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Surgically assisted rapid maxillary expansion is an accepted method for correction of transverse skeletal and dental discrepancies. The surgical technique includes a Lefort I osteotomy with medial palatine osteotomy. The maxillary must be totally released to achieve the desired expansion. There are several advantages: bone apposition in osteotomy sites, reduced risk of dental version or extrusion compared with orthopedic care, secondary surgical cure of complex dysmorphism requiring fewer segmentary osteotomies. Finally, we examined skeletal side effects induced by surgically assisted rapid maxillary expansion in the vertical and sagittal dimension of the face.

Three cases of permanent constriction of the jaw are reported. One was a sequela after a noma, the second occurred in a child with arthrogryposis and the third was an inborn malformation. Each case raised specific problems for diagnosis and treatment. Mechanicotherapy is essential postoperatively and requires a specific electric apparatus to mobilize the joint.

Case report of a patient with myasthenia and dysmorphic facial features. Pluridisciplinary treatments approach.

Even if the functional factors are the most important in the decision, we have always to remember the need of our patient concerning aesthetic improvement. At this moment, the traditional approach based upon morphologic cephalometric analysis (which are frequently discordant) must be substituted by an aesthetic approach. The goal is to obtain a realistic 3D-imaging of the face as it will be after surgery. But it cannot really be achieved yet and we are obliged to work on lateral X-ray cephalograms. The most important at this stage of the decision is not to make a static aesthetic evaluation. It is on the contrary to perform a prospective simulation of the new profile line, as accurate as possible, based upon statistical correlations between soft- and hard-tissues changes. Even if there are some technical problems, even if the results are not currently good enough, the aesthetic prospective analysis allows validation or modulation of the initial functional surgical indication. We can compare for instance the aesthetic results of different amounts of displacements in bimaxillary surgery. Meanwhile, it is sure that the result depends also on the precision of the surgical procedure and on the good functional re-equilibration which is essential for the stability.

The author endeavours to make a detailed description of the clinical examination of the face, which, if performed systematically, allows establishing an accurate diagnosis of the lesions in dysmorphosis and thus locating the latter's seat. The precise modalities of the surgical procedure are defined on the basis of cephalometry and of casts. Cephalometry does not define the site of surgery; it merely confirms it. In our opinion, the esthetic study of the face with the detailed clinical examination remains the key element for the assessment of dysmorphosis.

Most of the scientific papers concerning facial osteotomies are focused on the surgical procedures. However, the most important thing to consider is how to go to the right indication and not how to do it. By an only morphological approach, as we can do with dental casts and cephalometric studies, it is obvious that we forget the functional factors. They nevertheless are essential to consider. Their knowledge permits understanding the physiopathology of the deformity and avoiding the postsurgical relapses. The main five factors concern: the dentoalveolar corridor, between tongue and orbicularis oris muscle, the facial bone growth modeling by functional matrix, the relations between upper incisors, lower incisors and lips, the posterior airway and the rest position of the tongue, the vertical muscular balance. Surgery has to normalize the abnormal function which is at the origin of the abnormal morphology. For this reason, maxillary surgery is better than mandibular surgery for the correction of a Class III deformity. Moreover, the transversal and vertical dimensions are always to be considered at the light of the functional parameters. Most of cases of dentofacial deformities are to be treated by bimaxillary osteotomies, including often transversal and/or vertical modifications. When the anatomical sites of these surgical procedures are determined, then we have to make an aesthetic facial profile simulation to validate the total amount of the bone displacements (cf. Part 2).

The authors emphasize the interest of the frontal cephalometric analysis in facial asymmetries; principles of a simple cephalometric study are given. They analyse the mandibular abnormalities and his maxillary participation. Possibility of surgical treatment and postoperative control can be done. Three cases are presented. This method concerns post traumatic as well as congenital facial asymmetries.

A retrospective statistical analysis is made on 45 patients who have undergone a facial osteotomy. The authors study the vertical changes of the stomion on pre- and post-operative lateral cephalograms. Considering the bad initial results, it has been necessary to create subdivisions on the surgical procedure and to work on homogeneous groups. The results of this study led to the following conclusions: the stomion follows the vertical displacement of the maxilla on an approximative ratio of 1/3, with rather great variations between the subjects; the functional osseous genioplasties, specially with vertical displacement, are not accompanied by significant vertical changes in the position of the stomion. Furthermore, it is obvious that it is necessary to use a "multivariable" method for a better prevision of the cutaneous changes after facial osteotomies, specially for the lips. Indeed, vertical soft tissue changes are the result of the interactions of many vertical and horizontal surgical squelettal displacements.

We habitually use cephalometric analysis to confirm the diagnosis of a latero-facial deformity. A photographic examination completes the clinical evaluation, with the study of the aesthetic profile. For treatment, after study of the dental occlusion (use of study models and surgical set-up of the teeth) this analysis permit-us to determine the ideal place of the maxilla or the mandible.

An improved simplified technique is described for reducing the volume of the tongue by operation. A plastic support has been designed on which the tongue can be spread out symmetrically and fixed in position. Gallbladder forceps are applied to the base of the tongue to avoid hemorrhage. An initial incision is made through the whole thickness of the tongue down to the support, and a partial resectomy performed, followed by apposition of the wound edges. The results obtained with this procedure are far superior to those previously reported using other techniques: the operation takes less time and there is almost no loss of blood.

Genioplasty constitutes an adjunctive surgical procedure used in adult plastic surgery of the facial profile. It is used after dental malocclusion has been corrected and facial morphological features have been reassessed (soft tissue changes consecutive to maxillary osteotomy should be previously analyzed by cephalometry). Genioplasty permits achieving a modification of the chin point in the three planes. The authors describe several types of genioplastic operations, depending on the aim.