Success Rate of Mid-Secondary Alveolar Cleft Reconstruction Using Anterior Iliac Bone Grafts: A Retrospective Study.

Introduction: Bony reconstruction of the alveolar process and its adjacent platform largely represents the final step in surgical achievement of functionality and aesthetics in cleft patients. Throughout the years, the success of this procedure has been investigated. The aim of this study was to assess the success rate of autogenous mid-secondary alveolar bone grafting in this setting. Methods and Material: A retrospective cohort study was performed. All cleft patients receiving secondary alveolar bone grafts between 1990 and 2020 were reviewed. Criteria for assessing success were long-term preservation of alveolar bone stock, ability of spontaneous or orthodontic-guided eruption and periodontal health of permanent lateral incisors and canine teeth, absence of exposed root structures of neighbouring teeth, absence of fistula and successful placement of implants. Failure of alveolar bone grafts was indicated by radiographically demonstrable total or near-total graft loss requiring reintervention. Results: A number of 124 patients were included and grouped as those primarily operated following our (two-staged palatoplasty) protocol and those receiving cheilorhinoplasty and palatoplasty (one-staged) at other centres. Given the limited cohort size, no complex statistical analysis was performed. In the first group of 64 patients 12 experienced complications (Veau III, eight/36; Veau IV, four/18). In the second group of 60 patients, 12 experienced complications (Veau III, six/37; Veau IV, six/17). Discussion: Our surgical protocol using anterior iliac bone grafts for secondary alveolar reconstruction achieved good results, comparing favourably with previous literature.

Massive Facial Presentation of Dermatofibrosarcoma Protuberans.

Dermatofibrosarcoma protuberans is a low-grade cutaneous sarcoma typically located on the trunk or proximal extremities. Less common locations include the head, face, and neck area. This tumour is slow growing with variable clinical appearance. It is known for its locally invasive nature and low metastatic propensity. Because imaging findings are rather nonspecific, biopsy is needed for definite diagnosis. This case describes an unusually large example of dermatofibrosarcoma protuberans in the less common preauricular region.

A systematic review of cranioplasty material toxicity in human subjects.

PURPOSE: Local and systemic toxic reactions to implanted materials can result in morbidities. However, little is reported about cranioplasty implants. Therefore, we performed a systematic review on the toxicity of different materials used for cranioplasty implants. MATERIALS AND METHODS: A systematic search was conducted by browsing the Pubmed, Embase, and Cochrane Library databases. All human studies that identified toxic (aseptic) reactions to any types of material used as cranioplasty implants or onplants, published up to January 1, 2019, were included in the review. RESULTS: Nineteen studies were identified. Collectively, 36 patients endured some type of toxic reaction to an implanted material. Eleven studies presented several types of toxicity for PMMA cranioplasties in several tissue types. One article highlighted the risk of neurotoxicity for PMMA cranioplasty. Three articles presented toxic reactions to calcium phosphate and titanium implants. Three additional articles presented toxic reactions to PEEK, polypropylene-polyester, and polyethylene. CONCLUSION: All materials currently used for cranioplasty showed occasional toxicity and morbidities. Therefore, none can be considered completely biologically inert. We found that aseptic inflammatory reactions have been underreported in the literature due to a high incidence of infections with questionable evidence.

Visual Loss after Cosmetic Blepharoplasty Using Local Anaesthesia Containing Epinephrine - A Case Series.

Rationale: Surgeons should be aware of the risk of vision loss associated with blepharoplasty. Patient Concerns: All patients complained of decreased vision, redness and/or pain after blepharoplasty using only local anaesthesia containing epinephrine. Diagnosis: Diagnosis of angle-closure glaucoma (ACG) was made clinically (decreased visual acuity (VA), increased intraocular pressure and a mid-dilated pupil) and through examination (slit lamp examination and dynamic gonioscopy revealed corneal oedema and a shallow anterior chamber respectively). Perioperative posterior ischaemic optic neuropathy (PION) was a diagnosis of exclusion based on the relative afferent pupil defect. Treatment: ACG was treated medically (intravenous [IV] mannitol and topic antiglaucoma medication or oral acetazolamide) and surgically (YAG iridotomy and an additional cataract extraction with trabeculectomy in one patient). PION was treated with IV methylprednisolone. Outcome: Patients with ACG fully recovered. Patients with PION improved clinically, but presented with a pale optic disc and an optic nerve-related visual field defect. Take-Away Lesson: Surgeons should intervene quickly to minimize the chance of permanent vision loss.

Extended Total Temporomandibular Joint Replacement with Occlusal Adjustments: Pitfalls, Patient-reported Outcomes, Subclassification, and a New Paradigm.

CONTEXT: Alloplastic temporomandibular joint (TMJ) replacement is a treatment strategy for segmental mandibular defects with occlusal abnormalities. AIMS: To describe our experience with extended total TMJ replacement (eTMJR) by reporting operative obstacles, complications, and patient-reported outcomes, as well as to suggest a subclassification system and paradigm shift. SETTING AND DESIGN: University hospital and private clinic; case series with retrospective follow-up. METHODS AND MATERIALS: Five patients (6 eTMJRs) were followed for more than 1 year after surgery. Patient-reported outcomes were assessed using FACE-Q™ "Satisfaction with Outcome" questionnaires (sum and corresponding transformed Rasch scores). STATISTICAL ANALYSIS: Descriptive analyses were performed. RESULTS: Problems were related to contralateral mandibular osteotomy healing (if performed), keying the prosthetic condyle into the fossa component, intra- and postoperative prosthetic lag, and intraoperative proper establishment of the occlusion when unilateral replacement was performed. Patients reported high satisfaction with the outcome, with a mean Rasch score of 89.2/100. CONCLUSIONS: Unilateral eTMJR obstacles related to three-dimensional rotational repositioning of the remaining mandible. We suggest a paradigm shift, considering primary alloplastic replacement instead of microvascular osseous transplantation for reconstruction when radiotherapy is not required. This can avoid donor site morbidity and long reconstructive surgery. An autologous osseous transplant is still available in case of implant failure. A subclassification system is proposed for eTMJR, which accounts for contour corrections, occlusal adjustments, and simultaneous contralateral mandibular osteotomy.

Reconstruction of a Subtotal Maxillectomy Defect Using a Customized Titanium Implant in a 4-Year-Old Child: An 8-Year Follow-Up Report.

Condition: This case report demonstrates the use of alloplastic reconstruction in young children. Method: A three-dimensionally printed titanium implant was used to reconstruct a subtotal maxillectomy defect in a 4-year-old child. Results: We report an 8-year follow-up. The endoprosthesis was split at the midline to address transverse growth. The main finding is that the stigma surrounding resection and surgical reconstruction in pre-adolescents can be prevented by the use of alloplastic reconstruction based on titanium osseointegration. An additional finding is that shear forces should be prevented at the insertion points of the fixation screws in the facial walls by providing a vertical support for the maxillary/palatal shelves. Lastly, transverse maxillary growth in the circumferential sutures and functional matrix was not hampered by splitting the endo- and exoprostheses in the middle (where the mid-palatal suture would normally be located). Conclusion: Alloplastic reconstruction of maxillectomy defects in childhood can offer a viable temporary solution.

Autologous Fat Grafting in Total Temporomandibular Joint Replacement Surgery.

CONTEXT: Alloplastic temporomandibular joint replacement. AIMS: To search for evidence for the use of periprosthetic autologous fat transplantation. SETTING AND DESIGN: Systematic review. MATERIALS AND METHODS: We searched in PubMed Central, Elsevier ScienceDirect Complete, Wiley Online Library Journals, Ovid Lippincott Williams and Wilkins, and Cochrane Library plus Results. Six studies reported improved results with the use of autologous fat graft (AFG) in patients treated with a total joint replacement, mainly about increased mobility. Three studies involved patients from the same surgeon with increased inclusions and increased follow-up period. A 1997 study by Wolford showed a significant difference in heterotopic bone formation between patients treated with AFG, compared to those who were not, indicating the potential and usefulness of AFG. CONCLUSION: A prospective multicenter randomized controlled trial of this promising concept is warranted before justifying common application because of the added morbidity and the questionable advantage.

Fast-track Orthognathic Surgery: An Evidence-based Review.

The aim of this study was to establish a fast-track protocol for bimaxillary orthognathic surgery (OGS). Fast-track surgery (FTS) is a multidisciplinary approach where the pre-, intra-, and postoperative management is focusing maximally on a quick patient recovery and early discharge. To enable this, the patients' presurgical stress and postsurgical discomfort should be maximally reduced. Both referral patterns and expenses within the health-care system are positively influenced by FTS. University hospital-literature review through Medline, Embase, and the Cochrane Library (January 2000-July 2016) using the following words - "fast track, enhanced recovery, multimodal, and perioperative care" - to define a protocol evidence based for OGS, as well as evidenced-based medicine search of every term added to the protocol during the same period. The process has resulted in an OGS protocol that may improve the outcome of the patient through several nonoperative and operative measures such as preoperative patient education and intra/postoperative measures that should improve overall patient satisfaction, decrease morbidity such as postoperative nausea, headache, dizziness, pain, and intubation discomfort, and shorten hospital stay. A literature review allowed us to fine-tune a fast-track protocol for uncomplicated OGS that can be prospectively studied against currently applied ones.

Le Fort I-Type Osteotomy Retractor.

A new instrument for retracting the maxilla after mobilization is described. It does neither compress nor inadvertently pierce the lower lip and it does neither obliterate the view nor hinder access to bone removing instruments.

Narrow-Bladed "Endo" Sagittal Split Osteotomy Retractor.

A modification of the Obwegeser sagittal split retractor is presented. It is slender while still protecting the soft tissues and is particularly suitable for endoscopically assisted surgery.

Guidelines for patient-specific jawline definition with titanium implants in esthetic, deformity, and malformation surgery.

CONTEXT: Asymmetry and unfavorable esthetics of the jawline have become possible to correct in three dimensions using computer aided design and computer aided manufacturing. AIMS: The aim of this study was to provide esthetic, technical, and operative guidelines for mandibular angle and border augmentation using patient-specific titanium implants made by selective laser melting. SETTINGS AND DESIGN: University hospital - prospective registry. SUBJECTS AND METHODS: Twelve patients and 17 implantation sites were documented and prospectively registered. Malformational, deformational, and purely esthetic indications were encountered. STATISTICAL ANALYSIS USED: Descriptive. RESULTS: Patient satisfaction was high, probably because the patients had input into the planned dimensions and shape. A serious infection with implant removal occurred in one patient who had six previous surgeries at the same sites. Technical and surgical guidelines were developed including splitting implants into two segments when the mental nerve was at risk, using a three-dimensional (3D) puzzle connection, providing at least two screw holes per segment, using scaffolds at the bony contact side, using a "satin" finish at the periosteal side, referring to anatomical structures where possible, making provisions for transbuccal and transoral fixation, using a high vestibular incision, and using a double-layer closure. Esthetic guidelines are discussed but could not be upgraded. CONCLUSIONS: Mirroring techniques and 3D print accuracy up to 0.1 mm allow precise planning of jaw angle implants. Patients are pleased when given preoperative renderings for their consideration. Infections can be managed using technical and operative recommendations and careful patient selection.

Creating a normative database of age-specific 3D geometrical data, bone density, and bone thickness of the developing skull: a pilot study.

OBJECT: Finite element models (FEMs) of the head are used to study the biomechanics of traumatic brain injury and depend heavily on the use of accurate material properties and head geometry. Any FEM aimed at investigating traumatic head injury in children should therefore use age-specific dimensions of the head, as well as age-specific material properties of the different tissues. In this study, the authors built a database of age-corrected skull geometry, skull thickness, and bone density of the developing skull to aid in the development of an age-specific FEM of a child's head. Such a database, containing age-corrected normative skull geometry data, can also be used for preoperative surgical planning and postoperative long-term follow-up of craniosynostosis surgery results. METHODS: Computed tomography data were processed for 187 patients (age range 0-20 years old). A 3D surface model was calculated from segmented skull surfaces. Skull models, reference points, and sutures were processed into a MATLAB-supported database. This process included automatic calculation of 2D measurements as well as 3D measurements: length of the coronal suture, length of the lambdoid suture, and the 3D anterior-posterior length, defined as the sum of the metopic and sagittal suture. Skull thickness and skull bone density calculations were included. RESULTS: Cephalic length, cephalic width, intercoronal distance, lateral orbital distance, intertemporal distance, and 3D measurements were obtained, confirming the well-established general growth pattern of the skull. Skull thickness increases rapidly in the first year of life, slowing down during the second year of life, while skull density increases with a fast but steady pace during the first 3 years of life. Both skull thickness and density continue to increase up to adulthood. CONCLUSIONS: This is the first report of normative data on 2D and 3D measurements, skull bone thickness, and skull bone density for children aged 0-20 years. This database can help build an age-specific FEM of a child's head. It can also help to tailor preoperative virtual planning in craniosynostosis surgery toward patient-specific normative target values and to perform objective long-term follow-up in craniosynostosis surgery.

Measuring pragmatic skills: early detection of infants at risk for communication problems.

BACKGROUND: For the early detection of children who are at risk of communication problems, we need appropriate assessment instruments. Two Dutch-language standardised screening instruments are available: the Dutch version of the Non Speech Test (NNST) and the Dutch version of the MacArthur Communicative Development Inventories (N-CDIs). These instruments gauge the precursors of language development, early vocabulary and early morphosyntactic skills. However, they do not adequately assess pragmatic skills. AIMS: To develop a norm-referenced instrument to examine the pragmatic skills of Dutch-speaking infants that is translatable into other languages. METHODS & PROCEDURES: The instrument 'Lists for the Evaluation of Pragmatic Skills in Infants' is based on 'The Pragmatics Profile of Everyday Communication Skills in Children' Dewart and Summers (1995). We translated the instrument into Dutch and transformed the structured interview format into a parent questionnaire. The parent questionnaire-Evaluatie van Pragmatische Vaardigheden (EPV)-was created following extensive research on item selection, norm table development, and reliability and validity studies. The EPV1 is applicable to children 6-15 months old; EPV2 is applicable to children 16-30 months old. OUTCOMES & RESULTS: We developed norm tables for the number of pragmatic skills achieved by the child and also for how and to what extent the skills are exhibited. For the norming study of EPV1 and EPV2 we included 390 and 534 infants respectively. The reliability scores are high for both lists. Concept validity and criterion validity studies demonstrate adequate results for the overall lists, the subscale components and specific items. CONCLUSIONS & IMPLICATIONS: The parent questionnaire is a valuable tool that specifically targets pragmatic skills in infants. The instrument can detect communication delays in infants. It is translatable into other languages and avoids having the infant examined directly by a stranger.

A serological investigation of rotavirus infections in a shanty town population in Rio de Janeiro

Cento e trinta e seis plasmas coletados aleatoriamente de crianças entre 0 e 33 meses (primeiro grupo) residentes na favela de Manguinhos, Rio de Janeiro, RJ, e 255 soros coletados de 85 crianças aos 2, 6 e 9 meses de idade (segundo grupo), residentes na mesma área, foram analisados para a presença de anticorpos (classe IgG para rotavirus por ELISA. Anticorpos foram detectados em alto percentual de crianças recém-nascidas, declinando até o 11§ mês. Elevaçäo dos anticorpos foi observada a partir do 12§ mês de vida, mas houve evidências de infecçäo a partir do 7§ mês