Michael F. Zide

Indications for open reduction of mandibular condyle fractures

Abstract Most condylar fractures of the mandible may be treated by closed reduction and appropriate physiotherapy. Some, however, absolutely should be opened and reduced anatomically; with others, good arguments for open reduction may be offered. This article reviews the possible indications for open reduction and presents an approach that conceals the scar.

Alveolar ridge augmentation using nonresorbable hydroxylapatite with or without autogenous cancellous bone.

A four-year prospective evaluation of the use of nonresorbable, particulate hydroxylapatite (HA) to augment deficient alveolar ridges was performed. The material was used alone and in combination with finely crushed autogenous cancellous bone. Implants were delivered subperiosteally by syringe injection, usually using local anesthesia for Class I to Class III ridges and general anesthesia for Class III and Class IV ridges. The improved ridge height and width were stable. Postoperative resorption with significant loss of ridge height, frequently seen with rib and iliac crest onlayed grafts, was not observed with HA augmentation. Permanent denture construction began as early as three weeks postoperatively and by four to six weeks if HA was combined with autogenous cancellous bone. It was possible to place mandibular staple implants simultaneously or following HA augmentation. Visor osteotomy techniques were improved by use of HA to produce a wider, more convex stable ridge. Although skin, mucosa, or dermal vestibuloplasties were performed as early as three months postoperatively in a small number of patients, there appeared to be a lesser need for vestibuloplasty after HA augmentation than after onlay bone grafting. In addition, prosthodontists performed fewer denture relines after HA augmentation than after onlay bone grafts. The authors believe the most significant factor accounting for these observations is the firm, nonmobile mucosal base resulting from augmentation with HA. The resultant stable, soft tissue base and improved ridge height and contour have contributed to a comfortable, retentive, stable denture for these patients. The prosthetic and surgical procedures are easier to perform and have produced superior, more permanent results than onlay bone grafts and alloplasts. Preliminary studies also point to exciting possibilities for use of HA as a bone substitute/marrow extender in maxillary and mandibular defects, cysts, and clefts and in osteotomies for orthognathic surgery.

Hydroxylapatite blocks and particles as bone graft substitutes in orthognathic and reconstructive surgery.

A three-year clinical evaluation of 98 patients in whom dense hydroxylapatite in particle and block form had been placed in facial contour defects and osteotomy sites, and in cystic and reconstructive defects, alone or with autogenous bone, was conducted. The results indicate that the implants were effective in reducing operating time and potential for infection and relapse, as well as in reducing or eliminating the necessity of a donor site. The clinical response was excellent, and complications with both forms were minor, generally related to lack of initial fixation or failure to use autogenous bone in specific situations.

Late treatment of malunited malar fractures

Malunited malar fractures are considered from the points of view of pathophysiology and anatomy. Clinical and radiographic approaches to assessment are described. Surgical techniques are presented in detail. Four representative cases are reported.

Late posttraumatic enophthalmos corrected by dense hydroxylapatite blocks

Late enophthalmos caused by an unrepaired zygomatic or orbital blowout fracture can cause esthetic and functional impairment. The sunken appearance of the superior suicus and the depressed globe are obvious cosmetic defects. Functional impairment of the eye can also be troublesome, with restriction of motion and diplopia being common complaints. Early repair of surgically correctable fractures, prior to scar contraction or fat atrophy, is the most acceptable procedure. Even so, early repair is at times fraught with uncertainty, since the only parameter for measuring the adequacy of treatment is the late cosmetic and acceptable functional result. The various materials that have been used to treat orbital floor complications in the nonseeing eye include glass beads,’ tantalum,2 Teflon,3 polyethylene,4 polymethylmethacrylate,5 and Silastic6 In the seeing eye the placement of Silastic, cartilage,7 fascia,8 and bone,9,10 as well as osteotomy” have been used. Both the use of autogenous materials that resorb or move and osteotomy constitute only crude nonreproducible methods for the correction of late enophthalmos. This case report describes the use of hydroxylapatite in dense block form (Calcitek, San Diego, California) to correct late posttraumatic enophthalmos in a seeing eye.

Delayed repair of skin cancer defects

PURPOSE A review of surgical outcomes in 280 patients who underwent in-office excision of skin lesions, open wound therapy, and delayed reconstruction is presented. Advantages of open wound therapy and delayed reconstruction are discussed. PATIENTS AND METHODS The surgical records of all patients treated between January 1, 1994 and December 31, 1996 were evaluated for outcome and complications. RESULTS One hundred seventeen patients presented with biopsy-confirmed malignant skin lesions of the head and neck. After surgical excision of the malignancy, the wounds were treated with a semiocclusive dressing while waiting for the results of the biopsy report and reconstruction (open wound therapy). Eighty-nine percent of the residual skin defects were repaired within 10 days. The remaining 11% were closed within 35 days. Except for one allergic reaction to neomycin and slight blood oozing from the wound in two patients, no other complications occurred. CONCLUSIONS Open wound therapy is an effective method for managing skin defects after excision of malignant lesions. It is cost-effective and can be done quickly as an in-office procedure under local anesthesia without complications.

Freehand full-thickness grafting for facial defects: A review of methods

PURPOSE This article reviews the use of full-thickness skin grafts for closure of facial defects. PATIENTS AND METHODS In almost 3 years, 30 patients had full-thickness skin grafting after removal of premalignant or malignant facial skin lesions. The most common graft harvest sites included the preauricular and postauricular, neck, and supraclavicular areas. RESULTS Few complications were seen except for rare surface necrosis and depression of the grafted site, and the esthetic results were generally satisfactory. CONCLUSION Full-thickness skin grafts offer a reliable alternative to the use of flaps in selected cases.

Actinic Keratosis: From the Skin to the Lip

PURPOSE Actinic keratoses are commonly the result of intense sun damage to the skin and lips of susceptible patients. The purposes of this 2-section article are to familiarize the surgeon with options for care and to suggest methods of incorporation into practice as a true benefit to patients. PATIENTS AND METHODS The first section discusses the options chosen for patients who were referred to the Facial Lesion Clinic in a county hospital for precancerous or cancerous facial lesions; the second section reviews ramifications for precancerous sun-damaged lips with clinical leukoplakia. RESULTS Methods are available to aid patients with precancerous facial and lip lesions. Choices have been presented with patient examples. CONCLUSION Patients with precancerous facial and lip lesions should receive therapy that diagnoses or treats these lesions. Long-term avoidance or mere observation of these lesions will portend future cancer.

Scar revision with hypereversion

PURPOSE Scar revision techniques rarely describe methods of deep tissue closure. This article reinvestigates an often-forgotten method of deep wound closure that produces wide eversion. CONCLUSION The process may be used alone, with subcutaneous closure, or as an adjunct to W and Z-plasty techniques. Advantages are discussed, and representative cases are presented.

The placement of screws above the zygomaticofrontal suture

The use of plates in the zygomaticofrontal (ZF) region for stabilization of zygoma fractures necessitates use of screw holes. This anatomic study was done to assess where these holes can be safely placed. A study of 20 adult skulls showed that when drilling perpendicular to the bone above the ZF suture, the cranial cavity can be entered as low as 12 mm above it (average, 15 mm). Therefore, when drilling more than 12 mm over the ZF suture, the surgeon should angle the drill at an acute angle to the forehead to prevent cranial encroachment. In addition there is great variability of depth of bone around the ZF suture. When drilling perpendicularly on the frontal bone in the first centimeter above the ZF suture, the orbital cavity will always be entered.