Paediatric oral & maxillofacial surgery.

Children have differences in their physiology, anatomy and they are continuing to grow and develop. The management of pathology, trauma, deformity and upper airway obstruction in the young growing patient has to take into account these factors in the treatment planning for these conditions. It is important for Oral & Maxillofacial Surgeons to understand the potential impact of disease or injury on the developing facial skeleton and dentition. This chapter will provide an overview of the some of the major components of paediatric maxillofacial surgery and their management.

Skeletal stability of maxillary advancement with and without a mandibular reduction in the cleft lip and palate patient.

The stability of surgical maxillary advancement in a consecutive series of patients with cleft lip and palate who underwent Le Fort I osteotomy with and without simultaneous mandibular setback surgery was evaluated. Preoperative, postoperative, and follow-up lateral cephalograms of 21 patients were assessed to compare differences in surgical movement and postoperative relapse between two groups: those who underwent maxillary surgery alone and those who underwent bimaxillary surgery. Differences in the number of patients who experienced relapse of <2mm, 2-4mm, and >4mm between the groups were also compared. Mean advancement of the cleft maxilla was 5.5mm in the maxilla only group and 3.6mm in the bimaxillary group, with a mean horizontal relapse of 0.8mm and 0.2mm, respectively. Mean surgical movement in the vertical dimension was comparable in the two groups and the magnitude of vertical relapse was less than 0.4mm overall. Approximately 80% of patients in both groups experienced horizontal relapse of less than 2mm. There was no significant difference in the degree of postoperative relapse between those who had single-jaw surgery and those who had two-jaw surgery.

Odontogenic myxoma in the paediatric patient: a review of eight cases.

Paediatric odontogenic myxoma (OM) is a rare pathological condition in the oral and maxillofacial region. There has been much debate in the literature regarding the preferred method of treatment; however due to the rare nature of this disease, definitive algorithms of management are yet to be determined. A case series of eight paediatric patients with OM is presented. Six of the lesions were in the maxilla and two were mandibular lesions. The patients were aged between 2 and 18 years. Treatment ranged from excision and the application of Carnoy's solution to segmental resection and reconstruction. From this case series it can be seen that even in situations where treatment was limited to excision and the application of Carnoy's solution, no recurrences occurred. As such the present authors favour an initially more conservative approach to the management of these lesions where possible and reserving conventional resective treatment for recurrences, lesions causing pathological fracture, and those in regions that are difficult to access.

Isolated orbital floor fractures in the paediatric patient: case series and review of management.

Orbital injuries warranting surgical intervention are infrequent in the paediatric population, but 'blowout, trap door' fractures are unique in children and may constitute a relative surgical emergency. A retrospective review of isolated orbital floor fractures at the Royal Children's Hospital of Melbourne over a 10-year period was undertaken to evaluate the outcome of those patients who required surgical exploration. Twenty-two patients with documented isolated orbital floor injuries were studied. Preoperative signs and symptoms including diplopia, ocular motility, paresthesia, enophthalmos, hypoglobus, and the presence of nausea and vomiting were recorded. Thirteen patients underwent non-surgical management and nine patients underwent surgical exploration of the orbital floor via a trans-subconjunctival approach to reduce any entrapped soft tissue. Postoperative follow-up of these patients varied between 1 month and 18 months and none had any visual disturbance or diplopia in central gaze; however, two patients experienced diplopia in upward gaze at follow-up, although this did not impair the quality of life. Due to the risk of permanent soft tissue damage from the entrapment of the periorbita with or without extraocular muscle tissue, it is recommended that exploration be undertaken as soon as possible to minimize the risk of persistent diplopia due to impaired ocular motility.

Skeletal stability following maxillary impaction and mandibular advancement.

The purpose of this study was to retrospectively evaluate the stability of combined Le Fort I maxillary impaction and mandibular advancement performed for the correction of skeletal Class II malocclusion. Twenty-nine patients, mean age 22.6 years, underwent bimaxillary surgery with rigid internal fixation. Standardised cephalometric analyses were performed using serial lateral cephalometric radiographs. The post-surgical follow-up was a minimum of 12 months, with a mean of 25.2 months. The maxilla was impacted by a mean of 4.3 +/- 3.3 mm, and horizontally advanced by a mean of 2.6 +/- 2.3 mm. The results demonstrated that the maxilla tended to move anteriorly and inferiorly but this was not significant in either horizontal or vertical planes (P > 0.05). The mean advancement of the mandible, at menton, was 10.7 +/- 5.6 mm, and in 14 cases (48.2%) menton was advanced greater than 10 mm. In 34.7% of the patients the mandible underwent posterior movement between 2 and 4 mm. In the vertical plane, gonion moved superiorly by a mean of 2.7 +/- 3.6 mm which was significant. Significant mandibular relapse was found to have occurred in five female patients, with high mandibular plane angles who had undergone large advancements of greater than 10 mm. In conclusion, the majority of patients undergoing bimaxillary surgery for the correction of skeletal Class II malocclusions maintained a stable result. However, a small number of patients, exhibiting similar characteristics, suffered significant skeletal relapse in the mandible secondary to condylar remodelling and/or resorption.

Canine eruption into grafted alveolar clefts: a retrospective study.

BACKGROUND: The contemporary treatment of cleft lip and palate involves a sequence of surgical procedures and orthodontic management. Alveolar bone grafting (ABG) is usually undertaken after orthodontic expansion of the maxillary segments between the ages of eight and 12 years. Two of the important goals of alveolar bone grafting are the provision of bony support for the eruption of the canine and the closure of residual oro-nasal fistulae. The purpose of this study was to retrospectively evaluate the root development and eruption of the canine following ABG. METHODS: Group 1: radiographic and clinical records of a sample of 19 cleft patients who underwent alveolar bone grafting procedures, performed between 1996 and 1999 were reviewed. Group 2: a random sample of 15 cleft patients attending for routine dental review were clinically examined. The age of patient, degree of root development and eruption status of the canine, and presence of oronasal fistulae pre and post alveolar bone grafting were evaluated. RESULTS: Most cleft canines had continued root development and descended in the alveolus towards eruption following ABG. Four canine teeth (8 per cent) were impacted and required surgical exposure and orthodontic treatment following failure of eruption. Closure of anterior oro-nasal fistulae at the time of grafting was maintained post-operatively. CONCLUSIONS: This study demonstrated that canine root development and eruption continued satisfactorily through grafted alveolar clefts in most cases and closure of anterior oro-nasal fistulae was achieved in all cases.

Juvenile mandibular chronic osteomyelitis: a distinct clinical entity.

Sclerosing osteomyelitis of the mandible is an uncommon disease of unknown aetiology. A series of eight female children (6 to 12 years old) with a distinct mandibular inflammatory disease were studied. Each presented with pain and a recurrent soft tissue swelling overlying a predominantly unilateral mandibular enlargement. On imaging, this deformity demonstrated a mixture of patchy sclerosis and radiolucency. A raised erythrocyte sedimentation rate was the only consistent serological finding. Treatment varied from symptomatic control with non-steroidal anti-inflammatory medication, to surgical management that included decortication and contouring and, in one case, resection with reconstruction. A potential protocol for treatment of this disease is given. The early age of onset of the disease process and the uniformity of the features distinguish this condition from other groups of disorders that, previously, have been collectively designated as chronic diffuse sclerosing osteomyelitis. It is proposed that this inflammatory disease of mandibular bone, in the paediatric patient, should be regarded as a separate clinical entity: 'juvenile mandibular chronic osteomyelitis'.

Allogeneic bone grafting of calvarial defects: an experimental study in the rabbit.

The purpose of this study was to investigate the incorporation of fresh frozen irradiated membranous allogeneic bone grafts into critical size calvarial defects in the rabbit. Fifteen rabbits had calvarial defects prepared. Twelve rabbits received allogeneic grafts and three received autogenous bone grafts. The rabbits were sacrificed at 9 and 12 months postoperatively, and the specimens were examined radiologically, histopathologically and with fluorescence microscopy. Neovascularization, bone marrow regeneration and new bone formation was evident throughout the grafts however revitalization of the entire graft was incomplete at 12 months. This study revealed that the FFI membranous grafts were well incorporated into rabbit calvarial defects.

Ascending necrotising fasciitis as a result of odontogenic infection: a report of two cases.

Necrotising fasciitis is a severe soft tissue infection which spreads rapidly through fascial planes, is characterised by soft tissue necrosis and is potentially life-threatening. It is a rare entity in the head and neck region. The management of this condition is difficult and early diagnosis and aggressive surgical and medical management are essential. This paper reports two cases of necrotising fasciitis as a result of ascending odontogenic infection involving the temporalis muscle.

Use of a resorbable fixation system in orthognathic surgery.

We present our early experience with the use of a resorbable plating system in orthognathic surgery. Thirty-one patients who have finished growing and who had dentofacial deformities that were not part of syndromes were treated by routine orthognathic repositioning procedures: maxillary (n = 8) and mandibular (n = 9) osteotomies, or bimaxillary procedures (n = 14). All skeletal fragments were fixed with resorbable plates and screws. The follow-up period ranged from 2-8 months (mean 5). All the patients recovered normally except for one who developed a localized buccal space infection. In the early postoperative period, six patients had mild mobility of the maxilla, but stability was within normal limits at six weeks postoperatively. We conclude that, though technique has an important influence on success, LactoSorb is a good fixative for maxillo-mandibular repositioning.

Maxillofacial injuries at the Royal Children's Hospital of Melbourne: a five year review.

There are important differences in the incidence and nature of facial injuries between the paediatric and adult population. While some of the aetiological factors and principles of management are similar, important differences exist in the treatment of growing patients. This study reviews maxillofacial trauma managed at the Royal Children's Hospital of Melbourne between 1995 and 2000.

Juvenile ossifying fibroma of the midface.

Juvenile ossifying fibroma is an unusual maxillofacial fibro-osseous lesion characterized by cell-rich osteoid strands. A 7-year-old girl presenting with a massive juvenile ossifying fibroma of the maxilla resulting in facial deformity, orbital displacement, and extension into the anterior skull base is discussed. The importance of combining clinical, radiographic, and histopathological findings for the diagnosis and management of the tumor is discussed.

The use of bone grafts and substitutes in the craniomaxillofacial region.

Craniomaxillofacial defects arise from congenital abnormalities or are acquired following trauma or ablative surgery. Various bone grafting techniques have been developed for application in the facial skeleton to assist in the reconstruction of small alveolar deficiencies to more complex, extensive bony defects. Autogenous grafts from different sites vary in volume, stability and contour characteristics. The introduction of allogeneic grafts has further increased the possibilities for hard tissue replacement as have alloplastic substitutes which have been used successfully. Recent advances in bone regeneration in the maxillofacial region using distraction osteogenesis and the recent advent of cell culture techniques have introduced new therapeutic approaches that will provide the foundation for a significant shift in the approach to reconstructive surgery of the facial skeleton.