Secondary management of the nose in the cleft patient.

The management of the cleft lip and palate patient usually requires multiple primary and secondary surgical procedures to correct the deformity. This paper presents surgical methods in the secondary management of the cleft nose and presents three case reports to help illustrate these methods.

Indications for simultaneous orthognathic and septorhinoplastic surgery.

Orthognathic and rhinoplastic surgery can be combined successfully when certain guidelines are understood. Relative indications and contraindications have been established that generally yield predictable results. Tip position (rotation and projection) may be the most difficult aspect to predict and, therefore, is best avoided during simultaneous surgery. Major deformities of the dorsum can be easily corrected in conjunction with maxillary surgery. Three cases demonstrating these guidelines are presented and discussed.

Incorporation of facial plastic surgery in the planning and treatment of orthognathic surgical cases.

Until recently, orthognathic surgery and cosmetic soft tissue surgery have been separate clinical endeavors. This article presents examples of soft tissue surgical procedures carried out with orthognathic surgery to enhance the overall result. Video imaging techniques have been integrated into the planning process to more clearly define functional and esthetic goals. The technical achievement of combined orthognathic and esthetic procedures, as well as the timing of treatment between the orthodontist, oral surgeon, and plastic surgeon, is discussed.

Craniofacial osseous restoration with osteoinductive proteins in a collagenous delivery system.

Implants fabricated from mixtures of extracted bovine bone proteins and highly purified human type I collagen have been tested for efficacy in the restoration of osseous defects. Experimental implants composed of osteoinductive proteins and collagen, and control implants composed of collagen alone were placed in 15 x 15 mm cranial defects in New Zealand white rabbits. Implants harvested at 10, 12 and 14 week intervals were subjected to histological evaluation as well as quantitative analysis utilizing a computer morphometric planimeter. Defects filled with control implants displayed highly variable repair with a mean of 31% bony healing. Experimental implants were consistently effective in inducing significant bony regeneration with a mean of 91% repair within the time range of the study. In light of these results, it is apparent that an osteoinductive-collagenous implant system represents an efficacious treatment modality in osseous reconstruction and augmentation.

The use of autologous auricular cartilage for temporomandibular joint disc replacement: a preliminary report.

The technique of harvesting auricular cartilage and its use in 22 patients (35 joints) is described. Follow-up was from 3 to 24 months. Pain relief was achieved in 90% of the cases. Function was equal or better to the preoperative situation in all cases.

A review of matrix-induced osteogenesis with special reference to its potential use in cranio-facial surgery.

Current data suggests that purified osteoinductive protein packaged into a collagenous delivery vehicle represents a viable alternative to restoring osseous defects with conventional implant materials. The proteins responsible for matrix-induced osteogenesis are the same as those that initiate and complete osseous repair of fractures. Consequently, the process of matrix-induced osteogenesis produced by implantation of the osteoinductive protein mimics the naturally occurring phenomenon of reparative osteogenesis. The collagenous delivery vehicle apparently serves the same role as the inactive collagenous bone matrix which is left after removal of the osteoinductive proteins from demineralized bone and, is required if osteogenesis is to occur. This collagenous delivery vehicle apparently serves a scaffold for the migration into, proliferation, and subsequent differentiation of cells responsible for osteogenesis. In addition, the original form of the collagenous implant dictates the dimensions of the resulting bony tissue. Finally, it is possible to generate an osteoinductive response in many mammals probably including man with purified xenogenic osteoinductive proteins. In conclusion, there is currently much research investigating the phenomenon of matrix-induced osteogenesis and its potential clinical use. In the past few years, there has been a sharp increase in the number of manuscripts published in this area of connective tissue research. Consequently, if the current trend continues, clinicians in the near future can look forward to seeing this material being developed into a convenient "off the shelf" bone replacement system which stimulates host bone formation and repair of cranio-facial osseous defects.

Video imaging for planning and counseling in orthognathic surgery.

With the advancements of computer knowledge today, treatment planning and counseling are becoming more efficient by means of video imaging. Using a video image of a patient, esthetic and functional decisions can be made by the surgeon, orthodontist, and patient in a consensus manner. Distortion characteristics of video hardware, software, and the video camera are established, and adoption of imaging techniques is employed to maximize accuracy of the imaging process. Patients' attitudes toward video imaging concerning expectations, value of visual prediction, and degree of realism are also discussed. This study is intended to establish some of the basic goals of video imaging with general information in regard to hardware and software requirements.

Hydroxylapatite: an adjunct to cranial bone grafting.

Hydroxylapatite is a dense pure ceramic material which has been used extensively in the reconstruction of atrophic maxillary and mandibular ridges. The authors describe a technique for the use of hydroxylapatite in combination with grafting of bone, either autogenous or from the bone bank, to restore contour to cranial defects. The use of hydroxylapatite in combination with bone grafting for contour restoration is recommended, as attempts to place the material directly on dura were not successful.

Simultaneous rhinoplasty procedures in orthognathic surgery.

22 septorhinoplasties were performed in conjunction with orthognathic surgery, and followed for at least 12 months. No significant difference could be established between 15 cases done with a LeFort I and 7 cases done with isolated sagittal split osteotomies. Rigid bicortical fixation of the mandible was required to change the endotracheal tube from nose to mouth. Plating of the maxilla is recommended to achieve a stable bony support for the nose. Patient satisfaction and perception were surveyed. Clinical results are presented with pre- and post-operative photographs, along with mean data for the total group.

Zygomatic augmentation with hydroxylapatite: a preliminary report.

This paper describes the use of hydroxylapatite in combination with microfibrillar collagen and blood to yield a cohesive mixture that can be sculptured to correct symmetry over the zygomatic bones. Eleven cases were studied retrospectively, and the augmentation was found to remain stable and esthetically pleasing.

Clinical evaluation of Durapatite submerged-root implants for alveolar bone preservation.

A study was undertaken to evaluate the safety and efficacy of Durapatite cones as an immediate submerged-root implant in the mandibular symphysis region. The study involved 30 patients of which 15 received 96 implants and the other 15 served as controls. The clinical and radiographic results revealed the implants to be well-accepted by alveolar bone. No evidence of rejection or major complications were observed. The principal problem which occurred was dehiscence of mucosa over some implants. This problem was attributed to operative technique. There was significantly less vertical bone loss and contour change in the anterior part of mandible in the implant group than in the control group.

Compressive strength measurement and microstructure studies of hydroxyapatite cones.

Compressive strength measurement and microstructure studies of standard, diamond bur-ground, and fracture surfaces of durapatite cones were reported. The compressive strength measurements of durapatite cones were variable and strongly dependent on the test method. The fracture force ranged from 1090 to 3692 N and the calculated compressive strengths ranged from 113 (16,333 psi) to 389 mN/m2 (56,462 psi). The outer surface of durapatite cones was rough, irregular, and dense. Sharp fracture lines occurred along the longitudinal axis of the cones. Isolated porosity was seen in the fracture surface of one specimen. Grinding hydroxyapatite cones using a high-speed diamond bur with water spray produced a surface grinding feature, an irregular surface topography, and microcracks. The microcrack directions were perpendicular to the direction of the diamond bur cutting features.

Evaluation of a subcutaneously implanted hydroxylapatite-avitene mixture in rabbits.

Avitene, a microfibrillar collagen hemostatic agent was mixed with hydroxylapatite and implanted subcutaneously along the inferior border of the mandible in ten rabbits. This mixture clearly enhanced surgical manipulation of the implants. Radiographic and histologic examination of the implant sites at one, three, and six months showed an acceptable host response with no apparent alteration of the favorable characteristics of hydroxylapatite implants.

Histologic study of hydroxylapatite as an implant material for mandibular augmentation.

Dogs were used to compare supraperiosteal implantation of hydroxylapatite with subperiosteal implantation with and without partial decortication of the underlying bone. Whereas supraperiosteal implants were unstable, nine months of observation indicated that the subperiosteal implants developed a strong attachment and mechanical stabilization as a result of formation of investing fibrous and osseous tissues. These results provide a basis for a technique of alveolar augmentation and denture construction.

Surgical treatment of bony ankylosis in a child using a composite cartilage-bone iliac crest graft.

A previously unreported approach to the treatment of temporomandibular ankylosis in the child is reported. The procedure involves using the iliac crest and fixing it to the zygomatic portion of the temporal bone, with the cartilagenous portion facing the stump of the mandibular ramus. The procedure is easier to accomplish than a costochondral graft, does not require maxillomandibular fixation, and offers the possibility of appositional growth. In our case, opening has been maintained and growth sustained in a five-year-old child for 18 months without physiotherapy.