoms were relieved after surgery. Perioperative complications were minimal, with no evidence of infection, facial nerve injuries, or bleeding. Patients with unilateral or bilateral ankylosis of traumatic cause achieved satisfactory functional results after surgery, while those in our bilateral congenital patients were far more limited. Rationales for this divergence in results are presented.

Skeletal stability and relapse patterns after Le Fort I osteotomy using miniplate fixation in patients with isolated cleft palate.

We present a series of 14 consecutive isolated cleft palate patients aged 17 to 25 years (mean 19 years) who underwent Le Fort I maxillary advancement fixed with miniplates by the senior author (Posnick) over the period 1987-1991. Ten of the patients underwent autogenous bone grafting; all were stabilized intraoperatively with four miniplates, a prefabricated acrylic splint, and intermaxillary fixation. The patients were analyzed to determine amount and timing of horizontal and anterior and posterior vertical relapse, correlation between advancement and relapse, effect of a pharyngoplasty in place at time of osteotomy, effect of performing multiple jaw procedures, and maintenance of overjet and overbite. Tracings of preoperative and serial postoperative lateral cephalograms (immediate, 6 to 8 weeks, and 1 year) were analyzed to calculate horizontal and vertical maxillary changes and the amount of overjet and overbite maintained. Clinical follow-up ranged from 1.5 to 5.5 years (mean 2.5 years). No significant difference was seen in vertical or horizontal change or relapse between patients who had maxillary surgery alone (n = 10) and those who had operations in both jaws (n = 4), nor did outcome vary significantly for those who had a pharyngoplasty in place (n = 8) at the time of their Le Fort I osteotomy. The mean "effective" maxillary advancement for the group was 6.4 mm, with 5.4 mm maintained 1 year later (mean relapse 1.0 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

Skeletal stability and relapse patterns after Le Fort I maxillary osteotomy fixed with miniplates: the unilateral cleft lip and palate deformity.

The outcomes of a consecutive series of 35 adults and adolescents judged to be skeletally mature (mean 18 years) who had unilateral cleft lip and palate and had undergone Le Fort I advancement fixed with miniplates were investigated. All patients had received grafts of autogenous iliac bone and were stabilized intraoperatively with four miniplates. The amount and timing of horizontal and vertical relapse, correlation between advancement and relapse, effect of a pharyngoplasty in place at the time of osteotomy, effect of performing multiple jaw procedures, and maintenance of overjet and overbite were analyzed. Tracings of preoperative and serial postoperative lateral cephalograms (taken immediately and at 6 to 8 weeks and 1 year) were analyzed to calculate horizontal and vertical maxillary change and the amount of overjet and overbite maintained. Clinical follow-up ranged from 1.5 to 4.5 years (mean 1.5 years). No significant difference was seen in horizontal or vertical surgical change or relapse between patients who had maxillary surgery alone (n = 24) and those who had operations on both jaws (n = 11), nor did outcome vary significantly for those with a pharyngoplasty in place (n = 13) at the time of their Le Fort I osteotomy (p < 0.05). The mean effective horizontal advancement achieved for the group was 6.9 mm, with 5.3 mm maintained 1 year later (mean relapse of 1.6 mm). The mean effective vertical change of the maxilla was 2.1 mm initially and 1.7 mm 1 year later (mean relapse of 0.4 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

Cleft-orthognathic surgery: complications and long-term results.

We reviewed the complications and long-term results of a consecutive series of adolescents (67 males, 49 females; age range 15 to 25 years; mean 18 years) born with a cleft who underwent primary repair in childhood and later developed a jaw deformity and malocclusion that required orthognathic surgery. Between 1986 and 1992, 116 adolescents with either unilateral cleft lip and palate (n = 66), bilateral cleft lip and palate (n = 33), or isolated cleft palate (n = 17) underwent an orthognathic procedure that included a Le Fort I osteotomy; 32 also underwent simultaneous sagittal split osteotomies of the mandible; and 87 underwent osteoplastic genioplasty. Clinical follow-up ranged from 1 to 7 years (mean 40 months) at the close of the study. The preoperative clinical examination varied according to cleft type and individual variation, but all patients had maxillary hypoplasia. Additional cleft-related deformities included residual oronasal fistula and bony defects, clefted alveolar ridges that retained dental gaps, and mobile premaxilla that lacked union to the lateral segments. Overall, 89 percent of residual fistulas underwent successful closure as part of the orthognathic procedure. Surgical cleft dental gap closure was achieved and maintained to the extent planned at 92 percent of the cleft sites. A fixed (prosthetic) bridge was used successfully for dental rehabilitation to close the gap in all other patients at each cleft site (n = 9). All patients with alveolar clefts (n = 99) maintained keratinized mucosa along the labial surface of the cleft-adjacent teeth (n = 264 teeth). Complications were few and generally not serious. There was no segmental bone loss of teeth because of aseptic necrosis or infection. Only 5 percent of cleft adjacent teeth underwent a degree of gingival recession and root exposure as a result of the maxillary osteotomy procedure; all were retained long term. The long-term maintenance of overjet and overbite measured directly from the late (> 1 year) postoperative lateral cephalometric radiograph indicated that 97 percent of patients maintained a positive overjet and 89 percent maintained a positive overbite; 5 percent shifted to a neutral overbite. The methods used to manage jaw deformity, malocclusion, residual oronasal fistula, and bony defects in adolescents born with a cleft are safe and reliable and offer the patient an enhanced quality of life. They also provide a stable foundation in which final soft-tissue lip and nose revisions may be carried out.