Laura A. Monson

History of synthetic materials in alloplastic cranioplasty

When faced with calvarial defects, surgeons have long searched for repair materials. General criteria include ease of use, low cost, availability, cosmetic shape, and osteointegrative potential. While autologous bone is widely used and favored in contemporary reconstructive procedures, synthetic alternatives have been used throughout history and are necessary in current practice for select cases when autograft reconstruction is not an option (such as cases with severe bony comminution, bone graft resorption, infection, and limited donor site options). For centuries, surgeons have experimented with metals, ceramics, plastics, and later, resorbable polymers. This paper provides a tour of the materials that have been used and experimented with throughout the history of alloplastic cranioplasty.

Bilateral sagittal split osteotomy.

The bilateral sagittal split osteotomy is an indispensable tool in the correction of dentofacial abnormalities. The technique has been in practice since the late 1800s, but did not reach widespread acceptance and use until several modifications were described in the 1960s and 1970s. Those modifications came from a desire to make the procedure safer, more reliable, and more predictable with less relapse. Those goals continue to stimulate innovation in the field today and have helped the procedure evolve to be a very dependable, consistent method of correction of many types of malocclusion. The operative surgeon should be well versed in the history, anatomy, technical aspects, and complications of the bilateral sagittal split osteotomy to fully understand the procedure and to counsel the patient.

Prenatal Identification of Pierre Robin Sequence: A Review of the Literature and Look towards the Future

Fetal ultrasonography is an important tool used to prenatally diagnose many craniofacial conditions. Pierre Robin sequence (PRS) is a rare congenital deformation characterized by micrognathia, glossoptosis, and airway obstruction. PRS can present as a perinatal emergency when the retropositioned tongue obstructs the airway leading to respiratory compromise. More predictable and reliable diagnostic studies could help the treating medical team as well as families prepare for these early airway emergencies. The medical literature was reviewed for different techniques used to prenatally diagnose PRS radiologically. We have reviewed these techniques and suggested a possible diagnostic pathway to consistently identify patients with PRS prenatally.

Management of Pediatric Mandible Fractures

When determining the optimal treatment strategy for a pediatric mandible fracture, planning must factor in the patients age, anatomy, stage of dental development, fracture site, and ability to cooperate with the proposed treatment plan. Careful consideration must be given to the possibility of long-term growth disturbance with various fracture locations and types of treatment. This article reviews the current principles of the management of pediatric mandibular fractures.

Treatment effects of dexmedetomidine and ketamine on postoperative analgesia after cleft palate repair.

Primary cleft palate repair may result in significant pain in the immediate postoperative period, which can lead to vigorous crying resulting in wound dehiscence and pulmonary complications. Effective pain control with opioids is the mainstay but administration on the floor has to be countered with the complications associated with their use, chiefly respiratory depression and sedation. We retrospectively examined the efficacies of intraoperative administration of intravenous (IV) dexmedetomidine (DEX) and ketamine (KET) to prevent early postoperative pain in children undergoing primary cleft palate repair and compared the results against relevant literature. The Texas Childrens Hospital anesthesia database was queried to identify children undergoing a palatal surgery from December 2011 to December 2012. Inclusion criteria permitted completed primary palatal surgery without major complications and intraoperative administration of DEX or KET. The control group (CTRL) received no additional drug. A comprehensive literature review was performed. A total of 71 pediatric patients underwent palatal surgery during the study period with 46 patients qualifying for analysis. Although results were not significant, consistent trends were observed with regards to lower opioid requirements during the first 24 hours for both medications compared with the CTRL. KET also had shorter time to discharge. The literature review resulted in several studies supporting decreased postoperative pain end points for both DEX and KET. In our sample, DEX and KET reduced postoperative opioid requirements. KET seems to have the added benefit of a shorter hospital stay. These finding are supported in the literature. With further investigation, the addition of these drugs may serve to provide improved pain relief without over sedation in patients undergoing cleft palate repair.

A standard set of outcome measures for the comprehensive appraisal of cleft care

Care of the patient with cleft lip and/or palate remains complex. Prior attempts at aggregating data to study the effectiveness of specific interventions or overall treatment protocols have been hindered by a lack of data standards. There exists a critical need to better define the outcomes- particularly those that matter most to patients and their families-and to standardize the methods by which these outcomes will be measured. This report summarizes the recommendations of an international, multidisciplinary working group with regard to which outcomes a typical cleft team could track, how those outcomes could be measured and recorded, and what strategies may be employed to sustainably implement a system for prospective data collection. It is only by agreeing on a common, standard set of outcome measures for the comprehensive appraisal of cleft care that intercenter comparisons can become possible. This is important for quality-improvement endeavors, comparative effectiveness research, and value-based health-care reform.

Virtual surgical planning and 3D printing in repeat calvarial vault reconstruction for craniosynostosis: technical note

Repeat surgery for restenosis after initial nonsyndromic craniosynostosis intervention is sometimes needed. Calvarial vault reconstruction through a healed surgical bed adds a level of intraoperative complexity and may benefit from preoperative and intraoperative definitions of biometric and aesthetic norms. Computer-assisted design and manufacturing using 3D imaging allows the precise formulation of operative plans in anticipation of surgical intervention. 3D printing turns virtual plans into anatomical replicas, templates, or customized implants by using a variety of materials. The authors present a technical note illustrating the use of this technology: a repeat calvarial vault reconstruction that was planned and executed using computer-assisted design and 3D printed intraoperative guides.

Secondary Lip and Palate Surgery

To properly treat a patient with a secondary cleft lip or palate deformity, one must make an accurate diagnosis of the underlying problem. Recognition of specific recurring patterns and common deformities will help facilitate the surgical planning process and assist the surgeon during future procedures. Through a combination of accurate analysis, clinical patience, and technical precision, successful correction of secondary cleft lip and palate deformities can be delivered.

Complete resolution of papilledema in syndromic craniosynostosis with posterior cranial vault distraction

We report a case of surgical management of Crouzon syndrome with multisuture craniosynostosis presenting with increased intracranial pressure (ICP) manifesting with chronic papilledema without ventriculomegaly. A 12-month-old boy had complete resolution of papilledema after posterior cranial vault distraction followed by staged fronto-orbital advancement. Expansion of the cranial vault with posterior distraction osteogenesis posed an elegant treatment, obviating ventriculoperitoneal shunt placement for cerebrospinal fluid (CSF) diversion. Strategies for the management of elevated ICP without ventriculomegaly in craniosynostosis include CSF shunting and cranial vault expansion. Posterior calvarial vault distraction associated with resolved papilledema has not been previously reported. Addressing the craniocephalic disproportion for this child with chronic papilledema, without ventriculomegaly, allowed the possibility of shunt freedom.

Radioprotection with Amifostine Enhances Bone Strength and Regeneration and Bony Union in a Rat Model of Mandibular Distraction Osteogenesis

Background Using distraction osteogenesis (DO) to regenerate robust endogenous bone could greatly enhance postoncologic reconstruction of head and neck cancer. However, radiation (XRT) corrosive effects still preclude DOs immense potential. We posit that adjunctive pretreatment with the radioprotectant amifostine (AMF) can optimize wound healing and allow for successful DO with quantifiable enhancements in bony union and strength despite previous surgical bed irradiation. Methods Two groups of murine left hemimandibles were exposed to a human equivalent radiation dosage fractionated over 5 daily doses of 7 Gy. AMF-XRT-DO (n = 30) received AMF before radiation, whereas XRT-DO (n = 22) was untreated. All animals underwent left hemimandibular osteotomy and external fixator placement, followed by distraction to a 5.1-mm gap. Left hemimandibles were harvested and mechanically tested for parameters of strength, yield, and breaking load. Results Radiation-related complications such as severe alopecia were significantly increased in XRT-DO compared with the AMF-treated group (P = 0.001), whereas infection and death were comparable (P = 0.318). Upon dissection, bony defects were grossly visible in XRT-DO distraction gap compared with AMF-XRT-DO, which exhibited significantly more complete unions (P = 0.004). Those results were significantly increased in the specimens prophylactically treated with AMF (yield: 39.41 N vs 21.78 N, P = 0.023; breaking load: 61.74 N vs 34.77 N, P = 0.044; respectively). Conclusions Our study revealed that AMF enhances biomechanical strength, regeneration, and bony union after radiation in a murine model of DO. The use of prophylactic AMF in combination with DO offers the promise of an alternative reconstructive option for patients afflicted with head and neck cancer.