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.