Pitfalls in Orthognathic Surgery: Avoidance and Management of Complications

Anatomical Variations of the Greater Palatine Foramen in Different Facial Skeletal Relationships and its Implications on LeFort 1 Osteotomy (Trimble's Modification)

Purpose

To determine the positional variations of the greater palatine foramen in different facial skeletal relationships and discuss its surgical implications on the Trimble's modification of Lefort I osteotomy.

Materials and Methods

This retrospective study examined 50 computed tomography scans of patients a total of 100 sides. The sample was divided into four groups: Class 1, Class 2, Class 3 malocclusion and Unilateral cleft lip and palate). The outcome variables included the distance between anterior, middle and posterior points of the GPF to the distal of second molar and variables to assess relative position of the GPF to the posterior maxilla. Outcome measures were to demonstrate intra- and intergroup variability.

Results

Fifty patients (100 sides) were divided into four groups. This included 23 males and 27 females with a mean age of 24.1 years. Significant intergroup variability was observed between all the parameters that demonstrate the relative position of the GPF to (i) the maxillary second molar and (ii) the posterior maxilla. The analysis revealed that the GPF was positioned significantly anterior in Class 2 patients when compared with Class 3 patients.

Conclusion

The GPF exhibits significant positional variability in different facial skeletal relationships which should be borne in mind while designing and performing the Trimble's modification of the Lefort 1 osteotomy.

Papilla reconstruction for an iatrogenic RT3 gingival defect using a tuberosity soft tissue graft: A case report

BACKGROUND

Orthognathic surgery is a reliable and safe method to improve maxillo-mandibular malformations. However, it is a complex procedure that can affect deeper structures and the terminal blood supply of specific areas, thereby affecting the results. Occasionally, despite careful digital planning and diagnosis, esthetic complications may occur, such as scarring or mucogingival alterations, including localized aseptic necrosis with associated recessions. In more severe cases, larger fragments of necrosis may be involved.

METHODS AND RESULTS

The aim of this case report was to present a case, including diagnosis, treatment plan, periodontal plastic surgical technique, and follow-up for a recession type 3 (RT3) defect. This RT3 gingival defect was associated with necrotic crestal bone exposure in the anterior esthetic area resulting from a complication after orthognathic surgery.

CONCLUSIONS

Partial reconstruction of the interdental papilla can be possible through consideration of the defect characteristics, use of microsurgical principles, and utilization of a suitable connective tissue grafting technique.

KEY POINTS

Why is this case new information? To the authors' knowledge, there is very limited clinical and scientific evidence regarding the management of esthetic complications associated with ischemic necrosis resulting from orthognathic surgeries. This case study identified the management of papillary reconstructions of these mucogingival defects. What are the keys to the successful management of this case? For an ideal case management, adequate plaque and infection control and timely notice of the defect appearance are critical. Additionally, proper surgical soft tissue management of the affected papillae and surrounding area is required. Finally, the type of connective tissue graft to be used, its management and fixation, and proper postoperative protocols are needed for case success. What are the primary limitations to success in this case? Despite the limitations of this study, the authors consider that the treatment of mucogingival complications related to orthognathic surgeries is possible, using microsurgical concepts and connective tissue grafts to reconstruct papillae.

Early Outcomes and Risk Factors in Orthognathic Surgery for Mandibular and Maxillary Hypo- and Hyperplasia: A 13-Year Analysis of a Multi-Institutional Database

BACKGROUND

Orthognathic surgery (OS) is a frequently performed procedure for the correction of dentofacial deformities and malocclusion. Research on OS is mostly limited to single-surgeon experience or single-institutional reports. We, therefore, retrospectively analyzed a multi-institutional database to investigate outcomes of OS and identify risk factors for peri- and postoperative complications.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2020) to identify patients who underwent OS for mandibular and maxillary hypo- and hyperplasia. The postoperative outcomes of interest included 30-day surgical and medical complications, reoperation, readmission, and mortality. We also evaluated risk factors for complications.

RESULTS

The study population included 674 patients, 48% of whom underwent single jaw surgery, 40% double jaw surgery, and 5.5% triple jaw surgery. The average age was 29 ± 11 years, with an equal gender distribution (females: n = 336; 50%, males: n = 338; 50%). Adverse events were relatively rare, with a total of 29 (4.3%) complications reported. The most common surgical complication was superficial incisional infection (n = 14; 2.1%). While the multivariable analysis revealed isolated single lower jaw surgery (p = 0.03) to be independently associated with surgical complication occurrence, it also identified an association between the outpatient setting and the frequency of surgical complications (p = 0.03) and readmissions (p = 0.02). In addition, Asian ethnicity was identified as a risk factor for bleeding (p = 0.003) and readmission (p = 0.0009).

CONCLUSION

Based on the information recorded by the ACS-NSQIP database, our analysis underscored the positive (short-term) safety profile of OS. We found OS of the mandible to be associated with higher complication rates. The calculated risk role of OS in the outpatient setting warrants further investigation. A significant correlation between Asian OS patients and postoperative adverse events was found. Implementation of these novel risk factors into the surgical workflow may help facial surgeons refine their patient selection and improve patient outcomes. Future studies are needed to investigate the causal relationships of the observed statistical correlations.

Risk factors of neurosensory disturbances at 1 year postoperatively after bilateral sagittal split osteotomy

OBJECTIVE

To investigate morphologic and surgical risk factors causing neurosensory disturbances (NSDs) after bilateral sagittal split osteotomy (BSSO).

STUDY DESIGN

A total of 237 patients (with 474 sides) who underwent BSSO were followed up for 1 year. Parameters examined included age, sex, asymmetry, mandibular movement direction, mandible cutting devices, split type, intraoperative exposure of the inferior alveolar nerve (IAN), contact between the IAN and screw, distance between mandibular canal and inner surface of the cortical bone (distance A), distance from lateral osteotomy to mental foramen (distance B), and NSD at 1 year postoperatively.

RESULTS

NSD was observed in 62 (13.1%) sides of 51 patients. Exploratory factor analysis determined 4 factors (factor 1: distance A; factor 2: direction of mandibular movement; factor 3: distance B and cutting devices; factor 4: IAN exposure). Logistic regression analysis was performed using the above factors and age, sex, and asymmetry, making a total of 7 variables. Age, factor 1, and factor 4 were significant predictors of NSD.

CONCLUSIONS

Advanced age, close distance between mandibular canal and inner surface of the cortical bone, and IAN intraoperative exposure are risk factors for NSD 1 year postoperatively. Cases at high risk for NSD must be treated with great care.

Imaging of Facial Reconstruction and Face Transplantation

Pre- and postoperative imaging is increasingly used in plastic and reconstructive surgery for the evaluation of bony and soft tissue anatomy. Imaging plays an important role in preoperative planning. In the postoperative setting, imaging is used for the assessment of surgical positioning, bone healing and fusion, and for the assessment of early or delayed surgical complications. This article will focus on imaging performed for surgical reconstruction of the face, including orthognathic surgery, facial feminization procedures for gender dysphoria, and face transplantation.

Osseous Genioplasty: Prevention of Witch's Chin Deformity with No-Degloving Technique

BACKGROUND

Osseous genioplasty is a powerful procedure that can correct chin dysmorphology; however, traditional techniques may result in chin ptosis or a "witch's chin" deformity. Iatrogenic chin ptosis is thought to be caused by excessive degloving of soft tissue with a failure to reattach the mentalis muscle. In the authors' study, they compared the "no-degloving" technique (using a 90-degree plate with lag-screw fixation) to the "traditional" technique, for minimization of chin ptosis.

METHODS

The authors compared genioplasty techniques for consecutive patients: group 1 (traditional) underwent degloving for fixation of a stair-step plate, whereas group 2 (no-degloving) underwent lag-screw fixation (n = 50; 25 patients per group). The authors compared operating room time, advancement, complications, preoperative-to-postoperative vertical height change of the pogonion and menton (obtained through cone beam computed tomographic scans), surgeons' assessment of witch's chin, and FACE-Q surveys.

RESULTS

No-degloving versus traditional groups had similar age and sex distributions, horizontal/vertical change (5 mm/2 mm versus 6 mm/2 mm), length of surgery, and complication rate (5 percent). The traditional group had more deviation from expected position for both the pogonion (3.4 mm versus 1.2 mm; p ≤ 0.05) and menton (2.9 mm versus 0.8 mm; p ≤ 0.05), and more occurrences of witch's chin (six versus zero). No-degloving was superior for several FACE-Q scales, including Chin Appearance, Quality of Life, Satisfaction with Decision to Undergo Procedure, and Satisfaction with Outcome.

CONCLUSION

No-degloving osseous genioplasty is a safe, reproducible technique that results in decreased soft-tissue ptosis and increased patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Polyetheretherketone patient-specific implants (PPSI) for the reconstruction of two different mandibular contour deformities

BACKGROUND

This study aims to prospect the soft and hard tissue changes after augmentation of two different local mandibular contour defects using polyetheretherketone (PEEK) patient-specific onlay implants.

METHODS

Six patients with disfiguring local mandibular deformities were included in this study (five males and one female) and received seven PEEK patient-specific implants (PSI), virtually designed and surgically settled to augment seven mandibular defects, three deficient chins, and four mandibular angels. The analysis of the soft and hard tissue changes utilized the superimposition of the preoperative and the 6-month postoperative sagittal and coronal CT views, after standardizing the radiographic interpretation.

RESULTS

The soft tissue gain for the chin was 6.8 mm ± 0.98 with a 45.8% increase versus 4.42 mm ± 0.41 with a 22.9% increase for the angle. The difference in the soft tissue gain between the two groups was statistically significant (P = 0.0001). Comparing the soft tissue gain to the planned implant thickness, the percentage of the soft tissue gain for the chin recorded 109.2% versus 65.57% for the angle. The difference between the two groups was also statistically significant (P < 0.0001).

CONCLUSION

PEEK patient-specific onlay implants represented an efficient and straightforward modality to augment local mandibular contour deformities with favorable esthetic outcomes; the total soft tissue profile gain of the chin region markedly exceeded that of the mandibular angle.

Measuring patient-reported outcomes in orthognathic surgery: Linguistic and psychometric validation of the Mandarin Chinese version of FACE-Q instrument

Background

Orthognathic surgery is useful for correction of dental malocclusion and improvement of facial appearance. The FACE-Q is a patient-reported outcome instrument for evaluation of surgical and psychosocial effect. The purposes of this study were to conduct a linguistic validation of all FACE-Q scales to Mandarin Chinese, to test the orthognathic surgery-related scales for reliability and validity, and to evaluate the effect of orthognathic surgery.

Methods

All FACE-Q scales and checklists were translated from English to Mandarin Chinese according to international recommendations: forward translations, backward translation, and cognitive interviews. Psychometric testing of orthognathic surgery-related scales of translated version was administered to patients with facial deformities and history of orthognathic surgery (n = 53; 17 scales) or no history of orthognathic surgery (n = 44; 11 scales), and control subjects (n = 57; 11 scales).

Results

All FACE-Q scales and checklists were linguistically validated into Mandarin Chinese. The contents were confirmed valid among Mandarin Chinese-speaking population. The FACE-Q scales had excellent internal consistency (Cronbach's alpha >0.70) and discriminated (p < 0.05) well between patients before and after orthognathic surgeries and normal subjects.

Conclusions

This study discovered significant benefit of orthognathic surgery on improving facial appearance and psychosocial function, as compared with the non-surgical patients and normal controls.

Experience with Anterior Maxillary Osteotomy Techniques: A Prospective Study of 20 Cases

Aim

This prospective study aimed at studying the complications associated with different techniques of anterior segmental maxillary osteotomy.

Material and Method

The study was conducted on 20 cases diagnosed with anteriorly prognathic maxilla with class 1 molar relation. The patients were followed up for a period of at least 1 year. The clinical and demographic data along with the intraoperative and postoperative complications associated with different treatment techniques were recorded.

Results

In five cases, Wassmund technique was followed with average time span of 32 min. Wunderer and Cupar technique took average time span of 23 min. Two patients presented with four non-vital teeth in a follow-up period of 1 year and one patient treated with Cupar's technique had complication of palatal tear. Only one patient reported with relapse in a follow-up period and none of the patients had any complication associated with hemorrhage, neurosensory alteration or requiring plate removal. The findings of our study recommend ASMO as treatment modality of choice in patients with bimaxillary and/or dentoalveolar protrusion with Cupar's technique providing more ease of operation.

Complications associated with orthognathic surgery: A retrospective study of 485 cases

PURPOSE

To identify the most prevalent types of complications associated with orthognathic surgery and its possible risk factors.

METHODS

This study was a retrospective investigation of records of 485 patients who underwent orthognathic surgery between 2008 and 2014 at the Oral and Maxillofacial Surgery Service at the Federal University of Paraná, Curitiba, Brazil. Types of complications were recorded. Independent variables such as sex, age, duration of surgery and hospitalization, number of surgeries, surgical site, and types of osteotomy performed were evaluated. Complications were also evaluated based on the treatment according to the Clavien-Dindo Classification. Data were submitted to statistical analysis with a significance level of 0.05.

RESULTS

A total of 93 complications were reported (19.2%), including postoperative malocclusion, hemorrhage, inferior alveolar nerve injury, bad split, and infection. Complications were more common in men (p = 0.029). The number of complications was higher in surgeries that took more time to perform (p < 0.05) when the entire sample was taken into consideration. The prevalence of complications was related to a higher number of procedures per surgery (p = 0.019). Complications were more frequent in mandibular procedures (p = 0.010), particularly in bilateral sagittal split osteotomies (p < 0.001). Related to treatment, Clavien-Dindo grade I complications were the most frequent (72.04%). There was no association between sex, age, surgery duration, length of hospitalization, or surgical site with complication grades according to the Clavien-Dindo classification (p ≥ 0.05).

CONCLUSION

Postoperative malocclusion, hemorrhage, inferior alveolar nerve injury, bad split and infection are the most prevalent complication in orthognathic surgery. They seem to be related to sex, duration of surgery, number of surgeries, surgical site, and the type of osteotomy performed. With these in mind, it is possible to explain to the patient the different levels of severity of complications related to the surgery.

Autologous Fat Grafting to the Chin: A Useful Adjunct in Complete Aesthetic Facial Rejuvenation

The chin makes up the central unit of the face and neck, and is a significant factor in facial harmony and aesthetics. Historically, correction of microgenia required surgical intervention with a sliding genioplasty, or placement of a permanent implant. However, these techniques require more extensive surgical intervention, prolonged downtime, with higher costs and complications. Furthermore, chin rhytides and descent of chin fat lead to an aged appearance of the chin and lower face that is difficult to correct with a chin implant alone. Autologous fat grafting in facial rejuvenation has expanded in its application and can serve as an effective technique to correct and enhance chin aesthetics, including lateral chin hollowing, asymmetry, mild microgenia, and correction of deep labiomental sulcus or a bifid chin. This article and accompanying video demonstrate the authors' technique for chin augmentation and refinement with autologous fat.

Early, Computer-Aided Design/Computer-Aided Modeling Planned, Le Fort I Advancement With Internal Distractors to Treat Severe Maxillary Hypoplasia in Cleft Lip and Palate

Traditionally, maxillary hypoplasia in the setting of cleft lip and palate is treated via orthognathic surgery at skeletal maturity, which condemns these patients to abnormal facial proportions during adolescence. The authors sought to determine the safety profile of computer-aided design/computer-aided modeling (CAD/CAM) planned, Le Fort I distraction osteogenesis with internal distractors in select patients presenting at a young age with severe maxillary retrusion. The authors retrospectively reviewed our "early" Le Fort I distraction osteogenesis experience-patients performed for severe maxillary retrusion (≥12 mm underjet), after canine eruption but prior to skeletal maturity-at a single institution. Patient demographics, cleft characteristics, CAD/CAM operative plans, surgical complications, postoperative imaging, and outcomes were analyzed. Four patients were reviewed, with a median age of 12.8 years at surgery (range 8.6-16.1 years). Overall mean advancement was 17.95 + 2.9 mm (range 13.7-19.9 mm) with mean SNA improved 18.4° to 87.4 ± 5.7°. Similarly, ANB improved 17.7° to a postoperative mean of 2.4 ± 3.1°. Mean follow-up was 100.7 weeks, with 3 of 4 patients in a Class I occlusion with moderate-term follow-up; 1 of 4 will need an additional maxillary advancement due to pseudo-relapse. In conclusion, Le Fort I distraction osteogenesis with internal distractors is a safe procedure to treat severe maxillary hypoplasia after canine eruption but before skeletal maturity. Short-term follow-up demonstrates safety of the procedure and relative stability of the advancement. Pseudo-relapse is a risk of the procedure that must be discussed at length with patients and families.

The pterygomaxillary junction: An imaging study for surgical information of LeFort I osteotomy

Maxillary osteotomy is a common surgical procedure and often involves separation of the pterygomaxillary junction (PMJ), which is a “blinded” procedure with inherent risks. Knowledge of the PMJ structure is essential. It remains unclear whether patients with different facial types have different PMJ structures, or different surgical outcome. This study evaluated the computed tomographic images of 283 consecutive patients who received orthognathic surgery. Patients were classified into Angle class I, II, III and cleft lip/palate groups. The results showed that the PMJ was 5.1 ± 1.4 mm in thickness, 9.7 ± 1.7 mm in width, and 102.0 ± 4.0 degrees relative to the sagittal plane in the level of posterior nasal spine. There were no statistically significant differences in these measurements among the groups. The class III group demonstrated significantly smaller angle relative to the maxillary occlusal plane. The cleft group showed significantly longer vertical distance between the posterior nasal spine and the lower border of PMJ, shorter distance between the second molar and PMJ, and longer distance between the descending palatine artery and PMJ. With regard to postoperative outcome, the cleft group showed higher incidence of pterygoid plate fracture. The results in this study provide additional surgical anatomic information.

Complications after orthognathic surgery: our experience on 423 cases

INTRODUCTION

Orthognathic surgery is widely used to correct dentofacial discrepancies. However, this procedure presents numerous possible complications. The aim of our study is to review intraoperative and postoperative complications related to orthognathic surgery based upon a 10-year period in the Maxillofacial Surgery Department of Federico II University of Naples.

MATERIALS AND METHODS

Medical records of 423 patients who undergone orthognathic surgery in a 10-year period were retrospectively analyzed and complications was noted. Statistical analysis was conduced in order to understand if the type of surgical procedure influenced complications rate.

RESULTS

One hundred eighty-five complications in 143 (33.8%) of the 423 treated patients were reported. Complications detected were nerve injury (49 cases, 11.9%), infections (10 cases, 2.4%), complications related to fixation plates or screws (30 cases, 7.1%), bad split osteotomy (8 cases, 1.9%), secondary temporo-mandibular joint disorders (36 cases, 8.5%), dental injuries (21 cases, 5%), condilar resorption (2 cases, 0.5%), and necessity of a second-time surgery (24 cases, 5.7%).

CONCLUSIONS

Serious complications seem to be quite rare in orthognathic surgery. Some of the surgical complications found are related to the surgeon experience and not strictly to the risks of the operation itself. Understanding potential complications allows the surgeon to guarantee safe care through early intervention and correctly inform the patient in the preoperative colloquy.

Changes in Maxillary Canine Pulpal Blood Flow During Dentoalveolar Distraction Osteogenesis

OBJECTIVE

The aim of this study was to assess the effects of dentoalveolar distraction osteogenesis (DD) on the pulpal blood flow (PBF) of maxillary canines.

MATERIALS AND METHODS

A laser Doppler flowmeter (LDF) was used to measure PBF in maxillary canines of 10 patients undergoing DD (study group) and 10 nonsurgical subjects who received no orthodontic treatment (control group). PBF was measured at baseline, at 4 and 7 days postoperatively, at the end of distraction and at the end of consolidation in the study group and at similar time-points in nonsurgical control subjects. Data were analyzed using paired and Student t tests, with the significance level set at 0.05.

RESULTS

Study findings showed that baseline PBF values did not differ significantly between groups. PBF in the control group did not vary over time; however, in the study group, an initial decrease in PBF was observed at 4 days postoperatively and was followed by a gradual increase to preoperative levels at the end of distraction.

CONCLUSIONS

During the DD latency period, there appears to be a short-lived ischemic phase when perfusion of pulp tissue declines; however, blood-flow returns to normal by the end of distraction.

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.

Unfavourable outcomes in orthognathic surgery

Unfavourable outcomes are part and parcel of performing surgeries of any kind. Unfavourable outcomes are results of such work, which the patient and or the clinician does not like. This is an attempt to review various causes for unfavorable outcomes in orthognathic surgery and discuss them in detail. All causes for unfavorable outcomes may be classified as belonging to one of the following periods A) Pre- Treatment B) During treatment Pre-Treatment: In orthognathic surgery- as in any other discipline of surgery- which involves changes in both aesthetics and function, the patient motivation for seeking treatment is a very important input which may decide, whether the outcome is going to be favorable or not. Also, inputs in diagnosis and plan for treatment and its sequencing, involving the team of the surgeon and the orthodontist, will play a very important role in determining whether the outcome will be favorable. In other words, an unfavorable outcome may be predetermined even before the actual treatment process starts. During Treatment: Good treatment planning itself does not guarantee favorable results. The execution of the correct plan could go wrong at various stages which include, Pre-Surgical orthodontics, Intra and Post-Operative periods. A large number of these unfavorable outcomes are preventable, if attention is paid to detail while carrying out the treatment plan itself. Unfavorable outcomes in orthognathic surgery may be minimized If pitfalls are avoided both, at the time of treatment planning and execution.

Morphologic features of the mandibular ramus associated with increased surgical time and blood loss in sagittal split-ramus osteotomy

PURPOSE

To determine whether specific morphologic features of the mandibular ramus can predict increased surgical time and blood loss in sagittal split-ramus osteotomy (SSRO).

MATERIALS AND METHODS

The clinical and morphologic features of the mandibular ramus, obtained from computed tomographic images (n=50), were analyzed to predict the surgical time, the time required for ablation of the medial mandibular ramus, and the time required for sectioning of the mandible in performing a modified Obwegeser SSRO.

RESULTS

Significant factors associated with surgical time were an anterior border of the ramus at least 10.5 mm wide, a maximal length of the thickened ramus of at least 8.5 mm, and a distance from the mandibular incisor to the posterior border of the mandible of at least 97.5 mm. There were significant differences in blood loss between the 2 axial aspects of the medial ramus.

CONCLUSIONS

The greater protrusion of the medial oblique ridge, thickened ramus, and longer distance from the mandibular incisors to the posterior border of the mandible may increase the surgical time and blood loss in patients undergoing classic SSRO. When planning or performing an SSRO, the morphologic features obtained from computed tomographic images may help surgeons gain a better understanding of the potential difficulties when the surgical site involves the medial aspect of the ascending ramus of the mandible.

Long-term results and complications after treatment of bilateral fractures of the mandibular condyle

The purpose of this study was to investigate the long-term results of conservative treatment of bilateral condylar fractures and to study the influence of possible functional impairment on intensity of pain and associated disability. We studied 71 patients (mean (SD) age 33 (14) years) with conservatively treated bilateral condylar fractures. Traffic crashes (n=42, 59%) and falls (n=20, 28%) were the main cause of the fractures. Forty-one patients (58%) were re-examined after about 90 months (mean 86, range 3-193). Five of the 41 (12%) had developed malocclusion, but did not experience any pain in the temporomandibular joint according to the Research Diagnostic Criteria for Temporomandibular Disorders. There was a significant negative relation between the presence of pain and the duration of follow up (p=0.02). Increasing age was significantly related to reduction in the intensity of pain (p=0.03). Of the remaining 30 patients who were not followed up, 2 had had bilateral sagittal split osteotomy and 1 a Le Fort I osteotomy. One patient had had orthodontic correction for a malocclusion. Including the five malocclusion patients, at least 9 of the total of 71 (13%) developed a malocclusion after conservative treatment. Functional impairment had no influence on the intensity of pain or pain-related disability in the patients with malocclusion after conservatively treated bilateral condylar fractures. This report may therefore be of value in the debate about whether open or closed treatment is better for bilateral mandibular condylar fractures.

Internal carotid dissection after Le Fort III distraction in Apert syndrome: a case report

A 10-year-old girl with Apert syndrome underwent a Le Fort III osteotomy with the positioning of internal and external distraction devices. The operation was straightforward with no intraoperative complications. Very soon after completion of surgery an anisocoria (unilateral dilation of a pupil) was noticed. This was followed by intracranial oedema which was fatal. The aetiology was dissection of the right internal carotid artery is reported. The complications of Le Fort osteotomies are discussed regarding patients with complex syndromal craniosynostosis and midface hypoplasia, such as Apert syndrome.