brazilian journal u of craniomaxillofacial surgery …€¦ · brazilian journal u of...

BRAZILIAN JOURNAL U OF

CRANIOMAXILLOFACIAL SURGERY

Official publication of the Brazilian Sociefy of Craniomaxillofacial Surgery

4 I

Volume 3 - Number 2 - December 2000

--.,. ---

Sociedade Brasileira de Cirurgia

Craniomaxilofacial Bra~ilian'societ~ of Craniomaxillofacial Surgery

President Vice President

Jose Carlos Ferreira (SP) SBrgio Moreira da Costa (MG)

=~ ... ,, -. , Secretary , : Treasurer

Marcus Vinicius Martins Collares (RSt ' .. ~ ~

.. . <~- .. >.;

Eliza Minami (SP) . ' ..L- -. z...: - .~ -.*

-

Sociedade Brasileirs de Cirurgia Cmniornaxilofadal

BRAZILIAN JOURNAL OF CRANIOMAXILLOFACIAL SURGERY

Official publication of the Brazilian Society of Craniomaxillofacial Surgery

EDITOR ASSOCIATE EDITOR

Marcus Vinicius Martins Collares. MD, PhD Silvio Ant8nio Zanini, MD

Hospital de Clinicas de Porto Alegre Hospital de Reabilita~ito de Anomalias Craniofaciais

Universidade Federal do Rio Grande do Sui Universidade de SHo Paulo

Brazil Brazil

SCIENTIFIC COUNCIL

Nivaldo Alonso, MD, PhD (Brazil)

Elisa Altmann, MD (Brazil)

Cassio Raposo do Amaral, MD (Brazil)

Carlos Alberto Ballin, MD (Brazil)

Vera Nocchi Cardim, MD (Brazil)

Roberto Corr6a Chem, MD, PhD (Brazil)

Edgard Alves Costa, MD (Brazil)

Sbrgio Moreira da Costa, MD fBrazilt

Ricardo Lopes da Cruz, MD (Brazill

Pedro Dogliotti, MD (Argentina)

Jose Carlos Ferreira, MD, PhD (Brazil)

Luis Francisco Fontoura, MD (Brazil)

Omar Gabriel, DDS (Brazil)

Eduardo Grossmann, DDS, PhD (Brazil)

Paulo Hvenegaard, MD (Brazil)

Ian Thomas Jackson, MD (United States of America)

Luls Paulo Kovalski, MD (Brazil) _.. ,;' 2.

Jose Alberto Landeiro, MD (Brazil)

Luis Tresserra Llauradd, MD, PhD (Spain)

Michael T. Longaker, MD (United States of America) %. (2

Gilvani Azor de Oliveira e Cruz, MD (Brazil) f. .I

Antonio Richieri-Costa, MD, PhD (Brazil)

Didgenes Laercio Rocha, MD (Brazil)

Fl6vio M. Sturla, MD (Argentina)

Fausto Viterbo, MD, PhD (Brazil)

USE OF OSTEOGENIC MANDIBULAR DISTRACTION IN NEONATES WITH SEVERE AIRWAY OBSTRUCTION ........ Marcus Vinicius Martins Collares, Rinaldo De Angeli Pinto, Gustavo L. Berlim, Ciro P. Portinho

MANAGEMENT OF HEAD AND NECK HEMANGIOMAS ......... Dov C. Goldenberg, Nivaldo Alonso, Marcus C. Ferreira

ESTHETIC AND FUNCTIONAL REHABILITATION OF MAXILLA AND ALVEOLAR RIDGES WITH SINUS LIFT BONE GRAFTING .......... Wilson Cintra Junior, Nivaldo Alonso

SURGICAL OPTIONS FOR THE CLOSURE OF LARGE MYELOMENINGOCELES .......................... Dov C. Goldenberg, Nivaldo Alonso, Marcus C. Ferreira

LONG-LASTING BILATERAL DISLOCATION OF THE TEMPOROMANDIBULAR JOINT ...................... Marcus Vinicius Martins Collares, Eduardo Grossmann

USE OF OSTEOGENIC MANDIBULAR DISTRACTION IN NEONATES WITH SEVERE AIRWAY OBSTRUCTION

Marcus Vinicius Martins Collares, MD, PhD1; Rinaldo De Angeli Pinto, MD2; Gustavo L. Berlim,

MD3; Ciro P. Portinho, MD4

The Pierre-Robin sequence (PRS) is characterized by micrognathia, glossoptosis, and palatal anomalies. The clinical spectrum of the disease is quite variable, and may include severe airway obstruction. Several techniques have been used to treat this associated dysfunction, such as positional therapy, labio-lingual suture, pelviplasty. and tracheostomy. Osteogenic distraction is a mandibularlengthening technique based on the llizarovpnnciple, discarding the use of bone grafts. It has been used in children older than 2 years presenting micrognathia, as occurs in PRS. This study describes a series of four cases of neonates presenting PRS and severe airway obstruction submitted to osteogenic mandibular distraction with external distraction devices provided with four pins (using extemal approach and osteotomy). The application of traction started on the 1st postoperative day at a rate of 0.5 mm twice a day. The consolidation period was either equal to the duration of distraction or set at 2 weeks (minimum). The following aspects were assessed: distraction distance, duration of distraction, complications, time to extubation (postoperatively), presence/absence of apnea after distraction, and mean oxygen saturation values before and after distraction. Improvement was obsen/ed in the main respiratory parameters analyzed (Sa02) andalso in the nutritionalpattem. There were no important complications associated with the method. Our study showed that osteogenic distraction is an effective treatment for respiratory and nutritional abnormalities resulting from micrognathia. In addition. we suggest that it should be considered for the definitive treatment of less severe manifestations of PRS.

KEY WORDS: Osteogenesis, distraction; Pierre Robin sequence; airway obstruction.

Braz J Craniomaxillofac Surg 2000;3(2):7-12

T h e pierre-~obin sequence (PRS) (figure I ) is a condition characterized by the presence of multiple defects, such as micrognathia, glossoptosis, pseudomacroglossia, cleft palate posterior to the incisive foramen or ogival palate andlor bifid uvula. The incidence of PRS is of approximately 1:30,000 live births. Prognosis is good, provided thechild isable to resist airway obstruction during the neonatal period (1 ). Damage caused by mild but continuous respiratory

distress in this crucial phase of development is still to be measured. Several techniques have been employed to treat airway obstruction in PRS cases, such as positional therapy, labio-lingual suture, pelvipiasty, and tracheostomy (1).

In 1905, Codivilla described the concept of bone lengthening (he used a femur). Later on, in 1927, Abbotldescribed the lengthening of a tibia and reported a high incidence of complications. Therefore, the technique was not acknowledged by the scientific community, and remained unexplored until 1950, when Gavriel llizarov decided to use the technique to realign ' Professor of Surgery, Graduate Program in Medicne: Surgery. Universi-

dade F ~ ~ ~ ~ ~ I do R ~ O Grande do SUI. B ~ ~ z ~ I . ~ ~ ~ d , c ~ ~ ~ , ~ ~ ~ ~ ~ I I ~ ~ ~ ~ ~ ~ I and lengthen fractured limbs. The incidence of Surgery Unit. Service of Plastic Surgery, Hospital de Ciinlcas de Porto cOmplicationS was low, only one corticotomywas Alegie. Brazil. CorreSpOndence to: Se rv i~o de Cirurgia Pidsrica. Haspi- ral de Clinicas de Pono Aleore. Rua Rarnira Barcelas. 2350. 6' andar. carried out, with minimal ru~ture in osteoclenic tissues. - sale 600. 90035-003. Porta Alegre, RS. Brasil. E-mail: mvcaiiares@via- ,$.net.

Osteogenic mandibulardistraction isa mandibular Head, Service of Plastic Surgery. Hospital de Clinicas de Porto Aegre, lengthening technique that applies iliZar0v'S principle Biazii, Resident. Service of Plastic Surgery, Hospital de Clinicas de Porto A e - lengthening, discarding the bonegrafls. ore. Brazil It consists of an "endogenous tissue engineering" Resident. Service of Generai Surgery, Hospital de Clinicas de Porta Alegre. Brazil. method (2) that uses natural mechanisms

Braz J Craniornaxillofac Surg 2000;3/21 7

Collares et al.

..

Figure 1. PI _.,.. . - ,-. .--, ,-.. ent with PRS.

of cicatrization to generate bone. Therefore, osteogenic mandibular distraction may be used in the treatment of children with mandibular hypoplasia resulting from PRS, either alone or in association with several other craniofacial syndromes, such as Hanhart's syndrome (aglossia-adactylia) or craniofacial microsomy (2,3).

In PRS patients, the occurrence of airway obstruction in the neonatal period may be due to mandibular hypoplasia or micrognathia (4), which results in posterior displacement of the tongue base and an inadequate hypopharyngeal space. Tracheostomy is the definitive treatment for airway obstruction in childhood, but it is associated with high morbidiiand problems related to clinical management and social interaction.

Cohen et al. (5) studied patients submitted to osteogenic mandibular distraction and son-tissue procedures forthe treatment of airway obstruction. After distraction, a decrease in respiratory alterations was observed, as well asan improvement in the meanvalue of oxygen saturation (from 70% to 89%).

The ideal age for the performance of distraction is still under discussion (6). However, children with respiratory and nutritional alterations are considered potential candidatesfordisbaction as early as possible.

The basic steps of osteogenic distraction are: osteotomy; placement of the distractor; application of traction; consolidation period; distractor removal.

The parameters that have to be observed to guarantee a successful distraction are: preservation of osteogenic tissues during osteotomy; latency period; distraction index; distraction rhythm; fixator stability; and consolidation period.

Latency period is one of the most important factors for the success of the procedure. Distractions of over 1 .5 mm a day may result in fibrous joint, local ischemia, and either retarded ossification or pseudoarthrosis. Distractions of less than 0.5 mm a day, on their turn, result in premature ossification. Experimental histologic and histomorphometric analyses showed thatthe distraction rate of 1 mmlday was associated with the best osteoblastic activity and with a more consistent bone (7). When the distraction is performed at a higher frequency it seems to accelerate bone formation.

In a computer-based analysis (8), a bidimensional model was used for the simulation of osteogenic mandibular distraction. Distractors placed in parallel with the mandible caused lateral dislocation of the posterior components, as well as a reduced distraction gap during mandibular growth. These effects did not occur when the distractor was placed in parallel with the distraction axis. Additional ramus osteotomies may be necessaly in these cases, with the use of devices aimed at angular correction in order to compensate for rotational movements of the mandibular condyles (secondary to the midline osteodistraction). So, although several factors influence the success of osteodistraction, devices should be placed in parallel with the distraction axis (9), so as to minimize adverse biomechanical effects during mandibular lengthening.

This study aims at describing a series of cases of neonates with PRS and severe airway obstruction submitted to osteogenic mandibular distraction.

METHODS

This prospective study was carried out in 1999 and 2000, and included patients treated at Hospital de Clinicas de Porto Alegre and Hospital Moinhos de Vento, Porto Alegre, Brazil, presenting severe airway obstruction (oxygen saturation ~ 8 5 % ) as a result of micrognathia (PRS). A total of four patients were selected. They had already been treated with positional management, oxygen mask, and catheter, with no success.

Exclusion criteria were: patients born with micrognathia, but without severe airway obstruction; patients with severe airway obst~ction, but who had

8 Braz J Craniomaxillofac Surg 2000;3/21

Mandibular distraction in neonates with

no clinical conditions (not related to the respiratory anomaly) to undergo surgery.

Sample characteristics: of the four patients, three were females, with ages between 5 and 17 days in three cases and of 35 days in the fourth case (the latter presented Moebius' syndrome); gestational age ranged between 36 and 40 weeks, and weight at birth was between 2500 and 3500 g; the Moebius case required cardiopulmonary resuscitation in the delivery room; all children presented intercostal andlor supraclavicular retraction, in addition to nutritional difficulties (weight loss, nasoenteral feeding tube).

Computed tomography with tridimensional reconstruction and fibrobronchoswpy were performed in all cases prior to surgery, in order to determine the extension of deformities and thelaryngotracheal status.

All children were submitted to osteogenic distraction (external approach and osteotomy) using external distraction devices with four pins (figure 2). ~j~~~~ 2. patjenr afterp/acemen~ofdistractor. The application of traction started on the 1st postoperative day and was set at a rate of 0.5 mm, with two daily applications (total of 1.0 mm a day). The wnsolidation period was either equal to the distraction RESULTS duration or set at 2 weeks (minimum). All patients underwent 2-mm overcorrections. Distractor removal The results or outcomes observed in the four was performed under sedation. patients included in the study are presented in table 1.

Patients were assessed in relation to: distraction The distance of distraction ranged from 10 to distance, duration of distraction, local complications, 14 mm. Two complicationswere observed: one patient systemic complications, time to extubation (in the presented operative wound infection after distraction, postoperativeperiod), presencelabsenceofapneaafler and the Moebius patient had to be resubmitted to distraction, and mean oxygen saturation values before tracheostomy 5 days afler the end of treatment due to and after distraction. tracheomalacia (this patient died at 4 months of life

Relatives (usually parents) of the patients were due to multiple organ failure). informed about the details of the procedure, as well All patients finished treatment. In one case, the as of the risks involved. In all cases, parents signed distractor was accidentally removed by the nurse an informed consent form. technician and had to be repositioned on the 5th

Table 1. Outcomes observed in patients submitted to osteogenic distraction

Patient DT TE Respiratory Nutritional Mean oxygen Comorbidities

(d) (dl improvement improvement saturation (before 1 afler)

1 12 7 Yes Yes 82 1 96 Foot deformity, IAC, IVC, BCP 2 14 9 Yes Yes 81 I94 IAC, sepsis 0 ' 4 8 Yes Yes 77 1 95 Atelectasis

6 18 Yes Yes Tr 186 Moebius' syndrome, IAC, Tr, hand and foot malformation, two ~revious CRA

DT: distraction time; TE: time to extubation; IAC: inter-atrial communication; IVC: interventricular communication; BCP: bronchopneumonia; Tr: tracheostomy; CRA: cardiorespiratory arrest.

Braz J Craniomaxillofac Surg 2000;3/21 9

Collares et al.

postoperative day, with no interference with the final result.

Patients remained with a catheter or an oxygen mask for 3 days after extubation. Nasoenteral feeding was used for up to 3 or 4 days prior to distractor removal.

Significant mandibular growth was observed in all cases (figures 3 and 4). There was improvement in oxygen saturation values in all cases, except for patient number 4, due to the tracheostomy-related complication. External scars were very little noticeable.

DISCUSSION

The use of osteagenic distraction in craniofacial surgery has had a significant influence on the treatment of congenital mandibular deficiencies (10). Due to the experience accumulated in the field of mandibular distraction, differences between endochondral and membranous bonedistraction becamevisible (11), and osteogenic mandibular distraction has shown to be an effective method in the treatment of uni- or bilateral hypoplasia.

. -. . . - =. --. , , . . . .. . . . . -. . . . -. . -. - . . -. . - - - . . - . . - - . . - . ., - . . - . . . . .a . . , . . . . - . - -. . - . . .. - and BJ its correction after osteogenic distraction,

Figure 4. Al Six- and Bl 18-month postoperative result in patient with PRS, showing significant mandibular growth.


Man dibular distraction in neonates with airway obstruction

Osteogenic distraction is currently accepted for the treatment of micrognathia in children above 2 years of age, at the rate of 1 mmlday. It is a safe technique that resolves obstructive sleep apnea in most cases, discarding the need for tracheostomy or other techniques associated with higher levels of morbidity

Latency time is an important aspect of distraction that should be further discussed and studied. Diner et al. (12) have described the results of distraction in 26 pediatric patients operated from 1993 to 1998. Distraction was performed at a rate of 1 mmlday divided into two applications (0.5 mm each) after a complete mandibular osteotomy. However, in children younger than 2 years, distraction could possibly be performed at a higher frequency, since at this age bone metabolism, aswell as the growth of the body in general, isfaster. The speed of the process could also possibly be increased, in view of these same aspects.

The complications associated with osteogenic distraction are usually of easy resolution, although several variables are still under study. In the patients included in our study, complications were not significant. Operative wound infection was observed in one case, requiring distractor removal 2 days prior to the date that had been previously determined; however, in spite of that, the final result was satisfactory. It is important to note that the occurrence

of tracheomalacia observed in one case was provoked by tracheostomy, and not by distraction; this reinforces the high potential for complications associated with tracheostomy.

Between 1989 and 1997, Hollier et al. (6) operated 14 patients older than 2 years of age and recorded the following complications: one case of relapse due to the presence of a dentigerous cyst (requiring removal of the cyst and repetition of distraction), and one case of ankylosis (submitted to surgical correction).

In the cases described in the present study, extubation occurred between the 5th and the 9th postoperative day. The criteria taken into consideration to determine tube removal were those usually adopted in neonatal intensive care units, according to the orientations of the neonatologist.

Although the results presented herein are derived from a case series, the improvement observed in respiratory and nutritional patterns is of extreme importance. The performance of osteogenic distraction allowed for patients to surpass the main obstacle to an adequate prognosis in cases of PRS, namely, severe airway obstruction in the neonatal period.

Finally, this study allowed us to establish an algorithm for the treatment of PRS, as indicated in figure 5.

Diagnosis of PRS (micrognathia, glossoptosis, clefl palate)

Resplratory dysfunction (other Muses excludedl

i Symptomatic? ~

Computed tomography of the mandible (record)

CIn8cal foliow-up , Diagnostic tests:

Computed tomography of the mandrble with lrldlmenslonal reconstruction r Respiratory Fibrobranchoacopy parameters

I Osteotomy and use of dissactor I osteooenic disctraction ofthe mandible

Computed tomography with tridimensional recon~tr~ct!on at distractor removal

Clinical follow-up (every 3 months during the 1st year of life and once a year afler that;

cornpuled tomography at 1 year and then every 3 years)

Figure 5. Profocol suggested for the treatment of PRS.

Braz J Cranlomaxillofac Surg 2000;3/21 11

Collares et al.

REFERENCES

Cohen JR. Cleft palate, micrognathia and glossoptosis. In: Bergsma D. Birth defects compendium. 2nd ed. New York: Alan R. Liss; 1979. p. 228. Kollar EM, Diner PA. Vazquez MP, Accart G, Pirollo M. Bone distraction using an external fixator: a new mandibular lengthening technique. A preliminary study apropos of 2 cases of children w i th mandibular hypoplasia. Rev Stomatol Chir Maxillofac 1994;9516):411-6. Collares MVM, et al. DistraqBo osteogenica da mandibula em paciente com slndrome de Hanhart. Arquivos Catarinenses de Medicina 2000;29 Supl 1:24. Williams JK, Maull D, Grayson BH. Longaker MT, McCarthy JG. Early decannulation with bilateral mandibular distract ion for t racheostomy- dependent patients. Plast Reconstr Surg 1999; 103(1):48-57. ~. Cohen SR, Burstein FD, Williams JK. The role of distraction osteogenesis in the management of craniofacial disorders. Ann Acad Med Singapore 1999:28(5):728-38. Hollier LH, Kim JH, Grayson B, McCarthy JG.

Mandibular growth after distraction in patients under 48 months of age. Plast Reconstr Surg 1999;103i5):1361-70.

Stewart KJ, Weyand B, van-T-Hof RJ, White AS, Lvoff GO, Maffulli N, et al. A quantitative analysis of the effect of insulin-like growth factor-1 infusion during mandibular distraction osteogenesis in rabbits. Br J Plast Surg 1999;52(3):343-50. Samchukov ML, Cope JB, Harper RP, Ross JD. Biomechanical considerations of mandibular lengthening and widening by gradual distraction using a computer model. J Oral Maxillofac Surg 1998;56(1):51-9. Cope JB, Sarnchukov ML, Cherkashin AM. Mandibular distraction osteogenesis: a historic perspective and future directions. Am J Orthod Dentofacial Orthop 1999;l 15(4):448-60. Williams JK, Rowe NM, Mackool RJ, Levine JP, Hollier LH, Longaker MT, et al. Controlled multiplanar distraction of the mandible. Part II: Laboratory studies of sagittal (anteroposteriorl and vertical (superoinferior) movements. J Craniofac Surg 1998;9(6):504-13. McCarthy JG, Williams JK, Grayson BH, Crombie JS. Controlled multiplanar distraction of the mandible: device development and clinical application. J Craniofac Surg 1998;914):322-9. Diner PA, Tomat C, Soupre V, Martinez H, Vazquez MP. lntraoral mandibular distraction: indications, technique and long-term results. Ann Acad Med Singapore 1999;28(5):634-41.

1 2 Braz J Craniomaxillofac Surg 2000;3/21

MANAGEMENT OF HEAD AND NECK HEMANGIOMAS Dov C. Goldenberg, MD'; Nivaldo Alonso, MD, PhD2; Marcus C. Ferreira, MD, PhD3

The therapeutic management of hemangiomas remains controversial. Surgeiy is currently indicated only for cases with visuai impairment and airway obstruction. The aim of this study was to define a treatment program forhemangiomas at Hospital de Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, according to the severity and evolution oflesions. From Februaiy 1998 to April 2000,50 cases of headand neck hemangiomas were submitted to either observation, drug therapy, surgea or combined therapy. Observation was the first treatment in 22 cases, and 13 of these did not require further treatment. Clinical treatment (corticosteroids) was indicated in 32 cases (including previous obsen~ation patients), and was effective in 19. Surgeiy was performed in 18 (including previous observation and drug therapy patients). A total of 13 patients received combined therapy. Since the goal of hemangioma treatment is to improve the quality of life of patients, the ind~cation of active treatment should be more often considered when no risks are present.

KEY WORDS: Hemangioma; head; neck; surgery.


Vascular anomalies constitute one ofthe most challenging diseases in plastic surgery. For a long period of time, problems related to diagnosis, nomenclature and treatment of vascular anomalies have been impairing the appropriate management of these lesions.

Mulliken and Glowacki (I), in 1982, published the most accepted classification of vascular anomalies. The biologic classification correlates cellular patterns with the clinical behavior and the natural history of the lesions.

Hemangioma is truly a neoplasm. It maintains a benign behavior and presents antenatal and postnatal endothelial proliferation. The natural history of hemangiomas includes proliferative, involuting, and involuted phases. Typically they are present at orsoon after birth, as red spots on the skin. Growth is variable

* AsSlStant Phys~clan, Drv8~80n of PlaStlC Surgery and Burn. Hospital de Clinicas da Faculdade de Medicina da Universidade de SSo Pauio. Brar~l. Member. Sociedade Brasileira de Cirurgia Piastlca. Brazii. Associate Member. Sociedade Brasileiia de Cirurgia Cianiomanilofacial. Brazil. Correspondence ro: Rua Pedro de Toledo 9801124, 04039-002, SBo Paulo. SP. Brazil. E~mail: [email protected].

2 Assistant Physician. Division of Plastic Surgery and Burn. Hospital de Clinicas da Faculdade de Mediclna da Universidade de Sao Paulo. Braril. Member, Sociedade Brasiielra de C,rurg>a Plbstica. Brazil President. Sociedade Brasilelra de Cirurgia Craniomax~lofacial. Brazil. Professor, Plastic Surgery. School of Med~clne. Universidade de Sdo Paulo. Brazil. Head. D~vision of Plastic Surgery and Burn. Hospital de Clinicas da Faculdade de Medcina da Universidade de Sao Paulo. Brazil.

during the proliferative phase and usually faster than the child's development. It sometimes may impair vital functions.

Hemangiomas usually increase in size (proliferative phase) until completion of the 1 st year of life. Involution is complete in the majority of cases at preschool age. The presence of involuted stigmata is variable and may also produce esthetic and functional problems.

About 30 to 40% of cases of hemangiomas are present at birth as birthmarks - of these, 80% consist in an isolated lesion and 20% in multiple. They are more common in females, and premature newborns are frequently affected. The cetvicofacial region is the most frequent site of lesions (approximately 60% of cases).

Due to the potential for involution shown by hemangiomas, treatment remains controversial. Cases indicated for prompt active treatment include lesions causing visual impairment, airway obstruction, or serious systemic complications. Although treatment may be expectant in the majority of cases, some nonalarming situations may require active treatment.

The purpose of the present study was to define a treatment program for head and neck hemangiomas at Hospital de Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Brazil, in orderto delineate the management of lesions with not an absolute indication for surgery.

Braz J Craniomaxillofac Surg 2000;3(21 13

Goldenberg et al.

MATERIALSAND METHODS

From February 1998 to April 2000, 50 consecutive cases of head and neck hemangiomas were included in a prospective treatment protocol. Patient data regarding sex, color, birlh date, age at first medical visit, history of preterm delivery, birthweight, age at first symptoms, location and clinical history of lesion, and occurrence of local or systemic complications were recorded.

Based on size and location of hernangiomas, functional impairment, presence of local or systemic complications, and psychosocial aspects, a protocol treatment was adopted, according to the following options:

1. Observation and follow-up (using photographs) 2. Clinical treatment

a. Systemic corticosteroids b. lnterferon alpha-2a

3. Surgical treatment 4. Combined treatment (clinical + surgical) Observation was indicated in the absence of

visual impairment, orifice obstruction, anatomic distortions, psychological alterations, and local or systemic complications. Ambulatory follow-up was monthly in the 1st yearof life, every 3 months until the 3rd year and biannual until complete involution. Photographic follow-up was carried out every visit (figure 1).

Clinical treatment was indicated when partial obstruction of orifices or anatomic distortions of facial structures were present, but did not cause visual impairment. Also, lesions with frequent local complications, such as ulceration, bleeding or infection, were indicated for clinical treatment (figure 2).

Figure 2. Patient with cervicofacial hemangioma treated with clinical approach with systemic corticosteroids. View A1 before treatment, Bl at 6 months of follow-un. and . .

& Cl at 1 year of follow-up.

Corticosteroids (prednisone) constituted the first drug of choice, at the Initial dose of 2 mglkglday. lnterferon (3 million lUlm2iday) was mainly used as a second option, when no response to wrticosteroids occurred.

Surgical treatment had absolute and relative indications. Absolute indications consisted in visual impairment or airway obstruction. Relative indications included small pedunculated lesions, frequent local complications in small lesions, nasal or oral disfigurement. Complete or partial resections were performed based on morbidity and the aim of each surgical intervention (figures 3 and 4).

Figure 7. A1 Frontal hemangioma. BI Spontaneous involution after 3 years

14 Braz J Craniornaxillofac Surg 2000;3/21

Head and neck hemangiomas

Combined therapy (fgure 4) was adopted in two different situations: when clinical treatment had to precede surgery in order to make the surgical resection possible; and when clinical treatment failed and surgery had to be indicated as a secondary procedure.

Epidemiological data were collected and treatment outcome was evaluated. Results were analyzed in terms of efficacy of the treatment option chosen, occurrence of complications, or need for changing the treatment option.

RESULTS

Clinical data for the 50 patients included in the study showed predominance of female patients, with a ratio of 3.51 (39 females, 11 males). Twenty-nine oatients were Caucasians. 19 were mulattos. one was ,~ ~

~ ~

Figure 3. Patient with lower eyelid hemangioma

black and one had oriental origin. Preterm delivery

managed with surgical occurred in 12.5% of cases, and mean birthweight was resection. View A) before 3092 g. surgery, BI 8 months Hemangioma was present at birth in 26 cases after surgery, and CI 2 years after surgew (52%). became visible in the first I5 days of life in nine

cases (18%) and appeared afier 15 days in 15 cases (30%). Mean ageatfirst medical visit was 17.4 months. The first symptom or sign was a red spot on the skin in 91.6% of cases.

In terms of location in the head and neck, lesions occurred predominantly in the cheek (38%). Uniform distribution occurred in upper lip (20%), neck (20%), lower lip (1 6%), uppereyelid (14%), lowereyelid (12%), nose (12%), and frontal region (8%) (table 1).

Table 1. Anatomic distribution of lesions.

Location n Oh

Cheek Upper lip Neck Lower lip Upper eyelid Lower eyelid Nose Frontal

Local complications included bleeding in 19 cases (38%), ulceration in 19 cases (38%), and infection in 15 cases (30%). Bleeding was

Figore 4. Four-month old female patient with controlled with compression, ulceration with aggressive hemangioma in the left orbit. Short-term occlusive dressing, and infections with local and/or . systemic cortjcosteroid treatment allowedparrisi systemic antibiotics. surgical resection. View AI before treatment, 8 ) during surgical resection, CI 4 months after In 22 cases, the first treatment option was surgery, and DI 2 years after surgety. observation (42%). Of these, 13 (62%) did not require

Braz J Cranniomaxillofac Surg 2000;3(2/ 1 5

Goldenberg et al.

additional treatment. Clinical treatment with corticosteroids was indicated in 32 cases (64%), including patients who had initiated observations as the first modality (nine cases). Clinical treatment was effective in 19 patients. Surgery was performed in 18 patients (34%). Of these, combined treatment occurred in 13 patients (26%). Figure 5 summarizes treatment modalities and evolution.

First modality I Observation Observation

(n=22) (n=13)

Surgery

Total

/ ' Combined therapy (clinical +surgery) I Fbure 5. Summary of treatment modalities during follow-up.

No adverse effects were observed during clinical treatment that could suggest the interruption of corticosteroid or interferon use. In the combined therapy, the use of corticosteroids did not increase the rate of infections or cause any healing problem.

In patients surgically treated, no complications were observed in terms of wound problems or functional impairment. Esthetic and psychological improvement was observed.

DISCUSSION

Although the introduction of the biologic classification by Mulliken and Glowacki in 1982 (1) provided adequate guidelines for the understanding of vascular anomalies, the treatment of hemangiomas remains controversial.

In the present study, epidemiological data regarding predominance of sex and race were similar to other studies (2,3). However, differently from the reports of some authors (4,5), the incidence of prematurity and low birthweight was low.

Observation is the best option for the majority of hemangiomas. Photographic follow-up and psychological support are of fundamental importance.

On the other hand, cases presenting severe disfigurements, visual impairment or airway obstruction should obviously be referred to immediate treatment (6).

However, a great number of patients are in a special situation: they do not require urgent treatment, but observation alone sometimes causes distress and impairs quality of life. Shifting from observation to active therapy does not mean treatment failure. In these situations, our aim is to offer patients a safe approach. Drug therapy with corticosteroids seems to be safe if patients are followed very closely, in a multidisciplinary way. Few complications were observed in our study, and the literature confirms our findings (2,4,7,8).

Finally, when drug therapy is not completely efficient, surgery should be indicated. Afler drug therapy, many lesions decrease in size, which facilitates their surgical resection. In addition, if surgery is likely to produce a similar or better result when compared to spontaneous involution, the surgical resection of the hemangioma seems reasonable.

In conclusion, the goal of hemangioma treatment is to improve the quality of life of patients and parents. Active treatment must have a solid indication, but should be more often considered when benefits surpass the risks.

REFERENCES

1. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classtf~cataon oaseo on enaorhel~a, cnaracterlstlcs Plast Reconstr S ~ r a 1982.6913J 412-20 . ~

2. Bartlet JA, Riding KH, Salkeld LJ. Management of hemangiomas of the head and neck in children. J Otolaryngol 1988;17121:111-20. Pitanguy I, Machado BH, Radwanski HN, Amorirn NF. Surgical treatment of hemangiomas of the nose. ~ " n Plast Surg 1996;36(6):586-93.

4. Ezekowitz RA. Mulliken JB. Folkman J. Interferon alfa-2a therapy for life threatening hemangiomas of infancy. New Engl J Med 1992;326122): 1458-63.

5. Mulliken JB. Vascularanomalies. In: Grabb, Smith. Plastic surgery. 5th ed. Philadelphia: Lippincott- Raven; 1997. p. 191-203.

6. Carramaschi FR, Ferreiar MC, Goldenberg DC, Carnargo CP, Faria JC. Tratamento dos angiomas do Iabio. Rev Hosp Clin Fac Mad Sao Paulo 1991; 46(3J:128-31.

7. Achauer BM, Chang CJ, Vandrkam V . Management of hemangioma of infancy: review of 245 patients. Plast Reconstr Surg 1997;99150): 1301-8.

8. Kushner BJ The treatment of periorbital infantile hernangioma with intralesional corticosteroid. Plast Recontr Surg 1985;76(4):517-26.


ESTHETIC AND FUNCTIONAL REHABILITATION OF MAXILLA AND ALVEOLAR RIDGES WITH SINUS LIFT BONE

Wilson Cintra Junior, MD2; Nivaldo Alonso, MD, PhD3

Patients in general and especially young patients with maxillary andalveolar ridge atrophy caused by tooth loss due to severe traumas orperiodontal diseases should undergo a surgical procedure aimed at providing the bone tissue with sufficient height and thickness in order to enable the performance of osteointegrated implants. Some methods of bone grafting in the maxilla are described in the literature. The purpose of this study was to describe the use of a cortical bone graft technique in the maxillaly sinus floor and alveolar ridge with the purpose of obtaining a thicker bone site (both horizontally and vertically), and to provide better esthetic and functional rehabilitation after implantintegration. Seventeen patients undement the surgicalprocedure between July 1998 and June 2001. All presented significant esthetic improvement, which was confirmed by clinical and radiological examinations performed both before and after surgery.

KEY WORDS: Bone and bones; maxilla; atrophy; rehabilitation; plastic surgery


Severe dental disease may cause natural tooth loss (1). The absence of contraposition between upper and lower teeth and the consequent lack of stimulus to bone growth may activate osteoblasts and make them start the process of bone resorption. In the maxillary bone, resorption causes a remodeling and posterior atrophy of the maxillaryalveolarprocess; so, the accomplishment of oral rehabilitation by means of dental prostheses or osteointegrated implants becomes impossible (2).

Young patients who have had severe partial or total losses of dental elements feel embarrassed and face certain difficulties in terms of social interaction, since they have to use prostheses. Although dental prostheses may be very advanced nowadays, the

' This study was carried out at Hospital dar Clinicas da Faculdade de Medicina da Universidade de SBa Paulo and at Hospital Professor Edmundo Vasconcelos. SBo Paulo. Brazil. Physician. Plastic Surgery, School of Medicine, Univerridade de SSo Paulo. Brazil. Associate Member, Sociedade Braslleira de Cirurgia PIBs- tica. Brazil. Member, Sociedade Brasileira de Cirurgia Craniomaxilofacial, Brazil Correspondence to: Av SBo Gabriel. 201. conj. 70415, 01435~001, Iraim. SBo Paulo, SP. Brazil. Phone: +55-11-3704-7284. E-mail: [email protected]. Assistant Physlcan. Piastic Surgery. School of Medicine, Universidsde de SBo Paulo. Brarll. President. Sociedade Biasileira de Ciiurgia Craniomaxilofacial. Brazil. Member, Sociedade Brasileira de Cirurgia Pidstica, Brazil.

possibilities of spontaneous expulsive loss, hygiene problems and, especially, bone resorption, which leads to maxillary and mandibular atrophy, still remain. On the other hand, osteointegrated implants provide the patient with an improved esthetic effect and comfort, and promote maxillary and mandibular bone maintenance.

When the alveolar bone ridge is deficient, that is, when the dimensions of the bone tissue that is necessary forthe insertion of implantsare not adequate (5 mm of thickness and 7 mm of height), the use of tissue grafls, vestibuloplasty, and interposition of bone grafts are possible treatments (3). These surgical procedures present disadvantages, such as the need for a donor site, risk for bleeding, long operating time, and pain (1.4-6).

Patients with acute resorption of the alveolar process of the maxilla are not good candidates for the use of osteointegrated implants, and bone grafts associated with the sinus litechnique have been used to solve that problem. Several methods have been described: autologous bone grafts with previously integrated implants (7-lo), subperiosteal insertion of grafts directly into the atrophied maxilla, bone grafl in the space between the osteotomized maxilla and the


Cintra Junior & Alonso

maxillary sinus floor (9), and bone graft inside the maxillary sinus (8).

Breine and Branemark carried out a comparative study on the use of bone grafts in reconstructive surgeries. The first group received implants in the proximal tibial metaphysis; afler 3 to 6 months, the tibial grafl that contained the implants was extracted and grafted in eight maxillae. Afler 12 months, 50% of the graft volume was preserved, and 60% of the implants remained integrated. The second group received bone grafts with simultaneous placement of implants in 14 maxillae, which resulted in only 25% of integrated implants (7).

In 1980, Boyne and James described the use of iliac bonegrafl in the maxillary sinus floor; in their study, three of the patients received implants that adequately supported prostheses (1).

In 1987, Keller described the bone graft interposition technique through horizontal osteotomy of the maxillary alveolar process (11). In 1995, Krekmanov used the same technique with the simultaneous placement of implants in 35 patients; the success rate of osteointegration was 86.6% (12).

Jensen used a different technique with the aim of increasing the thickness of the maxillary alveolar process. The author placed osteointegrated implants 4 to 5 months afler the bone was grafled and obtained 75% of success (9).

In 1996, Tulasne described a bone graft technique in the maxillary sinus floor that prese~ed the mucous integrity of the sinus (personal communication, 1996).

The purpose of this study was to describe the use of the same technique used by Tulasne, namely, the sinus lhft technique, for the esthetic and functional rehabilitation of the maxilla.

PATIENTS AND METHODS

Patients were assessed by means of physical examination and mainly radiological examination - a panoramic radiograph of the mandible and specific thin-section computed tomography (dental scan) - in order to assess the thickness of the maxilla and the alveolar ridge, and also to define the amount of bone tissue that would be necessary for the insertion of implants. Patients underwent surgery under general anesthesia. An incision in the gingivolabial sulcus up to the periosteum and subperiosteal displacement up to the emergence of the infraorbital nerves were carried out.

We pelformed osteotomy of the anterior wall of the maxillaty sinus and extracted a fragment (bone window). Afler carefully moving the maxillary sinus mucosa upwards, leaving a space between the displaced mucosa and the maxillaty sinus floor, we impacted a cortical bone fragment into that space, and under that fragment we placed several smaller fragments of porous bone, aiming at filling completely the space between the cortical bone and the maxillary sinus floor (figure 1).

We performed incisions in the alveolar ridge with perpendicular extensions in the ends, and the subperiosteal displacement of the whole ridge was performed. Then, we placed laminar fragments of cortical bone in the vestibular, palatal and inferior alveolar side, fixing them with miniboards and screws. The advancement of mucoperiosteal flaps was carried out in order to cover the bone grafts. Suture was performed with absorbable threads.

The donor site of the bone grafis was the outer table of the skull in the parietal region (figure 2).

Figure I . A1 Submucosal displacement of the maxillary sinus floor through osteotomy in the anterior sinus wall, preserving the integrity of the mucosa. 8) Impactation of the bone graft from the outer table of the skullinside the maxillary sinus. CI Fixation of the osteointegrated implant.

18 Braz J Craniomaxillofac Surg 2000;3(21

Oral rehabilitation with sinus lift bone grafting

Figure 2. Donor site: outer table of the skull, parietal region.

RESULTS

Seventeen young adults underwent surgery; their ages ranged from 32 to 55 years. All patients presented successful esthetic and functional results, with sufficient final bone thickness for the placement of osteointegrated implants and well-fixed, esthetically improved prostheses (figure 3).

Among the 17 patients who underwent the procedure, two presented partial dehiscence of the mucosa suture. However, this problem was solved by means of complementary surgeries and continuous cleaning, and the synthesis was completed. Resulting

bone absorption was insignificant and did not haveany negative influence on the final result.

DISCUSSION

Toothless patients develop atrophy of the maxillary alveolar process, which may prevent esthetic and functional oral rehabilitation, since the insufficient thickness and height of the bone make it inappropriate for dental implants. Younger individuals feel the need for esthetically improved, well-fixed prostheses, which consequently are easier to clean.

Autogenous bone grafts have been considered the gold standard due to their high capacity of osteogenesis, osteoinduction, and osteoconduction (1 3). However, several maxillary bone graff techniques have been developed with the aim of increasing graft volume and favoring the placement of osteointegrated implants for the posterior insertion of prostheses. The technique used in our study (sinus liifftechnique) showed to provide sufficient bone tissue for osteointegrated implants. In addition, it did not provoke lesions in the maxilla~y sinus mucosa, and provided resistant bone tissue grafts (cortical tissue), complemented by pornus bone tissue in order to achieve a complete fulfillment of spaces. The sinus lii technique favored esthetic oral rehabilitation, and showed to be especially indicated for young patients and those who need bone stimulation to avoid atrophy of the alveolar ridge.

Figure 3. A1 Presurgical view. B) Bone window in the anterior wall of the maxillary sinus. Ci Complementary grafcs in the anterior alveolar ridge. Dl Synthesis.


Cintra Junior & Alonso

CONCLUSION

In patients with maxilla and alveolar ridge

atrophy caused by severe trauma or periodontal

diseases, especially young adults, the performance

of a surgical procedure aimed at providing bone

tissue with sufficient height and thickness for the

insertion of implants is indicated to avoid bone

resorption and atrophy and the resulting functional

and esthetic problems that may appear.

Even though several different bone graft

methods have been proposed to augment the

thickness and height of the alveolar ridge, the

technique used in this study presents several

advantages:

1) It preserves the integrity of the maxillary sinus

mucosa, decreasing the risk for local infection;

2) Cortlcal bone grafts are used, which allow for

better fixation of dental implants and present

lower incidence of bone resorption due to their

greater density;

3) It causes insignificant esthetic sequelae, since

the scar at the donor site is located on the scalp;

4) At last, it yields satisfactory and harmonious

functional and esthetic rehabilitation.

REFERENCES

1. Boyne P, James R. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613-6.

Lader AJ. McElroy J, Deasy MJ. Reconstruction of the severely atrophic maxilla with autogenous iliac bone graft and hydroxylapatiteldacalcified freeze-dried bone allograft in the same patient: a preliminary report. Periodontal Clin lnvestig 1993; 15(1):5-9. Smiler DG, Johnson PW, Lozada J, Misch C, Rosenlicht JL, Tatum OH, et al. Sinus lift grafts and endosseous implants. Dent Clin North Am 1992;36(1):151-86. Cranin A. Applications of hydroxylapatite in oral and maxillofacial surgery. Part II: Ridge augmentation and repair of major oral defects. Compend Contin Educ Dent 1987;8:334-45. Finn RA, Bell WH, Brammer JA. Interpositional "graning" with autogenous bone and coralline hydroxyapatite. J Maxillofac Surg 1980;8:217-27. Holmes R, Hagler H. Porous hydroxyapatite as a bone graft substitute in mandibular augmentation. J Oral Maxillofac Surg. In press. Breine U, Branemark PI. Reconstruction of alveolar jaw bone. Scand J Plast Reconstr Surg 1980;14:23-8. lsaksson S , Alberius P. Maxillary alveolar ridge augmentation with onlay bone grafts and .inmediare enoosseous irnpnants. J Craniomaxillofac Surq 1992:20.2-7. - Jensen J, Simonsen E. Pedersen S. Reconstruction of the severely resorbed maxilla with bone grafting and osteointegrated implants: a preliminary report. J Oral Maxillofac Surg 1990;48:27. Kahnberg KE. Nystrom E, Barthoidsson L. Combined use of bone grafts and Branemark fixtures in the treatment of severely resorbed maxillae. Int J Oral Maxillofac Implants 1989;4:297-304. Keller EE, Van Roekel NB, Desjardins RP, Tolman DE. Prosthetic reconstruction of the severely resorbed maxilla with iliac grafting and tissue integrated prostheses. Int J Oral Maxillofac Implants 1987;2:155-61 Krekmanov L. A modified method of simultaneous bone grafting and placement of endosseous implants in the severely atrophic maxilla. Int J Oral Maxillofac Implants 1995;10(6):682-8. Garg AK. Augmentation grafting of the maxillary sinus for placement of dental implants: anatomy, physiology and procedures. Implant Dent 1999;8(1):36-46.

20 Braz J Craniomaxillofac Surg 2000;3121

SURGICAL OPTIONS FOR THE CLOSURE OF LARGE MYELOMENINGOCELES Dov C. Goldenberg, MD'; Nivaldo Alonso, MD, PhD2; Marcus C. Ferreira, MD, PhD3

There are two options for the surgical treatment of myelomeningoceles: primary closure and flap repair. Since the latter technique is more complex and is used in larger lesions, the presence of a plastic surgeon may be important for an adequate evaluation and for the definition of which flaps should be used. This study aimed at defining the role of plastic surgery in the repair of large myelomeningoceles and at standardizing the use of specific surgical flaps (fasciocutaneous or musculocutaneous). From January 1999 to June 2000, 31 patients presenting myelomeningoceles were selected at Hospital de Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Brazil. All cases were evaluated by the neurosurgery and plastic surgery teams for treatment planning. Flap repair was performed exclusively by the plastic surgery team in 20 patients (PS group); primary soft tissue closure was carried out by the neurosurgery team in I1 patients (NS group). In the PS group, two patients undewent only primary closure. Fasciocutaneous simple rhomboid flaps were used in three cases, double rhomboid flaps in 10 cases, and musculocutaneous latissimus dorsi flaps in five cases. The mean area of defects was lower in the NS group than in the PS group. Incidence ofpostoperative hydrocephalus and need for ventriculoperifoneal shunt were higher in the PS group (p<0.05). In sum, this multidisciplinary approach allowed for increased safety and quality of treatment and may potentially reduce complication and failure rates.

KEY WORDS: Myelomeningoceles; congenital defects; surgery.

Congenital deformities of the neural tube affect approximately one in every 1,000 newborns. They can vary from simple skin birthmarks to large and complex defects. Myelomeningoceles correspond to 85% of all neural tube defects and are the most common cases of neurological malformation referred to pediatric neurosurgeons (1-3).

Nowadays it is possible to obtain a survival rate of 90% for patients with myelomeningoceles. Of these, 75% have normal intelligence, 80% achieve urinary and fecal continence when using proper medication, and 80% can walk with assistance (1,4,5). In view of these good results, the performance of a safe and stable surgical procedure aimed at repair is of paramount importance.

Assistant Physiclan. Division of Plastic Surgery and Burn. Hospital de Clinicas da Faculdade de Medicina da Universidade de SBa Paulo. Brazil.

In myelomeningoceles, the skin, the subcutaneous layer, the lumbodorsal fascia, and dural and neural tissues are affected. Small defects may be easily treated with primary closure of all layers, that is, medular reconstruction, dural closure, and repair of the lumbodorsalfascia, subcutaneous tissue, and skin. However, in more severe cases, soft tissue closure may require a complex reconstructive procedure.

In the surgical keafmentof large myelomeningoceles, the presence of a plasticsurgeon may be importantfor an adequate reconstruction. Depending on the patient's stature and the anatomic location and size of the lesion, complex techniques may be necessary.

Unsuccessful attempts of primary closure of large myelomeningoceles by neurosurgeons affect the surgical planning offlap repair and increase failure rates. So, the most difficult aspect in the treatment of myelomeningoceles is to define limits for the use of either primary closure or flap repair. Several authors

Member. Socledade Bras~lelra de Cirurga PBstica. Brarll. Associate have tried to determine these limits, D~ chalain et al, Member, Socldade Brasileira de Clrurgia Craniomaxilofacial. Brarll. correspondence to: RUB pedro de T O I ~ ~ O 9801124. 04039~002. SBO (4) reported that defects larger than 25 cm2 should be Paulo. SP. Braril. E-maii: [email protected].

2 Assistant Physician. Division of Plastic Surgery and Burn. Hospital de submitted to plastic surgical treatment using flaps.

Clin>cas da Faculdade de Medlcina da Unlveisidade de SBa Paulo, Brazil. Lanigan (6) used the transverse diameter to determine Member. Sociedade Brasiieira de Cirurgia Plds~ica. Brazil. President. sacledade ~~~~~i~~~~ de clrurgla cranlomaxlofacai. B ~ ~ Z , I . the performance of either primary or flap closure.

3 Professor. Plastic Surgery. School of Medicine. Un~versidade de SBa Another important aspect in the surgical management Paulo. BfazI. Head. Dlvislon of Plastic Surgery and Burn. Hosptta de Cin8cas da Faculdade de Medicina da Universldade de SBo Paulo. Bra281 these lesions is the definition Of which flaps should


Goldenberg et al

be used, based on the size of defects and other quantitative parameters.

In view of these aspects, the purposes of the present study were: 1) to define the role of plastic surgery in the repair of large myelomeningoceles, by determining limits for either primary or flap closure; and 2) to standardize the use of specific surgical flaps based on the defect dimensions.

MATERIALS AND METHODS

From January 1999 to June 2000, all patients born at Hospital de Clinicas da Faculdade de Medicina da Universidade de SLo Paulo, Brazil, and presenting myelomeningoceles in thoracic,.lumbar, andlor sacral regions were included in the study. A total of 31 newborns presented the iesion (figure 1).

Data collected included mother's age, prenatal diagnosis and follow-up, sex of the newborn, and birthweight. Lesion location and size (area) were analyzed, and the occurrence of preoperative rupture was recorded. The time interval between birth and surgery, as well as information regarding surgical options, were also recorded. Incidence of pre- and postoperative hydrocephalus and need for ventriculoperitoneal shunt were evaluated.

Prior to surgery, all cases were evaluated by the neurosurgery and plastic surgery teams with the aim of planning treatment. Treatment was divided into two stages: the first stage consisted of dissection of the neural tissue and closure of the dura and the lumbodorsal fascia, carried out by t& neurosurgeon; the second stage consisted of soft tissue closure, performed by theneurosurgeon orthe plasticsurgeon. All cases were evaluated using a multidisciplinary approach.

Soft tissue defects were primarily closed by either the neurosurgeon or the plastic surgeon. When flaps were necessary, surgery was performed exclusively by the plastic surgery team. Surgical decision was based on the area and location of the defect, local skin conditions, and newborn weight and height. Primary sofl tissue closure was done in three or four layers, including the dura, lurnbodorsal fascia, subcutaneous tissue, and skin (figures 2 and 3).

Figure 2. Primary closure < ,f myelomeningocele.

Surgical flaps were divided into fasciocutaneous and musculocutaneous. Fasciocutaneous flaps were designed as single or double rhomboid flaps (Limberg's flaps); they were closed in two layers (fascia and skin), and the donor area was primarily closed (figures 4-6). Latissimus dorsi musculocutaneousflaps, obtained by means of lateral incisions, were used in cases of larger defects. In these cases, donor areas were grafted or left open with dressings for spontaneous secondary healing (figure 7).

.

Figure I . Anatomk lorarion of rnyelornen~r~goceles: At Ihorac~c; 61 rhorncolumbar, Ct kmbar; Dt lumhosacral; €1 sacral.

22 Braz J Craniomaxillofac Surg 2000;3121

Surgical treatment of myelomeningoceles

rtgure 3. Primary closure of myelomeningocele.

Figure 4. Single fasciocutaneous rhomboid flap Rimberg's flap).


Goldenberg et al.

Figure 5. Single fasciocutaneous rhomboid flap (Limberg's flapl.

Figure 6. Double fasciocutaneous rhomboid flaps (Limberg's flapl.

Figure 7. Bilateral latissimus dorsi musculocutaneous flap obtained by means of lareral incisions. The arrow indicates late postoperative secondary heaihg of lateral incisions, without skin grafts.


Surgical treatment o f myelomeningoceles

Cases were followed after surgery and observed in terms of surgical results, complications and need for ventriculoperitoneal shunt. Complications included dehiscence, infection, cerebrospinal fluid (CSF) leak, and need for reoperation.

Epidemiological data and surgical results were analyzed comparing patients operated exclusively by the neurosurgery team (NS group), that is, undergoing primary closure of soft tissue defects, and patients operated by the neurosurgery and the plastic surgery teams (PS group), with flap closure of soft tissue defects.

Statistical analysis was performed using Student's t test, Fisher's exact test and Wilcoxon's test.

RESULTS

Thirty-one patients presenting rnyelorneningoceles at birth were surgically treated between January 1999 and June 2000. In 20 patients, soft tissue closure was performed by the plastic surgery team (PS

group). In the remaining 11 patients, primary closure was performed by neurosurgeons (NS group) after plastic surgery evaluation.

Results for the PS group and the NS group are shown in table 1.

Surgical procedure was performed between 18 hours and 10 days after birth (mean = 4.4 days). In 40% of cases, surgery was performed in the first 72 hours of life.

When mean area of the defects was compared to flap options (table 2), no statistically significant difference was observed.

The mean area of defects in the NS group was 25.11 cm2, which is statistically lower than the mean area observed in the PS group (p<0.05).

Complications in the PS and the NS groups can be observed in table 3. Comparison between the two groups showed no differences in terms of sex and birthweight. Mothers in the PS group were younger than those in the NS group (p<0.05). Lesion location and occurrence of rupture were not statistically different.

Table 1. Clinical data in the PS and NS groups

Plasticsuraerv Neurosuraerv Total

Number of patients Sex

Male Female

Birthweight (mean, grams) Mother's age (mean, years) Prenatal diagnosis Hydrocephalus Dimension of the defect (cm2)

Minimum Maximum Mean

Defect location Lumbar Sacral Thorawlumbar Lumbosacral

Time elapsed until surgery (mean, days of life) Occurrence of preoperative rupture Surgical procedure

Primary closure Use of single rhomboid flap Use of double rhomboid flap Use of latissimus dorsi flap


Goldenberg et al.

Table 2. Defect areas in the PS group.

Single rhomboid Double rhomboid Latissimus dorsi fasciocutaneous flap fasciocutaneous flap musculocutaneous flap

Number of patients 3 10 5 Size of the defect (cm2)

Minimum 20.0 20.0 50.2 Maximum 50.2 70.0 72.0 Mean 32.4 38.9 59.2

Table 3. Complications in the PS and NS groups.

Plastic surgery Neurosurge~y Total

Number of patients 20 11 31 Need for ventriculoperitoneal shunt 20 (1 00%) 6 (55%) 26 (84%) Complication

Minor dehiscence with no need for reoperation 7 (35%) 2 (18%) 9 (29%) Major dehiscence with need for reoperation 1 (5%) 1 (9%) 2 (6%) Surgical infection I (5%) 1 (9%) 2 (6%) Cerebrospinal fluid leak 3 (1 5%) - 3 (9%)

lncidence of postoperative hydrocephalus and need for ventriculoperitoneal shunt were higher in the PS group (p<0.05). Minor dehiscence was more frequent in the PS group (p<0.05), but no differences were observed in infection or reo~eration rates.

DISCUSSION

Myelorneningoceles (or spina bifida) is the most common malformation of the central nervous system seen by pediatric neurosurgeons. lncidence is variable, from 1:200 to 1:1000 newborns.

Treatment of myelorneningoceles requires a multidisciplinary approach, including neurosurgeons, plasticsurgeons, neurologists, orthopedists, urologists, pediatricians, geneticists, and social care professionals.

Improvement in prenatal diagnosis and neonatal intensive care have increased survival rates for patients with multiple congenital malformations. Patients with myelomeningoceles are included in this group. They require a stable sofl tissue coverage of the exposed neural tissue (73) in order to provide a better quality of life.

26 Braz J Craniomaxi/lofac Surg 2000;3/2)

Early surgical treatment is recommended in the literature- mainly due to the risk for rupture - and was adopted in this study. Seidel et al. (9) recommend surgery during the first 48 hours of life. However, simultaneous conditions may delay the procedure.

According to the classical approach, the neurosurgeon closes any type of lesion, being likely to face several complications in more complex cases. The impact of unsuccessful repair on morbidity and mortality is high. In addition, attempts to use flap repair afler several unsuccessful experiences of primary repair with massive dissection of tissues increasesflap loss and dehiscence. Therefore, the participation of plastic surgery professionals in the treatment of myelomeningoceles is highly justified. The choice of the closure technique by plastic surgeons potentially decreases complication rates or at least the incidence of unsuccessful attempts at primary repair.

The location and dimension of the defect in relation to the patient's stature are of paramount importance for treatment decision. If all locations are considered, sacral lesions are more easily treated. Patients in the PS group had lesions predominantly in the thoracolurnbar and lumbosacral regions. Sacral lesions occurred in only 15%. On the other hand, 40% of the patients in the NS group presented sacral lesions.

Surgical treatment of myelomeningoceles

The rate of involvement of plastic surgery teams In the treatment of myelomeningoceles is variable in the literature. In 41 patients, De Chalain (4) found a rate of 24.4% of cases referred to plastic surgery for the closure of soft tissue defects. In the study of Seidel et al. (9), the rate was of 25.8% in 65 patients. In the present study, a rate of 64.5% of plasticsurgical treatment of soft tissue defects was observed. This index surpasses expectations and illustrates the effectiveness of the multidisciplinary approach.

Measurement of the defect size helps surgical planning and flap choice. In ourstudy, primary closure was indicated only when tension-free closure was possible prior to sofl tissue undermining.

In our cases requiring flap repair, fasciocutaneous flaps were used in 65%. Fasciocutaneous flaps have been shown to present some advantages when compared to musculocutaneous flaps. One of these advantages refers to the distal blood supply, since fasciocutaneous vessels and musculocutaneous perforators can be preserved in fasciocutaneousflaps. Ohtsuka et al. (10) reinforced the use of fasciocutaneous flaps in myelomeningocele closure.

Flap design is currently being discussed in the literature. Rhomboid flaps seem to be the most adequate ones, since they present a good width-to- length ratio and sutures are not located exactly over the dural sutures (11-13).

In our study, options for the use of single or double flaps were defined during the procedure. The first flap was elevated, and if it was not enough for tension-free closure, a second previously designed flap was elevated.

The literature suggests the use of musculocutaneous flaps in cases of larger defects (14). In our series, the defects in which this type of flap was used had a mean area of 59.2 cm2, against 38.9 cm2 in defects receiving fasciocutaneous flaps. No statistically significant difference was observed between defect areas and flap options, but cases requiring more complex flaps presented higher defect areas. The absence of statistical significance may be explained by the different relationships between defect area and patient stature.

Bilateral latissimus dorsi flaps are associated with a high morbidity rate when compared to fasciocutaneous flaps. In the present study, this type of flap was considered as the last option for the treatment of large defects, rather than as a routine surgical option. Increased blood loss, need for skin grafting in some cases and functional impairment

are common problems associated with latissimus dorsi flaps.

Complication rates in this study were similar to those reported by other authors (4,9). It is important to note that cases in the PS group were more complex, and therefore a higher rate of complications was expected in this group. We observed an increase in the number of minor dehiscence in the PS group when compared to the NS group, but major complications were similar. The final result was not significantly altered by this parameter.

Hydrocephalus seems to be the most important prognostic factor in myelomeningoceles. Problems directly related to treatment as well as secondary infections are the leading causes of mortality. The more severe the myelomeningocele, the higher the chance for hydrocephalus in the postoperative period. All patients in the PS group had hydrocephalus prior to surgery or developed hydrocephalus after closure and the need for ventriculoperitoneal shunt. This aspectwas statistically different in the NS group.

The multidisciplinary approach allows for a good-quality treatment in terms of safety and quality of soft tissue coverage. It reduces the incidence of unsuccessful attempts at surgical closure and allows the neurosurgeon to correct the dural defect with more safety, with no distress about soft tissue coverage. Soft tissue coverage in complex defects is a responsibility to the plastic surgery team, which is more familiar to this type of problem. This may potentially reduce complication and failure rates.

REFERENCES

1. Zide BM. Spina bifida. In: McCarthy. Plastic surgery. Philadelphia: W.B. Saunders; 1990. p. 3780-96.

2. Fiala TGS, Buchman SR, Murazko KM. Use of lumbar periosteal turnover f laps in myelomeningocele closure. Neurosurgery 1996; 39(3):522-6.

3. Ramasastry SS, Cohen M, Radhaksihnan J. Congenital back defects. In: Bentz ML. Pediatric plastic surgery. Stamford: Appleton & Lange; 1998. p. 757-82.

4. De Chalain TMB, Cohen SR, Burstein FD, Hudgins RJ, Boydston WR, O'Brien MS. Decision making in primary surgical repair of myelomeningoceles. Ann Plast Surg 1995;3513):272-8.

5. Fobe JL, Rizzo AML, Silva IM, Da Silva PP, Teixeira CE, De Souza AM, et al. lQ in hydrocephalus and myelomeningocele Implication o f surgical treatment. Arq Neuropsiquiatr 1999;5711):44-50.


Goldenberg et al.

6. Lanigan MW. Surgical repair of myelomeningocele. Ann Plast Surg 1995:31(6):514-21.

7. Mirzai H, RsahinY, Mutluer S, Kayahan A. Outcome of patients with rnyelorneningocele: the Ege University experience. Childs Nerv Syst 1998: 14(3):120-3.

8. Casari EF, Fantino AG. A longitudinal study of cognitive abilities and achievement status of children with myelomeningocele and their relationship with clinical types. Eur J Pediatr Surg 1998;8 Suppl 1: 52-4.

9. Seidel SB, Gardner PM, Howard PS. Soff-tissue coverage of the neural elements after rnyelomeningocele repair. Ann Plast Surg 1996; 37(3):310-6.

28 Brar J Craniomaxillofac Surg 2000;3(21

10. Ohtsuka H, Shioya N, Yada K. Modified Limberg flap for lurnbosacral meningornyelocele. Ann Plast Surg 1979;3:114.

11. Akan IM, Ulusoy MG, Bilen BT, Kapucu MR. Modified bilateral advancement flap: the slide in flap. Ann Plast Surg 1999;42(5):545-8.

12. Stephens DR, Grott ing JC. Sof t tissue reconstruction. Coverage of the chest wall and spine. Orthop Clin North Am 1993;24(3):449-60.

13. Zide BM, Epastein FJ, Wisoff J. Optimal wound closure after tethered cord correction. Technical note. J Neurosurg 1991;74(4):673-6.

14. Jaworsk i S, Dudkiewica 2 , Lodzinski K, Lenkiewicz T. Back closure with a latissimus dorsi musculocutaneous flap. J Pediatr Surg 1992; 27(1):74-5.

LONG-LASTING BILATERAL DISLOCATION OF THE TEMPOROMANDIBULAR JOINT Marcus Vinicius Martins Collares, MD, PhD'; Eduardo Grossrnann, DDS, MSc, PhD2

This study describes a case of bilateraldislocation of the temporomandibularjoint (TMJJ lasting forseven months. Conservative therapy (mandibularmanipulation) failed, andsuig~cal treatment wascamedout using thepreauricular approach, so that the articular disks and the mandibular condyles could be cleady visualized. Severe bilateral fibrosis was observed between the temporal articular tubercle, the disks (the right side was anteriorly displaced and the left side was well-positioned), and the mandibular head. On surgev, the mandibular head was first released, followed by reduction of the right disk and condyle to the mandibular fossae. Next, a green-stick fracture of the temporal zygomatic process was perfonned on both sides and fixed wIth steel wires. Thus, an anterior support was created to avoid relapse. After 30 months of follow-up, relapse was not obsetved, and mandibular movements (opening, lateral movements. protrusion) were normal.

KEY WORDS: Temporomandibularjoint; dislocation; suigev.


T h e temporomandibular joint (TMJ) is formed by a group of anatomical structures, including special muscle groups that allow wide mandibular movements during mastication. Taking into consideration thatthere is an additional dental joint resulting from the active contact between maxillary and mandibular teeth, it is easy to understand the close, interdependent relationship between both joints. Therefore, any functional or pathological alteration in one of them will affect the other (1).

The pathological dislocation of the TMJ is also referred to as luxation or limited mouth opening (2). In this condition, the mandibular condyle slides excessively to an anterior direction, surpassing the articular tubercle, but remains within the limits of the capsular ligament (3-8). The patient is not able to close hisiher mouth, as a result of condylar dislocation; pain and spasm of the lateral pterygoid muscle are usually observed (9-13). TMJ dislocation can be acute or chronic (repeated or long-lasting), uni- or bilateral.

The most common causes of temporomandibular joint dislocation are related to long-lasting dental treatment, yawning, laughter, vomiting, external trauma, shouting or even tracheal intubation during general anesthesia (2,6,10,14).

Some predisposing factors for dislocation include: flat fossae or short articular tubercle (in these cases, when the mandibular head moves, it does not find a natural and appropriate barrier): inadequate articulation between the mandibular head, disk, and fossa (caused by either a congenital oracquired malformation); fatigue of the ligaments andlor masticatory muscles (resulting in joint hypermobility) (14,15).

The anterior dislocation of the mandibular head in relation to the articular tubercle is probably due to muscular forces (muscles directly responsible for elevating, projecting, and lowering the mandible) in opposition to the action of ligaments. This results in upward and downward pressure on the condyle, keeping it from returning to its original cavity, namely the mandibular fossa (12).

In unilateral cases, the menton is dislocated to the opposite side, and both anterior open bite and protrusion are observed. In bilateral cases, the whole mandible is anteriorly dislocated, with bilateral open bite and no deviation from the midline (2.4,5.14).

Severe, long-lasting dislocations are unusual. There are no guidelines forthe treatment ofsuch cases. The aim of this study was to present a proposal for solving this unusual problem.

I Professor of Surgery. Graduate Program in Medicine: Surgery. Universi- CASE REPORT dade Federal do Rio Grande do Sul. Brazil. Correspondence to: S e r v i ~ a de Cirurgla Pldstica. Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos. 2350. 6' andar. sala 600. 90035-003. Pono Alegre. RS. A 77-year old female patient presenting B ~ ~ s ~ I . E-mad: ~ v c o I I ~ ~ ~ s @ v ~ ~ - r s n e t . leukoderma, hypertension and diabetes was seen at Professor. Graduate Program in Medicine: Oral Faclal Pain. Universida- de Federal do Rio Grande do SUI. B ~ ~ Z ~ I . orofaciai pain cemer. our clinic.

Braz J Craniornaxillofac Surg 2000;3/2/ 29

Grossman & Collares

She reported having suffered afall seven months deglutition during the test. CT confirmed the clinical before, with trauma to the mandibular body - the finding, and diagnosis of anterior dislocation of the menton. Since then, she had been experiencing mild mandibular condylewas made. discomfort, altered bite, and difficulty to appropriately close her mouth (figure 1). She also mentioned that it was the first time such a problem had happened.

Figure I . Frontal view of the patient's altered bite, with difficulty to close the mouth.

On clinical examination (palpation), the physician observed that the mandibular fossae were empty (depression) and that interincisal distance was 26.82 mm (figure 2), which corresponds to an open locking. There were no signs of ligament fatigue (hypermobilii syndrome). The patient wore a fixed and a partially removable prosthesis in the upper dental arch and a totally removable prosthesis in the lower arch. During assessment of the stomatognatic system, she did not feel pain (score 0 on Visual Analog Scale).

Figure 2 . Interincisal distance 126.82 mml.

The following tests were performed: panoramic radiograph, tridimensional computed tomography (CT) with lateral (figures 3 and 4). coronal, and axial sections (we did not use iodized contrast medium), and nuclear magnetic resonance imaging (MRI) with sagittal and coronal sections (TI and T2). On MRI, it was not possible to visualizethe disk due to the patient's d'ficuky to keep the intraoral device (mouth opening stabilization) in the same position and to avoid

30 Braz J Craniomaxillofac Surg 2000;3(21

Figure 3. Tridimensional computed tomography, sagittalsection, pretreatment, left side. The arrow indicates that the condyle is placed in front of the articular tubercle lanterior dislocarion to the left).

Figure 4. Tridimensional computed tomography, saginal section, pretreatment, right side. The arrow indicates that the condyle is placed in front of the articular tubercle (anterior dislocation to the right).

As the first treatment option, we tried to reduce the mandibular head by means of mandibular manipulation, but this attempt resulted unsuccessful. Then, surgerywas carried out, with general anesthesia and nasotracheal intubation. We used the preauricular a~oroach accordinq to the recommendations of Kaolan . . - and Assael(l6). While making an incision into the joint capsule and accessing the TMJ, severe fibrosis was observed on both sides between the temporal articular tubercle, the disk (the right side was anteriorly displaced and the left side was well-positioned), and the mandibular head. The mandibular head was released, followed by reduction of the right disk and condyle to the mandibular fossa. Next, we performed a green- stick fracture on both sides of the temporal zygornatic process, with steel wiretixation, and created an anterior support aimed at preventing relapse.

Bilateral discolation of the TMJ

The patient received advice on hygiene, food ~ntake, as well as use of medication.

Thirty days after surgery, a new tridimensional CT of the joint was carried out, following the same patterns of the first one. According to the second CT, the condyles were adequately placed in the mandibular fossae (figures 5 and 6).

Figure 5. Tridimensional computed tomography, sagittal section, posttreatment, left side. The arrow indicates the condyle replaced in the mandibular fossa.

Figure 6. Tridimensional computed tomography, sagittal section, posttreacrrrmt, right side. The arrow indicates the condyle replaced in the mandibular fossa.

After 30 months, the patient remained asymptomatic (figures 7 and 8).

Figore 7. Frontal view of the patient's bite at 3 0 months of follow-up.

. .,,., ,. ...,,,.,.,,,,. ,.stance at 3 0 months of follow-up (40.45).

DISCUSSION

In cases of TMJ dislocation, it is importanttodeted the etiological factors of the conditidn and the activities that may worsen or maintain the functional disorder. Parafunctional habits, such as yawning or opening the mouth widely to ingest food, should be avoided. These activities cause the strain of the posterior ligaments of the TMJ and joint capsule (10). In the case described here, the cause of dislocation was probably an association between inadequate adaptation of the prosthesis to the alveolar ridges, patient's age, and mandibulartrauma.

Clinical advice for patients suffering from repeated TMJ dislocation includes: ingest only nonsolid food, chew slowly and bilaterally, without excessivety opening . .

the mouth. The patient should alsoavoid awideopening of the mouth while yawning, which can be achieved by two different ways: by everting the lower lip over the anterior lower teeth or over the prosthesis (as in our patient), or by placing one ofthe hands underthe menton during the yawn, thus controlling mouth opening.

When mandibular dislocation is acute, clinical therapy shows great results. When clinical measures fail, mandibular manipulation is the next treatment to be considered for acute TMJ dislocation, and aims at placing the mandibular head again in its original position. The procedure is performed with the patient sitting and hislher head being supported. The professional stands in front of the patient, with hislher thumbs wrapped in gauze, inserted into the patient's mouth and placed on the occlusal surface of molars or on the alveolar ridges (in cases of patients who do not have teeth). Next, firm downward and backward pressure is applied on the posterior region, aiming at placing the mandibular head in its original site -the mandibular fossa. If severe spasm of elevator muscles of the mandible is observed, muscle relaxants or even sedation may be used (5,14,17).


Grossman & Collares

On the other hand, when TMJ dislocation is chronic (repeated or long-lasting), surgely should be the treatment of choice. Some of the surgical techniques that may be used in the treatment of TMJ dislocation are: discectomy, which aims at augmenting mandibular fossae; capsulorrhaphy, which aims at shortening the TMJ ligament; and fixation of the temporal fascia next to the capsule, in order to provide greater resistance and restrain condylar movements. Some other techniques involve the skeleton. One is called eminectomy or eminoplasty, and reduces the amount of bone tissue in the anterior edge of TMJ, thus allowing the condyle to movefreelyfrom thefossa to the anterior edge of the articular tubercle (which is partially or totally removed). In contrast, the other technique increases the amount of bone tissue in the anterior edge of TMJ, consequently increasing the size of the articular tubercle. This provides a mechanical barrier to the mandibular condyle. Surgely is carried out by means of bone grafling, placement of a steel pin, green-stick fracture of the temporal zygomatic process, and fixation with miniplates, screws, and wires used for osteosynthesis (12-1 5,17,18).

In cases of chronic, long-lasting dislocation, fibmsis involving thewhole TMJ and the shortening of the muscular shafts should be considered.

Since the anterior dislocation of TMJ is mainly carried out by muscles directly responsible for elevating, projecting, and lowering the mandible (in opposition to the action of ligaments), in long-lasting shortened and fibrotic muscles, the risk of postoperative dislocation is present even after the use of eminectomy. Eminence may always be present, preventing the condyle to retum to the fossa due to these powerful shortening mechanisms that pull the mandibular head upwards.

REFERENCES

CONCLUSIONS

Although thetradiional method (manual reduction of the mandibular head), associated or not with anesthetic infiltration or sedation, is effective to place the condyle back to its original position in acute cases, it may not be adequate for patients presenting chronic TMJ dislocation.

The use of an anterior barrier, associated with a green-stick fracture of the temporal zygomatic process on both sides, was effective to create an anterior support aimed at preventing relapse in a case of long- lasting TMJ dislocation.

Figun ME, Garino RR. Anatomia odontologica funcional y aplicada. 4th ed. Buenos Aires: El Ateneo; 2001. Okeson JP. Orofacial pain - guidelines for assessment, diagnosis, and management. The American Academy of Orofacial Pain. Carol Stream: Quintessence; 1996. Teixeira LMS, Reher P, Reher VGS. Anatomia aplicada a odontologia. Rio de Janeiro: Guanabara Koogan; 2001. Bell WE. Temporomandibular disorders: classification, diagnosis and management. 3rd ed. Chicago: Year Book; 1990. Digman RO, Natvig P. Cirurgia das fraturas faciais. Santos: S3o Paulo; 1983. Henny FA. Articulacao temporo-mandibular. In: Kruger GO, editor. Cirurgia bucal e maxilofacial. 5th ed. Rio de Janeiro: Guanabara Koogan; 1984. p. 297-309. Helman J, Laufer D, Minkov B, Gutman D. Eminectomy as surgical treatment for chronic mandibular dislocations. Int J Oral Surg 1984; 13:486-9. Kobayashi H, Yamazaki H, Okudera H. Correction of recurrent dislocation of the mandible in elderly patients by the Dautrey procedure. Br J Oral Maxillofac Surg 2000;38:54-7. Macfarlane WI. Recurrent dislocation of the mandible: treatment of seven cases by a simple surgical method. Br J Oral Surg 1977;14:227-9. Ochs MW, Dolwick MF. Condylar injuries and their sequelae. In: Zarb GA, Carlsson GE, Sessle BJ, Mohl ND, editors. Temporomandibular joint and mast icatory muscle disorders. 2nd ed. Copenhagen: Munksgaard; 1994. p. 315-45. Srivastava D, Rajadnya M, Chaudhary MK, Srivastava JL. The Dautrey procedure in recurrent dislocation: a review of 12 cases. Int J Oral Maxillofac Surg 1994;23:229-31 Undt G, Weichsselbraun A, Wagner A, Kermer C, Rasse M. Recurrent mandibular dislocation under neuroleptic drug therapy, treated by bilateral eminectomy. J Craniomaxillof Surg 1996;24: 184-6. Whear NM, Langdon JD, Macpherson DW. Temporomandibular joint eminence augmentation by down-fracture and inter-positional cartilage graft. A new surgical technique. J Oral Maxillofac Surg 1991;20:357-9. Rode SM, Rode R. Luxa~Bo da ATM. In: Barros JJ, Rode SM, editors. Tratamento das disfuncoes craniomandibulares. Santos: SBo Paulo; 1995. p. 31 3-20. Holmlund AB, Gynther GW, Kardel R, Axelsson SE. Surgical temporomandibular joint luxation. Swed Dent J 1999;23:127-32. Kaplan AS, Assael LA. Temporomandibular disorders: diagnosis and treatment. Philadelphia: W.B. Saunders; 1991. Peter RA, Gross SG. Clinical management of temporomandibular disorders and orofacial pain. Carol Stream: Quintessence; 1995. Mahan PE, Alling CC. Facial pain. Philadelphia: Lea & Febinger; 1991.


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34 Braz J Craniomaxillofac Surg 200

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