Maxillofacial Reconstructive Surgery Research Articles

Withdrawal of Continuous Positive Airway Pressure Therapy after Malar Advancement and Le Fort II Distraction in a Case of Apert Syndrome with Obstructive Sleep Apnea.

Apert syndrome is a congenital syndrome characterized by craniosynostosis and craniofacial dysostosis, among other features, and is reported to cause obstructive sleep apnea (OSA) because of upper airway narrowing associated with midfacial dysplasia. We recently encountered a case involving a patient with Apert syndrome complicated by OSA who began to receive continuous positive airway pressure (CPAP) therapy at the age of 4. OSA resolved after maxillofacial surgery performed at the age of 11, and CPAP was eventually withdrawn. In pediatric patients with maxillofacial dysplasia complicated by OSA, a long-term treatment plan including CPAP in addition to maxillofacial plastic and reconstructive surgery should be considered in view of the effects of OSA on growth.

Development of a three-dimensional hand model using 3D stereophotogrammetry: Evaluation of landmark reproducibility

Using three-dimensional (3D) photography, exact images of the human body can be produced. Over the last few years, this technique is mainly being developed in the field of maxillofacial reconstructive surgery, creating fusion images with computed tomography (CT) data for accurate planning and prediction of treatment outcome. However, in hand surgery, 3D photography is not yet being used in clinical settings. The aim of this study was to develop a valid method for imaging the hand using 3D stereophotogrammetry. The reproducibility of 30 soft tissue landmarks was determined using 3D stereophotogrammetric images. Analysis was performed by two observers on 20 3D photographs. Reproducibility and reliability of the landmark identification were determined using statistical analysis. The intra- and interobserver reproducibility of the landmarks were high. This study showed a high reliability coefficient for intraobserver (1.00) and interobserver reliability (0.99). Identification of the landmarks on the palmar aspect of individual fingers was more precise than the identification of landmarks of the thumb. This study shows that 3D photography can safely produce accurate and reproducible images of the hand, which makes the technique a reliable method for soft tissue analysis. 3D images can be a helpful tool in pre- and postoperative evaluation of reconstructive trauma surgery, in aesthetic surgery of the hand, and for educational purposes. The use in everyday practice of hand surgery and the concept of fusing 3D photography images with radiologic images of the interior hand structures needs to be further explored.

Mesenchymal Stem Cells and Endothelial Progenitor Cells Stimulate Bone Regeneration and Mineral Density

Alveolar bone deficiency is a major clinical problem in maxillofacial reconstructive surgery. The available surgical techniques to enhance extracortical bone augmentation are generally unpredictable and not satisfying. The aim of the present study is to quantify extracortical bone augmentation and tissue mineral density (TMD) after cotransplantation of peripheral blood-derived endothelial progenitor cells (EPCs) and bone marrow-derived mesenchymal stem cells (MSCs) by microcomputed tomography (micro-CT). Bone regeneration was tested in the guided bone regeneration rat calvaria model. Gold domes filled with beta tricalcium phosphate (β-TCP; control [CNT]) or β-TCP mixed with 5 × 10(5) rat EPCs and 5 × 10(5) rat osteogenic transformed MSCs (EPC/otMSCs) were fixed to the exposed calvaria. Rats were sacrificed after 3 months. Bone volume fraction (BV/TV) and TMD were analyzed using micro-CT. In the middle of the dome, a cylindrical region of interest was defined (it represents the area in which implants are placed) and subdivided into bottom, middle, and top to analyze the effect of the distance from the calvaria on bone formation. In the whole cylinder, BV/TV and TMD were higher in the EPC/otMSC group compared with CNT (BV/TV: 22.9% ± 4.4% versus 29.1 ± 2.2%, P = 0.02; TMD: 937.79 ± 18.68 versus 960.78 ± 5.8 mgHA/ccm, P = 0.03; CNT versus EPC/otMSC, respectively). In each of the three subregions, BV/TV was higher in the EPC/otMSC group compared with CNT (top: 20.25% ± 2.4% versus 23.74% ± 1.5%, P = 0.007; middle: 23.2% ± 4.8% versus 28% ± 2.2%, P = 0.05; bottom: 25.3% ± 7.6% versus 35.7% ± 4.9%, P = 0.02; CNT versus EPC/otMSC, respectively). Three-dimensional quantification by micro-CT demonstrated that cotransplantation of EPC/otMSCs significantly improved bone formation and mineral density.

Microsurgical reconstruction of the head and neck – Current concepts of maxillofacial surgery in Europe

IntroductionMicrovascular surgery following tumour resection has become an important field of oral maxillofacial surgery (OMFS). This paper aims to evaluate current microsurgical practice in Europe. MethodsThe questionnaire of the DOESAK collaborative group for Microsurgical Reconstruction was translated into English, transformed into an online based survey and distributed to 200 OMFS units with the aid of the European Association for Cranio-Maxillo-Facial Surgery (EACMFS). Results65 complete and 72 incomplete questionnaires were returned. Hospitals from the United Kingdom, France, Italy, the Netherlands, Spain, Belgium, Greece, Slovenia and Lithuania participated. 71% of contributing centres were university hospitals, 87% out of these perform microvascular tumour surgery at least on a two-weekly base. Overall complication rate was at around five percent. Most frequently used transplants were the radial forearm flap and the fibular flap. The perioperative management varied widely. Success factors for flap survival, however, were uniformly rated, with the surgical skill being the most important factor, followed by the quality of postoperative management. Medication seems to play a less important role. ConclusionWithin Europe microvascular surgery is a common and safe procedure for maxillofacial reconstructive surgery in the field of OMFS. While there is a major accordance for the surgical procedure itself and the most frequently used flaps, perioperative management shows a wide variety of protocols with low presumed impact on surgical outcome.

Applications of Coronoid Process as a Bone Graft in Maxillofacial Surgery

The coronoid process can be easily harvested as a donor bone by an intraoral approach during many maxillofacial surgery procedures. The purpose of this study was to evaluate the utility of autogenous coronoid process bone grafts for maxillofacial reconstructive surgery. Twelve patients, who underwent coronoid process grafts for reconstruction of maxillofacial deformities due to trauma, alveolar atrophy, or temporomandibular joint ankylosis, were included in the study. There were 3 orbital defects after extended maxillectomy, 1 blowout fracture of the orbit, 2 cases of reconstruction after temporomandibular joint ankylosis surgery, 1 case of additional chin augmentation following horizontal flip genioplasty, 1 defect of anterior wall of maxilla due to trauma, 2 mandibular defects, and 2 cases of bone augmentation for implants.We recommend the use of coronoid process of the mandible as a source for autogenous bone graft as it can provide sufficient bone in quantity and quality for selected maxillofacial reconstructions.

Visibility of sutures of the orbit and periorbital region using multidetector computed tomography.

ObjectiveKnowledge of cranial suture morphology is crucial in emergency medicine, forensic medicine, and maxillofacial reconstructive surgery. This study assessed the visibility of sutures of the orbit and periorbital region on multidetector computed tomography.Materials and MethodsMultidetector computed tomography scans of 200 patients (127 males, 73 females; mean age 51.3 years; range, 6-92 years) were evaluated retrospectively. The slice thicknesses varied from 0.5 to 1 mm, and the tube current from 25 to 370 mAs, depending on the CT indication. The visibility of sutures was estimated according to a 4-point scale from "not visible" to "well visible". The chi-squared test was used to test the association of the visibility of sutures with the slice thickness, tube current, and age of patients. Statistical significance was assumed at p < 0.05.ResultsOverall, best visibility was found for the sutura frontozygomatica (98%), sutura frontonasalis (88.5%), and sutura sphenozygomatica (71.5%), followed by the sutura zygomaticomaxillaris (65.8%), sutura temporozygomatica (41.8%), sutura frontomaxillaris (44.5%), and sutura sphenofrontalis (31%). Poor visibility was found for the sutura frontolacrimalis (16.8%) and sutura frontoethmoidalis (1.3%). The sutura ethmoidomaxillaris, sutura lacrimomaxillaris, and sutura ethmoidolacrimalis were not visible.ConclusionAlthough the sutures of the superior, lateral, and inferior orbit are well visible, those of the medial orbit are poorly visible on CT scans.

Prospective Evaluation of a Negative Pressure Dressing System in the Management of the Fibula Free Flap Donor Site

The fibula free flap donor site has been associated with short-term donor site morbidity, most commonly delayed healing. To evaluate the effectiveness of a negative pressure dressing (NPD) system in the management of fibula free flap donor sites that required skin graft closure. Cohort study comparing a prospective cohort whose donor sites were managed with the NPD system from June 2009 through March 2012 with a retrospective cohort whose donor sites were managed with a conventional pressure (bolster) dressing (CPD) from August 2006 through May 2009. Tertiary regional head and neck reconstructive and maxillofacial surgery unit. All patients who had a composite fibula free flap for maxillofacial reconstructive surgery and required donor site closure with split-thickness skin grafts from August 2006 through March 2012. Negative pressure dressing used to manage the skin-grafted fibula donor site. Primary: time until complete healing of the fibula donor site. Secondary: skin graft take rate, infection rate, returns to operating theater for donor site problems, delayed hospital discharge due to donor site problems, and community intervention required for donor site dressing. All healing outcome measures were similar for the 21 patients in the NPD group and the 19 patients in the CPD group, with no statistically significant difference. Two patients in the CPD group required surgical debridement of the fibula donor site, compared with none in the NPD group (P = .22). The NPD group had a higher skin graft take success rate (15 [71%] vs 11 [58%]; P = .51) and required less nursing intervention for donor site dressings (8 [38%] vs 9 [47%]; P = .75) but had a higher wound infection rate (6 [29%] vs 2 [11%]; P = .24). Our findings would, at best, suggest that NPD may decrease the rate of return to the operating theater for donor site problems. The fibula donor site healing remains problematic, and our results suggest that routine use of the NPD system in the management of the fibula free flap donor site is not justified from a health economic perspective.

Tight Placement of Erich Arch Bar While Avoiding Wire Fatigue Failure

The Erich arch bar is an important surgical device to secure occlusion for jawbone fracture treatment including open and closed reduction, prior to temporomandibular joint and maxillofacial reconstructive surgery, and occasionally skeletofacial deformity correction. The main concern for placement of the Erich arch bar is time consumption during surgery due to a trial and error approach to wire tightening. The objective of this research was to determine the number of wire twists needed to acquire ideal Erich arch bar tightness before wire fracture (fatigue failure) in relationship to the different distance and angle at which the surgeon grasps the wire with the wire holder. Using this multi-variable clinical experiment, these data were used to present oral and maxillofacial surgeons with a primary clinical guide to aid in the application of Erich arch bars.

Cancer de la langue : expérience de l’Institut national d’oncologie de Rabat, à propos de 60 cas

Recurrence is one of the main reasons for poor prognosis of OSCC. The mortality rate is approximately 90% and the 5-year overall survival rate decreases from 90% to 30% when recurrence is diagnosed. Identification of clinicopathological risk factors predicting recurrence may be helpful for patient individualized management and improvement of therapy. Therefore we investigated in our study the incidence of locoregional recurrences and their association with clinicopathological factors to identify possible significant risk factors.Our retrospective study consisted of 517 patients, who were diagnosed and treated between 2003–2013 at the Department for Oral and Maxillofacial Plastic Surgery, University of Cologne. Inclusion criteria were patients with treatment naive oral squamous cell carcinoma and primarily curative intended surgery with negative resection margins. Contingency tables and χ2-test were performed to analyse associations between clinicopathological features and recurrence. Multivariate analysis was performed using binary logistic regression analysis.We found out a significant correlation in univariate analysis between locoregional recurrence and number of resected cervical lymph nodes (p = 0.013), number of positive cervical lymph nodes (p = 0.041), postoperative radiatio (p = 0.018), extracapsular spread (p = 0.028) as well as grading (p = 0.016). In multivariate analysis only grading was shown as independent risk factor for recurrence.Histological grading has been demonstrated as an independent risk factor for locoregional recurrence in the multivariate analysis. Furthermore, univariate analysis indicated the number of resected and positive lymph nodes, postoperative radiatio and extracapsular spread as significant risk factors. Taking these results into account, the mentioned parameters, especially histological grading, need to be considered for an individualized therapy management of patients with OSCC.

Imaging, Virtual Planning, Design, and Production of Patient-Specific Implants and Clinical Validation in Craniomaxillofacial Surgery

The purpose of this article was to describe the workflow from imaging, via virtual design, to manufacturing of patient-specific titanium reconstruction plates, cutting guide and mesh, and its utility in connection with surgical treatment of acquired bone defects in the mandible using additive manufacturing by electron beam melting (EBM). Based on computed tomography scans, polygon skulls were created. Following that virtual treatment plans entailing free microvascular transfer of fibula flaps using patient-specific reconstruction plates, mesh, and cutting guides were designed. The design was based on the specification of a Compact UniLOCK 2.4 Large (Synthes(®), Switzerland). The obtained polygon plates were bent virtually round the reconstructed mandibles. Next, the resections of the mandibles were planned virtually. A cutting guide was outlined to facilitate resection, as well as plates and titanium mesh for insertion of bone or bone substitutes. Polygon plates and meshes were converted to stereolithography format and used in the software Magics for preparation of input files for the successive step, additive manufacturing. EBM was used to manufacture the customized implants in a biocompatible titanium grade, Ti6Al4V ELI. The implants and the cutting guide were cleaned and sterilized, then transferred to the operating theater, and applied during surgery. Commercially available software programs are sufficient in order to virtually plan for production of patient-specific implants. Furthermore, EBM-produced implants are fully usable under clinical conditions in reconstruction of acquired defects in the mandible. A good compliance between the treatment plan and the fit was demonstrated during operation. Within the constraints of this article, the authors describe a workflow for production of patient-specific implants, using EBM manufacturing. Titanium cutting guides, reconstruction plates for fixation of microvascular transfer of osteomyocutaneous bone grafts, and mesh to replace resected bone that can function as a carrier for bone or bone substitutes were designed and tested during reconstructive maxillofacial surgery. A clinically fit, well within the requirements for what is needed and obtained using traditional free hand bending of commercially available devices, or even higher precision, was demonstrated in ablative surgery in four patients.

Poster 37: Is Virtual Surgical Planning in Orthognathic Surgery Error Proof?

The advent of virtual surgical planning (VSP) represents a fundamental shift in the work-up of orthognathic and reconstructive maxillofacial surgery cases. VSP utilizes computer assisted design-computer assisted modeling (CAD-CAM), and gives the surgeon the ability to make complex spatial changes on a virtual platform instead of a lab bench. This technology allows design and fabrication of an intermediate splint which in the past required cumbersome model surgery to control precise movements in yaw, pitch, and roll. The use of VSP for orthognathic surgery is described in the literature1,2, however, there are few studies comparing the precision of VSP movements with those previously performed with plaster models and articulators. This study is an analysis of error achieved with VSP for orthognathic surgery.

Current Knowledge and Perspectives for the Use of Platelet-Rich Plasma (PRP) and Platelet-Rich Fibrin (PRF) in Oral and Maxillofacial Surgery Part 2: Bone Graft, Implant and Reconstructive Surgery

Platelet concentrates for surgical use are innovative tools of regenerative medicine, and were widely tested in oral and maxillofacial surgery. Unfortunately, the literature on the topic is contradictory and the published data are difficult to sort and interpret. In bone graft, implant and reconstructive surgery, the literature is particularly dense about the use of the various forms of Platelet-Rich Plasma (PRP) - Pure Platelet-Rich Plasma (P-PRP) or Leukocyte- and Platelet-Rich Plasma (L-PRP) - but still limited about Platelet-Rich Fibrin (PRF) subfamilies. In this second article, we describe and discuss the current published knowledge about the use of PRP and PRF during implant placement (particularly as surface treatment for the stimulation of osseointegration), the treatment of peri-implant bone defects (after peri-implantitis, during implantation in an insufficient bone volume or during immediate post-extraction or post-avulsion implantation), the sinuslift procedures and various complex implant-supported treatments. Other potential applications of the platelet concentrates are also highlighted in maxillofacial reconstructive surgery, for the treatment of patients using bisphosphonates, anticoagulants or with post-tumoral irradiated maxilla. Finally, we particularly insist on the perspectives in this field, through the description and illustration of the use of L-PRF (Leukocyte- and Platelet-Rich Fibrin) clots and membranes during the regeneration of peri-implant bone defects, during the sinus-lift procedure and during complex implant-supported rehabilitations. The use of L-PRF allowed to define a new therapeutic concept called the Natural Bone Regeneration (NBR) for the reconstruction of the alveolar ridges at the gingival and bone levels. As it is illustrated in this article, the NBR principles allow to push away some technical limits of global implant-supported rehabilitations, particularly when combined with other powerful biotechnological tools: metronidazole solution, adequate bone substitutes and improved implant designs and surfaces (for example here AstraTech Osseospeed or Intra-Lock Ossean implants). As a general conclusion, we are currently living a transition period in the use of PRP and PRF in oral and maxillofacial surgery. PRPs failed to prove strong strategic advantages that could justify their use in daily practice, and the use of most PRP techniques will probably be limited to some very specific applications where satisfactory results have been reached. Only a few simple, inexpensive and efficient techniques such as the L-PRF will continue to develop in oral and maxillofacial surgery in the next years. This natural evolution illustrates that clinical sciences need concrete and practical solutions, and not hypothetical benefits. The history of platelet concentrates in oral and maxillofacial surgery finally demonstrates also how the techniques evolve and sometimes promote the definition of new therapeutical concepts and clinical protocols in the today's era of regenerative medicine.

일반인의 교정치료에 대한 지식수준, 태도에 대한 연구

ABSTRACTObjectives : The purpose of this study was to examine the knowledge of peo ple in general about orthodontictreatment and their attitude to that by conducting a survey in a bid to provide information on the improvementof their incorrect awareness of orthodontics and on the development of clinical orthodontic treatment.Methods and Results : The subjects in this study were 389 people in general who res ided in Seoul and GyeonggiProvince. A self-administered survey was conducted, and the fin dings of the study were as follows: 1. As forawareness of orthodontic treatment among the people in general by gender, the women knew better about ortho-dontic treatment than the men, and the gender gap was significa nt(p<0.05). 2. Concerning satisfaction with theshape and arrangement of the teeth by age, those who were in th eir 20s were most satisfied, and the teens weresatisfied the least. There were significant gaps according to a ge (p<0.05). 3. As a result of checking the degree oftheir inconvenience about the use of chewing teeth by age, the people who were in their 30s felt the most incon-venience, and the gap between them and the others was significant(p<0.01). 4. As a result of asking them whetherthey had an intention to receive orthodontic treatment, the wom en had a more intention to do that than themen(p<0.001). By age, the younger respondents had a more intent ion, and the gaps between them and the otherswere significant(p<0.001). 5. As a result of analyzing their pe rception of the positives of orthodontics by gender,the women took a more positive view of it than the men, and their gap was significant(p<0.01).Conclusions : When orthodontic treatment or orthodontic treatment counseling is provided to orthodontic treat-ment patients or people in general in the field of clinical den tistry, it should be noted that the way patients andpeople in general look at orthodontic treatment is different ac cording to their age and gender, and they should beinformed of the positives of orthodontic treatment to step up t he development of orthodontic treatment.(J KoreanSoc Dent Hygiene 2012;12(2):251-260)Keywords: malocclusion, maxillofacial plastic surgery, orthodontic treatment, orthodontics, orthodontic patients 색인: 교정치료, 교정환자, 부정교합, 악안면성형수술, 치열교정

Reconstructive maxillofacial surgery in a resource poor setting: Challenges encountered in a paediatric case

Background: Facial reconstruction in a paediatric patient requires peculiar considerations. For optimal outcome, comprehensive pre-surgical evaluation, surgical expertise, appropriate tools and facilities, and serial outcome monitoring are essential. The aim of this study was to highlight some challenges militating against optimal outcome in facial reconstruction in a developing country based on the experience in managing a paediatric patient. Methods: Using a case of post-traumatic facial deformity in a paediatric patient, the factors affecting optimal outcome in a resource-poor setting were identified and discussed. Results: Identified issues related to: nature of injury, age and gender considerations, depth of expertise and extent of surgery required for bony, soft tissue and nerve repairs, facility for comprehensive evaluation, surgical planning and execution and finance. Conclusion: The restoration of a deformed face is challenging, but the scenario could be further complicated when essential resources are not available. Additional considerations must be entertained in a paediatric patient. Keywords : facial reconstruction, paediatric, free tissue transfer

Blindness following severe midfacial trauma – Case report and review

PurposeSevere trauma of the viscerocranium or neurocranium may result in impaired visual acuity or even blindness. Case based epidemiology, pathomechanism and actual strategies in midfacial trauma for initial therapy and prevention of posttraumatic blindness are discussed. Case and reviewA 58-year old patient was treated at our Department of Oral and Maxillofacial Plastic Surgery after his central midface had been hit by a swinging steel girder. Initially he was blind on both eyes. Initial treatment started by applying 24 mg of dexamethasone and omeprazole. During the following 2 weeks, amaurosis persisted on the left eye. On the right eye complete visual acuity was regained. On the basis of data from our Department of Oral and Maxillofacial Plastic Surgery an Odds Ratio of 0.12 was calculated for the combination of blindness and midfacial trauma. Today cortisol therapy is still used. However, hypothermia, anti-Trendelenburg position, and application of mannitol seem to be more effective therapeutic strategies. Erythropoetine and progesterone are promising drugs with neuroprotective, anti-inflammatory as well as anti-oedematous effects. ConclusionThe risk of blindness is higher than expected. Latest findings regarding the neuroprotective effects of erythropoetine or/and progesterone seem to promise a more successful treatment.

Leech Therapy in Reconstructive Maxillofacial Surgery

Corrective plastic surgery is indicated after accidents, burns, cancer surgery, or postoperative wound healing disorders with large tissue defects. The range of reconstructive techniques includes local skin flaps, pedicle grafts, and microvascular anastomosed flaps in the case of large defects. Main complications such as arterial and venous insufficiency caused by a vessel collapse or a vascular spasm are reported regularly in the area of anastomosed vessels and are the concern of any surgeon. Today, leeches are used if wound healing is at risk because of hemodynamic imbalance or a venous insufficiency. A retrospective evaluation of 148 patients who underwent medical leech therapy in the case of local or pedicaled flaps and some patients who had undergone reconstruction with microvascular flaps from 2005 and 2010 was conducted. Our sample had the typical symptoms of venous congestions of their flaps, despite suture removal, relief of pressure on the flap, and the elimination of a hematoma beyond the flap after surgery. Medical leech therapy was used in these cases. Our series has confirmed the excellent and predictable healing after medical leech therapy for local and microsurgical anastomosed flaps in the case of venous congestion. Leech therapy should be considered as a reliable additional procedure and an advantage in maxillofacial and plastic reconstructive surgery to remedy complications resulting from a hemodynamic imbalance or venous insufficiency in the immediate postoperative period.

Way to increase mechanical strength during distraction osteogenesis of the mandibular symphysis: technical note

The First Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, 1-8, Ymadaoka, Suita, Osaka 565-0871, Japan Ohnishi Orthodontic Clinic, 1-4-8, Shibata, Kita-Ku, Osaka 530-0012, Japan Department of Oral and Maxillofacial Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentisitry and Pharmaceutical ciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama 700-8552, Japan

Esthetic and Functional Reconstruction of the Posttumoral Interrupted Mandible With Double-Barrel Fibular Free Flap Graft: Rationale for a Microsurgical and Prosthodontic Approach

Reconstruction after substantial osseous, cutaneous, and muscular tissue loss following a mandibular resection is a challenge. The use of a fibular free flap is an outstanding, but delicate, treatment option. These grafts, using the double-barrel technique, can achieve an almost complete reconstruction of the mandibular defect. The challenge posed by these treatments is to achieve an end result that is both functional and esthetically pleasing-an endeavor that requires a defined prosthetic plan prior to complete microsurgical reconstruction. Using a detailed clinical case, this article discusses the importance of planning the mandible reconstruction with double-barrel fibular graft in view of an implant-supported fixed partial denture. Immediate implant loading was even possible in this case. This approach allows improvement of the final esthetic and functional result of such a complex rehabilitation. Maxillofacial reconstructive surgery should seek to establish a near-as-normal anatomic situation that will allow a permanent implant rehabilitation that is both esthetic and durable.

The use of a T-shaped contoured unilocking titanium radial plate for prophylactic internal fixation of the radial osteocutaneous donor site

The radial osteocutaneous flap retains a limited role in reconstructive maxillofacial surgery The application of prophylactic internal fixation, using straight 3.5 mm plates, has become established to substantially reduce the incidence of fracture at the radial donor site. New lower profile T-shaped 2.4 mm plates and anatomically contoured 3.5 mm plates are now available, both with unilocking screw fixation systems. These plates are easy to apply and allow the removal of up to 50% of the circumference of the radial bone, including the maximum amount of good quality bone from the distal radius. Although there have been no reports of complications as a result of a stress shielding effect with larger plates these refinements in plate design should lessen any remaining concerns.

Mandibular Ramus/Coronoid Process Grafts in Maxillofacial Reconstructive Surgery

To evaluate the utility of autogenous extended mandibular ramus and coronoid process bone grafts for maxillofacial reconstructive surgery. Twelve patients aged 23 to 76 years (mean, 52) who underwent extended ramus/coronoid process grafts for reconstruction of maxillofacial deformities due to trauma, alveolar atrophy, or iatrogenic nasal deformity. All patients had either unilateral or bilateral combined coronoid process-mandibular ramus bone grafts for their reconstruction. There was 1 nasal reconstruction, 2 unilateral mandibles, 1 bilateral mandible, 4 unilateral maxillas, 1 unilateral maxilla and mandible combined, and 1 bilateral maxilla and mandible combined. The procedure was considered a success when the patient's deformities were reconstructed ad integrum and when there were no failures of the dental implants placed in the augmented areas as of the longest follow-up. All patients were successfully reconstructed. There was 1 infection at a donor site that resolved with local care and oral antibiotics. All but 1 of the maxillary and mandibular alveolar augmentations underwent endosteal implant placement approximately 4 to 6 months following grafting. The nasal reconstruction restored normal function and symmetry. Using both the coronoid process of the mandible and the mandibular ramus as a source for autogenous bone graft can provide sufficient bone in quantity and quality for selected maxillofacial reconstructions.