Philip A. van Damme

Timing and transplant materials for closure of alveolar clefts: A clinical comparison of 296 cases*

A retrospective study of bone grafting of 296 clefts (165 unilateral and 131 bilateral was required) to answer questions about the most favourable timing and the most appropriate bone graft material. The results as such are not exceptional in comparison with earlier publications by the same or other authors, but it is of special interest that operations with different graft materials applied at different times in development, in (usually) a sufficient number of cases, can be compared together. The patients have been operated on during a period of 11 years, by the same surgeons, applying the same principles and techniques. It is shown that early secondary grafting, before the eruption of the canine, results in by far, the highest success rate. Similarly, chin bone is considerably better than any other type of transplant. Aspects of general planning, timing, technique and failures are extensively discussed. Besides the afore-mentioned most significant findings, it is also concluded that the results of grafting during osteotomies are better than they appear; that tertiary grafting is extremely difficult, and requires special surgical skill; that rib grafts score as high as iliac crest grafts and that materials other than these three types of bone should be avoided.

Condylar resorption after orthognathic surgery. Evaluation of treatment in 8 patients.

Several articles have been published on the subject of condylar resorption as a complication of orthognathic surgery. However, since there is little reference to treatment, the frequency of this phenomenon and the results of therapy are evaluated in a retrospective study. 8 patients out of a group of 329 who underwent sagittal split osteotomy in a 10-year period (251 bilateral, 73 Le Fort I + bilateral and 5 unilateral), were treated actively following the development of condylar resorption. 4 patients were operated upon a second time while others underwent occlusal rehabilitation. The results for the patients who underwent revisional surgery were unsatisfactory, with poor aesthetics and occlusal stability. The patients treated with an occlusal splint (+/- orthodontics and/or prosthetic therapy) had a functional occlusion and tolerable temporo-mandibular-joint complaints.

Non-surgical treatment of condylar fractures in adults: a retrospective analysis

PURPOSE The aim of the study was to investigate the results of non-surgical treatment of condylar fractures in a group of 60 patients with 71 condylar fractures, in order to establish a protocol to select patients for surgical treatment of condylar fractures. MATERIAL Out of a group of 91 patients treated in a non-surgical fashion, 60 patients with a total of 71 condylar fractures responded to the request for follow-up. METHODS Retrospective study, including clinical analysis of occlusion, asymmetry at rest and during mouth opening, maximum interincisal distance, signs of TMJ-dysfunction and analysis of radiographic data, i.e. shortening of the ascending ramus as measured on sequential orthopantomograms. RESULTS There were five patients (8%) with an unacceptable malocclusion of which one also had considerably limited mouth opening. Fifty-five patients (92%) had none or only minor signs of TMJ-dysfunction not requiring further treatment. CONCLUSION Only in selected patients with shortening of the ascending ramus of 8mm or more and/or considerable displacement of the condylar fragment, surgical repositioning and rigid internal fixation should be considered.

Early secondary osteotomy-stabilization of the premaxilla in bilateral clefts

Using the same arguments as for early bone grafting of the alveolar process in unilateral clefts, the cleft team of the University of Nijmegen started about 10 years ago to apply early osteotomy-stabilization of the premaxilla to bilateral clefts. A series of 13 cases with a minimum follow-up of 15 months is presented. The patients were operated on at the age of 8 2/12 to 12 5/12 years. The results are considerably better than when doing the same operation in the adult. More than 90% are successful. In comparison with adults we additionally register more favourable eruption of the canine, the possibility of closing the dental arch without prosthetic appliances and in some cases also the elimination of a psychological handicap. The inhibition of growth by this operation seems not to be important. If need be, Le Fort I osteotomies are possible after completion of growth. They will be in one piece which is technically easier than the usual three-segment Le Fort I. In conclusion we prefer early secondary osteotomy and stabilization of the premaxilla to the tertiary operation.

A modification of the tibial bone-graft-harvesting technique

A modified method of tibial bone-graft harvesting is presented. A hollow, cylindric, hand-driven instrument is used to harvest the graft at the medial slope of the tibial tuberosity. Satisfactory amounts of autogenous cancellous bone graft are available to bridge osteotomy gaps and facial fractures, fill smaller defects, and even obliterate a frontal sinus. There is minimal donor-site morbidity, and complications have not been seen in a series of nine consecutive patients.

Secondary post-traumatic periorbital surgery: Incidence and results

Over a 6 year period 20 patients presented for secondary corrections of the periorbital region after trauma. Corrections after isolated fracture of the zygoma were necessary in 6 cases, mainly comprising re-osteotomies and contour corrections. A tertiary correction was needed only once (17%). Secondary treatment was indicated in 6 patients after fracture of the midface, necessitating mainly re-osteotomies of the zygoma, corrections of the nose and canthopexies. Tertiary corrections were performed in 3 cases (50%). In 8 patients the results of treatment of fronto-orbito-nasal fractures required further improvement. Again, osteotomies of the zygoma, corrections of the nose as well as corrections of scars and bony contours were often indicated. Four cases (50%) needed tertiary surgery. It is concluded that the more serious the primary trauma the greater the necessity for further secondary surgery. Independently of the kind of primary trauma the indication for secondary treatment was, in most cases, aesthetic. Not only was the number of re-osteotomies and nasal corrections high, but also the number of tertiary revisions. While this might not be very surprising for the nose, it is for the zygoma and proves the difficulties which arise for perfect positioning when there are no clear landmarks. Forty percent of all patients underwent tertiary and one patient needs a quaternary correction.

Angioleiomyoma of the upper lip : report of a case

A rare case of vascular leiomyoma of the upper lip in a 51-year-old man is presented. The differential diagnosis, frequency, treatment, and prognosis are discussed.

Disturbances of smell and taste after high central midface fractures

Estimation of the senses of smell and taste in patients who had suffered a high central midface fracture between 1979 and 1989 was carried out. 180 of these patients were operated on for repositioning and fixation of their fractures. A written questionnaire was sent to 165 living patients, 109 individuals responded, a response rate of 66%. Of these patients, 38% claimed to suffer impaired ability to smell and 23% not to taste well. 64% mentioned unconsciousness after the trauma. With rising seriousness of the trauma, more disturbances of smell are found: from 25% of the nasal fractures, to 80% of the fronto-nasal-Le Fort fractures. In more than half of the cases of disturbance of smell, a simultaneous impairment of taste was reported. It can be concluded that disturbance of smell most often appears after fronto-maxillary and fronto-nasal fractures. However, the higher and more extensive the fracture is, the more frequently is unconsciousness reported. Consequently, impairment of smell can be attributed to the fracture itself, but also to a cerebral lesion located more proximally.

Radiologic analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats

Palatal soft-tissue expansion might be appropriate for use in cleft palate surgery. Seventy-five cats were divided into four different experimental groups and one control group. Intraoral tissue expansion was started at the age of 14 weeks in normal or scarred mucoperiosteum. The experiment lasted until 24 weeks of age. Serial standardized lateral cephalograms from each animal were digitized, and the results were statistically analyzed. The results indicate that the effects are independent of the presence of scarred tissue, that sagittal growth is impaired by tissue expansion, and that the tissue expander induced resorption of palatal bone.

Cranio-maxillo-facial tissue expansion, experimentally based or clinically empiric? A review of the literature

The literature over 10 years covering tissue expansion in cranio-maxillo-facial surgery is reviewed. Since 1981, an evolving set of indications for application of the soft-tissue expansion technique has been published. However, it seems to be based much more on clinical experience (empiricism) than on the results of thorough experimental research. The direction of future research should be aimed at effects on bone, cartilage and mucosa at a microscopical level, and at the influence on growth and development of cranio-maxillo-facial structures.