Biomedical subjects
Publications and source records attributed to J F Tulasne.
Failure of osseointegration and mechanical accidents are the most common complications of dental implants. The functional prognosis is preserved in any case. Most of these complications can be avoided by a careful patient selection, a strict surgical phase and restorative procedures realized by competent practitioners.
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The reconstruction of an edentulous maxilla with bone graft is not a challenge. It is considered when the remaining bone cannot provide a firm anchorage for implants. The grafts are harvested from the ilium, the chin or the cranial vault. According to the case, the implants are placed either simultaneously or 6 months later after control with C.T. Scan. They are uncovered after another 6 month period, as in the usual procedure, and osseointegration is checked. The percentage of success on 24 operated cases seems at least equal to the regular cases without bone graft. Longer follow-up is needed for reliable statistics.
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In the authors' experience, correction of hypertelorbitism either by facial bipartition or by moving only the orbits has proved to be very stable. This is based on the design of the osteotomies and the use of the frontal bar. On the contrary, the rotation of the midfacial segment combined with mandibular lengthening for the correction of Treacher Collins has a strong tendency to relapse because of the backward pull of the soft tissues. Primary stability in these cases depends on the quality of bone grafts, their placement, and skeletal fixation.
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The overlapping bone flap genioplasty is the transposition of the inferior part of the mandibular symphysis in front of the anterior mandibular cortex. The fragment remains attached to the medial fibres of the suprahyoid muscles. A study of long-term results (minimum 6 months) in 29 adults and 17 adolescents has shown a mean bone resorption of 24% in the first group, and 40% in the second group, with some unpredictable variations. The maximum resorption occurs between the 3rd and the 6th postoperative months and there is minimal change afterwards. The soft-tissue-osseous advancement is close to 75% in the adult and is comparable to the result of the standard sliding genioplasty.
Hemifacial microsomia and Treacher Collins syndrome are the most frequent among the first and second branchial arch syndromes to include anomalies of the facial skeleton. Hemifacial microsomia is almost always unilateral and is characterised by hypoplasia or agenesis of the mandibular ramus. Treacher Collins syndrome is always bilateral and involves specifically the zygomatic bones. The treatment of skeletal anomalies is seldom started before 10-12 years of age, except in severe form with major aesthetic impairment. Such cases are treated at the beginning of school age, on and after 6-8 years. Several operations, including osteotomies of the jaws and bone grafts, are usually necessary to achieve an acceptable result.
Six patients with Crouzon's syndrome who were operated on by Dr. Paul Tessier between 1966 and 1976 were reviewed for long-term follow-up. Cephalometric study with superimposition was not possible because the radiographs were taken in different places according to different standards. However, it is interesting to observe the 10- to 17-year soft tissue follow-up of these patients.
A rapid survey of eight cases with orbital hypertelorism did not reveal any evident change in maxillary displacement during facial growth following resection of nasal septum and medial displacement of orbital cavities. Accurate analysis of four cases according to the Ricketts long-term growth forecast showed a reduction of growth in the region of anterior nasal spine and only in the posteroanterior direction. This is not necessarily due to the absence of nasal septum. These patients have such severe deformities and the surgical procedure is so extensive that many factors can be responsible for deficient premaxillary growth. Further studies are needed, particularly in patients who, since 1975, have had the same operative method, but without septal resection, to know whether this more conservative procedure has changed the posteroanterior growth of the premaxilla. However, a nasal bone graft has a good prognosis, even when performed in children.
A new procedure is proposed for correction of the malformations of severe cases of Treacher Collins syndrome in the areas of the maxilla, mandible, and orbit. The operation essentially consists of a rotation of the midfacial segment around a transverse axis at the frontonasal angle. The midface is rotated forward anteriorly and downward posteriorly. It is stabilized by cranial grafts impinged into the temporal bone and the maxilla. The mandible is lengthened either by V shape osteotomy or bone grafting of the ramus. The mandible is fixed in an overjet class III dental occlusion. A posterior bite wafer is maintained for 2 months. The construction of the orbital cavity is completed with cranial bone grafts. The Tessier integral procedure for Treacher Collins syndrome has been done in one stage in six patients and in two stages in five patients. Sufficient data were available for analysis of only four patients.
A considerable number of procedures have been described for secondary improvements of the lip. They involve the scars, the Cupid's bow, the philtrum, the alar base, the vestibulum and the columella. In fact, these procedures may give a good aesthetic result in a static position, but the truly successful results occur with normal movements. A normal motion of the lip is impossible without a proper dissection and reorientation of the muscles. Satisfactory lip motion cannot be realized with a defective alveolus or piriform aperture that retracts the alar base. Consequently, a good lip or nasal base cannot be achieved without bony restoration of the alveolus and piriform aperture. A transversely short lip never has normal mobility, and it must be widened by an Abbé flap. A tight, retruded lip on a retruded maxilla cannot be improved by a prosthetic vestibular plate because a greater tension will restrict movements. The lip must be advanced with the maxilla, then widened if necessary by an Abbé flap. A thick prolapsed lip never has normal movement; it must be raised by an infranasal excision. A cleft lip has nothing to gain from being displayed under a short nose, or, still worse, under a upturned nose. The nose must be kept long enough to cast a shadow on the lip. For the same reason, a bone graft is often necessary in bilateral clefts because the nose is short and retruded.
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Condylectomy is an indication of choice for unilateral hypercondylia, whatever the age of the patient, and should be conducted as early as possible and associated with intermaxillary elastic traction. Complementary one- or two-stage operations for mandibular correction are necessary in severe advanced cases. Complementary maxillary osteotomies are very rarely required.
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