Postero-lateral expansion osteotomy of maxilla. A case report.

The posterior-maxillary osteotomy introduced by Schuchardt was designed to close skeletal anterior open bite. Also, it can be used to reduce a posterior cross bite. But in this latter case, the most important problem is the difficulty in expanding the maxilla because of the relative inelasticity of the palatal mucosa. This paper reports on the result obtained by a surgical expansion technique without orthodontic treatment. The use of a local soft tissue flap is necessary; the anteroposterior part of the palatal incision is placed contralaterally to the bone incision. A palatal appliance is used for the retention of the palatal flap.

Long face: new proposals for taxonomy, diagnosis, treatment.

The authors suggest a taxonomy and a specific terminology from Greek etymology for vertical maxillo/mandibular excess dysmorphies, "long face" or "high face" (hypsoprosopia) to be more exact, so as to make their diagnosis and their therapeutic approach easier. They distinguish three anomalies which may, separate or in association, cause an increased vertical dimension of the face: hypsomaxillia, hypsogenia and inter incisal anterior vertical gap or hyposostomy, which may itself be differentiated into 3 aetiological sites (vertical posterior maxillary dento-alveolar excess, vertical anterior mandibular dento-alveolar deficiency, excessive gonial angle opening or amblygonia). They submit a clinical and teleradiographic table specific for each anomaly, relying on patients having achieved their full dento-osseous growth. When confronted with associated cases, they can therefore more systematically apply the various osteotomies, partial or total, maxillary or mandibular, or even combined operations.

[Facial injuries]. / Les traumatismes de la face

In spite of a certain reduction in their numbers, facial injuries still raise frequent problems for general surgeons. Car accidents are now less commonly responsible than motorcycle accidents. In the most complex cases, one may find lesions of the soft parts and bony lesions in association. The wounds should be examined carefully, all foreign bodies removed and should only be sutured if one is certain tht the subjacent structures are undamaged, e.g. facial bony canals are often damaged in vertical wounds of the cheek situated behind the anterior border of the masseter muscle. As far as bony lesions are concerned, they rarely give rise to typical breakdowns of the suture lines described by Lefort, but more commonly cause true dislocations which are impossible to describe. Fractures are often undiagnosed owing to oedema which masks them, e.g. those of the malar bone and of the orbit and even those of the nose. This failure to diagnose them is serious for, at a later stage, surgical correction is more difficult and the prejudice is then not only esthetic but also functional, e.g. causing diplopia. Clinical examination of a patient with trauma of the face includes a series of simple gestures which a general surgeion should carry out in order to avoid failure to diagnose such lesions. Although he may not treat them all, he sould recognise them and decide which have priority in the treatment of multiple injuries. Careful inspection and palpation usually permit one to detect bony lesions which XRays then demonstrate only by careful choice of appropriate views.

[An unusual form of isolated fracture of the orbital floor: "valve fracture". Therapeutic problems]. / Une forme inhabituelle de fracture isolée du plancher orbitaire: "la fracture en clapet". Problèmes thérapeutiques.

Among isolated fractures of the orbital floor, the authors are pointing out an unusual clinical type characterized by the irreducibility of the orbital contents ruptured in the maxillary sinus by using classical procedures. This primary failure is due to a bone fragment dropped in the sinus and being attracted by the herniated collar when trying to integrate the hernia in the orbit. To name this type of lesion, the word "valve fracture" is proposed because of the analogy of the one way function of a valve and its different mechanism from the classical trapdoor fracture. The different concepts of the pathogenesis of isolated fractures of the orbital floor and the physiopathology of the frequently associated ocular disturbances are briefly exposed. The authors report the case which confronted them to the valve fracture. Following a direct trauma to the right orbital area a 13-year-old child presented a limitation of the upwards movements of the right eye with diplopia and a positive forced duction test. The surgical exploration shows an orbital hernia in the sinus which is impossible to reposition either with a higher incision (under the orbital rim) or with a lever incision, upper vestibular incision (through maxillary sinus). Only the infraorbital marginotomy described by P. Tessier exposes completely the lesions and allows understanding of the mechanism of this primary irreducibility related to the valve movement of the fractured bone fragment. Above all, marginotomy allows an atraumatic set. If is performed combining gentle handles of pulling and forcing back on the ruptured pieces while keeping opened the valve.

[Vertical maxillo-mandibular dysmorphias due to excessive growth. Terminology, diagnosis and treatment]. / Dysmorphies verticales maxillo-mandibulaires par excès. Propositions taxinomiques, diagnostiques et thérapeutiques.

The authors propose a system of terminology for vertical maxillo-mandibular dysmorphia, "long face" or rather "high face", and "hypsoprosopia" hypsomaxillia to facilitate the diagnosis and the therapeutic approach. They distinguish 3 abnormalities which are responsible, alone or in combination, for an increased height in the face: hypsomaxilla, hypsogenia and vertical anterior inter-incisive aperture (open bite), which can arise in three situations (supra erupted posterior alveolar maxillary segment, infra erupted anterior alveolar mandibular segment, exaggerated opening of the angle of the mandible or amblygonia). They present the clinical picture and the specific teleradiographic features of each abnormality, supported by cases of patients with definite dento-maxillary growth. On the basis of this classification, the authors propose a more systematized approach to the various segmental or total maxillary or mandibular osteotomies, which may be coupled or even combined with advancements or transverse movements in cases of associated dysmorphosis.

[Coronal approach of zygoma and direct osteosynthesis in post-traumatic dysmorphic sequelae]. / Voie d'abord coronale du zygoma et ostéosynthèse directe dans les séquelles dysmorphiques post-traumatiques.

A direct approach to the zygomatic arch can be a useful alternative for primary or secondary deformities in which simple well known technics are ineffective. This approach is very limited because of the anatomical elements located directly over the zygomatic region. The exposure of the fracture site is performed by an unusual surgical approach which allows visualization of both zygomatic arches simultaneously, to correct all deformities and to perform osteosynthesis. Four cases using this technique are reported and the value of this approach is assessed.

Fronto-orbito nasal dislocations. Initial total reconstruction.

The craniofacial trauma can produce compound fractures with bone displacement in the central part of the upper face, i.e. the bones constituting the forehead, orbit, and nose. such dislocations are called fronto-orbito-nasal dislocations. A total and definite surgical reconstruction in one stage offers advantages such as good aesthetic and functional results. An injured person can enter professional and social life without further delay. A major advantage is also the minimizing of the risk of meningeal fistula with infectious mortal risk. A prerequisite for this surgery is accurate clinical and radiological examination to permit a preoperative three-dimensional visualization of the lesions as a basis for careful planning of the operation. The surgical team should include neurosurgeons and plastic surgeons with experience in the maxillofacial area. The operative procedure should start with repair of the orbital frame, beginning at the upper and lateral side, followed by exploration of the four walls of the orbital chamber and of the lacrimal system. The reconstruction then proceeds with the eyelid ligaments and the nervous and vascular pedicles, especially the infra-orbital one, followed by reconstruction of the sinus maxillaris. Afterwards transnasal internal canthopexy wires are placed, the nose reconstructed and bone grafts are used to restore the orbital chamber behind the frame. The lacrimal system is repaired before the tightening of the canthopexies. In cases where neurosurgical intervention is necessary, such as suturing of dura sores or reconstruction of the anterior cranial fossa by bone grafting, this will precede the facial reconstruction. Without a strong frontal cornice it is impossible to restore the nose and orbit. Ocular injuries are treated by ophthalmic surgeons when the orbit is repaired. The last phase of the reconstruction is suturing of the muscular, mucosal and cutaneous lacerations.

[Application of various types of osteosynthesis in facial injuries (author's transl)]. / De l'utilisation des différents types d'ostéosynthèse en traumatologie faciale.

The authors describe their results obtained in facial injuries treated by various osteosynthesis methods. They recall the different techniques available (steel wires, screws, plates, and pins), and give, for each localization, their opinion as to the best method for obtaining the most satisfactory functional result with the best possible reduction and immobilization, using the simplest and least disturbing procedure for the injured patient.

Craniofacial trauma.

The treatment of combined major dislocations of the face and skull requires a craniofacial team consisting of a plastic maxillofacial surgeon, a neurosurgeon, an anesthesiologist, and radiologists. The best results can only be achieved at the primary intervention both from a functional and an esthetic standpoint. Careful preoperative clinical and radiologic examinations are mandatory to reach these high goals. In primary repair, the cranial approach aims at constructing "a monobloc bone flap" to suture meningeal tears and to reinforce them with a pericranial graft, to close the cranial base completely using cancellous bone grafts, and to exclude the frontal sinuses. The facial skeleton is repaired by constructing a rigid external facial frame and thereafter progressing centrally finishing with the "internal" orbitonasal dislocations. The reconstruction aims at a self-stabilizing bone puzzle fixed with interosseous wires, making external fixation unnecessary. Secondary repair requires osteotomies at fracture sites to reposition malunited fractures and the use of autogenous bone grafts for stabilization.

Fronto-orbito-nasal dislocations. Secondary treatment of sequelae.

Fronto-orbito-nasal dislocation untreated or maltreated can have many important sequelae for both function and aesthetics. Two types of cases may be observed, those with: -extensive bone loss -malunited fracture. The treatment of sequelae caused by bone loss in order to be rational, logical and complete necessitates: 1. protection of the underlying elements = eye and meningo-cerebral tissues, 2. reconstitution of an harmonious cranio-facial profile, 3. definitive isolation of cranial contents from the facial cavities. 4. repair of nasal and orbital walls and the necessary ligamentous re-insertions on them. The best material for such a repair remains the autogenous bone graft. The treatment of sequelae caused by malunited fractures necessitates repositioning osteotomies. In addition to rotation, elevation and translation osteotomies the following may be required: -either a monoblock advancement osteotomy, -or an "expansion" osteotomy. They require solid fixation. This may be obtained by: -either superior fixation to a previously conserved intermediate frontal strut -or a rebuilding of the shape of the vault, laterally fixed to sound bone parts, and an interposed bone graft to act as a "keystone" of the vault. Such repairs seem to be better than simple onlay bone grafts which are useful from an aesthetic point of view, but which neglect the underlying injuries with their concomitant functional sequelae, and which expose the patient to secondary sinus or cerebro-meningeal complications. They permit a single, total, simultaneous, and definitive repair of all the sequelae both functional and aesthetic; an approach which is more rational than successive surgical sessions. But they require: 1. Dura mater repair by suture and pericranial grafting. 2. Total isolation of cranial contents from the face. 3. Obliteration of the frontal sinus. It is therefore necessary to work with a combined neuro- and maxillo-facial team. Four cases are described to illustrate these proposed procedures, one case with very extensive bone loss, three with malunited fractures: the first orbito-frontal, the second with a fronto-zygomatic lateral component, the third with a fronto-nasal medical component.

Fronto-orbito-nasal dislocations., Secondary treatment of sequelae.

Untreated or maltreated fronto-orbito-nasal dislocations can give rise to serious sequelae of a functional or aesthetic nature. Two major problems may be discerned, namely extensive bone loss and malunited fractures. The loss of bone can result in an unfavourable aesthetic appearance and functional disturbances, e.g. loss of eye motility, cerebral herniations and meningitis. The treatment should therefore include protection of the underlying elements, such as eye and meningocerebral tissues with a definite isolation of the cranial content from facial cavities. An important measure to be taken is also the repair of nasal and orbital walls, including re-insertion of the canthal ligaments. Autogenous bone grafting is superior in the repair of bone defects. Malunited fractures are treated by repositioning osteotomies, sometimes including rotation, elevation, or translation. The reposition can be achieved either by advancement of a monobloc or by an expansion. Solid fixation is essential and can be obtained either by an upper fixation to an intermediary frontal bridge or by lateral fixation to safe bone parts with an intermediary bone graft in cases of trauma in the midline. Our approach allows a definite and total repair in one operation and requires repair of the dura mater by suturing and, if necessary, pericranial grafting. In cases of interference of the frontal sinus, 'cranialization' must be performed. In our opinion it is necessary to work in a team including maxillofacial and neurosurgeons.

[Fractures of the frontal sinus. Therapeutic indications]. / Fractures du sinus frontal. Indications thérapeutiques.

Attitudes towards therapy of frontal sinus fractures, in the Plastic and Maxillofacial Surgical Department of the Foch Medical-Surgical Unit, are discussed. Only those fractures with displacement, a possible cause of complications, are envisaged, the conduct adopted being described in detail as a function of the wall affected. Treatment should be directed along the following lines: --A harmonious frontal outline can be obtained by osteosynthesis of the bone fragments if certain conditions are fulfilled, or by a bone graft. --The sinus cavity should be excluded and filled by spongy grafts when an anterior wall graft is inserted. --Neurosurgical explorations are necessary if a posterior wall defect provides a threat to the meninges, followed by cranialization and obturation of the nasofrontal canal. --Physiological drainage must be ensured for the sinus cavity, particularly in inferior wall fractures.

[Retro-maxillary sequellae of craniofacial stenosis. The value of fronto-facial advancement using the Tessier monobloc technic]. / Rétromaxillie séquelle de cranio-facio-sténose. Intérêt de l'avancement fronto-facial par monobloc Tessier.

Monobloc fronto-facial advancement (TESSIER's technic) seems to be the best therapeutic to correct retromaxillia, sequellae of cranio-facio-stenosis. From an aesthetical and functional point of view the result is more satisfactory than with a simple LE FORT III osteotomy advancement. Intermaxillary fixation is not necessary. Of course an orthodontic sequence must be associated to correct dental malposition.