Midface distraction osteogenesis: internal vs. external devices.

This study compares internal and external distraction devices in the treatment of midface retrusion. 20 patients were treated with midface distraction (12 Crouzon, 4 Apert, 4 others); 12 with internal distraction (MID device), 8 with external distraction (Red or Blue device). The two groups were compared regarding operation time, peroperative blood loss and complications. The groups were comparable regarding patient age, sex, weight and diagnosis. In the MID-group, 7 of 12 patients (58%) underwent Le Fort III, 5 underwent 12 monobloc (32%). In the Blue device group, three of eight patients underwent Le Fort II (38%), three of eight underwent Le Fort III (38%), and two of eight underwent monobloc (25%). Operation time was shorter in the Blue device (mean 298 min) than in the MID group (mean 354 min). Peroperative blood loss and complication rates were similar. The internal distraction device is the 'gold standard' for treating midface retrusion. The use of an external distraction device in midface distraction osteogenesis is associated with a shorter operation time; peroperative blood loss and complications were similar. An external device affords better 3-dimensional control during the distraction process, so external distraction is preferable in patients who will tolerate this treatment.

Mandibular osteoradionecrosis: reconstructive surgery.

Osteoradionecrosis of the mandible is a serious complication following radiotherapy of head and neck cancers. A retrospective study of 20 reconstructions of mandibular defects due to osteoradionecrosis was performed. Various osseocutaneous free flaps were used: upper lateral arm (n = 5), radial forearm (n = 1), iliac crest (n = 4) and fibula (n = 7). Four grafts had a condylar prosthesis, and for seven grafts fixation was accomplished with a reconstruction plate. In three patients the mandibular defect was reconstructed using a bridging plate only. We defined a successful reconstruction as a graft or plate that did not need removal. Success was noted in 15 out of 20 patients, giving an overall success rate of 75%. For the free grafts alone (n = 17), successful reconstruction was achieved in 15 patients (88%). Two fibular grafts were lost owing to exposure and infection, as well as all three alloplastic reconstructions. Minor postoperative complications were observed in 11 patients (58%).

Plate fixation of extra-oral subcondylar ramus osteotomy for correction of mandibular prognathism: clinical aspects and short term stability.

AIM: The present study describes an extra-oral approach for subcondylar oblique ramus osteotomy using stable fixation for setback of the mandible. The aim was to investigate the incidence of neurosensory disturbances of the mandibular nerve, evaluate facial scar appearance, and assess skeletal stability following the procedure. METHODS: Forty-two consecutive patients with mandibular prognathism were operated upon using the subcondylar oblique ramus osteotomy and plate fixation. The patients were followed up for 6 months following surgery. Intra-operative and postoperative complications, neurosensory function, and facial scar characteristics were recorded. Lateral cephalograms were available immediately before operation, and immediately after operation and 6 months postoperatively. Skeletal stability was based on cephalometric assessment. RESULTS: Among the 19 patients operated earliest, neurosensory disturbances were recorded in five individuals at the 6 month follow-up. In the subsequent group of 23 patients, no disturbances were reported. All but two patients were not concerned about the facial scar 6 months postoperatively. Mean anterior relapse at the 6 month follow-up was 0.5 mm, representing 9% of the surgical setback. CONCLUSION: Extra-oral subcondylar oblique ramus osteotomy with plate fixation is a stable procedure with a low incidence of neurosensory disturbances if the osteotomy is placed well behind the mandibular foramen. Facial scar appearance was rarely a matter of concern to the patients.

[Distraction osteogenesis--a new therapeutic principle in complex craniofacial synostosis]. / Distraksjonsosteogenese--et nytt behandlingsprinsipp ved komplekse kraniofaciale synostoser.

BACKGROUND: Surgical treatment of syndromal craniofacial synostosis consists of combined neurosurgical and maxillofacial reconstructions of the neurocranium and midface. Patients often need several operations if they are to achieve a functionally and cosmetically good result. This is, in part, due to limitations in the amount of "acute" correction possible peroperatively with conventional surgical technique. MATERIAL AND METHODS: In recent years, a new method called distraction osteogenesis has been developed, by which the skeletal elements are gradually advanced. The method is based upon a process whereby the reparative callus formed between the surfaces of two bone segments is subjected to traction. This leads to new bone formation parallel to the vector of distraction. RESULTS: Distraction osteogenesis allows for greater mobilizations, hence the promise of fewer reoperations. INTERPRETATION: The method seems to be a valuable treatment modality in syndromal craniofacial synostosis, where major fronto-orbital, midface or maxillary reconstructions are often called for.

Monobloc and midface distraction osteogenesis in pediatric patients with severe syndromal craniosynostosis.

We present 2 children with severe syndromal craniosynostosis who were in need of urgent midface advancement surgery due to recurrent ocular dislocations (Pfeiffer's syndrome type II) or severe upper respiratory obstruction (Crouzon's syndrome). They were operated using distraction osteogenesis, with gradual midface or monobloc advancements. In the Pfeiffer patient, a maxillary distraction of 25 mm achieved effective cessation of ocular dislocations, whereas a 23-mm monobloc advancement in the Crouzon patient achieved cessation of nocturnal arterial desaturations. No major postoperative complications were recorded. Distraction osteogenesis has become a versatile and safe technique that allows for large skeletal advancements.

[Frontoethmoidal meningoencephaloceles]. / Frontoetmoidale meningoencefaloceler.

Frontoethmoidal meningoencephalocele is a rare congenital disease where intracranial masses protrudes through a midline defect at foramen coecum from the anterior cranial fossa into the facial skeleton. The patient presents at birth with a soft-tissue swelling at the nasal bridge. In the majority of cases, the cele is completely covered by skin. The face is elongated, the nasal bridge is broad, the upper part of the nose is long, and the patients have telecanthus. Frequently, the patients have a normal psychomotor development, but may have intracerebral malformations and a shunt dependent hydrocephalus. Spinal fluid leakage may result in meningitis. Anosmia is infrequent. The patients may have a wide range of ophthalmological problems. Newborns with meningoencephalocele should be examined by a neurosurgeon. The investigation and work-up commences with a multidisciplinary approach. We present two patients with meningoencephaloceles.

Prolonged analgesic effect of ketamine, an N-methyl-D-aspartate receptor inhibitor, in patients with chronic pain.

We examined the role of N-methyl-D-aspartate (NMDA) receptors in chronic (pathological) pain in humans by using the NMDA receptor antagonist ketamine as a probe. Thirty patients with neuropathic pain in the trigeminal area were given an i.m. injection of ketamine 0.4 mg/kg combined with midazolam 0.05 mg/kg. Pethidine 1.0 mg/kg served as a control. Three different response patterns were observed. Ketamine caused a long-term (6-24 h) analgesic effect partly dissociated from the mental side effects in 8 of the 26 patients who completed the study; these patients also had a slight analgesic effect of pethidine. In nine patients, ketamine caused a short-lasting (<2 h) analgesic effect closely associated with the mental side effects, whereas pethidine caused little or no analgesia. The remaining nine patients did not experience any reduction of pain after either drug in spite of characteristic side effects. One week after the i.m. challenge the patients received either 4.0 mg/kg ketamine hydrochloride or placebo capsules to be taken orally as a nightly dose for three consecutive nights. Five of the eight patients who had a long-term analgesic effect of the i.m. challenge reported decreased pain on days after ketamine. None of the others reported an analgesic effect. The phenomenon of long-term depression of pain in a subgroup of patients was thus confirmed when ketamine was given p.o. These findings indicate that NMDA receptors are involved in the perception and maintenance of pathological pain in some patients. In others, pain appears to be mediated by NMDA receptor-independent mechanisms. We suggest that NMDA receptor-independent transmission in central pain pathways may contribute to the reduced efficiency of analgesic drugs often seen in chronic pain states.

The effect of peripheral glycerol on trigeminal neuropathic pain examined by quantitative assessment of abnormal pain and sensory perception.

In nine patients with trigeminal neuropathic pain after nerve injury, we examined prospectively the effect of peripheral glycerol neurolysis on abnormal pain and sensory perception. In the painful facial skin area of these patients, we found increased temperature and tactile thresholds and the presence of abnormal temporal summation of pain. In seven patients, neuropathic pain was peripheral and disappeared after application of local anaesthesia at or proximal to the site of nerve injury. Neuropathic pain was central in two patients, and unresponsive to local anaesthesia applied proximal to the site of nerve injury. Six weeks after injection of glycerol proximal to the site of nerve injury, no or marginal pain relief was found in 8 patients with peripheral or central trigeminal neuropathic pain. On the other hand, in one of the patients with peripheral trigeminal neuropathic pain, glycerol was given at the site of nerve injury, and produced total pain relief for the whole observation period of 7 months. In this patient, pain relief was associated with normalisation of abnormal temporal summation of pain, which was not observed in the 8 patients with no or marginal pain relief. No further changes in temperature or tactile thresholds were found in any of the 9 patients after a single injection of absolute glycerol. Total pain relief in one of the patients probably is related to the ability of glycerol to inhibit ongoing ectopic impulse generation at the site of nerve injury. We suggest that glycerol-induced reduction of primary afferent hyperactivity may secondarily result in down-regulation of central neuronal hyperexcitability. The efficacy of application of glycerol at the site of nerve injury in patients with peripheral trigeminal neuropathic pain may warrant further investigation. However, this prospective study does not provide evidence that application of glycerol proximal to the site of nerve injury has a place in the treatment of trigeminal neuropathic pain.

[Reconstruction of the jaw and oral cavity with free vascularized grafts]. / Kjeve- og munnhulerekonstruksjon med frie, vaskulariserte transplantater.

59 microvascular graft transfers performed in 50 patients in our department since 1985 have been studied retrospectively. The indications for microvascular reconstruction were sequelae after tumour surgery in 38 patients, gunshot injury in seven, chronic osteomyelitis of the mandible in three, complication after jaw fracture in one patient, and atrophy of the alveolar ridge also in one patient. Transplants from the iliac crest, fibula, radius, radial forearm skin and jejunum were used. Three transplants were lost because of arterial thrombosis, giving a success rate of 94.9%. Complications were registered in 19 cases, the largest group being wound infections. 21 of the 50 patients have been treated with dental implants for total rehabilitation of masticatory function. Transfer of free vascularized bone and soft tissue grafts has greatly improved the functional and cosmetic results obtained in reconstructive surgery of the orofacial region.

Laser Doppler flowmetry in the assessment of tooth vitality after Le Fort I osteotomy.

The aim of the present study was to evaluate pulp vitality in 15 patients, 11 to 29 months after a Le Fort I osteotomy. Assessment of pulpal blood flow was obtained by means of laser Doppler flowmetry, and it was measured bilaterally from the first maxillary premolar to the central incisor. The results were compared with those obtained by electric pulp testing in the same teeth. In addition, periodontal ligament perception was evaluated by applying axial loads to the central incisors. Radiographs were also studied. Fourteen subjects served as a control group. There was no significant difference between the level of pulpal blood flow in the teeth of the operated group compared with the control group. Twenty-one per cent of the teeth in the group operated on were insensitive to electric pulp testing, and in the remaining 79% the mean threshold was significantly higher than in the corresponding teeth in the control subjects. Similarly, the axial load threshold for the incisors for the control subjects was below 5 g, but in the group operated on 66% had a threshold above 5 g. These experiments clearly demonstrate that teeth without normal innervation can have an intact blood supply and be vital.

Effect of homoeopathy on pain and other events after acute trauma: placebo controlled trial with bilateral oral surgery.

OBJECTIVE: To examine whether homoeopathy has any effect on pain and other inflammatory events after surgery. DESIGN: Randomised double blind, placebo controlled crossover trial with "identical" oral surgical procedures performed on two separate occasions in 24 patients. INTERVENTIONS: Treatment started 3 hours after surgery with either homoeopathy or placebo. MAIN OUTCOME MEASURES: Postoperative pain and preference for postoperative course assessed by patients on visual analogue scales. Measurements of postoperative swelling and reduction in ability to open mouth. Assessment of bleeding after surgery. RESULTS: Pain after surgery was essentially the same whether treated with homoeopathy or placebo. Postoperative swelling was not significantly affected by homoeopathy, but treatment tended to give less reduction in ability to open mouth. No noticeable difference was seen in postoperative bleeding, side effects, or complaints. Thirteen of the 24 patients preferred the postoperative course with placebo. CONCLUSIONS: No positive evidence was found for efficacy of homoeopathic treatment on pain and other inflammatory events after an acute soft tissue and bone injury inflicted by a surgical intervention. Differences in the order of 30% to 40% would have been needed to show significant effects.

[Anti-inflammatory agents in acute tissue trauma. Choice and effects]. / Antiinflammatoriske midler ved akutte vevstraumer. Valg og virkninger.

The choice of drugs to reduce pain and excessive inflammatory reactions after surgery or accidental trauma is reviewed and discussed, with particular reference to a series of Norwegian studies based on bilateral oral surgery. In this model, paracetamol has proved capable of reducing post-operative swelling by about 30%, while acetylsalicylic acid (in common analgesic doses) failed to reduce or even tended to increase swelling. Paracetamol is a recommendable alternative for reducing acute post-traumatic pain and swelling, while acetylsalicylic acid should be avoided. Non-steroidal anti-inflammatory drugs which efficiently reduce rheumatoid swelling may provide good pain relief, but the effect on an acute post-operative swelling is less impressive. In the oral surgical model, glucocorticoids reduced post-traumatic swelling by about 50% and provided better or at least as good pain relief as any tested non-steroidal anti-inflammatory drug, including paracetamol. Single dose or short-term administration of a glucocorticoid is recommended as an efficient and valuable means of reducing both pain and excessive inflammation in surgery and traumatology. Of practical implication in traumatology is the finding that, for both paracetamol and glucocorticoids, almost the same reductions were recorded in swelling and pain whether the drug was administered prior to surgery or 2-3 hours afterwards.

[Management of facial injuries]. / Praktisk om ansiktsskader.

Major maxillofacial injuries are common in patients with multiple injuries and may be life-threatening due to obstruction of airways and bleeding. The initial treatment is to secure and maintain a free passage of air and to control bleeding. The extent of the injury is assessed after careful clinical examination and CT scanning of the facial skeleton. Treatment consists of suturing soft tissue, and reduction and fixation of fractures. Open reduction and stable fixation using lag screws, microplates and miniplates are recommended. The best results are obtained by operative treatment of major maxillofacial injuries as early as possible.

Analgesic efficacy of acetaminophen 1000 mg, acetaminophen 2000 mg, and the combination of acetaminophen 1000 mg and codeine phosphate 60 mg versus placebo in acute postoperative pain.

Acetaminophen (APAP) 1000 mg, APAP 2000 mg, the combination of APAP 1000 mg plus codeine phosphate 60 mg (APAPCOD), and placebo (PBO) were compared in a 6-hour, randomized, single-dose, double-blind, parallel-group analgesic trial. All active treatments were statistically superior (p less than 0.05) to placebo for 4 hours after medication with respect to pain intensity (PI) and pain intensity difference (PID), and up to 3 hours regarding pain relief (PAR). The combination scored better than all other treatments on the summary analgesic efficacy measures sum PI (SUMPI), sum PID (SPID), and total PAR (TOTPAR). The combination was statistically superior to APAP 1000 mg on SUMPI, TOTPAR and maximum PAR (MAXPAR). Acetaminophen 2000 mg showed marginal numerical superiority over 1000 mg for SUMPI, but was not statistically superior for any summary efficacy measure. The 2000-mg dose was numerically inferior to APAPCOD for every summary efficacy measure and statistically inferior regarding SPID and MAXPAR. We concluded that codeine 60 mg added to acetaminophen 1000 mg offers analgesic advantages, and acetaminophen reaches an analgesic ceiling effect at 1000 mg using the dental pain model.

Comparison of the analgesic effect of a corticosteroid and paracetamol in patients with pain after oral surgery.

In a double-blind crossover study identical oral surgical procedures were performed on two separate occasions in 24 patients. After one operation they were given capsules of methylprednisolone. A total of 84 mg was administered in decreasing doses for 4 days, starting with 24 mg 2 h after surgery. After the other operation 1 g paracetamol was given at 2, 6 and 9 h after surgery, then 500 mg four times daily for the next 2 days. Several measurements/assessments were recorded for paired comparisons of the postoperative courses. There was no significant difference in pain scores when comparing the two treatments. However, 3 and 4 h after the operation, there was a tendency towards better pain relief with paracetamol (P greater than 0.05). The results suggest that methylprednisolone, after a delay, may exert analgesic efficacy comparable to a standard regimen with paracetamol. On the third postoperative day methylprednisolone reduced measured swelling by 29% compared to paracetamol (P = 0.03). Overall preference scores evaluated the two treatments as equally efficient on the day of surgery. The first and second postoperative day the scores were in favour of methylprednisolone (P = 0.03). Present and previous results in this model suggest that corticosteroids deserve attention as a means of reducing both pain and inflammation after surgery and trauma.

The effects of indoprofen vs paracetamol on swelling, pain and other events after surgery.

The capability of indoprofen compared to paracetamol in reducing swelling, pain and other events of an acute inflammatory reaction was tested in a double-blind crossover study with bilateral oral surgery. Identical surgical procedures were performed on two separate occasions in 24 patients. After one operation they received tablets of indoprofen, after the other, paracetamol. A double-placebo method was used, as dosage regimens for the two treatments were different. Medication started 3 h after surgery and continued for 3 days. Almost identical swelling was measured after both treatments indicating that indoprofen has the same anti-inflammatory activity as previously found with paracetamol, which reduces swelling with about 30% compared to placebo. The pain and preference assessments were significantly in favor of indoprofen. Subjective bleeding scores were significantly increased with indoprofen. However, bleeding was minimal, and the occurrence of hematoma/ecchymosis was not increased with indoprofen. The results indicate that indoprofen is capable of reducing an acute, post-operative inflammatory reaction. For this purpose, it appears to be more efficient than other non-steroid anti-inflammatory drugs like ibuprofen, oxyphenbutazone, indomethacin and naproxen.