108 Journal of Cranio-Maxillofacial Surgery

Laser Focus in Surgical Photography Smith H. W.

School of Medicine, Columbia University, New York, USA

A simple lightweight focusing device is presented for use in the operating room using ruby laser pointers. The focusing system makes it possible for a recruited photographer to use a preset camera system which is directed by the operating surgeon. This system is especially useful in surgical cavities and positions where it is not possible for the photographer to view the area and accurately focus through the camera lens. This system arrangement can be used with most 35 mm single lens reflex cameras which have a ring flash, a power unit and a 50-55 mm macro lens. The use of an automatic exposure mode makes it unnecessary to bracket the exposures. The surgeon may elect to have a camera with either a mechanical or a motorized film advancement.

Firstly the orbital bone structure should be repaired with osteotomies and/or bone grafts. Then an implant, the bigger the better, is placed in the cavity. The muscles are fixed to it. A conchal cartilage graft is almost always used to protect the implant. The last stages are the reconstruction of the fornix with buccal mucosa graft, the reconstruction of the eyelids with a palatal mucosa graft and local musculo cutaneous flaps. Finally a thin prosthesis is adapted. We present a series of patients illustrating this approach, focusing on the details of each operation. The results are shown.

Advance the Face to Improve It: Different Uses of the Cranial Vault Harvesting Sorrel-Dejerine E., Ozun G.

Department of Plastic Cranio-Maxillo-Facial and Burns Surgery, Foch Hospital, Suresnes, France
Advancing the face generally rejuvenates and improves it. Bone is the best material to use, especially that from the cranial vault, as has been popularised by Paul Tessier. The nose is the area of choice to be projected, not only on the dorsum, but also on the base by a special spine graft maintained by a miniplate. Advancing a retruded maxilla or a retruded mandibula, of course, rejuvenates, as advancing a retruded chin associated to a face lift improves the face. Malar bone projection by bone graft or osteotomy is sometimes useful. It is exceptionally necessary to project the forehead. In spite of an osteotomy with a cranial approach which creates a dangerous dead space we prefer simple onlay bone ships, embedded behind a modelled biodegradable plate, to obtain a perfectly smooth frontal bone in an advanced position. We present a series of patients who illustrate different techniques of craniofacial osteotomies and bone grafts. These techniques of reconstructive or aesthetic surgery are detailed and the results shown.

Immediate Primary Management of Craniofacial Trauma Patients: New Opportunities due to Faster Computed Tomography Scanning Smith A. T.

Department of Maxillofacial Surgery, Royal London Hospital London, UK

Historically, the treatment of significant craniofacial injury has of necessity been deferred until life-threatening intracranial injuries have been adequately assessed and managed. Assessment of brain injury in the modern neurosurgical unit relies on clinical evidence and brain imaging. Computed tomography (CT) scanning forms the mainstay of this monitoring of neural tissue. The radiographic parameters and scan settings for imaging brain tissue differ from those for craniofacial bony injury evaluation. This involves resetting the scanner for a second scan sequence. In the severely injured patient with probability of intracranial bleeding or rising intracranial pressure, this delay may be unacceptable and often the definitive bony windows are deferred. Prolonged delay of the bony assessment and thus the primary treatment of craniofacial disruption renders surgery more difficult. Optimal treatment may be impossible and the outcome may be poor quality of repair. New rapid dynamic CT scanning permits rapid imaging of both critical neural tissue and facial bony structures within a time frame less than 25% of that needed previously. The worth of this system was tested on its introduction by the aftermath of the Irish Republican Army (IRA) bomb blast in the London Docklands. Neurosurgeon and Maxillofacial surgeon alike now see CT scans adequate to allow co-ordinated treatment planning, and craniofacial fractures can often be treated at the first operation, via access shared with the neurosurgeon.

Mandibular Reconstruction with Free Fibular Flap in Surgical Treatment Head and Neck Tumours

Sotosek B., Arnez'~Z. Medical Centre, Department of Maxillo-Facial Surgery, Ljubljana, Slovenia
Immediate reconstruction following segmental mandibulectomy is an accepted surgical technique. During the last two years in our department, 13 patients underwent immediate reconstruction with a fibula free flap after segmental surgical excision of the mandible. Nine patients had squamous cell carcinoma of the oral cavity, two ameloblastoma, one adenoid cystic carcinoma and one had osteoradionecrosis of the mandible with pathological fracture. In 8 patients we used osseous free fibular flaps in combination with radial forearm free flaps. In 5 patients we used free osseocutaneus fibular flap. One free flap (fibula) failed in the immediate postoperative period and could not be revascularized. The failed flap was immediately replaced by a reconstruction plate and covered with a radial forearm free flap. Two free fibular flaps failed after radiotherapy, the bone became exposed and was removed without secondary reconstruction. All complications occurred when the mandibular defect included the anterior mandibular arch. In this series, 10 patients had malignant disease; 8 of them are alive and free of disease; Four patients were able to eat a regular

Complex Acquired Orbital Anophtalmos SorreI-Dejerine E., Ozun G.

Department of Plastic Cranio-Maxillo-Facial and Burns Surgery, Foch Hospital, Suresnes, France
The treatment of post-traumatic or post radiodystrophy orbital anophtalmos is usually complex, with a reconstruction in several stages, usually from the deep to the surface.

Free oral communications 109 diet, others semi-solid and all of them are without significant compromising speaking ability. With this method the majority of patients can be restored to a good functional and aesthetic state. with severe dislocations of the condyle thickening and irregularities of the condylar and temporal articular coverings were seen. The joints showed changes in the condyles, temporal surfaces, and the discs consistent with a diagnosis of osteoarthrosis. According to those results, it seems to be indicated to avoid clinically severe displacements of the condyle-bearing fragments after ramus osteotomies.

A Method for Bone Matrix Osteoinductive Capacity Assessment

Soumarokov D.D., Ognivenko V.M., Kudymov V.M.

Private Practice, Moscow, Russia

A method for assessment of new formed ectopic bone quantity was elaborated. It was based on integration of biochemical and gravimetrical parameters into a general index (osteoinductive activity index). Several extracted tissue parameters were measured: (i) mass increment over implant's mass, (ii) calcium content, (iii) phosphorus content, (iv) calcium/phosphorus molar ratio, (v) acid phosphatase activity, and (vi) alkaline phosphatase activity. All measured parameters were transformed into relative values according to the formula:
(Xma x - Xexp)/(Xma x - Xmin)

The Use of the Kite Flap for the Reconstruction of Facial Skin Defects

Stajcic Z., Roncevic R. Faculty of Stomatology, University Clinical Centre, Beograd, Yugoslavia
The kite flap is the latest generation of local flaps which skin island receives its blood supply from the subcutaneous pedicle. The aim of this paper is to present our experience with the use of the kite flap for the reconstruction of defects created following the excision of skin lesions of the face. The technique was applied in 76 consecutive patients in the following anatomical regions: the cheek (12), nasolabial fold (26), vermilion (3), lower eyelid (16), eyebrow (14) and forehead (5). Created defects were either rectangular or circular and the decision to use one or two flaps for closure depended on the size of the defect, anatomical region and the mobility of the adjacent skin. The treatment was successful in 74 patients. Cosmetic results were very well accepted by patients. In only two cases, a partial necrosis of the flap was recorded. The kite flap proved to be extremely efficient for the repair of the defects around the eyebrows, in the nasolabial folds and the vermilion border because the anatomical structures were not distorted as a result of reconstruction. The technique of raising the flap in order to prevent complications will be discussed. It is concluded that the kite flap is a reliable technique for the reconstruction of defects of the facial skin, especially in regions where it is important not to distort adjacent anatomy.

where Xmax is the maximum value of the parameter, Xm~ n the minimum value of the parameter a n d Xexp the mean experimental value. Then they were summarized. The sum obtained represents OAI (osteoinductive activity index). Histological slides from the same samples were examined by independent experts to estimate the bone. The results obtained from different methods correlated.

Interest of the Prosthetic Restoration in Large Maxillary Defects

Souryis F., Fourcade C., Jammet P., Atlan P. Y.

Department of Stomatology and Maxillo Facial Surgery, Hdpital Lapeyronie, Montpellier, France
In spite of the surgical up-dated procedures, maxillo-facial prostheses remain aesthetically and functionally interesting. With some recent examples taken in young female patients, we justify the choice of such procedures for maxillary and palate reconstruction versus the surgical repair.

The Historical Development of the Mandibular Sagittal Split Osteotomy

Steinhiiuser E. W.

Department of Oral and Maxillofacial Surgery, University of Erlangen-Niirnberg, Erlangen, Germany

The idea of obtaining broad contact surfaces with a sagittal splitting of the mandible was originally published by two general surgeons, Perthes and Schloesmann from Tfibingen, Germany. The technique of this operation was an extraoral approach in the region of the mandibular angle and an ascending oblique osteotomy from the buccal to the lingual cortex. No bone fragment fixation was applied. It was 1953 when Obwegeser as an assistant of Trauner in Graz performed the first intraoral sagittal split osteotomy, but it took another 2 years until he published this operative technique in the German literature in 1955 and in an American journal in 1957. An assistant of Obwegeser, an Italian, Dal Pont modified the original technique by extending the buccal bone cut further anteriorly; he published this modification in 1958 in the Italian literature. Modifications of the lingual bone cut were reported by the American colleagues Hunsuck in 1968 and Epker in 1977. Another important improvement was the application of rigid fixation by bone screws, which was first described by Spiessl in 1974 thus,

Morphological Changes after Different Types of Condylar Displacement: An Experimental Study

Spitzer W., Steinhiiuser E., Erbe M., Sitzmann F. Department of Oral and Maxillofacial Surgery, University of Erlangen-Niirnberg, Erlangen, Germany
There are some hazards for the condylar position especially after ramus sagittal split osteotomy with the application of rigid fixation. To evaluate the morphological changes after condylar dislocation, different types of condylar displacements were surgically produced in 11 adult Macacafascicularis monkeys. The condyle-bearing fragments were fixed rigidly with two position screws. After different survival times, the animals were killed and skull blocks containing the temporomandibular joints (TMJs) were excised. The sections are studied with light and scanning electron microscope and microradiographically. Especially in the animals