Algorithms for the management of frontal sinus fractures: A retrospective study.

The aim of this study was to evaluate the long-term results and to evaluate the validity of the treatment algorithm that can be safely applied in dfrontal sinus fractures. All patients were evaluated in terms of late-term contour deformity and further craniometric analysis for measurement of maximum amount of displacement, fracture surface area (mm2) and the maximum angulation of the fracture (degree) were done. 125 patients (101 male, 24 female) with frontal sinus fractures with an average age of 22.4 years (range,17-66 years) were reviewed. All patients with isolated anterior table fractures without displacement were followed up on conservative basis. 33 patients with anterior table fractures with displacement and 39 patients with anterior and posterior table fractures were also followed on conservative basis without surgical intervention. The cut-off value of the maximum amount of displacement was confirmed to be 4.5 mm in prediction of late-term contour deformities (p < 0.001). The maximum amount of displacement was decreased by an average of 1.8 mm at late-term. Apart from the standard protocols, within the limitations of the study it seems that isolated anterior table fractures with a maximum amount of displacement of less than 4.5 mm can be treated conservatively without leading to contour deformities. CSF leakage in the acute setting might not always require cranialization and this may spontaneously resolve within 10 days. Cranialization should be considered whenever CSF leakage lasts longer than 10 days.

The Effects of Maxillary Movements on Nasal Aesthetics Following Orthognathic Surgery.

Improvement of the harmony between facial subunits is the ultimate goal of orthognathic surgery and surgeons must accurately make soft tissue projections for planned bony movements. Yet, few studies have examined the effects' of orthognathic surgery on aesthetic parameters of nasolabial area on a thorough basis.This retrospective study included 61 patients that underwent orthognathic surgery. Demographic data, evaluation period, and surgical details were analyzed. Superficial topographical analysis of intercanthal distance, alar width, nasal height, nasal length, nasal tip protrusion, upper lip height, nasal bone angle, supratip break angle, nasal dorsum angle, nasal tip angle, columellar-lobular angle, columellar-labial angle, upper lip angle, and tip-to-midline angle was recorded before and after surgery. Postoperative changes in these parameters and their correlation to maxillary movements were analyzed.Alar width, upper lip height, columellar-labial angle, supratip break angle, nasal dorsum angle, and upper lip angle increased postsurgery, whereas tip-to-midline angle decreased. Upper lip height and columellar-labial angle were significantly correlated with clockwise/counter-clockwise rotation and anterior re-positioning. Columellar-labial angle increased 2° for each 1 mm of anterior movement and decreased 4° for each 1 mm of counter-clockwise rotation. Novel parameters, such as columellar-lobular angle and tip-to-midline angle, were not associated with any maxillary movement postsurgery.Orthognathic surgery primarily affected the lower third of the nose and changed alar width, upper lip height, supratip break angle, nasal dorsum angle, columellar-labial angle, upper lip angle, and tip-to-midline angle in this region; however, only columellar-labial angle and upper lip height were found to be correlated solely with maxillary movements.

Pharyngeal airway changes associated with maxillary distraction osteogenesis in adult cleft lip and palate patients.

PURPOSE: To investigate 1) the changes in pharyngeal airway sizes associated with maxillary distraction osteogenesis and 2) the correlations between maxillary skeletal variables and the pharyngeal airway in adult patients with cleft lip and palate. PATIENTS AND METHODS: The study was carried out in 14 adult subjects with cleft lip and palate. Predistraction records were taken at a mean age of 22.7 ± 4.6 years. All patients had placement of a rigid external distraction device (RED I; KLS Martin, Tuttlingen, Germany) after Le Fort I osteotomy. Lateral cephalograms were assessed before surgery and at short-term follow-up (8.0 ± 6.4 months). The cephalometric skeletal and pharyngeal airway variables were statistically evaluated by use of the Wilcoxon signed-rank test. Spearman ρ correlation was performed to check the correlations between maxillary skeletal and pharyngeal variables. RESULTS: The maxillary movement was 8.7 mm (P < .01). The maxillary depth angle (+7.9°) and effective maxillary length (9.4 mm) increased significantly (P < .01) after distraction, whereas the palatal plane angle remained unchanged. Anterior nasal spine (8.2 mm) and Posterior nasal spine (6.9 mm) moved anteriorly. The overjet increased (9.5 mm) significantly (P < .01). Posterior, superoposterior, and middle airway spaces increased significantly, with mean differences of 7.5 mm, 5.1 mm, and 3.3 mm, respectively. The soft palate moved anteriorly, with the greatest movement at its superior point. Significant positive correlations were observed for the posterior and superoposterior airway spaces and maxillary movement. PNS changes showed the highest correlation with posterior airway changes. CONCLUSIONS: The significant anterior movement of the maxilla resulted in significant increases in posterior, superoposterior, and middle airway spaces. The posterior airway space showed the highest significant positive correlation with the movement of PNS. The posterior and superoposterior airway spaces also showed significant positive correlations with the maxillary skeletal variables.

A new concept in treatment of burn injury: controlled slow-release granulocyte-monocyte colony-stimulating factor chitosan gel system.

OBJECTIVE: The aim of the study is to investigate the effectiveness of the controlled slow-release granulocyte-monocyte colony-stimulating factor (GM-CSF) system in burn wound healing. MATERIAL AND METHODS: In vivo effect of controlled slow-release GM-CSF from chitosan gel on burn wound healing was evaluated on 18 Wistar-Albino rats, weighing between 250 and 300 g. They were randomly divided into 3 groups; (1) burned only group (n = 6), (2) burned + chitosan group (n = 6), (3) burned + chitosan + GM-CSF group (n = 6). Wound area was measured macroscopically. Hematoxylin and eosin and Masson's trichrome stained sections were evaluated for wound healing and tissue response to the polymer. RESULTS: The best healing process was observed with the controlled slow-release GM-CSF-applied group (group 3) in which the wound area was significantly narrowed. CONCLUSION: The study demonstrated the positive contribution of the single-dose controlled slow-release GM-CSF from chitosan gel on burn wound healing.

Splint-assisted reduction of comminuted or complex maxillofacial fractures.

The aim of the study was to obtain anatomic bone healing and restoration of the patient's premorbid occlusion in complex facial fractures or comminuted facial fracture. Ten patients who applied to a tertiary health care clinic with complex or comminuted fractures, and mandibular fractures combined with condylar fractures which may impair the occlusal harmony were included in the study.After the preparation of premorbid occlusal splints and direct bonded orthodontic brackets, splint-assisted reduction and internal fixation have been performed. The treatment protocol was completed with 4 to 6 weeks of intermaxillary fixation over the splint. All fracture lines showed complete bone healing, without major complications requiring further treatment. Complications included a minor degree of malocclusion in one of the panfacial fracture patients and slight avascular resorption of the condyle in one of the avulsive open comminuted mandibular fracture patients.Using orthodontic splints and direct bonded brackets to obtain and maintain delicate reduction is an efficacious method for the prevention of occlusal disharmony and aesthetic impairments in comminuted lower facial unit and complicated facial fracture patients.

Skeletal and dental stability after maxillary distraction with a rigid external device in adult cleft lip and palate patients.

PURPOSE: To evaluate skeletal and dental stability in adult cleft lip and palate patients treated with a rigid external distraction system at the end of distraction and during the postdistraction period. PATIENTS AND METHODS: Lateral cephalograms of 7 patients were obtained before distraction, at the end of distraction, and during the postdistraction period. The mean age before distraction was 21.56 +/- 4.73 years. The mean follow-up was 37.3 +/- 12.4 months. RESULTS: The assessment of findings showed that skeletal maxillary sagittal movement was achieved in a superoanterior direction. The maxillary depth angle and effective maxillary length increased significantly (2 degrees and 9 mm, respectively) after distraction, whereas the palatal plane angle increased by 8 degrees , resulting in an anterior movement of the maxilla with a counterclockwise rotation. The lower facial height showed no significant changes after distraction. The sagittal movement of the upper incisors and the angulation of the upper first molars increased significantly (4.5 mm and 5.5 degrees , respectively). During the postdistraction period, the maxilla showed a slight relapse (22%). The effective maxillary length decreased by 2 mm. The palatal plane angle almost returned to its original position, showing 7 degrees of clockwise rotation. The lower facial height remained stable. The upper incisors moved anteriorly and the upper first molars showed a significant mesioangular change during follow-up. CONCLUSIONS: After distraction, significant maxillary advancement was achieved with a counterclockwise rotation. The upper incisors moved labially, and the upper first molars angulated mesially. After 3 years, a 22% relapse rate was seen in the maxilla. The counterclockwise rotation of the maxilla was returned to its original position. The upper incisors moved more anteriorly.

Semirigid fixation of mandible and maxilla in orthognathic surgery: stability and advantages.

Although the use of rigid fixation of bony segments in orthognathic surgery has become a standard of care, the question remains, 'With use of rigid fixation has stability of common orthognathic surgical procedures improved?' Because of the problems with various methods of osteosynthesis for the osteotomies commonly used in orthognathic surgery, we have developed our own way of semirigid fixation method to stabilize the osteotomized fragments for bone healing with enough flexibility to avoid the problems arising from absolute rigid fixation. The purpose of this article is to review the existing data to determine whether our method of semirigid fixation yields enough short-term and long-term stability after orthognathic surgery procedures. The study was designed as a retrospective trial. A total of 23 patients with double jaw surgery and 12 patients with mandibular set back surgery were reviewed. Preoperative lateral cephalometric radiographs obtained 1 month before the surgery, early postoperative cephalometric radiographs obtained after intermaxillary fixation was opened and late postoperative cephalometric radiographs were evaluated. Pog-McNamara vertical (mm) was used to measure the anteroposterior movement of mandible. Facial axis (degrees) was used to measure the vertical movement of the anterior part of the mandible. A-McNamara vertical (mm) was used to measure the anteroposterior movement of maxilla. Maxillary height (degrees) was used to measure rotational movement of the osteotomized maxillary segment in vertical dimension. The raw data obtained from cephalometric analysis were evaluated by using the computerized statistical program SPSS version 11.5 for Windows. The differences in linear and angular measurements between time intervals were tested for statistical significance, using repeated measures analysis of variance. A value of P < 0.05 was considered significant. None of the patients had infection at maxillary osteotomy side. Unilateral local infection at osteotomy side was seen in only one patient after double jaw surgery. Condylar malpositioning was not observed in any of the patients. Although postoperative maxillaomandibular fixation with elastics was applied routinely to all patients for 15 days, none of the patients had complaint related with temporomandibular joint discomfort, such as pain, restricted joint motion, etc. There is significant difference in anteroposterior movement of mandible in all time intervals. In terms of facial axis, the differences at T1 and T2 and at T2 and T3 are significant, while the difference at T1 and T3 is not significant. There is significant difference in anteroposterior movement of maxilla in all time intervals. In terms of maxillary height, the differences at T1 and T2 and at T2 and T3 are significant, while the difference at T1 and T3 is not significant. Method of semirigid fixation with 2 plates for maxillary fixation and 2 screws for mandibular fixation provide enough stability after LeFort I and bilateral sagittal split osteotomy procedures where mainly anteroposterior linear displacements were performed. There was no significant clinical short-term or long-term relapse. Stability in rotational movements needs to be further evaluated.

Use of three-dimensional medical modeling methods for precise planning of orthognathic surgery.

Stereolithographic (medical rapid prototyping) biomodeling allows three-dimensional computed tomography to be used to generate solid plastic replicas of anatomic structures. Reports in the literature suggest that such biomodels may have a use in maxillofacial surgery, craniofacial surgery, orthopedics, neurosurgery, otology, vascular, and nasal research. A prospective trial to assess the usefulness of biomodeling in orthognathic surgery has been performed. In 12 patients with mandibular prognathism and/or maxillary retrusion, in addition to routine preoperative cephalometric analysis, preoperative high-resolution (cutting slice thickness of 1 mm) three-dimensional computed tomography scan of the patients was obtained. Raw data obtained from computed tomography scanning was processed with a Mimics 9.22 Software (Materialise's Interactive Medical Image Control System, Belgium). Fabrication of three-dimensional medical models was obtained through a process called powder depositional modeling by use of a Spectrum Z 510 3D Color Printer (Z Corporation, Burlington, MA). Alveolar arches of the maxilla and mandibula of the models were replaced with orthodontic dental cast models. Temporomandibular joints of the models were fixed with Kirschner wire. Maxillary and mandibular bony segments were mobilized according to preoperative orthodontic planning done by analysis of cephalometric plain radiographs. The relation between proximal and distal mandibular segments after bilateral sagittal split osteotomies were evaluated on models preoperatively. The same surgeon had a role in both model cutting preoperatively and as an instructor preoperatively. The same bony relation was observed both in preoperative modelsand in the perioperative surgical field in all patients. Condylar malpositioning was not observed in any of the patients. Studying preoperative planned movements of osteotomized bone segments and observing relations of osteotomized segments of mandibula and maxilla in orthognathic surgery increased the intraoperative accuracy. Limitations of this technology were manufacturing time and cost.

Tridimensional evaluation of maxillary and mandibular movements in orthognathic surgery.

For better evaluation of long-term results of orthognathic surgery, movements of osteotomized maxillary and mandibular segments should be documented both in x-, y-, and z-axes and in terms of kind of movement (either linear or rotational movements). Lateral cephalometric, anteroposterior cephalometric, and submentovertex radiographs of 14 patients, treated with combined orthodontic and surgical treatment for skeletal class III malocclusion, were reevaluated retrospectively to demonstrate the applicability and usefulness of defined parameters in four maxillary and five mandibular movements. There was no clinically significant relapse in the follow-up period of 6 months in any of the patients. Differences between preoperative and postoperative measurements to demonstrate the linear movement in the z-axis, rotational movements in the x-axis and y-axis of the maxilla, and the linear movement in the z-axis of the mandibula were found to be statistically significant. Differences between early postoperative and late postoperative measurements to demonstrate rotational movement in the y-axis of the maxilla and rotational movement in the y-axis of the mandibula were found to be statistically significant. In this article, the possible tridimensional movements and cephalometric measurements of osteotomized bony segments after LeFort I and sagittal split osteotomy surgery were defined for better evaluation and follow up of the postoperative results.

Bicortical biodegradable screws for rigid fixation of traumatic sagittal split mandibular fracture.

Rigid fixation is the most important issue in the bone healing process. Although internal metallic bone fixation has become increasingly popular over the past 10 years, the presence of several potential problems of metallic bone implants with the popularity of the use of biodegradable plates and screws for craniomaxillofacial fixation have increased in the last 10 years. Rigid fixation of bony fragments was achieved by bicortical applied biodegradable screws in a patient with a sagittal oblique mandibular fracture. Precise bone reduction was maintained with bicortical applied biodegradable screws in the postoperative period. The postoperative period was uneventful and the patient retained the intraoperatively achieved perfect occlusion within a 9-month follow-up period. In this particular case, the advantages of use of resorbable fixation systems are combined with the advantages of bicortical screw fixation of split osteotomy without sacrificing the stability of rigid fixation.

Botulinum toxin in closed treatment of mandibular condylar fracture.

BACKGROUND: The topic of condylar injury in adults has generated more discussion and controversy than any other in the field of maxillofacial trauma. The treatment of condylar fractures in adults is still a highly debated theme. METHODS: Patients with unilateral subcondylar or condylar neck fractures of the mandibula without any significant angulation of the condylar head were managed with closed-treatment protocol. Closed treatment was applied through the injection of 100 units of botulinum toxin A, diluted to a concentration of 20 IU/mL, into the muscles of mastication of the fractured side. Masseter and anterior fibers of temporalis muscles were reached through percutaneous extraoral route and 30 IU of the toxin was injected to each muscle. Additional 40 IU of the toxin was injected around the fractured bone fragments through transmucosal intraoral route to paralyze medial and lateral pterygoid muscles as much as possible. An asymmetric occlusal splint was applied for maxillomandibular fixation to restore the vertical height for 10 days. Functional therapy with intermaxillary guiding elastics was advocated for 2 months. RESULTS: There were no complications related to either toxin injections or splint application procedures. The toxin was effective on all occasions. Fractured condylar process and ramus of the mandibula were in good approximation and remained in reduced positions. None of the patients had any occlusal disturbance, mandibular asymmetry, or joint dysfunction in the follow-up period. CONCLUSIONS: We believe that modification of treatment options concerning the clinical situation of the patients is the best method for condylar injury. The purpose of this study is to present and discuss the results achieved in closed treatment of a selected group of patients with mandibular condylar fractures to whom botulinum toxin A was injected to relieve the spasm of muscles of mastication, along with special splint application.

Closed treatment of frontal sinus fracture with percutaneous screw reduction.

Fractures of the frontal sinus are a relatively common injury presenting to trauma units that deal with craniofacial injuries. Approximately one third of frontal sinus fractures affect the anterior wall alone, with two thirds involving the anterior wall, posterior wall, or frontonasal duct. Isolated posterior wall defects are exceedingly rare. Frontal sinus fracture management is still controversial and involves preserving function when feasible or obliterating the sinus and duct, depending on the fracture pattern. In the standard treatment modality of frontal sinus fractures, repair is best performed by way of a coronal approach, which offers excellent access. Most of the frontal sinus fractures deserve this attentive surgical manipulation to prevent late sequelae of infection or mucocele formation. In this article, we present a case of isolated depressed anterior wall fracture of the frontal sinus that was treated by closed reduction to avoid coronal incision. Anterior wall fracture of the right frontal sinus was diagnosed with preoperative evaluation of three-dimensional CT of a 34-year-old male patient with maxillofacial trauma. The anterior wall fracture was reduced by traction of two percutaneously applied screws to the depressed fragments. Accurate reduction was obtained, and neither recurrent displacement nor infection was observed during the follow-up period of 3 months. The screws were removed in the clinical setting without difficulty. Although percutaneous reduction of noncomminuted anterior wall frontal sinus fractures has limited indications, it has its own advantages over open techniques. This method is a less-invasive technique and can be performed without problem in selected cases. Our technique is not suitable for complex fractures of the frontal sinus.

Goldenhar complex with atypical associated anomalies: is the spectrum still widening?

Goldenhar syndrome is a well-known developmental anomaly of maxillofacial skeleton and hemi-facial soft tissue, was later included to a broader classification called oculo-ariculo-vertebral spectrum. Here we report a patient presenting goldenhar syndrome with accessory auricula, defined as polyotia, coloboma and bifid tongue.

Stoppers in RED II distraction device: is it possible to prevent pin migration?

Distraction osteogenesis has become popular for the treatment of hypoplastic congenital craniomaxillofacial anomalies. Rigid external distraction (RED II) after Le Fort III osteotomy was shown to be a highly effective treatment for the management of midface hypoplasia. This device is used with a halo vest, which is placed at the cranial equator. Intracranial penetration of the fixation pins of the halo is one of the complications of an external distraction device. To prevent pin penetration in rigid external distraction, the authors designed polylactic acid/polyglycolic acid (PLA/PGA) plates that were circular; the plates were 0.8 cm in diameter and had 1.5-mm holes in the center, through which the tip of the pins would pass. To quantify the applied torque by manual tightening of the screws of the distraction device and to measure intraosseous cone depth created by the penetration of the conical part of the screws with and without the PLA/PGA composite stopper, first an in vitro experiment was undertaken on cadaver. Then these PLA/PGA plaques, or stoppers, were placed over the bone surfaces of the cranium of the patients where the tip of the pins press. PLA/PGA stoppers are malleable and adapt their shape to the interactive forces between bone and the pins. They act as a second barrier, and spread the pressure of the screws to larger surfaces, thus securing better stabilization. The penetration of wider portions of the screw into scalp is reduced, minimizing the scalp damage caused by the screws. Biodegradable and biocompatible PLA/PGA stoppers avoid intracranial migration of the fixation pins, especially in children.

Examining microcirculation improves the angiosome theory in explaining the delay phenomenon in a rabbit model.

Topographic and temporal changes in circulation were studied with laser Doppler flowmetry in rabbit dorsal skin flaps comprised of three vascular territories. The reduced caliber vessels along the dorsal median line, rather than the vessels interconnecting the thoracodorsal and deep circumflex iliac vascular trees, behaved as true choke vessels. The authors found an increased proximal circulation lasting for 48 to 72 hr. This coincided with the reported rapid phase of choke vessel dilatation. The increase in distal circulation began after postoperative day 3, coinciding with the resolution of proximal hyperemia but not with the earlier prominent vasodilatation. Secondary elevation of the flaps at 3 weeks did not disturb the homogeneous distribution of circulation and did not cause a hyperemic response at postoperative 24 hr. Based on these findings, the authors postulate that the same mechanisms may underlie the rapid choke vessel dilatation and microvascular dilatation observed at 48 to 72 hr postoperatively. Surgical delay may work not only by diminishing the resistance to blood flow along the flap, but also by diminishing the steal effect of increased proximal microcirculation, which characterizes this period, over the distal circulation.