Spontaneous hemorrhage of an adrenal cortical adenoma causing Cushing''s syndrome

A modified surgical splint for Le Fort I osteotomies with transverse expansion is presented. The splint is made of a transpalatal stainless steel bar with acrylic abutment against the palatal surface of the molar and bicuspid tooth. It is rigid and renders excellent retention. It causes minimal patient discomfort, and oral hygiene is hardly compromised.     

Six year's experience with the zygomatic "sandwich" osteotomy for correction of malar deficiency

PURPOSE: This study discusses the rationale, modifications, and complications of an osteotomy technique used to increase malar projection. PATIENTS AND METHODS: Seventy "sandwich" zygomatic osteotomies were performed in a 6-year period. Hydroxyapatite (HA) blocks were used to stabilize the anterolateral rotation of the zygomatic body in 44 osteotomies, calcium carbonate blocks were used in 23, calvarial bone grafts in three, a piece of bovine cartilage in one, and a bone graft from a chin ostectomy procedure combined with mesh osteosynthesis in one procedure. Fifty-six zygomatic osteotomies were combined with Le Fort I-type osteotomies (eight with a midline split). Nineteen zygomatic osteotomies were performed simultaneously with a Le Fort I-type osteotomy and a rhinoplasty with lateral osteotomies. RESULTS: The increase of malar projection and the stability of the procedure could not be measured on conventional three-plane cephalograms. However, patient's and surgeon's satisfaction were high and remained so during the follow-up period (maximum, 6.5 years; minimum, 6 months). Three patients developed maxillary sinusitis. In two of them, this was clearly related to fragmentation of an HA block. A Treacher-Collins patient developed a chronic fistula in the upper vestibule, caused by leakage of infraorbitally placed HA granules. In two cases, a fracture of the zygomatic arch occurred. Osteosynthesis was performed in one of them. CONCLUSION: With proper technique and care not to fracture the interpositional HA block, complications are rare. The procedure is expedient and provides predictable and stable correction of malar deficiency.     

In vivo treatment with recombinant IL-12 protects C57BL/6J mice against secondary alveolar echinococcosis

A sample of 259 patients with vertical maxillary hyperplasia, mandibular hypoplasia and anterior vertical open bite, collected from three different institutions, was analysed regarding temporomandibular joint (TMJ) sounds, condylar remodelling, and condylar resorption. All patients underwent Le Fort I osteotomies, and bilateral sagittal split advancement osteotomies were performed in 117 patients. Intraosseous wire fixation was used in 149 and rigid internal fixation in 110 patients. Cephalometric and orthopantomographic radiographs were available before surgery, immediately after surgery, one year postoperatively and at the latest follow up. The mean follow up was 69 months (range 20-210 months). The number of patients with TMJ sounds decreased from 38% to 31%. At the latest follow up 23.6% of the patients showed condylar remodelling, 7.7% unilateral condylar resorption and 7.7% bilateral condylar resorption. Condylar contours, as assessed on orthopantomographic radiographs, were classified as five different types. Condyles with preexisting radiological signs of osteoarthrosis or having a posterior inclination were at high risk for progressive resorption. Female patients with severe anterior open bite, high mandibular plane angle and a low posterior-to-anterior facial height ratio, who underwent a bimaxillary osteotomy, were prone to condylar resorption. Bone loss was predominantly found at the anterior site of the condyle. The incidence of condylar resorption was significantly higher after bimaxillary osteotomies (23%) than after only Le Fort I intrusion osteotomies (9%). Avoidance of intermaxillary fixation by using rigid internal fixation tended to reduce condylar changes, in particular in patients who underwent only a Le Fort I osteotomy. Rigid internal fixation in bimaxillary osteotomies resulted in condylar remodelling in 30% and progressive condylar resorption in 19% of the patients. Condylar changes were not significantly different after using either miniplate osteosynthesis or positional screws in bilateral sagittal split osteotomy procedures.     

Treatment of condylar hyperplasia of the mandible using unilateral ramus osteotomies

PURPOSE: The long-term outcome of bilateral and unilateral ramus osteotomies used for the treatment of unilateral condylar hyperplasia of the mandible are evaluated and compared. MATERIALS AND METHODS: Thirteen cases of unilateral condylar hyperplasia of the mandible were surgically treated during a 10-year period from 1985 to 1995. Seven of the patients were treated by bilateral ramus osteotomies alone; six were treated by unilateral ramus osteotomies of the affected side. Unilateral ramus osteotomy was combined with a maxillary Le Fort I procedure in two of the six cases. Preoperative analysis of patients, indications for case selection, and postoperative results relating to facial symmetry, temporomandibular joint (TMJ) pain, occlusion, and stability were compared in the two groups. RESULTS: The postoperative findings and long-term results in both groups of patients were favorable. Symmetry, arch coordination, and occlusion remained stable. TMJ pain and dysfunction were invariably cured postoperatively. Unilateral ramus osteotomies alone, or in combination with maxillary surgery when deemed feasible and applicable by preoperative clinical analysis, was sufficient to restore symmetry and occlusion in dentally compensated cases. CONCLUSIONS: This study shows that patients with unilateral condylar hyperplasia of the mandible and deviation can be treated favorably by unilateral ramus osteotomy of the affected side; bilateral ramus osteotomy did not have any advantage in such cases. In addition, this procedure, combined with a Le Fort I osteotomy of the maxilla, was also effective in restoring occlusal canting and facial symmetry in dentally compensated cases. However, bilateral ramus osteotomy was required in prognathic cases and in cases in which a unilateral procedure would cause excessive rotation of the contralateral condyle.     

Hemispheric control of motor function: a whole brain echo planar fMRI study

A sample of 130 patients with vertical maxillary hyperplasia; mandibular hypoplasia with a high mandibular plane angle; narrow, tapered maxillary dental arch form; and anterior vertical open bite were collected from three different institutions to evaluate the stability of transverse maxillary arch dimensions after correction of the open bite. Surgical treatment consisted of Le Fort I or bimaxillary osteotomies. Intermolar, interpremolar, and anterior arch widths were measured three-dimensionally on dental casts using a Reflex microscope, and transverse stability after orthodontic or surgical maxillary expansion was analyzed. Orthodontic expansion followed by a one-piece Le Fort I intrusion osteotomy was performed in 77 patients, and surgical maxillary expansion by a multisegment Le Fort I intrusion osteotomy was performed in 53 patients. The increase of transverse arch width and the relapse after orthodontic or surgical expansion were not significantly different. The transverse arch width in these two groups did not relapse in 20% of the patients after a mean follow-up of 69 months. An additional bilateral sagittal split osteotomy had no detectable effect on stability. Patients who underwent a multisegment Le Fort I osteotomy stabilized with rigid internal fixation showed better transverse stability than those with intraosseous wire fixation and maxillomandibular fixation. Maxillary intermolar and interpremolar arch width relapses were not correlated with tongue interposition or loss of interdigitation. The relapse of these arch widths showed significant correlations with clockwise rotation of the mandible but not with changes of overbite or overjet.     

A new condylar positioning appliance for two-jaw osteotomies (Le Fort I and sagittal split ramus osteotomy)

We have presented a new appliance for easy, rapid, and exact repositioning of the proximal segment of the mandible in two-jaw osteotomies (Le Fort I and sagittal split ramus osteotomy).     

Midfacial advancement by bone distraction for treatment of craniofacial deformities

Craniofaciostenosis is often associated with midfacial hypoplasia and has been treated traditionally using Le Fort advancement osteotomies and bone grafts. The surgical procedure requires a prolonged operating time, several osteotomies with a significant blood loss, and wide surgical exposure. According to the principles of bone lengthening, we performed midfacial advancement by bone distraction in 4 patients with midfacial hypoplasia to reduce the operative time and complication rate. In 2 patients with Crouzon's syndrome we performed a Le Fort III osteotomy and placed the distraction device behind the malar eminence and screwed it on the temporal bone bilaterally. In the other 2 children, with Apert's syndrome, we performed frontal advancement and remodeling before placing the device during the same surgery behind the malar bone without any midfacial osteotomy. It appears to us that patients with more severe deformities will need surgical procedures to offer more satisfactory results. In these patients, distraction is an initial therapy to reduce the severity of the deformity, making it possible to effect a better treatment afterward.     

Elevated plasma and urinary endothelin-I levels in human salt-sensitive hypertension

The influence of anterior mandibular height is often overlooked when planning treatment of facial vertical excess or deficiency. Although treatment decisions tend to focus primarily on Le Fort I maxillary osteotomies, genioplasty remains a useful adjunctive surgical procedure. Components of anterior facial vertical dysplasia are reviewed, and six genioplasty strategies are described.     

Management of posttraumatic malocclusion caused by condylar process fractures

PURPOSE: The aim of the study was to evaluate the results of orthognathic surgery in cases with posttraumatic malocclusion as a long-term complication of condylar process fractures. PATIENTS AND METHODS: A retrospective study on 21 patients with posttraumatic malocclusions attributable to condylar process fractures was performed. In group I, 15 patients were treated for asymmetric malocclusion with unilateral or bilateral mandibular ramus osteotomies. In group II, six patients were treated for anterior open bit with either a Le Fort I osteotomy (n=5) or a bilateral ramus osteotomy (n=1). All patients had clinical and radiographic follow-up for at least 1 year. RESULTS: Stable dental and cephalometric results were obtained in all patients except the one in group II who was treated with bilateral sagittal split osteotomies. In two cases, both in the asymmetric group, minor occlusal interferences had to be treated by equilibration in the early postoperative period. CONCLUSIONS: Orthognathic surgery is a predictable and stable method for the treatment of posttraumatic malocclusion due to condylar process fractures. Maxillary orthognathic surgery is successful in correcting symmetric anterior open bites due to bilateral condylar process fractures. Because posttraumatic malocclusion is a rare complication after closed treatment of condylar process fractures, and it can be treated satisfactorily using orthognathic surgery, routine open reduction and fixation of condylar process fractures is not indicated to prevent posttraumatic malocclusion.     

A Le Fort I osteotomy approach to lateral sphenoid sinus encephalocoeles

Meningo-encephalocoeles of the skull base may present as spontaneous cerebrospinal fluid rhinorrhoea or acute meningitis. Previous approaches to midline skull base lesions have been either intracranial, via a craniotomy, or by transfacial or endoscopic extracranial approaches. This paper presents an alternative approach to lateral sphenoid sinus encephalocoeles through a Le Fort I osteotomy approach.     

Distraction osteogenesis for lengthening of the hard palate: Part I. A possible new treatment concept for velopharyngeal incompetence. Experimental study in dogs

Many procedures have been described to correct velopharyngeal incompetence. Significant complications can occur, and the results may not be satisfactory. If the short soft palate has satisfactory muscle function and if it could be moved toward the posterior pharyngeal wall by distraction osteogenesis of the hard palate, an entirely new concept of treatment for velopharyngeal incompetence would be available. The object of the present study was to explore the possibility of osteogenesis occurring in the hard palate in dogs after gradual distraction (callus distraction). Six adult, mix-bred dogs were anesthetized, and the palatal mucosa was elevated. A midpalatal transverse osteotomy and two lateral osteotomies were performed. Tantalum bone markers for cephalometric analysis were placed, and an individually fabricated, orthodontic-like distraction device with an expansion screw in the sagittal direction was inserted. The device was stabilized on the premolars and fixed to the palatal bone with titanium miniscrews. Gradual distraction began after a latency period of 10 to 18 days. The rate of the distraction varied from 0.25 to 0.75 mm per day. The device was left in place for 6 to 8 weeks after expansion to allow for bony consolidation. Assessment was by direct examination, cephalograms, computed tomography, and histology with bone labeling. Impressions of the jaws were taken preoperatively and after device removal to examine plaster cast changes in the dental occlusion. Cephalometric and computed tomographic scan analysis demonstrated a distraction of up to 8 mm. All gaps were filled with de novo osteogenesis. Comparison of the plaster casts revealed no change in the occlusion. At 1 month after distraction, the computed tomographic scan showed the first signs of ossification of the experimental gap from the anterior and posterior bone ends. After 4.5 months ossification was almost complete with a small translucent zone in the middle of the experimental gap. After 7 months ossification was complete.     

Fixation of osteotomies using bioabsorbable screws in the canine femur

The purpose of this study was to compare the healing properties of femoral osteotomies fixed by bioabsorbable screws (20:80 polyglycolic copolylactic acid copolymer) to standard stainless steel screws of a similar design in a dog femoral model. Two osteotomies were used, the trephine osteotomy (10 mm diameter) in the metaphyseal lateral femoral condyle and in the femoral diaphysis, and a unilateral osteotomy in the lateral femoral condyle. Two months after the trephine osteotomies, the femurs that contained the polymer screws were not significantly different in mechanical strength from the femurs treated with the stainless steel screws, either in the diaphyseal or metaphyseal model. There was no histological difference in bone healing between the metallic and polymer screws for all periods (2, 9, and 17 months). There was no adverse inflammatory response to the polymeric or metallic screws. By month 17, the polymer screws were resorbed completely. All the diaphyseal screw tracks had healed with bone and areas of remodeling were evident in two specimens. For the femoral condyle osteotomy model at 2 months, the polymer screws were present and intact, and all osteotomies healed with no evidence of inflammation. By 9 months, only one specimen had polymeric material left in the screw track. At 15 months, the screw tracks still were present but no evidence of any polymer remained. The tracks were filled with fibrous and adipose connective tissue. All osteotomies stabilized with either bioabsorbable polymer screws or stainless steel screws did heal satisfactorily without any complications, inflammation, or osteolysis. The polyglycolic polylactic acid copolymer may have a clinical role as a bioabsorbable material without the concerns for the osteolysis, foreign body reaction, and sterile abscess formation that have occurred with bioabsorbable fixation methods in the past.     

Small extra ring chromosome derived from chromosome 10p: clinical report and characterisation by FISH

We report our experience with a modified Le Fort I osteotomy developed to avoid nasal tip upturning, alar base widening, and upper lip flattening in anterosuperior repositioning of the maxilla. We compare the aesthetic results obtained with this variation of the surgical technique to those obtained using the more traditional Le Fort I osteotomy combined with the alar cinch suture and the anterior nasal spine reduction procedures on a sample of 20 patients.     

The role of Na,K-ATPase inhibitors in hypertension and end-stage renal disease

In Part I of this two-part study, the authors investigated heat production during osteotomy drilling at three different speeds, and determined that high-speed drilling produced the least heat when using 700 XL carbide burs. Part II of the study histologically examines the rate and quality of healing after drilling osteotomies at the three speeds in the mandible. Osteotomies were histologically examined 2, 4, and 6 weeks postoperatively. Histologic findings suggested that in the initial 6 weeks, the rate of healing and quality of new bone formation were higher after high-speed drilling than after low- or intermediate-speed drilling. These results, when considered with the results reported in Part I in which a 4.3 degrees C difference in heat production was observed between the speeds, seem to imply a relationship between heat production and healing for osteotomy drilling.     

Allogeneic vascularized grafting of human knee joints under postoperative immunosuppression of the recipient

Vascularized knee joint transplantations have been performed in various animal systems. Up to now no allogeneic vascularized transplantation of a fresh and perfused human knee joint has been realized. This paper reports on the first four grafted human knee joints, performed between April 1996 and July 1997 at the Trauma Center Murnau. The indication for transplantation of a human knee joint is total loss of the joint, including the extensor apparatus, following severe trauma. Management of this defect is first to effect closure of the soft tissue defect combined with external transfixation and bone cement spacers. For the second phase the external stabilization is switched to internal stabilization using femoral tibial nails and a temporary knee joint prosthesis manufactured of polyethylene. The transplantations are performed with respect to ABO compatibility, ignoring the HLA system after a negative crossmatch. Osteosyntheses are employed by femoral and tibial nails. The vascular anastomoses are established in an end-to-side technique between the recipient's superficial femoral vessels and the graft vascular pedicles. Immunosuppression starts as quadruple induction therapy for 3 days. Subsequently it is reduced to a two-drug maintenance protocol with cyclosporin A and azathioprine. We utilize radiography, digital subtraction angiography, duplex sonography, scintigraphy, and arthroscopy for graft monitoring. Six months after transplantation the osteotomies were bridged with callus, and the patients were completely mobilized. The motion in the transplanted knee joint ranges from complete extension to 110 degree flexion.     

Ovarian mucinous cystadenocarcinoma with sarcoma-like mural nodules

Relapse of the maxilla was studied retrospectively in a group of 61 patients with previously repaired cleft lip and palate who had undergone Le Fort I osteotomy. The extent of surgical move and relapse over a mean period of 28 months was measured with reference to the cranial base, and found to be similar to those in other studies. The use of direct bone plates for fixation of the maxilla is associated with a significantly more stable postoperative result.     

Hepatitis C virus infection and heart diseases: a multicenter study in Japan

We present our experience of transcutaneous truncal anaesthesia of the maxillary nerve in association with transmucosal anaesthesia of the sphenopalatine ganglion in surgically assisted rapid maxillary expansion. Twelve patients with a skeletal transverse discrepancy of the maxilla were treated in our department from 1994 to 1995. Maxillary transcutaneous nerve block was done with a Quincke 8 cm spinal needle together with transmucosal anaesthesia of the sphenopalatine ganglion. Mepivacaine without adrenaline and sodium bicarbonate 1/10 was used for truncal anaesthesia and lidocaine-prilocaine cream for transmucosal anaesthesia. A Le Fort I osteotomy, lateral nasal wall osteotomy, pterygomaxillary osteotomy, and a palatal osteotomy were done for all patients before the maxillary expansion. Total anaesthesia of the maxillary area facilitated the operations and appreciably reduced the amount of postoperative pain. The ease of achieving effective anaesthesia before and after operation and the absence of side-effects make this form of anaesthetic particularly useful in surgically assisted rapid maxillary expansion.     

Open bite deformity in amelogenesis imperfecta. Part 2: Le Fort I osteotomies and treatment results

Functional conditions, skeletal and dento-alveolar stability and condylar changes in 15 patients with mandibular hypoplasia, anterior open bite (AOB) and amelogenesis imperfecta (AI), who had undergone a Le Fort I osteotomy, were analysed after a mean follow-up of 5 years. Two patients underwent a one-piece Le Fort I intrusion osteotomy and 13 patients a multi-segment Le Fort I osteotomy. In three of these patients, an additional bilateral sagittal split osteotomy was performed. Thirteen patients underwent a genioplasty. Surgery was followed by prosthetic rehabilitation in 10 patients. Skeletal and dento-alveolar stability were analysed on lateral cephalometric radiographs and condylar changes on orthopantomographic radiographs. Transverse stability of the dental arches was analysed on dental casts. The treatment results in this group were compared with patients with similar skeletal features but without amelogenesis imperfecta. The harmony of the long faces was restored and a reasonable vertical stability of the maxilla was achieved, however, a slight open bite and tongue interposition was still present. The transverse stability of dental arches (60%) was disappointing. Rigid internal fixation produced better transverse stability. Progressive condylar resorption was seen in two patients (13%). Less occlusal stability could be achieved in patients with AI, but resulted neither in less skeletal stability nor in more susceptibility to morphological condylar changes.     

Superior gluteal artery perforator free flap for breast reconstruction

The purpose of this paper is to present a new method of breast reconstruction utilizing skin and fat from the buttock without muscle sacrifice. Cadaver dissections were done to study the musculocutaneous perforators of the superior gluteal artery and vein. Eleven breasts were reconstructed successfully with skin/fat flaps based on the superior gluteal artery with its proximal perforators. Long flap vascular pedicles allow the internal mammary or thoracodorsal vessels to be used as recipient vessels. This new technique has several advantages over the previously described gluteus maximus myocutaneous flaps, including long vascular pedicle and no muscle sacrifice.     

Complications in connection with venous port systems: prevention and therapy

OBJECTIVE: To assess the effects of graded intramedullary reaming and nailing on the healing pattern of segmental diaphyseal fractures using male Wistar rats. STUDY DESIGN: In male Wistar rats we produced two standardized, partial osteotomies with an eight-millimeter intermediary fragment in the femoral diaphysis. The osteotomies were subsequently manually broken. In Group A, intramedullary reaming was performed to 1.6 millimeters, and the fracture was stabilized with a 1.6-millimeter steel pin. In Group B, the femoral canal was reamed to 2.0 millimeters, and a hollow steel tube of 2.0 millimeters was installed. The rats were allowed free movement. After four, eight, and twelve weeks, eight rats in each group were sacrificed and callus formation, biomechanical properties, and bone blood flow were evaluated. RESULTS: The callus area was relatively constant with time in Group B, whereas a reduction was observed in Group A at twelve weeks. The biomechanical properties increased throughout the experimental period in both groups, and no significant differences between the groups were detected in bending moment, bending rigidity, or fracture energy. Total bone blood flow was substantially increased at four weeks in both groups and decreased throughout the experimental period. In addition, blood flow of the segmental fractured area was substantially increased after four weeks and decreased gradually thereafter. The increases in blood flow tended to be largest in the moderately reamed group. CONCLUSION: This study indicates that the degree of reaming does not significantly affect the healing pattern measured as restoration of mechanical characteristics.