Advancement of the midface, from conventional Le Fort III osteotomy to Le Fort III distraction: review of the literature.

Since its introduction in about 1950, the Le Fort III (LF III) procedure has become a widely accepted treatment for correction of midface hypoplasia and related functional and esthetic problems. As long-term surgical experience grows and improvements are made in technique, equipment and peri-operative care, the number of LF III procedures performed worldwide is increasing. A number of fundamental questions concerning the technique remain unclear, and large, conclusive studies are lacking owing to the relative rarity of severe midface hypoplasia. This literature review aims to address problems, such as the indication field, timing of surgery, rate of relapse and the use of distraction osteogenesis. An overview of the history and technique of LF III osteotomy and distraction is provided, together with a comprehensive review of the available clinical data.

Recombinant human erythropoietin alpha modulates the effects of radiotherapy on colorectal cancer microvessels.

Recent data suggest that recombinant human erythropoietin (rhEPO) modulates tumour growth and therapy response. The purpose of the present study was to examine the modulation of radiotherapy (RT) effects on tumour microvessels by rhEPO in a rat colorectal cancer model. Before and after 5 x 5 Gy of RT, dynamic contrast-enhanced -magnetic resonance imaging was performed and endothelial permeability surface product (PS), plasma flow (F), and blood volume (V) were modelled. Imaging was combined with pO(2) measurements, analysis of microvessel density, microvessel diameter, microvessel fractal dimension, and expression of vascular endothelial growth factor (VEGF), hypoxia-inducible factor-1 alpha (HIF-1alpha), Bax, and Bcl-2. We found that RT significantly reduced PS and V in control rats, but not in rhEPO-treated rats, whereas F was unaffected by RT. Oxygenation was significantly better in rhEPO-treated animals, and RT induced a heterogeneous reoxygenation in both groups. Microvessel diameter was significantly larger in rhEPO animals, whereas VEGF expression was significantly lower in the rhEPO group. No differences were observed in HIF-1alpha, Bax, or Bcl-2 expression. We conclude that rhEPO results in spatially heterogeneous modulation of RT effects on tumour microvessels. Direct effects of rhEPO on neoplastic endothelium are likely to explain these findings in addition to indirect effects induced by increased oxygenation.

Arthrography of the temporomandibular joint: pictorial essay.

Although arthrography of the TMJ is nowadays considered as old-fashioned, the technique remains a valuable alternative in cases where MRI is contraindicated. The authors discuss the technique of inferior joint space arthrography and present a review of typical arthrographic cases of the most common types of TMJ pathology.

[Importance of diagnosis in facial pain]. / Het belang van de diagnostiek bij facialgieën.

The diagnosis and treatment of facial pain remains a great challenge for oral and maxillofacial surgeons. By taking an exact anamnesis--especially a pain anamnesis--and by starting specific examinations the patient can quickly be recommended to a qualified therapist. The pain syndromes are classified according to the IASP (International Association for the Study of Pain). The pain syndromes the maxillofacial surgeon is most frequently confronted with--idiopathic trigeminal neuralgia, atypical facial pain and the temporomandibular joint--are described. The necessity of a multidisciplinary examination is emphasized and the different diagnostic investigations are illustrated, particularly in the case of myo-arthropathy. Beside the analysis of temporomandibular joint dysfunction, a radiologic examination is performed. In some cases the advise of a neurologist, ophthalmologist or otolaryngologist may be indicated.

Arthro-CT in detecting sideways displacement of the temporomandibular joint disk.

One of the major disadvantages of sagittal arthrotomography of the temporomandibular joint is its limited capability to detect sideways (medial or lateral) disk displacement. Several arthrographic signs, suggesting sideways disk displacement have been described in recent reports. The most important one is the edge sign. In doubtful cases, arthro-CT can be used for depiction of medial or lateral disk displacement.

Arthrographic imaging of post-traumatic temporomandibular joint disorders.

Clinical, arthrographic and surgical findings in 20 patients who showed persisting TMJ-pain or dysfunction after an acute traumatic event were reviewed and compared to findings in a control group of 65 patients who did not remember an acute post-traumatic onset of symptoms. Anterior disk displacement (82%), disk perforation (65%) and rotational anteromedial disk displacement (34%) were the most common abnormalities encountered. Other important abnormalities were joint adhesions and capsule perforation. When compared with the control group, all these abnormalities occurred more often in traumatised joints. Arthrography was found to be highly accurate in detecting most types of abnormalities found during surgery. Arthrography is reported to be more effective than MRI in detecting disk perforations, adhesions and capsule perforations, which points to its continuing importance as an imaging tool for evaluating post-traumatic temporomandibular joint disorders.

[Technique and interpretation of arthrography of the temporomandibular joint. Study of 120 cases]. / Techniek en interpretatie van arthrografieën van het temporo-mandibular gewricht. Studie van 120 gevallen.

The goal of the study was to assess the predictive value of inferior joint space arthrography for detection of abnormalities found during surgery. Therefore, a retrospective analysis of arthrographic and surgical findings in 120 joints was performed. Arthrography showed high accuracy for detection of anterior disk displacement (90%) and disk perforation (90.8%). The shape of the anterior recess proved to be the most valuable arthrographic criterium for detection of anterior disk displacement. Cinematographic registration of joint dynamics after injection of contrast material and arthrotomographic analysis of the shape of the superior margin of the anterior recess of the inferior joint space were necessary for an optimal evaluation of the disk position.

[Peri-orbital surgical approaches]. / Operatieve toegangswegen tot de peri-orbita.

After having made a definitive diagnosis in patients with orbito-frontal pathology, the choice of incision is an important factor to achieve good intra-operative exposure of the region, as well as to obtain a good functional and aesthetic result. In the majority of cases we prefer to utilize the incisions commonly used for blepharoplasty, especially the transconjunctival approach popularized by Tessier. Other more classic accesses such as the superolateral, infra-orbital and intra-oral incisions, are reserved for treatment of cases of orbitomalar (communition) fractures. We feel there are limited indications for use of incisions through the eyebrows with medial extensions for exposure of isolated lesions of the medial orbital wall, orbital roof, and the anterior wall of the frontal sinus. However they may become very useful as the primary incisions in the treatment of open fractures of the orbital region. The bicoronal incision, a classical approach in neurosurgery, is also being used by us in cases of tumors and complicated middle face fractures which appear to extend to the orbito-frontobasal region in 40% of our patients. In addition it provides excellent access for post-traumatic reconstruction of orbito-frontal bone defects and impacted fractures. A combination of different incisions: bicoronal, peri-orbital and intra-oral, may be indicated for the correction of syndromal anomalies such as Treacher-Collins, for treatment of complicated facial fractures, or for pure aesthetic surgery procedures, such as the "mask-lift" introduced by Tessier.

[Pedicled facial bone flap for closure of the approach in Caldwell-Luc type sinus operations. Its role in the prevention of postoperative complications]. / Het gesteeld faciale botdeksel ter afsluiting van de toegang bij sinus-operaties type Caldwell-Luc. Rol bij de preventie van post-operative complicaties.

The primary or secondary reconstruction of the facial access after Caldwell-Luc and the more selective resection of sinusal mucous membranes can be important in the therapy and prevention of postoperative complications such as neuralgic facial pain, formation of cysts and chronic sinusitis. The different osteoplastic sinus operations are described and the use of a pedicled bonelid is illustrated. The most common accepted ethiology of post-operative pain is based on the formation of scar-tissue. Postoperative pain is first being treated conservatively, while in case of persisting pain an exploration with dissection of the infra-orbital nerve and reconstruction of the facial defect can be indicated. In a retrospective study of 36 patients the results of our surgical therapy are illustrated.

[Complications of orbito-frontobasal fractures]. / Complicaties van orbito-frontobasale fracturen.

Complications of fronto-basal trauma can, as a function of their severity, be divided into three classes: life-threatening situations, functional complications and cosmetic defects or facial deformities. They find their origin in the type of trauma, the extent of the lesions of bone and soft tissues, as well as in their timely management and quality of treatment. The etiology of the most common complications and their significance are covered with accent on inadequate primary treatment, insufficient repair of dural lesions, inadequate drainage, unstable osteosynthesis, insufficient treatment of scalp- and frontal defects, and finally the lack of antibiotic prophylaxis. The major complications of frontobasal trauma such as chronic cerebral spinal fluid fistulae and pneumocephalus are reviewed. Attention is also given to the importance of adequate drainage in cases of chronic ethmoidofrontal sinusitis, and on the treatment of osteomyelitis and sinus cysts. The therapeutic possibilities in patients with tissue deficits, i.e. reconstruction of frontal skull defects using autologous hip and rib material, as well as split calvarial bone grafts is discussed.

Aesthetic maxillo-facial surgery: face lifting and S.M.A.S.

The article illustrates the importance of face lifting and S.M.A.S. tightening as an adjunct to the aesthetic aspect of maxillo facial surgery, for instance in combination with extreme mandibular set back or advancement in adults. The theory and basic techniques of the face lifting procedure and the S.M.A.S. tightening technique are described. A clinical example is presented. The indications pre- and postoperative management and complications have been mentioned.

Submental liposuction in maxillo-facial surgery.

Liposuction is a relatively recent surgical technique used in body contouring plastic surgery to correct fatty dysharmonies. It is of particular interest to the maxillo-facial surgeon to treat submental fat excess. This relatively easy technique is described, using a few clinical examples. Indications in maxillo-facial surgery are the correction of "double chin" deformity and increased submental fullness after orthognathic surgical procedures as mandibular setback, as well as an adjunct to rhytidectomy.

[Role of arthrography in imaging of the temporomandibular joint in 1992]. / De plaats van de arthrografie in de beeldvorming van het temporomandibulair gewricht anno 1992.

In this text we briefly want to discuss the role of the arthrographic examination of the temporomandibular joint for detection of disc pathology. We will mention the normal anatomy and function of the temporomandibular joint, the technique for performing arthrograms and the classification of the most frequent disc pathology. This will be illustrated by some arthrographic examples of anterior disc displacement without reduction, disc perforation, and medial disc displacement. Finally the advantages of arthrography in comparison with other investigation techniques will be discussed.

[Treatment concept of facial pain]. / Behandelingsconcept van facialgieën.

The therapy of chronic facial pain still poses an important challenge. A therapeutical scheme in four steps has been developed. This scheme enables modification of the pain therapy depending on localisation, intensity and former treatment. It consists of the following steps: 1. Transcutaneous electrical nerve stimulation. 2. Medication 3. Extracranial glycerol blocking of the trigeminal nerve 4. Neurosurgical treatment with thermocoagulation, chemical glycerol-rhizotomy and microsurgical decompression. The different therapeutical steps have no influence on each other.

Current diagnosis and therapy of parotid tumours.

After reviewing a group of more than 400 patients with parotid tumours, we feel that clinical examination, screening ultrasound scanning and pre-operative CT-scan are our most important diagnostic tools. Our treatment concept is based on direct posterior dissection of the main trunk of the facial nerve, total conservative parotidectomy with ablation of all glandular tissue especially in pleomorphic adenomas so that recurrency can be avoided, intra- and postoperative histological examination and filling in the post-operative soft tissue depression in all cases where intra-operative histological examination excludes malignancy. Primary post-parotidectomy defect substitution techniques using the platysma (Roscic) and the sternocleidomastoid muscle (Rausch) as well as a SMAS- and temporoparietal fascia- or galea-flap are illustrated. We currently use the combination of the Rauch- and Roscic- techniques in a way that a sternocleidomastoideus muscle rotation-flap together with a platysma-SMAS-fat-flap entirely cover the defect. We believe that the substitution-plasty, primarily performed for aesthetic reasons, acts as a mechanical barrier for the misdirected regeneration of the nervs to the skin and the sweat glands, and thus tends to avoid Frey's Syndrome. Using our technique concept, we feel that any disadvantage is counter-balanced by the absence of recurrences, no permanent facial paralysis, relatively good aesthetic results and lower incidence of Frey's Syndrome.

Somato-sensory evoked potentials in facial pain diagnosis.

This study analyses the possibilities of somato-sensory evoked potentials following trigeminal stimulation in order to classify pain sensations provoked by the trigeminal nerve. 43 patients suffering from trigeminal neuralgia, atypical facial pain and from pain due to carcinoma were investigated. Pain sensations correlated with the responses of the evoked potentials--usually with increased latencies. However, it was not possible to point out specific correlative pathological peaks for individual diseases. Therefore, the judgement of TSEP alterations requires knowledge of each patient's clinical symptoms.

[Priorities and treatment principles in maxillofacial trauma]. / Prioriteiten en behandelingsprincipes bij maxillo-faciale traumata.

The outline of therapeutic priorities in case of maxillo-facial traumatism may be divided in three different stages according to the need of acute urgent, urgent and necessary intervention. Acute urgent therapy is called for when the bleeding of the arteria carotis externa or the maxillary artery cannot be quenched or when the superior airways are obstructed by the soft tissues of the tongue or the floor of the mouth. A description of the therapeutic attitude in such cases is given. Urgent therapy should be given within 8 hours after the accident and mostly consists in the immobilisation of bony injuries and definite care of soft tissue lacerations. Necessary therapy includes the final surgical treatment such as osteosynthesis by titanium mini-plates. More specific problems like frontobasal fractures and fractures of the orbital floor are described separately.

[Differential indications for the surgical management of fractures of the mandibular condyle]. / Differentiaal-indicatie voor operatieve verzorging van collum mandibulae-fracturen.

The frequency and importance of collum mandibulae fractures is indicated, especially in connection with the sequels of conservative-functional therapy, and the different classifications and types of fractures are described. The non-surgical approach is evaluated as a treatment. Its inconvenient and sometimes unsatisfactory results necessitate the surgical treatment of certain types of collum mandibulae fractures. Absolute en relative indications for osteosynthetic treatment of condylar fractures are noted, the proposed surgical technique is discussed. The importance of a universal preauricular incision continued in an incision for parotidectomy and resulting in a standard incision or a combined preauricular-submandibular incision, is pointed out. Surgical technique for intra and extra capsular collum fractures is illustrated. Our preference goes to functional stable osteosynthesis using titanium mini-plates and the often obligatory dissection of the facial nerve. The so called "condylar shave" or remodelling condylotomy in analogy with the DAUTREY-operation is a therapeutic contingency in case of bilateral collum mandibulae fractures with unilateral low condylar fracture where classical mini-plate osteosynthesis is done, and intracapsular multi-fractured condylar head on the other side where the condylar shave or rubble clearing is performed The attitude towards children is discussed. The result of this surgical technique is illustrated through the follow-up of 73 surgical treatments of collum fractures in 59 patients. We conclude that surgical osteosynthetic treatment of collum mandibulae fractures with a strict indication in case of dislocated and luxated fractures should be included in the therapeutic range of modern maxillo-facial traumatology.