Surgical Algorithm for Alveolar Bone Augmentation in Implant Dentistry.

Replacement of failing and ailing natural teeth with dental implants has become a mainstream treatment option since the discovery of osseointegration by P.-I. Brånemark in the 1960s. The techniques and the variety of methods for alveolar bone reconstruction have evolved to address a restoratively driven approach in implant dentistry. Modern 3D cone-bean computed tomography has helped with the diagnosis and treatment of bone deficiencies to idealize implant positioning. This article focuses on bone augmentation techniques, classified into horizontal and vertical ridge augmentation, and discusses block grafting, guided bone regeneration particulate grafting, distraction osteogenesis, and ridge-split expansion procedures.

Implant Treatment after Sagittal Splitting Ramus Osteotomy and Alveolar Ridge Augmentation in Patient with Mandibular Prognathism and Multiple Missing Maxillary Teeth.

An abnormal maxillomandibular ridge relationship frequently hinders oral implant treatment in patients with jaw deformities. Here, we describe a patient who was experiencing difficulty using dentures due to multiple maxillary tooth loss and mandibular prognathism. Treatment comprising sagittal splitting ramus osteotomy and alveolar ridge augmentation using bone grafts harvested from the mandibular ramus followed by implant treatment yielded good outcomes. The patient was a 47-year-old woman presenting with an unstable upper partial denture. Although prior prosthetic treatment for mandibular prognathism had resulted in normal overbite, she had since lost an increasing number of teeth due to advanced periodontal disease, impairing support for the denture. She was referred to the Department of Oral Implantology at the Tokyo Dental College Chiba Hospital in October 2008. Subsequent treatment comprised implant treatment following maxillary alveolar ridge augmentation and sagittal splitting ramus osteotomy to correct the maxillary-mandibular relationship. In January 2010, sagittal splitting ramus osteotomy and alveolar bone augmentation using a bone graft from the mandibular ramus were performed under general anesthesia. In July and August 2010, a total of 7 implants were placed in the maxilla and implant superstructure preparation started after 3 months. Taking both the patient's wishes and ease of maintenance into account, retrievable superstructures made of Auro Galvano Crown were fitted in April 2011. The jaw-to-jaw alveolar ridge relationship was improved by sagittal splitting ramus osteotomy, rendering subsequent treatment, from implant placement to superstructure preparation, feasible by conventional methods. The use of surplus bone generated during sagittal splitting ramus osteotomy for bone augmentation avoided the need to harvest bone from another area.

[On the history of the problem of the rehabilitative treatment of the subjects suffering wounds in the maxillofacial region with the concomitant disorders of the speech function]. / K istorii voprosa o reabilitatsii cheliustno-litsevykh ranenykh s narusheniem rechevoi funktsii.

The authors made an attempt to highlight the issues of rehabilitation of the patients suffering wounds in the maxillofacial region with the concomitant disorders in the function of the organs of speech. The secondary objective of the study was to prove that rehabilitation of such patients is possible only by means of the joint efforts and close cooperation of dentists, physiotherapists, and speech therapists. The results of the clinical observations of the most severe cases of the impaired speech function obtained in the evacuation hospitals have been considered, with the special emphasis placed on the leading role of the speech therapist in the rehabilitation of such patients. A scheme of therapeutic physical exercises and speech therapy is presented that includes the correction and development of respiration. The guidelines are proposed for the breathing exercises and exercises for the muscles of the shoulder girdle, neck, pharynx, tongue, and the soft palate, chewing-articular muscles and mimic-articular muscles as well as for the correction of open and closed rhinolalia. Special attention is given to the implementation of socio-psychological rehabilitation for the restoration of the stable, clear and comprehensible speech function. The rehabilitation teams have been organized for the first time comprised of the maxillofacial surgeon, the orthopedic dentist, the physiotherapist, the speech therapist, and the physiotherapist. The classification of the disorders of interest have been developed based on the available data concerning the anatomical-physiological and sound-producing disturbances. The methods for the restoration of the speech function in the patients presenting with the injuries to the maxillofacial region with the concomitant disorders of the speech function are described together with the newly developed modalities of physical therapy and speech therapy.

Prosthetic, orthodontic and implant-supported rehabilitation of five maxillary anterior teeth with alveolar bone loss.

INTRODUCTION: Treatment of maxillofacial injuries is complex and requires the establishment of a comprehensive and accurate diagnosis and correct treatment planning. OBJECTIVE: The objective of this case report was to describe the re-treatment of a 27-year-old woman who was involved in a severe car accident that resulted in the loss of five anterior teeth and alveolar bone, and whose previous orthodontic and surgical treatments had been unsuccessful. CASE REPORT: In this case, the space for the missing mandibular molar was reopened to allow for rehabilitation. The positions of the mandibular incisors were improved. The right mandibular canine was moved to the mesial, allowing for correction of the Class II canine relationship on that side, and implants were placed to replace the maxillary anterior teeth. CONCLUSION: Anterior aesthetic and functional rehabilitation using a multidisciplinary approach was essential to improve the patient's facial aesthetics, to obtain great improvement in function and to achieve occlusal stability after 2 years of follow-up.

Prosthetic, orthodontic and implant-supported rehabilitation of five maxillary anterior teeth with alveolar bone loss

ABSTRACT Introduction: Treatment of maxillofacial injuries is complex and requires the establishment of a comprehensive and accurate diagnosis and correct treatment planning. Objective: The objective of this case report was to describe the re-treatment of a 27-year-old woman who was involved in a severe car accident that resulted in the loss of five anterior teeth and alveolar bone, and whose previous orthodontic and surgical treatments had been unsuccessful. Case report: In this case, the space for the missing mandibular molar was reopened to allow for rehabilitation. The positions of the mandibular incisors were improved. The right mandibular canine was moved to the mesial, allowing for correction of the Class II canine relationship on that side, and implants were placed to replace the maxillary anterior teeth. Conclusion: Anterior aesthetic and functional rehabilitation using a multidisciplinary approach was essential to improve the patient's facial aesthetics, to obtain great improvement in function and to achieve occlusal stability after 2 years of follow-up.

RESUMO Introdução: o tratamento de danos bucomaxilofaciais é complexo e requer diagnóstico abrangente e preciso, além de um correto plano de tratamento. Objetivo: o objetivo deste relato de caso foi descrever o retratamento de uma paciente do sexo feminino, 27 anos de idade, envolvida em acidente automobilístico grave, que resultou na perda de cinco dentes, além de perda óssea alveolar na região anterior. Relato de caso: a paciente apresentava histórico de insucesso de tratamento ortodôntico e cirúrgico. No caso apresentado, o espaço referente aos molares inferiores ausentes foi reaberto, para possibilitar a reabilitação. Houve melhora no posicionamento dos incisivos inferiores. O canino inferior direito foi deslocado para mesial, possibilitando a correção da relação de Classe II intercaninos do mesmo lado. Implantes foram inseridos a fim de substituir os dentes superiores da região anterior. Conclusão: a reabilitação estética e funcional da região anterior, realizada por meio de uma abordagem multidisciplinar, foi fundamental para valorizar a estética facial da paciente, melhorar a função e promover estabilidade oclusal após dois anos de acompanhamento.

Oral motor and electromyographic characterization of adults with facial fractures: a comparison between different fracture severities.

OBJECTIVES:: To characterize the oral motor system of adults with facial injuries and to compare the oral motor performance/function between two different groups. METHODS:: An observational, descriptive, cross-sectional study was conducted in 38 patients presenting with facial trauma who were assigned to the Division of Orofacial Myology of a Brazilian School Hospital. Patients were divided into two groups: Group 1 (G1) consisted of 19 patients who were submitted to open reduction of at least one facial fracture, and Group 2 (G2) consisted of 19 individuals who were submitted to closed fracture reduction with maxillomandibular fixation. For comparison purposes, a group of 19 healthy volunteers was recruited. All participants underwent a clinical assessment that included an oral motor evaluation, assessment of the mandibular range of motions, and electromyographic assessment of the masticatory muscles. RESULTS:: Clinical assessment of the oral motor organs indicated that G1 and G2 presented deficits related to the posture, position, and mobility of the oral motor organs. Patients also presented limited mandibular ranges of movement. Deficits were greater for individuals in G1, especially for maximal incisor opening. Additionally, patients in G1 and G2 presented a similar electromyographic profile of the masticatory muscles (i.e., patients with facial fractures presented lower overall muscle activity and significant asymmetrical activity of the masseter muscle during maximum voluntary teeth clenching). CONCLUSION:: Patients in G1 and G2 presented similar functional deficits after fracture treatment. The severity of facial fractures did not influence muscle function/performance 4 months after the correction of fractures.

Oral motor and electromyographic characterization of adults with facial fractures: a comparison between different fracture severities

OBJECTIVES: To characterize the oral motor system of adults with facial injuries and to compare the oral motor performance/function between two different groups. METHODS: An observational, descriptive, cross-sectional study was conducted in 38 patients presenting with facial trauma who were assigned to the Division of Orofacial Myology of a Brazilian School Hospital. Patients were divided into two groups: Group 1 (G1) consisted of 19 patients who were submitted to open reduction of at least one facial fracture, and Group 2 (G2) consisted of 19 individuals who were submitted to closed fracture reduction with maxillomandibular fixation. For comparison purposes, a group of 19 healthy volunteers was recruited. All participants underwent a clinical assessment that included an oral motor evaluation, assessment of the mandibular range of motions, and electromyographic assessment of the masticatory muscles. RESULTS: Clinical assessment of the oral motor organs indicated that G1 and G2 presented deficits related to the posture, position, and mobility of the oral motor organs. Patients also presented limited mandibular ranges of movement. Deficits were greater for individuals in G1, especially for maximal incisor opening. Additionally, patients in G1 and G2 presented a similar electromyographic profile of the masticatory muscles (i.e., patients with facial fractures presented lower overall muscle activity and significant asymmetrical activity of the masseter muscle during maximum voluntary teeth clenching). CONCLUSION: Patients in G1 and G2 presented similar functional deficits after fracture treatment. The severity of facial fractures did not influence muscle function/performance 4 months after the correction of fractures.

Brief alcohol intervention in alcohol involved facial fracture patients-a survey of patient attitudes to screening and intervention.

PURPOSE: Alcohol intoxication is an important contributor to traumatic facial injuries. The period following injuries afford clinicians a useful window of opportunity to provide alcohol screening and brief intervention (SBI) which may affect changes in patients' future drinking behaviour. Although SBI has been reported to decrease at risk drinking and potentially trauma recurrence, it is not routinely utilised in most clinical settings in the world. This study aims to assess utilisation of, as well as patients' knowledge and attitude towards SBI in the management of patients presenting with alcohol-related facial fractures. METHODS: Twenty consecutive patients who presented to Western Health with facial fractures who met selection criteria were offered an alcohol screening and survey questionnaire. RESULTS: Ninety percent of patients were male and 50% were aged between 19 and 34. ASSIST score showed 65% were in the moderate risk category; 75% reported this was their first admission with alcohol related trauma. Although 75% acknowledged alcohol as a main cause of injury, only 40% agreed they drink too much. Forty-four percent felt that talking to a healthcare worker might help and 33% would consider accepting help. Forty-seven percent felt reading materials would be helpful in changing future drinking habits. Whilst 63% would like to know safe drinking limit, only 45% would like to have a discussion about alcohol-related harms. CONCLUSIONS: Most patients presented in this survey were in moderate risk category who are amenable to behavioural change with provision of SBI. However, there is resistance to implementation of this intervention due to lack of knowledge, self-awareness and willingness to change. Nonetheless, patients are prepared to accept advice from clinicians and some formats of intervention. It is important to formulate a simple screening questionnaire and intervention strategy that are easy to administer to affect positive changes in patients with harmful drinking behaviours.

Repercusión social de un Servicio de Rehabilitación de la Cara y Prótesis Bucomaxilofacial en la provincia Ciego de Ávila / Social repercussion of a Rehabilitation of the Face and Bucomaxillofacial Prosthesis Service in Ciego de Ávila province

Introducción: antes del triunfo de la Revolución los servicios de prótesis bucomaxilofaciales eran prácticamente inexistentes en Cuba. Actualmente en la provincia Ciego de Ávila no existen servicios de rehabilitación bucomaxilofacial, por lo que los pacientes que requieren el empleo de prótesis reciben atención en el Centro de Rehabilitación de la Cara y Prótesis Bucomaxilofacial de la provincia Villa Clara. Objetivo: fundamentar –a partir de su repercusión socialla necesidad de crear el Servicio Provincial de Rehabilitación de la Cara y Prótesis Bucomaxilofacial en Ciego de Ávila.Método: se revisó la bibliografía sobre el tema, correspondiente a los últimos cinco años; a partir de los artículos seleccionados se elaboró la fundamentación. Desarrollo: el tamizaje mediante búsqueda activa efectuado en el período 2010-2014 reveló que de 534 pacientes con defectos bucomaxilofaciales en la provincia, sólo 356 estaban rehabilitados; la mayoría (70 por ciento) de los 178 pacientes no rehabilitados tuvo diversas dificultades para viajar a Villa Clara, debido a los gastos que implican los frecuentes viajes con acompañamiento de un familiar. Conclusiones: la creación de este servicio en la provincia facilitaría a los pacientes el acceso a la rehabilitación en menor tiempo y sin afectación económica personal, la explotación de las potencialidades del servicio para tratar pacientes de otros países posibilitaría la recuperación de la inversión, los profesionales de la especialidad accederían a un campo de investigación nuevo y se impartirían en la provincia los módulos suprimidos del plan curricular de la asignatura Prótesis Bucomaxilofacial en la Tecnología en Prótesis y Atención Estomatológica(AU)

Introduction: before the triumph of the Revolution, the services of oral and maxillofacial prostheses were virtually nonexistent in Cuba. Currently in the province of Ciego de Ávila there are no bucomaxillofacial rehabilitation services, so that patients requiring the use of prostheses receive care at the Center for Rehabilitation of the Face and Bucomaxillofacial Prosthesis in Villa Clara province.Objective: to lay the foundation –based on its social repercussionof the need to create the Provincial Service for Rehabilitation of the Face and Bucomaxillofacial Prosthesis in Ciego de Ávila.Method: the bibliography on the subject was reviewed for the last five years; from the selected articles the foundation was elaborated.Development: screening through active search carried out in 2010-2014 revealed that of 534 patients with buccomaxillofacial defects in the province, only 356 were rehabilitated; the majority (70 percent) of the 178 non-rehabilitated patients had various difficulties to travel to Villa Clara, due to the expenses involved with frequent trips accompanied by a relative.Conclusions: the creation of this service in the province would facilitate to the patients the access to the rehabilitation in less time and without personal economic affectation, the exploitation of the potential of the service to treat patients from other countries would enable the recovery of investment, the professionals of the specialty would accede to a field of new research and would be imparted in the province the modules suppressed of the curricular plan of the subject Bucomaxillofacial Prosthesis in Technology in Prosthetics and Stomatological career(AU)

[Multidisciplinary approach to oral rehabilitation in wounded fighters].

Maxillofacial injuries during military service and in operations in particular, often involve soft and hard tissues, including fractures of bone and teeth. This kind of injury demands a multidisciplinary approach including specialists in oral and maxillofacial surgery periodontists, endodontics, orthodontics and prosthodontics. A comprehensive therapy is achieved by a complete cooperation between the disciplines for a long-term. We present a case report of a complex oral rehabilitation of a fighter wounded in "Zuk Eitan" operation, as an example of the multidisciplinary approach in our department.

Consideraciones clínico-epidemiológicas de los defectos bucomaxilofaciales y su rehabilitación en el municipio Ciego de Ávila / Clínical-epidemiological considerations of the buccomaxillofacial defects and their rehabilitation in Ciego de Ávila municipality

Introducción: la rehabilitación correcta del paciente con pérdida de estructuras de la cara o de áreas adjuntas a ella posibilita su recuperación física y psicológica y su reintegración normal a la vida social. Las prótesis bucomaxilofaciales de aspecto realista son una excelente alternativa cuando la reconstrucción plástica no es posible; no obstante, su empleo implica la posibilidad de desalojo del aparato por su tamaño, alto peso y ubicación frecuente en zonas de movilidad facial.Objetivo: determinar el comportamiento de algunas variables clínico-epidemiológicas relacionadas con los defectos bucomaxilofaciales y su rehabilitación en el municipio Ciego de Ávila en el período de enero de 2015 a enero de 2016. Método: se realizó un estudio descriptivo de corte transversal en pacientes con defectos bucomaxilofaciales. El universo de estudio abarcó toda la población del municipio, del que se seleccionó una muestra de 59 pacientes que cumplieron con los criterios de inclusión. Se confeccionó un cuestionario para la recogida de datos y los resultados se reflejaron en tablas. Resultados: la prevalencia de pérdida total o parcial de estructuras bucomaxilofaciales fue de 0,043 por ciento; la mayoría de los casos fueron pacientes masculinos, de edades entre 35 y 59 años, tez blanca y con lesiones oculares. Las principales causas de pérdida de estructuras fueron los traumatismos y las lesiones oncológicas. La mayoría de los pacientes estaban rehabilitados. Conclusiones: aún cuando la prevalencia de estos defectos es numéricamente baja, su repercusión psicosocial en los afectados es alta, de ahí la importancia de la atención multidisciplinaria para su eehabilitación(AU)

Introduction: the correct rehabilitation of the patient with loss of face structures or areas attached to it makes possible their physical and psychological recovery and their normal reintegration into social life. Realistic-looking buccomaxillofacial prostheses are an excellent alternative when plastic reconstruction is not possible; however, their use implies the possibility of eviction of the device due to its size, high weight and frequent location in areas of facial mobility. Objective: to determine the behavior of some clinical and epidemiological variables related to bucomaxillofacial defects and their rehabilitation in Ciego de Ávila municipality from January 2015 to January 2016.Method: a cross-sectional descriptive study was carried out in patients with buccomaxillofacial defects. The universe of study covered the entire population of the municipality, from which a sample of 59 patients who met the inclusion criteria were selected. A questionnaire was prepared for the data collection and the results were reflected in tables. Results: the prevalence of total or partial loss of buccomaxillofacial structures was 0,043 percent; the majority of the cases were male patients, aged between 35 and 59 years, white skin and with ocular lesions. The main causes of structures loss were trauma and oncological lesions. Most of the patients were rehabilitated. Conclusions: although the prevalence of these defects is numerically low, its psychosocial impact on those affected is high, hence the importance of multidisciplinary care for rehabilitation(AU)

Physiotherapy Maneuver Is Critical to Recover Mouth Opening After Pediatric Trauma.

PURPOSE: A restricted mouth opening (MO) is predominantly a complication of maxillofacial trauma in pediatric patients and develops in 4 to 26.2% of cases. The purpose of the present study was to quantitatively investigate the influence of patient demographic data, fracture characteristics, and regular vigorous physiotherapy, with either voluntary or forcible MO exercises, on the recovery of a post-traumatic restricted MO in pediatric patients. PATIENTS AND METHODS: A prospective cohort study was performed of pediatric patients with maxillofacial injuries who had been referred to Al-Zahraa and El-Fayoum Hospitals from 2013 to 2015. The predictive variables were patient demographic data, fracture characteristics, and regular vigorous physiotherapy. The patients were treated with a closed technique. The MO measurements were the clinical outcome variables and were recorded at the first week and then monthly for 12 months. Regular vigorous physiotherapy was performed until the patients had returned to their preoperative MO. The data were tabulated and statistically analyzed. RESULTS: Eighty-six patients were enrolled in the present study. Males predominated. Falls were the most common cause of fracture. Condylar fractures had the greatest incidence. A restricted MO occurred in 81 patients. The results showed no interaction between MO recovery and age, gender, etiology, or fracture site. After physiotherapy, the patients had returned to their preoperative MO at the fourth month, with the measurements fixed at normal values at the sixth month. The recovery rate was nonlinear, with faster improvement in the months closest to the injury. CONCLUSION: Physiotherapy is more critical in the recovery of the MO and prevention of bony ankylosis than patient data or fracture characteristics in pediatric trauma. We highly advocate the performance of voluntary mouth exercises, even in the absence of fracture. Forcible MO exercises are mandatory to recover a restricted MO. These exercises should be performed under close supervision of the patient's surgeon with the parents motivated to cooperate for at least 6 months.

Un enfoque integral sobre prótesis bucomaxilofacial / A comprehensive approach to maxillo-facial prosthesis

La prótesis bucomaxilofacial es la disciplina que se encarga de rehabilitar personas que carecen de parte de sus estructuras faciales o bucales debido a defectos congénitos, traumatismos o extirpación de tumores. El objetivo de este trabajo fue presentar los conceptos y principios de la rehabilitación bucomaxilofacial, clasificación y descripción de los defectos faciales, habilidades y técnicas para abordar cada caso. Se realizó una revisión bibliográfica usando la base de datos de PubMed/Medline, utilizando los siguientes términos de búsqueda: maxillofacial prosthetics; maxillofacial reconstruction; ocular, nasal, auricular and mandibular defects. La prótesis facial es un dispositivo artificial que reemplaza una malformación del rostro. Puede ser ocular, orbital, nasal, auricular, defecto maxilar y mandibular, craneal o compleja. Se confecciona en acrílico termopolimerizable o silicona de tipo médico, caracterizados por simular la pigmentación del individuo. La prótesis bucomaxilofacial ofrece una alternativa de rehabilitación cuando la reconstrucción quirúrgica no lo puede lograr y representa una ayuda imprescindible para la reinserción social y profesional del paciente mutilado.(AU)

Un enfoque integral sobre prótesis bucomaxilofacial / A comprehensive approach to maxillo-facial prosthesis

La prótesis bucomaxilofacial es la disciplina que se encarga de rehabilitar personas que carecen de parte de sus estructuras faciales o bucales debido a defectos congénitos, traumatismos o extirpación de tumores. El objetivo de este trabajo fue presentar los conceptos y principios de la rehabilitación bucomaxilofacial, clasificación y descripción de los defectos faciales, habilidades y técnicas para abordar cada caso. Se realizó una revisión bibliográfica usando la base de datos de PubMed/Medline, utilizando los siguientes términos de búsqueda: maxillofacial prosthetics; maxillofacial reconstruction; ocular, nasal, auricular and mandibular defects. La prótesis facial es un dispositivo artificial que reemplaza una malformación del rostro. Puede ser ocular, orbital, nasal, auricular, defecto maxilar y mandibular, craneal o compleja. Se confecciona en acrílico termopolimerizable o silicona de tipo médico, caracterizados por simular la pigmentación del individuo. La prótesis bucomaxilofacial ofrece una alternativa de rehabilitación cuando la reconstrucción quirúrgica no lo puede lograr y representa una ayuda imprescindible para la reinserción social y profesional del paciente mutilado.

Implant esthetic restoration in ridge deficiencies in cases of trauma: a case report.

The long-term success of implant therapy does not depend solely on osseointegration, but the gingival architecture surrounding the implant system. It becomes very important to restore the gingival tissues in the areas that enhance one's esthetics. The esthetic zone can be defined as any dentoalveolar area of esthetic concern to the patient. The anterior maxillary teeth in the esthetic zone usually extend from first premolar to first premolar, but in some individuals can extend as far distally as the first molar. The patients requiring esthetic reconstruction at the site of trauma pose a great problem in implant placement and prosthetic restoration as scar tissue interferes with the same. To be successful, an implant-supported restoration should meet biological, mechanical, and esthetic goals. The most challenging situation is when esthetics is of prime concern in deficient ridge cases. This clinical report presents problems faced during implant placement and the sequential procedure to rehabilitate with an implant that was esthetically harmonized at the site of trauma.

Oral rehabilitation of severe dentoalveolar trauma: a clinical report.

This clinical report describes the oral rehabilitation of an adult male who suffered severe dentoalveolar trauma as a result of a motor vehicle accident. The specific objectives of this treatment were to restore esthetics and masticatory function. Treatment included removal of fractured roots, placement of multiple endosseous implants, and placement of anterior and posterior metal-ceramic crowns and fixed partial dentures. Three year clinical examination revealed no pathology associated with the rehabilitation. The patient's esthetic and functional expectations were successfully achieved.

The need for versatility in the prosthodontic treatment of maxillofacial defects.

The main objective of this study was to survey the different maxillofacial defects of patients who presented to the Wits Dental Hospital and to review the methods that have been used to rehabilitate these patients. Forty six patient records were retrieved from patients' files and from final year reports of prosthodontic postgraduate students. The data were used to determine the type of maxillofacial defects that these patients suffered from and the treatment that had been carried out. Duration and cost of treatment was also noted. The study showed that the majority of the patients' defects were caused by cancer resections, followed by trauma, clefts, burns, and infection. Most patients received conventional 'appropriatech' treatments such as the use of adhesive-retained prostheses, whilst a small number received more sophisticated 'high tech' treatments of implant rehabilitation. The need for versatility in the prosthodontic treatment of maxillofacial defects.

Comprehensive rehabilitation after severe maxillofacial injury in a cleft patient.

We present here a complex oral rehabilitation procedure for a 19-year-old male patient with an operated cleft lip and palate who suffered motorcycle accident injuries including facial lacerations, and a severe mandible fracture with loss of teeth, gingiva and alveolar bone. His initial skeletal and occlusal relationship made the emergent surgical management extremely difficult. Emergent soft tissue repair and open reduction surgery for the comminuted fracture at the mandible were performed during the intensive care period. A 2-year period of comprehensive procedures including surgical/orthodontic treatment, implant surgery and bone graft and prosthetic restoration for oral and maxillofacial rehabilitation to treat the severely compromised soft and hard tissue status, intermaxillary jaw discrepancy, and severe malocclusion, were sequentially performed. Satisfactory results were observed after a 5-year follow-up.

Reconstruction of the maxilla and midface: introducing a new classification.

Most patients requiring midface reconstruction have had ablative surgery for malignant disease, and most require postoperative radiotherapy. This type of facial reconstruction attracts controversy, not only because of the many reconstructive options, but also because dental and facial prostheses can be very successful in selected cases. This Personal View is based on a new classification of the midface defect, which emphasises the increasing complexity of the problem. Low defects not involving the orbital adnexae can often be successfully treated with dental obturators. For the more extensive maxillary defects, there is consensus that a free flap is required. Composite flaps of bone and muscle harvested from the iliac crest with internal oblique or the scapula tip with latissimus dorsi can more reliably support the orbit and cheek than soft-tissue free flaps and non-vascularised grafts, and also enable an implant-borne dental or orbital prosthesis. Nasomaxillary defects usually require bone to augment the loss of the nasal bones, but orbitomaxillary cases can be managed more simply with local or soft-tissue free flaps. We review the current options and our own experience over the past 15 years in an attempt to rationalise the management of these defects.