Alexander Ballon

Skeletal stability in bimaxillary orthognathic surgery: P(L/DL)LA-resorbable versus titanium osteofixation.

Background: One-year skeletal stability following bimaxillary orthognathic surgery was assessed by comparing poly(L-lactide-co-DL-lactide) to titanium osteofixation. Methods: Thirty patients underwent osteofixation with poly(L-lactide-co-DL-lactide) copolymer and 30 had 2.0-mm titanium-miniplate osteosyntheses. Lateral cephalograms were analyzed preoperatively, postoperatively, and at 1-year follow-up. Average ± SD values were as follows in resorbable plate-osteosyntheses (number of cases/titanium controls): for maxillary advancement, 3.5 ± 4.1 mm (n = 19)/5.4 ± 3.5 mm (n = 21); setback, 2.8 ± 3.7 mm (n = 9)/1.9 ± 1.8 mm (n = 8); elongation, 4.2 ± 3.6 mm (n = 18)/3.7 ± 5.2 mm (n = 14); and intrusion, 1.9 ± 1.7 mm (n = 12)/3.3 ± 2.7 mm (n = 13); for mandibular advancement, 4.6 ± 3.6 mm (n = 10)/6.3 ± 8.8 mm (n = 18); setback, 7.5 ± 8.3 mm (n = 20)/7.2 ± 3.2 mm (n = 12); enlargement of the mandibular angle, 11.8 ± 9.9 degrees (n = 19)/7.9 ± 6.6 degrees (n = 21); and reduction, 4.5 ± 3.2 degrees (n = 9)/6.3 ± 6.6 degrees (n = 9). Results: Preoperative to postoperative landmark positions within the study and control groups differed highly significantly (p = 0.008, paired t test), yet the amount of operative movement was comparable between the study and control groups (p = 0.5, two-sided t test). Absolute instability at the advanced A-point was (study group/controls) 2.3 ± 1.8/2.4 ± 2 mm, setback was 2.3 ± 1.9 mm/2.5 ± 1.7 mm, elongation at the anterior nasal spine was 3.8 ± 3.1 mm/3.1 ± 3.6 mm, intrusion was 2.1 ± 1.9 mm/2.2 ± 1.5 mm, advancement instability at the B-point was 4.9 ± 4.3 mm/5.1 ± 8.2 mm, setback was 3.0 ± 2 mm/1.7 ± 2 mm, mandibular angle enlargement instability was 6.7 ± 8.9 degrees/8.2 ± 9.6 degrees, and angle narrowing was 6.8 ± 5.2 degrees/4.2 ± 5.9 degrees. Absolute postoperative instability did not differ significantly between the study and control groups (p = 0.6). Conclusions: Resorbable osteofixation as tested proved to be as reliable as titanium, but as the study and control groups were not matched, the results have to be interpreted as preliminary. Resorbable materials permitted clinically faster occlusal and condylar settling than standard titanium osteosyntheses, as bone segments showed slight clinical mobility up to 6 weeks postoperatively.

Treatment of mandibular angle fractures – Linea obliqua plate versus grid plate

OBJECTIVES To compare treatment outcomes, handling and long term results between two osseo-fixation systems for mandibular angle fractures - the external oblique ridge (external oblique) plate and the grid plate. MATERIAL AND METHODS Sixty patients with mandibular angle fracture were analyzed regarding their operative treatment: 30 patients were treated with an external oblique plate and compared to 30 patients treated with a grid plate on the vestibular cortex. The follow up period was at least 1 year for both groups and the following complications were noted: infection, abnormality in fracture healing, nonunion, pain, hypoaesthesia and dysocclusion. RESULTS The overall average operation time (from intubation to extubation) was 102.1 min (± 44.1 min). Single sided fractures treated with the grid plate needed in average 81.07 min (± 37.9 min) of operation time while single sided fractures treated with the external oblique plate needed 89.3 min (± 42.2 min). In multiple mandibular fractures, no significant change in the operation time between either plating system was found (118.8 ± 35.2 min). After the follow up period fracture healing was considered clinically complete in all patients, but complications occurred significantly more often in the external oblique group (13.3%; N=8) than in the grid plate group (0%; N=0). CONCLUSION Isolated mandibular angle fractures can be more effectively treated using grid plates than using other osteosynthesis techniques. It is an easy to use alternative to conventional miniplate systems with good clinical outcome and fewer complications. An angulated burr and screwdriver has to be used to put on the plate laterally.

Indications and limitations in resorbable P(L70/30DL)LA osteosyntheses of displaced mandibular fractures in 4.5-year follow-up.

Background: This study evaluates prospective 4.5-year follow-up of available poly(l-lactide-co-dl-lactide) [P(L70/30DL)LA] resorbable plate osteosyntheses in displaced traumatic and pathological mandibular fractures. Methods: P(L70/30DL)LA miniplates and screws were used to fixate 50 displaced fractures in 30 patients, aged 1 to 83 years, with their informed consent. There were 15 traumatic paramedian, seven corpus, 11 angle, and 10 condyle fractures, and seven pathological fractures due to atrophy, osteomyelitis, or third molar osteotomy. Double osteosyntheses were preferred, with one monocortical plate at the dentoalveolar basis (6-mm screws) and a second plate at the inferior margin (8-mm screws). Results: The average follow-up was 31 months (range, 6 to 53 months). Fifteen (100 percent) traumatic paramedian, seven (100 percent) corpus, 10 (91 percent) angle, 10 (100 percent) condylar, and three (43 percent) pathological fractures healed primarily. Two mandibular angle fractures, traumatic and pathological, each initially healed, but 6 weeks postoperatively the first fracture re-dislocated on removal of a dental impression by the family dentist, and the second re-dislocated after mastication of hard food. One atrophic corpus fracture developed a rigid fibrous union in an 83-year-old patient; a preexistent osteomyelitis and fracture progressed to further bone loss and finally required preformed fibula reconstruction. Conclusions: Use of the tested resorbable plates can be encouraged in multiple displaced mandibular fractures in children and likewise in highly compliant dentate adolescents and adults with doubled osteosyntheses; traumatic mandibular angle and pathological fractures, however, remain critical for nonunion. These necessitate evaluation with future smaller, more rigid, and, it is hoped, more economical fixations.

Segmental stability of resorbable P(L/DL)LA-TMC osteosynthesis versus titanium miniplates in orthognatic surgery☆

After two decades of the use of resorbable miniplates, new polymer compositions for resorbable osteosynthesis are still being developed to make the handling and outcome of operations even more predictable and give higher stability to the repositioned segments. This study investigates a new resorbable osteosynthesis system in orthognathic patients. 50 patients were treated with P(L/DL)LA-TMC resorbable osteosynthesis and compared to a group of 50 patients treated with titanium miniplates. Segmental stability and relapse were measured comparing preoperative, postoperative and follow-up lateral cephalograms. Throughout this study, resorbables appeared to be as stable as titanium miniplates except in maxillary elongation and mandibular setback. Here, the titanium miniplates showed significantly higher stability than resorbable plates. P(L/DL)LA-TMC osteosynthesis seem to have less strength against compressive forces after maxillary elongation and they are less resistant to the forces the tongue exerts, pressing against the mandible after setback. It can therefore be concluded that the resorbable osteosynthesis can be used in the same situations as titanium miniplates except in maxillary elongation and mandibular setback.

Segment stability in bimaxillary orthognathic surgery after resorbable Poly(L-lactide-co-glycolide) versus titanium osteosyntheses.

This study compared segment stability after bimaxillary orthognathic surgery, comparing poly(L-lactide-co-glycolide) with titanium osteofixation at 12 months follow up. Fifteen patients were osteofixated with poly(L-lactide-co-glycolide) copolymer, 30 with 2.0-mm titanium miniplates. Preoperative, postoperative, and 1-year follow-up lateral cephalograms were analyzed. Maxillary average advancement in resorbable plate osteosyntheses (± standard deviation) was (case numbers/titanium controls) 2.5 (± 1.0) mm; n = 7/5.4 (± 3.5)mm; n = 21, setback 2.2 (± 2.4) mm; n = 7/1.9 (± 1.8) mm; n = 8, elongation 6.5 (± 3.4) mm; n = 9/3.7 (± 5.2) mm; n = 14, intrusion 1.0 (± 0.7) mm; n = 5/3.3 (± 2.7)mm; n = 13, mandibular average advancement was 5.5 (± 3.7) mm; n = 4/6.3 (± 8.8) mm; n = 18, setback 11.2 (± 7.7) mm; n = 7/7.2 (± 3.2) mm; n = 12, mandibular angle enlargement 7.9 (± 2.4)°; n = 9/7.9 (± 6.6)°; n = 21, reduction 6.9 (± 2.6)°; n = 4/6.3 (± 6.6)°; n = 9. Changes in landmark position within the study and control groups differed significantly in paired t testing (P =.01); operative movements were comparable in between study and control groups (P = 0.5, two-sided t test), only maxillary advancement was significantly smaller (P = 0.04) within study cases. Absolute instability at advanced A-point was (study group/controls) 1.2 (± 0.8)/2.4 (± 2) mm; setback 1.8 (± 1.9) mm/2.5 (± 1.7) mm; elongation at anterior nasal spine (ANS) 2.0 (± 1.4) mm/3.1 (± 3.6) mm, intrusion 1.1 (± 1.1) mm/2.2 (± 1.5) mm; advancement instability at B-point was 2.6 (± 2.7) mm/5.1 (± 8.2) mm, setback 2.7 (± 2.6) mm/1.7 (± 2) mm; mandibular angle enlargement instability 2.4 (± 2.7)°/8.2 (± 9.6)°, angle narrowing 7.0 (± 5.4)°/4.2 (± 5.9)°. Absolute postoperative instability was not significantly different in between study and control groups (P = 0.3). Tested resorbable poly(L-lactide-co-glycolide) osteofixation proved to be as reliable in segment fixation as titanium; however, study and control groups were not matched; the study group was small and therefore the results (especially advancement) have to be interpreted as preliminary until larger prospective cohorts become evaluated.

Treatment of Malar and Midfacial Fractures With Osteoconductive Forged Unsintered Hydroxyapatite and Poly-L-Lactide Composite Internal Fixation Devices

PURPOSE To evaluate the internal fixation of malar and midfacial fractures, long-term results, and biocompatibility of osteoconductive internal fixation devices composed of a forged composite of unsintered hydroxyapatite and poly-L-lactide (F-u-HA/PLLA). MATERIALS AND METHODS From January 2006 to June 2010, 29 patients (24 males and 5 females; age 33 ± 15 years) were included in the present prospective study. The fracture type was malar in 24 patients, midfacial in 5, isolated orbital floor blowout in 2, and frontal sinus, cranial base in 2 patients. The fractures were fixed with internal fixation devices; these were plates and screws composed of F-u-HA/PLLA. The 24 patients with malar fractures were treated with a single 4-hole L-plate or a straight plate at the infrazygomatic crest. RESULTS All fractures with internal fixation using devices composed of F-u-HA/PLLA healed well. All malar and midfacial fractures had satisfactory long-term stability. The follow-up examinations at 12 to 67 months after surgery showed that most patients had no complaints, although 2 patients (15%) had a foreign body reaction that was treated by implant removal, with complete symptom resolution. At 5 years after fracture fixation, 2 patients had ultrasound and 2 had radiographic evidence of residual material. An exemplar biopsy showed direct bone growth into the material. CONCLUSIONS In patients with malar and midfacial fractures, hardware composed of the F-u-HA/PLLA composite provided reliable and satisfactory internal fixation, intraoperative handling, long-term stability, and biocompatibility. Direct bone growth into the material could be histopathologically exemplified, in contrast to previous polymer fixations that were resorbed and surrounded by a connective tissue layer. This finding indicates that long-term F-u-HA/PLLA residual material will be included into the remodeled bone, which was confirmed on long-term follow-up radiographs.

Patients' preoperative expectations and postoperative satisfaction of dysgnathic patients operated on with resorbable osteosyntheses.

Background: This study evaluated whether personal expectations and satisfaction throughout orthognathic surgery were fulfilled. In addition, patients were interrogated about their experience of resorbable osteosynthesis. Methods: A total of 50 patients were interviewed 3 times each throughout the study by a mixed questionnaire of standard psychologic tests and a tailored itemized questionnaire regarding their expectations regarding resorbable osteofixation and their postoperative satisfaction. Results: A postoperative increase in self-esteem and approach to life were evident. An examination of Oral Health-Related Quality of Life showed constant quality of life; an examination of Oral Health Impact Profile-Germany) showed no postoperative difficulties in dental hygiene and nutrition. No statistically significant change in any of the tests could be expressly determined. Avoidance of secondary surgery motivated 94% to choose resorbable osteofixations, although a mere 66% had heard of them before; 90% of patients were satisfied with the operation result. Conclusions: Orthognathic surgery cannot change preexistent depression or a problematic social background. Mastication and oral health improved, and postoperative happiness and confidence increased. When given the choice between resorbable fixation and titanium osteofixation, patients generally preferred resorbable fixations.

INTRAORAL ANASTOMOSIS OF A PRELAMINATED RADIAL FOREARM FLAP IN RECONSTRUCTION OF A LARGE PERSISTENT CLEFT PALATE

In this report, we present a case of a prelaminated radial forearm flap in reconstruction of a large persistent cleft palate with transoral single arterial and three venous anastomoses. A 17‐years‐old female patient presented a large cleft palate defect and complete dentition, dysmelia of both arms and bilateral thumb aplasia. A radial flap was prelaminated using oral mucosa 5 days prior to transplantation. Five days after flap prelamination, the facial artery and vein, submandibular vein, and a venous branch to the masseter muscle behind the buccinator muscle fibers were exposed through an intraoral incision lateral to the inferior right mucogingival junction. The radial artery, its bilateral accompanying veins, and the cephalic vein of transplanted flap were anastomosed transorally to the facial vessels, submandibular vein, and masseter branch. The vessel pedicle ran through the palatoglossal arch dorsal to the second upper molar. Good flow and flap perfusion were evinced, and further‐on successful healing was achieved. The case encourages similar treatment in comparable situations avoiding facial nerve hazard and extraoral scars.

The importance of the primary reconstruction of the traumatized anterior maxillary sinus wall.

This study evaluates the importance of specific posttraumatic reconstruction of the fractured anterior sinus wall. Several methods of different complexity of reconstruction are being compared by means of radiologic, rhinoscopic, and clinical data. Four groups of a total of 207 patients (age, 18-73 years; follow-up average, 4.2 years) with midfacial fractures, divided by operation technique and year, were evaluated. Control groups 1 to 3 received standard procedures without special regard on the reconstruction of the anterior sinus wall; the study group received specific reconstruction. The study group 4 showed a lower complication rate in nearly all measured parameters in comparison to groups 1 and 2. Study group 4 had the smallest incidences of posttraumatic sequelae in radiologic examinations; the clinical outcome was even to group 3. During open reduction and fixation procedures of midfacial fractures, attention should be given to the reconstruction of the anterior sinus wall to avoid postoperative discomfort.

Six years clinical experience with the dorsally pedicled buccal musculomucosal flap.

A dorsal pedicled buccal musculomucosal flap was developed to reconstruct medium-sized intraoral defects, too large for primary closure if major functional and esthetic impairment is to be avoided. Although free flaps, axial, or perforator flaps are excellent in large defects, they may not provide mucosal sensitivity, motility, volume, and texture to replace lost structures with similar tissue. Twenty-five flaps were performed in 24 patients, 1(bilateral) up to a flap-size of 60 × 35 mm, in average 45 × 34 mm. Reconstructed became the lateral mouth floor, lateral oral vestibule, lateral tongue margin, the oropharynx, hard and soft palate. Partial necrosis occurred in 1 flap, 22 (92%) patients recovered with good objective as subjective speech and swallowing, esthetics, and if necessary prosthetic rehabilitation. The donor site was closed primarily, mimics and mouth opening resolved after less than 3 months. The parotid duct had to be marsupialized in large flap preparations, never provoking stasis or infection. The 2-point sensitivity of the flaps was in average equal to the nonoperated mucosa in intraindividual correlation and the flaps lost in average 10% of their original size; 5 (21%) had weakness inflating their cheeks postoperatively. The results indicate dorsal pedicled buccal musculomucosal flap to be reliable and technically easy for reconstructing lateral intraoral, medium-sized defect that yields sensitivity, merely risking occasional buccal muscle weakness but facilitating the rehabilitation of oral function.