Condylar surface CT value in sagittal plane before and after sagittal split ramus osteotomy

PURPOSE

The purpose of this study was to evaluate the relationship between computed tomography (CT) values of the condylar surface and temporomandibular joint (TMJ) disc position in the sagittal plane before and after sagittal split ramus osteotomy (SSRO) setback surgery, retrospectively.

MATERIALS AND METHODS

The subjects were 75 patients (150 condyles) who underwent bilateral SSRO setback surgery. They were divided into two groups (42 symmetric patients and 33 asymmetric patients). Maximum CT values (pixel values) of five points of the condylar surface and condylar height, length, fossa height, fossa length, and ramus angle in the sagittal plane were measured preoperatively and 1 year postoperatively. Disc position was classified as anterior disc displacement, anterior type, fully covered type, and posterior type, both pre- and postoperatively, using magnetic resonance imaging (MRI).

RESULTS

Postoperative value was significantly higher than preoperative one in CT value of 135° (P = 0.0199) and 180° (0.0363), in the non-deviation side in the asymmetry group. The anterior disc displacement group was significantly larger than those of some other areas pre- and postoperatively in the CT value of 0° point (P < 0.05).

CONCLUSIONS

This study suggested that CT value of the posterior site of the condylar surface could change in the non-deviation side in the asymmetry group after 1 year SSRO, and the condyle with anterior displacement showed high CT value at the anterior site of the condyle before and after surgery.

Cone-beam computed tomography evaluation on the condylar displacement following sagittal split ramus osteotomy in asymmetric setback patients: Comparison between conventional approach and surgery-first approach

OBJECTIVE

To compare the condylar displacement following sagittal split ramus osteotomy (SSRO) in asymmetric setback patients between the conventional approach and surgery-first approach and to determine whether the condylar displacement is affected by asymmetric setback in SSRO patients.

MATERIALS AND METHODS

This was a retrospective study. The subjects consisted of patients with facial asymmetry who underwent SSRO and had cone-beam computed tomography taken before and 1 month after surgery. They were allocated into the conventional (n = 18) and surgery-first (SF) groups (n = 20). Descriptive, independent t-tests and Pearson correlation analysis were computed.

RESULTS

The amount of condylar displacement in x-, y-, and z-directions and Euclidean distance showed no statistically significant differences between the conventional and SF groups. Comparing the postoperative condylar position with the preoperative position, the condylar displacement occurred in posterior (P < .05) and downward (P < .05) directions in both groups except on the deviated side in the conventional group. The condylar displacement occurred in a posterior (P < .05) direction on the deviated side of the conventional group. However, the condylar displacement in three dimensions showed no statistically significant differences between the two groups. In the correlation analysis, the condylar displacement in both the deviated and contralateral sides showed no significant correlation with asymmetric setback in either group.

CONCLUSION

The condylar displacement in three dimensions and the distance of condylar displacement in SSRO patients with facial asymmetry showed no significant difference between conventional and SF groups. Condylar displacement was not associated with asymmetric setback.

Vertical ramus elongation and mandibular advancement by endobuccal approach: Presentation of a new osteotomy technique

INTRODUCTION

Several surgical procedures have been proposed for the treatment of hyperdivergent dentoskeletal deformities. We propose a new osteotomy technique allowing for lengthening and advancement of the mandibular ramus by intra-oral approach.

SURGICAL PROCEDURE

This technique differs from the conventional sagittal split osteotomyin that which the anterior osteotomy line is not continued until the basilar edge but stopped 5-6mm above it. Cutting of the pterygomasseteric sling is systematically done allowing for the lowering of the mandibular angle. Osteosynthesis is performed by transjugal and intra-oral approaches, using two adjustable miniplates. Our supra-angular technique allows for both elongation of the ramus and advancement of the mandible. Unlike the vertical ramus osteotomy proposed by Caldwell-Letterman, external incision and intraoperative cervical hyperextension are not required.

Sequential changes of postoperative condylar position in patients with facial asymmetry

OBJECTIVE

To evaluate sequential images of the condylar position in relation to the glenoid fossa after orthognathic surgery in patients with facial asymmetry using cone beam computed tomography.

MATERIALS AND METHODS

A total of 20 adult patients (11 men and 9 women; mean age, 22.1 ± 4.02 years) with facial asymmetry who underwent sagittal split ramus osteotomy with rigid fixation were involved. Cone beam computed tomography scans were obtained before treatment (T0), 1 month before the surgery (T1), and 1 day (T2), 3 months (T3), 6 months (T4), and 12 months (T5) after the surgery. The condyle position was evaluated.

RESULTS

At 1 day after surgery (T2), the condylar position on both sides significantly changed posteriorly, inferiorly, and laterally, but no significant difference was observed between the nonaffected and affected sides. The condyle on the nonaffected side had a tendency to recover its preoperative position at 3 months after surgery (T3) and inclined slightly laterally up to 1 year after the surgery (T5). The condyle on the affected side returned more closely to the glenoid fossa than to its pretreatment position at 3 months after surgery (T3). Thereafter, it showed a more backward and downward position (T5).

CONCLUSIONS

The overall condylar position after an orthognathic surgery in patients with facial asymmetry was relatively stable at 1 year after surgery. However, the condyle on the affected side during the first 3 months after surgery should be carefully monitored for surgical stability.

[Sagittal split ramus osteotomy combined with intraoral distraction osteogenesis for hemifacial microsomia]

OBJECTIVE

To investigate the effect of sagittal split ramus osteotomy(SSRO) combined with distraction osteogenesis(DO) for hemifacial microsomia (HFM).

METHODS

From January 2013 to September 2015,7 cases of unilateral HFM were included in the study. The 3-dimensional reconstruction images were used for the operation design. The location of the germs and inferior alveolar nerve was marked to avoid injury. The distractor was fixed after SSRO. The distractor was distracted 2-4 mm intraoperatively and began enlongation 3-5 days after operation,1-2 mm every day until the pre-designed length attained. The patients were followed up for 3-D CT and measurement of the height of bilateral ramus.

RESULTS

The enlongation length was 7 mm to 20 mm(mean,14.6 mm).The facial symmetry and occlusion plane was improved a lot. No complication occurred. The mean follow-up period was 22 months (range 17-32 months) with almost symmetrical appearance and occlusion function.

CONCLUSIONS

SSRO combined with DO has a good therapeutic effect and low complication for patients with HFM. The distraction rate is relatively high with a short treatment period. The ramus width, even thickness, are not decreased, or even can be increased after DO.

Does mandibular osteotomy affect gonial angle in patients with class III deformity? Vertical ramus osteotomy versus sagittal split osteotomy

The mandibular angle represents an important part of facial aesthetics. Mandibular osteotomy can affect the gonial angle. The aim of this study was to compare the effects of sagittal split osteotomy (SSO) and intraoral vertical ramus osteotomy (IVRO) on the gonial angle. This retrospective cohort study assessed subjects with mandibular prognathism who underwent SSO (group 1) or IVRO (group 2). Lateral cephalograms obtained before and 1 year after the osteotomies were analyzed. In this study, age, sex, the change in occlusal plane (OP) and mandibular plane (MP) angles, and the amount of mandibular setback were considered as variable factors, while the type of surgery (SSO or IVRO) was considered the predictive factor. Fifty-six subjects were studied: 26 in group 1 and 30 in group 2. The changes in MP angle and OP angle were not significantly different between the groups (P>0.05). The change in gonial angle was 6.07±4.46° in group 1 and 7.33±5.73° in group 2; assessment of the data did not demonstrate a significant difference between the two groups studied (P=0.53). Mandibular osteotomy (SSO or IVRO) may change the gonial angle, but a significant difference between SSO and IVRO was not detected.

Bad splits in bilateral sagittal split osteotomy: systematic review of fracture patterns

An unfavourable and unanticipated pattern of the mandibular sagittal split osteotomy is generally referred to as a 'bad split'. Few restorative techniques to manage the situation have been described. In this article, a classification of reported bad split pattern types is proposed and appropriate salvage procedures to manage the different types of undesired fracture are presented. A systematic review was undertaken, yielding a total of 33 studies published between 1971 and 2015. These reported a total of 458 cases of bad splits among 19,527 sagittal ramus osteotomies in 10,271 patients. The total reported incidence of bad split was 2.3% of sagittal splits. The most frequently encountered were buccal plate fractures of the proximal segment (types 1A-F) and lingual fractures of the distal segment (types 2A and 2B). Coronoid fractures (type 3) and condylar neck fractures (type 4) have seldom been reported. The various types of bad split may require different salvage approaches.

[Short sagittal osteotomy]

Bilateral sagittal split osteotomy has become the standard mandibular surgery for the treatment of dento-facial deformities. Even patients with less important deformities may undergo surgery. The morbidity must be as low as possible. We describe a technique with reduced split surfaces. The osseous section follows an oblique line since the thorn of Spix below and outside towards the supra-angular region. This section is completed by an osteotomy of the posterior border of the mandible. This split never reaches the inferior alveolar nerf tunnel. The protection of the alveolar nerve is increased what decreases considerably the risk of nervous complications of this intervention. The majority of the mandibular movements are possible by this technique with the exception of the important advancements and the increase of the height of the ramus.

Reduced somatosensory impairment by piezosurgery during orthognathic surgery of the mandible

PURPOSE

This clinical trial aimed to test the hypothesis that piezosurgery causes reduced nerval irritations and, thus, reduced somatosensory impairment when used in orthognathic surgery of the mandible.

METHODS

To this end, 37 consecutive patients with Angle Class II and III malocclusion were treated using bilateral sagittal split osteotomies (BSSO) of the mandible. In a split mouth design, randomized one side of the mandible was operated using a conventional saw, while a piezosurgery device was used on the contralateral side. In order to test the individual qualities of somatosensory function, quantitative sensory testings (QSTs) were performed 1 month, 6 months and 1 year after surgery.

RESULTS

A comparison of the data using a two-way analysis of variance (ANOVA) revealed a significant reduction in postoperative impairment in warm detection threshold (WDT) (P = 0.046), a decreased dynamic mechanical allodynia (ALL) (P = 0.002) and a decreased vibration detection threshold (VDT) (P = 0.030) on the piezosurgery side of the mandible as opposed to the conventionally operated control side. In the remaining QSTs, minor deviations from the preoperative baseline conditions and a more rapid regression could be observed.

CONCLUSIONS

Piezosurgery caused reduced somatosensory impairment and a faster recovery of somatosensory functions in the present investigation.

Adjustable selective maxillary expansion combined with maxillomandibular surgery: A case report

BACKGROUND

Surgically assisted rapid maxillary expansion (SARME) is usually considered the gold standard for maxillary transverse expansion in adults. However, a second surgical procedure is needed in cases of associated sagittal or vertical discrepancies. We describe the use of two new innovative devices for the correction of discrepancies in all dimensions during a single surgical procedure, thus reducing treatment duration.

MATERIAL

We report the case of a 21-year-old female patient, referred to our department for skeletal Class III malocclusion associated with right-side laterognathism and transverse maxillary deficiency. The patient underwent one-stage surgery, using sliding osteosynthesis plates and an adjustable bone-borne distractor. Pre-surgical orthodontics consisted in leveling and aligning the mandibular arch; maxillary leveling was initiated 3 months before surgery. Postoperative palatal distraction combined with orthodontic finishing enabled complete correction of dental and bony discrepancies after 3 months.

CONCLUSION

In our experience, treatment of transverse, sagittal and vertical discrepancies has been possible in a single surgical procedure, using two innovative techniques: sliding osteosynthesis and an adjustable bone distractor. Two years post-surgery, the correction is stable in all dimensions.

Combined surgical-orthodontic treatment: how did it evolve and what are the best practices now?

It has been 50 years since the landmark presentation by Hugo Obwegeser at Walter Reed Army Hospital. At that conference, Professor Obwegeser offered American surgeons techniques to correct facial skeletal deformities with access through intraoral incisions. As important advances in surgical technique and anesthesia evolved for the surgical procedures, a major contribution by American orthodontists in collaboration with surgeons was the creation of a common diagnostic, planning, and treatment scheme for use by both clinician groups in the treatment of dentofacial deformities, the skeletal and dental problems of the most severely affected 5% of the population. This article summarizes what American orthodontists and surgeons have learned in the late 20th and early 21st centuries, and forecasts what might be the future of treatment for patients with dentofacial deformities.

Evaluation of long-term soft tissue changes after bimaxillary orthognathic surgery in Class III patients

OBJECTIVE

To assess soft tissues in the short and long term after bimaxillary surgery in Class III patients by comparing the hard tissue changes and results between time periods.

MATERIALS AND METHODS

Twenty-six Class III adult patients treated with bimaxillary surgery were included in the study. Cephalometric records were taken before surgery (T1) and 5 months (T2), 1.4 years (T3), 3 years (T4), and 5 years (T5) after surgery.

RESULTS

There was no significant relapse in skeletal parameters. Overjet was significantly reduced between T4-T3 time intervals (P < .01). There were significant increases in Sn-HR, ULA-HR, LLA-HR, B-B(∧) (P < .01), and B(∧)-HR (P < .05) between T4-T3 time intervals. There was no significant change in the soft tissue parameters between T5-T4 time intervals.

CONCLUSION

Soft tissue vertical relapse occurs in skeletally stabile Class III bimaxillary surgery patients in the first 3 years after surgery.

Does the Pharyngeal Airway Recover After Sagittal Split Ramus Osteotomy for Mandibular Prognathism?

PURPOSE

Mandibular setback surgery can adversely affect the pharyngeal airway. The aim of this study was to investigate changes of the pharyngeal airway at specific intervals during a 12-month period after bilateral sagittal split ramus osteotomy (BSSO) for correction of mandibular prognathism.

MATERIALS AND METHODS

This retrospective cohort study included patients with mandibular prognathism who underwent BSSO. The pharyngeal airway was measured at 3 different levels on lateral cephalograms: the uvula tip, the most inferior-anterior point on the body of the second cervical vertebra (low-C II), and a midanterior point on the body of the third cervical vertebra (mid-C III). The pharyngeal airway was measured preoperatively, immediately postoperatively, and 1, 3, 6, and 12 months postoperatively. The measurements at each level were compared. Multivariable analysis of variance was used to measure the changes in pharyngeal airway space over time.

RESULTS

The study sample was composed of 30 patients (14 men and 16 women) who were diagnosed with mandibular prognathism. The pharyngeal airway at the uvular tip level was significantly reduced by 39% (P < .001) after surgery and was significantly improved by 26% (P < .01) from baseline at 1 month postoperatively. The pharyngeal airway at the low-C II level was significantly reduced by 27% (P < .001) after surgery and was significantly improved by 24% (P < .01) from baseline at 1 month postoperatively. The pharyngeal airway at the mid-C III level was significantly reduced by 23% (P < .001) after surgery and was improved by only 13% from baseline at 1 month postoperatively. Additional statistical changes were not noted on 3 and 6 months postoperative radiographs at all levels. The pharyngeal airway was decreased by 16, 19, and 8% from baseline at 12 months postoperatively, respectively. The upper airway length was significantly increased immediately after surgery (P < .001), but was incompletely recovered at 12 months postoperatively.

CONCLUSION

The outcomes of this study indicate that the pharyngeal airway gradually recovers over time. An immediate postoperative reduction in pharyngeal airway space can induce or exacerbate obstructive sleep apnea symptoms; thus, any pre-existing symptoms should be screened and considered for surgical treatment planning.

Unilateral condylar hyperplasia: diagnosis, clinical aspects and operative treatment. A case report

BACKGROUND

Condylar hyperplasia of the mandible is an uncommon idiopathic disorder of the jaw characterised by increased volume of the condyle, unilaterally or bilaterally, leading to facial asymmetry, mandibular deviation, malocclusion and articular dysfunction.

CASE REPORT

The authors present one case of unilateral condylar hyperplasia of a 16-year-old patient affected by severe facial asymmetry. Conventional X-rays examinations, multislice spiral CT and bone SPECT were used for the final diagnosis of primary condyle hyperplasia. The patient was treated with a combined orthodontic and surgical approach.

CONCLUSION

Treatment of condylar hyperplasia with a combined orthodontic and surgical approach including condylectomy yield good aesthetic and functional outcomes.

A Modified Method of Proximal Segment Alignment After Sagittal Split Ramus Osteotomy for Patients With Mandibular Asymmetry

PURPOSE

The purpose of this study was to evaluate a modified method of aligning the proximal segment after bilateral sagittal split ramus osteotomy (BSSO) in the treatment of patients with facial asymmetry.

PATIENTS AND METHODS

Eleven patients with mandibular excess and facial asymmetries were enrolled in this prospective study. The surgery was planned according to a computer-aided surgical simulation protocol. In addition, the proximal segment on the hypoplastic side was intentionally flared out after the distal segment was rotationally set back. If the gap between the proximal and distal segments was too wide, then bone grafts were used. The surgery was completed according to the computerized plan. The proximal segment on the hypoplastic side was fixed with bicortical lag screws, and the proximal segment on the hyperplastic side was fixed with a 4-hole titanium miniplate. Postoperative evaluation was performed 6 months after surgery. Statistical analyses were performed.

RESULTS

All surgeries were completed uneventfully. Of the 11 patients, 4 also underwent genioplasty and 3 underwent bone grafting to fill in the gap and smooth the anterior step. The physicians and patients were satisfied with the surgical outcomes. Only 1 patient underwent a secondary revision using an onlay hydroxyapatite implant. Results of statistical analyses showed that the computerized surgical plan could be accurately transferred to the patients at the time of surgery and the surgical outcomes achieved with this modified method were better than with the routine method of aligning the proximal and distal segments in maximal contact.

CONCLUSION

The present modified method of aligning the proximal segment for BSSO can effectively correct mandibular asymmetry and obviate a secondary revision surgery.

Do changes in oral health-related quality-of-life, facial pain and temporomandibular disorders correlate after treatment of severe malocclusion?

INTRODUCTION

The aim was to evaluate the relationships of changes in facial pain, temporomandibular disorders (TMDs) and oral health-related quality-of-life (OHRQoL) in adults who underwent orthodontic or orthodontic/surgical treatment.

METHODS

Sixty-four patients (46 women, 18 men, range 18-64 years) with severe malocclusion and functional problems were treated in Oulu University Hospital. Of these, 44 underwent orthodontic-surgical and 20 orthodontic treatment. Data were collected with questionnaires and clinical stomatognathic examinations before and on average 3 years after treatment. The OHRQoL was measured with OHIP-14 (The Oral Health Impact Profile), the intensity of facial pain with the Visual Analogue Scale (VAS) and the severity of TMD with the Helkimo's anamnestic (Ai) and clinical (Di) dysfunction indices.

RESULTS

A significant improvement was found in facial pain, signs and symptoms of TMD and OHRQoL after the treatment (p < 0.05). The decrease in VAS was associated with improvement in OHIP-14 severity (r = 0.296, p = 0.019). The correlations between changes in OHIP-14 severity and Ai and Di were not statistically significant.

CONCLUSION

Treatment of severe malocclusion seemed to improve OHRQoL via decreased facial pain. Decreased facial pain was associated especially with improved OHRQoL dimensions of physical pain, physical disability and social disability.

Weight loss in orthognathic surgery: a clinical study

OBJECTIVE

To analyse weight change, body composition change and Body Mass Index change in patients undergoing orthognathic surgery.

DESIGN

A service evaluation was undertaken in orthognathic patients pre-operatively and at 4 weeks post-surgery.

SETTING

Queen Elizabeth Hospital Birmingham outpatient department.

SUBJECTS

Thirty-one patients scheduled for single- or two-jaw orthognathic surgery and rigid internal fixation.

METHODS

Immediately pre-operatively and at 4 weeks post-surgery the following information was gathered: (1) patient height; (2) patient weight (kg); (3) Patient Body Mass Index; and (4) patient body fat percentage.

RESULTS

In the 4-week post-operative period, the average weight loss was -4·96 kg (range: -9·6 to +3·0 kg), with a body fat reduction of -3·07% (range: -5·80% to +2·30%) and an average reduction in Body Mass Index of -1·63 (range: -3·4 to +0·8). There was no statistically significant difference in weight loss (P = 0·1562) or body fat composition change (P = 0·2391) between single- or two-jaw surgery. There was no statistically significant difference in weight loss (P = 0·4858) or body fat composition change (P = 0·5321) between male and female patients.

CONCLUSIONS

Weight loss observed was similar to that reported in studies using inter-maxillary fixation. Closer psychological and dietetic support is needed for patients who have a low normal or underweight Body Mass Index. Better and more bespoke tailored Oral Nutritional Supplementation must be provided for all orthognathic surgery patients to potentially reduce this significant weight loss.

A modified occlusal wafer for managing partially dentate orthognathic patients--a case series

A multidisciplinary approach is essential in orthognathic surgery to achieve stable and successful outcomes. The model surgery planning is an important aspect in achieving the desired aims. An occlusal wafer used at the time of surgery aids the surgeon during correct placement of the jaws. When dealing with partially dentate patients, the design of the occlusal wafer requires modification to appropriately position the jaw. Two cases with partially dentate jaws are presented in which the occlusal wafer has been modified to provide stability at the time of surgery.

Distraction osteogenesis and orthognathic surgery for a patient with unilateral cleft lip and palate

Maxillary deficiency is a common feature in patients with repaired cleft lip and palate. Orthognathic surgery has been the conventional approach for the management of cleft-related maxillary hypoplasia. However, for patients with a severe maxillary deficiency, orthognathic surgery alone has many disadvantages, such as high relapse rates of 25% to 40%, instability, limited amount of advancement, and a highly invasive surgical technique. As an alternative treatment method, distraction osteogenesis has been used successfully in the distraction of the mandible, the maxilla, the entire midface, and the orbits as well as the cranial bones, with stable outcomes. The type of distraction device, either external or internal, can be chosen based on the surgical goals set for the patient. In this study, we report on the use of a rigid external distraction device for maxillary advancement in a 22-year-old woman with a repaired unilateral cleft lip and palate and severe maxillary hypoplasia. After the distraction osteogenesis, 2-jaw surgery was performed to correct the maxillary yaw deviation and the mandibular prognathism.

Evaluation of pharyngeal airway space changes after bimaxillary orthognathic surgery with a 3-dimensional simulation and modeling program

INTRODUCTION

The aims of this study were to use 3-dimensional simulation and modeling programs to evaluate the effects of bimaxillary orthognathic surgical correction of Class III malocclusions on pharyngeal airway space volume, and to compare them with the changes in obstructive sleep apnea measurements from polysomnography.

METHODS

Twenty-five male patients (mean age, 21.6 years) with mandibular prognathism were treated with bilateral sagittal split osteotomy and LeFort I advancement. Polysomnography and computed tomography were performed before surgery and 1.4 ± 0.2 years after surgery. All computed tomography data were transferred to a computer, and the pharyngeal airway space was segmented using SimPlant OMS (Materialise Medical, Leuven, Belgium) programs. The pretreatment and posttreatment pharyngeal airway space determinants in volumetric, linear distance, and cross-sectional measurements, and polysomnography changes were compared with the paired samples t test. Pearson correlation was used to analyze the association between the computed tomography and polysomnography measurements.

RESULTS

The results indicated that setback procedures produce anteroposterior narrowing of the pharyngeal airway space at the oropharyngeal and hypopharyngeal levels and the middle and inferior pharyngeal volumes (P <0.05). In contrast, advancement of the maxilla causes widening of the airway in the nasopharyngeal and retropalatal dimensions and increases the superior pharyngeal volume (P <0.05). Distinctively, bimaxillary orthognathic surgery induces significant increases in the total airway volume and the transverse dimensions of all airway areas (P <0.05). Significant correlations were found between the measurements on the computed tomography scans and crucial polysomnography parameters.

CONCLUSIONS

Bimaxillary orthognathic surgery for correction of Class III malocclusion caused an increase of the total airway volume and improvement of polysomnography parameters. A proposed treatment plan can be modified according to the risk of potential airway compromise or even to improve it with 3-dimensional imaging techniques and polysomnography.

Correction of facial asymmetry and maxillary canting with corticotomy and 1-jaw orthognathic surgery

Although 2-jaw orthognathic surgery is a typical recommendation for the treatment of facial asymmetry, another good treatment alternative is maxillary corticotomy with temporary skeletal anchorage devices followed by mandibular orthognathic surgery. The corticotomy procedure described here can achieve unilateral molar intrusion and occlusal plane canting correction with potentially fewer complications than 2-jaw orthognathic surgery. The approach allows movement of dentoalveolar segments in less time than with conventional dental intrusion using temporary skeletal anchorage devices. A 2-jaw asymmetry with occlusal plane canting might be corrected using maxillary corticotomy and mandibular orthognathics rather than 2-jaw orthognathics. Two patients with facial asymmetry are presented here. In each one, the maxillary cant was corrected over a period of 2 to 3 months with 3.5 mm of intrusion of the unilateral buccal segment. After the preorthognathic cant correction, orthognathic surgery was done to correct the mandibular asymmetry.

Impact of Perioperative Fluid Administration on Postoperative Morbidity and Length of Hospital Stay Following Maxillomandibular Advancement for Obstructive Sleep Apnea

PURPOSE

The purpose of this study was to evaluate whether the volume of perioperative fluids administered to patients undergoing maxillomandibular advancement (MMA) for treatment of obstructive sleep apnea (OSA) is associated with an increased incidence of postoperative complications and prolonged length of hospital stay.

MATERIALS AND METHODS

A retrospective cohort study design was implemented and patients undergoing MMA for OSA at the Mayo Clinic were identified from 2001 through 2014. The primary predictor variable was the total volume of intravenous fluids administered during MMA. The primary outcome variable was length of hospital stay in hours. Secondary outcome variables included the presence of complications incurred during postoperative hospitalization. Additional covariates abstracted included basic demographic data, preoperative body mass index, preoperative apnea-hypopnea index, preoperative Charlson comorbidity index, preoperative American Society of Anesthesiologists score, type of intravenous fluid administered, surgical complexity score, duration of anesthesia, duration of surgery, and the use of planned intensive care unit admission. Univariate and multivariable models were developed to assess associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables.

RESULTS

Eighty-eight patients undergoing MMA for OSA were identified. Total fluid volume was significantly associated with increased length of stay (odds ratio [OR] = 1.34, 95% confidence interval [CI], 1.05-1.71; P = .020) in univariate analysis. Total fluid volume did not remain significantly associated with increased length of hospital stay in stepwise multivariable modeling. Total fluid volume was significantly associated with the presence of postoperative complications (OR = 1.69; 95% CI, 1.08-2.63; P = .021) in univariate logistic regression.

CONCLUSION

Fluid administration was not found to be significantly associated with increased length of hospital stay after MMA for OSA. Increased fluid administration might be associated with the presence of postoperative complications after MMA; however, future large multicenter studies will be required to more comprehensively assess this association.

Tongue Size and Posterior Airway Space Changes in Class III Malocclusion After Maxillomandibular Surgery: A Retrospective Study

The purpose of this study was to evaluate the changes in the airway space after surgical correction of Class III skeletal dentofacial deformity and to determine if orthognathic surgery alters the airway space and improves obstructive sleep apnea. Twenty-four Class III adults treated with orthognathic surgery were divided into two groups as Mandibular set-back (Bilateral Sagittal Split Osteotomy-BSSO, 10 patients) and two jaw surgery (Bilateral Sagittal Split Osteotomy combined with Le Fort I maxillary advancement, 14 patients). Lateral cephalometric radiographs were traced before (T0) and 6 months after surgery (T1). Steiner and McNamara analysis, linear pharyngeal airway measurements (PNS-PPW1, SPT-PPW2, E-PPW3, PNS-SPT), tongue volume measurements (TH, Tt-Eb) and pharyngeal area measurements (nasopharyngeal, upper oropharyngeal, lower oropharyngeal, epiglottis area) were performed. The data obtained was analyzed statistically by repeated measurement ANOVA and Duncan's test. The increase of PNS-PPW1 was important in two jaw surgery group (p < 0.05). The nasopharyngeal area was statistically different between T0 and T1 (p < 0.01), and the lower oropharyngeal area was statistically significant between BSSO and two jaw surgery groups (p < 0.05). Surgical correction of Class III skeletal dentofacial deformity alters posterior airway dimensions. Two jaw surgery is advantageous considering the risk for obstructive sleep apnea, because it evokes an increase in the upper pharyngeal airway dimensions. Keywords: Tongue size, posterior airway space, maxillomandibular surgery.

In vitro comparison of the sagittal split osteotomy with and without inferior border osteotomy

PURPOSE

By adding an osteotomy of the inferior border of the mandibular body to the classic sagittal split osteotomy, the authors expected to prevent unfavorable splits and damage to the inferior alveolar nerve.

MATERIALS AND METHODS

Thirty-five human mandibles were used to perform 70 sagittal split osteotomies as an in vitro study. Conducted as a split-mouth model, each mandible was split at the midline. One side of the mandible was split using the traditional Obwegeser-Dal Pont technique, and the other side was split in the same manner with an additional osteotomy of the inferior mandible border. The torque used to split the mandible was measured, and the fracture line of the mandible was recorded.

RESULTS

The average torque associated with the original technique was 1.38 Nm (standard deviation, 0.60 Nm), with a fracture line along the mandibular canal. The average torque required to split the hemimandible with the modified technique was 1.02 Nm (standard deviation, 0.50 Nm), a significant (P < .001) difference, with a fracture line parallel to the posterior ramus of the mandible. The fracture pattern depended significantly on the technique used (P < .001), but not on the applied torque force.

CONCLUSION

By adding an osteotomy of the inferior mandibular border to the sagittal split osteotomy, less torque was needed to split the mandible. The fracture line was more predictable, even when all the surgical manipulations were performed at a safe distance from the inferior alveolar nerve.

Severity and outcome assessments of patients undertaking surgical orthodontic treatment

BACKGROUND

Combined orthognathic-orthodontic treatment can be lengthy and expensive. It is therefore important to evaluate the effectiveness of proposed treatment and the likely outcomes.

OBJECTIVES

To determine the demographic and surgical details of patients who received orthognathic-orthodontic treatment at Christchurch Hospital, New Zealand, and to assess treatment using the Severity and Outcome Index (SOI).

METHODS

An observational and retrospective study was conducted of patients who received surgical orthodontic treatment between 2005 and 2012 at Christchurch Hospital. Pre- and post-treatment lateral cephalometric radiographs of 93 patients were evaluated. Seven cephalometric parameters were assessed using the Severity and Outcome Index. A severity score ranged from 0 for the most severe to 7 for the least severe, while the outcome score ranged from 0 for the worst to 7 for the best outcome.

RESULTS

Class II patients had a severity score of 3.4 and the best outcome score of 6.2. Class III patients had a severity score of 3.3 and an outcome score of 6.1. Patients with an anterior open bite (AOB) had the worst severity score of 3.0, and the worst outcome score of 5.9. The overall treatment outcome scores for all groups were statistically significantly greater than the severity scores, which increased from 3.4 to 6.1 (p < 0.05).

CONCLUSIONS

Favourable outcomes were achieved for a group of patients with a high need for treatment. Christchurch Hospital appeared to be treating cases of increased severity and gained better treatment outcomes when compared with a United Kingdom (UK) national audit.

Volumetric three-dimensional computed tomographic evaluation of the upper airway in patients with obstructive sleep apnoea syndrome treated by maxillomandibular advancement

Obstructive sleep apnoea syndrome is the periodic reduction or cessation of airflow during sleep together with daytime sleepiness. Its diagnosis requires polysomnographic evidence of 5 or more episodes of apnoea or hypopnoea/hour of sleep (apnoea/hypopnoea index, AHI). Volumetric 3-dimensional computed tomographic (CT) reconstruction enables the accurate measurement of the volume of the airway. Nasal continuous positive airway pressure (CPAP) is the conventional non-surgical treatment for patients with severe disease. Operations on the soft tissues that are currently available give success rates of only 40%-60%. Maxillomandibular advancement is currently the most effective craniofacial surgical technique for the treatment of obstructive sleep apnoea in adults. However, the appropriate distance for advancement has not been established. Expansion of the air-flow column volume did not result in an additional reduction in AHI, which raises the important issue of how much the maxillomandibular complex should be advanced to obtain an adequate reduction in AHI while avoiding the risks of overexpansion or underexpansion. We have shown that there is a significant linear relation between increased absolute upper airway volume after advancement and improvement in the AHI (p=0.013). However, increases in upper airway volume of 70% or more achieved no further reduction in the AHI, which suggests that the clinical improvement in AHI reaches a plateau, and renders further expansion unnecessary. This gives a new perspective to treatment based on the prediction of changes in volume, so the amount of sagittal advancement can be tailored in each case, which replaces the current standard of 1cm.

Maxillary incisor inclination of skeletal Class III patients treated with extraction of the upper first premolars and two-jaw surgery: conventional orthognathic surgery vs surgery-first approach

OBJECTIVE

To investigate the differences in the amount and pattern of the maxillary incisor (MXI) inclination change in skeletal Class III patients treated with extraction of the maxillary first premolars (MXP1) and two-jaw surgery (TJS) between conventional orthognathic surgery (COS) and surgery-first approach (SFA).

MATERIALS AND METHODS

The study included 60 skeletal Class III patients who had normal maxillary position, prognathic mandible, and mild crowding in the maxillary arch (≤4 mm). The patients were divided into group 1 (COS, n  =  36) and group 2 (SFA, n  =  24). Lateral cephalograms were taken before treatment (T0), 1 month before surgery (T1), within 1 month after surgery (T2), and after debonding (T3) for COS patients and at T0, T2, and T3 for SFA patients. After measurement of the skeletodental variables, statistical analyses were performed.

RESULTS

During T0-T2, the amount of MXI inclination change (ΔU1-SN) in group 1 was significantly larger than that in group 2 (-12.8° vs -4.4°; P < .001). During T2-T3, ΔU1-SN in groups 1 and 2 occurred in opposite directions (3.8° vs -5.9°; P < .001). However, the total amount of ΔU1-SN during T0-T3 was not different between groups 1 and 2 (-9.0° vs -10.3°). At T3 the U1-SN values for groups 1 and 2, respectively, moved closer to normal according to the values of the normal range rate (all 83%), relative percentage ratio (102.4% and 100.1%), and achievement ratio (77.7% and 97.8%).

CONCLUSIONS

The results of this study might provide basic data for predicting the amount and pattern of MXI inclination change in SFA for skeletal Class III TJS patients.

Long-term orthodontic and surgical treatment and stability of a patient with Beckwith-Wiedemann syndrome

Beckwith-Wiedemann syndrome (BWS) is a congenital growth disorder. Children born with BWS develop enlarged organs, including the tongue, a large body, and other signs. A woman with BWS was treated and followed for 30 years. Treatment consisted of tongue reduction, orthopedic and orthodontic treatment, orthognathic surgery, and retention. The patient was first treated when she was 5 years old. Her original orthodontic problems included macroglossia, anterior open bite, anterior crossbite, and a skeletal Class III jaw relationship caused by significant mandibular protrusion. The jaw-base relationships did not improve in the early preadolescent period after phase 1 of orthodontic treatment with a vertical chincap. With the growth spurt accompanying puberty, she developed a severe skeletal Class III jaw relationship and a constricted maxillary arch. Surgically assisted rapid maxillary expansion was performed at 23 years of age to correct the severe discrepancy between the maxillary and mandibular dental arch widths. Then, at 26 years, a LeFort I osteotomy, a horseshoe osteotomy, a bilateral sagittal split ramus osteotomy, and genioplasty were performed after presurgical orthodontic treatment with extraction of the mandibular first molars. Both the facial profile and the occlusion were stable after 6 years of retention. This case report discusses the result of long-term observation of a patient with BWS who underwent tongue reduction, early orthodontic treatment, and surgical-orthodontic treatment.

Transpalatal distraction--state of the art for the individual management of transverse maxillary deficiency--a review of 50 consecutive cases

Transpalatal distraction has been established as a technique for surgical assisted rapid palatal/maxillary expansion (SARPE/SARME) in order to correct transverse maxillary deficiency. From 2007 until 2013 bone borne transpalatal distraction devices have been inserted in 50 patients affected by transverse maxillary deficiency and transpalatal distraction has been performed by the same surgical team. Patient records were retrospectively evaluated after ending of the active distraction phase with respect to indication, achieved expansion, additional procedures and side effects. In all cases the existing transverse maxillary deficiency was corrected by means of transpalatal distraction according to the individual needs. No complications were observed that interfered with that therapeutic aim. Evaluation of the records showed a wide variance of parameters which impedes evidence based statements. According to that series transpalatal distraction is a safe, powerful and reliable procedure and can be recommended as a state of the art procedure for the individually adapted correction of transverse maxillary deficiency if well known parameters of distraction are respected.

Wassmund osteotomy for excessive gingival display: a case report with three-dimensional facial evaluation

AIMS

This case report describes the management of an adult patient presenting with a skeletal Class II malocclusion with congenitally missing lower second premolars, maxillary dentoalveolar protrusion, and an excessive gingival display in full smile.

METHODS

The treatment plan consisted of a combination of a segmental osteotomy to reposition the anterior part of the maxilla after upper premolar extractions and a bilateral sagittal split osteotomy (BSSO) to advance the mandible. Because the upper left permanent second molar required extraction, the upper left third molar was moved mesially during post-surgical orthodontic treatment.

RESULTS

After active treatment, bilateral Class I molar and canine relationships were achieved. Two years after retention, a satisfactory facial profile and dental occlusion remained with optimum overjet and overbite. Treatment also produced changes in the threedimensional (3D) configuration of the face, which was characterised by decreased labial protrusion, increased protrusion of the chin, and increased cheek prominence.

CONCLUSION

A segmental osteotomy of the anterior part of the maxilla produced favourable treatment results by reducing excessive gingival display, but also by a relative improvement in cheek prominence.

Factors related to stability following the surgical correction of skeletal open bite

OBJECTIVES

If a skeletal anterior open bite malocclusion is treated by orthognathic surgery directed only at the mandible, the lower jaw is repositioned upward in a counter-clockwise rotation. However, this procedure has a high risk of relapse. In the present study, the key factors associated with post-surgical stability of corrected skeletal anterior open bite malocclusions were investigated.

MATERIAL AND METHODS

Eighteen orthognathic patients were subjected to cephalometric analysis to assess the dental and skeletal changes following mandibular surgery for the correction of an anterior open bite. The patients were divided into two groups, determined by an increase or decrease in nasion-menton (N-Me) distance as a consequence of surgery. Changes in overbite, the displacements of molars and positional changes in Menton were evaluated immediately before and after surgery and after a minimum of one year post-operatively.

RESULTS

The group with a decreased N-Me distance exhibited a significantly greater backward positioning of the mandible. The group with an increased N-Me distance experienced significantly greater dentoalveolar extrusion of the lower molars.

CONCLUSIONS

A sufficient mandibular backward repositioning is an effective technique in the prevention of open bite relapse. In addition, it is important not to induce molar extrusion during post-surgical orthodontic treatment to preserve stability of the surgical open bite correction.

[Orthognathic surgery in adults: state of the art]

The objective of orthognathic surgery is the repositioning of the osseous bases of the jaws. Its consequences are both aesthetic and functional. As adults are increasingly concerned with appearance, orthognathic surgery is today, more than ever, a close collaboration between the orthodontist, surgeon and general dentist. The whole team must be capable of coordinating its approach with an aesthetic objective. For the surgeon, a perfect knowledge of complementary techniques (rhinoplasty, bone grafts, plastic surgery of the face, lipostructure or fillers) makes orthognathic surgery a completely separate surgical speciality. The aim of this article is to establish the philosophy underlying this type of treatment and define relevant fundamental aspects. We propose an esthetic "extra-oral" clinical approach not focused on occlusal anomalies but on classification of tooth positional abnormalities in the smile and the therapeutic options that we have for placing teeth in correct positions in the smile.

[Application of three-dimensional printing technique in correction of mandibular prognathism]

OBJECTIVE

To establish a method to prefabricate titanium plate with three-dimensional (3-D) printing technique for correction of mandibular prognathism in sagittal splint ramous osteotomy (SSRO).

METHODS

Between January 2012 and May 2013, 12 patients with mandibular prognathism (Angle III malocclusion) were treated. Among them, 9 cases were male and 3 cases were female. Their ages ranged from 19 to 35 years (mean, 25.6 years). With the 3-D facial CT data of these patients, 3-D printer was used to print the models for preoperational simulation. SSRO was performed on 3-D models, and the titanium plates were prefabricated on the models after the distal segments were moved backward and rotated according to occlusal splint. During operations, the proximal segments were fixed to distal segments by the prefabricated titanium plates. 3-D CT scans were taken to examine the temporomandibular joint position changes before operation and at 6 months after operation.

RESULTS

The skull models were manufactured by 3-D printing technique, and the titanium plates were reshaped on the basis of them. Twenty-four prefabricated titanium plates were placed during operations, and they all matched with the bone segments well. Evaluation of 3-D CT scans showed that the temporomandibular joint position had no change. All patients were followed up 7-12 months (mean, 10.6 months). The face type and dental articulation were improved greatly. All cases obtained satisfactory opening function and occlusion.

CONCLUSION

With the titanium plate fabricated based on 3-D models, surgeons are able to improve or refine surgical planning so that the operation can be performed according to preoperative simulation precisely and the complications, such as dislocation of temporomandibular joint, can be prevented.

Lingual orthodontics as an aesthetic resource in the preparation of orthodontic/surgical treatment

The lingual technique was introduced in the late '70s and, just like orthodontics, it has developed significantly in the past few years. Adult and young adult have been attracted to such alternative aesthetic treatment. Despite their need of orthodontic treatment, they want to have an aesthetic alternative, as "invisible" as possible--something that can be achieved with the lingual technique. Nevertheless, many treatment or re-treatment cases also demand correction through orthognathic surgery, a process which is nowadays much simpler and considered an effective auxiliary method for the malocclusion correction. Having posed that, this study aims to show correction of malocclusion and discrepancy between dental arches through lingual orthodontic technique associated to orthognathic surgery. This study shows that it is possible to provide the patient who suffers frJom malocclusion with proper correction, achieving the desired aesthetics by using lingual braces and pe?forming lingual orthognathic surgery.

[Sensory disorders in inferior alveolar nerve after sagittal split osteotomy of the mandible]

Methodology of the sagittal split osteotomy of the mandible improved from year to year. However, there is still the problem of neurosensory disorders of inferior alveolar nerve in the early and late postoperative period is widely covered in the foreign literature. The incidence of these disorders ranges from 40 to 55%. During 2009-2013 years in Central Research Institute of Stomatology and Maxillofacial Surgery were operated 127 patients with associated deformities of the jaws: 102 according to traditional methods, 25 - by improved methods. Assessment of lower alveolar nerve conducted by electric teeth pulp test methods, blink reflex, computed tomography in 3D mode and the questionnaire. The results showed that the improved method of the sagittal split osteotomy of the mandible by using piezoelectric bone surgery saw during cutting of the cortical bone of the mandible and special splitters with replacing of damaging factors makes it possible to reduce the incidence of neurosensory disorders of inferior alveolar nerve and reduce the time of rehabilitation.

Surgical treatment of class II malocclusion in the orthodontic boundaries: a case report

The aim of this study was to report a clinical case of treatment of Class II division I malocclusion with facial aesthetic impairment, whose therapeutic approach comprised the association of orthodontic treatment with orthognathic surgery. The treatment for the present case consisted of decompensation oflower incisors and extraction oftwo lower premolars, in order to obtain horizontal discrepancy allowing the surgery for mandibular advancement. At the end of treatment, we could clinically observe a Class I molar/canine relationship, normal overbite and overjet, presence of lip seal, type I facial profile with considerable aesthetic improvement. We can conclude that the ortho-surgical treatment is a therapeutic alternative providing the best prognosis in terms of aesthetic correction in patients with unpleasant facial profile.

Evaluation of minimal versus conventional presurgical orthodontics in skeletal class III patients treated with two-jaw surgery

PURPOSE

The purpose of this study was to compare changes in hard and soft tissues and the treatment efficacy of 2-jaw surgery combined with nonextraction treatment for skeletal Class III malocclusion in patients who received minimal presurgical orthodontics (MPO) versus those who received conventional presurgical orthodontics (CPO).

MATERIALS AND METHODS

Thirty-two patients (16 in each group) with skeletal Class III malocclusion who underwent 2-jaw surgery were included in the study. Serial lateral cephalometric films were traced at 4 stages: before treatment (T0), before surgery (T1), 1 month after surgery (T2), and at debonding (T3). Cephalometric measurements and treatment duration were compared using independent t test and Mann-Whitney U test.

RESULTS

After the presurgical treatment phase, the angle between the lower incisor axis and mandibular plane, overjet, and soft tissue pogonion to the vertical reference line showed larger changes (P < 0.01) in the CPO group, whereas the pogonion to the horizontal reference line showed larger changes (P < .05) in the MPO group. In the postsurgical phase (T2 to T3), there were no significant differences between the 2 groups. Total treatment duration was significantly shorter in the MPO group.

CONCLUSIONS

There were no significant differences between the MPO and CPO groups in the hard and soft tissue cephalometric variables. The MPO group had a shorter total treatment time. It is therefore recommended that clinicians consider these results when selecting MPO as a treatment option for accurate diagnosis and treatment planning of Class III surgical patients.

Augmented corticotomy combined with accelerated orthodontic forces in class III orthognathic patients: morphologic aspects of the mandibular anterior ridge with cone-beam computed tomography

PURPOSE

This study used cone-beam computed tomography to evaluate morphologic changes of the mandibular anterior ridge after using augmented corticotomy plus accelerated orthodontia to decompensate mandibular incisors in patients with surgical skeletal Class III.

MATERIALS AND METHODS

Fourteen patients (8 men, 6 women; mean age, 26.14 yr) with skeletal Class III were treated before orthognathic surgery with a technique that combined corticotomy, bone grafting, and accelerated orthodontic forces to decompensate the lower incisors. Three-dimensional cone-beam computed tomograms were taken before treatment (T0) and at the completion of presurgical orthodontic treatment (T1). Measurements of the amount of vertical alveolar bone changes and horizontal bone thickness at the midroot and root apex levels of the mandibular incisors were evaluated.

RESULTS

All patients showed significant proclination of the mandibular incisors at T1. The mean alveolar bone thickness from T0 to T1 increased buccally at the midroot and apex levels, showing statistically significant horizontal bone augmentation at the labial side of the lower anterior mandibular teeth (P < .05). The mean amount of vertical bone change did not show any significant vertical loss of alveolar bone.

CONCLUSION

This new combined technique provided adequate decompensation of the mandibular incisors by increasing horizontal bone thickness in the labial aspect of the mandibular anterior area, without any vertical bone loss. This approach decreases the risk of the typical periodontal complications associated with traditional orthodontics, such as marginal bone loss and gingival recession.

[Clinical application of condylectomy via intraoral approach under computer assisted surgical navigation]

OBJECTIVE

To assess the application of computer assisted surgical navigation in condylectomy via intraoral approach and its clinical results.

METHODS

Eight patients aged from 16 to 56 were treated by condylectomy via intraoral approach under computer assisted surgical navigation. There were 6 female and 2 male. The lesions were condyle osteoma in 3 patients, hemimandibular hyperplasia and condylar hyperplasia in 5 patients. Most patients had concomitant LeFortIosteotomy (6 cases), bilateral sagittal split ramus osteotomy (BSSRO) (5 cases),contralateral sagittal split ramus osteotomy (SSRO) (1 cases), genioplasty (4 cases) and mandible contouring (6 cases) to recover the facial symmetry.

RESULTS

All patients had good occlusion, oral function and facial symmetry after the operation. The average mouth opening was 38 mm before operation, and 41 mm one month after operation. The temporomandibular joint(TMJ) dysfunction syndrome alleviated or disappeared. The follow-up period was 3-12 months, and results were stable.

CONCLUSIONS

Computer assisted surgical navigation can precisely accomplish the condylectomy via intraoral approach.It causes less trauma to the patient than traditional condylectomy, and can better preserve the TMJ structure and function.

Skeletal stability after mandibular advancement in bilateral sagittal split osteotomies during adolescence

Bilateral sagittal split osteotomy (BSSO) is the most frequently performed surgery for correcting mandibular retrognathia. Few studies have reported the use of BSSO in young patients, as growth may cause relapse. The aim of the present study was to determine the amount of relapse after performing BSSO in patients aged less than 18 years. Patients who had a mandibular advancement by BSSO surgery between January 2003 and June 2008 were evaluated. Eighteen patients were treated before the age of 18 years and compared with patients treated at 20-24 years of age. Cephalometric radiographs were used to determine the amount of relapse. For patients aged less than 18 years, the mean horizontal relapse after 1 year was 0.5 mm, (10.9% of perioperative advancement). For patients aged 20-24 years, the mean relapse was 0.9 mm, (16.4% of perioperative advancement). There were no significant differences between the age groups (p > 0.05). In conclusion, the BSSO procedure is a relatively stable procedure, even during adolescence.

Closure of anterior open bites with mandibular surgery: advantages and disadvantages of this approach

INTRODUCTION

While closure of an anterior open bite with a mandibular procedure may predispose a surgical case to instability, there are instances where this type of treatment planning is indicated.

METHODS AND MATERIALS

In this paper, the authors review the advantages and disadvantages of this approach and present three cases with varying degrees of success. Additionally, treatment strategies are presented for managing large advancements of the maxilla and mandible.

RESULTS AND SUMMARY

Counterclockwise rotation of the mandible is a valuable tool that can be used in the treatment of patients with dentofacial deformities.

Skeletal Class III malocclusion with thin symphyseal bone: a case report

AIM

To describe the management of a severe skeletal Class III patient with thin symphyseal bone and alveolar bone covering the mandibular incisors.

METHOD

A 24 year-old female presented with a skeletal Class III malocclusion characterised by thin alveolar bone in a mildly crowded, mandibular incisor region. Computerised tomography (CT) assisted in the determination of possible tooth movement within the anterior mandibular alveolar bone. The finalised treatment plan aimed to align the maxillary and mandibular dental arches following the extraction of the maxillary right first premolar and the mandibular right permanent lateral incisor. The surgical repositioning of the maxilla and mandible with a LeFort I osteotomy and a bilateral sagittal split osteotomy (BSSO) would follow.

RESULTS

After treatment, an acceptable facial profile and a solid intercuspation of the teeth were obtained. Significant root resorption was not observed. The occlusion remained stable with normal overjet and overbite after two years of retention.

CONCLUSION

CT examination provided an assessment of the three-dimensional morphological characteristics of anterior alveolar bone which enabled an evaluation of possible tooth movement.

Orthodontic and surgical treatment of a patient with Apert syndrome

The aim of this case report was to present the combined orthodontic and surgical treatment of a patient with Apert syndrome in an adult stage. A 15 years old male patient with Apert syndrome was concerned about the appearance of his face and malocclusion. His profile was concave with a retruded maxilla and prominent lower lip. He had an Angle class I molar relationship with a 9.5 mm anterior open bite. The amount of crowding was 20.4 mm in the maxilla and 6 mm in the mandible. Cephalometric analysis revealed a skeletal Class III relationship due to maxillary hypoplasia with a dolichofacial growth pattern. Orthodontic treatment and orthognathic surgery were planned for the patient. After 45 months of presurgical orthodontics, the patient underwent two surgeries sequentially. The first surgery was performed to advance the maxilla and the second surgery was performed to correct the mandibular rotation and increase the overbite at the time of removing halo device. The amount of maxillary advencement was 8 mm. Mandibula was moved 1.5 mm anteriorly and rotated 1° to 1.5° (SNB and facial depth) in a counterclockwise direction. After a relatively long treatment, an esthetically pleasing and functional occlusion and correction of the skeletal problem was achieved in this adult case.