Osteotomy Approach Research Articles

Comparison of the Le Fort I Maxillary Osteotomy With the Sublabial Transnasal and Endonasal Approaches to the Sphenoid Sinus and Sella: A Cadaveric Study

The purpose of this study is to compare the access afforded by the Le Fort I osteotomy with the more traditional sublabial and endonasal approaches to the pituitary fossa. Five fresh cadaveric heads were obtained for this study. Endonasal, sublabial, and Le Fort I osteotomy approaches to the pituitary fossa were performed on each specimen. Retractors were placed in the surgical field to simulate the intraoperative speculum position for each approach. Fluoroscopic images were obtained in 2 views. For each specimen, all images for a given approach were digitally superimposed to compare the magnitude of exposure obtained by each approach. Angular measurements were then compared among the 3 approaches. In the axial plane the degree of lateral exposure with the Le Fort I approach ranged from 15 degrees to 35 degrees, with a mean of 22.6 degrees. By comparison, minimal or no lateral movement of the speculum was possible with the sublabial and endonasal approaches. In the sagittal plane the degree of vertical exposure with the Le Fort I approach ranged from 13 degrees to 22 degrees, with a mean of 17 degrees. The sublabial approach provided 6 degrees to 17 degrees of vertical exposure, with a mean of 11.4 degrees. Minimal or no vertical movement of the speculum was possible with the endonasal approach. The Le Fort I osteotomy is a valuable midline approach for pituitary lesions that require broad exposure. Access in both the axial and sagittal planes is greater than with traditional trans-septal approaches.

Surgical advances in periacetabular osteotomy for treatment of hip dysplasia in adults

Hip dysplasia is characterized by an excessively oblique and shallow acetabulum with insufficient coverage of the femoral head. It is a known cause of pain and the development of early osteoarthritis in young adults. The periacetabular osteotomy is the joint-preserving treatment of choice in young adults with symptomatic hip dysplasia. The surgical aim of this extensive procedure is to reorient the acetabulum to improve coverage and eliminate the pathological hip joint mechanics. Intraoperative assessment of the achieved acetabular reorientation is therefore crucial. The "classic" surgical approaches for the periacetabular osteotomy inflict extensive trauma to the tissues and some involve detachment of muscles. The type of surgical approach may affect the occurrence of complications, duration of surgery, intraoperative blood loss, transfusion requirements, and length of hospital stay. The aims of the PhD thesis were I) to assess the outcome of a new, minimally invasive transsartorial approach for periacetabular osteotomy; II) to compare the minimally invasive approach with the previously used "classic" ilioinguinal approach; and III) to assess the reliability of a novel device for intraoperative assessment of the achieved acetabular reorientation. Three studies underly this PhD thesis. In studies I and II, the experience with the minimally invasive and ilioinguinal approaches was retrospectively assessed by database inquiry and evaluation of radiographic material. Data regarding patient demographics, patient history, intraoperative measures and complications was recorded in a validated database. Center-edge and acetabular index angles were measured in preoperative and postoperative pelvic radiographs to assess preoperative dysplasia and the achieved acetabular reorientation. The well-defined study groups consisted of 94 and 263 periacetabular osteotomies in studies I and II, respectively. In study III, intraoperative angle measurements were carried out prospectively in 35 periacetabular osteotomies. The obtained measures (center-edge and acetabular index angles) were compared with those of postoperative pelvic radiographs. Furthermore, a cadaver study was conducted to evaluate intra- and interobserver variability of the device and to assess whether pelvic positioning influenced the variability of measurements. The applied methodology was critically reviewed. Study I--The minimally invasive approach had the following outcome. The mean duration of surgery was 73 min and the median intraoperative blood loss was 250 ml. Blood transfusion was required following 3% of the procedures. There were no cases of moderate or severe technical and neurovascular complications, and the achieved center-edge and acetabular index angles suggest that optimal reorientation can be achieved. Hip joint survival with total hip arthroplasty as the end point was 98% at 4.3 years. Study II--When compared with the outcome of the ilioinguinal approach, the procedures performed by using the minimally invasive approach had a statistically significant shorter duration of surgery, less intraoperative blood loss and hemoglobin reduction, and fewer transfusion requirements. The achieved reorientation was comparable between groups. There were no cases of moderate or severe complications in the minimally invasive group and three cases (3%) of arterial thrombosis in the ilioinguinal group. At follow-up 4.9 years after hip joint surgery, survival rates were 97% in the minimally invasive group and 93% in the ilioinguinal group. Study III--Intraoperatively obtained angle measures differed less than +/- 5 degrees from measurements on postoperative pelvic radiographs, and the intra- and interobserver variability of the device was confined well within +/-5 degrees. Positioning did not influence the variation of angle measurements beyond intraobserver variability of the device. The new minimally invasive transsartorial approach appears to be a safe technique, allowing optimal acetabular reorientation, and seems to minimize tissue trauma. In addition, short-term hip joint survival rate is encouraging. The outcome compares favorably with that of the ilioinguinal approach, and the results support continued use of the minimally invasive approach for periacetabular osteotomy. Optimal reorientation of the acetabulum is crucial in periacetabular osteotomy. The novel measuring device is a potentially helpful tool for intraoperative assessment of center-edge and acetabular index angels. It is simple to use and facilitates repeated reliable angle measurements during acetabular reorientation, making intraoperative radiographs unnecessary. The new, minimally invasive approach and the novel measuring device represent important surgical advances in contemporary periacetabular osteotomy.

Le Fort I osteotomy for extensive juvenile nasopharyngeal angiofibroma: a retrospective study

Juvenile nasopharyngeal angiofibroma (JNA) is a rare, nonencapsulated, benign neoplasm typically diagnosed in adolescent boys. Surgery is the usual treatment modality for JNA. The optimal surgical procedure should allow maximal exposure of the tumor for complete excision with minimum morbidity. One possible surgical approach is Le Fort I maxillary osteotomy. The aim of this study was to review our experience with the Le Fort I osteotomy and to investigate the feasibility of this approach for extensive JNA invaded into pterygopalatine and infratemporal fossae. We retrospectively studied patients who had undergone JNA resection via the Le Fort I osteotomy approach from July 2000 to September 2007, considering tumor location and size, complications, and tumor recurrence associated with the surgical approach. Six patients of JNA (all boys; mean age, 15.5 years) were identified through the chart review. All the angiofibromas had extended into the pterygomaxillary space and infratemporal fossa. The mean follow-up for this cohort was 50.1 months. No intraoperative and postoperative complications were noted, except for slight diplopia in one patient due to injury of the left medial rectus muscle. There were no cases of tumor recurrence that could be attributed to the procedure. Our experience suggests that the Le Fort I osteotomy approach is a useful technique for the removal of extensive JNA invaded into pterygopalatine and infratemporal fossae. It has distinct advantages over traditional anterior or lateral approaches, providing a more direct vision, improved exposure, and cosmesis.

Tibial tubercle osteotomy in primary total knee arthroplasty: A safe procedure or not?

The objective of this study was to investigate the influence of tibial tubercle osteotomy on postoperative outcome, intra- and postoperative complications, as well as postoperative clinical results and failures in primary total knee arthroplasty (TKA). In a continuous, consecutive series of 1474 primary TKA, we analysed 126 cases where a tibial tubercle osteotomy approach was performed and 1348 cases without tibial tubercle osteotomy. Before surgery, all patients underwent a systematic assessment that included a clinical examination, radiographs (stress hip–knee–ankle film [pangonogram], weight bearing, anteroposterior knee view, schuss view, profile and patellar axial view at 30°, stress valgus and varus view) and International Knee Society scores. When analysing intraoperative complications, tibial plateau fissures or fractures and tibial tubercle fracture were considered as complications relating to the tibial tubercle osteotomy group ( p < 0.001, p = 0.007). With a 2-year minimum follow-up, there was no statistical difference in the number of revisions carried out in the two study groups ( p = 0.084). However, postoperative tibial tubercle fracture and skin necrosis were significantly related to the osteotomy ( p = 0.001 and p ≤ 0.001, respectively). Tibial tubercle osteotomy cannot be considered an entirely safe procedure in primary TKA as it is associated with local complications, particularly skin necrosis and fracture of the tibial tubercle. Therefore, tibial tubercle osteotomy should be performed only when necessary, i.e. in cases where there are difficulties gaining adequate surgical exposure, ligament balance and correct implant positioning. The procedure also demands considerable surgical experience to achieve a good outcome.

The trochanter slide osteotomy approach for resurfacing hip arthroplasty

The aim of this prospective study was to assess the safety and efficacy of the greater trochanter slide osteotomy approach for resurfacing hip arthroplasty. Fifty consecutive hips (47 patients) with degenerative joint disease were enrolled in the study. Serial clinical and radiological assessments were performed after the index operation. At 1-year follow-up, the clinical outcome and patient satisfaction were rated excellent or good in all hips. The radiological assessment showed signs of satisfactory implant alignment. Periprosthetic fractures and non-unions of the greater trochanter were not observed. The greater trochanter slide osteotomy approach for resurfacing hip arthroplasty is a safe procedure and provides optimal exposure of the acetabulum and proximal femur, maintaining the soft-tissue integrity of the hip joint. Blood supply of the proximal femur is not violated using this approach.

A Quantitative Comparison of Surgical Approaches for Posterolateral Osteochondral Lesions of the Talus

Exposure of the posterolateral talar dome for osteochondral autograft transfer can be challenging. The purpose of this study is to compare surgical exposures for perpendicular access to the posterolateral talar dome using osteochondral transfer instrumentation. Five surgical approaches were performed on each of eight cadaveric ankles. The sequence was: (1) Anterolateral arthrotomy with ATFL release, (2) Anterolateral tibial osteotomy, (3) Fibular osteotomy with ATFL intact, (4) Fibular osteotomy with ATFL release, and (5) Fibular osteotomy with ATFL/CFL release. (ATFL repaired between 1 and 2). While maintaining the orientation of the harvester perpendicular to the talar dome articular surface, osteochondral plugs were harvested as far posteriorly as possible using a 6-mm harvester. Distances from the anterior talar articular surface to the posterior aspect of the recipient site were measured. Statistical analysis used ANOVA and Fisher post hoc tests. Average AP exposure (mm) and percentage of AP talar dome dimensions exposed: (1) Anterolateral arthrotomy with ATFL release: 21.2 mm (43.3%), (2) Anterolateral tibial osteotomy: 33.7 mm (68.5%), (3) Fibular osteotomy(ATFL intact): 43.2 mm (87.8%), (4) Fibular osteotomy with ATFL release: 44.9 mm (91.2%), and (5) Fibular osteotomy with ATFL/CFL release: 46.6 mm (94.6%). All osteotomies provided greater exposure than anterolateral arthrotomy with ATFL release (p < 0.0001). A significant difference was obtained between each of the fibular osteotomies and tibial osteotomy (p < 0.0001). Differences between the fibular osteotomy approaches (3 to 5) were not significant. Fibular osteotomy provides the greatest perpendicular exposure to the posterolateral talar dome. Anterolateral tibial osteotomy provides greater exposure than arthrotomy alone. This study provides a guide for surgical exposures to the posterolateral talar dome for osteochondral autograft transfer.

Application of parasymphyseal mandible osteotomy combined with set-back tongue flap in treatment of tongue base carcinoma

To evaluate the efficacy of the approach of parasymphyseal mandible osteotomy combined with set-back tongue flap in treatment of tongue base carcinoma. In total 18 patients with cancer of tongue base, 13 were males and 5 females aged of 30 to 65 y (average 52.9 y). Eighteen patients were treated by parasymphyseal mandible osteotomy combined with set-back tongue flap in our hospital from June 2001 to June 2006. The range of follow-up period was 2 to 5 years. All patients had satisfactory speech, swallowing and taste function. Parasymphyseal mandible osteotomy provides good exposure, and set-back tongue flap to reconstruction of the base of tongue can partially restore the function of tongue.

A New Minimally Invasive Transsartorial Approach for Periacetabular Osteotomy

A new minimally invasive transsartorial approach for the Bernese periacetabular osteotomy was developed. We investigated whether this technique was safe and successful with regard to minimizing tissue trauma and, more importantly, whether it was possible to obtain optimal reorientation of the acetabulum. Our experience with this approach was retrospectively assessed by means of database inquiry and the evaluation of radiographs. We assessed ninety-four procedures performed between April 2003 and August 2005 to determine perioperative and early postoperative outcome measures, the achieved acetabular reorientation, and hip joint survival. The mean duration of surgery was 73.1 minutes, the median perioperative blood loss was 250 mL, and the mean reduction in the hemoglobin level was 33 g/L. Blood transfusion was required following 3% of the procedures. No injuries to the great vessels or nerves, arterial thromboses, unintended extension of the osteotomy, or deep infections occurred. The postoperative acetabular reorientation was assessed by measuring the center-edge and acetabular index angles, the medians of which were 34 degrees and 3 degrees , respectively. With total hip arthroplasty as the end point, the hip joint survival rate was estimated to be 98% at 4.3 years. Osteotomy with use of this minimally invasive transsartorial approach appears to be a safe, relatively short surgical procedure associated with a relatively small amount of blood loss and minimal transfusion requirements. Optimal acetabular reorientation can be achieved with this technique.

Comparison of the minimally invasive and ilioinguinal approaches for periacetabular osteotomy 263 single-surgeon procedures in well-defined study groups

Background and purpose Periacetabular osteotomy is the treatment of choice in young adults with hip dysplasia. Patient morbidity and surgical outcome may depend on the choice of surgical approach. We compared the outcome of a new minimally invasive approach to that of the frequently used “classic” ilioinguinal approach.Patients and methods We retrospectively evaluated our experience with the ilioinguinal and minimally invasive approaches, which were used in successive time periods at our institution between December 1998 and February 2007 (n=263). Intraoperative and early postoperative outcome factors together with analysis of hip joint survival were compared in well-defined study groups.Results In the minimally invasive and ilioinguinal groups respectively, the median (interquartile range) intraoperative blood loss was 250 (200–350) mL and 500 (350–700) mL (p<0.001), the mean (95% CI) hemoglobin reduction was 2.0 (1.9–2.1) mmol/L and 2.5 (2.4–2.7) mmol/L (p<0.001), transfusion was required following 4% and 18% of the procedures (p<0.001), and the median (interquartile range) duration of surgery was 70 (60–75) min and 100 (80–120) min (p<0.001). Median (interquartile range) postoperative center-edge and acetabular index angles were 33˚ (30–36) and 2˚ (0–6), respectively, in the minimally invasive group and 31˚ (25–35) and 9˚ (1–14) in the ilioinguinal group. There were no cases of moderate or severe complications in the minimally invasive group and 3 cases of arterial thrombosis in the ilioinguinal group (3%). At follow-up of 5 years, the hip joint survival rates were 97% in the minimally invasive group and 93% in the ilioinguinal group.Interpretation Given the accumulated experience of the surgeon, the outcome of the minimally invasive approach compares favorably with that of the ilioinguinal approach, and the results support continued use of the minimally invasive approach for periacetabular osteotomy. Using this approach, we did not encounter any complications and acetabular reorientation was not compromized.

Three kinds of posterior approach procedure for treatment of intercondylar fractures of the humerus

目的 探讨三种肘后入路术式治疗肱骨髁间骨折的效果.方法 2000年2月-2006年6月,我院对49例肱骨髁间骨折的患者,按AO分型属B型27例,C型22例,随机采用三种肘后入路术式(传统入路、尺骨鹰嘴截骨和经肱三头肌腱尺骨鹰嘴处入路)进行治疗.结果 术后肘关节功能按JOA标准评定:优35例(35/49),占71.4%;良12例(12/49),占24.5%;一般2例(2/49),占4.1%.其中传统手术入路者术后功能的优良率明显低于其余2种手术入路.结论 三种肘后入路对肱骨近端都能充分暴露,但采用传统入路术式者术后功能恢复欠佳,且产生医源性并发症的概率较高.尺骨鹰嘴入路是最佳手术入路,但对惧怕尺骨鹰嘴截骨者亦可采用经肱三头肌腱尺骨鹰嘴处入路,二者都能获得良好的疗效,且医源性并发症的发生率较低。

Management of ulnar nerve in treatment of type C distal humeral fractures and its prognosis

目的 探讨治疗肱骨远端C型骨折时尺神经松解与筋膜下前置术的手术疗效.方法 采用肘后侧正中切口入路,对40例肱骨远端关节内骨折(按AO分型C1型24例,C2型10例,C3型6例,其中9例伴有不同程度尺侧半手指麻木)的患者,采用尺骨鹰嘴V形截骨入路,重建肱骨远端的内外侧柱,并形成稳定的三角形框架结构的方法进行治疗.术前9例有尺神经症状者,术中均见尺神经有明显压迫,其中2例伴有尺神经的挫伤.术中保护尺侧上副血管并游离尺神经,骨折固定后将尺神经于筋膜下前置.除1例尺骨鹰嘴骨折与肘关节脱位患者术后石膏托保护3周外,其余病例术后早期进行被动功能训练.结果 31例术前无尺神经损伤症状者术后无并发尺神经损伤症状.9例有尺神经症状者6例完全恢复,3例不同程度的恢复;按照中华医学会上肢部分功能评定试用标准评定:优7例,良1例,可1例,优良率为88.9%.35例经过平均16个月的随访(5例失访),骨折全部愈合,4例有轻度骨化性肌炎,占11.4%.按照Mayo clinic肘关节评分评定:优11例,良好17例,可5,差2例,优良率为80.0%.结论 常规尺神经松解并进行筋膜下前置,便于肱骨远端关节内骨折的双柱固定,并可以防止术中尺神经损伤与术后进一步卡压的发生。

Correction of Valgus Second Toe by Closing Wedge Osteotomy of the Proximal Phalanx

Valgus deviation of the second toe can be associated with metatarsophalangeal joint pain, footwear fitting problems, and cosmetic concerns. It also reduces the buttress effect of the second toe on the hallux and may allow progression of hallux valgus. The traditional operative approaches for digital arthrodesis or lesser metatarsal osteotomy have unpredictable results. This study reviewed the effect of a closing wedge osteotomy on the proximal phalanx in 26 women with an average age of 59 years (SD 10) who had a valgus second toe. The patients had weightbearing radiographs preoperatively and at an average 28 months postoperatively. Clinical examination assessed for floating toe, range of metatarsophalangeal joint motion, and patient satisfaction. Before surgery the average second toe valgus angle measured 28 degrees and at final review this had reduced to 14 degrees (p < 0.001). Postoperatively, the average range of dorsiflexion of the digit was 42 degrees (SD 20). The average plantarflexion was 16 degrees (SD 10). Floating of the digit was noted in five patients and recurrence of the deformity in four patients. Nineteen patients (73%) were completely satisfied with the outcome of their surgery, seven were satisfied with reservations, and no patient was dissatisfied. Twenty five patients (96%) considered their second toe to be better than before the operation. Closing wedge osteotomy of the second toe is technically simple, reasonably safe, and relatively effective for valgus deformity of the second toe. Recurrence of the second toe valgus usually was associated with recurrence of hallux valgus.

EXTRACRANIAL NASOPHARYNGEAL CRANIOPHARYNGIOMA

Craniopharyngiomas (CPs) are benign tumors that almost always occur in a suprasellar location, making complete resection difficult and often necessitating radiotherapy. A case of CP presenting in an unusual location in an 8-year-old boy highlights the goals of CP treatment. An 8-year-old boy sought treatment for symptoms of nasal obstruction and snoring. He also had a history of mild developmental delay, and his father had a thyroglossal duct cyst resected in his own youth. After tonsillectomy and adenoidectomy failed to improve the patient's symptoms, nasal endoscopy and biopsy revealed an intranasal CP. After this treatment, he experienced chronic thin brown nasal discharge. Magnetic resonance imaging further revealed tumor invading the sphenoid body and the clivus and that the tumor had no intracranial extension. The child underwent surgical resection via a Le Fort I osteotomy approach. Complete resection was accomplished based on intraoperative frozen section pathological examination and postoperative magnetic resonance imaging results. CP with no intracranial extension is a very rare but benign tumor. We recommend vigorous attempts to resect such tumors completely to minimize the chance of recurrence and the possible need for radiotherapy. Although radiotherapy controls CP growth quite well, it has its own risks that should be avoided if possible. Cranial base techniques may facilitate total resection.

Medial Approach for Humeral Rotational Osteotomy in Children with Residual Brachial Plexus Birth Palsy

Residual brachial plexus birth palsy often results in an internal rotation contracture. The constant position of internal rotation leads to glenohumeral joint deformity that progresses over time. In the older child, the glenohumeral joint deformity is advanced, and the joint cannot be reduced. Humeral osteotomy can reposition the limb into external rotation, which improves appearance and enhances activities of daily living, such as eating, washing hair, and grooming. This article discusses my preferred technique for humeral osteotomy using a medial approach along with its advantages and disadvantages. The technique involves a medial incision along the arm. The internervous plane is between the median and ulnar nerves. The intermuscular septum is traced to the medial aspect of the humerus. The periosteum is incised and provisional fixation is obtained. A transverse osteotomy is performed, and the humerus is rotated into the desired position. Rigid plate and screw fixation is applied. Postoperative immobilization is nominal, although the osteotomy is protected until union. Improvement in function of activities of daily living, such as dressing, washing, self-cleaning, and feeding is obtained. An added benefit is better limb appearance with improved symmetry.

Prosthesis survival after total hip arthroplasty—does surgical approach matter? Analysis of 19,304 Charnley and 6,002 Exeter primary total hip arthroplasties reported to the Norwegian Arthroplasty Register

Background and purpose Controversies still exist about whether there is any effect of operative approach on survival of hip prostheses. We compared long-term survival of primary total hip arthroplasties in a welldefined study population from a national prospective population-based registry with regard to the three most commonly used surgical approaches.Methods We assessed prosthesis survival according to surgical approach (the lateral with or without trochanteric osteotomy, and the posterolateral) for 19,304 Charnley and 6,002 Exeter total hip arthroplasties performed from 1987 to 2004.Results For Charnley total hip arthroplasties, lateral approach with trochanteric osteotomy had a lower probability of revision than lateral approach without trochanteric osteotomy (RR = 0.6, 95% CI: 0.5–0.8). The lower revision rate was due to fewer revisions for aseptic loosening and dislocation. The differences had declined in the latest time period (1995–2004). We observed no differences between lateral approach without trochanteric osteotomy and posterolateral approach, except that there were more revisions due to dislocation in the posterolateral approach group (RR = 1.9, 95%CI: 1.1–3.2). No statistically significant differences were observed for Exeter total hip arthroplasties.Interpretation For Charnley prostheses, the lateral approach with trochanteric osteotomy gave a reduced revision risk compared to the other approaches, which was due to fewer revisions for dislocation, and in the first time period also fewer revisions due to aseptic loosening.

Comparison of two techniques in hemivertebra resection: transpedicular eggshell osteotomy versus standard anterior–posterior approach

Hemivertebrae are the most frequent cause of congenital scoliosis. They have growth potential similar to normal vertebra, creating wedge-shaped deformity that progresses during further spinal growth. This study aims to compare the interventions for hemivertebrae resections in congenital scoliosis by posterior transpedicular eggshell osteotomy approach only and with combined anterior and posterior approach. Ten patients who underwent hemivertebra resection between 1995 and 2002 were evaluated by retrospective charts and radiographic views. Mean follow-up time was 32 months (range 12–48). Except one patient, all were female and mean age at surgery was 7 years (range 3–13). Transpedicular eggshell osteotomy was performed in five patients (group I) and by combined anterior and posterior approach in five patients (group II). All patients had a single non-incarcerated hemivertebra and the locations of the hemivertebra were Th7, Th8, Th11, Th12, L2 in group I and Th7, Th10, L1, L4, L5 in group II. The average operation time was 3 h in group I and 6 h in group II (P 0.05). The loss of correction was 8% in group I and 9% in group II (P > 0.05). No intra-operative complications were noted and no implant failure was verified at the final radiographic evaluations. Transpedicular eggshell osteotomy is a technique that should be considered for older patients who have congenital scoliosis with multiplanar spinal abnormalities. It is a technically demanding procedure that provides an effective correction in selected patients.

Maxillary calcifying epithelial odontogenic (Pindborg) tumor presenting with abnormal eye signs: case report and literature review

Calcifying epithelial odontogenic tumors (CEOT) are uncommon, accounting for less than 1% of all odontogenic tumors. The CEOT, since its description by Pindborg in 1958 as a separate pathologic entity, is commonly known as the Pindborg tumor. We present an unusual case of such a tumor in the maxilla presenting with abnormal eye signs. The case demonstrates the use of a Le Fort I down-fracture osteotomy approach to maxillary tumors.

A double buccal fat pad flap for middle palate defect closure—a new technique for palate closure

In this article a new method of closing palatal defects by means of buccal fat pad flaps is reported. A double buccal fat pad flap in association with Le Fort I osteotomy approach was adopted to remove tumours of the palate and nasal fossae. The technique is described in a case of adenocarcinoma arising from the nasal septum and its indications and advantages are discussed.

Early Osteotomy With Delayed Implant Placement: A Step Further for Immediate Loading

The commonly used implantation technique involves a 2-stage surgical protocol for load-free and submerged healing to ensure predictable osseointegration. This article presents a new approach that benefits from previous bone and soft tissue protocols. It combines new surgical and insertion techniques to perform immediate loading with delayed implant placement, avoiding the problems of discomfort, inconvenience, and anxiety associated with healing periods. It maintains a similar success rate to the present common technique. After osteotomy, bone healing passes through 3 stages (i.e., inflammation, fibrous tissue, and maturation). In the new approach, implant insertion is performed 2 weeks after drilling (i.e., during the fibrous phase). The insertion timing is so selected because collagen formation and revascularization represent an acceptable implant bed configuration. Flap surgery offers the optimal osteotomy approach, but esthetic outcomes are definitely compromised. Accordingly, adopting the punch technique alleviates several postoperative problems, such as pain, tenderness, and swelling. Moreover, the punch technique avoids the sutures needed to adjust the gingiva around the abutment. It provides both cosmetic and functional properties.

Buccal corticotomy for removal of deeply impacted mandibular molars

Sagittal split ramus osteotomy has been used to remove deeply impacted mandibular third molars. 1 Jones T.A. Garg T. Monaghan A. Removal of a deeply impacted mandibular third molar through a sagittal split ramus osteotomy approach. Br J Oral Maxillofac Surg. 2004; 42: 365-368 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar , 2 Amin M. Haria S. Bounds G. Surgical access to an impacted lower third molar by sagittal splitting of the mandible: a case report. Dent Update. 1995; 22: 206-208 PubMed Google Scholar , 3 Toffanin A. Zupi A. Cicognini A. Sagittal split osteotomy in removal of impacted third molar. J Oral Maxillofac Surg. 2003; 61: 638-640 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar The main disadvantages of conventional operations for such teeth are the extent of bone removed, limited visibility, 1 Jones T.A. Garg T. Monaghan A. Removal of a deeply impacted mandibular third molar through a sagittal split ramus osteotomy approach. Br J Oral Maxillofac Surg. 2004; 42: 365-368 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar high risk of injury to the inferior alveolar nerve, and fracture of the mandible. 2 Amin M. Haria S. Bounds G. Surgical access to an impacted lower third molar by sagittal splitting of the mandible: a case report. Dent Update. 1995; 22: 206-208 PubMed Google Scholar In comparison, sagittal split ramus osteotomy gives good access, conserves bone that would otherwise have been removed, and allows the nerve to be seen and avoided. 1 Jones T.A. Garg T. Monaghan A. Removal of a deeply impacted mandibular third molar through a sagittal split ramus osteotomy approach. Br J Oral Maxillofac Surg. 2004; 42: 365-368 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar , 2 Amin M. Haria S. Bounds G. Surgical access to an impacted lower third molar by sagittal splitting of the mandible: a case report. Dent Update. 1995; 22: 206-208 PubMed Google Scholar , 3 Toffanin A. Zupi A. Cicognini A. Sagittal split osteotomy in removal of impacted third molar. J Oral Maxillofac Surg. 2003; 61: 638-640 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar However, the osteotomy puts the occlusion at risk (although this is rare) and there is a risk of an unfavourable split in either the proximal or distal segment (2%). 4 Mehra P. Castro V. Freitas R.Z. Wolford L.M. Complications of the mandibular sagittal split ramus osteotomy associated with the presence or absence of third molars. J Oral Maxillofac Surg. 2001; 59: 854-858 Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar This is about twice as high if the third molar is impacted. 4 Mehra P. Castro V. Freitas R.Z. Wolford L.M. Complications of the mandibular sagittal split ramus osteotomy associated with the presence or absence of third molars. J Oral Maxillofac Surg. 2001; 59: 854-858 Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar The published incidence of disturbance of the inferior alveolar nerve is high: as much as 58% at 6 months, and 35% at 1 year postoperatively.