Alfred G. Becking

Complications in bilateral mandibular distraction osteogenesis using internal devices

OBJECTIVE We sought to evaluate the possibility of distraction osteogenesis as an alternative to conventional bilateral sagittal split osteotomy. Complications (intraoperative, intradistraction, and postdistraction) were evaluated retrospectively. STUDY DESIGN Seventy consecutive patients (40 males and 30 females, 11.2-37.3 years old; mean, 14.2 years) underwent distraction osteogenesis to lengthen the mandible. The surgical procedure was carried out with the patient under general anesthesia. After the osteotomy was performed, 2 intraoral monodirectional distraction devices were placed on the mandibular cortex in the third molar region. The rate of distraction was 1 mm/day. The different complications encountered during all phases of the distraction procedure were recorded. RESULTS A total of 28 complications (40%) were recorded. In 10 patients (14.3%), the complications were technique- or device-related, or both, and occurred early in the learning period. Five patients (7.1%) had infection occur, and 3 patients (4.3%) had prolonged sensory loss in the distribution of the alveolar nerve. Severe complications occurred in 6 patients (8.6%). Rehospitalization was necessary in 5 patients (7.1%), 4 of whom (5.7% of the series) required further surgery under general anesthesia. CONCLUSION Distraction osteogenesis can be considered a safe and predictable procedure for lengthening the mandible, with a low incidence of major complications. The infection rate and the incidence of damage to the inferior alveolar nerve (2.1%) are low. Compliance of both patients and parents during the whole treatment period is of the utmost importance.

Facial corrections in male to female transsexuals: A preliminary report on 16 patients

PURPOSE The need for facial corrective surgery to facilitate passing as a member of the other sex occurs in a relatively low percentage of male-to-female transsexuals. The aim of this study was to explore criteria and techniques for facial corrections in male-to-female transsexuals because little is known on objective measures for meaningful facial alterations in the female direction. PATIENTS AND METHODS In the period 1992 to 1994, 16 male-to-female transsexual patients were eligible for bony facial corrections. Several techniques were used to feminize the masculine appearance: mandibular angle reduction, genioplasty, bimaxillary osteotomy, and zygoma onlay and zygoma sandwich osteotomies. RESULTS Subjectively good results were obtained. Improvement in quality of life was not objectively assessed. CONCLUSIONS Facial corrective surgery seems to be promising in selected cases of male-to-female transsexualism. Further research is recommended on quantification of the differences in male and female faces for optimal indications and design of this type of surgery. The psychosocial aspects of the facial surgery and long-term stability of the surgical result also need to be further investigated.

Complications in Transpalatal Distraction Osteogenesis: A Retrospective Clinical Study

PURPOSE Transpalatal distraction osteogenesis is a bone-borne technique to expand the maxilla and has become a routine method in treating patients with transverse maxillary hypoplasia. Limited reports concerning treatment difficulties have been published. The purpose of this study was to investigate and categorize the short- and middle-term incidence of peri- and postoperative difficulties (categorized by the classification of Paley in problems, obstacles, and complications). The signs of adverse dental and periodontal effects were established at least 1 year after removal of the distractor. PATIENTS AND METHODS A total of 73 patients (27 male, 46 female; mean age: 28 years; range: 9-59) that underwent bone-borne SARPE in 3 centers were retrospectively investigated. Clinical follow-up was performed in 63 patients after an average period of 23.9 months (range: 6-63 months). RESULTS Twenty-seven problems (mainly appliance related), 10 obstacles (appliance-related and asymmetric maxillary expansion), and 1 complication (premature loss of the TPD-module, due to lack of space, in a cleft patient) occurred. Clinical examination showed minimal periodontal damage (gingival recession on 15 sites and pocket depths 4-5 mm in 11 sites). In 28.6% of the incisors radiographic signs of external apical root resorption were seen. CONCLUSION Bone-borne SARPE is a reliable technique with predictable outcomes. These results suggest that bone-borne SARPE is associated with a low incidence of dental and periodontal damage. Nevertheless, further research, preferably in randomized controlled design, is needed to evaluate the long-term effects and stability.

Comparison of planar bone scintigraphy and single photon emission computed tomography in patients suspected of having unilateral condylar hyperactivity.

OBJECTIVE A comparison is made of single photon emission computed tomography (SPECT) and planar bone scintigraphy in the diagnosis of patients with suspected unilateral condylar hyperactivity (UCH). STUDY DESIGN The subjects comprised 56 patients with suspected UCH who underwent SPECT and regular planar bone scans. Accuracy of SPECT and planar scintigraphy were compared using left-right condylar activity. RESULTS Of the 56 patients, 29 were diagnosed with active UCH and 27 without UCH. The mean relative activity of the hyperactive condylar region in the planar scans was 53.5% (SD +/- 2.3%), which was significantly higher in the SPECT scan with a mean value of 60.5% (SD +/- 5.4%), P < .005 (t = 8.951). Receiver operating curves (ROC) were clearly in favor of SPECT over the planar bone scan. The area under the curve (AUC) of the planar ROC was 0.87 +/- 0.049 while that of the SPECT ROC was 0.97 +/- 0.024. The optimal cut-off value for planar scanning was 52%, yielding a sensitivity of 67% and a specificity of 85%. For SPECT scanning, the optimal cut-off was 56%, resulting in a sensitivity of 93% and a specificity of 96%. CONCLUSIONS It can be concluded that in patients with a clinically suspected active UCH, SPECT scanning is the preferred diagnostic tool rather than planar bone scanning. However, treatment planning should be done in combination with clinical assessment of progressive mandibular asymmetry as well as taking into account the patient history.

Management of posttraumatic malocclusion caused by condylar process fractures

PURPOSE The aim of the study was to evaluate the results of orthognathic surgery in cases with posttraumatic malocclusion as a long-term complication of condylar process fractures. PATIENTS AND METHODS A retrospective study on 21 patients with posttraumatic malocclusions attributable to condylar process fractures was performed. In group I, 15 patients were treated for asymmetric malocclusion with unilateral or bilateral mandibular ramus osteotomies. In group II, six patients were treated for anterior open bit with either a Le Fort I osteotomy (n=5) or a bilateral ramus osteotomy (n=1). All patients had clinical and radiographic follow-up for at least 1 year. RESULTS Stable dental and cephalometric results were obtained in all patients except the one in group II who was treated with bilateral sagittal split osteotomies. In two cases, both in the asymmetric group, minor occlusal interferences had to be treated by equilibration in the early postoperative period. CONCLUSIONS Orthognathic surgery is a predictable and stable method for the treatment of posttraumatic malocclusion due to condylar process fractures. Maxillary orthognathic surgery is successful in correcting symmetric anterior open bites due to bilateral condylar process fractures. Because posttraumatic malocclusion is a rare complication after closed treatment of condylar process fractures, and it can be treated satisfactorily using orthognathic surgery, routine open reduction and fixation of condylar process fractures is not indicated to prevent posttraumatic malocclusion.

Rhinoplasty as part of gender-confirming surgery in male transsexuals : Basic considerations and clinical experience

Because psychotherapy will not change the profound incongruence between the objective biological sex and subjective gender identity experienced by transsexuals, hormonal and surgical treatment to change the body toward the experienced gender is the only way out of this dilemma. To allow the male-to-female transsexual to pass as a member of this gender in public, rhinoplasty may be as important as genital reassignment surgery. In this paper the surgical considerations on gender-confirming rhinoplasty are presented and discussed. From December 1985 to January 1996, 22 male-to-female transsexuals underwent rhinoplasty at the Department of Plastic and Reconstructive Surgery of the Academisch Ziekenhuis Vrije Universiteit to obtain a less masculine appearance. Although revisional surgery was performed in four patients, all were satisfied with the final result in that they were convinced that their faces had become more feminine. We conclude that in selected patients rhinoplasty may help to create a feminine countenance for male-to-female transsexuals.

Outcome in patient-specific PEEK cranioplasty: A two-center cohort study of 40 implants

OBJECTIVE The best material choice for cranioplasty following craniectomy remains a subject to discussion. Complication rates after cranioplasty tend to be high. Computer-assisted 3-dimensional modelling of polyetheretherketone (PEEK) was recently introduced for cranial reconstruction. The aim of this study was to evaluate patient- and surgery-related characteristics and risk factors that predispose patients to cranioplasty complications. MATERIAL AND METHODS This retrospective study included a total of 40 cranial PEEK implants in 38 patients, performed at two reference centers in the Netherlands from 2011 to 2014. Complications were registered and patient- and surgery-related data were carefully analysed. RESULTS The overall complication rate of PEEK cranioplasty was 28%. Complications included infection (13 %), postoperative haematoma (10 %), cerebrospinal fluid leak (2.5 %) and wound-related problems (2.5 %). All postoperative infections required removal of the implant. Nonetheless removed implants could be successfully re-used after re-sterilization. CONCLUSION Although overall complication rates after PEEK cranioplasty remain high, outcomes are satisfactory, as our results compare favourably to recent literature reports on cranial vault reconstruction.