Johan S.V. Abeloos

Skeletal Stability Following Miniplate Fixation After Bilateral Sagittal Split Osteotomy for Mandibular Advancement

Skeletal stability after monocortical miniplate fixation of bilateral sagittal split osteotomies to advance the mandible was evaluated in 20 patients. Three angles and four linear measurements were analyzed on lateral cephalometric radiographs before surgery, immediately after surgery, and at least 6 months after surgery. The mean horizontal advancement at pogonion was 5.0 mm; 6 months after surgery the advancement increased 0.3 mm because of occlusal settling. The mean lengthening of the distance gonion to menton was 5.8 mm and a relapse of 0.3 mm (5.2%) was found. The mean increase of anterior facial height measured at long-term follow-up was 3.6 mm. This study shows that fixation of the advanced mandible with intraorally applied monocortical miniplates after the bilateral sagittal split osteotomy is a stable procedure.

Temporomandibular joint symptoms in an orthognathic surgery population

The records of 317 consecutive patients who underwent orthognathic surgery in the Division of Maxillo-Facial Surgery of the General Hospital St. John, Bruges, Belgium, between 1.10.90 and 1.10.92 were evaluated for pre- and postoperative temporomandibular joint (TMJ) symptoms. Only 143 patients, with a normal/low angle mandibular deficiency deformity, treated by mandibular advancement, and 53 high angle absolute mandibular retrognathism patients having bimaxillary operations, were selected. Fewer TMJ symptoms were found postoperatively, than preoperatively in the total group (17.8% vs 26.5% p = 0.025, Mc Nemar). In the normal/low angle group, there was a decrease in TMJ symptoms after surgery from 30.0% to 14.6% (p = 0.0001, Mc Nemar). In the high angle group, however, more TMJ symptoms are seen postoperatively 26.4% versus 16.8% (p = 0.228, Mc Nemar). Possible hypothetical explanations are given.

Creating lip seal by maxillo-facial osteotomies. A retrospective cephalometric study

Lateral head films taken immediately pre-operatively and at least 6 months postoperatively were analysed in 99 selected orthognathic surgery patients to study soft and hard tissue ratios in relation to lip seal creation. The patients were grouped according to the osseous correction carried out. In maxillary advancement patients, the overall position of stomion superius was difficult to predict when important horizontal and vertical movements had been made. The vertical movement of stomion superius was 30% of that seen at the anterior palate point, and 25% of that at the upper incisal point, when the main vector of maxillary repositioning was vertical (either intrusion or extrusion). There was a weak linear correlation between mandibular advancement at pogonion and vertical changes at stomion inferius. The correlation increased if vertical movement at menton and mentolabial angle were added as independent variables. Good linear correlations between vertical changes at stomion inferius and vertical changes at lower incisal point and menton were observed in mandibular set-back surgery. In mandibular autorotation, the best linear correlation with single predictors was found between vertical changes at stomion inferius and those at menton (about 80% + 1 mm upward movement), and vertical changes at stomion inferius and horizontal changes at lower incisal point. Vertical changes at stomion inferius were mainly determined by vertical changes at menton in genioplasties, the change at stomion inferius being 40% of that at menton. The horizontal component at pogonion had almost no influence. In combined genioplasty and Le Fort I procedures, the vertical changes at stomion inferius were 50% of those at menton + 1 mm upward movement, this difference being due to mandibular autorotation.

Orthognathic surgery: patients' subjective findings with focus on the temporomandibular joint

Two hundred and ninety-six patients who underwent various orthognathic surgery procedures were questioned, a minimum of 1 year postoperatively, on their overall subjective findings. Patient satisfaction, willingness to resubmit to surgery, self-confidence and subjective changes in their temporomandibular joints (TMJ) function and masticatory efficiency were evaluated. 87% would undergo the combined surgical-orthodontic treatment again. Self-confidence improved in 77% of the patients. There was a subjective improvement in TMJ function in 40% of the patients and a worsening in 11%; masticatory function was improved in 41% and worsened in 7% of the patients.

Use of fibrin glue in lower blepharoplasties

This prospective study investigates the long-term appearance of the scar following closure of lower blepharoplasty incisions with the fibrin adhesive Tissucol compared with the usual subciliary suturing. Eighteen eyelids closed with fibrin adhesive were compared with 12 eyelids where a 5-0 running suture was used for closure and to 10 eyelids that did not undergo surgery. The measurement team consisted of a panel, blind to patients and technique, that scored the scar morphology on a scale of 1-4. The Dunn test showed no difference between the group treated with the tissue adhesive and the group with conventional subciliary closure. There was a difference between the Tissucol treated group and the control group (P < 0.01). The surgical technique and the advantages in lower lid incision closure are discussed.

Evaluation of the slot osteosynthesis technique in mandibular advancement

The slot osteosynthesis technique (SLOT) was evaluated in 25 mandibular advancements. SLOT was successfully used to readjust skeletal and occlusal malpositioning in 48% of the cases. Neurosensory tests in the lower lip and chin region revealed a low disturbance rate (immediately postsurgery 20% of patients, at 7 months 8%). This may be due to the specific splitting and fixation techniques applied.

Brow and forehead lift with cranial suspension

Summary Cranial suspension of the forehead skin in a coronal lift enables more precise modelling of the brows. The tension on the skin closure line, and consequently the risk of local alopecia, are considerably reduced.

Allotransplantation or autotransplantation to the face, which first?

The idea of composite tissue allotransplantation (CTA) of (cranio-maxillo-) facial tissues has evoked an intense, society-wide ethical debate in the years 2002e2007, in both the scientific and lay press. It focused on identity change, social ostracism and re-acceptance, immunosuppressive burden with associated life-long risks, quality and quantity of life, and indications. In the meanwhile, the spectrum of indications has been narrowed to traumatic loss of oral and eyelid sphincter functions, extensive non-malignant tumoural malformation, and extensive burns of face and scalp, impossible to reconstruct properly with autologous tissue. It was considered that many of such attempts should have preceded the transposing of a face, because the risk of loss of the allotransplant would be a disaster (Agich and Siemionow, 2004; Strong, 2004; Siemionow and Sonmez, 2008). The CTA would constitute the last resort. We question this philosophy. Let us face the risk of acute rejection, and compare hand transplantation to other CTA such as the face. Of the first 36 hand transplants performed in 24 registered patients, 75% experienced acute rejection within the first year (Banff grade IeIII, Cendales et al., 2008), but none was lost because of that. Temporary intensification of the anti-rejection regimen based on periodic biopsies reversed rejection (Petruzzo, 2009). One hand was lost because of venous obliteration (day 45) and one because of intimal hyperplasia (day 275 e after 4 untreated acute rejection periods e donor specific antibody (DSA) negative before amputation and positive after graft loss e Banff grade I). The longest follow-up is 10 years. The rate of medical non-compliance is 1 in 24. Hence, today, immunosuppressive therapy is able to deal effectively with acute rejection in 100% of cases. Chronic rejection however, as observed in solid organ transplants, will be an important issue in the future. Facial transplants risk to fail after 10e20 years due to intimal proliferation and arterial occlusion. The exact percentage and time span may be different from lung (high), heart and kidney (medium) or liver (low) transplantation, but vasculopathy will strike. Besides constant monitoring by biopsies of the skin and arteries, and early on plasmapheresis or application of mammalian target of rapamycin (mTOR) inhibitors or human immunoglobulin such as after heart transplantation, there is not much that can be done today. Hence, an exit strategy should be considered from in the beginning. This could mean another allotransplant, such is done upon availability for solid organs. Another

Postoperative Respiratory Complications After Cleft Palate Closure in Patients With Pierre Robin Sequence: Operative Considerations

Background: In cleft palate surgery, there is currently no consensus on the management of patients with Pierre Robin Sequence (PRS). The authors aimed to evaluate the treatment strategy of cleft palate in our centers, with emphasis on patients with PRS, as the authors noted some patients with severe respiratory distress. Moreover, the authors aimed to investigate the prevalence of postoperative respiratory complications, using a modified-Furlow palatoplasty in combination with intravelar veloplasty in both patients with PRS and patients with non-PRS. Methods: The authors retrospectively identified all consecutive patients, both PRS and non-PRS, who underwent palate repair between January 1, 2012 and December 15, 2014 at 2 cooperating cleft centers (Bruges, Belgium; Budapest, Hungary). The treatment modality was uniform and performed by the same 2 surgeons. Results: In 92 consecutive patients, 4 patients experienced respiratory distress after palate repair. The female-to-male ratio was 1:1. The mean age at surgery in these 4 patients was 15 months (range 13–19 months). Fifteen percent (2/13) of patients with PRS experienced respiratory distress in comparison to 3% (2/79) of non-PRS (&khgr;2 = 4.43; P = 0.035). Conclusions: This is the first report of postoperative respiratory difficulties, while using a modified-Furlow palatoplasty in combination with intravelar veloplasty. In the present authors experience, the authors suggest to perform a 2-stage closure of the cleft palate in patients with PRS and to do so at a later age, when the palatal tissues and airway structures are more mature. Moreover, patients with PRS should be monitored closely, as they can present with different degrees of respiratory distress after palatoplasty.

Planning en plaatsing van implantaten in de bovenkaak op basis vanct-scan van proefopstelling, gevolgd door onmiddellijke belasting

Ons bezoekt een 62-jarige gezonde man vanwege het feit dat zijn volledige bovenprothese niet voldoet. Hij consulteert ons met de vraag wat er aan de, zowel functioneel als sociaal lastige, toestand te doen valt en of er met implantaten een oplossing geboden zou kunnen worden. Indien mogelijk opteert de patient voor een snelle comfortabele en vaste oplossing. In de onderkaak heeft hij nog slechts de zes frontelementen, met een uitneembare frameprothese die voldoet.