Long-term assessment of early alveolar bone grafts using three-dimensional computer-assisted tomography: a pilot study.

Fifteen patients with complete unilateral cleft lip and palate who had primary alveolar bone grafting were studied with computer-assisted tomography at a mean age of 12 years. Keeping the maxillary alveolar crest parallel to the plane of the scan, 1.5-mm cuts of the maxilla were made from the infraorbital rim to the gingival third of the crowns of the teeth. A single operator reformatted the data into three-dimensional images using the Maxiview 3200 computer workstation. This allowed examination of the position, size, and spatial relationship of the grafted area and quantification of the amount of bone coverage of root surface and bone height of the alveolus in or adjacent to the graft site. Ten patients showed a lateral incisor in the line of the cleft. The average bony coverage of these tooth roots was 76.5 percent. In the five patients in whom there was lateral incisor agenesis, the canine root had average bony coverage of 82.6 percent. The average height of bone at the lateral incisor was 8.7 mm; at the canine, 14.1 mm. In two patients in whom there was only 42 percent tooth root coverage, the teeth were still viable, stable, and without mobility. Computed tomographic (CT) scans of the 15 patients demonstrated good graft survival with adequate volume. The functional and aesthetic status of the dentition in the area of the cleft also was demonstrated.

Comparison of 2-D calculations from periapical and occlusal radiographs versus 3-D calculations from CAT scans in determining bone support for cleft-adjacent teeth following early alveolar bone grafts.

OBJECTIVE: This investigation was conducted to determine the agreement between three-dimensional (3-D) calculations from CAT scans and two-dimensional (2-D) calculations from standard dental radiographs in evaluating bone support for cleft-adjacent teeth after primary bone grafting. DESIGN: This retrospective study utilized CAT scans and dental radiographs taken of the alveolar cleft in patients an average of 11 years after primary bone grafting. SETTING: The subjects were patients treated by the Cleft Palate Team at Children's Memorial Hospital and Loyola University Medical Center, Chicago, Illinois. PATIENTS: Fourteen UCLP patients (9 males, 5 females) agreed to participate in this study by undergoing CAT scan assessment of their alveolar cleft sites. They also had to have periapical or occlusal radiographs of the grafted cleft site taken within 6 months of the CAT scan. INTERVENTIONS: All patients underwent primary lip repair, placement of a passive palatal plate, primary alveolar bone grafting (mean age 6.4 months), and palatoplasty before 1 year of age. Major tooth movement through final orthodontics was completed by the time of the radiographic assessment. MAIN OUTCOME MEASURES: CAT scan sections were reformatted and reconstructed to three-dimensionally calculate the percentage of root covered by bone support for the 15 teeth adjacent to the graft cleft sites. Dental radiographs of the same teeth were also traced and digitized. Percentages of root supported by bone were also established using the dental radiographs by dividing the amount of root covered by bone, by the anatomic root length. RESULTS: A paired, two-sample t test revealed no significant differences between the two methods of assessment, while linear regression showed a statistically significant correlation between the CAT scan assessment and the percentages found on the radiographs. CONCLUSIONS: Routine dental radiographs were able to estimate the total 3-D bone support for the roots of cleft adjacent teeth as determined by CAT scan to a statistically significant degree when groups where compared. The clinical significance for evaluation of individual cases was less impressive with a wide range of variability and a level of agreement that required acceptance of differences up to 25%.

The use of tissue expansion for the treatment of burn scar alopecia.

Tissue expansion is an ideal reconstructive procedure for burn scar alopecia. Donor tissue is generated in situ, allowing for the use of hair-bearing tissue to reconstruct an area of alopecia. The process of tissue expansion results in a redistribution of the remaining hair follicles to replace the area of alopecia.

Primary (early) alveolar bone grafting.

Early primary bone grafting is successful when performed as a separate operative procedure after lip repair and before palate closure. It must be done in conjunction with neonatal orthopedics. The graft is placed only after the alveolar segments have molded and grown to a butt joint. Minimal soft-tissue dissection of the alveolus and maxilla are performed. The graft stabilizes arch form, allows for tooth migration and eruption through its site, and decreases anterior and posterior crossbite. There is no facial growth attenuation, and a good foundation for further soft-tissue growth is provided.

Massive craniofacial injuries from recreational fireworks: a report of three cases.

Recreational rocket injuries can result in massive destruction of facial soft tissues and bone and can produce long-term sequelae. This study reviews the cases of three patients who arrived at our medical center within a 3-week period in July 1990 who sustained severe craniofacial injuries from fireworks. A timely multidisciplinary approach is important in the care of these injuries, since there are usually associated serious ophthalmologic and cranial injuries that require immediate attention. We present the management dilemmas confronting the personnel who treat such injuries as well as tips on avoiding long-term complications.

The Tessier number 5 cleft: a report of two cases and a review of the literature.

Two cases of facial clefts that fit the anatomic description of the rare Tessier number 5 cleft are presented and bring the total number of reported cases to 19. These cases and a review of the literature help define the soft-tissue course of the cleft from just medial to the oral commissure to the junction of the middle and lateral thirds of the lower eyelid. They also emphasize the role of axial CT scanning to define the bony cleft as one passing from just distal to the canine tooth to the orbital rim lateral to the infraorbital foramen. The widespread use of CT scanning and a thorough dental examination of these patients should provide more accurate diagnosis and classification of these clefts.

The case for early bone grafting in cleft lip and palate: a second report.

In 1982, the first long-term study of our early bone-grafting and infant maxillary orthopedic approach to newborn complete clefts of the lip, alveolus, and palate was published. The protocol and sequence of procedures were shown on the first 16 consecutively treated orthodontic patients, with a mean age of 14 years. Cephalometric analysis evaluated anteroposterior and vertical facial growth. This report follows the next 37 consecutively treated individuals in a similar manner and includes not only 20 complete unilateral clefts, but also 17 complete bilateral clefts. Results, when evaluated alone and in comparison with the original series, show once again that there are no adverse growth restraints and that early primary bone grafting in our protocol leads to teeth in better overall occlusion than if it had not been undertaken.

Experience with the functional cleft lip repair.

The first 12 functional cleft lip repairs performed on unselected consecutive patients immediately following the completion of training by the author are presented. Previous reports on this cleft lip repair have shown excellent results but have always been based on patients operated on by the originator of the procedure. This report gives credence to the ease with which a cleft lip repair that gives reproducible good results can be taught and learned even by plastic surgeons with limited experience. It reviews the technical steps of the procedure, which emphasizes wide undermining and release of the orbicularis oris muscle on the lateral side of the cleft to allow redraping and lengthening of the lip skin, step-by-step layered closure of the mucosa, muscle, and skin, and further vertical lengthening of the lip with a Z-plasty skin closure. Three elements that are difficult to achieve or restore with cleft lip revision are evaluated: (1) achievement of a good skin scar, (2) maintenance of the alar-facial groove, and (3) achievement of adequate lip height without sacrificing horizontal lip length. Ten of the 12 patients had a satisfactory scar, 9 patients had a good alar-facial groove, and all patients had a normal-appearing horizontal lip length. Nine patients required secondary surgery; however, in six patients, this included correction of the nasal deformity that was not corrected at the time of cleft lip repair.

Management of burns of the hands in children.

Burns of the hand occur in children when the infant or toddler suffers a scald burn or a contact burn to the palm of the hand. Older children frequently suffer burns from experimenting with matches or gasoline. Although burns of the hand in children are not always as deep as in adults, optimal treatment involves the correct acute management, with skin grafting and proper splinting and physical therapy playing a large role, as well as long-term follow-up due to the excessive scar tissue that may form and the continued growth of the child's hand. The psychosocial needs of the burned child, including an understanding of the nature of child abuse and/or neglect, are also important.

Absorption of onlay bone grafts in immature rabbits: membranous versus enchondral bone and bone struts versus paste.

The absorption of onlay membranous and enchondral bone graft struts and paste was studied in immature New Zealand rabbits using a volume-displacement technique to determine the volume change in the grafts 8 weeks and 21 weeks after grafting. Membranous and enchondral bone paste does not survive as an onlay graft. Both enchondral and membranous bone graft struts undergo significant resorption (78% decreased volume in the enchondral grafts and 50% in the membranous bone grafts). These data support the clinical experience that both types of onlay bone grafts lose significant volume, and are in relative contradistinction to prior animal studies comparing membranous and enchondral onlay bone grafts.

Analysis of the lengthening effect of the muscle repair in functional cleft lip repair.

In 14 patients undergoing functional cleft lip repair, changes in the lengths of the key lip segments were measured preoperatively, after the muscle layer was repaired, and after the skin was repaired using pieces of wire bent to follow the curves of the lip in three dimensions. The cleft side of the lip was shorter than the normal side in the vertical and horizontal dimensions. Freeing the muscle from its dermal insertions, splitting it, and advancing it into the medial side of the cleft lengthened the cleft side of the lip vertically and horizontally. The Z-plasty skin repair further lengthened the cleft side of the lip in the vertical dimension. The lengthening effect of the muscle repair appears to be the result of the loose skin redraping over the dissected muscle and further explains elimination of the orbicularis bulge and superior scar formation in the functional cleft lip repair.

Experience with electrothrombosis in the treatment of angiomas.

We report unsatisfactory results of electrothrombosis for the treatment of venous angiomas. After we reviewed a report of successful use of electrothrombosis for treating cirsoid angiomas of the face and scalp and varices of the leg, a clinical trial was begun with 6 patients in whom previous conventional surgery was relatively unsuccessful and in whom further surgery had not been recommended owing to the high risk or probability of unsatisfactory results. Two patients had objective clinical improvement, resulting in no further treatment in 1 patient and allowing secondary surgical correction in the other. Four patients had no significant improvement. We now recommend and will continue further laboratory research with electrothrombosis for the treatment of angiomas before treating additional clinical cases.

Radiographic analysis of the midface of a stillborn infant with a unilateral cleft lip and palate.

The midface of a full-term stillborn infant with a right complete unilateral cleft lip and palate was studied with plain-film radiography and tomography, xeroradiography, and computerized axial tomography. Gross skeletal and soft-tissue deficiencies on the cleft side were evident as compared to the noncleft side and involved the entire bony maxillary complex and antrum, the orbit, and the nasal pyramid and intranasal structures. The area on the cleft side was 19 percent less than the noncleft side, and the maximal anteroposterior dimension was 16 percent less. The cleft bony palatal shelf was 12.5 mm wide compared to 20 mm on the noncleft side. The findings demonstrate the deficient and abnormal functional matrix inherent in the cleft condition.

Upper and lower lip reconstruction using the step technique.

The step technique for lip reconstruction is a simple, flexible, one-stage operation that allows reconstruction of full-thickness defects spanning up to two-thirds of the lower lip and, in our experience, one-half of the upper lip without violating the opposite lip or using distant advancement flaps. Twelve patients, ranging in age from 24 to 86 years, underwent full-thickness lip excisions for squamous cell and deeply invading basal cell carcinomas. Reconstruction was achieved by advancing the remaining lateral lip elements to close the defects in a stepwise fashion without violating the remaining orbicularis oris muscle. All patients had a symmetrical, mobile, oral sphincter with intact commissures, adequate buccal sulcus, no symptomatic microstomia, and normal sensation at the completion of the procedure. There have been no recurrences in a nine-month to four-year follow-up, and satisfactory aesthetic results were achieved.