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Maxillary protraction: different effects on facial morphology in unilateral and bilateral cleft lip and palate patients
Journal Abstracts
R. S. Tindlund & P. Rygh. Maxillary protraction: diHerent effects on facial morphology in unilateral and hilateral cleft lip and palate patients. Cleft Palate Craniofac J 1993; 30(2): 208-22 I.
The radial forearm flap donor site: should we vein graft the artery? A comparative study. Melund A’B, Core GB, Iiowrruan VR. Plast
Orthopedic response to improve maxillary rctrusion seems more lavourahlc in younger patients where it is closely linked to sutural growth. However in older patients (over I2 years) the response principally occurs at a dentoalvcolar level. Since 1977 patients with antcrior,postcrior crossbites in the care of the Bergen CLP team have undergone an interceptive orthopedic protraction phase during the deciduous and mixed dentition period. Eighty-seven cases with complete clefts (63 unilateral and 24 hilatcral) displaying anterior crossbite were treated to normal occlusion. A tixed quadhelix appliance was used in combination with a Delaire facial mask. In the UCLP group, mean age at start of treatment was 6 years IO months. In the BCLP group, mean age at start of treatment was 7 years with mean duration of treatment of IS months. The effect of dentofacial treatment differed in the UCLP and BCLP groups. In the UCLP group. 45% of forward maxillary movement occurred at a skeletal level whereas in the BCLP group, 90% of forward maxillary movement occurred at a dentoalvcolar level. However, after protraction there was no longer a significant diffcrence in maxillary prognathism between the two CLP groups and the sagittal position of the upper molars was normal in both groups. ‘The upper incisors remained rctroclined in both groups, significantly moreso in the BCLP group. Increase in the upper facial height and clockwise rotation of the occlusal line were significantly greater in the BCLP group. W. P. Smith
This excellent paper from the Mayo Clinic reviews a total of I3 patients who underwent radial forearm flap harvesting from the non-dominant arm over a 2%month period. The majority (9) of the Raps were for head and neck reconstruction. No patient had cein grafting of the radial artery defect. Postoperatively the patients were examined and questioned about the function of the hand in order to evaluate the vascular status. Median follow up was 6 months (range l-24 months). Evaluation of the postoperative vascular status consisted of any history of claudication. cold intolerance. blanching or discoloration, physical examination including an assessment of grip strength and non-invasive investigation of cutaneous blood flow measured by a laser Doppler flowmetcr, transcutaneous oxygen levels, digital/brachial hlood pressure ratios, cutaneous temperature at rest and following immersion in ice cold water for 2 min. The non-donar hand acted as a control in all cases. No statistical difference was found in any of the parameters of vascular analysis when compared with controls except for a minimal delay in early rewarming at I min after cold immersion in ice water. On the basis of this study. the authors conclude that in contrast to current suggestions in the literature. reconstruction of the radial artcry after radial forearm flap harvesting is not necessary as long as cross-flow is present within the vascular arches of the hand. The authors discuss a rare complication of vascular insuficiency to the hand following flap elevation, despite a normal Allen test and therefore to circumvent this rare problem they always begin flap elevation by isolating the radial artery at the proximal wrist crease and place a microvascular clamp on it. The tourniquet is then released and the hand is observed and monitored by ~0,. In their series of 60 radial forearm flaps. vein grafting has nevcl been pcrformcd and no vascular sequelae have resulted.
Rcconstr
Senior Registrar Chichester
Surg 1993; 91: 865. 869.
A. G. Smyth Senior Registrar Stoke-on-Trent
R. S. Tindlund, P. Rygh & 0. E. Roe. Orthopedic protraction of the upper jaw in cleft lip and palate patients during the deciduous and mixed dentition periods in comparison with normal growth and development. Cleft Palate Craniofac J lYY3; 30(2): 182-194.
Fractures of the frontal sinus: a rationale of treatment. loannides CA. Freiho/k HP & Friens .I. Br J Plast Surg 1993; 46: 208-214.
Cleft lip and palate (CLP) patients often develop maxillary retrusion after cleft repair characterized by reverse ovcrjef and posterior cross bite. Since 1977. a group of 98 cases has been treated during the deciduous dentition by the Bergen CLP team. Early orthopedic treatment creates a more falpourable environment for midfacial growth. in particular allowing the permanent incisors to erupt spontaneously into a positive ovcrjet and overbite. The average age at start of treatment was 6 years I I months and a mean duration of treatment was I3 months. The protraction force was 700 g dclivercd through a Delaire face mask and a modified quadheix handed to the maxillary primary canine and second molar teeth. The serial lateral cephalographs. employing skclctal as well as dcntoalveolar landmarks, compared the treated CLP group with a noncleft group with normal growth. In the untreated CLP group, the maxilla was of normal length but retropositioned with it’s vertical height reduced. Orthopedic protraction resulted in several significant changes including forward maxillary movement in relation to the cranial base, clockwise rotation of the mandible with an overall effect of increasing the mean value of ANB. In addition. the upper incisor teeth had been protruded although the lower incisors remain almost unaffected. The variation was considerable. This paper reports the OVCrdll changes in the whole CLP group. W. P. Smith
A protocol of management of frontal sinus fractures is proposed based on experience with 71 patients operated on at the University llospital KIJ Sijmcgan during a IO-year period. The anterior wall of the sinus or the anterior wall and the orbital roof were fractured in 45 of the patients. whereas fractures of both the anterior and the posterior wall wcrc seen in the other 26 patients. All patients were primarily treated and early management (6- I2 h post injury), when necessary with intracranial pressure monitoring, wds the treatment of choice. In casts of sevcrc comminution of the posterior wall with extensive loss of hone. cranialisation was performed by removal of all remaining elements of the posterior wall. through removal of all mucosal lining from the sinus and obliteration of the nasofrontal duct with peyicranium. When there is no loss of bone or gross comminution. the authors recommend obliteration of all posterior wall fractures including those which are undisplaced and not associated with any CSF Icakage. This is based upon the dcvclopmcnt of meningitis in 2 of their IO patients with a posterior wall fracture without displacement in whom the sinus was not obliterated. Hence the recommended form of treatment of all posterior wall fractures is thorough removal of all mucosal lining and obliteration of the cavity down to the nasofrontal duct with cancellous hone harvested from the iliac crest. Anterior wall fractures were managed by excision of torn mucosa, dehidement of the cavity. reduction of the fragments and fixation with wires or mini-
Senior Registrar Chichester
327
R. S. Tindlund & P. Rygh. Maxillary protraction: diHerent effects on facial morphology in unilateral and hilateral cleft lip and palate patients. Cleft Palate Craniofac J 1993; 30(2): 208-22 I.
The radial forearm flap donor site: should we vein graft the artery? A comparative study. Melund A’B, Core GB, Iiowrruan VR. Plast
Orthopedic response to improve maxillary rctrusion seems more lavourahlc in younger patients where it is closely linked to sutural growth. However in older patients (over I2 years) the response principally occurs at a dentoalvcolar level. Since 1977 patients with antcrior,postcrior crossbites in the care of the Bergen CLP team have undergone an interceptive orthopedic protraction phase during the deciduous and mixed dentition period. Eighty-seven cases with complete clefts (63 unilateral and 24 hilatcral) displaying anterior crossbite were treated to normal occlusion. A tixed quadhelix appliance was used in combination with a Delaire facial mask. In the UCLP group, mean age at start of treatment was 6 years IO months. In the BCLP group, mean age at start of treatment was 7 years with mean duration of treatment of IS months. The effect of dentofacial treatment differed in the UCLP and BCLP groups. In the UCLP group. 45% of forward maxillary movement occurred at a skeletal level whereas in the BCLP group, 90% of forward maxillary movement occurred at a dentoalvcolar level. However, after protraction there was no longer a significant diffcrence in maxillary prognathism between the two CLP groups and the sagittal position of the upper molars was normal in both groups. ‘The upper incisors remained rctroclined in both groups, significantly moreso in the BCLP group. Increase in the upper facial height and clockwise rotation of the occlusal line were significantly greater in the BCLP group. W. P. Smith
This excellent paper from the Mayo Clinic reviews a total of I3 patients who underwent radial forearm flap harvesting from the non-dominant arm over a 2%month period. The majority (9) of the Raps were for head and neck reconstruction. No patient had cein grafting of the radial artery defect. Postoperatively the patients were examined and questioned about the function of the hand in order to evaluate the vascular status. Median follow up was 6 months (range l-24 months). Evaluation of the postoperative vascular status consisted of any history of claudication. cold intolerance. blanching or discoloration, physical examination including an assessment of grip strength and non-invasive investigation of cutaneous blood flow measured by a laser Doppler flowmetcr, transcutaneous oxygen levels, digital/brachial hlood pressure ratios, cutaneous temperature at rest and following immersion in ice cold water for 2 min. The non-donar hand acted as a control in all cases. No statistical difference was found in any of the parameters of vascular analysis when compared with controls except for a minimal delay in early rewarming at I min after cold immersion in ice water. On the basis of this study. the authors conclude that in contrast to current suggestions in the literature. reconstruction of the radial artcry after radial forearm flap harvesting is not necessary as long as cross-flow is present within the vascular arches of the hand. The authors discuss a rare complication of vascular insuficiency to the hand following flap elevation, despite a normal Allen test and therefore to circumvent this rare problem they always begin flap elevation by isolating the radial artery at the proximal wrist crease and place a microvascular clamp on it. The tourniquet is then released and the hand is observed and monitored by ~0,. In their series of 60 radial forearm flaps. vein grafting has nevcl been pcrformcd and no vascular sequelae have resulted.
Rcconstr
Senior Registrar Chichester
Surg 1993; 91: 865. 869.
A. G. Smyth Senior Registrar Stoke-on-Trent
R. S. Tindlund, P. Rygh & 0. E. Roe. Orthopedic protraction of the upper jaw in cleft lip and palate patients during the deciduous and mixed dentition periods in comparison with normal growth and development. Cleft Palate Craniofac J lYY3; 30(2): 182-194.
Fractures of the frontal sinus: a rationale of treatment. loannides CA. Freiho/k HP & Friens .I. Br J Plast Surg 1993; 46: 208-214.
Cleft lip and palate (CLP) patients often develop maxillary retrusion after cleft repair characterized by reverse ovcrjef and posterior cross bite. Since 1977. a group of 98 cases has been treated during the deciduous dentition by the Bergen CLP team. Early orthopedic treatment creates a more falpourable environment for midfacial growth. in particular allowing the permanent incisors to erupt spontaneously into a positive ovcrjet and overbite. The average age at start of treatment was 6 years I I months and a mean duration of treatment was I3 months. The protraction force was 700 g dclivercd through a Delaire face mask and a modified quadheix handed to the maxillary primary canine and second molar teeth. The serial lateral cephalographs. employing skclctal as well as dcntoalveolar landmarks, compared the treated CLP group with a noncleft group with normal growth. In the untreated CLP group, the maxilla was of normal length but retropositioned with it’s vertical height reduced. Orthopedic protraction resulted in several significant changes including forward maxillary movement in relation to the cranial base, clockwise rotation of the mandible with an overall effect of increasing the mean value of ANB. In addition. the upper incisor teeth had been protruded although the lower incisors remain almost unaffected. The variation was considerable. This paper reports the OVCrdll changes in the whole CLP group. W. P. Smith
A protocol of management of frontal sinus fractures is proposed based on experience with 71 patients operated on at the University llospital KIJ Sijmcgan during a IO-year period. The anterior wall of the sinus or the anterior wall and the orbital roof were fractured in 45 of the patients. whereas fractures of both the anterior and the posterior wall wcrc seen in the other 26 patients. All patients were primarily treated and early management (6- I2 h post injury), when necessary with intracranial pressure monitoring, wds the treatment of choice. In casts of sevcrc comminution of the posterior wall with extensive loss of hone. cranialisation was performed by removal of all remaining elements of the posterior wall. through removal of all mucosal lining from the sinus and obliteration of the nasofrontal duct with peyicranium. When there is no loss of bone or gross comminution. the authors recommend obliteration of all posterior wall fractures including those which are undisplaced and not associated with any CSF Icakage. This is based upon the dcvclopmcnt of meningitis in 2 of their IO patients with a posterior wall fracture without displacement in whom the sinus was not obliterated. Hence the recommended form of treatment of all posterior wall fractures is thorough removal of all mucosal lining and obliteration of the cavity down to the nasofrontal duct with cancellous hone harvested from the iliac crest. Anterior wall fractures were managed by excision of torn mucosa, dehidement of the cavity. reduction of the fragments and fixation with wires or mini-
Senior Registrar Chichester
327