Peter Ayliffe

Orbital fractures in children

In children, differences in the properties and proportions of bone in the craniofacial skeleton and the lack of development of the paranasal sinuses result in orbital fractures that present differently from those in adults. Facial growth may be disturbed by such injuries and also by surgical intervention, which should therefore be as conservative as possible. However, urgent operation is needed to prevent irreversible changes when fractures of the orbital floor involve entrapped muscle. We present an approach to such injuries.

The surgical management of Treacher Collins syndrome.

Treacher Collins syndrome (TCS), mandibulofacial dysostosis, or Franceschetti-Zwahlen-Klein syndrome, is a rare genetic disorder characterised by dysgenesis of the hard and soft tissues of the first and second branchial arches. Early operations focus on maintaining the airway, protecting the eyes, and supporting auditory neurological development. Later operations include staged reconstruction of the mouth, face, and external ear. Bimaxillary surgery can improve the maxillomandibular facial projection, but correction of malar, orbital rim, and temporal defects may be more difficult. We present a clinical review of the syndrome with a chronological approach to the operations.

Segmental maxillary distraction with a novel device for closure of a wide alveolar cleft

Treatment of a wide alveolar cleft with initial application of segmental distraction osteogenesis is reported, in order to minimise cleft size prior to secondary alveolar bone grafting. The lesser maxillary segment was mobilised with osteotomy at Le Fort I level and, a novel distractor, facilitated horizontal movement of the dental/alveolar segment along the curvature of the maxillary dental arch. Following a latency period of 4 days distraction was applied for 7 days at a rate of 0.5 mm twice daily. Radiographic, ultrasonographic and clinical assessment revealed new bone and soft tissue formation 8 weeks after completion of the distraction phase. Overall the maxillary segment did move minimising the width of the cleft, which allowed successful closure with a secondary alveolar bone graft.

Interleukin 12 Receptor β1 Chain Deficiency in a Child With Disseminated Tuberculosis: A Case Report

F a nterleukin (IL) 12 receptor 1 chain (IL-12R 1) deciency is 1 of 5 rare genetic defects of Mendelian usceptibility to mycobacterial disease. The known utations in the IL-12R 1 genes are autosomal recesive and associated with the abolition of the response o IL-12 and IL-23. Affected individuals have an inreased susceptibility to Mycobacterium tuberculosis nd non-typhoid salmonellosis. Etiologic agents inlude bacille Calmette-Guérin (BCG) vaccine, envionmental nontuberculous mycobacteria (NTM), and on-typhoid Salmonella species. The typical onset is in early childhood. The patient ay present with disseminated lymphadenopathy, reuiring medical and sometimes surgical intervention. owever, the prognosis is poor and may cause death n the first decade of life. Less frequently, when the nset of the disease is delayed until adulthood, there s a better prognosis. Antimycobacterial therapy is he treatment of choice. Because there is a high incience of relapse, this therapy may even have to be ontinued after complete healing has been achieved.

Esthetic and functional rehabilitation in patients with cleft lip and palate.

Oral rehabilitation of missing teeth in cleft patients has acceptable success rates. A two-stage approach is indicated; however, timing of implant placement in the grafted maxilla varies within existing protocols. This case highlights successful implant osseointegration and esthetic oral rehabilitation following placement of two implants at 5 months after maxillary grafting (alveolar bone grafting) with a corticocancellous block obtained from the iliac crest. A 31-year-old male patient had already undergone repair of his bilateral cleft lip and soft palate according to established guidelines for cleft patients. Initial closure of his alveolar clefts and further correction of the maxillary hypoplasia with a bi-maxillary osteotomy were completed in 2002. However, bone resorption due to infection in 2003 necessitated removal of all maxillary incisors. The patient was not satisfied with the removable partial denture provided. In 2007, he did undergo anterior maxillary augmentation under general anesthesia, and 5 months later two implants were placed. A 3-unit bridge did replace functional and esthetic demands. Postoperative recovery was uneventful, and overall bone loss, and oral health remain within standards 28 months following implant placement. Optimal outcome is achievable when replacing missing teeth in cleft patients when timing does not exceed approximately a 6-month interval from bone grafting to implant placement. This article demonstrates that overall esthetic and functional rehabilitation is feasible in cleft lip and palate patients. In this patient, overall oral treatment was achieved with an implant prosthesis.

Costochondral grafting for paediatric temporomandibular joint reconstruction: 10-year outcomes in 55 cases

Costochondral grafting (CCG) can be used for the reconstruction of ankylotic, hypoplastic, and resected temporomandibular joint (TMJ) defects. CCGs have previously been considered the gold standard in children due to their growth potential and autogenous origin, but the disadvantages are unpredictable growth and joint ankylosis. This was a retrospective study of all children who received CCGs for TMJ reconstruction from 1985 to 2004, to allow a 10-year follow-up. Fifty-five patients were included in this study, with 74 grafts being placed; their mean age was 7.9±4.2years. Infection-related ankylosis (18.2%) and craniofacial microsomia (16.4%) were the most common diagnoses. Overall, 58.2% of patients suffered one or more complications over the follow-up period, with ankylosis (32.7%) and overgrowth (16.4%) being most common. There was a significant correlation between those with infection-related ankylosis and subsequent complications (χ2=8.8, df=1, P<0.005), while ankylotic patients in general exhibited greater overall complication rates (χ2=9.0, df=1, P<0.005). Patients with congenital TMJ defects were more likely to be complication-free than those with acquired defects (χ2=4.0, df=1, P<0.05). Caution is advised when placing CCGs in paediatric patients with ankylosed TMJs, especially those with infection-related ankylosis.

Electronic Follow-Up of Developing World Cleft Patients: A Digital Dream?

OBJECTIVE To identify potential access to telemedicine follow-up of children with clefts operated on a humanitarian mission. METHODS A cross-sectional study of parents of children presenting to a humanitarian cleft lip and palate mission in a Provincial Hospital in the Philippines. A purpose designed questionnaire was used to assess access to electronic and digital resources that could be used to aid follow-up. Forty-five (N = 45) parents of children having primary cleft lip and or palate surgery participated. There were no interventions. Access to the Internet was through Parent Perceived Affordability of Internet Access and Parent Owned Devices. RESULTS Thirty-one (N = 31) respondents were female. There was 93% mobile phone ownership. The mean distance traveled to the clinic was 187 km. Majority (56%) were fluent in English. Thirty-one percent accessed the Internet daily. Sixteen percent reported use of e-mail. Fifty-one percent accessed the Internet on a mobile device, and short message service use was the most affordable means of communication. CONCLUSIONS Due to perceived unaffordability and low levels of access to devices with cameras and the Internet, as well as issues with privacy, we cannot recommend relying on electronic follow-up of patients in the developing world.

Erratum to “Craniofacial and extracraniofacial anomalies in craniofacial macrosomia: A multicenter study of 755 patients” [J Craniomaxillofac Surg vol. 45(8) (August 2017), 1302–1310]

Erratum to “Craniofacial and extracraniofacial anomalies in craniofacial macrosomia: A multicenter study of 755 patients” [J Craniomaxillofac Surg vol. 45(8) (August 2017), 1302e1310] Cornelia J.J.M. Caron a, *, , Britt I. Pluijmers a, , Eppo B. Wolvius , Caspar W.N. Looman , Neil Bulstrode , Robert D. Evans c, , Peter Ayliffe , John B. Mulliken , David Dunaway , Bonnie Padwa , Maarten J. Koudstaal a, c, e a The Dutch Craniofacial Centre, Department of Oral and Maxillofacial Surgery, Erasmus University Medical Center, Sophias Childrens Hospital, Rotterdam, The Netherlands b Department of Public Health, Biostatistics, Erasmus MC, Rotterdam, The Netherlands c The Craniofacial Unit, Great Ormond Street Hospital, London, United Kingdom d Dental and Maxillofacial Surgery Department, Great Ormond Street Hospital, London, United Kingdom e The Craniofacial Center, Boston Childrens Hospital, Boston, USA

Resorption of the mandibular condyle after injections of botulinum toxin A

Temporomandibular joint disorders occur when the omeostasis of the joint is disrupted, either by a reduction n the adaptive capacity, or by sustained or excessive stress n it.1 The most common presentation is myalgia and the pathohysiology is based on Hilton’s law, which states that the erves that innervate a joint also supply the associated uscles.1 To minimise damage to a disrupted temporoandibular joint (TMJ), masticatory muscles reflexively ontract to reduce movement, and this overstimulation causes iscomfort.1 An option for treatment for myalgia is botulinum toxin (Botox ® , Allergan, Co. Mayo, Ireland).2 Botox ® inhibits he release of acetylcholine at the neuromuscular junction, educes the frequency of action potentials, and so prevents verstimulation.2 As the neurotoxic effects are temporary, egular injections are required. A 55-year-old woman with a 13-year history of TMJ disrder was referred to the maxillofacial surgery department t University College Hospital in March 2015. In 2012, she ad been diagnosed with Meige Syndrome, which is characerised by oromandibular dystonia and blepharospasm. She enied having had any treatment for this condition, but said hat earlier management had included the use of ibuprofen nd heat treatment. Examination of the TMJ showed limited translation bilatrally with tenderness in all masticatory muscles. The aximal interincisal distance was 22 mm. Dynamic magetic resonance imaging (MRI) showed adhesions, a right nteriorly displaced disc with reduction on opening, and little ovement of the left disc (Fig. 1). In April 2015, arthroscopy nd arthrocentesis greatly improved her symptoms, and she as discharged. In December 2015, she was referred again after a sudden eterioration in function. A second MRI showed further adheions and a similar reduction of movement. She had bilateral

Mandibular osteomyelitis after group A streptococcal septicaemia in a child.

Mandibular osteomyelitis in children is rare, and usually dontogenic in origin.1 We have read of only two other children with septicaemiaelated mandibular osteomyelitis, in both of whom it was n acute presentation in a newborn baby and was related to ethicillin-resistant Staphylococcus aureus.2,3 We describe n unusual case secondary to life-threatening septicaemia, ith a successful outcome after operation. A two-year-old boy was referred by his dentist to a speialist children’s oral and maxillofacial unit, because of an symptomatic “firm white plaque” in the lower right quadant. He had non-tender, exposed bone (8 × 12 mm) around he apex of his right mandibular canine with diffuse mucosal rythema. His teeth had no caries, but teeth B, C, and D had rade II-III mobility. His medical history showed that three months earlier he ad developed group A streptococcal septicaemia secondary o varicella zoster. This rapidly deteriorated into sepsisssociated, disseminated intravascular coagulopathy, and led o multiple organ failure. He had had a cardiac arrest on ransfer to a children’s intensive care unit, and had had a hromboembolism that affected the first and second toes on is left foot. Shortly after admission, a purpuric swelling of his chin nd neck was noted on the right. Ultrasound examination howed extensive oedema but no necrosis or collection. This esolved completely after eight weeks of combined antimirobial treatment given intravenously (antimicrobial drugs: ntravenous ceftriaxone, clindamycin, vancomycin, gentamcin and fluconazole, and oral amoxicillin). Before this illness is medical and social history had been unremarkable. This secondary presentation was indicative of chronic steomyelitis, with the characteristic features of exposed one and sequestration.4 Initial management was conservaive, with regular review and antibiotics given orally, because e had no symptoms and we wanted to prevent damage to his