Management of alveolar cleft bone grafting--state of the art.

Bone grafting of the alveolus is an essential step in the reconstruction of the orofacial cleft deformity. Secondary grafting with iliac marrow consistently produces trabecular bone to unify the maxilla and provide odontogenic support. It requires preoperative maxillary alignment, well designed mucoperiosteal flaps, and good oral hygiene to be optimally successful. Its high success rate currently makes it the preferred approach at most centers. Primary grafting with rib results in a unified maxilla, eliminates the oronasal fistula, and does not adversely affect midfacial growth. It assists in preventing maxillary segmental collapse, particularly in the bilateral cleft patient. Whether it can produce enough alveolar bone to support long-term odontogenic needs awaits further clinical documentation in the limited numbers of centers that routinely perform this procedure.

Primary alveolar cleft bone grafting in unilateral cleft lip and palate: arch dimensions at age 8.

The purpose of this investigation is to determine whether primary alveolar cleft bone grafting in infants with unilateral cleft lip and palate (N = 17) leads to less favorable dental arch dimensions at age 8 when compared with other 8-year-old patients with unilateral cleft lip and palate who received no alveolar bone grafting procedures (N = 49). Dental casts were obtained for the primary grafted group, and arch lengths and widths were digitally recorded with a reflex microscope. These arch dimensions were then compared with the reported data for a nongrafted group and a noncleft group of 8-year-old children. The major findings were: 1) that the dental arches of both cleft groups generally demonstrated a significant diminution in length and width (P < 0.05) compared with the noncleft groups, and 2) that the patients who underwent primary alveolar cleft bone grafting showed no statistically significant difference for any arch dimension (P < 0.05) when compared with the nongrafted group lacking this additional surgical procedure.

Primary alveolar cleft bone grafting in unilateral cleft lip and palate: craniofacial form at age 8.

Counterpart analysis can be advantageous for the clinician interested in the underlying determinants of the craniofacial form for any given person. This analysis was performed for a group of patients who underwent primary alveolar cleft bone grafting (N = 18) and a group of patients who did not undergo grafting (N = 19) who were 8 years of age (+/- 6 months). The primary grafting group more frequently noted maxillary retrusion, but of a nonsignificant magnitude. Also, the primary grafting group had greater mean magnitudes of mandibular opening as a compensatory adjustment in some patients, but this could not be generalized to all patients who had underdone primary grafting. The mean magnitude of craniofacial vertical shortening was also greater for some patients who had undergone primary grafting, but it, too, did not exhibit a generalized pattern for all patients who had undergone primary alveolar cleft bone grafting procedures. This study emphasizes the great diversity of craniofacial skeletal adjustments made within each group of patients with unilateral cleft lip and palate and cautions the clinician against generalizations concerning a particular treatment protocol.

Amniotic band facies.

Craniofacial deformities of 14 patients with amniotic band syndrome at one institution were reviewed for morphologic similarities. In addition to associated cleft lip and palate, vertical and oblique facial clefts, which were not associated with embryologic lines of fusion, were seen. It is hypothesized that the prominence of the nasal processes combined with the adjacent stomodeal orifice results in utero surfaces, which can lead to free band attachment and adherence, resulting in a spectrum of similarly oriented facial defects.

Computer-generated patient models for reconstruction of cranial and facial deformities.

The use of three-dimensional, computer-generated anatomic models can be used in the diagnosis and reconstruction of a variety of craniofacial problems. They are readily manufactured from computed tomography scans at a reasonable cost with only several weeks of preparation and delivery time. Their contemporary value is in the preoperative treatment planning, intraoperative implant fashioning, and preoperative implant fabrication in appropriately selected patients.

Resorbable plate fixation in pediatric craniofacial surgery.

Resorbable bone plates composed of a copolymer of polylactic and polyglycolic acids stabilized into position with metallic microscrews were used in the reconstruction of pediatric craniofacial deformities. In 100 patients between 4 and 15 months of age, a total of 912 resorbable plates were implanted over a 2 1/2-year period. Their application was simple and rapid and required no special instrumentation. Currently, 85 patients are more than 1 year postimplantation, which is the known time for complete resorption of this copolymeric compound. No complications have been seen with this use, including infection, overlying soft-tissue reactions, reconstructive instability, or underlying osteolysis around the screws, as determined by postoperative plain radiographs at 6 months and 1 year postoperative time periods. Four patients have had screws removed due to either palpability or secondary reconstructive surgery between 9 and 18 months postoperatively, all of whom exhibited complete polymer resorption and normal bone healing. These clinical results demonstrate the safety and effectiveness of this copolymeric material for pediatric craniofacial applications.

Resorbable bone fixation: its potential role in cranio-maxillofacial trauma.

The concept of biodegradable bone fixation devices, which provide sufficient rigidity to allow fracture healing and resorption thereafter, has significant appeal in cranio-maxillofacial trauma treatment; however, biodegradable bone fixation devices have not yet become available for clinical use in the craniofacial skeleton. This article reviews the obstacles in developing a resorbable polymer bone fixation system and describes the initial use of such a system in the treatment of cranio-maxillofacial trauma patients. It also discusses the potential role of a resorbable polymer bone fixation system in conjunction with the use of metal fixation in the management of facial fracture.

Pediatric plastic surgery.

Pediatric plastic surgery has seen widespread advances during the past decade. These have been primarily in the biologic understanding of certain disease processes as well as in diagnostic and therapeutic technologies. These advances have contributed to a potential new array of treatment options for congenital deformities and traumatic injuries. This review identifies several of the most significant new trends and treatment concepts in pediatric plastic surgery from anesthesia to wound healing.

Resorbable coupling fixation in craniosynostosis surgery: experimental and clinical applications.

The use of resorbable bone fixation devices composed of a copolymer of polyglycolic acid and polylactic acid were investigated in an animal model as well as in human application. We used resorbable plates and metallic microscrews in immature rabbits; plating of the coronal suture resulted in complete device resorption and increased interscrew distances (i.e., growth across the suture) after 8 postoperative months. In 20 infants with calvarial deformities, thin, straight resorbable plates were used for skeletal fixation after osteotomies and repositioning. A total of 231 fixation devices were implanted without complications after 12 postoperative months. These encouraging results have led to further clinical application in craniosynostosis deformities.

HTR polymer facial implants: a five-year clinical experience.

Forty-three patients at two different international sites underwent onlay facial augmentation of the malar, paranasal, and chin regions using 61 HTR polymer preformed implants. All implants were placed intraorally and rigidly fixed with a titanium screw. Over postoperative periods ranging from two to five years, one implant was removed because of infection. Two other implants in patients with rheumatic and connective tissue disease were removed because of persistent pain and erythema. Another peri-implant infection was treated successfully without removal. One-year postoperative radiographs in patients with chin implants demonstrated no underlying bone resorption. This porous polymeric material appears to offer clinical results comparable to other alloplastic materials for onlay facial skeletal augmentation.

A comparison of resorbable and metallic fixation in healing of calvarial bone grafts.

The effects of a resorbable fixation plate composed of a polylactic acid-polyglycolic acid copolymer were compared with those of a metallic fixation plate of similar dimensions in an animal calvarial bone-graft healing model. Bilateral parietal bone grafts in 20 mature rabbits were fixed into position with a titanium mesh plate on one side and a polymer mesh plate on the other side. After 2, 6, 9, and 12 months, cross-sectional histology was used to compare osteotomy line healing, tissue response to the fixation material, and the amount of resorbable plate degradation. After 2 months, no changes in the dimensions of the resorbable plate were observed. The bone grafts fixed by both metal and polymer plates exhibited incomplete healing along the osteotomy lines. After 6 months, there was a 66 percent reduction in the dimensions of the resorbable plate and vertical shortening of screw length. Complete healing was seen along all osteotomy lines of both bone grafts. After 9 months, less than 1 percent of the resorbable mesh plate remained as a small film underneath a collagenous capsule. No polymer was seen within the confines of the screw holes. After 1 year, no evidence of polymer was seen either on the external cranial surface or within any of the screw holes. Bony union was observed across all osteotomy sites. The screw hole outlines persisted. The resorbable plate demonstrated fixation stability similar to that of metal with comparable osteotomy line healing. No adverse local inflammatory reactions were seen as the polymer composite progressed to complete degradation by 1 year.

Mandibular vascular malformations: treatment and long-term results.

Two cases of intraosseous vascular anomalies of the mandible--including surgical treatment and 10-year follow-up--are reported. Early aggressive resection not only resulted in resolution of symptoms and restoration of facial symmetry but also exhibited significant osseous regeneration without grafting.

Surgical correction of metopic suture synostosis.

Premature fusion of the metopic suture is an uncommon form of craniosynostosis, historically reported with an incidence of less than 10% among the various forms of craniosynostoses. Despite its infrequency, it is the most obvious deformity associated with premature fusion of a single suture with its prominent frontal keel, narrow forehead, and close-set eyes. This article discusses the timing, long-term results, and recent advances of surgical techniques.

Cranial reconstruction in osteogenesis imperfecta.

Although osteogenesis imperfecta (OI) is recognized as a cause of craniosynostosis, therapeutic endeavors have not been reported. We present an 8-month-old girl with type 3 OI, in whom bilateral occipital flattening, biparietal widening, and frontal narrowing were effectively managed with a combined surgical release and reconstruction and molding cap therapy. The quality of the calvarial bone in OI requires a modified approach to the conventional bone techniques commonly used in the correction of craniosynostosis deformities.

A potential biomaterial composite for dermal and subcutaneous augmentation.

Based on previous experimental connective tissue work in cutaneous wound healing, cell culture, and fat transplantation, the use of positively charged dextran beads for subcutaneous and dermal augmentation was evaluated. When combined with a biocompatible liquid medium, the material easily flowed through small-gauge needles. When injected beneath the facial skin in rats, a profound macrophage response was initially seen at 30 days accompanied by fibroblast proliferation and new collagen formation. By 1 year, a quiescent noninflammatory cellular response with extensive intermaterial collagen deposition was evident. No adverse reactions were seen in the contralateral facial sites, which were injected with only the liquid medium. These preliminary findings suggest good tissue compatibility of this composite biomaterial and provide further evidence of the significant regulatory role of the macrophage in the tissue response to implanted biomaterials.

Effects of resorbable fixation on craniofacial skeletal growth: modifications in plate size.

On the basis of previous experimental work in young rabbits, modifications in the polymer fixation used (i.e., smaller plate size, change in ratio of polymer components) were studied for potential alleviation of known growth restriction in this model. Ten juvenile rabbits with metallic markers placed at the calvarial sutural junctions were plated across the left coronal suture. At 6 months of age, measurements were taken of both intermarker distances radiographically (growth) and the plates directly. Unlike previous reports, these resorbable plates permitted symmetrical frontal bone development, unaffected growth across the coronal suture, and a histologically normal underlying suture. These changes appear to be the result of elongation of the fixation plate across a growth site. These results indicate that the change in shape of resorbable fixation after initiation of degradation is more important than complete degradation of the material in rapidly growing bone sites.