Dermatografie

Oral
surgery

Short history of oral surgery

Peru 800 BC cleft lip and tattoo of snake in face

Much of the knowledge currently available regarding the treatment of Maxillofacial fractures and surgery comes from long before Christ. From prehistory there are found just a few skulls with healed fractures. From the Neolithic period(10000 – 4000 BC) there are only 4 skulls found with healed fractures. April 2006 a group of researchers in Pakistan discovered a tomb of about 9000 years old, where a skull was found with restored teeth with clear traces of polish, and they also found drills made of flintstone. This discovery shows that dentistry is 4,000 years older than previously thought. Bérenger - Féraud tells us that in the writings of Moses there are found notes and records about the treatment of jaw fractures by surgeons.

From the Mesolithic period (4000 - 200 BC) we know about 1 skull with a healed fracture of the mandible. This fracture is consolidated with little dislocation of the fragments and a slight callus formation is still recognizable. One of the oldest medical writings comes from China, the "Nei Chung" (theory of internal medicine). The script was probably written by Emperor Huang Ti and is based on Chinese medicine that found its origin about 2700 BC. The referred document was not until the third century BC compiled into the form in which it is known today. The treatment of mandibular fractures through bamboo sticks is clearly described in this script.

Another important document in which the treatment of jaw fractures is described in detail, is a "surgical papyrus" from Egypt, from the middle of the sixteenth century BC. In this papyrus the traumata of 48 patients are described in detail, including some nose and mandibular fractures and their treatments.

Hyppocrates

Also Hippocrates (460-375 BC) left mysticism and started to base the practice of medicine on scientific observations. He describes in his "Corpus Hyppocraticum" among others the manual repositioning of jaw fractures with as starting point the restoration of the occlusion. This will sound familiar in the ears of modern oral surgery nowadays, because this principle is still being used. He assumed that a mandibular fracture could heal in 20 days, except for complications such as infections, etc. The ancient Roman Medical School relies on the basic teaching lessons of Hippocrates.

Due to the Arabs and due to the rise of the Islam, many writings are translated into Arabic. One of the main Islamic physicians is Albucasis (Abu Li – Qasim, 936-1013 AD) living in Córdoba, Spain. He treats fractures of the mandible in the tradition of Hippocrates.


ABU AL-QASIM AL-ZAHRAWI / ABULCASIS MEDICUS

al-Zahrawi medical instruments

Abu al-Qasim Khalaf ibn al-Abbas al-Zahrawi (known in the West as Abulcasis or Albucasis) was born in 936 AD in Zahra in the area of Córdoba. He became one of the most famous surgeons in the Islamic world and was a physician at the court of al-Hakam II. After a long medical career, in which he wrote many original works. He died in 1013 AD. He is best known for his early, original innovations in surgery and his famous medical encyclopedia al-Tasrif. This work consists of thirty volumes (1,500 pages) covering different aspects of medical science. The main parts are the three that concern surgery, in which surgical treatments are described which he performed himself, like cauterization, removal of bladder stones, section on animals, obstetrics, haemostatics, and throat, nose and ear surgery in detail. He optimized several delicate surgical techniques, such as the removal of a dead fetus and amputations. Al-Tasrif was translated by Gerard van Cremona (d.1187) in Toledo in Latin. After that it is edited by many others in Europe. The book contains numerous diagrams and illustrations (200 in total) of surgical instruments that were used or developed by Abu al-Qasim. His medical encyclopedia was an integrated part of the medical curriculum in European countries. In contrast to the opinion that Muslims had little to do with surgery, it shows that al-Tasrif is a monumental encyclopedia for this part of the applied sciences.

Al-Zahrawi was the inventor of several surgical instruments, of which three stand out:
1. a tool for examining the interior of the ear
2. a tool for examining the interior of the urethra
3. a tool to remove foreign objects from the throat

His specialty was the use of cauterization (using branding irons) for curing diseases, a technique which he applied in more than 50 treatments. In al-Tasrif, al-Zahrawi also treats the preparation of various medicines, in addition to surgical treatment in specializations such as otolaryngology, ophthalmology, etc. Because of the preparation of medicines he also describes in detail the methods of sublimation and decantation. Another specialty of al-Zahrawi was dentistry. His book contains several sketches of the tools and descriptions of various important treatments such as apexresection (the removal of an infected root tip) and dental regulation. He has developed the manufacturing of artificial teeth to replace bad teeth.

Galenus van Pergamon

In medicine, al-Zahrawi was the first to recognize the unusual disorder hemophilia. He described a family in which the male members died after apparently benign injuries. His description of the family clearly shows that he was aware of the hereditary nature of the disease. It is obvious that Al-Zahrawi had a profound effect on the development of medical science and surgery, and that the principles he had fielded were very important for the medical world during more than five centuries. His influence in this respect was greater than that of Galen (Pergamon, Greek Asia, 3rd century AD). [copyright L. den Dulk]

al-Zahrawi. Some drawings of his instruments








Canonis Medicinae

Avicenna

Avicenna (Ibn - Sina 980-1280 AD), living in Persia being a physician, poet, philosopher and politician, wrote in his book "Canonis Medicinae" a chapter on the mandibular fracture. He also advises to warn a surgeon, so that he can restore the dental arch using bandages and gold. In the 11th and 12th century AD, other important works of Islamic doctors also were translated into Latin. The first European medical school was established in the 11th century in Salerno in Italy.










Dutch contributions

The first Dutch book on surgery - which also contains a writing about "the diseases of the mouth" - appears at around 1310 and was written by Jan Yperman from Flanders. In 1343 the book "Der Surgien" by Master Thomas Scellinck also appears. He talks about "van den tandvleesche en van den tandsweer" (about toothflesh and caries) and also deals with the fractured jaw. Carolus Battus, the so-called “city physician” of Dordrecht, writes around 1589 a translation of the German Book of Medication, written by Christoforus Wirzung and he dedicates it to our Prince Maurits. In the preface he writes: “Den hoochsten Schat die de mensche op dezer aerde hebben maech (naest de rechte erkentenisse van Jesu Christi) is de gesontheijt deses tijdelicken levens” (“the biggest treasure a man can have on this earth (beside the recognition of Jesus Christ), is health in this temporarily life”).

Ambroise Paré

Carolus Battus also translated the biggest work of Ambroise Paré's, also known as "the father of modern surgery”.

This "Cinq Livres Surgery" was published in 1592 in the Dutch translation and in 1634 in the English translation. It describes and shows the treatment of facial injuries, including war injuries. For the treatment of jaw fractures the treatment principles of Hippocrates and the intermaxillary fixation are recommended. Paré describes the successful reïmplantation of teeth and recommends this technique as a routine procedure. The Frenchman is like Hippocrates impressed by the human resilience. In 1684, in The Hague, a book about the surgery and obstetrics of the city physician Cornelis Solingen appears. In the chapter on the treatment of "Haze Mouths" he distinguishes six types of cleft lips. In its treatment Solingen needs three assistants: two to hold the child and a third to give the instrument !






Herman Boerhaave

Hermanus Boerhaave

The great physician Hermanus Boerhaave (1668-1738) became professor of medicine at Leiden in 1709. In a lecture in 1732, he speaks of a canine that penetrates the mucus of the upper cavity and accuses to all sides violent inflammation, suppuration, and fistulas .For healing, Boerhaave recommends to remove the tooth because "otherwise incurable, often fearsome diseases of eye, nose, cheeks, mouth, throat and palate occur."

In 1771 Petrus Camper from Groningen publishes a paper on the manufacture of an artificial nose and a palate for a man who had had a big defect caused by a trauma. This was what we can call an "early" surgical prosthesis, "The nose was cut from linden wood, painted, and pinned with a silver ring through the nasal cavity around the canine". As a palate he placed a piece of leather, with a sponge as uvula. His motto was 'Simplex sigillat verum' - Simplicity is the hallmark of the true. Zijn motto was ''Simplex sigillat verum'' - Eenvoud is het kenmerk van het ware.

Social status tooth masters

The dentist, as we knowhim now, did not exist. The doctors were limited mostly to giving good advice and writing theoretical considerations. The practical dentistry at that time takes place on the market, where "the barber - surgeon - surrounded by drums and prying eyes shows his skills, but above all arts to the people." Dentistry and surgery were at that time considered as a handicraft and therefore not worthy to be operated by university-trained physicians. Still in 1782 Lassus writes that "the common man sees healing a fracture by putting it straight as just an odd job that requires little skills and just as well could have been done by a farrier as by an experienced physician."

From dental master to MA

It took more than 100 years (1876) beforer the first lecturer (dr.Th. Dentz) was nominated at the University of Utrecht. After this event it goes fast forward. In 1918 Dr. H. de Groot, K.N.O. physician, was appointed a lecturer in the Mouth Surgery and Maxillofacial Surgery at Utrecht, and he is also Director of the Dental Institute. In 1920, the first female lecturer was appointed in Prosthetic Dentistry, mrs. J. G. Schuiringa. Only in the 50s, in 1953 to be precise, the very progressive plastic surgeon dr. Jan Hage, who was educated in England and had just started at the St. Elisabeth Hospital in Tilburg, asked for a surgically trained dentist (Dental Surgeon) to qualify for the extensive maxillofacial injuries and for the manufacture of resection prostheses. The medical director did not waste time, when Jan Hage expressed this wish. It was found in P.Moolhuysen, a dentist, who became one of the first Oral Surgeons in The Netherlands. He was nominated by dr. Jan Hage to acquire further skills for six weeks at the RAF hospital in East Grinstead, at the expense of the hospital.

Two other pioneers followed J.Tolmeijer to the Rotterdam Eye Hospital. This was decided within 5 minutes by Prof. Flieringa: a piece of the bike shed was transformed into treatment room/poli-operation-clinic. T. van den Berg started in Arnhem in the Municipal Hospital. There was working a surgeon, dr. Bax, also a physician / director, who was open to new developments, and Van den Berg was assisted by an assistant general surgeon who, according to Bax "needed the necessary steps to learn to become and stay all-round ." Those were different times, the specialty was still not recognized, and it lasted for 7 years before a price list came out.

From the market to the doctor's office

All kinds of products are still traded on the market today, but the former barber-surgeon has succeeded in moving to a clinic, where he now practices his profession in an environment of waiting rooms, lab coats and a lot of complicated equipment (which is rapidly subject to aging), computer-controlled scans, and successive new techniques. Maxillofacial surgery is one of the medical disciplines that contains a very extensive specialization and is extremely innovative. The course is in recent years not only related to the mouth but now includes the entire face, with many sub-specializations. In addition, the surgeon is since 1990 beside dentist also a doctor.

Dentistry

Orthodontics, gnathology, endodontics, paradontology, implantology, prosthetic dentistry, cranio surgery, head and neck surgery, aesthetic dentistry, reconstructive dental surgery, orthognathic surgery, pediatric dentistry, anesthesia dentistry, social preventive dentistry and caries dentistry. Cariologie.

Specialism Dentistry - Oral Surgery

orthodontics: dental specialty for treating abnormalities in the position of the teeth; If there is a deviation in the position and / or ratio between the jaws orthognathic surgery may be necessary; after the regulation, the teeth will be as beautiful in line as the keys of a piano.

gnathology: dental specialty for treating disorders of the jaw joints and chewing muscles, including mouth opening limitation, popping jaw joints, sore jaw muscles; after the treatment you can effortlessly put a croquette-sandwich cross-stabbing between the teeth.

endodontics: dental specialty for the treatment of the root canals of teeth, e.g. the treatment of an inflamed tooth nerve; when the tooth nerve treatment has taken place, the dentist can put the drill in without anesthesia and you won’t fly against the ceiling.

periodontics: dental specialty for the prevention and treatment of diseases of the supporting tissues of the teeth, including the gums, the surrounding bone and ligament; Periodontitis is a common disease in which the teeth get wonky. Prevention is the best.

implantology: branch of dentistry in which lost teeth are replaced by one or more implants; with these implant teeth you can again smile from ear to ear, although you won’t laugh any longer when you see the bill.

prosthodontics: branch of dentistry for specialized treatments for tooth replacement and dental prosthesis.

aesthetic dentistry: a branch of dentistry which focuses on making teeth nicer (eg whiter). After an aesthetic treatment you have teeth like a movie star.

pedodontia: dental specialty for the prevention and treatment of diseases of (young) children; desperate parents can safely go there; the furniture in waiting room and practice room is designed vandal proof so the little rascals can’t do harm.

narcodontia: dental care that takes place under general anesthesia; it's like going in for a big maintenance.

special care: normal dental care but care that takes place in the hospital because of a particular (rare) dental disease or a complicated disease, condition or disability; a normal regular dentist is also very special.

oral and maxillofacial surgery: formerly called shortened 'oral surgery'; dental specialty for (surgical) treatment of various diseases and injuries of the masticatory system including birth defects, infections, accidents, growth disorders; an oral surgeon is beside dentist also a doctor.

orthognathic surgery: part of the jaw surgery for the surgical correction of malocclusion (deviation in the position of the teeth), dysgnatie (deviation in the relationship between the jaws) and laterognatie (misalignment of the jaw).

cranio-facial surgery: part of the jaw surgery for the surgical correction of (congenital) malformations of the entire skull.

head and neck surgery: part of the jaw surgery (mainly tumor surgery) that deals with the entire head and neck and can be very complex. Several projects in this discipline can last a whole day.

reconstructive jaw surgery: part of the jaw surgery for the surgical correction of complex defects, usually after tumor surgery; many similarities with the plastic surgery and oral surgery. Often there is consultation between these three fields before surgery.

cleft lip and palate surgery: part of the jaw surgery for the surgical correction of congenital cleft lip, jaw and palate cleft.

Development of dermatography from 1986

Prof.dr. D.Müller

dr. F. Noorman van der Dussen

April 1986 I was invited to the University Hospital Utrecht (AZU) by Prof. Dr. D. Müller and Dr. F. Noorman van der Dussen to come to discuss an issue. Some patients got ink markers (Methyl-blue) gently injected into the mucous membrane of the mouth in order to give these patients anesthesia because it was difficult for these patients to get the regular anesthesia. This technique was also used to check whether for instance tumors treated in the mucous membranes of the mouth remained stable, disappeared or showed growth. When the tumor had grown, the marking made sure that the tumor could be well removed .


This method was often counterproductive and they saw that as a big problem. The technique which I applied was not injecting, (because by putting pressure with a syringe the ink liquifizes also to places where it should not go) but I gently applied with 3 bundled needles a drop of black dye to the mucous membrane. After the puncture a drop of ink remains in the epidermis which is stable and does not give discoloration on the outside of the skin. After two years we published our findings in an international medical journal.

Blue discoloration at the outside.

Leaked discoloration at the inside of the mucosa.













Marking 1 drop of black dye (The Van der Velden Method).

Marking 3 drops in the mucosa without leak.

Needles with a thickness of 0.32 mm.













The question and the goal was clear: What can medical tattooing (from 1990 known as dermatography) mean in medicine and how can we develop a reliable way of ringing pigments in the skin without reactions of allergy and, very important, do this with a scientific based evidence.

A group that would qualify for this research were for instance patients with transplants. Besides severe discoloration of the new skin that was transplanted, there were also often seen ugly scars. If I could reduce these scars from hypertrophic to atrophic and also color the scars, that would be a spectacular improvement, both for the patient and for his environment. Because of my knowledge and training in Japan (1980 - 1986) I had the experience to set up this specific profession with the medical support of Müller and Noorman van der Dussen. Within eighteen months, I developed 144 skin tones and many skin biopsies which I took from patients during my research looked promising. Both histo-pathology and electron microscopy showed that the dyes were safe and that there were no inflammatory responses, even not in the long run. Beside patients of the Oral Pathology Department and Oral Surgery I got patients of Professor B.D. de Jong of the department of plastic surgery and Prof. TH.Theodoridis, professor in vascular graft surgery. They were very supportive, they liked my method and were a great stimulation for me. Patients who had suffered from visible discoloration and scarring after trauma and major surgery's (mostly in the face and neck area) were treated by me. Being an artist I liked to delve into the anatomy of the head and neck, so I often assisted Dr. Noorman van der Dussen in the morning during his work in the big Operation Room. I could not imagine there is a better teacher. He gave me the opportunity to expand my medical knowledge and insight. The big amount of ideas back and forth about what would be possible, were very useful in later years, not to mention my historical medical knowledge.

The first group of patients with transplants:

1 year after transplant (tumorresection in the mucosa).

Upper portion treated, middle portion untreated, lower portion immediately after treatment.













After 15 x 1 hour of dermatography and 2 year follow-up.

2 year after transplantation.

After 2 year follow-up dermatography. The scars have a smoother color en the skin is more flexible.













1 year after transplantation.

15 months after 12 treatments of dermatography.

Beside the color the scar edges are smoother and flatter.


















Scars after surgery

The scars that are inevitable after major surgical procedures were treated by me with Intracicatricialekeloïdectomie (by means of needles which have a cutting effect and at the same time apply pigment in the scar). This way hypertrophic scars can change into atrophic scars. (change from hard scars to soft scars that blend into the normal skin area. In other words, they become softer and because they perform more space the scarsd are less painful and flatter.

After operation throat/neck tumor.

After 8 treatments of dermatography.

After operation throat/neck tumor.

After 6 treatments of dermatography.

After operation trauma.

After 12 treatments of dermatography.

After throat/neck dissection and radiation (discoloration of the skin).

After 15 treatments of dermatography.





































Cheilognathopalatoschisis (cleft lip)

Patients who are born with a cleft lip (single or double) can be treated after their 16th birthday to their remaining scars, with or without pseudo hair growth. First we put the scar in color and then, with a special technique similar to pointillism, we put little dots into the skin so that it looks like hair or stubble. Research showed that this group of patients who was treated by dermatography started to articulate better and became more self-assured

After operation schisis duplex.

After 6 treatments of dermatography.













After operation schisis duplex.

After 4 treatments of dermatography.

After 6 treatments of dermatography, including pseudo hair growth.











Scars after cranio surgery

After a cranio-surgical operation we always see nasty scars. They often run from one ear to the other on the middle of the skull, because the hair growth often does not come back after this type of surgery. The scar is almost always white colored. First, we put the scar in color and then, with a special technique similar to pointillism, we make little dots into the skin so it looks like hair growing or stubble. Also grafts that are applied to the skull (Cranio) can be colored well, and the edges of the graft are often smooth and run over in the normal skin.

After a cranio-surgery operation.

After 4 treatments of dermatography and pseudo hair growth.