Evaluation of Post-operative Complication Rate of Le Fort I Osteotomy: A Retrospective and Prospective Study

Anatomical Factors of the Anterior and Posterior Maxilla Affecting Immediate Implant Placement Based on Cone Beam Computed Tomography Analysis: A Narrative Review

BACKGROUND

The aim of this narrative review was to provide insights into the influence of the morphological characteristics of the anatomical structures of the upper jaw based on cone beam computed tomography (CBCT) analysis on the immediate implant placement in this region.

MATERIAL AND METHODS

To conduct this research, we used many electronic databases, and the resulting papers were chosen and analyzed. From the clinical point of view, the region of the anterior maxilla is specific and can be difficult for immediate implant placement.

FINDINGS

Anatomical structures in the anterior maxilla, such as the nasopalatine canal and accessory canals, may limit and influence the implant therapy outcome. In addition to the aforementioned region, immediate implant placement in the posterior maxilla may be challenging for clinicians, especially in prosthetic-driven immediate implant placement procedures. Data presented within the recently published materials summarize the investigations performed in order to achieve more reliable indicators that may make more accurate decisions for clinicians.

CONCLUSION

The possibility for immediate implant placement may be affected by the NPC shape in the anterior maxilla, while the presence of ACs may increase the incidence of immediate implant placement complications. The variations in IRS characteristics may be considered important criteria for choosing the implant properties required for successful immediate implant placement.

Determination of safety margin of nasal septum osteotomy for sphenoid sinus in cleft lip and palate patients

BACKGROUND

Nasal septum osteotomy is used for separating the nasal septum and maxilla during a Le Fort I osteotomy. If this osteotomy is applied too high or is tilted into the nasal cavity, the sphenoid sinus and various adjacent vital structures may be damaged, and serious bleeding, neurological complications, blindness or even death may occur. The aim of this study is to determine the safety margin of the nasal septum osteotomy for sphenoid sinus during the Le Fort I surgery in cleft lip and palate (CLP) patients.

METHODS

Twenty cleft lip and palate (the CLP group) and 20 healthy individuals (the control group) were included in this study. Three values (two lines and an angle) were measured by cone beam computed tomography (CBCT). The first line is the line passing through the junction of the spina nasalis anterior point and the lower point of the perpendicular lamina of the palatine bone. The undersired line is the line passing through the junction of the spina nasalis anterior point and the lower anterior border of the base of the sphenoid sinus. The osteotomy angle is the angle between these two lines.

RESULTS

In the control group; a surgical line of 44.11-61.14 mm (mean 51.91 ± 4.32), an undesired line of 52.48-69.58 mm (mean 59.14 ± 5.08) and an angle of 18.22-27.270 (mean 22.66 ± 2.55) were found, while in the CLP group, a surgical line of 34.53-51.16 mm (mean 43.38 ± 4.79), an undesired line of 46.86-61.35 mm (mean 55.02 ± 3.24) and an angle of 17.60-28.810 (mean 22.60 ± 2.81) were found.

CONCLUSIONS

Although the angle to the sphenoid sinus was not significantly affected by CLP, careful planning and consideration of these anatomical differences are crucial to prevent complications and ensure the safety of Le Fort I surgery in CLP patients. Further research with larger sample sizes and subgroup analysis of unilateral and bilateral CLP cases is needed to improve our understanding of these anatomical variations and improve surgical approaches to individuals with CLP undergoing orthognathic procedures.

The evaluation of nasolacrimal duct injury in Le Fort I osteotomy patients

BACKGROUND

Although Le Fort I surgeries are safe and successful procedures; nasolacrimal duct injuries may be observed due to these surgeries. The study aimed to investigate the prevalence of nasolacrimal duct injury in Le Fort I osteotomy patients.

MATERIAL AND METHODS

The authors conducted a retrospective cohort study consisting of patients who underwent Le Fort I osteotomies between 2017 and 2021 in the Erciyes University Faculty of Dentistry. The primary predictor variables were the distance of the nasolacrimal canal to the outer cortex of the maxilla and the nasal floor, as well as the superior-inferior level of the superiorly positioned screw inserted in the maxilla aperture region relative to the nasolacrimal canal. The outcome variable was the presence of a nasolacrimal duct injury. Mann Whitney U test was used for quantitative variables between the two groups. A Pearson chi-squared analysis was used to compare categorical data. A p-value <0.05 was considered statistically significant.

RESULTS

A total of 290 nasolacrimal canals were evaluated in 145 patients, 87 females, and 58 males. The mean age was 23.47± 6.67. There was a statistically significant relationship between screw level and nasolacrimal canal perforation (p<0,001). The distance between the most anterior border of the nasolacrimal canal and the outer cortical of the maxilla was significantly less in the perforation group (p<0,001). The fixation screw was significantly closer to the nasolacrimal canal in the perforation group (p<0,001).

CONCLUSIONS

In Le Fort I surgery, nasolacrimal duct injury may occur during screw fixation to the aperture region. Superiorly positioned fixation screws in the aperture region may damage the nasolacrimal canal. In patients where the nasolacrimal canal is close to the outer cortex, care should be taken when applying the fixation screws to the aperture region to avoid damaging the canal.

Incidence of Sinusitis Postoperatively in Orthognathic Surgery: A Systematic Review and Meta-Analysis

Maxillary osteotomies as a component of orthognathic surgery disrupt the normal anatomy and function of the sinus. The osteotomy with advancement of the inferior component of the sinus leaves a bony and mucosal opening in the sinus. Immediately after surgery, nasal drainage is impeded because of intranasal swelling. Acute and chronic maxillary sinusitis would be expected; however, its incidence as an expected complication is not well documented. A systematic review and meta-analysis was completed using PubMed to determine the incidence of sinusitis after maxillary orthognathic surgery. Studies were reviewed by two authors, and incidence data were extracted. Two hundred six articles were identified with 24 meeting the criteria for analysis. The incidence of sinusitis was based on 4213 participants who had undergone orthognathic surgery. Twenty-three studies reported a total number of sinusitis cases, and the results demonstrated a pooled incidence of 3.3% (95% confidence interval: 1.77, 6.06). One study did not report a total number of cases but reported chronic sinusitis survey-duration-based and Lund-Mackay scores. These scores, respectively, worsened from 7.6 to 14.8 and from 1.58 to 2.90 postoperatively. Despite the variability of maxillary surgery, the surgical technique, and the postoperative management, the incidence is low but sinusitis does occur. Prospective studies with validated questionnaires within the context of a specific protocol may further elucidate the causality of sinusitis. Further, patients with sinonasal symptoms postsurgery should be encouraged to consult with an otolaryngologist to ensure prompt treatment.

Postoperative hemorrhage after Le Fort I osteotomy hemostasis with angiographic embolization: report of two cases

This study reported two cases of acute life-threatening hemorrhage after Le Fort I osteotomy. In both cases, computed tomography and angiography revealed damage to the descending palatine artery, which was successfully treated by angiographic embolization. Although massive hemorrhage after Le Fort I osteotomy is rare, acute hemorrhage from the postoperative area may occur. Angiographic embolization is useful in cases of such hemorrhage from the posterior nasal cavity where endoscopic hemostasis is not possible.

Sphenoid Sinus Foreign Body After Le Fort I Osteotomy

This report describes a rare case of a foreign body in the sphenoid sinus from the tip of an osteotome, which was lodged during the Le Fort I osteotomy. After surgery, a 2-mm-diameter round-shaped foreign body was seen as an opaque image in the right sphenoid sinus on computed tomography. The tip of the broken osteotome (Bauer) was confirmed after the intraoperative instruments were investigated. The foreign body was removed using an interventional endoscope and navigation computed tomography, and a good prognosis was obtained.

Readmission after orthognathic surgery

OBJECTIVE

To evaluate the readmission rate after orthognathic surgery and identify associated risk factors.

STUDY DESIGN

Retrospective analysis of patients who underwent orthognathic surgery and had an unexpected hospital admission, with or without return to the operating room (OR), within the first postoperative year. Study variables included sex, age, American Society of Anesthesiologists (ASA) status, type of surgery, concomitant third molar extraction, concomitant genioplasty, duration of surgery, first assistant experience, and duration of hospitalization. Bivariate associations were calculated between variables and readmission status. Chi-square and Fisher's Exact tests were used to compare categorical variables, and a 2-sample t test was used to compare continuous variables.

RESULTS

There were 701 patients included in the study. The readmission rate was 9.70%. Twelve patients were managed non-surgically, and 56 patients required an OR procedure. The most common reason for readmission without return to the OR was an infection, and for reoperation was hardware removal. Age, sex, type of surgery, third molar extraction, genioplasty, duration of surgery, and experience of first assistant were not found to be predictors for readmission.

CONCLUSIONS

Only ASA classification and duration of initial hospitalization were significant risk factors for readmission of patients within the first postoperative year after orthognathic surgery.

Association Between Maxillary Segmentation and Perioperative Complications in Le Fort I Osteotomy

The Le Fort I osteotomy is used to reposition the maxilla to correct numerous maxillofacial and occlusal deformities. The aim of this study was to delineate perioperative complication rates associated with Le Fort I osteotomy and determine whether the number of maxillary segments or bone grafting yielded increased complication rates. Patients undergoing Le Fort I osteotomy from 2012 to 2019 were identified from the multi-institution "National Surgical Quality Improvement Program" database using Current Procedure Terminology codes. The predictor variables of interest included maxillary segmentation defined as 1, 2, or 2 pieces and the presence or absence of bone graft. Perioperative complications were collected as the primary outcome variable, including superficial and deep space infections, wound dehiscence, airway complication, peripheral nerve injury, and hemorrhage. The secondary outcome variables included readmission and reoperation rate within the 30-day postoperative period. Complication rates were compared using multivariate analysis across groups stratified by the number of maxillary segments and inclusion of bone grafting. Of the 532 patients that met the inclusion criteria, 333 (63%) underwent 1-piece, 114 (21%) 2-piece, and 85 (16%) 2-piece Le Fort I osteotomy procedures. A total of 48 patients exhibited complications (9%), with hemorrhage (2.3%) being the most common complication observed. The number of maxillary segments was not a significant predictor of perioperative complications ( P = 0.948) nor was the use of bone grafting ( P = 0.279).

Effect of Bone-Borne Trans -Sutural Distraction Osteogenesis Therapy on the Cranial Base of Children With Midfacial Hypoplasia Due to Cleft Lip and Palate

Bone-borne trans -sutural distraction osteogenesis (TSDO) is widely used to treat midfacial hypoplasia in children with cleft lip and palate; however, its effects on the cranial base are still poorly understood. The authors aimed to study morphological changes in the cranial base after TSDO. Pre and postoperative computed tomography (CT) images of cleft lip and palate children with midfacial skeleton dysplasia who underwent TSDO were collected retrospectively, and their corresponding 3-dimensional models were measured. Results showed no significant change in the length of the anterior or posterior cranial fossa, but the length of the middle cranial fossa increased significantly. The anterior cranial base rotated upward with the sella turcica at the center, whereas the cranial base angle increased. The sphenoid bone exhibited morphological changes. Post-TSDO, the lateral plate of the pterygoid process increased in length. The angle of the 2 lateral plates of the pterygoid process, the greater wings of the sphenoid bone, and the smaller wings of the sphenoid bone decreased. Posterior inclination of the pterygoid process increased. Mean volume of the sphenoidal sinus increased postoperatively compared with the preoperative volume. Apparent changes in the cranial base after TSDO are primarily in the middle cranial fossa, manifesting as an increase in the sphenoid bone body length, expansion of the sphenoidal sinus volume, growth of the pterygoid process forward and downward, a decrease in the angle of both the greater and smaller wings of the sphenoid bone, and an increase in the posterior inclination of the pterygoid process.

Linear and angular measurement using cone-beam computed tomography to enhance safety in Le Fort I osteotomy with tuberosity cut

OBJECTIVE

The study aimed to evaluate surgical angles for tuberosity cut and linear and angular measurements for all horizontal cuts in Le Fort I osteotomy using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

This study included 189 CBCT scans to assess the surgical angles on 3 different sites distal to maxillary second molars relative to the midsagittal plane (MSP) and the buccal cortical plane (BCP) in relation to the descending palatine foramen for tuberosity cut. The linear and angular measurements for all horizontal cuts in Le Fort I osteotomy were also evaluated.

RESULTS

The mean surgical angles for tuberosity cut varied from 58.90 to 95.28° and 74.85 to 100.93° according to the MSP and the BCP, respectively. For the horizontal cuts, mean lengths (angles) for posterior buccal and lateral nasal wall osteotomies were 27.44 mm (13.62°) and 33.20 mm (9.60°), respectively, and a mean length of 47.12 mm was measured for nasal septum osteotomy. Additionally, the presence of impacted third molar resulted in significantly higher mean surgical angles than those with fully erupted or without third molars (p < 0.01).

CONCLUSIONS

Overall, angles running through the buccal midpoint of the third molars relative to the MSP (76.56°) or the BCP (92.31°) might be the most appropriate in clinical practice. Furthermore, some caution seems warranted when performing tuberosity cuts with the impacted third molars.

CLINICAL RELEVANCE

To avoid potential damage to the descending palatine artery for tuberosity cut in Le Fort I osteotomy.

Epistaxis After Orthognathic Surgery: Literature Review and Three Case Studies

Study Design

This is a literature review with 3 case studies.

Objective

Intraoperative and postoperative bleeding are the most common complications of orthognathic surgery and have the potential to become life-threatening. The rarity of severe postoperative epistaxis has resulted in limited characterization of these cases in the literature. The purpose of this study is to 1) differentiate various presentations of epistaxis following orthognathic surgery in the literature, 2) identify management approaches, and 3) to synthesize a treatment algorithm to guide future management of postoperative epistaxis.

Methods

A literature search of PubMed was conducted and 28 cases from 17 studies were assessed.

Results

Bleeding within the first week may indicate isolated epistaxis, often resolved with local tamponade. Half of cases were attributed to pseudoaneurysm rupture (n = 14), with epistaxis onset ranging from postoperative day 6 to week 9. Angiography was used in most cases (n = 17), often as the primary imaging modality (n = 11). Nasal endoscopy is a less invasive and effective alternative to angiography with embolization. Proximal vessel ligation was used in 3 cases but is not preferred because collaterals may reconstitute flow through the defect and cause rebleeding. Repeat maxillary down-fracture with surgical exploration was described in 4 cases.

Conclusions

As outlined in our management algorithm, nasal packing and tamponade should be followed by either local electrocautery or vascular imaging. Angiography with embolization is the preferred approach to diagnosis and management, whereas surgical intervention is reserved for cases of embolization failure or unavailability.

Computer-Assisted Microvascular Free Flap Reconstruction and Implant Rehabilitation of the Maxilla-Treatment of a Rare Post-orthognathic Complication

Orthognathic surgery is generally a safe and predictable procedure. Major postoperative complications are rare and often non-life threatening. An example of a rare complication associated with the LeFort I osteotomy is avascular necrosis of the maxilla (ANM). While cases of ANM have been described in the literature, the majority involves only a portion or segment of the maxillary complex and is commonly treated with conservative measures such as strict oral hygiene, hyperbaric oxygen therapy and local debridement. Occasionally, larger segments of osteonecrosis may require extensive reconstruction such as bone grafting with local soft tissue flaps. Here, we present a patient that underwent a single-stage microvascular free tissue reconstruction with concomitant placement of dental implants and a patient-specific implant (PSI) for post-orthognathic ANM.

Epistaxis in dental and maxillofacial practice: a comprehensive review

The lifetime incidence of epistaxis in dental and maxillofacial practice has been reported to be as high as 60% and can be caused by dental implant placement, Le Fort I osteotomy, intranasal supernumerary tooth, odontogenic tumors, blood disorders and maxillofacial trauma. Most epistaxis cases are minor and easily managed with direct compression on the nares for 10 minutes. For more significant or recurrent epistaxis, other techniques might include electrocautery, anterior or posterior nasal packing, or Foley catheter balloon. For patients with refractory epistaxis, cauterization of the sphenopalatine artery under endonasal endoscopy or embolization of the internal maxillary artery should be performed. Epistaxis control is required in patients diagnosed with inherited or acquired bleeding disorders or with drug-induced coagulopathies during dental procedures. In these cases, hemostatic system adjustment and hemostasis achieved by local and adjunctive methods are required. Dentists and maxillofacial surgeons must be aware that the nasal cavity is a potential source of perioperative hemorrhage. Depending on the invasiveness of the dental intervention, preoperative involvement of the hematologist and cardiologist is usually necessary to reverse anticoagulation or to cease anticoagulant therapy.

A clinico-statistical study of factors associated with intraoperative bleeding in orthognathic surgery

Background

Excessive bleeding is a major intraoperative risk associated with orthognathic surgery. This study aimed to investigate the factors involved in massive bleeding during orthognathic surgeries so that safe surgeries can be performed. Patients (n=213) diagnosed with jaw deformities and treated with bimaxillary orthognathic surgery (Le Fort I osteotomy and bilateral sagittal split ramus osteotomy) in the Department of Oral and Maxillofacial Surgery at the Suidobashi Hospital, Tokyo Dental College between January 2014 and December 2016 were included. Using the patients’ medical and operative records, the number of cases according to sex, age at the time of surgery, body mass index (BMI), circulating blood volume, diagnosis of maxillary deformity, direction of maxillary movement, operative duration, incidence of bad split, injury of nasal mucosa, and blood type were analyzed.

Results

The results revealed that BMI, circulating blood volume, nasal mucosal injury, and operative time were associated with the risk of intraoperative massive bleeding in orthognathic surgeries. Chi-square tests and binomial logistic regression analyses showed significant differences in BMI, circulating blood volume, direction of maxillary movement, operative duration, and injury to the nasal mucosa. Operative duration emerged as the most important risk factor. Furthermore, a >4-mm upward migration of the posterior nasal spine predicted the risk of massive bleeding in orthognathic surgery.

Conclusions

The upward movement of the maxilla should be recognized during the preoperative planning stage as a risk factor for intraoperative bleeding, and avoiding damage to the nasal mucosa should be considered a requirement for surgeons to prevent massive bleeding during surgery.

A Novel Device for Blood Drainage after Le Fort I Osteotomy: Maxillary Sinus Ventilation Drainage (MSVD)

The purpose of this study is to present a novel maxillary sinus ventilation drainage (MSVD) device which facilitates blood drainage and nasal breathing after Le Fort I osteotomy. One hundred patients who underwent bimaxillary orthognathic surgery from January 2016 to June 2016 at the Department of Oral and Maxillofacial Surgery, Chung-Ang University Hospital were retrospectively selected and divided into two groups. MSVD was applied in 50 patients, who were allocated to the MSVD group, while the remaining 50 patients, in whom MSVD was not applied, were allocated to the non-MSVD group. All patients underwent a cone-beam computed tomography (CBCT) scan before and 2 days after surgery. CBCT was used to analyze middle meatus patency and the percentage of hematoma volume per entire maxillary sinus volume. Statistical comparisons between the two groups were performed using the Chi-squared and Mann–Whitney U tests to investigate the clinical effectiveness of MSVD. The MSVD group showed significantly higher maintenance ratio of the middle meatus patency and a higher percentage of maxillary sinus air volume (p < 0.05) than the non-MSVD group. MSVD facilitated nasal breathing after Le Fort I osteotomy by reducing hematoma inside the maxillary sinus and promoting middle meatal patency.

Evaluation of Related Factors of Maxillary Sinusitis After Le Fort I Osteotomy Based on Computed Tomography: A Retrospective Case-Control Study

ABSTRACT

Maxillary sinusitis is 1 of the postoperative complications of the Le Fort I osteotomy, this study investigated the related factors of maxillary sinusitis after Le Fort I osteotomy. A total of 23 cases, 92 controls, and 11 related factors were included in this case-control study with a 1:4 case-control ratio. The risk factors for maxillary sinusitis after Le Fort I were examined by least absolute shrinkage and selection operator multivariate conditional logistic regression and least absolute shrinkage and selection operator multivariate linear regression. The patency of maxillary sinus ostium at 6 months after surgery was significantly associated with maxillary sinusitis after Le Fort I osteotomy. Compared with the obstructed maxillary sinus ostium, the percentage of the volume of the healthy air cavity in the complete sinus cavity increased 70.7% when the maxillary sinus ostium was unobstructed, and 95% confidence interval was 0.610 to 0.805. Similarly, when the maxillary sinus ostium was wide, the percentage increased 6.0% compared with the narrow 1, and 95% confidence interval was 0.013 to 0.107. This study indicated that the patency of maxillary sinus ostium has an important impact on maxillary sinusitis after Le Fort I osteotomy. Close attention should be paid to maintain the maxillary sinus ostium and the drainage of maxillary sinuses unobstructed in a clinical setting.

Evaluating Morphology of the Pterygomaxillary Junction and Its Association With the Orbit in Different Facial Skeletal Relationships

PURPOSE

The etiology for blindness after Le Fort I osteotomy is poorly understood. The authors propose that a study of the morphology and anatomical relationship of the pterygomaxillary junction to orbital vital structures may be crucial for understanding the possible etiology.

MATERIALS AND METHODS

This retrospective observational study involved analysis of data procured from computed tomography scans of individuals who were categorized into 4 groups based on their skeletal characteristics: skeletal Class I, II, and III and cleft lip palate (CLP). The outcome variables included i) the height, width, and thickness of the pterygomaxillary junction (PTMJ) which represent its morphology and ii) distance of the PTMJ to the superior orbital fissure and optic canal, to demonstrate its proximity to orbital vital structures. Primary outcome measures were to i) compare variance of the outcome variables across groups, ii) determine association between PTMJ morphology and its proximity to the orbit, and iii) determine association between skeletal morphology and the outcome variables. Data were analyzed using descriptive and inferential statistics to study variance and association.

RESULTS

Forty patients (80 sides) were divided into 4 groups. The CLP group demonstrated maximum height and thickness of the PTMJ, whereas the Class II group demonstrated the minimum (P < .001 and P = .001, respectively). The CLP group demonstrated the closest proximity of the PTMJ to orbital vital structures (P < .001), with Class II being the farthest (P < .001). There was a weak positive correlation between the PTMJ height and its thickness and width, whereas a moderate negative correlation was seen between the PTMJ height and its distance from the optic canal and superior orbital fissures (P < .001).

CONCLUSIONS

Morphology of the PTMJ varies with facial skeletal relationship and also influences the relationship of the PTMJ with the orbital vital structures. This may be critical in understanding the pathophysiology of blindness after Le Fort I osteotomies.

Surgical procedures for correcting vertical maxillary excess: A review

INTRODUCTION

Vertical maxillary excess, a common orthodontic problem that leads to long faces and open bites, can be repositioned with a Le Fort I osteotomy. However, the Le Fort I osteotomy poses the risk of a variety of complications including descending palatine artery (DPA) injury. Although several Le Fort I osteotomy modifications were reported to avoid complications associated with this osteotomy, only a few of such studies were conducted in Japan, and details remain scarce.

PATIENTS AND METHODS

We performed a literature review regarding modifications of Le Fort I osteotomies, including Le Fort I with a horseshoe osteotomy, modified horseshoe osteotomy, unilateral horseshoe osteotomy, pyramidal osteotomy, and U-shaped osteotomy. We identified eight relevant studies conducted in Japan; one study did not provide the number of patients examined. The 77 patients (seven studies) with vertical maxillary excess who underwent orthognathic surgery were ≥17 years old.

DISCUSSION

There were no severe complications after the modified Le Fort I osteotomies. The postoperative maxillary changes obtained by the conventional horseshoe, modified horseshoe, unilateral type of horseshoe, pyramidal, and U-shaped osteotomies were nearly repositioned to the planned position and remained stable for ≥12 months post-surgery.

CONCLUSION

Our review indicates that preserving the DPA can lower the incidence of intra- and post-operative complications. Each modification of the Le Fort I osteotomy (i.e., conventional horseshoe, modified horseshoe, unilateral horseshoe, pyramidal, and U-shaped osteotomy) has its respective advantages and indications.

A new pattern of cranial nerve injuries caused by unfavorable fractures during Le Fort I osteotomy

Cranial nerve injury is a described complication of Le Fort I osteotomy technique. The authors present the case of a 45-year-old patient that underwent bimaxillary orthognathic surgery and suffered unfavorable skull base fractures, which resulted in cranial nerve injury of the II, III, IV, V, and VI nerves on the left side and of the V nerve on the right side, through different mechanisms. One of the mechanisms was cavernous sinus thrombosis, which was never described following Le Fort I technique in a non-cleft patient. The fracture pattern involved the foramen ovale and Meckel's cave, which was also never described after this technique. The resolution of the deficits at the final follow-up at 14 months was incomplete. Le Fort I osteotomy technique is considered a safe technique to correct dentofacial deformities, but serious complications can occur. Pterygomaxillary disjunction and down-fracture must be performed with the utmost care to avoid it.

Pediatric Orthognathic Surgery: National Analysis of Perioperative Complications

BACKGROUND

Orthognathic surgery has traditionally been performed after skeletal maturity. Although these procedures are also being performed in children, the implications of earlier intervention and specific risk factors in this younger population remain unknown.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Pediatric dataset was queried for orthognathic procedures performed in 2018. Complications, readmissions, and reoperations were analyzed with appropriate statistics.

RESULTS

Overall adverse event rate after orthognathic surgery in pediatric patients was 7.8% (n = 22 of 281), which were associated with having any comorbidity (P < 0.001), overall respiratory comorbidities (P = 0.004), structural pulmonary abnormality (P < 0.001), developmental delay (P = 0.035), structural central nervous system abnormality (P < 0.001), and neuromuscular disorder (P = 0.035). Most common complications were excessive bleeding (2.5%), surgical site infection (1.1%), and pneumonia (0.7%). Orthognathic surgery in children below 6 years of age is associated with significantly increased adverse events (P < 0.001), including surgical site infection (P < 0.001), pneumonia (P = 0.022), readmission (P < 0.001), and reoperation (P < 0.001). Le Fort I osteotomies (P < 0.001) and bilateral sagittal split osteotomies (P = 0.009) took significantly longer for older patients in the years of permanent dentition than younger patients in the years of deciduous dentition. Single- and double-jaw procedures in pediatric patients have similarly low adverse events (P all ≥0.130). Interestingly, bilateral sagittal split osteotomies performed before 13.5 years of age were associated with a higher risk of adverse events (P = 0.012), such that these younger patients were 7.1 times more likely to experience adverse events if their procedure was performed earlier.

CONCLUSIONS

Orthognathic surgery is relatively safe, but children in the years of deciduous dentition under 6 years of age have significantly increased risk of adverse events.

A prospective cohort study evaluating subjective and objective neurosensory changes following LeFort I osteotomy

INTRODUCTION

This study aimed to investigate the incidence and recovery of neurosensory deficit (NSD) after LeFort I osteotomy over 12 months and identify any association between age, gender, and extent of surgical movement on recovery. Furthermore, the study explored the relationship between objective and subjective outcome measures.

METHODS

A prospective cohort study consisting of 31 patients. Subjects were assessed at baseline, 1 week (T1), 1 month, 3 months, 6 months, and 12 months (T5) after LeFort I osteotomy. Objective assessment measures included pinprick (PP), static light touch (SLT), static 2-point discrimination (STPD), and electric pulp testing (EPT). Subjective reporting was undertaken using a visual analog scale. Patients rated the impact of NSD on intraoral and extraoral sites at the same time points as for objective measures.

RESULTS

Twenty-eight patients (16 females and 12 males) with a mean age of 24.5 years (standard deviation, 7.4) completed the study. There was a notable reduction in NSD from T1 (85.7%) to T5 (17.9%). No significant differences were found with respect to the influence of gender; PP (P = 0.06), SLT (P = 0.10), STPD (P = 0.65) and EPT (P = 0.19) or extent of surgical movement; PP (P = 0.50), SLT (P = 0.72), STPD (P = 0.06) and EPT (P = 0.74) on NSD. Age is a significant factor for intraoral NSD in the immediate postoperative period; PP (P < 0.0001) and SLT (P < 0.0001). Subjectively, patients reported a high degree of concern associated with NSD immediately after surgery with a gradual reduction from T1 to T5. There is a significant difference in subjective reporting between those with intraoral NSD than those with no intraoral NSD at 12 months (P = 0.031).

CONCLUSIONS

NSD is high after LeFort I surgery, particularly intraorally in the palate. At 12 months, the incidence of NSD is 17.9%. Recovery of NSD to a nonsignificant value from baseline takes up to 3 months for extraoral sites and between 3 and 6 months for intraoral soft tissues. The maxillary dentition continues to recover from NSD up to 12 months postsurgery. Age, gender, and extent of the surgical movement do not influence the extent of NSD at 12 months. Increasing age is associated with increased NSD at intraoral sites immediately after surgery. Intraoral NSD is more of a concern to patients than extraoral NSD. Patients' concerns associated with NSD reduced over time, demonstrating a degree of adaptation in the longer term.

Peri- and postoperative complications in Le Fort I osteotomies

This retrospective study was performed to report the peri- and postoperative complications encountered by patients who underwent Le Fort I osteotomy, as well as predictor variables affecting the risk of complications. Patients who underwent only Le Fort I osteotomy were included in the study. Information on peri- and postoperative complications were collected from the patient data records. The effects of certain predictor variables on complication rates were also studied. Twenty-four per cent of the patients suffered from complications, six (6.1%) of whom were reoperated. Most of the complications were minor and transient. Compared with one-piece osteotomy, segmental osteotomy was a significant risk factor predisposing patients to postoperative complications (p = 0.04619). Additionally, the use of patient-specific implants seemed to increase the risk of both perioperative and postoperative complications (p = 0.0248). Currently, the conventional plate fixation method is the primary method in Le Fort I osteotomies. Careful patient selection, surgical planning, and selection of surgical technique seem to be the most important factors in reducing the complication risk. Special attention should be paid with segmental osteotomy surgery.

Vascular Complications in Le Fort I Osteotomy: Incidence, Reasons, and Management of the Intraoperative Hemorrhage

PURPOSE

The aim of this study was to investigate the incidence, types, and reasons for the intraoperative hemorrhage during Le Fort I osteotomy.

METHODS

The study sample was composed of the population of the patients who underwent orthognathic surgery from April 2011 to February 2017. The vascular complications of the patients who underwent Le Fort I osteotomy during the surgery were identified. Type of the bleeding, suspected vessel, amount of the intraoperative blood loss, cause, and management of the bleeding were specified and investigated. Descriptive statistics were computed for each study variable.

RESULTS

A total of 200 patients underwent Le Fort I osteotomy. The sample's mean age was 22.4 ± 5.8 and 55.5% of patients were female. The intraoperative vascular complication was seen in only 10 (5%) samples. The suspected source of the hemorrhage was the descending palatine artery (DPA) in 8 (4%) cases, while the pterygoid venous plexus in the other 2 (1%) cases. The cause of the bleeding was suspected down-fracture in 8 cases, while pterygomaxillary junction (PMJ) separation in the other 2 cases. DPA was ligated with ligation clips and cauterized in arterial injury cases. The hemorrhage was taken under control using a hemostatic matrix with thrombin (Surgiflo, Ethicon, USA) in the venous bleeding cases.

CONCLUSIONS

The down-fracture of the maxilla was found to be more related to the occurrence of vascular complications. Severe bleeding was managed by the use of the hemostatic matrix with thrombin and this hemostatic agent can be used to control this type bleedings in orthognathic surgery.

Does angulation of osteotome during pterygomaxillary dysjunction for a Le Fort I osteotomy influence stress transmission to the orbit? A finite element simulation in normal and cleft maxillae

Pterygomaxillary (PTM) dysjunction is a technique-sensitive step in Le Fort I osteotomy. Various studies implicate improper osteotomy techniques and anatomical variations of the midface in ophthalmic/orbital complications. The aim of this study was to assess the stress distribution and its transmission to the orbit during PTM dysjunction while using different angulations of the osteotome. The study involved the generation of two virtual models from the computed tomographic images of a non-cleft and cleft patient. Nonlinear, three-dimensional finite element analysis (3D-FEA) of the models was performed for mapping the equivalent stress (in megapascals [MPa]) and maximum principal stress (in MPa) at the PTM junction, optic canal, and superior orbital fissures. The results of our study showed that there was no significant change in the transmission of stress to the bony orbit in a normal maxilla, with variations in the angulation of the osteotome. However, the equivalent stress generated for the cleft maxilla showed an increase that could potentiate indirect globe injury. The study shows that a judicious technique for PTM dysjunction and a cautious approach in cleft maxillae could reduce incidence of ophthalmic complications in clinical practice.

Le Fort 1 and Bimaxillary Osteotomies Increase the Length of Stay but not Postoperative Morbidity Compared to Mandibular Osteotomies and Single Jaw Procedures

PURPOSE

The purpose of this study is to examine the association between type of facial osteotomies performed during orthognathic surgery and postoperative outcomes including complications, length of stay, and readmission.

METHODS

A retrospective review of orthognathic surgery cases from the Pediatric Health Information System (PHIS) database from 2004 to 2014 was undertaken. Osteotomy procedures were classified as Le Fort 1 (LF 1), Mandibular osteotomy, Genioplasty or their combinations. Primary outcome variable was major complications. Secondary outcomes included postoperative LOS > 1 day and 90-day readmission. Random-intercept logistic regression models were utilized to assess the association between the type of osteotomy performed and the outcomes. Bonferroni approach was used to account for multiple comparisons.

RESULTS

The sample included 5413 patients, with a mean age of 17.1 ± 1.68 years and 60.65% were female. The most common procedures were LF1 (39.4%), followed by bimaxillary surgery (23%). Major complications occurred in 8.57% of patients, postoperative LOS > 1 day in 52.4% and 90-day all-cause readmission in 11.16%. In adjusted analyses comparing LF1 compared to mandibular osteotomies, there were no significant differences for major complications (OR = 0.78), 90-day readmission rate (OR = 0.98). However, LF1 was associated with an increased odds for LOS compared to mandibular osteotomies (OR = 1.42). Addition of osteotomies is associated with a significant increase in LOS (P < 0.001).

CONCLUSIONS

Patients undergoing orthognathic surgery demonstrated increased length of stay for LF1 or bimaxillary osteotomies. Osteotomy type did not impact the odds of readmission or complications. The trends revealed should be helpful for patient counseling.

An idiopathic delayed maxillary hemorrhage after orthognathic surgery with Le Fort I osteotomy: a case report

A Le Fort I osteotomy is a common procedure for correcting dental and facial deformities in orthognathic surgery. In rare cases, a delayed hemorrhage can occur as early as several hours or up to 12 weeks, postoperatively. The most frequently involved blood vessels in a delayed hemorrhage are the descending palatine artery, the internal maxillary artery, and the pterygoid venous plexus of veins. Intraoral bleeding accompanied by severe epistaxis in these cases makes it difficult to locate the precise bleeding focus. Eventual uncontrolled bleeding would require Merocel packing or surgical intervention. In general, a severe late postoperative hemorrhage is most effectively managed by angiography and embolization. Herein we describe a delayed hemorrhage case in which the cause was not evident on angiography. We were able to detect the bleeding point through an endoscopic nasal approach and treat it using direct cauterization.

Evaluating the July Effect in Oral and Maxillofacial Surgery: Part II-Orthognathic Surgery

PURPOSE

The purpose of this study was to determine if there is an increased postoperative complication rate in orthognathic surgery during the first academic quarter (Q1) (July to September).

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was accessed to identify cases with Current Procedural Terminology codes pertaining to orthognathic procedures from 2008 to 2017. Procedures were separated into 2 groups based on time in the academic year: Q1 (July to September) versus remaining quarters (RQ). The inclusion criteria were Current Procedural Terminology codes representing operations resulting in movement of the dentate portion of the jaws and age of 18 years or older. Patient demographic characteristics and perioperative complications were compared between the groups. Descriptive statistics, Fisher exact tests, and χ² tests were executed.

RESULTS

The Q1 cohort included 877 cases, and the RQ cohort included 2,062 cases. The average age of patients was 47.0 ± 19.5 years in Q1 versus 47.2 ± 19.4 years in RQ. The most frequent complications were blood transfusion (11.97% in Q1 vs 12.57% in RQ, P = .64), reoperation (8.67% in Q1 vs 8.84% in RQ, P = .87), and combined superficial and deep-space infection (5.02% in Q1 vs 5.76% in RQ, P = .51). Medical complications involving other organ systems were rare (<1%). Analyses showed no significance between complication rate and time of year.

CONCLUSIONS

The results of this study indicate that there is no association between time of year and complication rates after orthognathic surgery. Additional investigations could be useful in shining light on this topic as it pertains to the training of future surgeons.

Interproximal bone in maxillary anterior teeth in subjects with Class III facial deformity: Are there options for segmental maxillary osteotomy in "surgery first"?

Our aim was to give a morphometric description of the interproximal bone between the anterior maxillary teeth of subjects with class III facial deformity, who were candidates for segmented Le Fort I osteotomy. We measured the width of the interproximal bone from the upper right canine to the upper left canine in cone-beam computed tomographic images of 35 subjects, and identified five interproximal areas of measurement. The lower and upper measurements were established 5mm and 10mm from the cervical crest of the interproximal bone. A paired samples t test and Pearson's correlation coefficient were applied and probabilities of less than 0.05 were accepted as significant. In all the scans of interproximal bone, the apical zone was significantly wider than the inferior zone (p<0.001). The area between the central incisors was the widest, with a mean (SD) of 2.42 (0.68) mm in the lower, and 4.27 (0.99) mm in the upper, region followed by the space between the canines and lateral incisors. The minimum interproximal spaces in the lowest area were between 1.1 and 1.5mm, which suggested the potential for damage to the teeth during segmental osteotomy. The interproximal spaces were at potential risk of dental and periodontal injuries, and the area between the central incisors seemed to be most suited to interproximal osteotomies in "surgery first".

Intra- and Postoperative Complications of Le Fort I Maxillary Osteotomy

BACKGROUND

The Le Fort I maxillary osteotomy is a versatile and simple procedure, which has gained popularity nowadays, to correct a wide range of malocclusion and maxillofacial deformities. This procedure is often associated with significant but rare postoperative complications. The aim of this study was to evaluate the types and frequencies of intra- and perioperative complications related to Le Fort I osteotomies in noncleft Iranian patients.

MATERIALS AND METHODS

In this prospective study, all the healthy systemic patients, (ASA I, II) with the age range of 18 to 30 years from both genders, who had the skeletal class II or III deformities and required only isolated 1-piece maxillary Le Fort I osteotomy, were included in this study. These patients had no craniofacial cleft history and were candidates for orthognathic surgery in Maxillofacial Surgery Department of Qaem Hospital of Mashhad (Iran), 2015 to 2017. All of the operations were carried out or supervised by a single surgeon and anesthesiologist using the same protocol. The patients were monitored for occurrence of intra- or postoperative complications till 6 months. The t-test, Chi-squared test, and Fisher exact test were performed for data analysis using SPSS version 16 (SPSS Inc, Chicago, IL).

RESULTS

In the present study, a total of 114 consecutive patients with the average age of 22 ± 5 years from October 2015 to November 2017 were recruited. About 77 (67.54%) patients were presented skeletal class III deformity and 37 (32.46%) were class II. The most prevalent maxillary movement after Le Fort I osteotomy was identified to be isolated maxillary advancement in 51 (44.75%) patients. Only 10 (8.77%) of all 114 patients confronted surgical complications. Hemorrhagic complication (arterial bleeding from descending palatine artery and epistaxis) and anatomic complications (septal deviation and bad fracture) would be the most prevalent complications with the frequency of 5.25% and 3.5% in total. Maxillary setback with impaction presented the highest rate (36.4%) of complications compared to other maxillary movement types. On balance, there was a significant association between Le Fort I surgery complications and maxillary movement types in our research (P = 0.002).

CONCLUSION

The rate of intra- and postoperative complications following Le Fort I osteotomy for healthy noncleft adults in our center was low. Therefore, it can be concluded that this technique is safe and reliable. The maxillofacial surgeon should pay more attention for prevention or even management of the risk of intra- and perioperative complications in patients with anatomic irregularities (previous craniofacial cleft or trauma history) and those who required maxillary setback concomitant with impaction movements.

Major Complications and 30-Day Morbidity for Single Jaw Versus Bimaxillary Orthognathic Surgery as Reported by NSQIP

OBJECTIVE

Acute complications in orthognathic surgery are reported in single-institution studies with small sample sizes. We aimed to analyze risk factors for acute complications using a national data set to better inform surgical decision-making.

METHODS

2005-2015 National Surgical Quality Improvement Program (NSQIP) data sets were analyzed for patients undergoing Le Fort 1 and/or bilateral sagittal split osteotomies (BSSO) for nontraumatic indications. Demographics, comorbidities, medical, and surgical 30-day complications were tabulated. A logistic regression model was used to determine predictors of complications.

RESULTS

Five hundred eight patients met the inclusion criteria: 228 underwent Le Fort I osteotomies, 152 BSSO, and 128 patients underwent both during a single surgical encounter. Overall complication rate was 4.5% (23/508). Superficial infection was the most common complication (11 in BSSO and 2 in Le Fort I cohorts). Increasing age and undergoing BSSO alone were associated with higher overall complication rates (P < .05) and surgical complications specifically (P < .05). Patients undergoing the combined procedure had shorter operative time (208 minutes) than the times for Le Fort I osteotomies alone (177 minutes) and BSSO alone (155 minutes) added together and did not have a longer hospital stay (P = .608) or increased need for transfusion (P = 1.0) compared to the surgeries being done separately.

CONCLUSION

This is the first complication risk factor analysis for Le Fort I osteotomy and BSSO using the multi-institutional NSQIP data set. Combining BSSO and Le Fort I osteotomy leads to a shorter overall operative time and does not increase hospital stay duration or 30-day complication rate when compared to the 2 procedures being done separately.

Determining the Margin of Safety for Damaging the Sphenoid Sinus with Nasal Septum Osteotome during Le Fort I Surgery in Young Adults

Nasal septum (Obwegeser) osteotome is a basic instrument used for separating the nasal septum and maxilla during Le Fort I osteotomy. If this instrument is placed too high or tilted into the nasal cavity, sphenoid sinus and various adjacent vital structures may be damaged and serious bleeding, neurological complications, or blindness or even death may occur. The aim of this study is to determine the margin of safety for damaging the sphenoid sinus and the adjacent structures with nasal septum osteotome in the young adults: 49 male and 51 female patients between 15 and 25 ages who required a Cone Beam Computed Tomography (CBCT) examination as part of their routine examination. In the study sample consisting of CBCT images, the aimed surgical line, the line between spina nasalis anterior and vomer and the base of sphenoid sinus (undesired line), and tilt angle between surgical and undesirable lines were measured. As the primary outcome of this study, margin of safety for damaging the sphenoid sinus and adjacent vital structures with nasal septum osteotome during Le Fort surgeries in young adults recommended as 5 mm and 12⁰. For this reason the importance of planning with preoperative CBCT before Le Fort I osteotomies has been revealed.

Morphologic Evaluation for Safe Le Fort I Osteotomy in Cleft Lip and Palate

OBJECTIVE

The present study aimed to determine the structure and morphology of the maxilla in patients with cleft lip and palate to ensure safe Le Fort I osteotomy.

PATIENTS

A total of 34 sides of 17 patients with unilateral cleft lip and palate (nonsyndromic cases) were included in this study. The control group included 10 sides of 5 patients who exhibited skeletal mandibular protrusion without malformation.

METHODS

Finite element analysis was performed to examine the distribution of occlusal force over the maxilla, and continuous 3-dimensional measurement was performed at the sites of stress concentration.

RESULTS

In patients with cleft lip and palate, bones at the lateral border of the piriform aperture and the anterior wall of the maxillary sinus were significantly thicker than those in controls ( P < .05). Furthermore, the attachment of the pterygomaxillary junction was wider and thicker ( P < .05), and the anterior distance to the descending palatine artery was shorter ( P < .01) in patients with cleft lip and palate than in controls. Our results further indicated that alveolar bone grafting may significantly influence bone thickness and the attachment state of the pterygomaxillary junction.

CONCLUSIONS

Our results suggest that the complications of LFI can be reduced in patients with cleft lip and palate by ensuring proper understanding of each patient's maxillary anatomy and bone thickness, as well as the location of the descending palatine artery and the attachment state of the pterygomaxillary junction.

Postoperative Complications Following LeFort 1 Maxillary Advancement Surgery in Cleft Palate Patients

Objective:

To investigate the postoperative complication rates of LeFort 1 maxillary advancement surgery in cleft patients when performed by a single surgeon over a 5-year period.

Design:

A retrospective case note review of 79 cleft palate patients.

Setting:

All surgery was performed by a single oral and maxillofacial surgeon in a tertiary care center.

Participants:

All cleft palate patients over 17 years of age who opted for surgical correction of maxillary hypoplasia with a LeFort 1 between 2010 and 2015. Patients required full surgical and clinical records.

Interventions:

Complete surgical advancement of the maxilla ranging from 2.0 to 18.0 mm performed by conventional osteotomies (87%) or distraction osteogenesis (13%).

Main Outcome Measure(s):

Postoperative patient- and clinician-reported complications at set-interval follow-up appointments.

Results:

Twenty-one patients (26.58%) reported no complications; 11 postoperative complications were identified in the remaining cohort. Temporary paresthesia of the infraorbital nerve was the most common complication (53.16%) followed by infection (13.92%). Other complications included relapse (11.39%), maxillary instability (6.33%), velopharyngeal impairment (6.33%), nasal obstruction (5.06%), chronic sinusitis (3.80%), bony dehiscence (1.27%), gingival necrosis (1.27%), partial necrosis of the maxilla (1.27%), and loss of tooth vitality (1.27%).

Conclusions:

LeFort 1 maxillary advancement surgery in cleft palate patients is associated with a wide range of postoperative complications, most commonly temporary paresthesia of the infraorbital nerve. Detailed, informed consent is essential prior to surgery.

Open Versus Closed Reduction of Maxillary Fractures: Complications and Resource Utilization

INTRODUCTION

Maxillary fractures are frequently managed depending on the surgeon's preferences, nature of the injury, presence of associated injuries, and comorbidities. Current literature advocates open reduction with plating versus closed techniques. However, data defining associated costs and complications comparing the 2 approaches remains lacking.

METHODS

National Inpatient Sample (2006-2011) was examined for patients undergoing closed or open (76.73-76.74) reduction of maxillary fractures. Treatment-related complications were regarded as re-exploration of surgical site, hemorrhage, hematoma, seroma, wound infection, and dehiscence.

RESULTS

Overall, 22,157 patients were identified. There were 18,874 closed and 3283 open procedures. Median age was 35 (interquartile range 27). Median length of stay (LOS) was 4 days. Median total charges were reported as 51486.80 USD. Males comprised 77% of the cohort. 68% of patients were Caucasian. Private payer/HMO accounted for the largest source of health care coverage (43.5%). On risk-adjusted multivariate analysis, there was no difference in surgical approach regarding incidence of postoperative complications. Males (2.73), nonprivate insurer payer (P = 0.002), South region (2.49), and transferred patients (2.55) had higher incidence of complications. Presence of chronic pulmonary disease (2.87) and coagulopathy (6.62) also increased risk of complications. Length of stay was shorter for open reduction (0.68) versus closed. Total charges were also less for open approach (0.37).

CONCLUSION

While surgical approach did not affect complications, open approach favorably affected LOS and total charges. Future studies should focus on comorbidities, demographics, and associated injuries in relation to resource utilization for maxillary fractures. In current economic environment, such information might further dictate management options.

Massive Middle Cerebral Artery Infarction After Surgically Assisted Rapid Palatal Expansion: A Case Report

Dentofacial deformities have a marked impact on a patient's quality of life. Fortunately, these deformities often can be corrected through orthodontic and surgical treatment. In adults, transverse maxillary discrepancies are often corrected by performing a surgically assisted rapid palatal expansion (SARPE) procedure. This procedure is accompanied by many of the same complications involved in performing a Le Fort I osteotomy. Although major complications from maxillary surgery are uncommon, severe hemorrhage and cerebrovascular accidents are real risks accompanied by serious sequelae. The purpose of this case report is to describe a case in which a patient developed a massive middle cerebral artery infarct after a SARPE procedure. The authors discuss the possible etiology and pathogenesis of the complication. They also aim to remind surgeons of this rare complication to ensure prompt recognition and management to prevent delays in care.

Slotplates revisited - A retrospective analysis

CONTEXT

Slotplates were specifically designed to meet the special requirements of corrective surgeries of the facial skeleton. This design enables small readjustments of bone fragments in the midface and chin area during surgery without complete removal of plates and screws.

OBJECTIVE, DESIGN, AND SETTING

The aim of this study was to compare morbidity rates of slotplates versus meshplates after Le Fort I osteotomy, genioplasty and/or zygoma 'sandwich' osteotomy performed in a tertiary care centre.

RESULTS

The investigators analyzed chart records of 190 patients, including a total of 257 surgeries. Slotplates were used in 109 patients, meshplates in 81 patients. Plate infection rates were 9.2% in the slotplate group and 7.4% in the meshplate group. Twelve patients (11.0%) from the slotplate group underwent plate removal versus four patients (4.9%) from the meshplate group. In total, there were two cases of delayed union, both in the slotplate group, one progressed to non-union.

CONCLUSION

Due to the low study power significant differences between the two types of plates could not be detected. However, there is a slight tendency towards higher morbidity associated with the use of slotplates. The probability of mechanical weakness of the configuration being responsible for the fatigue fractures is also discussed in this article.

Professional oral health care reduces the duration of hospital stay in patients undergoing orthognathic surgery

The present study reviewed the records of 58 patients who underwent orthognathic surgery [sagittal split ramus osteotomy (SSRO), Le Fort I osteotomy, genioplasty, anterior maxillary alveolar osteotomy] between 2010 and 2015. To investigate the influence of preoperative oral health care on postoperative inflammation, infection and length of hospital stay in those patients, white blood cell (WBC) count and C-reactive protein (CRP) levels were compared between patients who received and did not receive preoperative oral care. The mean CRP level throughout the postoperative term was lower in the oral care group as compared to the non-oral care group. By contrast, the oral care group had a lower occurrence of postoperative infectious complications (surgical site infection, anastomotic leak) (13.6 vs. 20.8%) and a shorter average length of hospital stay (16.2±3.8 vs. 21.2±7.4 days). These results suggest that preoperative professional oral health care decreases the duration of hospital stay following orthognathic surgery by inhibiting inflammation and infectious complications during the postoperative stage.

Is Le Fort I Osteotomy Associated With Maxillary Sinusitis?

PURPOSE

The purpose of the present study was to investigate the association between Le Fort I osteotomy and the anatomic, radiologic, and symptomatic modifications of the maxillary sinus.

MATERIALS AND METHODS

Subjects who had undergone Le Fort I osteotomy from January 2008 to December 2013 were enrolled in a retrospective cohort study. The eligibility criteria were the availability of a cone beam computed tomography (CBCT) scan taken before and 12 to 24 months after the procedure. The exclusion criteria were the unavailability of CBCT scans, the use of tobacco, and previous orthognathic procedures. The primary predictor variable was time (pre-vs postoperative). The primary outcome variables were the sinus volume, mucosal thickening, iatrogenic alterations in the sinus anatomy, and rhinosinusitis symptoms, evaluated using the Sino-Nasal Outcome 20-item Test (SNOT-20). Descriptive statistics were computed for each variable, and paired analyses were used to compare the pre- and postoperative values.

RESULTS

The data from 64 subjects (mean age 27; 59.4% were female; median follow-up 32.4 months, range 13 to 66 months) were studied. Postoperatively, 1.6% of the sample (0% preoperatively) had moderate-to-severe and 15.6% (3.1% preoperatively) had mild-to-moderate sinusitis symptoms. The rest of the sample presented with mild to no symptoms. The increase in the SNOT scores after surgery was statistically significant (P = .016). Radiologic evidence of postoperative inflammatory processes affecting the paranasal sinuses was found in 27.3% of the sinuses (9.4% preoperatively). The postoperative Lund-Mackay scores were significantly greater (P = .0005). A 19% decrease was found in the mean postoperative sinus volume, with a 37% incidence of iatrogenic injury.

CONCLUSIONS

The study results indicate that Le Fort I osteotomies can have an important impact on sinus health. The postoperative radiologic evidence of maxillary sinus inflammatory processes and the incidence of rhinosinusitis symptoms and iatrogenic damage in these patients have led us to conclude that CBCT scans and the SNOT-20 questionnaire should be used routinely during postoperative monitoring. Larger long-term studies are warranted to clarify the postoperative outcomes and complications.

Etiology and clinical characteristics of symptomatic unilateral maxillary sinusitis: A review of 174 cases

The purpose of the study was to analyze the causative pathology associated with symptomatic unilateral maxillary sinusitis requiring surgical treatment. A retrospective review of all patients that have been treated surgically for unilateral symptomatic maxillary sinusitis between 2006 and 2013 at a single institution was performed. Demographic, anamnesis, clinical, radiological, microbiological and histological data were gathered and analyzed. The patients were allocated into groups depending on the underlying cause of the disease. Descriptive and inferential statistics were computed (level of significance: p ≤ 0.05). The study sample was composed of 174 patients (72 female; 102 male) with a mean age of 52.7 years (SD 16.9). Most cases (130; 75%) were triggered by odontogenic pathology following dentoalveolar surgical interventions (83/130 patients; 64%). Other etiological factors for odontogenic unilateral sinusitis were periapical (23/130 cases; 18%) and periodontal pathology (13/130 cases; 10%). Rhinogenic factors for sinusitis were detected in 13 patients (7.5%) and dental implant-associated unilateral maxillary sinusitis was diagnosed in nine patients (5.2%). Four patients (2.3%) had undergone previous sinus augmentation surgery. A leading cause for the sinus infection could not be identified in 18 patients (10%) who all had a history of midfacial surgery. Medication-related osteonecrosis of the jaw (8) and squamous cell carcinoma (2) were incidental findings. There were no differences in the clinical appearance of the disease with respect to its etiology. Odontogenic causes for maxillary sinusitis must be considered especially in unilateral cases. Maxillary dental implants may induce symptomatic unilateral maxillary sinusitis.