Removal of bicortical screws and other osteosynthesis material that caused symptoms after bilateral sagittal split osteotomy: a retrospective study of 251 patients, and review of published papers

Facial scars resulting from a transbuccal approach during osteosynthesis of a sagittal split osteotomy: A retrospective study

The purpose of the current study was to assess the quality of facial linear scars. The Stony Brook Scar Evaluation Scale (SBSES) was developed and validated as a tool to assess postoperative scars. Postoperative facial scars were rated using high-quality macrophotographs and SBSES by three independent raters at baseline and three months thereafter. Percentage agreement (PA) and intraclass correlation coefficient (ICC) were used to measure interrater and intrarater reliability. Scar outcomes ranging from 0 (worst) to 5 (best) were evaluated against age and gender. One-hundred-sixty-six patients with a mean age of 30.6 years (range of 17-59) were included in this study. Forty-four were male (26.5%), and 122 were female (73.5%). Mean total SBSES scores were 4.63 (range of 4.56-4.76) at baseline and 4.60 (range of 4.54-4.72) at three months. As patient's age increased, mean total SBSES scores also decreased significantly (r = -0.216, p = 0.005). Gender did not significantly affect raters' perception of scar cosmesis (p = 0.847). Interrater reliability showed an ICC of 0.675 (95% CI, 0.609-0.731) and a PA of 65.4% at baseline, and an ICC of 0.655 (95% CI, 0.585-0.715) and a PA of 64.2% at three months. Intrarater reliability found ICCs ranging from 0.988 to 0.990 and a PA of 96.8% with 3 separate raters. Within the limitations of the study it seems that the transbuccal approach during osteosynthesis of a sagittal split osteotomy seems still to be acceptable when the patient gives his or her informed consent and advanced instruments like an angled screwdriver are not available.

Comparative assessment of osteotomy cut using bur and saw for bilateral sagittal split osteotomy of mandible: a prospective clinical study

PURPOSE

To compare the intraoperative utility of bur and saw and to examine the pattern of lingual split during bilateral sagittal split osteotomy of mandible.

MATERIAL AND METHODS

This study prospectively compares the intraoperative utility of bur and saw in bilateral sagittal split osteotomy as split-mouth model. Study includes 16 patients (representing 32 sagittal split osteotomies) divided into two groups. The procedure to be performed was explained to the patient, followed by written informed consent. The institutional ethical committee approved the clinical study and all subjects gave informed consent.

RESULTS

We found that the ease of handling of the bur was good compared to saw. The duration required for completion of osteotomy using bur was less compared to saw.

CONCLUSIONS

The use of surgical drills and burs is still the gold standard in most developing nations and countries in transition like India. Depending upon the expertise of the surgeon, availability of precise dissecting instruments, one can go with either of the instrument for BSSO.

Fixation Methods for Mandibular Advancement and Their Effects on Temporomandibular Joint: A Finite Element Analysis Study

Objectives

Bilateral sagittal split osteotomy (BSSO) is a common surgical procedure to correct dentofacial deformities that involve the mandible. Usually bicortical bone fixation screw or miniplates with monocortical bone fixation screw were used to gain stability after BSSO. On the other hand, the use of resorbable screw materials had been reported. In this study, our aim is to determine first stress distribution values at the temporomandibular joint (TMJ) and second displacement amounts of each mandibular bone segment.

Methods

A three-dimensional virtual mesh model of the mandible was constructed. Then, BSSO with 9 mm advancement was simulated using the finite element model (FEM). Fixation between each mandibular segment was also virtually performed using seven different combinations of fixation materials, as follows: miniplate only (M), miniplate and a titanium bicortical bone fixation screw (H), miniplate and a resorbable bicortical bone fixation screw (HR), 3 L-shaped titanium bicortical bone fixation screws (L), 3 L-shaped resorbable bicortical bone fixation screws (LR), 3 inverted L-shaped titanium bicortical bone fixation screws (IL), and 3 inverted L-shaped resorbable bicortical bone fixation screws (ILR).

Results

At 9 mm advancement, the biggest stress values at the anterior area TMJ was seen at M fixation and LR fixation at posterior TMJ. The minimum stress values on anterior TMJ were seen at L fixation and M fixation at posterior TMJ. Minimum displacement was seen in IL method. It was followed by L, H, HR, M, ILR, and LR, respectively.

Conclusion

According to our results, bicortical screw fixation was associated with more stress on the condyle. In terms of total stress value, especially LR and ILR lead to higher amounts.

Evaluation of one-point fixation for zygomaticomaxillary complex fractures using a three-dimensional photogrammetric analysis

BACKGROUND

The goal of treatment for zygomaticomaxillary (ZM) complex (ZMC) fractures is to achieve stability and restore aesthetic appearance through three-dimensional reduction and rigid fixation. The purpose of this study was to evaluate the stability and aesthetic appearance outcomes of one-point fixation using a three-dimensional photogrammetric analysis.

METHODS

From March 2014 to December 2014, 34 patients with ZMC fractures were treated by one-point fixation in the ZM buttress using unsintered hydroxyapatite (u-HA)/poly-L-lactide (PLLA) plates. Differences in soft tissue inter-malar height between the fractured side and unfractured sides were evaluated using photogrammetric analysis with a three-dimensional camera (Morphius®) at the preoperative and 1 week, 1 and 3 months after surgery. The differences in bony inter-malar height between the fractured and unfractured sides were evaluated using computer tomography at the pre-operative and 6 months after surgery. The paired t-test was used to compare differences in malar height.

RESULTS

Six months after surgery, 34 patients achieved satisfactory bony stability and symmetric malar appearances. Comparisons of differences in soft-tissue inter-malar height revealed statistically significant differences between the pre-operative period and 1 week and 1 month after surgery (p < .01). There was no statistically significant difference between 1 and 3 months after surgery. Comparison of differences in bony inter-malar height revealed a statistically significant difference between before and 6 months after surgery (p < .01).

CONCLUSIONS

When we conducted a three-dimensional photogrammetric analysis, although it has restricted surgical indications, one-point fixation of the ZM buttress using an u-HA / PLLA plate yielded reliable, satisfactory, and safe clinical results in patients with ZMC fractures.

CLINICAL QUESTION / LEVEL OF EVIDENCE

Therapeutic, III.

Delayed Pharyngeal Migration of a Mandibular Fixation Screw 30 Years After Orthognathic Surgery

There have been reports of migrated screws after cervical spine procedures; however, similar cases after orthognathic procedures are rare. A 48-year-old female patient presented with a 6-month history of left-sided neck pain and left-sided otalgia. Her medical history was relevant for orthognathic surgery 30 years earlier. Flexible fiberoptic endoscopy and a computed tomography scan showed the tip of a fixation screw in the lateral pharyngeal wall on the left side. The patient was taken to the operating room for direct microlaryngoscopy using a carbon dioxide laser, with successful removal of the screw. We report a safe method for removal of pharyngeal foreign bodies.

Orthognathic Surgery: A Review of Articles Published in 2014-2015

OBJECTIVES

We did a retrospective study and reviewed some of the orthognathic surgery related papers that were published between January 2014 and December 2015 in a leading International Maxillofacial Surgery Journal. It was conducted to ascertain the trends of articles being published.

METHOD

A total of around 57 articles were reviewed, of which most of the full length articles were on post operative outcomes and obstructive sleep apnoea.

RESULTS

Bulk of the studies were retrospective, and less interest was shown onto experimental researches.

CONCLUSION

A thorough review and analysis thus gives an impression that there is a high requirement of well designed clinical studies.

Early Complications From the Use of Calcium Phosphate Paste in Mandibular Lengthening Surgery. A Retrospective Study

PURPOSE

Calcium phosphate paste is used in mandibular lengthening surgery to avoid unesthetic notching at the lower border and to help stabilize the segments when osteosynthesis slippage is a concern. The aim of this study was to investigate whether the hardened paste increases the incidence of infections.

MATERIALS AND METHODS

This was a retrospective cohort study of medical charts of all patients who underwent a bilateral sagittal split osteotomy from February 2012 through July 2015. The outcome and predictor variables were postoperative infection and calcium phosphate paste use, respectively. Other study variables included age, gender, tobacco use, type of fixation, type of surgery, antibiotic prophylaxis regimen, third molar extraction, and medical comorbidities. Variables were analyzed using the Fisher exact test and logistic regression.

RESULTS

The sample included 196 patients (115 female and 81 male) 9 to 57 years old. The overall infection rate was 12.2%. Of the 102 patients who received calcium phosphate paste, 18.6% developed an infection compared with 5.3% in the control group. The difference in infection rate was statistically significant (odds ratio = 0.14; 95% confidence interval [CI], 0.04-0.48; P = .002) after adjusting for the other variables. Of the 392 surgical sites, 204 had received calcium phosphate paste, of which 10.3% became infected. Of the 188 sites without defect reconstruction, 6 (3.2%) became infected (P = .008 by bivariate analysis). There was a statistically significant association between third molar removal and infections (odds ratio = 8.01; 95% CI, 1.28-50.1; P = .026) and between the use of amoxicillin plus clavulanate and the use of cefazolin (odds ratio = 3.92; 95% CI, 0.87-17.63; P = .07).

CONCLUSION

There was a relevant trend of increased infection with calcium phosphate paste use. Third molar removal also was identified as a risk factor. Prospective studies after procedural modifications are recommended to determine whether the benefits of using calcium phosphate paste outweigh the risks.

Reconstruction of tooth-bearing portion of mandible using polyglactin 910 sutures for internal fixation in the third-world: functional and cosmetic outcome

BACKGROUND

This study analyzed the cosmetic and functional outcome of cases involving reconstruction of tooth-bearing portion of the lower jaw, using a polyglactin 910 suture for fixation.

PATIENTS AND METHOD

This prospective intervention study documented the treatment outcome in 25 consecutive adult patients, who underwent immediate mandibular reconstruction following segmental resection of tooth-bearing portion of mandible. Cortico-cancellous bone graft was taken from the inner table of iliac bone, sparing the crest. Use of post-surgical inter-maxillary fixation was avoided.

RESULTS

Twenty-five patients were recruited for the study. Seventeen were males and eight were females. Their ages ranged from 18 to 50 years, with a mean of 30.0 years. Average length of grafted bone was 9.8 cm. Following surgery, all 25 (100%) patients were judged to have satisfactory facial symmetry. One (4.0 %) had altered dental occlusion. Twenty-five (100%) had satisfactory bone union. All of the patients claimed to masticate satisfactorily. Assessment was carried out at the last post-operative follow-up visit for each patient who ranged between 22 and 83 months.

CONCLUSION

Use of polyglactin 910 suture material for fixation in mandibular reconstruction following segmental resection of tooth-bearing portion has proven to be a cosmetic and functional success. It may serve as alternative for those among whom conventional treatment methods may be contraindicated. This method of bone fixation may serve as a reliable and much cheaper alternative in low-income countries.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Transoral Fixation of Bicortical Screws Is Safe and Feasible for Lower Jaw Osteotomies

PURPOSE

Transoral placement of bicortical screws is a rigid fixation method in orthognathic surgery that is used less often than transbuccal placement. The aim of this study was to examine the postoperative outcome of transoral bicortical screw insertion during orthognathic surgery and to compare it with the more common transbuccal fixation technique.

MATERIALS AND METHODS

A retrospective cohort study was conducted. Clinical files of orthognathic surgery patients operated on from January 2010 through December 2012 were reviewed. Screw insertion approach (transoral vs transbuccal) was examined as a predictive variable for postoperative complications (hardware removal and infection). Type of surgery, fibrin sealant, preoperative third molar removal, and patient age and gender were analyzed as potential risk factors. Descriptive and bivariate statistics and regression analyses were performed.

RESULTS

Of the 606 patients whose cases were reviewed, 509 patients (185 men; mean age, 26.3 ± 11.1 yr) met the inclusion criteria. Most presented with a Class II malocclusion (84.5%). A transbuccal approach was used in 27.5% of cases, leading to a screw-related infection of 6.3%. Patients treated with a transoral technique (72.5%) had fewer infections (3.5%), but this was not statistically relevant. Screw removal was indicated in 3.3% of patients. Screw placement using the transoral and transbuccal approaches was performed in 3.0 and 4.2% of patients, respectively. Infection and screw removal rates did not differ significantly between fixation techniques (P = .16 and P = .49, respectively).

CONCLUSION

The present findings showed an overall low rate of screw removal and infection secondary to bicortical screw insertion during orthognathic surgery. The postoperative outcome was similar for the transoral and transbuccal approaches.

Angled Osteotomy Design Aimed to Influence the Lingual Fracture Line in Bilateral Sagittal Split Osteotomy: A Human Cadaveric Study

PURPOSE

The traditional osteotomy design in the bilateral sagittal split osteotomy includes a horizontal lingual bone cut, a connecting sagittal bone cut, and a vertical buccal bone cut perpendicular to the inferior mandibular cortex. The buccal bone cut extends as an inferior border cut into the lingual cortex. This study investigated a modified osteotomy design including an angled oblique buccal bone cut that extended as a posteriorly aimed inferior border cut near the masseteric tuberosity.

MATERIALS AND METHODS

The authors implemented a randomized controlled study. The study sample was comprised of 28 cadaveric dentulous mandibles. The primary outcome variable was the pattern of lingual fracture induced using the conventional (n = 14) and modified (n = 14) osteotomy designs. The secondary outcome variables included the incidence of bad splits and the status of the inferior alveolar nerve (IAN). Descriptive and bivariate statistics were computed.

RESULTS

The angled osteotomy design resulted in a significantly larger number of the lingual fractures originating from the inferior border cut (odds ratio [OR] = 1.54; 95% confidence interval [CI], 1.27-1.86; P < .01), with a significantly more posterior relation of the fracture line to the mandibular canal (OR = 2.11; 95% CI, 1.22-3.63; P < .01) and foramen (OR = 1.99; 95% CI, 1.28-3.08; P < .01). No bad splits occurred with the angled design, whereas 3 bad splits occurred with the conventional design, although this difference was not statistically significant (OR = 1.11; 95% CI, 0.99-1.25; P = .07). IAN status was comparable between designs, although the nerve more frequently required manipulation from the proximal mandibular segment when the conventional design was used (OR = 1.21; 95% CI, 0.99-1.47; P = .06).

CONCLUSION

The results suggest that the angled osteotomy design promotes a more posterior lingual fracture originating from the inferior border cut and a trend was apparent that this also might decrease the incidence of bad splits and IAN entrapment. These results must be carefully extrapolated to the clinical setting, with future studies clarifying these findings.