Operative time, length of stay and reoperation rates for orthognathic surgery

Single-jaw patient-specific implants in bimaxillary orthognathic surgery: Randomized cross-controlled comparison between maxilla-guided and mandible-guided approach

This randomized trial aims to compare the efficacy of Patient Specific Implants in bimaxillary orthognathic surgery via maxilla-guided or mandible-guided technique, focusing on the accuracy of pre-operative planning transfer in the operating room. Twenty patients with dentoskeletal dysmorphism were enrolled and virtual surgical planning (VSP) was performed. Subsequently, they underwent bimaxillary orthognathic surgery using either a maxilla-guided or a mandible-guided approach, as determined via a blind randomization process. Post-operative CBCT scans were conducted one month after surgery to assess maxillo-mandibular positioning. Finally, a roto-translational rigid body analysis was conducted to compare the initial VSP and the post-operative results. Results revealed high reproducibility with both techniques, maxilla-guided approach demonstrating an increased accuracy in vertical, antero-posterior and total translational repositioning of the maxilla, and the antero-posterior repositioning of the mandible compared to the mandible-guided approach. However, the mandible-guided approach offered greater flexibility in controlling the vertical dimension. The two methods have proven to be largely comparable in terms of mandibular rami positioning. Both techniques exhibited clinically equivalent precision in reproducing the VSP, with no surgical complications observed. In conclusion, while the maxilla-guided approach exhibited generally lower discrepancies in the reproduction of the VSP, both techniques were deemed equally effective in bimaxillary orthognathic surgery.

A Novel Intraoral Mandibular Osteotomy For Set-Back Surgery In Complex Mandibular Anatomy

OBJECTIVE

Complex mandibular anatomy including rolled-out inferior mandibular border, thin rami with cortically adherent inferior alveolar nerve (IAN) complicate the application of the current mandibular osteotomies. This study aims to introduce an intraoral Inverted-L Ramus Osteotomy (ILRO) modified with IAN lateralization and intra-canal osteotomy for management of complex mandibular anatomical variations during mandibular setback surgery.

PATIENTS AND METHODS

This prospective study included 20 skeletal class III patients (mean age: 21.6 ± 3.3 years) with complex mandibular anatomy indicated for mandibular setback surgery (mean setback: 6.05 ± 1.1 mm). Preoperative CBCT imaging, digital planning, and fabrication of cutting / drilling guides were performed. Surgery involved mandibular setback through the application of the ILRO modified with nerve lateralization and intra-canal osteotomy. IAN function evaluated preoperatively at intervals up to one year postoperatively. Data on bad splits and surgical duration were also analyzed.

RESULTS

The mean surgical duration was 2.26 ± 0.21 h, with bilateral IAN exposure completed in 11 ± 3.2 min per side. All 40 osteotomy sites were separated without bad splits. Neurosensory deficits were observed in 90% of patients at two months, decreasing to 35% at six months and 5% at one year.

CONCLUSION

The introduced osteotomy overcomes the limitations of the traditional mandibular osteotomies in dealing with mandibular complex anatomy with adequate IAN protection and split segments integrity during mandibular setback surgery.

CLINICAL RELEVANCE

The introduced osteotomy provides a safe alternative to the current mandibular osteotomies utilized in mandibular setback surgery.

Bimaxillary osteotomies as a less than 24-hour stay procedure

Historically, Le Fort I bimaxillary osteotomy (BMO) in the UK has generally been regarded as a surgical procedure requiring a full day of operating with subsequent hospital stay for several days, including potential intensive care admission and blood transfusions. Following the introduction of the national standards on day case surgery in the UK in 2011, the authors have routinely and successfully performed bilateral sagittal split osteotomy surgery (BSSO) as a day-case procedure, whilst achieving excellent patient satisfaction since 2015. The desire to improve efficiency in the management of patients requiring short-term surgical admission, was also applied to BMO procedures, with aims for a short, less than 24 h (<24-hour) stay admission, for patients with appropriate medical and social circumstances. With day surgery and short stay admission considered fundamental to modern care, this presents multiple benefits for both patients and the National Health Service (NHS). Our aim was to demonstrate that our BMOs conform to current national standards, and could be carried out both successfully and safely, as a <24-hour stay procedure. All patients undergoing BMOs (n = 165) were planned as a <24-hour stay procedure between 2012 and 2023 by the same consultant. Demographic details, operative time, length of stay, and re-admittance rates were reviewed retrospectively. Of these patients, 96.4% (n = 159) were discharged within 24 h of the procedure. Four patients (2.4%) were discharged within 24-48 h, and two (1.2%) within 48-72 h. There were no re-admissions within 48 h of discharge. We concluded that BMOs, along with concurrent wisdom tooth removal, can be carried out successfully and routinely as a single, short stay procedure. However, to reduce the rate of prolonged admission, it is recommended that a strict perioperative protocol be followed.

Evaluating Post-surgical Stability and Relapse in Orthognathic Surgery: A Comprehensive Review

Orthognathic surgery is a procedure that allows oral and maxillofacial surgeons to resolve jaw asymmetry issues and restore function, esthetics, and balance. Orthodontics plays a major part in the pre-surgical and post-surgical phases, thus necessitating a multidisciplinary approach. Certain skeletal discrepancies may remain despite correction with routine growth modification and camouflage treatment, or they may not qualify for these treatments. These skeletal discrepancies are addressed through orthognathic surgeries such as the Le Fort I osteotomy for the maxilla and the bilateral split sagittal osteotomy (BSSO) for the mandible. This narrative review aimed to investigate the factors leading to the instability and relapse of the different surgical procedures by comparing the related literature for all three planes: sagittal, vertical, and transverse. Additionally, it highlights the new trends and modern technology in orthognathic surgery. These findings are targeted at elucidating better surgical approaches, understanding what practices ensure long-term stability, and improving outcomes with greater practitioner and patient satisfaction.

Current Orthognathic Surgery Practice Patterns Among Academic OMS

OBJECTIVE

Currently there is variation in perioperative care of orthognathic surgery patients and limited clinical practice guidelines. The current orthognathic surgery practice patterns among US academic OMFS training centers have not been described. The purpose of this study is to describe the practice patterns among US academic OMFS training centers.

DESIGN

The study design is cross-sectional. Data was collected through a survey of the sample.

SETTING

OMFS programs in the US.

PARTICIPANTS

Academic OMFS. 573 surgeons were contacted and 85 responses were received.

MAIN OUTCOME MEASURE

Descriptive and bivariate statistics were reported.

RESULTS

Respondents were 87% male and worked in full-time academic (80%), part-time academic (19%), or military settings (1%). Thirty-one percent have practiced for 30 years or more and then 29% with 11-20 years, 18% with 21-30 years, 12% with 6-10 years and 11% with 1-5 years. Twenty-six percent of respondents perform 20-40 orthognathic surgeries a year, 22% perform less than 20 surgeries a year, 21% perform 40-60 surgeries per year, and 19% perform more than 100 surgeries per year. Intraoperatively, 48% of surgeons request a mean arterial pressure of 60-64 mmHg, 25% utilize tranexamic acid (TXA), 85% report a blood loss of less than 400 milliliters, and 93% report a blood transfusion rate of <1%.

CONCLUSION

There are variations in orthognathic surgery practice patterns with limited clinical practice guidelines. Only 13 of the 32 survey questions had a single response holding a simple majority. This study demonstrates the need for further research and evidence-based protocols and decision making.

Comparison between one-jaw and two-jaw designs in virtual surgery planning for patients with class III malocclusion

Orthognathic surgery is highly effective for treating maxillomandibular discrepancies in patients with class III malocclusion. However, whether one- or two-jaw surgery should be selected remains controversial. Our study aimed to evaluate quantitative differences between one-jaw and two-jaw surgical designs. In total, 100 consecutive patients with skeletal class III malocclusion who underwent orthognathic surgery with preoperative three-dimensional simulation between August 2016 and November 2021 were recruited. Based on the same final occlusal setup, a two-jaw surgery design and two types of one-jaw design were created. In total, 400 image sets, including preoperative images and three types of surgical simulation, were measured and compared. The one-jaw mandibular setback design led to improvement in most cephalometric measurements and facial symmetry. Although the one-jaw maxillary advancement design improved the ANB angle and facial convexity, it induced maxillary protrusion and reduced facial symmetry. Compared with the other designs, the two-jaw design provided significantly closer cephalometric measurements to the normative values, better symmetry, and less occlusal cant. Overall, the two-jaw design provided a quantitatively better facial appearance in terms of symmetry, proportion, and profile. Although an optimal surgical design necessitates thorough preoperative evaluation and a shared decision-making process, two-jaw surgery can be considered for improving overall facial esthetics and harmony.

Cost minimization analysis of indication-specific osteosynthesis material in oral and maxillofacial surgery

PURPOSE

Following the introduction of the Regulation (EU) 2017/745 by the European Parliament, any bioactive substance or surgical implant introduced into the human body must be documented. The regulation requires any implant to be traced back to the manufacturer. Lot numbers need to be available for every single medical implant. Also, the manufacturer is required by law to provide implants individually packaged and sterilized. Previously, model tray systems (MOS tray) were used for osteosynthesis in oral and maxillofacial surgery, in which the individual implants could not be registered separately. The new regulation made it impossible to use such processes during surgery anymore and a need for a change in the medical practice surged. We examined a possible solution for the new legislation. The aim of this prospective cohort study is to analyze the MOS tray systems to osteosynthesis materials prepackaged in sets. We record and evaluate parameters such as surgical time and documentation time. We perform a short cost analysis of our clinic. The primary aim is to determine how much time is gained or lost by the mandatory increased patient safety. The secondary aim is to describe change in costs.

METHODS

Patients that underwent standard surgical procedures in the clinic of oral and maxillofacial surgery of the faculty hospital Carl Gustav Carus in Dresden were included. We chose open reduction and internal fixation (ORIF) of anterior mandibular corpus fractures as well as mandibular advancement by means of bilateral sagittal split osteotomies (BSSO) as standardized procedures. Both of these procedures require two osteosynthesis plates and at least four screws for each plate. MOS trays were compared to prepackaged sterilized sets. The sets include a drill bit, two plates, and eight 5-mm screws. A total number of 40 patients were examined. We allocated 20 patients to the ORIF group and the other 20 patients to the BSSO group. Each group was evenly subdivided into a MOS tray group and a prepackaged group. Parameters such as the incision-suture time (IST) as well as the documentation time (DT) by the operating room (OR) staff to complete documentation for the implants are the main focus of investigation.

RESULTS

For open reduction, the incision-suture time was significantly different in favor of the MOS tray (p < 0.05). There was no difference in the BSSO groups. However, we observed a significantly different (p < 0.01) documentation time advantage for the prepackaged sets in both the ORIF and BSSO groups. On top of that, we find that by using the prepackaged kits, we are able to reduce sterilization costs by €11.53 per size-reduced container. Also, there is also a total cut of costs of €38.90 and €43.70, respectively, per standardized procedure for implant material.

CONCLUSIONS

By law, a change in the method of approaching surgery is necessary. For standardized procedures, the right choice of implants can lead to a reduction of documentation time and costs for implant material, sterilization, as well as utilizing less instruments. This in turn leads to lower costs for perioperative processing as well as provision of state-of-the-art implant quality implementing higher patient security.

Current Trends in Orthognathic Surgery

Orthognathic surgery has evolved significantly over the past century. Osteotomies of the midface and mandible are contemporaneously used to perform independent or coordinated movements to address functional and aesthetic problems. Specific advances in the past twenty years include increasing fidelity with computer-assisted planning, the use of patient-specific fixation, expanding indications for management of upper airway obstruction, and shifts in orthodontic-surgical paradigms. This review article serves to highlight the contemporary practice of orthognathic surgery.

Clinical Analysis of Patients who Underwent Reoperation After Orthognathic Surgery: A 14-Year Retrospective Study

PURPOSE

The purpose of this study was to analyze the patients clinically who underwent reoperation after certain Orthognathic procedures, and to assess the reoperation rate. Furthermore, the authors also evaluated the incidence of intraoperative and postoperative complications that led to the need for reoperation.

METHODS

Total 526 patients were selected who underwent Orthognathic surgery between July 2008 and February 2022 at the Department of Oral and Maxillofacial Surgery in Pusan National University Dental Hospital by single surgeon. All the patients information were extracted from electronic database of our university. Demographic, radiologic, intraoperative, and postoperative data were recorded and compiled.

RESULTS

Out of 526 patients, 265 (50.3%) were males and 261 (49.6%) were females. The total number of patients who showed complication is 89 (16.9%) and the patients who underwent reoperation are 17 (3.2%). The common complications that occurred were postoperative sensory disturbance (31; 5.8%), unwanted fractures (17; 3.2%), intraoperative nerve injury (11; 2%), wound dehiscence (11; 2%), infection (10; 1.9%), tooth injury (2; 0.3%), and others (18; 3.4%). The serious complications that led to reoperation include severe bleeding (6; 1.1%), unesthetic results (5; 0.9%), non-union of maxilla (4; 0.7%), and failed osteosynthesis (2; 0.3%). After 2018, all the orthognathic surgeries were performed with the help of virtual surgical planning. After application of virtual surgical planning, the number of patients with complications statistically decreased.

CONCLUSION

The present study showed that the reoperation rate after orthognathic surgery was low, this rate was more decreased after applying 3-dimensional virtual surgery and 3-dimensional printed plate, especially in unesthetic cases.

What factors influence the cost of orthognathic surgery among patients in the US?

OBJECTIVE

The purpose of our study was to analyze what factors influence the cost of orthognathic surgery performed within the US.

STUDY DESIGN

This retrospective cohort study was completed using the Kids' Inpatient Database (KID) from 2000 to 2012 on all patients aged 14 to 20 years who had undergone orthognathic surgery. The predictor variables included patient and hospitalization characteristics. The primary outcome variable was hospital charge ($). Multivariate linear regression was conducted to determine independent predictors for increased/decreased hospital charge.

RESULTS

The final sample consisted of 14 191 patients (mean age, 17.4 ± 1.6 years; females, 59.2%). Each additional day in the hospital added $8123 in hospital charges (P < .01). Relative to mandibular osteotomy, maxillary osteotomy (+$5703, P < .01) and bimaxillary osteotomy (+$9419, P < .01) were each associated with increased hospital charges. Genioplasty (+$3499, P < .01), transfusion of packed cells (TPC) (+$11 719, P < .01), continuous invasive mechanical ventilation (CIMV) <96 hours (+$23 502, P < .01), and CIMV ≥96 hours (+$30 901, P < .01) were each associated with significantly increased hospital charges. Obstructive sleep apnea (OSA) added $6560 in hospital charges (P < .01).

CONCLUSIONS

Maxillary osteotomy and bimaxillary surgery were each associated with significantly increased charges relative to mandibular osteotomy. Concomitant genioplasty, TPC, CIMV, and OSA each significantly increased the charges. Each additional day to the length of stay significantly increased the charges.

Starting a Swedish national quality registry for orthognathic surgery: a tool for auditing fundamentals of care

BACKGROUND

National quality registries (NQRs) provide open data for user-directed acquisition. National Quality Registry (NQR) data are often used to analyze the rates of treatment success and adverse events for studies that aim to improve treatment quality and patient satisfaction. Thus, NQRs promote the goal of achieving evidence-based therapies. However, the scientific literature seldom focuses on the complex process of initiating, designing, and implementing an NQR. Starting an NQR may be particularly challenging in a setting where specialized care is decentralized, such as orthognathic surgery in Sweden. The present study describes the initiation and early phases of a new NQR for orthognathic surgery in Sweden.

METHODS

The initial inventory phase included gaining knowledge on regulations, creating economic plans, and identifying pitfalls in existing NQRs. Next, a crude framework for the registry was achieved. Outcome measures were selected with a nation-wide questionnaire, followed by a Delphi-like process for selecting parameters to include in the NQR. Our inclusive process comprised a stepwise introduction, feedback-based modifications, and preparatory educational efforts. Descriptive data were collected, based on the first 2 years (2018-2019) of registry operation.

RESULTS

Two years after implementation, 862 patients that underwent 1320 procedures were registered. This number corresponded to a 91% coverage rate. Bimaxillary treatments predominated, and the most common were a Le Fort I osteotomy combined with a bilateral sagittal split osteotomy (n = 275). Reoperations were conducted in 32 patients (3.6%), and the rate of patient satisfaction was 95%.

CONCLUSIONS

A National Quality Registry should preferentially be started and maintained by an appointed task force of active clinicians. A collaborative, transparent, inclusive process may be an important factor for achieving credibility and high coverage, particularly in a decentralized setting.

Current Trends in Orthognathic Surgery in Poland—A Retrospective Analysis of 124 Cases

The analysis aims at assessing the current trends in orthognathic surgery. The retrospective study covered a group of 124 patients with skeletal malocclusion treated by one team of maxillofacial surgeons at the University Hospital in Zielona Góra, Poland. Various variables were analysed, including demographic characteristics of the group, type of deformity, type of osteotomy used, order in which osteotomy was performed and duration of types of surgery. The mean age of the patients was 28 (ranging from 17 to 48, SD = 7). The group included a slightly bigger number of females (59.7%), with the dominant skeletal Class III (64.5%), and asymmetries were found in 21.8% of cases. Types of osteotomy performed during surgeries were divided as follows: LeFort I, segmental LeFort I, BSSO, BSSO with genioplasty, LeFort I with BSSO, LeFort I with BSSO and genioplasty, segmental LeFort I with BSSO, isolated genioplasty. Bimaxillary surgeries with and without genioplasty constituted the largest group of orthognathic surgeries (49.1%), and a slightly smaller percentage were one jaw surgeries (46.7%). A statistically significant correlation was found between the type of surgery and the skeletal class. In patients with skeletal Class III, bimaxillary surgeries were performed significantly more often than in patients with skeletal Class II (57.5% vs. 20.0%; p = 0.0002). The most common type of osteotomy in all surgeries was bilateral osteotomy of the mandible modo Obwegeser–Epker in combination with Le Fort I maxillary osteotomy (42.7%). The order of osteotomies in bimaxillary surgeries was mandible first in 61.3% of cases. The longest surgery was bimaxillary osteotomy with genioplasty (mean = 265 min), and the shortest surgery was isolated genioplasty (mean = 96 min). The results of the analysis show a significant differentiation between the needs of orthognathic surgery and the types of corrective osteotomy applied to the facial skeleton.

Evaluation of an Enhanced Recovery After Surgery Protocol (ERAS) for Same-Day Discharge and Reduction of Opioid Use Following Bimaxillary Orthognathic Surgery

PURPOSE

This study sought to evaluate the impact of implementation of a comprehensive enhanced recovery after surgery (ERAS) protocol upon patients undergoing maxillary and mandibular osteotomy (MMO).

METHODS

This study was a retrospective, observational study of patients undergoing MMO. The study intervention group consisted of patients who underwent MMO with utilization of ERAS protocol compared to control group without ERAS. The primary outcome measure was same-day discharge. Secondary outcome measures included hospital length-of-stay (LOS), overall dose of opioids administered, total operating room time, estimated blood loss, need for hospital admission, and complications. Descriptive statistics and multivariable analysis were computed and the P value was set at .05.

RESULTS

We compared 189 patients who underwent MMO with and without genioplasty and received a comprehensive surgical and multimodal analgesic regimen to 170 control patients who underwent MMO with or without genioplasty without receiving the above protocol. There was a statistically significant decrease in hospital admission post-surgery (83.5% - control vs 22.2% - intervention) and in overall hospital length-of-stay in the intervention group. There was no change in the overall operating room time, but there was a decrease in blood loss in the intervention group.

CONCLUSION

The results suggest that use of a comprehensive ERAS protocol for patients undergoing MMO will decrease hospital length-of-stay without an increase in readmissions or complications. Future studies are needed to evaluate if pain scores, postoperative nausea and vomiting, and other complications differed when using a ERAS protocol.

Hilotherapy following orthognathic surgery - patient and cost perspective

A meta-analysis evaluating the effect of hilotherapy following orthognathic surgery demonstrated improvements in postoperative pain and swelling.¹ In this prospective survey, we investigated the patient experience with hilotherapy following orthognathic surgery. Forty-five respondents completed the questionnaire. A high proportion of respondents found the Hilotherm mask to be comfortable (n = 40), were willing to wear it at home (n = 37) and were willing to pay for the rental service (n = 35). This highly positive patient-reported experience suggests that at-home use of hilotherapy following orthognathic surgery should be explored to enhance recovery and improve patients' comfort.