Joram Raveh

Classification and treatment of zygomatic fractures: a review of 1,025 cases.

The treatment of zygomatic fractures varies among surgeons, and the cosmetic and functional results are frequently less than optimal. A treatment guideline based on a simple classification of zygomatic fractures is presented. The emphasis is placed on the indications for closed and open reduction, consistent methods of three-dimensional alignment and fixation, and the management of concomitant infraorbital rim and orbital floor fractures. Postoperative results with regard to infraorbital nerve and maxillary sinus dysfunction, malar asymmetry, and orbital complications in the treatment of 1,025 consecutive zygomatic fractures are presented.

Use of the titanium-coated hollow screw and reconstruction plate system in bridging of lower jaw defects

Clinical results obtained with hollow titanium screws and reconstruction plates in the bridging of mandibular bone defects of 17 patients are described. Following implantation the newly forming bone establishes direct contact with the sprayed titanium surface of the screw and the underside of the plate and permeates the screw. The stability of anchorage therefore increases with the duration of implantation. The reconstruction system also allows salvaging of small fragments such as the condyloid process. The adjustable, individually shaped, mandibular condylar prosthesis permits precise restoration of articular guidance on the reconstructed side while preventing incorrect loading of the opposite joint. The clinical results confirm the recently published findings from animal studies.

Open reduction of the dislocated, fractured condylar process: Indications and surgical procedures

The subject of this paper is the evaluation of the results after surgical management of 29 dislocated fractures of the condylar process. Only fractures with total dislocation of the condyle out of the articulate fossa were surgically treated. The surgical procedure, making a broad exposure necessary, is detailed. The low rate of complications as well as the satisfactory function of the joints in spite of severe dislocation seems to confirm the surgical treatment of this type of fractures.

Temporomandibular joint ankylosis: Surgical treatment and long-term results

The surgical treatment of 26 patients with ankylosis of the temporomandibular joint, as well as various methods and materials used for functional restoration are described. The significance of radical removal of the ankylotic bone, as well as the advantages of the interpositioning of the lyophilized cartilage, are emphasized.

New techniques for reproduction of the condyle relation and reduction of complications after sagittal ramus split osteotomy of the mandible

One hundred three patients underwent a modified sagittal ramus split osteotomy of the mandible. Maintenance of the temporomandibular joint relationship prior to the procedure was achieved postoperatively by using a three-dimensionally adaptable fixation bar. Techniques were also developed to avoid damage to the inferior alveolar nerve during the osteotomy and application of lag screws. These procedures avoided the disadvantages of lag screw osteosynthesis, and reduced relapse.

Plate osteosynthesis of 367 mandibular fractures. The unrestricted indication for the intraoral approach.

Experience in the management of 916 fractures of the mandible stimulated us to develop new methods and surgical techniques for functionally-stable intraoral internal plate osteosynthesis. The development of a fixation bar which is adapted to the alveolar process of the fractured mandible enables a compression of this area prior to the plate osteosynthesis. This procedure facilitates the plate application from the intraoral approach so that in 358 cases all types of fractures of the body, angle and ascending ramus can be reduced using this access, and not only the selected favourable cases. A new plate and screws of our own design have been successfully used in cases with comminuted multifragmentary and defect fractures. The rigid fixation of the head of the screws to the plate produces an optimal functional stability compared with conventional systems. The combination of the advantages of an external fixation device and those of stable internal osteosynthesis produces a long term functional stability even in cases with extensive defects where delayed consolidation is to be expected; tilting and loosening of the screws or resorption of the compact bone underneath the plate do not occur. Thus the extraoral approach and visible skin incisions can be avoided. This procedure is time sparing and less traumatic to the soft tissues compared with the extraoral approach. The extremely low complication rate in 358 fractures managed by plate osteosynthesis using the intraoral approach confirms the efficiency of this method.

The surgical one-stage management of combined cranio-maxillo-facial and frontobasal fractures. Advantages of the subcranial approach in 374 cases

The aim of this paper is to emphasize the advantages of a one-stage, step by step repair of facial skeletal injuries as well as the dural tears and lesions of the anterior fossa, by one and the same team. The methods described permit optimal reduction of the pseudohypertelorism and major displacements in severe combined craniofacial injuries. The simultaneous subcranial exposure of the entire basal region of the anterior fossa obviates the intracranial approach or frontal lobe retraction thus making early stage surgical management feasible. The surgical treatment of these injuries as a single entity, as well as further modifications reduce complications such as recurrent CSF leakage, anosmia, mucocoele or secondary operations for inadequate fracture reduction. The significance of primary meticulous reconstruction of the combined cranial vault and midface fractures for the achievement of normal physiological function of the various systems is particularly highlighted.

Mandibular Reconstruction with the Titanium Hollow Screw Reconstruction Plate (thorp) System: Evaluation of 62 Cases

The titanium hollow screw reconstruction plate (THORP) system for reconstruction of lower jaw defects provides a functional stable fixation and is used as a long-term or permanent implant in tumor surgery and in traumatology. The rigid fixation of the head of the screw to the plate, avoiding unphysiologic loads to the bone underneath the plate, and the titanium plasma-coated perforated hollow screws, enabling the development of direct bone-titanium contact as well as the ingrowth of bone into the lumen and perforations, are the major advantages of this system compared to conventional systems. The different surgical methods, such as preservation of the condylar process with only two screws, intra-operative freely adjustable condylar prosthesis, lingual application of the plate, and primary bone transplantation, are described. The evaluation of 62 patients reconstructed with the THORP system between 1981 and 1986 revealed no plate loosening, even in irradiated bone, and showed satisfactory aesthetic and functional results.

Esthesioneuroblastoma: irradiation alone and surgery alone are not enough

PURPOSE To evaluate the long-term outcome of patients with esthesioneuroblastoma treated with neoadjuvant or definitive radiotherapy (RT). METHODS AND MATERIALS Between 1980 and 2001, 28 patients with histologically confirmed esthesioneuroblastoma underwent RT, with a median dose of 60 Gy (range 38-73). The median age was 58 years (range 16-85). According to the Kadish classification, 4 patients had Stage A, 8 Stage B, and 16 Stage C tumors. Radical resection was performed in 13 cases, in 9 before RT and in 4 after RT because of stable or progressive disease. The outcome analyses included the median age (58 years), Kadish stage, skull base penetration, intraorbital extension, resection status, and total dose (<or=60 vs. >60 Gy). RESULTS After a mean follow-up of 68 months, 54% of patients were free of tumor progression. The 5- and 10-year local progression-free survival rate was 81% and 51%, respectively, and the disease-free survival rate was 70% and 25%, respectively. Four of ten deaths (4/10) were intercurrent, resulting in a cause-specific survival of 77% and 69% at 5 and 10 years, respectively. Radical resection offered significantly better local progression-free survival and disease-free survival (p <0.02). Skull base penetration (p <0.04), intraorbital extension (p <0.04), and Kadish C stage (p <0.06) were important for impaired disease-free survival. CONCLUSION Despite doses up to 73 Gy, radical RT cannot replace radical resection, which classifies esthesioneuroblastoma as rather radioresistant. Because of its biology and the high rates of late recurrence, we recommend a radical strategy with resection, high-dose RT, and simultaneous chemotherapy. We are aware that some tumors qualify for palliative treatment only.

Operative management of 194 cases of combined maxillofacial-frontobasal fractures: principles and surgical modifications.

The treatment modalities and results of 346 cases of frontobasal and midface fractures, 194 of which had to be managed by surgery, are reported, and the operative results are evaluated. The importance of an early one-stage operative repair of combined frontobasal-maxillofacial fractures is stressed. The indications for the pure transethmoidal, combined transethmoidal-transfrontal, and single neurosurgical handling of these patients are analyzed. Important surgical modifications that are decisive in the operative management of these fractures are described.