ABSTRACT BOOK

14-15 mars 2003

Chirurgie Orthognathique, Distraction et Esthétique Faciale

FONTENELLE A.
ORTHODONTICS , SURGERY : CONFLICTING OR CONVERGING OBJECTIVES AND MEASURES.

Aesthetic is the goal of both the orthodontist and the oro-facial surgeon.
While the surgeon focuses on the facial balance, the orthodontist concentrates on the occlusal objectives. Usually an ideal occlusion is the key for the best facial appearance and vice versa : the team work is simple.
But in some cases the orthodontist, in order to obtain an ideal occlusal relationship, may need surgical modifications that are detrimental to the facial harmony while in some other cases the surgeon may plane skeletal changes reaching a  good facial harmony but  achieving an unacceptable occlusion

Both surgeons an orthodontists have to work together on the treatment plans to solve conflicting objectives and this is even more important in complex cases when perio and prosthetic treatments are needed.

But the best treatment plan is useless if the patient does not accept it. The patients who consult a surgeon in order to obtain an improvement of facial aesthetics may anticipate a fast treatment with only few days of hospitalisation and are not prepared to wear braces for one year or more, while the patients who seek orthodontic treatment are anticipating a non-traumatic treatment without any major risk  and are usually not willing to accept a surgical solution to their problem.
The orthodontists have to improve the treatment procedures by using invisible appliances, while the surgeons have to reduce the aggressiveness of their procedures ;both have to be aware of the potential and limits of each other.

 
FERRI J., RAOUL G., VEREECKE F., LEMIERE E.
INTERET DU RECUL MAXILLAIRE PAR OSTEOTOMIE DE LEFORT I DANS CERTAINES CLASSES II DENTO-SQUELETTIQUES

Alors que l'ostéotomie de Lefort I est le traitement habituel des insuffisances maxillaires, elle peut, dans un certain nombre de cas, être utilisée pour traiter certaines classes II où il existe une importante promaxille.

En effet, le traitement du décalage antéropostérieur de ces dysmorphoses, par la seule ostéotomie mandibulaire, peut donner un aspect disgracieux malgré une occlusion satisfaisante.  L'ostéotomie de Lefot I de recul, seule ou associée à une ostéotomie sagittale d'avancée, est alors le traitement de choix.

Les indications, la technique chirurgicale et quelques résultats seront présentés.

 
OLSZEWSKI R., REYCHLER H.
ACRO 4D : NEW 4D CEPHALOMETRIC ANALYSIS FOR FOUR DIMENSIONAL DIAGNOSIS, 3D PLANNING AND SIMULATION IN ORTHOGNATHIC SURGERY

This new analysis permits to study different cranio-maxillo-facial malformations and facial asymmetry. The visualization of ACRO 4D analysis is done in 3D, understanding the results must be done in 4D (3D and time), which associates the Moss neural matrix theory, the Delaire ideal individual equilibrium concept and the new concept of structural–functional guidance. The ACRO 4D analysis contains 38 reference points and 28 plans. 5 angles, 10 surfaces and 9 volumes can be measured. The ACRO 4D analysis has been decomposed in 16 modules and 6 standard planning procedures have been implemented by combining these modules. 10 of these modules represent the 2D to 3D transformation from 2D Delaire analysis. The last 6 modules study the symmetry-asymmetry of the different craniofacial regions. The ACRO 4D analysis guides the surgeon, step by step, to the diagnosis, with clear guidelines and 3D incorporated examples. The generic tools, developed in this software, can achieve the transformation of every 2D to 3D cephalometric analysis with the creation of the independent reference points, lines, plans and volumes. Our further investigations are the validation of the method accuracy, the clinical validation on patients and development of 3D simulation based on this ACRO 4D analysis.

 
CHARRIER J.B., DELATTRE J ., DENOYELLE F., GARABEDIAN E. N.
DERMOÏDES CRANIOFACIAUX : THEORIE EMBRYOLOGIQUE UNISSANT LES KYSTES ET FISTULES DU DOS DU NEZ

OBJECTIVE: Nasal dermoid sinus cyst (NDSC) is an uncommon congenital lesion presenting as a large panel of midline craniofacial anomalies. The objective of this study was to review and reanalyze embryological hypotheses concerning NDSCs, and to propose an embryological theory unifying the various anatomical characteristics of these lesions.
RESULTS: We report the first case of intradiploetic frontal extension of a NDSC in a 9-month-old boy presenting as a medial frontal fistula with recurrent frontal swelling six month after a mild frontal trauma. Complete surgical removal was performed. There was no evidence of either persistent or recurrent disease one year after surgery.
CONCLUSION: The embryological and anatomical origins of NDSCs are reviewed. We propose to distinguish anterior topography of NDSCs, located at the anterior skull base level from the basal one, located at the middle skull base level. We reexamine and rehabilitate a forgotten embryological theory, which unify the various clinical presentations of anterior NDSCs.

 
BOULETREAU P., BRETON P., FREIDEL M., LONGAKER M.T.
INSIGHT INTO THE MOLECULAR MECHANISMS GOVERNING DISTRACTION OSTEOGENESIS

Although the histologic and ultrastructural changes associated with distraction osteogenesis have been extensively delineated, relatively little is known about the molecular mechanisms governing this process. However, such information has significant clinical implications because it may enable targeted therapeutic manipulations designed to accelerate osseous regeneration. Recently, our laboratory has described a rat mandibular distraction model that provides an excellent environment for deciphering the molecular mechanisms that mediate successful and unsuccessful distraction osteogenesis.
Using this model, we have demonstrated that gradual distraction osteogenesis stimulates the production of osteoinductive growth factors (Transforming Growth Factor-alfa 1) and extracellular matrix molecules (Collagen I and Osteocalcin). Furthermore, we have begun to investigate the molecular mechanisms by which successful gradual distraction osteogenesis differs from acute lengthening. We have demonstrated that gradual mandibular distraction, in contrast to acute lengthening, results in net accumulation of bone specific extracellular matrix products.
Based on experimental works, we present the hypotheses and current research that have furthered our knowledge of the molecular mechanisms that govern distraction osteogenesis. We believe that novel systems like the rat model will facilitate our understanding of the biomolecular mechanisms that mediate membranous distraction osteogenesis and will ultimately guide the development of targeted-strategies designed to accelerate bone healing.

This work was partially supported by the Leibinger-Stricker grant 1999

SPAEY Y, BETTENS R, MOMMAERTS M, VAN LANDUYT HW, ABELOOS J, DE CLERCQ C, LAMORAL PH, NEYT L.
A PROSPECTIVE STUDY ON INFECTIOUS COMPLICATIONS IN A SAMPLE OF 850 CONSECUTIVE ORTHOGNATHIC SURGERIES.

Aim
4.7 % of the 1106 patients who underwent corrective facial orthopaedic surgery at the GH St. Jan, Brugge, from 1992 till 1997, suffered from a postoperative wound infection (Acebal-Blanco et al., 2000). The antibiotic scheme in that era was 3 doses of 2g IV cephamandolnaftate on the day of surgery. Next, amoxycillin, 4 times a day, was given orally for 5 days. When the Belgian government implemented new rules for antibiotic prophylactics, a new antibiotic scheme following Peterson (1990) was started in our service. A prospective study was set up in October 1999 with the aim to analyse infection frequency, microbial spectrum and antibiotic sensitivity.

Materials and methods
The study protocol was supervised by a microbiologist and approved by the local Ethics Committee (#06 065). It was planned to administer cephazolin in a dose of 1g IV at time of induction and to repeat this every 4 hours. No postoperative antibiotics were planned for, except in case of haematoma. When an infection would occur, a swab culture had to be done according to a standardised protocol, abscess drainage had to be carried out and antibiotics to be given per-orally. At the moment of the writing of this abstract 502 patient charts had been analysed. In three hundred fifty surgeries, the study protocol was followed. This comprised 236 female and 114 male patients. There were 189 osteotomy procedures in the maxilla, 238 in the posterior mandible, 71 in the symphyseal area and 120 other accompanying procedures.

Results
Within the first 6 postoperative weeks, 24 infections (6,8%; 4 male and 20 female patients) with pus production occurred. All abscesses originated in the sagittal split area. The aerobe cultures showed in 8 cases a normal flora. In 6 of the anaerobe cultures the identified species was Bacteroides, all the others were sterile. Bacteroides is sensitive to amoxyclav and clindamycin, but resistant to cephazolin.

Conclusion
The current infection rate is higher than that of the years when antibiotics were prescribed for 6 days. We will present the rate, results of the cultures and any statistical difference with the former antibiotic scheme. The fact that all infections occurred in the sagittal split area requires further stratification (type of drain, transbuccal/transoral screw osteosynthesis). Definitive analysis will show if the current prophylactic antibiotic scheme will be maintained.

References

Acebal-Blanco F, Vuylsteke  PLPJ, Mommaerts MY, De Clercq CAS: Perioperative complications in corrective facial orthopedic surgery. A 5 year retrospective study. J Oral Maxillofac Surg 58: 754-760, 2000

Peterson LJ:  Antibiotic prophylaxis against wound infections in oral and maxillofacial surgery. J Oral Maxillofac Surg 48: 617-20, 1990

 
POLSBROEK R, MOMMAERTS MY, SANTLER G, CORREIA PEGS, ABELOOS JVS, VAN DEN AKKER H.
DENTAL AND PERIODONTAL BEHAVIOUR IN THE ACTIVE AND CONSOLIDATION PHASE OF SYMPHYSEAL DISTRACTION. A PROSPECTIVE STUDY

Aim:
To analyse prospectively the dental and periodontal behaviour in the active phase of symphyseal distraction.

Material and Methods
Fourteen consecutive patients (8 female, 4 male) planned to undergo transmandibular distraction, were selected. At time of analysis, two files were discarded (1 of a male, 1 a female patient) because of incompleteness of the records. Alginate impressions were taken at the time of placement of the distractor (mean age 19y 11m, min 12,2, max 35,2), when the activation phase was ended and at the time of the removal of the device, 2 months later. The plaster models were measured with a Polhemus 3-D digitizer to study the amount of distraction and spatial movement of the canines and incisors. Cold-sensitivity and mobility tests were performed, as well as pockets depths measured in the frontal region before distraction, at the start of the activation and at the end of the consolidation period. Intra-Rater reliability was tested with the Intraclass Correlation Test. Differences were tested with the T-test for Paired Differences.

Results:
At the end of active symphyseal distraction there was increased mobility, and deepened periodontal pockets of the teeth in the proximity of the osteotomy. Cold sensitivity testing resulted in diminished responses. After two months of consolidation, periodontal pocket depths were decreased. Mobility increase, especially of the first incisors, had stabilised. Cold sensitivity did not return to a normal level and longer follow-up will be needed to evaluate responses. One central incisor that showed discoloration and a negative cold sensitivity response underwent endodontic therapy. Considering this, the unilateral “wine-glass” osteotomy might be advantageous. The resilient central part of the Transmandibular Distractor (Mommaerts, 2000) allowed for condylar rotation (mean 9,4°, SD 5). This is in contrast to all other bone and tooth-borne distractors (Braun et al. 2002), that invoke lateral condylar translation. The incisor teeth tend to protrude, not to extrude, during the active phase of distraction.

References

Braun S, Bottrel JA, Legan HL Condylar displacement related to mandibular symphyseal distraction. Am J Orthod Dentofacial Orthop 121:162-5, 2002

Mommaerts, M. Transmandibular distraction as a method to broaden a small anterior apical base. Br. J. Oral Maxillofac. Surg. 39: 8-12, 2001

 
ABELOOS JVS, DE CLERCQ CAS, LAMORAL PH, MOMMAERTS MY, NEYT LF
OUTCOME OF MANDIBULAR ASYMMETRIES TREATED WITH UNILATERAL SAGITTAL SPLIT OSTEOTOMIES.

Aim
Mild to moderate mandibular asymmetry with malocclusion, can be corrected by a unilateral sagittal split osteotomy of the ascending ramus (USSO). As compared to bilateral sagittal split osteotomies, a longer operation and possibly surgical complications (mainly infections and sensitivity alterations in the inferior alveolar nerve) can be avoided. The aim of the retrospective study was to evaluate postoperative jaw and joint function in a sample of USSO. Condylar rotation at the non-operated side could indeed provoke a joint dysfunction.

Material and Methods
Out of 2528 patients who underwent orthognathic surgery in our service, from 1991 till 2001, 54 underwent an USSO. Three-plane cephalometric radiographs immediately post- and long-term postoperatively, and clinical parameters (click, pain, trismus) were analysed. Records were complete for 24 cases.

Results
Condylar rotation at the operated side was 2,7° (SD 2,7°) and at the non-operated site 3,4° (SD 2,3°). A click was present in 12,5% of the patients preoperatively and in none postoperatively. No joint pain present preoperatively but it was present in 8,3% of the cases postoperatively, and only at the operated side. The mean mouth-opening was 47,5mm preoperatively (range 37-60) and 52,5mm postoperatively (range 39-65).

Conclusion
Changes in condylar position are within the range of adaptability of the joints.
Moderate correction of mandibular asymmetry can be done by means of a USSO.

 
ALI N, MOMMAERTS MY, CORREIA PEGS
BIMAXILLARY TRANSVERSE OSTEODISTRACTION. A STORY ABOUT SMILE AESTHETICS AND STABILITY

Severe crowding due to a narrow upper and lower apical base can be corrected by four-premolar-extractions or by bimaxillary transverse osteodistraction. The first strategy is prone to unaesthetic changes in lip posture, nasolabial angle and buccal corridors. Life-long retention is necessary because of the known correlation between increased inter-canine distance and relapse of crowding. The second strategy involves surgery and the final outcome regarding stability is not known yet. Theoretically, because the canines have not been moved outside of the skeletal envelope, and because the functional matrix positively influences the dental arches, relapse of crowding should be less. Facial appearance is improved because of the reduction of the buccal corridors and the fullness of the mouth in rest and upon smiling. An in-depth literature study on aesthetic outcome and stability will be discussed and the potential of bimaxillary transverse osteodistraction will be highlighted

 
Ph. PELLERIN* ; N. CAPON DEGARDIN* ; P. DHELLEMMES** ; M. VINCHON** ; J. DELPIERRE*
PLACE DE LA DISTRACTION DANS LE TRAITEMENT DES DYSOSTOSES CRANIOFACIALES (CRANIOFASCIOSTENOSES)

*Service de Chirurgie Plastique Reconstructrice – Hôpital Roger Salengro – CHRU – 59037 Lille Cedex - France
**Clinique de Neurochirurgie Pédiatrique – Hôpital Roger Salengro – CHRU – 59037 Lille Cedex – France

Historiquement la première intervention de Chirurgie Crânio-Faciale était une ostéotomie totale de la face réalisée par Paul Tessier selon un tracé de Lefort chez un patient atteint d'une maladie de Crouzon.
Cette ostéotomie, intervention majeure et complexe, à la morbidité élevée de part sa difficulté, est longtemps restée l'intervention de chirurgie crânio-faciale par excellence.
La distraction faciale a révolutionné la prise en charge de ces patients, qu'il s'agisse de protocoles de distraction précoce sans ostéotomie chez le jeune enfant tels que nous les réalisons et qui sont devenus pour nous systématiques, ou qu'il s'agisse de l'association ostéotomie type Lefort III et distraction chez le grand enfant et l'adolescent. Ces protocoles sont maintenant parfaitement codifiés, ils sont réitérables, permettant de traiter tous les aspects fonctionnels et esthétiques des maladies de Crouzon, de Pfeiffer et d'Apert.

 
C. MALEVEZ , M. MEHBOD, F. SCHUTYSER, B. KOVACS, A. DE MEY, (H.U.D.E, ULB)
MANDIBULAR ANGLE CONTOURING IN HEMIFACIAL MICROSOMIA

The correction of the asymetrical hemifacial microsomia involves reconstructing hard and soft tissues in order to obtain an optimal esthetic result.
Distraction osteogenesis allows to correct the mandibular body and ramus length in case of severe difformities. Unfortunately, if the bone lengthening is quite satisfactory, the bone volume is still insufficient. Numerous techniques have been reported in order to compensate the lack of soft and hard tissue, using autogenous as well as alloplastic materials. Some of them have been successful but no long term results of these techniques are published. Mostly, the pre- and per-operative determination of the volume to be corrected is done by empiric evaluation.
With the use of a 3D image-based planning software (Maxilim), a mirror image of the normal mandibular angle is obtained and transposed to the affected area. In this software, an experimental toolbox was added to estimate the volume of bone grafting and to design a titanium plate implant. That titanium plate will provide a strong support to on-lay bone grafting and insure the symmetry of both mandibular angles improving facial contouring.

J. NEVEN, S. SICILIANO, H. REYCHLER
TRANSPORTING DISTRACTION OSTEOGENESIS USING THE MULTI-DIRECTIONAL EXTRA-ORAL DISTRACTOR (NORMED) FOR RECONSTRUCTING DISCONTINUITY MANDIBULAR DEFECTS. PRESENTATION OF TWO CASE REPORTS AND DISCUSSION.

Many options are available for mandibular reconstruction, including reconstruction plates, block grafts and free tissue transfer such as a fibular graft.
Distraction osteogenesis has proven also to be a reliable method for reconstructing missing segments of resected bone in both horizontal and vertical plane.
Two patients underwent a transport distracting osteogenesis using the Normed multi-directional extra-oral distractor for reconstructing the hard and soft tissues. The defects resulted from resection of squamous cell carcinoma. In both cases, we were able to obtain sufficient horizontal and vertical bone volume with attached gingival without the need of a free tissue transfer.

 
RICHTER M., LAURENT F.
MAXILLARY ANTERIOR STEP OSTEOTOMY FOR FACIAL REJUVENATION

Maxillary deficiency is frequently associated with pranasal flattening which hollowes the alar grooves and make the nose to appear more prominent.  This clinical signs give to the face a hard features and an aspect of premature ageing, especially if mandibular excess is present.  Maxillary anterior step osteotomy allows the creation of two strongs spurs which, after maxillary anterior repositionning masks the paranasal flatness.  This modification of the Le Fort I osteotomy is achieved during the same procedure and avoids autogenous bone grafts or synthetic implants.  The authors present the procedure on the base of clinical results which show the effect of rejuvenation of this surgical technic.

 
KARIMI A., MAHY P., REYCHLER H.
COMBINE OSSEOUS DISTRACTION WITH ORTHOGNATHIC SURGERY IN FIRST BRANCHIAL ARCH SYNDROME SEQUELAE'S CORRECTION

First branchial arch syndrome includes several head and neck anomalies, in particular mandibular hypoplasia. This hypoplasia (unilateral in 90% of cases) is often associated with panfacial asymmetry, mandibular retrognathia and dental malocclusion. As maxillar growth depends on mandible development, surgical treatment needs to consider both segments. Furthermore genioplasty may be useful in case of mental asymmetry. The case reported here concerns surgical treatment of first branchial arch syndrome where osseous distraction was combined to orthognathic surgery. Literature review on this particular subject is presented.

 
BOU SABA S. , SICILIANO S.
ORTHODONTIC AND ORTHOGNATHIC TREATMENT IN PATIENT WITH LIP PALATE CLEFT : UCL PHILOSOPHY

Patients affected by a cleft of lip and palate present many problems. A multidisciplinary team is demanded and necessary (ENT. Pediatrics, Maxillofacial surgeons, Plastic surgeons, orthodontists, Speech therapists, Psycologists, geneticiens, and dentists).

The role of the orthodontist is especially necessary during the first two decates of life.
 
During the permanent dentition the goals of the orthodontic treatment are :
- dental alignement
- bite stability
- occlusal and facial harmony

Because of skeletal dysmorphosis, especially maxillary hypoplasia owed to the cleft, orthodontic  procedures are very often associated with orthognathic surgery.
Actually in patients who follow our cleft repair protocol from the birth we perform an  osteogenetic distraction of upper maxillary in skeletal class III. The mean age is in children at about 10-11 years old after gingivoperiosteoplapsty and alveolar bone graft.
In older patients (not follow in our Department or in secondary cases) we prefer to do classic orthognathic surgery except if the dysmorphosis is so severe with a great over-jet and maxillary hypoplasia where we still use bone distraction. We don't perform the technique proposed by Posnick consisting in the advancement of the little fragments but we preserve the space of the cleft which is grafted by autologous bone. Further studies are necessary to confirm the benefits of distraction in young cleft patients.

 
D. DEQUANTER, G. ANDRY, PH. LOTHAIRE AND R. DERAEMAECKER
Department of Surgery, Institut Jules Bordet.
WIDE SURGERY AND RECONSTRUCTION FOR MINOR SALIVARY GLAND TUMORS

AIM : Limited excision is one of the main factors leading to recurrence of minor salivary gland tumor (1-6). Our aim is to perform large resections with immediate reconstruction in order to provide local control, as well as to achieve better cosmetical and functional results.
MATERIAL & METHOD : Four consecutive patients suffering from minor salivary gland tumors of the upper aerodigestive tract are reported : two adenoid cystic carcinoma (one of the lateral oropharyngeal mucosa, one of the retromolar area), one terminal duct adenocarcinoma (base of tongue), one mucoepidermoid carcinoma (floor of the mouth). Two radial forearm free-flaps, a trapezius myocutaneous pedicled flap (including an adjacent osseous part of the scapula) and a sternocleidomastoid muscular pedicled flap were respectively used for reconstruction. Additional external radiation was used for three patients (60 cGy), the 71 years old patient with the retromolar location was not irradiated.
RESULTS : Postoperative course were uneventfull and the ability to chew and swallow was rapidly restored (11 days, mean ; range : 10 to 25. days) in each case. Two patients, locally controlled, with adenoid cystic CA died : one from brain metastases (2 years), the other with pulmonary metastases (8 years).
One patient is alive with a recurrent tumor of the pterygomaxillary fossa (without trismus so far) 16 years after the original operation, the other patient is free of recurrent disease at the base of the tongue but has been recently operated (with success) for 2 pulmonary metastases 60 months after initial surgery.
CONCLUSIONS : For minor salivary gland carcinoma of the head and neck, large resection with immediate reconstruction afford fast recovery and long lasting locoregional control. Additional radiotherapy is feasible.

 
C. LAROCHE, H. ABBAR
MODIFICATIONS DU COMPLEXE NASO-LABIAL APRES OSTEOTOMIE DE LEFORT I

L'ostéotomie de Lefort I entraîne des répercussions sur les tissus mous naso-labiaux qui d'après de nombreux auteurs sont prévisibles mais mal quantifiables car multifactorielles. Ces modifications sont en général considérées comme défavorables. Après un bref rappel de l'anatomie de la région naso-labiale et de la morphogénèse du pré-maxillaire, notre étude tente de recenser les différents facteurs intervenant, de décrire les processus entraînant ces déformations et d'en déduire des techniques chirurgicales établies.
Douze patients regroupés en vecteur spécifique de mouvement ont bénéficié d'une ostéotomie de Lefort I. La technique de fermeture était un repositionnement musculaire sans fermeture en VY. L'étude des tissus mous a été réalisée avec photographies et céphalométries avant l'intervention et au moins un an après.
Nous concluons qu'en respectant l'équilibre architectural cranio-facial des patients, et en repositionnant la musculature naso-labiale de façon adaptée, ces modifications après ostéotomie de Lefort I sont soit favorables dans la majorité des cas, soit défavorables mais limitées dans les autres cas.

 
I. PONIKELSKY, C. VERVAET, E. DEROUX, A. BALON-PERIN, R. GLINEUR
IMPACT OF ORTHODONTIC AND SURGICAL TECHNIQUES ON MAXILLARY TRANSVERSAL EXPANSION. OBTAINED BY TRANSPALATAL DISTRACTION

Inadequate transversal development of the maxilla is a frequently observed problem in orthodontics.
In adolescents and adults, the preferred therapeutic attitude consists of a transversal expansion surgically assisted by transpalatal distraction.

Clinical studies show that the transversal expansion obtained by transpalatal distractor (TPD) is greater at the level of the canines than at the level of the molars.  Nevertheless, if a pterygomaxillary disjunction is carried out, and the TPD is placed at the level of the first molars, the expansion of the segments would be more parallel.

The orthodontic or bone anchors may modulate the antero-posterior gradient of the transversal expansion obtained by the transpalatal distractor.

V.SMATT,Y.SMATT,M.RAHAL,M.ROBIN,P.PAPON.
BASAL IMPLANTO-ORTHOGNATIC COMBINED SURGERY.  PRELIMINARY STUDY

Combination of  dento-alveolar process loss to maxillary deficiency  increases aesthetic and functional disturbances,  and may hamper dental conventional prosthesis realization. The complete dento-maxillo-facial rehabilitation covers  orthognatic  surgical  interalveolar arch discrepancy harmonization  followed  by implant-supported  dental restoration.
Facing a severe maxillary atrophy , SAILER advocated ,in 1989, an “  Implanto-Orthognatic Reconstructuive Surgery “  -I.O.R.S.- as preprosthetic protocol  in anticipation of implant-supported denture.
Confronted to  some patients peculiar requirements, as autologous bone grafting rejecting and for  immediate  post-operative fixed dental prosthesis  wishing , we have been stimulated to settle an original therapeutic concept we called :  “  Dento-Implanto-Orthognatic Rehabilitation “ –D.I.O.R.- , able to approximate these claims achievement. For this purpose ,  we have combined  Orthognatic and Basal Implantology techniques creating a revisited co-operative protocol. The Diskimplant is a laterally disk-design implant which , once inserted , provides adequate  strong multicortical anchorage allowing immediate loading a fixed dental bridge ; associated to « Structure »,a microthreaded screwtype axial inserted implant , it constitute  « all quality bone structure implant system », then diminishing  bone grafting  recourse or alveolar distraction manœuvres.
The D.I.O.R.'s  chronological process is displayed ;  prominence  of  pre-operative study is  established  ,operative planning intricating both distinct procedures steps is detailed ; post-operative survey is exposed.
Although being still at preliminary study , its convincing  satisfying first results allow   D.I.O.R. strategy  to  become a conservative , up to date, alternative method to I.O.R.S. , in selected cases.
               
 

M.Y. MOMMAERTS
ENDOSCOPIC FOREHEAD LIFTING, A SIMPLIFIED APPROACH

The endoscopic approach to brow- and forehead lift has increased patient's acceptance for this type of cosmetic correction.  It's success is dependent upon the avoidance of supra-orbital nerve dysaesthesia, medial brow lift and ecchymosis, and the elimination of midline vertical and horizontal furrows and wrinkles, whilst maintaining lateral brow mimics. A number of modifications have been implemented and focus mainly on the endoscopic retrieval of the supra-orbital and supra-trochlear nerves, the manually controlled release of the lateral supra-orbital periosteum, and the manually controlled scarification of the frontalis, procerus and corrugator supercillii muscles. Direct cranial skin suspension is done with the use of mono-cortical screws and skin staples. We use only 3 access incisions above the hairline. Adult patients requested facial rejuvenation can benefit from a combination of browlift and orthognathic procedures. The purchase of a TMJ arthroscopy tower in the early nineties can finally generate pay-off.

 
SICILIANO S., REYCHLER H.
OUR PHILOSOPHY IN THE USE OF OSSEOUS DISTRACTION VERSUS CLASSICAL ORTHOGNATIC SURGERY.

Bone osteogenetic distraction is a revolutionary technique in oral and craniofacial surgery.
Even already known by orthopaedics since the years fifties it was used in the head region for the first time only in 1992 by Mc Carthy and for severe malformations pathologies.
The progress of the the surgical techniques and technology of the devices have allowed to enlarge widely the indications and actually many classical procedures in different type of pathologies (oncology, traumatology, orthognatic surgery, pre-prosthetic surgery) have been replaced by the bone distraction.
The key of success is the apparent simple technique, the more physiological response of tissue the absence of donor site, the very good results often obtained compared to the ancillary procedures, sometimes vith high morbidity, used for reconstruction of hard tissue defects.
But bone osteogenetic distraction is not without inconvenients and sometimes ancillary or classical procedures still remain the best choice.
In this communication we report our philosophy at the University Hospital St. Luc (UCL) in Brussels in the use of bone osteogenetic distraction versus classical surgery especially orthognatic surgery : which are our indications, how we perform it.

 
J.L. BEZIAT – N. ABOU-CHEBEL – N. NIMESKERN – A. GLEIZAL
STANDARD SURGICAL ORTHOGNATIC TREATMENT OF CLASS II USUALLY REQUIRES A MANDIBULAR PROPULSION OSTEOTOMY, WHICH GENERALLY PRODUCES AN EXCELLENT AESTHETIC RESULT.

In the case of relative progeny, the dental gap is considerably wider than the gap observed in profile. The thickness of the soft parts and genian volume then partly mask class II. A mandibular propulsion osteotomy, which advances the chin as much as the free edge of the incisors, leads to an unacceptable result, with an aspect of class III which patients dread.

The carrying out of a complementary, sliding by moving back, genioplasty does not produce a good aesthetic result because it modifies the lip-chin angle and leads to an inelegant straightness of the lower level.

It is then better to carry out a mandibular propulsion osteotomy including a posterior impaction of the occlusal plane by a few millimeters. This movement leads to a much wider denti-labial  projection than the genian one, while preserving the lip-chin angle. It is obviously necessary to combine this with a posterior maxillary impaction of the same amplitude during the Le Fort I osteotomy. The orthodontic preparation must take this into account and give to the upper incisors an excessive slope, which the osteotomy will correct.

From a homogeneous series of 50 cases, the authors report the technique, the indications and the results of this therapeutic method.

 
N. NADJMI, J. DEFRANQ, F. NOORMAN VAN DER DUSSEN, B. VANASSCHE, G. VAN HEMELEN, H. VERCRUYSSE
THE STATE OF THE ART IN THE PLANNING AND PERFORMANCE OF MIDFACIAL DISTRACTION OSTEOGENESIS
  

Aims: The clinical experience with a small intra oral distractor in advancing severe hypoplastic mid-face is presented.
Method: Seventeen patients, aged 8 to 55 years with severe maxillary and mid-face hypoplasia due to bilateral or unilateral cleft lip and palate, acromegaly and class III dentofacial dysmorphosis, were treated in our centre since June 2000. The principle of distraction osteogenesis (DO) to advance the mid-face was used. A CT-scan of the maxillofacial massive and mandible was obtained following a special protocol. A 3D image-based planning software (MAXILLIM), containing modules specific for this surgery, was applied to the vector of distraction. With the use of stereolithographic models and individual templates the planning was transferred on to the operating theatre. A high LF I type osteotomy was performed. Two distractors (Trans Sinusoidal Maxillary Distractor, developed by Dr. Nadjmi in corporation with Martin, Tuttlingen, Germany) were placed intra-oraly and trans-sinusoidally at each side of the maxilla. Five days later distraction started at the ratio of 1 mm per day. A retention period of at least 2 months was followed.
Results: The accurate planning made it possible to perform predictable distraction results in all cases. Soft and hard tissue formation resulted in complete healing across the distraction gaps. This was macroscopically as well as microscopically indicated. No infection at the distractor sites were observed.
Conclusion: A completely new concept was used to accommodate an intraoral distractor in the mid-face. This will help to distract the maxilla in children and adults with severe mid-facial hypoplasia, using small intraoral distractors. The maxillary movements and new bone formation in the sagital, horizontal, and vertical planes could be predicted and achieved. The distractors are almost completely submerged, and can be left in place for as long as necessary to avoid relapse.

 
N. NADJMI, J. DEFRANQ, F. NOORMAN VAN DER DUSSEN, B. VANASSCHE, G. VAN HEMELEN, H. VERCRUYSSE
RECONTOURING OF THE AGED FACE

The evaluation of the aging process of the face is complex and multifactorial. The soft tissue problems that a maxillofacial surgeon is encountered in rejuvenating of the face are:

1. The dermal component in relation to the intrinsic and extrinsic facial aging (dermal elastosis).
2. Descending of the facial fat, with jowling and deep nasolabial fold as the result.
3. Increase or decrease of the facial fat during the aging proces.

Each individual patient shows different degree of the above mentioned problems at the time of consultation for facial rejuvenation. The specific need of each patient lies on the basis of the correction of the mentioned aging components.

Our experience in facial recontouring with Extended SMAS Facelift in combination with Endoscopic Brow lifting is presented.

 
MARECAUX Ch1,2, CHABANAS M2, PAYAN Y2, SIDJILANI BM1, PAOLI JR1, BOUTAULT F1.An original method to predict aesthetic outcomes from bone repositioning in orthognatic surgery is presented with quantitative validations.

(1) Service de Chirurgie Maxillofaciale et Chirurgie Plastique de la Face, Hôpital Purpan, CHU Toulouse, France.
(2) Laboratoire TIMC/GMCAO, Université Joseph Fourier, Grenoble, France.

Materials and methods:
1/ First, a generic biomechanical model of facial soft tissues is built using a Finite Element method.
2/ This generic model is matched by an elastic registration to the anatomy of the patient segmented from CT scan data, providing the specific model of the patient which is used for biomechanical simulation.
3/ The soft tissue deformation is simulated according to the underlying bone repositioning established by the therapeutic planning.
4/ Validations of the model generation and of the simulation are completed with distance maps comparing specific model to the pre operative CT scan on one hand and simulated morphological outcome to the post operative CT scan. 

Results:

Distance Specific modelto pre operative morphology Simulated outcometo post operative morphology
Mean  0,4 mm 1 mm
Max 4 mm 5,7 mm

Discussion:
This method is few time consuming and convenient with a current surgical practice.
If mean distances are satisfying, there are disparities located in important morphological areas interested by the surgical procedure (upper and lower maxillary sulcus, lips, nose).

Conclusion:
This new method seems reliable even if improvements are required.
Few other methods for 3D prediction of surgical outcomes in orthognatic surgery are described and none of them are validated.

 
A.HUTSEBAUT, A. GRYSOLLE, A. VERDONCK, J. SCHOENAERS
MAXILLARY DISTRACTION OSTEOGENESIS WITH A RIGID EXTERNAL DISTRACTION SYSTEM. CLINICAL EXPERIENCE.

Distraction osteogenesis has become an important technique to treat dissymmetry due to congenital malformations, diseases or traumas.
Bone distraction is the process of generating new bone in a gap between two bone segments in response to the application of graduated tensile stress across the bone gap.
Maxillary advancement by distraction has the advantage to provide new bone in combination with simultaneous expansion of the soft-tissue functional matrix.

At the University Hospital Leuven we have some experience with maxillary advancement using a RED (rigid external distraction) device.
Six subjects underwent maxillary advancement with a rigid external distraction device after a Le Fort I osteotomy.
There were 4 male and 2 female patients, ages 13.2 to 44.9  years. (mean 22.08 years)
The subjects included 2 unilateral cleft lip and palate (UCLP), 3 with bilateral CLP, 1 with Binder syndrome.

We will show in this presentation our results including distraction distance, stability and soft-tissue profile change.
All patients had correction of the maxillary hypoplasia with positive skeletal convexity and dental overjet after maxillary distraction.

 
P. LEYDER ; C. MEDARD ; H. CHAUSSARD,
MORPHOLOGICAL IMPACT OF VARIOUS GENIOPASTY PROCESSES IN MASSIVE SYMPHYSYS.
Department of Maxillo-Facial Surgery, Hopital R. Ballanger 93600 AULNAY SOUS BOIS

The authors aim will be to link the morphological impact of a genioplasty with the kind of process chosen for patients showing a massive apparance.
It consists in a retrospective study analysing clinically the pre and post surgical morphology of clins. The authors focuse on understanding which elements contribute to cause these massive appearences.
Various genioplasty processes were used. When the choice of a simple surgical act may enough be efficent, the authors highlight the issues of more complex technical choice. Thus, the operation might confronted to the incertainties of its fulfilment and the decision taken might cause indesirable effects or too strong morphological changes.
If it occurs that substraction genioplasty is not feasible, the authors suggest to completely change the overlapping bone flap genioplasty, so that the pogonion projection will not be exagerated and that an adaptation to the almost specific morphological issues of sheletal classe III malocclusion may be formed.

 
M.BIGORRE, L. MATTEI, G. CAPTIER, JL RAKOTOARIMANANA, P. MONTOYA 
SOFT TISSUE PROFILE CHANGES AFTER MAXILLARY DISTRACTION

The purpose of this study was to examine preoperative to postoperative changes of soft tissue profiles in the face of patients who underwent maxillary distraction and we have tried to correlate this changes with skeletal modifications.
Sixteen patients were examined: 11 patients had a unilateral cleft lip and palate, 2 patients had a bilateral cleft lip and palate and 3 patients had an Apert's syndrome. At the time of maxillary distraction, the patients were between 10 to 24 years old (average:  14.5 years old). 
Lefort I osteotomy followed by distraction with a Rigid External Distraction RED system of Polley-Figueroa were performed on all patients.
The changes of soft tissue profile were appreciated with a comparative lateral cephalograms analysis according to Burstone, Legan and Bell carried out before surgery, and 6 months post surgery.
The preoperative facial concavity (G-Sn-Pg') was reduced by 15°. The nasolabial angle increased by 8.25°at the expense of the nasocolumelar angle increased by 18.5°. 
The nasal tip and the columelar basis point moved 4 mm and 10 mm respectively forward.
The mandibular adaptation involved a 8° increase of chin angle (Sn-Gn-C) but little changes of vertical profile. This study showed a correlation between the progress of the anterior nasal spine and the nasal projection. The labial projection was influenced by  the protractive force axes.
This study showed the importance of control of  the protractive force axes for the skeletal and the soft tissue displacement.

 
J. KOERBER
SKELETAL AND DENTO-ALVEOLAR STABILITY OF THE COMBINED TREATMENT (ORTHODONTIC-SURGERY) IN ANTERIOR OPEN BITE DEFORMITIES

A review of literature  consisting of treatment of anterior open bite (AOB) is presented. In general orthodontic treatment of AOB deformity is not succesfull. A Le Fort I intrusion osteotomy with or without BSSO is indicated when a vertical maxillary hyperplasia, an anteroposterior Class II molar relation and a transverse maxillary deficiency has to be corrected. This surgical correction is preceded by dento-alveolar decompensation with orthodontic treatment.
This review shows a shortage of studies in large groups of patients with AOB deformities concerning the stability of surgical-orthodontic treatment. Also the adaptation of the orofacial soft tissues is not well understood.

A retrospective study to evaluate the stability of osteotomies in AOB patients at KULeuven was carried out. The aim, methods and results are presented and critically discussed.

 
E.GERE (1), K.OUOBA (2), B.COSTINI (3), P.SEGUIN (4), P.BELLITY (5), E.LAIGLE (6)
MISSION HUMANITAIRE NOMA AU BURKINA-FASSO OCTOBRE –NOVEMBRE 2002 : BILAN ET PERPECTIVES .

(1) Service de Chirurgie Maxillo-Faciale, HIA Robert Picqué, 33998 Bordeaux Armées. (2) Service d'ORL, CHN Yalgado Ouedraogo, Ouagadougou. (3) Chirurgien Plasticien, Eden Palace, 06000 Cannes. (4) Hôpital Bellevue, bd Pasteur, 42000 St Etienne. (5) Chirurgien Plasticien, 75000 – Neuilly (6) IPMC/CNRS 06560 Sophia Antipolis

A la demande de plusieurs organisations humanitaires, 2 équipes chirurgicales se sont succédées à Ouagadougou au Burkina-Fasso pour opérer 54 enfants ou adultes jeunes atteints de séquelles de noma.
Nous présentons le bilan de cette mission :
- organisation multinationale et moyens mis en œuvre
- revue des patients pris en charge
- bilan techniques des interventions effectuées
perspectives d'avenir

 
K. BORGHGRAEF; J. FERRI; N. NEYT; C. DE CLERCQ; H. SCHAUTTEET
MANDIBULAR HYPERPLASIA

Mandibular hyperplasia can result in complex facial asymmetry composed of degrees of condylar and ramus overgrowth, malocclusion and complementary maxillary deformity. Different diagnostic entities, described by Obwegeser and Delaire are showed with clinical cases. Early diagnose and treatment is necessary to prevent gross facial asymmetry and complementary maxillary deformation. Different treatment planning for the separate entities is discussed. Early high condylectomy is the treatment of choise in most cases.

H. DE CLERCK, S. SICILIANO, H. REYCHLER
BONE  ANCHORAGE :  AN ALTERNATIVE FOR CONVENTIONAL ORTHODONTIC ANCHORAGE

A new Bone Anchor was developed to increase orthodontic anchorage in the anterior or posterior region of the upper and/or lower jaw.  A 3 holes titanium miniplate is fixed by monocortical miniscrews.  A round bar is penetrating the soft tissues at the muco-gingival boarder.  A cylindrical fixation unit with a locking screw makes it possible to fix an auxiliary wire that connects the Bone Anchor with the fixed orthodontic appliance.
Since 3 years 119 Bone Anchors were placed in upper and lower jaw and used as anchorage in different orthodontic applications:
1. Distal movement of the anterior segment in premolar extraction cases.
2. Distal movement of the posterior and anterior segment in non-extraction cases.
3. Mesial movement of posterior teeth.
4. Intrusion of a single tooth or a group of teeth.
5. Uprighting of mesialised lower second and third molars.
6. Preprosthaetic orthodontics.
Six clinical trials were started with orthopaedic traction applied between 2 Bone Anchors placed on the zygoma and 2 Bone Anchors in the lower canine region to stimulate anterior growth of the maxilla in young skeletal class III patients.
Thanks to the section of the round connection bar penetrating the soft tissues, dental hygiene is very easy.  This reduces to a minimum the risks for local infection and loosening of the miniscrews. 
The surgical techniques and orthodontic applications will be illustrated by clinical cases.

 
P.DELCAMPE, J.MISINO, J.B.LECA, A.DURET, S.GIGON, J.B.KERBRAT, J.M.PERON.
TRANSPALATAL DISTRACTION : IS THERE AN AESTHETIC FACIAL CHANGE ?

Purpose : Until recently, transversal maxilla expansion in a skeletal adult, was primarily performed for Lefort I down-fracture. However, even with a prolonged retention of the palatal arch, this procedure had a significant relapse occurrence. Over a two year period, a transversal distraction of the maxilla was performed with a palatal device cemented on four teeth. The aim of the study was to assess the morphological benefit on the middle third of the face.

Method : Palatal distraction device is cemented to the first premolars and molars before the surgical procedure. Under general anaesthesia, a sagittal osteotomy of the maxilla is performed with a Lefort  I osteotomy. After section of the pterygoid-maxillary area, the curve osteotomy is torqued anteriorly to assure completeness of the osteotomy and fractures. Therefore, a real down-fracture is generally not necessary. The soft tissues are closed without any other fixation. On the third day, appliance activation is begun (1mm daily) until the desired expansion is achieved.

Results : Twelve cases were included in this study, six males and females(range 15 to 25 years). length of distraction from 7 to 15 mm. The procedure allowed increase of pyriform aperture with subjective improvement of nasal respiration. The paranasal area became "convex" which gave an excellent aesthetic result.

Conclusion The authors suggest that transversal expansion of the maxilla using Lefort  I osteotomy could provide morphological aesthetic benefit to the middle third of the face.

 
B.DEVAUCHELLE
BIORESORBABLE OSTEOSYNTHESIS IN ORTHOGNATIC SURGERY

More than 80 patients have been operated on in the field of orthognatic surgery, using resorbable plates and screws.
The authors  studied a serie of 40 patients with Lefort 1 osteotomy, using bioresorbable materials for osteosynthesis. The ability of use, the stability of the osteosynthesis, the complications and the cost will be here  analysed.
As results , it appeared that the bioresorbable material was very well tolerated, with only few complications.
The ability of use is rather  easy, and  needs some minimal  experience, because the tightening of the screws is different compared with the titanium materiel.
The stability of the osteosynthesis will be  analysed on radiography made just after surgery, six months later  and one year after surgical time .
Finally the use of such  material presented lot of advantages, not only in the field of orthognatic surgery, but for pediatric  craniofacial surgery, and perhaps we could use it to release  molecules such  as drugs or bioengeneeing products  around the osteosynthesis site.

 
H. OBWEGESER
MANDIBULAR ASYMMETRIES, DIAGNOSTIC AND TREATMENT PRINCIPLES

No other bone of the whole skeleton shows such a great variety of anomalies as the mandible does.  Mandibular asymmetries are the main reason for the large variation.  They present one of the most interesting chapter in the field of our speciality, because of its great possible aetiological varieties and possible variations of shape and often enough because  of their diagnostic and therapeutic difficulties.  One has to keep in mind that the mandible consists embryologically of two equal halves.  Both unite at the symphysis during the first years of life and develop equally under normal conditions.  But they can also grow independently and produce a different shape than the normal side does.  That means that one abnormality maybe existing on one half of the mandible only, or on both sides, equal or different in origin and shape.

Genetic and embryonic disturbance of growth, adverse postnatal events during growth periode or after growth has ceased and in particular abnormal growth regulation after birth, both during growth period as well as after growth termination, all these aetiological causes can present a great variation, and also often vertuy typical appearances of th shape of the affected mandibular half.

For diagnosing whether or not there exists an asymmetry and which side is causing the asymmetry a horizontal line between the supraorbital rims on the face or on the p.a. cephalogram is drawn with a perpendicular line to it at the middle of the forehead.  This  is a very good diagnostic help.  Even more affirmative is the facial planner of my nephew Joachim Obwegeser.

Diagnostically and therapeutically of greatest interest of all asymmetries of the mandible are those which are caused by condylar misregulation of growth, mostly starting during growing period, but occasionally also after growth has ceased.  I am of the opinion that the condyle holds underneath its surgace two growth regulators, one reponsible for producing length, the other for mass production to the same half of the mandible.  They can produce two typical hemimandibular abnormalities, either a hemimandibular hyperplasia or a hemimandibular elongation, both with very clearly different but typical shape abnormalities.  If both of them are hyperactive then they will produce a hybrid form, in excessive cases resulting in a grotesque shape of the mandible.  They can affect one mandibular side only or both, almost equally, but mostly in different degrees.  As long as these growth regulators are hyperactive they can be diagnosed scintigraphically after i.v. injection of Tc-99m-DPD.  A superficial resection of the condyle stops immediately the abnormal growth of the affected side.

The correction of the mandibular asymmetries depends on the cause of it, the age of the patient and on the shape of the abnormality.  When the abnormal growth, whether lack of it or surplus, begins in early childhood, the maxilla can also be involved.  In these cases the surgical correction will also have to include it.

In most cases of mandibular asymmetries orthodontic treatment can only deal with positioning the teeth into proper angulation of the respective base of the jaw but has very little chance to influence the actual growth of the mandible.

Litterature : H.L. Obwegeser, Mandibular Growth Anomalies, Springer-Verlag, 2001.

G. RAOUL, J. FERRI, H.F. HILDEBRAND
GREFFE DU PLANCHER SINUSIEN MAXILLAIRE A VISEE PRE-IMPLANTAIRE PAR OS AUTOLOGUE VERSUS BIOCORAL®

Cette présentation livre les résultats d'une expérimentation animale sur l'étude du comportement de la greffe sinusienne maxillaire par os calvarial versus biocoral® grâce à l'histomorphométrie et le marquage à la Tétracycline.

L'expérimentation animale a consisté en une greffe sinusienne maxillaire chez le porc.  Chez un même animal, d'un côté la greffe a été effectuée par de l'os autologue crânien, et de l'autre côté par du biocoral® .  La totalité des deux greffes sinusiennes a été prélevée arpès six mois et marquage à la Tétracycline pour étude histomorphométrique et dynamique.

L'expérimentation animale de ce DEA a été financée par la bourse Liebinger 2000 décernée àl'auteur lors du XXVIIème Congrès de l'AFCMD 17-18 mars 2000 à Lyon.

 
LTH. C. LUYTEN, V. CLAEYS , T. SAERENS, G. VAN DE VYVERE, G. WACKENS
ORTHOGNATIC SURGERY FOR BORDERLINE CLASS III PATIENTS

Department of stomatology and maxillofacial surgery.  Free University of Brussels.

Borderline Class III patients can be treated surgically or not, with possibly evidence of under- or overtreatment and subsequent sequelly.
If treated surgically different surgical procedures can be proposed after presurgical orthodontics, Lefort I, BSSO or even a combination of both.

So far the literature does not contain accurate scientific base to distinguish those who require orthognatic surgery and/or witch type of it.

Therefore the authors did a retrospective clinical study to determine in which procedure following goals where achieved :

1. stable occlusion in sagittal, transverse and vertical dimensions
2. correct overjet and overbite
3. proper incisal inclination
4. satisfying facial esthetics
5. long-term stability.

F. THIRY, S. SICILIANO, H. REYCHLER
TWO CASES OF ALVEOLAR OSTEOGENIC DISTRACTION

UCL, Brussels

When reconstructing the mandible with a fibular graft, the mandible is often vertically deficient, making placement of dental implants impossible.
This presentation review two cases of alveolar distraction ater microvascular bone graft to repair mandibular discontinuity.  One was due to a mandibular osteosarcoma and the second to chronic osteitis after othognatic surgery.  Both had vertical bone deficit compared with the non-resected part of the mandible.  Distraction devices were applied and activated to permit implant placement in the new alveolar ridge.