New Technique for Mandibular Symphyseal Distraction by a Double-Level Anchorage and Fixation System: Advantages and Results.

INTRODUCTION: A surgical technique to widen the mandible is the mandibular midline distraction: the most common indications for mandibular midline distraction are severe mandibular anterior crowding, severe mandibular transverse deficiency, uni- or bilateral crossbite, impacted anterior teeth with inadequate space, and tipped teeth. Commonly used distraction devices can be divided into 2 systems: bone-borne distraction system appliance, dental-borne distraction systems. Each system has peculiar advantages, disadvantages, and different indications. To combine advantages of both systems we developed a new technique adopting an immediate basal bone widening with fixation after osteotomy and a dental borne rigid lingual system for distraction. AIM: The aim of this work is to show a new technique for symphysis mandibular distraction based on a double-level anchorage and fixation system on clinical patients showing final results and advantages. METHODS: Two patients affected by dento-alveolar and basal bone maxillary and mandibular transversal collapse even in association with other skeletal malocclusion were selected. Patients were clinically and radiographically studied and analyzed at different times before and after surgery. Dental and basal bone measurements were performed clinically and radiographically. RESULTS: The results were optimal with perfect dental arches alignment followed by closing of the open bites with multiple-segmented surgery in a second surgical time. No misalignment of the 2 mandibular halves was noticed during the distraction procedure. DISCUSSION: Dental-bone discrepancies correction is mandatory before orthodontic treatment alignment. Transversal jaw expansion can be achieved safely and stably by distraction of both maxillae for the combination of osteogenesis and histogenesis with augmentation of both bone and soft tissue. Bone-borne distraction will result in more stable results; dental-borne devices will result in more simple and aesthetically rewarding procedures. Hybrid techniques usually show mixed results depending on the characteristics of the device. For this reason we developed a combination of both the aforementioned systems which is not a hybrid system but the combination of an immediate expansion of the symphysis and fixation by 1 miniplate with only 2 screws acting like hinges during distraction, combined with a lingual distraction system at the alveolar bone level. CONCLUSIONS: Bone-borne distraction systems result in more efficient basal bone mandibular widening with increased stability for dental results. For dental-borne appliance the advantages consist in no second surgery need for their removal, no transmucosal hardware emergence and better aesthetic, especially when lingual devices were used. Our technique combines advantages of both procedures.

Modified forked flap for controlling columella length in cleft lip open rhinoplasty.

BACKGROUND & PURPOSE: Suturing the columellar flap after open rhinoplasty often reduces the tip projection gained, especially in patients with cleft lip deformity, in whom the columella is usually short and inelastic. A modification of the classical forked flap is proposed for controlling the tension created by the columellar suture. PATIENTS: Five patients aged from 17 to 35 years underwent surgery in the previous 2 years using the described techniques. METHODS: The columella incision followed the classic tepee shape, although the inverted V was extremely narrow and long, with its arms extending beyond the columellar rims, stopping at the base of the vestibule, then making acute angles and heading vertically towards the nostril tip, and continuing into the nostrils as normal marginal incisions. Consequently, a complete "W" was used, in which the lateral angles and arms lay in the nostrils, while the central inverted V was in the columella. The rhinoplasty was performed as planned and a triple "V-Y" suture was made. RESULTS: The technique provided real lengthening of the columella or, at least, it closed the columellar incision without tension, thereby preserving the tip projection. CONCLUSIONS: In open rhinoplasty on patients with cleft lip involvement a triple V-Y columellar suture preserves the surgically obtained columella length.

Zygomatic fractures: Technical modifications for better aesthetic and functional results in older patients.

INTRODUCTION: The zygomaticomaxillary complex, with its intrinsically prominent convexity, is highly vulnerable to injury. In this study, we evaluated a novel combined approach to the reduction and stabilization of frontozygomatic dislocated fractures without aesthetic damage. MATERIALS AND METHODS: Ten patients (mean age, 52 years) were referred for complex frontozygomatic dislocated fractures. Five patients underwent a transconjunctival approach without canthotomy in association with a transoral maxillary approach and lateral-rim skin incision, also without canthotomy. The other five patients underwent a traditional subciliary incision at the lower eyelid and a vertical lateral incision at the lateral orbital margin. Orbital floor reconstruction was achieved using two to three fixation points and autologous platelet-rich fibrin (PRF). During the 6-month follow-up, the patients were routinely evaluated using computed tomography. RESULTS: Treatment was successful in all cases; there were no problems at surgery or postoperatively. During follow-up, all patients had satisfactory facial symmetry, no noticeable scar, ectropion, or lower-eyelid drop, and no functional impairment. DISCUSSION: Aesthetic considerations are an important aspect of treatment planning in patients with orbitozygomatic fractures, because of the importance of the eye and lid areas to facial aesthetics. In our patients, good aesthetic results were achieved using a novel combined approach. In patients with a large orbital floor dislocation, the reconstructive titanium mesh can be covered by autologous PRF membranes to improve vascularization of the surgical site. By preventing aesthetic damage and functional impairment, our conservative approach is of particular utility in older individuals due to age-related tissue laxity.

Extreme mandibular dentobasal discrepancy in orthognathic surgery: a proposal for a definitive solution.

Some cases in orthognathic surgery present with large discrepancies between the skeletal pattern and the occlusion. If there is little or no sagittal dental discrepancy, but the mandibular basal bone is prognathic, surgical correction can be critical. We describe a two-step procedure to treat these patients. The first step is to adapt the lower alveolar bone to the position of the chin. Distraction osteogenesis in the anterior dentoalveolar mandibular region carries the lower incisors to the same level as the chin. A one-tooth space is opened in the distraction area to obtain a full negative over-jet. Bimaxillary osteotomy can be used to correct class III dentoskeletal malocclusion. Five patients aged 20-40 years have been operated on during the last 2 years. The first step creates harmony between the chin and lower lip, together with a negative over-jet and a true prognathic profile. The class III malocclusion is corrected with a bimaxillary osteotomy. Our two-step plan achieves good occlusion and profile in patients with severe discrepancies between their occlusion and the position of the chin. Dental implants can then be inserted into the gaps left by distraction, which results in a third bicuspid on each side of the mandible.