Postoperative Swelling After Orthognathic Surgery: A Prospective Volumetric Analysis

Impacts of mandibular setback with or without maxillary advancement for class III skeletal correction on sleep-related respiratory parameters: A systematic review and meta-analysis

A systematic review and meta-analysis was conducted to evaluate the impacts of mandibular setback with or without maxillary advancement for class III skeletal correction on respiratory parameters measured by polysomnography (PSG) and to compare these respiratory parameters between these procedures for class III skeletal correction. Six electronic databases were searched up to June 2023. Studies comparing PSG parameters before and after orthognathic surgery for skeletal class III patients were selected for further analysis. The outcomes of interest were apnoea-hypopnea index (AHI), respiratory disturbance index (RDI), the lowest oxygen saturation (lowest SpO2), the average oxygen saturation (mean SpO2), and the 3% oxygen desaturation index (3% ODI). Data extraction, methodological quality assessment, risk of bias assessment, meta-analysis, and subgroup analysis were performed. Sixteen studies with a total of 476 patients who underwent orthognathic surgery for class III skeletal correction were included for meta-analysis. The risk of bias level was moderate for most studies. All PSG parameters before and after orthognathic surgery were not significantly different. The different surgical procedures also did not significantly affect post-operative PSG parameters. 5.8% of patients developed post-operative obstructive sleep apnoea (OSA). Most of them underwent a large distance of mandibular setback. There is a moderate level of evidence that mandibular setback with or without maxillary advancement for class III skeletal correction does not pre-dispose young and healthy patients to obstructive sleep apnoea when evaluated in the short term after surgery. However, post-operatively developed OSA was found in several isolated cases that underwent a large amount of mandibular setback with or without maxillary advancement.

Masticatory function and three-dimensional facial morphology of soft tissues: One year after orthognathic surgery

OBJECTIVE

Dentofacial deformities (DFD) require orthodontic treatment, orthognathic surgery, and speech therapy for aesthetic and functional problems. This longitudinal study analyzed changes in masticatory function and three-dimensional (3D) facial soft tissue in patients with Class II and Class III DFD after orthognathic surgery. In addition, the study investigated the relationship between facial measurements, maximum bite force (MBF), and orofacial myofunctional status (OMS).

DESIGN

The sample consisted of 46 participants, including 10 patients with Class II DFD, and 11 patients with Class III DFD. These groups were assessed before (T0) and 6 months (T1) after surgery. Twelve patients who completed the treatment protocol were evaluated 12 months post-surgery (T2). The patient groups were compared with each other and with a control group (CG) of 25 healthy subjects. The participants underwent MBF and clinical evaluation of OMS, including masticatory behavior, using a validated protocol. The 3D facial soft tissue was assessed using laser scanning.

RESULTS

Compared to the CG, DFD patients showed reduced MBF, masticatory behavior, and OMS scores at T0. At T2, there was an improvement in MBF, masticatory, and OMS scores, but differences were observed compared to the CG. Changes in facial soft tissue followed the underlying hard tissue movement resulting from surgery, and reduction of vertical measurements contributed to improvements in masticatory function.

CONCLUSION

These findings indicated that combined surgery, orthodontic treatment, and speech therapy can lead to a significant improvement in masticatory function and facial soft tissue in DFD patients, although not completely 12 months post-surgery.

Direction and Range of Condylar Positional Changes in the First-Year Post-surgical Orthodontics Interventions in Adult Patients with Skeletal Class III Deformity: A Systematic Review and Meta-analysis

Objectives

Assess the available scientific literature regarding the direction and extent of condylar positional changes during the first year of post-surgical orthodontics interventions in class III patients.

Materials and Methods

PubMed, Cochrane Library, Embase, and Google Scholar databases were searched up to March 2022 for studies involving the measurement of condylar positional changes after surgical treatment of Class III dentofacial deformity in adults with BSSO without or without Le Fort I osteotomies. The methodological index for non-randomized studies (MINORS) was utilized to assess the risk of bias and quality of non-randomized studies. Reporting of this review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was condyle positional changes between the following time points: T0: before treatment, T1: immediately post treatment, T2: 4, 6, or 9 months post treatment, T3: one year post treatment.

Results

Nineteen studies were included in the systematic review. Eleven studies were deemed low quality, and the rest were of medium quality. The meta-analysis included 12 studies and showed statistically significant downward, outward positional changes at T1(Immediately after surgery). Inward Yaw rotation was significant at T1(1-4 month post-surgery) and T2(4-9 months post-surgery).

Conclusion

Surgically induced condylar changes tend to go back to normal within the first year after surgery, except for condylar yaw rotations.

Comparative analysis of 3D tomography based soft tissue rendering and Proface facial scanning systems in orthognathic surgery

PURPOSE

This study aimed to investigate the linear and angular differences in the nasolabial soft tissue in patients who underwent bimaxillary orthognathic surgery using two different three-dimensional imaging methods. Furthermore, the advantages, disadvantages, and limitations of these methods were determined after comparing the data obtained from the imaging methods used in the study.

MATERIALS AND METHODS

Preoperative (T0) and 6-months postoperative (T1) cone-beam computed tomography (CBCT) and three-dimensional facial scanning (3DFS) data from 22 patients who underwent maxillary advancement surgery were examined. The DICOM (Digital Imaging and Communications in Medicine) data (CBCT group) and ".obj" format images (3DFS group) of the patients were analyzed using Dolphin software (Dolphin Imaging®, Version 12, Chatsworth, CA, USA). The linear and angular soft tissue measurements were calculated after determining the reference anatomical landmarks for both groups.

RESULTS

Measurements with CBCT and 3DFS imaging methods were compared at T0, T1, and all measurements (T0+T1). No statistically significant difference was observed between the CBCT and 3DFS groups for five measurements performed at T0 and T0+T1, but statistically significant differences were observed between the groups for the other seven measurements. There was no statistically significant difference between the CBCT and 3DFS groups for six measurements at T1, but there were statistically significant differences between the groups for the other six measurements. After reviewing the postoperative differences in the nasolabial soft tissue, a statistically significant increase in four linear and one angular measurement in the 3DFS group was observed, and there was a statistically significant increase in two linear and two angular measurements in the CBCT group. Upon comparison of postoperative differences in soft tissue alterations, no statistically significant difference between the 3DFS group and the CBCT group were observed in any of the soft tissue measurements.

CONCLUSION

Orthognathic surgery has significant effects on nose width and upper lip morphology. Although both 3DFS and CBCT methods can be used to evaluate such effects, the results of the present study revealed differences in sensitivity and limitations between the two methods. Thus, surgical outcomes should be evaluated in consideration of the abovementioned parameters.

Pulsed electromagnetic fields (PEMF) as a valid tool in orthognathic surgery to reduce post-operative pain and swelling: a prospective study

PURPOSE

PEMF (pulsed electromagnetic fields) founds application in several medical fields to accelerate bone wounds healing and to reduce inflammation. The aim of our study was to evaluate the effectiveness of PEMF in reducing postoperative swelling and pain in patients undergoing orthognathic surgery.

METHODS

A prospective observational monocentric study was conducted on a sample of 30 patients undergone to orthognathic surgery in Maxillofacial Surgery Unit of University of Naples Federico II. The patients who followed these inclusion criteria were enrolled in the study: age ≥ 18 years, Class III malocclusion, Surgical procedure of Le Fort I osteotomy + Bilateral Sagittal Split Osteotomy (BSSO), Written informed consent. Patients were divided into two groups: Group SD) postoperative standard treatment with medical therapy and cryotherapy, Group SD + PEMF) postoperative standard therapy + PEMF. Each patient underwent a 3D facial scan, at one (1d) and four (4d) days after surgery to compare the swelling reduction. The pain score was assessed through VAS score and analgesics administration amount.

RESULTS

In SD + PEMF group, the facial volume reduction between 1d and 4d scan was on average 56.2 ml (6.23%), while in SD group, it was 23.6 ml (2.63%). The difference between the two groups was 3.6% (p = 0.0168). VAS pain values were significantly higher in SD group compared to SD + PEMF group in the second day after surgery (P = 0.021) and in the total 4 days (P = 0.008).

CONCLUSIONS

Our data suggest that PEMF is valid tool to promote faster postoperative swelling and pain reduction in patients undergoing orthognathic surgery.

A reliable and reproducible method for repositioning 3D images to calculate changes in facial volume after orthognathic surgery

PURPOSE

An accurate, reproducible method to calculate post-operative facial swelling in patients who have undergone orthognathic surgery is important to evaluate the effects of different therapies and surgical techniques on edema. The purpose of this study was to describe such a method and assess its reliability.

MATERIALS AND METHODS

A prospective study of patients undergoing orthognathic surgery was conducted. 3D facial photographs were taken on these patients immediately postoperatively, and again at least 21 days later using the 3DMD face system (3DMD LLC., Atlanta, GA, USA). These were cropped using specific anatomic points and the difference in facial volume between the photographs was calculated. Intra-rater reliability and inter-rater reliability were assessed using the Intraclass Correlation Coefficient (ICC).

RESULTS

30 patients were included in the study for analysis. When the difference in facial swelling was calculated twice by the same rater, the mean difference between the two measurements was 4.0 ± 4.2 mL. When calculated by two separate raters, the mean difference was found to be 5.0 ± 3.8 mL. The ICCs for intra-rater and inter-rater reliability were excellent at 0.979 and 0.981 respectively.

CONCLUSION

This method allows for reproducible calculation of post-operative facial swelling and could be useful to evaluate the effects of different therapies used to limit swelling and to track the resolution of swelling. It can also potentially be used as a visual aid for patient counseling during the pre-surgical visits.

Measurement of Nasal Contour Landmarks in Septorhinoplasties with Special Regard to the Course of Postoperative Swelling Using a Three-Dimensional Camera

The integration of three-dimensional (3D) cameras into clinical practice for pre-operative planning and post-operative monitoring of rhinoplasties remains controversial. However, this technology offers the advantage of capturing the 3D surface without exposing patients to potentially harmful radiation. Continuous assessment allows the follow-up of swelling patterns, cartilage alignment, and bone remodeling. The primary objective of our study was to quantify changes in nasal structure before and after rhinoplasty by using 3D photography. Our study cohort consisted of 29 patients who underwent open structural rhinoplasty. We used the Artec Space Spider camera to acquire a total of 103 3D images. We collected pre-operative and at least two or three post-operative follow-up scans, which were taken one, three, and six months after surgery. We evaluated paired scans that included various time intervals to improve our understanding of swelling behavior and to ensure an objective analysis of changes. Eleven specific anatomical landmarks were identified for measurement. Two independent raters determined the distances between these landmarks over time. The calculation of intraclass correlation coefficients showed low inter-rater variability. Statistically significant changes over time (p < 0.05) were observed for various anatomical landmarks, including soft tissue nasion, soft tissue orbitale right, soft tissue maxillofrontale left, soft tissue maxillofrontale right, nasal bridge, and nasal break point. Conversely, no significant changes (p > 0.05) were observed in the measurements of soft tissue orbitale left, pronasale, subnasale, alare right, or alare left. A visual assessment was conducted using surface distance maps. The results indicate that the complete decrease in swelling takes at least 6 months or even longer. Additionally, 3D photography can provide an objectively comparable analysis of the face and external contours. Furthermore, it allows for a comparison of external contours and therefore pre- and post-operative differences.

The Accuracy of Three-Dimensional Soft Tissue Simulation in Orthognathic Surgery-A Systematic Review

Three-dimensional soft tissue simulation has become a popular tool in the process of virtual orthognathic surgery planning and patient-surgeon communication. To apply 3D soft tissue simulation software in routine clinical practice, both qualitative and quantitative validation of its accuracy are required. The objective of this study was to systematically review the literature on the accuracy of 3D soft tissue simulation in orthognathic surgery. The Web of Science, PubMed, Cochrane, and Embase databases were consulted for the literature search. The systematic review (SR) was conducted according to the PRISMA statement, and 40 articles fulfilled the inclusion and exclusion criteria. The Quadas-2 tool was used for the risk of bias assessment for selected studies. A mean error varying from 0.27 mm to 2.9 mm for 3D soft tissue simulations for the whole face was reported. In the studies evaluating 3D soft tissue simulation accuracy after a Le Fort I osteotomy only, the upper lip and paranasal regions were reported to have the largest error, while after an isolated bilateral sagittal split osteotomy, the largest error was reported for the lower lip and chin regions. In the studies evaluating simulation after bimaxillary osteotomy with or without genioplasty, the highest inaccuracy was reported at the level of the lips, predominantly the lower lip, chin, and, sometimes, the paranasal regions. Due to the variability in the study designs and analysis methods, a direct comparison was not possible. Therefore, based on the results of this SR, guidelines to systematize the workflow for evaluating the accuracy of 3D soft tissue simulations in orthognathic surgery in future studies are proposed.

Influencing factors for the development of obstructive sleep apnea after orthognathic surgery in skeletal class III patients: A systematic review

This systematic review aimed to investigate the factors that may contribute to the development of OSA after orthognathic surgery in patients with skeletal class III. Electronic searches of PubMed, Embase, Web of Science, and Cochrane databases were conducted up to December 10, 2022. In total, 277 studies were retrieved and screened according to the inclusion and exclusion criteria, and 14 were finally selected. All studies were of medium quality (moderate risk of bias). The occurrence of OSA after orthognathic surgery in patients with class III skeletal relationships depends on surgical factors and patient self-factors. Surgical factors include surgery type, amount of maxillary and mandibular movement, and the patient's postoperative swelling. Patient self-factors include weight, age, gender, and hypertrophy of the soft palate, tonsils, and tongue. According to information in the 14 selected articles, the incidences of OSA after Le Fort I impaction and BSSO setback, BSSO setback, and Le Fort I advancement and BSSO setback were 19.2%, 8.57%, and 0.7%, respectively, mostly accompanied with greater amounts of mandibular recession. However, no clear evidence exists to confirm that orthognathic surgery is a causative factor for postoperative sleep breathing disorders in patients with mandibular prognathism. The wider upper airway in patients with class III skeletal might be the reason for the rare occurrence of OSA after surgery. In addition, obesity and advanced age may lead to sleep apnea after orthognathic surgery. Obese patients should be advised to lose weight preoperatively.

Does mandibular osteotomy affect the infraorbital nerve? a prospective study

OBJECTIVES

The aim of this study was to evaluate the sensory function of the infraorbital nerve after orthognathic surgery (OS).

MATERIALS AND METHODS

Patients who underwent Le Fort I osteotomy with or without BSSO for dentofacial deformity treatment were studied. Two groups were created according to whether BSSO was performed. Class A tests were performed to determine the degree of peripheral nerve damage. The Class B test was performed if decreased sensation was detected in at least one of these tests. A Class C test was performed if abnormal sensation was detected.

RESULTS

Twenty-eight patients (n=56) who underwent OS were included in this prospective study. Of the patients, 57.1% were female, 42.9% were male, and the mean age was 24.6 (±3.8). Seven patients were in group 1 (n=14), and 21 patients were in group 2 (n=42). In both groups, there were statistically significant differences between T1 and T2 (p<0.001), and the mean NSD score at T2 was higher than that at T1. The mean NSD score in the single jaw group was higher than that in the double jaw group at all time points.

CONCLUSIONS

Bimaxillary surgeries had a negative effect on the somatosensory changes that developed in the early period. The upper lip's somatosensorial recovery was faster than IOR and single jaw recovery was faster than double jaw.

CLINICAL RELEVANCE

Maxillofacial surgeons performing orthognathic surgery should be aware that in double jaw operations, changes in the somatosensory function of the ION are more severe.

Factors affecting progressive facial swelling immediately after orthognathic surgery: A retrospective cohort study

The aim of this study was to identify clinical factors associated with progressive facial swelling after orthognathic surgery. Patients diagnosed with jaw deformities and undergoing orthognathic surgery were retrospectively evaluated, and those with surgical site infection, Le Fort I osteotomy, or genioplasty only were excluded. Facial swelling volume was calculated by comparing facial volume preoperatively and three days postoperatively using 3D images and image analysis software (VECTRA H2). FXIII was measured within three days after surgery in only patients with unexplained postoperative bleeding or hematoma. The correlation between facial swelling volume and clinical factors was statistically analyzed. Facial swelling volume was examined in 78 patients. Univariate analysis showed a significant difference between facial swelling volume (mean = 41.6 cm3) and operation time (mean = 209.3 min, r = 0.283, p = 0.012), ΔHb level (mean = 1.18 g/dL, r = 0.235, p = 0.039), as well as decreased factor XIII activity (mean = 75.3%, p = 0.012). Multivariate analysis showed a significant difference between facial swelling volume and FXIII deficiency (standard error = 6.44, p = 0.031).Progressive facial swelling immediately after orthognathic surgery may be due to factor XIII deficiency.

Changes of the facial soft tissue after mandibular reconstruction using vascularized iliac flap

OBJECTIVES

To reveal the change patterns of the facial soft tissue after applying mandibular reconstruction.

MATERIALS AND METHODS

16 Patients with mandibular benign tumor were recruited in this retrospective study. For all patients, segmental mandibular osteotomy and concurrent reconstruction using vascularized iliac flap were conducted. The soft tissue thickness of patients' lower face was measured with CT scans before surgery, 1 week, 6 months and 1 year after surgery. The time-dependent changes of tissue thickness were analyzed.

RESULTS

The most significant tissue swelling was 28.86%, at 1 week after the surgery. The average increase of tissue thickness was 4.78 ± 5.30 mm across patient. After 1 year of the surgery, tissue thickness decreased to the level before operation or the level of the healthy side. The thickness of the low-density tissue fluctuated mildly, while the thickness of the high-density tissue fluctuated significantly. The disuse atrophy of the masseter occurred 1 week after the surgery, and was reversed after 1 year. The removal of the submandibular gland caused depression in submandibular area, which intensified over time.

CONCLUSION

Across patients, soft tissue thickness in the lower face after mandibular osteotomy and reconstruction increased significantly 1 week after the surgery, and decreased over time. After 1 year, tissue thickness went back to the pre-surgery level, where matched up with the healthy side.

CLINICAL RELEVANCE

We documented the change patterns of the facial soft tissue after mandibular reconstruction. These results can help improve the planning of virtual surgeries and the timing for aesthetic assessment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: ChiCTR2100054103.

Risk factors for postoperative facial swelling at 1 week after bimaxillary orthognathic surgery in Class III patients

OBJECTIVE

To quantify facial swelling at 1 week after Le Fort I osteotomy and bilateral sagittal splitting ramus osteotomy in Class III patients and to identify factors contributing to the swelling based on clinical, morphologic, and surgical variables.

STUDY DESIGN

Data from 63 patients were examined in this single-center, retrospective study. Facial swelling was quantitatively measured by superimposing computed tomography data taken in the supine position at 1 week and 1 year postoperatively and extracting the area of maximum intersurface distance. Age, sex, body mass index, thickness of subcutaneous tissue, and of masseter muscle, maxillary length (A-VRP), mandibular length (B-VRP), and posterior maxillary height (U6-HRP), surgical movement (ΔA-VRP, ΔB-VRP, ΔU6-HRP), drainage method, and usage of facial bandages were examined. Multiple regression analysis was performed using the above factors.

RESULTS

The median swelling at 1 week postoperatively was 8.35 IQR (5.99-11.47) mm. Multiple regression analysis revealed three factors that were significantly associated with facial swelling: Use of postoperative facial bandages (P=0.03), masseter muscle thickness (P=0.03), and ΔB-VRP (P=0.04).

CONCLUSION

Absence of a facial bandage, thin masseter muscle, and large horizontal mandibular movement are risk factors for facial swelling at 1 week postoperatively.

Long-term evaluation of masseter muscle activity, dimensions, and elasticity after orthognathic surgery in skeletal class III patients

OBJECTIVE

To evaluate changes in the masseter muscle after orthognathic surgery using electromyography (EMG), ultrasonography (US), and ultrasound elastography (USE) in individuals with skeletal class III anomaly over long-term follow-up and compare with a control group.

MATERIALS AND METHODS

The study group included 29 patients with class III dentofacial deformities scheduled to undergo orthodontic treatment and orthognathic surgery. The control group included 20 individuals with dental class I occlusion. Assessment of the masseter muscles using EMG, US, and USE was performed before orthognathic surgery (T1) and at postoperative 3 months (T2) and 1 year (T3) in the study group, and at a single time point in the control group. All assessments were performed at rest and during maximum clenching. Masseter muscle activity, dimension, and hardness were analyzed.

RESULTS

Electromyographic activity of the masseter muscle during maximum clenching was increased at postoperative 1 year but did not reach control group values. On ultrasonography, the masseter muscle showed minimal changes in dimension at postoperative 1 year compared to preoperative values and remained below control group values. The postoperative increase in masseter muscle hardness at rest and during maximum clenching persisted at postoperative 1 year.

CONCLUSION

The results of this study suggest that after orthognathic surgery, additional interventions and much longer follow-up are needed to ensure better muscle adaptation to the new occlusion and skeletal morphology.

CLINICAL RELEVANCE

All assessment methods are useful for comprehensively evaluating changes in the masticatory muscles after orthognathic surgery.

An objective, quantitative, dynamic assessment of facial movement symmetry changes after orthognathic surgery

The aim of this study was to generate a quantitative dynamic assessment of facial movement symmetry changes after orthognathic surgery. Twenty-five patients diagnosed with skeletal class III malocclusion with facial asymmetry who underwent bimaxillary surgery were recruited. The patients were asked to perform a maximum smile that was recorded using a three-dimensional facial motion capture system preoperatively (T0), 6 months postoperatively (T1), and 12 months postoperatively (T2). Eleven facial landmarks were selected to analyse the cumulative distance and average speed during smiling. The absolute differences for the paired landmarks between the sides were analysed to reflect the symmetry changes. The results showed that the asymmetry index of the cheilions at T2 was significantly lower than that at T0 (P = 0.004), as was the index of the mid-lateral lower lips (P = 0.006). The mean difference in cheilions was 2.13 ± 1.41 mm at T0, 1.33 ± 1.09 mm at T1, and 1.00 ± 0.98 mm at T2. The facial total mobility at T1 was significantly lower than that at T0 (P < 0.001), while the total mobility at T2 was significantly higher than that at T1 (P = 0.012). The orthognathic surgical correction of facial asymmetry was able to improve the associated asymmetry of facial movements.

Do patients treated with Invisalign have less swelling after orthognathic surgery than those with fixed orthodontic appliances?

INTRODUCTION

Patients treated with perioperative Invisalign for orthognathic surgery may experience less postoperative swelling than those with fixed appliances because of a lack of mucosal irritation from bonded brackets and wires. The aims of this study were to (1) compare facial swelling after orthognathic surgery in subjects with Invisalign to those with fixed appliances using 3-dimensional (3D) subtraction imaging and (2) determine if the type of operation influences differences in swelling.

METHODS

This is a retrospective case-control study. To be included in the case group (Invisalign), patients had to have had: (1) LeFort I and/or bilateral sagittal split osteotomies, with or without genioplasty, (2) perioperative orthodontic treatment using Invisalign, and (3) 3D photographs at postoperative timepoints 1 week (T1), 3-4 weeks (T2), and 5-7 weeks. A sex and operation-matched control group with fixed appliances (standard) was also included. The primary outcome variable was the volume of facial swelling, measured by subtraction imposition of the T1 and T2 3D images using reference images (5-7 weeks).

RESULTS

Twenty-two subjects (36% female; mean age 20.7 ± 3.15 years) were included: Invisalign (n = 11) and standard (n = 11). For each group, 7 subjects had 1 operation (LeFort I or bilateral sagittal split osteotomies), and 4 had bimaxillary surgery ± genioplasty. At T1, the Invisalign group had significantly less swelling than the standard group (17.52 ± 10.79 cm³ vs 37.53 ± 14.62 cm³; P <0.001). By T2, the differences were no longer significant (6.62 ± 5.19 cm³ for Invisalign; 5.85 ± 4.39 cm³ for standard, P = 0.728).

CONCLUSION

Subjects with Invisalign had significantly less facial swelling in the first postoperative week than those with fixed appliances.

Perioperative therapies to reduce edema after orthognathic surgery: a systematic review and meta-analysis

Objective To systematically review the literature and assess the effectiveness of perioperative systemic and nonsystemic therapies in reducing edema after orthognathic surgery. Study Design Four databases (PubMed, Web of Science, Bireme, and Scopus) were searched. Only randomized clinical trials were included and assessed using the RoB 2.0 software (Cochrane Collaboration, London, UK). Studies were grouped into time of assessment and systemic/nonsystemic therapy. Results Eighteen studies were included in this review (8 in the meta-analysis, n = 349). The qualitative assessment of systemic (enzyme therapy, dexamethasone, betamethasone, and Venoplant) and nonsystemic therapies (thermotherapy and K-Taping) appear to reduce edema. Manual lymphatic drainage (MLD) after 72 hours (CI: -1.03 to 2.31; P = .45), and 30 days (CI: -1.53 to 0.49; P = .49), and laser after 24 hours (CI: -1.36 to 1.48; P = .93), 72 hours (CI: -4.81 to 2.92; P = .63), 30 days (CI: -3.44 to 0.99; P = .28), and 90 days (CI: -1.83 to 0.96; P = .54) showed no significance. Thermotherapy reduced edema after 48 hours (CI: -48.47 to -13.31; P = .0006) and 30 days (CI: -14.73 to -1.98; P = .01). Conclusion The Grading of Recommendations, Assessment, Development and Evaluations tool showed moderate evidence for thermotherapy (significant reduction of edema), whereas the MLD and laser results were rated as high certainty of evidence (no reduction of edema).

The Accuracy of Computer-Assisted Surgical Planning in Predicting Soft Tissue Responses After Le Fort I Osteotomy: Retrospective Analysis

PURPOSE

Mismatch between preoperative planning and surgical outcome in maxillofacial surgery relate to on-table replication of presurgical planning and predictive algorithm inaccuracy: software error was hereby decoupled from planning inaccuracy to assess a commercial software. The hypothesis was that soft tissue prediction error would be minimized if the surgical procedure was replicated precisely as planned and is independent of the extent of bone repositioning.

MATERIALS AND METHODS

Cone-beam computed tomography scans of 16 Le Fort I osteotomy patients were collected at Boston Children's Hospital. Preoperative and postoperative models of bone and soft tissue were constructed and the maxilla repositioning was replicated. Each model was subdivided into 6 regions: mouth, nose, eyes, and cheeks. Soft tissue prediction (performed using Proplan CMF-Materialise) for each patient was compared with the relative postoperative reconstruction and error was determined. P <0.05 was considered significant.

RESULTS

Le Fort I segment repositioning was replicated within 0.70±0.18 mm. The highest prediction error was found in the mouth (1.49±0.77 mm) followed by the cheeks (0.98±0.34 mm), nose (0.86±0.23 mm), and eyes (0.76±0.32). Prediction error on cheeks correlated significantly with mouth ( r =0.63, P < 0.01) and nose ( r =0.67, P < 0.01). Mouth prediction error correlated with total advancement ( r =0.52, P =0.04).

CONCLUSIONS

ProPlan CMF is a useful outcome prediction tool; however, accuracy decreases with the extent of maxillary advancement even when errors in surgical replication are minimized.

Reliability of 3D Stereophotogrammetry for Measuring Postoperative Facial Swelling

This study aimed to determine the reliability of three-dimensional (3D) stereophotogrammetry as a measurement instrument for evaluating soft tissue changes in the head and neck area. Twelve patients received a bilateral sagittal split osteotomy (BSSO). Test and retest 3D photographs were captured within the first three postoperative weeks, and a reference 3D photograph was capture at three months postoperatively. Distance measurements, mean and root mean square of the distance map, and volume differences were obtained. Reliability of these parameters was assessed by intraclass correlation coefficients (ICCs), standard error of measurement (SEM), and smallest detectable change (SDC). All distance measurements had an ICC > 0.91, and the distance map parameters and volume differences showed ICCs > 0.89. The neck region presented the largest SEMs (5.09 mL) and SDC (14.1 mL) for the volume difference. In conclusion, 3D stereophotogrammetry is reliable for distance and volume measurements of soft tissues in patients after a BSSO advancement.

Recovery following Orthognathic Surgery Procedures-A Pilot Study

This study aims at evaluating and categorizing patients’ objective and subjective postoperative recovery symptoms after bimaxillary orthognathic surgery assigning the healing process. The patients were monitored throughout the recovery process, and their symptoms were managed. A prospective, observational study was performed. Patients with Class II and III malocclusion (aged 18 to 35) were evaluated and monitored preoperatively, and postoperatively at 48 h, 2 weeks, 1 month, and 3 months postsurgery. A questionnaire was used to assess pain and anesthesia/hypoesthesia. The most common objective and subjective signs that were correlated with the healing process were edema, hematoma, trismus, pain, and anesthesia/hypoesthesia. Edema peaked at 48−72 h postoperatively (distance between eye’s external canthus and gonion, mean difference = 4.53, between tragus and cheilion, mean difference = 7, between tragus and gnathion, mean difference = 4.65, p < 0.001); mouth opening amplitude was significantly decreased during the first two weeks postsurgery (class II, mean difference = 32.42, p = 0.006, class III, mean difference = 44.57, p < 0.001), but it steadily and considerably improved over three months. The nose tended to widen postsurgery. The most severe pain experienced by patients was of medium intensity in the mandibular body, described as pressure, and usually did not spread. Patients were most severely and persistently impacted by anesthesia/hypoesthesia.

Determining Morbidity of Adding Genioplasty to Bimaxillary Orthognathic Surgery

BACKGROUND

Patients with dentofacial anomalies may undergo orthognathic surgery to address functional and aesthetic concerns. Past works have evaluated determinants affecting length of stay (LOS) in patients undergoing upper and/or lower jaw surgery alone. No studies have assessed the addition of genioplasty to double-jaw (Lefort I, bilateral sagittal split osteotomy (BSSO))) surgery and its effect on LOS and other outcomes. This study investigates whether the addition of genioplasty incurs additional morbidity to patients undergoing complex orthognathic surgery.

METHODS

This was a retrospective cohort study of patients undergoing orthognathic surgery at Yale-New Haven Hospital. Clinical and demographic information were compared across the "double"- and "triple"-jaw cohorts with t tests and Chi-squared analyses. Multivariable linear and logistic regression analyses were utilized to assess the impact of genioplasty when controlling for baseline patient differences.

RESULTS

A total of 27 patients received Lefort I and BSSO (double-jaw), and 224 received Lefort I, BSSO, and genioplasty (triple-jaw). Six (22.2%) double-jaw patients were segmental and fifty-eight (25.9%) triple-jaw patients were segmental (p > 0.05), during the study period. Triple-jaw surgery was associated with increased operative time (+ 41.1 min, p < 0.01). There was no increase in LOS, postoperative nausea and vomiting, opioid use, hematoma, or infection (p > 0.05).

CONCLUSIONS

This study attempted to determine if triple-jaw surgery could influence patients' LOS and other surgical outcomes compared to double-jaw surgery. Only the operative time was significantly affected. This indicates that incorporation of a genioplasty can provide aesthetic benefit without incurring significant additional morbidity to the patient.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Validation of Vectra 3D Imaging Systems: A Review

Aim: Three-dimensional facial imaging systems are a useful tool that is gradually replacing two-dimensional imaging and traditional anthropometry with calipers. In this varied and growing landscape of new devices, Canfield (Canfield Scientific, Parsippany, NJ, USA) has proposed a series of static and portable 3D imaging systems. The aim of this systematic review was to evaluate the current literature regarding the validation of Canfield’s Vectra imaging systems. Materials and Methods: A search strategy was developed on electronic databases including PubMed, Web of Science and Scopus by using specific keywords. After the study selection phase, a total of 10 articles were included in the present review. Results: A total of 10 articles were finally included in the present review. For six articles, we conducted a validation of the Vectra static devices, focusing especially on the Vectra M5, Vectra M3 and Vectra XT. For four articles, we validated the Vectra H1 portable system. Conclusions: All of the reviewed articles concluded that Canfield’s Vectra 3D imaging systems are capable of capturing accurate and reproducible stereophotogrammetric images. Minor errors were reported, particularly in the acquisition of the perioral region, but all the evaluated devices are considered to be valid and accurate tools for clinicians.

Changes in Facial Profile after Modified Anterior Maxillary Subapical Osteotomy

(1) Background: This study explored the effects of modified anterior maxillary subapical osteotomy (AMSO) on facial profile changes in patients with bimaxillary protrusion. (2) Methods: Cephalograms of patients were collected preoperatively and over 2 months postoperatively. The following landmarks were recorded: pronasale (Prn), subnasale (Sn), labrale superius (Ls), anterior nasal spine (ANS), and incisor superius (Is). The following distances and angles were measured: ANS-Prn, ANS-Sn, ANS-Ls, Is-Sn, Is-Ls, SNA angle, and nasolabial (NLA) angle. (3) Results: Is and ANS were significantly retracted by 7.3 and 2.3 mm, respectively. Soft tissue landmarks (Prn, Sn, and Ls) were significantly retracted (1.2, 1.6, 4.4 mm, respectively). Postoperative changes in soft/hard tissue ratios were 0.54, 0.72, 0.31, and 0.60 for Prn/ANS, Sn/ANS, ANS/Is, and Ls/Is, respectively. The NLA angle was increased significantly by 7.1°. (4) Conclusions: The horizontal soft/hard tissue ratios of Sn/Is, ANS/Is, and Ls/Is were 0.22, 0.31, and 0.60, respectively. The NLA angle was increased significantly by 7.1°. The modified AMSO provides an increased blood supply, allows for direct vision, and results in fewer complications than other AMSO methods.

Delayed Soft Tissue Changes after Clockwise Rotation of the Maxillo-Mandibular Complex

OBJECTIVE

The purpose of this study was to evaluate delayed soft tissue changes of the maxilla-mandibular complex MMC using three-dimensional (3D) cone-beam computed tomography after clockwise repositioning orthognathic surgery.

METHODS

This study included 21 patients that underwent maxilla-mandibular complex clockwise rotational orthognathic surgery by 1 doctor from January 2015 to June 2019. Radiographic images (panorama, lateral cephalogram, posteroanterior view, and cone-beam computed tomography) were taken and 3D analysis was performed using the Invivo 5 (Anatomage Inc, Santa Clara, CA) to acquire 3D images before surgery, immediately after surgery, at 6 months after surgery and 21 months after surgery. The 9 soft tissue landmarks were measured and compared in terms of postoperative changes in transverse, vertical, and anteroposterior directions. The points were at the outer commissure of the eye fissure (Exocathion; Exc_r, Exc_l), at the midline of both the nasal root and the nasofrontal suture, analogous to bony N (soft tissue nasion; N), the most prominent point on the nasal tip (Pronasale; Prn), the most lateral point in the curved baseline of each ala, indicating the facial insertion of the nasal wing base (Alare curvature; Ac_r, Ac_l), the most lateral point on the soft tissue contour of each mandibular angle (Soft tissue Gonion; Go_r, Go_l), and the most inferior midpoint on the soft tissue contour of the chin (soft tissue menton; Me).

RESULTS

The most prominent point of the nasal tip (Prn) moved 1.36 mm upward and 1.55 mm forward in the vertical and anteroposterior planes immediately after surgery. However, there were no significant changes in Ac_r and Ac_l even immediately after surgery. Both soft tissue gonions shifted downward and forward between immediately after surgery and 6 months after surgery. However, no significant change was observed in the value of any of the 9 soft tissue points between 6 months and 21 months after surgery (P value < 0.05).

CONCLUSIONS

No significant changes were observed between 6 and 21 months after surgery, which suggests no delayed soft tissue changes occur in surgically treated patients after the resolution of surgically-related facial edema and swelling and postsurgical remodeling of hard tissue in overlying soft tissue.

Intravenous ibuprofen versus diclofenac plus orphenadrine in orthognathic surgery: a prospective, randomized, double-blind, controlled clinical study

Objectives

The aim of this prospective, randomized, double-blind, controlled clinical study was to evaluate the analgesic effect of ibuprofen versus diclofenac plus orphenadrine on postoperative pain in orthognathic surgery.

Material and methods

Patients who underwent orthognathic surgery were randomized into two groups to receive intravenously either 600 mg of ibuprofen (I-group) or 75 mg diclofenac plus 30 mg orphenadrine (D-group), both of which were given twice daily. Additionally, both groups were given metamizole 500 mg. Rescue pain medication consisted of acetaminophen 1000 mg and piritramide 7.5 mg as needed. To assess the pain intensity, the primary end point was the numeric rating scale (NRS) recorded over the course of the hospital stay three times daily for 3 days.

Results

One hundred nine patients were enrolled (age range, 18 to 61 years) between May 2019 and November 2020. Forty-eight bilateral sagittal split osteotomies (BSSO) and 51 bimaxillary osteotomies (BIMAX) were performed. Surgical subgroup analysis found a significant higher mean NRS (2.73 vs.1.23) in the BIMAX D-group vs. I-group (p = 0.015) on the third postoperative day. Additionally, as the patient’s body mass index (BMI) increased, the mean NRS (r = 0.517, p = 0.001) also increased. No differences were found between age, gender, length of hospital stay, weight, operating times, number of patients with complete pain relief, acetaminophen or piritramide intake, and NRS values. No adverse events were observed.

Conclusion

The results of this study demonstrate that ibuprofen administration and lower BMI were associated with less pain for patients who underwent bimaxillary osteotomy on the third postoperative day. Therefore, surgeons may prefer ibuprofen for more effective pain relief after orthognathic surgery.

Clinical relevance

Ibuprofen differs from diclofenac plus orphenadrine in class and is a powerful analgetic after orthognathic surgery.

Face Lift after Facial Feminization Surgery: Indications and Special Considerations

SUMMARY

Iatrogenic jowling can be an unintended consequence of facial feminization surgery. Reduction of the mandible and chin without overlying changes to the soft tissue can lead to a redundant and deflated soft-tissue envelope, requiring a face lift to address jowling, cervicofacial laxity, and/or lower facial rhytids. Prospective quality-of-life outcomes data support this hypothesis, as patients who underwent mandible contouring with or without angle osteotomies were significantly more likely to express interest in face lift following facial feminization surgery on univariable analysis (90.0 percent versus 10.0 percent, p = 0.038). Patients with inherent skin laxity are at particularly high risk, such as those with advancing age, extrinsic skin damage (e.g., sun exposure, cigarette smoke), and history of massive weight loss. Before facial feminization surgery, the authors recommend comprehensive patient counseling that includes a discussion of the possible future need for a face lift, preferably around 1 year after facial feminization surgery. When performing a face lift after facial feminization surgery, technical considerations include those related to sequelae of prior facial surgery, anatomical differences between cismale and cisfemale facial soft tissue, and the mechanism of jowling after facial feminization surgery versus normal facial aging. The authors believe that these considerations can set more realistic expectations for facial feminization surgery patients, improve surgeons' ability to skillfully execute this procedure, and ultimately contribute to ongoing quality-of-life improvements in facial feminization surgery patients.

Scleral exposure changes after Le Fort I maxillary advancement with vertical component in individuals with skeletal Class III malocclusion-A stereophotogrammetric image study

OBJECTIVE

This retrospective study aimed to evaluate inferior scleral exposure changes in Class III patients that underwent orthognathic surgery with Le Fort I osteotomy with and without vertical displacement.

MATERIALS AND METHODS

Preoperative and 6-months postoperative cephalograms and stereophotogrammetric images of 45 subjects (mean age:21.66±2.97 years) that underwent orthognathic surgery for Class III correction were retrieved. Subjects were divided into 3 groups: maxillary advancement-only (AO); maxillary advancement+impaction (AI), maxillary advancement+downfracture (AD). Exclusion criteria were mandibular-only surgery, occlusal canting, facial asymmetry, orbital surgery, and craniofacial syndrome. One investigator measured inferior scleral exposure on both sides using following landmarks: upper eyelid margin (A), inferior limbus (B) and lower eyelid margin (C). Distance between A and C was recorded as overall eye height (E), distance between B and C was recorded as inferior sclera exposure (S). S:E ratio in percentage was calculated to standardize sclera exposure relative to overall eye height. Wilcoxon signed-rank and Kruskal Wallis tests were used for statistical analysis (p<0.05).

RESULTS

Mean value of maxillary movements were: 4.21±1.82mm advancement in AO; 5.08±2.18mm advancement and 2.33±0.99mm impaction in AI; 3.95±1.45mm advancement and 3.1±0.71mm downfracture in AD. Change in reduction of scleral exposure was significant in all groups (p<0.05). AI group bilaterally and AO group right side had highest differences (-4.96±4.86, -6.09±4.21, -4.99±3.23, respectively). There was no significant difference between groups in S:E ratio changes (p>0.05).

CONCLUSION

Intergroup comparisons showed no statistically significant difference, revealing similar reduction in all three groups despite the differences in the vertical movement variable.

Three-Dimensional Geometric Morphometry of Facial Soft Tissue Changes After Bilateral Sagittal Split Ramus Osteotomy

ABSTRACT

This study aimed to evaluate the performance of geometric morphometry (GM) to assess the changes in facial soft tissue after orthognathic surgery. Subjects were 27 patients (skeletal class III) who underwent bilateral sagittal split ramus osteotomy and 27 volunteers as a control group. Computed tomography images of each patient were obtained before surgery (T0) and 6 months after surgery (T1). Computed tomography images of 27 volunteers (skeletal class I) were also obtained as a control group. Using a three-dimensional (3D) modeling software, 3D models were created and exported to a 3D surface analyzing software for geometric morphometry and principal component (PC) analysis. Significant differences in facial soft tissue were found in the first and second of 15 PC. The first PC represented variation in the lower facial height, and the second PC represented variation in the anterior-posterior position of the chin. Comparing the pre- and post-operative images, they illustrated that lower facial height was decreased, and the chin and lower lip moved posteriorly. Geometric morphometry showed to be a successful tool to isolate surgery-related changes from interindividual morphological variations.

Postoperative Edema Resolution Post-Orthognathic Triple Jaw Surgery: A Three-Dimensional Volumetric Analysis

PURPOSE

The final result following orthognathic surgery may be hidden for months due to postoperative swelling. However, no substantial evidence supports this time estimate. Our study aims to three-dimensionally quantify volumetric changes in facial edema following triple-jaw surgery.

MATERIALS AND METHODS

This was a retrospective, three-dimensional (3D) study of patients who underwent primary orthognathic triple jaw surgery (Le Fort I, Bilateral Sagittal Split Osteotomy (BSSO), and osseous genioplasty) by the senior author (DMS). Vectra 3D Software (Canfield, Fairfield, NJ) was used to assess and quantify volumetric changes between serial 3D photos. An inverse line of best-fit was plotted to assess reduction in postoperative facial edema. The effects of gender, age, body mass index, and tranexamic acid administration on swelling resolution were analyzed through mixed linear model analysis.

RESULTS

A total of 46 patients (198 images) met the study criteria. The equation for the inverse function line of best fit was y = -13.14ln (x) + 39.54 (P < 0.01). On average, 60% of the swelling resolved in 1 month, 84% after 6 months, and nearly 93% after 12 months. There were no significant differences in the rate of swelling resolution when accounting for age, gender, body mass index, or tranexamic acid administration.

CONCLUSIONS

Most facial edema resolved during the first month following triple jaw surgery, with significant reduction in swelling between 6 and 12 months postoperatively. After 1 year, approximately 10% of the initial edema remained.

Analysis of Gull in Flight Appearance and Related Parameters Following Le Fort I Osteotomy

ABSTRACT

The present study aimed to investigate how "Gull in Flight" appearance and alar-columellar relationship change following maxillary surgery. Thirty-three patients who underwent Le Fort I osteotomy with or without mandibular osteotomy were included in this retrospective study. Measurements which were angle of columella triangle, alar-rim angle, columella lobular angle, and distance of points forming "Gull in Flight" appearance were evaluated on pre and postoperative frontal and lateral photos of patients. Data was submitted to statistical analysis and significance level was determined as 0.05. Following Le Fort I surgery, distance of points forming "Gull in Flight" appearance with respect to canthus was decreased significantly (P < 0.05). Positions of these points to each other were not changed (P > 0.05). Every 1 mm maxillary impaction led to 0.58 mm reduction in y3 (the distance from the point that illustrates Gull's body) (P = 0.032). There was a decrease in angle of columella triangle, alar-rim angle and increase in columella lobular angle. However, these changes were not found significant (P > 0.05). Angle of columella triangle was increased 2.51 degree for every 1 mm maxillary advancement (P = 0.028). In conclusion, maxillary surgery had an impact on nasal region from frontal view. However, "Gull in Flight" appearance which is one of the aesthetic parameters in nose was not changed following maxillary surgery.

Three-dimensional nasolabial changes after maxillary advancement osteotomy in class III individuals: a systematic review and meta-analysis

Background Class III malocclusions with maxillary retrognathia are commonly treated with single jaw Le Fort I maxillary advancement. The three-dimensional (3D) effects of surgery on the nasolabial region varies among the clinical studies. Quantifying these changes is of great importance for surgical planning and obtaining valid consent. Objectives To investigate the 3D relationship between soft tissue and skeletal changes secondary to Le Fort I maxillary advancement surgery in skeletal class III patients.Search methods Comprehensive search of multiple electronic databases supplemented by a manual and grey literature search were undertaken from inception to 9 June 2020.Selection criteria Studies that evaluated the 3D soft tissue changes of patients before and after maxillary advancement surgery alone.Data collection and analysis Study selection, data extraction and risk of bias assessment were performed independently by two reviewers, with disputes resolved by a third reviewer. A quantitative synthesis of the data was pre-planned for pooling similar outcome measures.Results Four studies were included in the final review and meta-analysis, with a total of 105 patients (mean age 16.7 + 33.9 years). The mean maxillary advancement of the included studies was 5.58 mm (95% CI 5.20-5.96). The sagittal effects of surgery on nose tip projection and prominence were insignificant (P >0.05, two studies); however, subnasal projection (MD 1.7 mm, two studies) and upper lip projection (MD 2.90 mm, four studies) increased significantly in a forward direction after surgery (P <0.05). Le Fort I osteotomy widens the upper philtrum width (MD 0.84 mm, two studies) (P <0.05). Inconsistencies among the included studies were identified; therefore, the results should be interpreted with caution.Conclusions There is weak evidence based on quantitative assessments that Le Fort I maxillary advancement significantly affects the nasolabial soft tissue envelope mainly in a sagittal dimension. These changes are concentrated around the central zone of the nasolabial region. Future prospective studies on maxillary advancement osteotomy with a standardised method of assessment, taking into consideration the confounding factors, are required.

Does the use of low-level light therapy postoperatively reduce pain, oedema, and neurosensory disorders following orthognathic surgery? A systematic review

The aim of this study was to evaluate the efficacy of low-level light therapy (LLLT) in improving pain, oedema, and neurosensory disorders of the inferior alveolar nerve (IAN) after orthognathic surgery. This systematic review was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searches were conducted in the PubMed, Embase, and Web of Science databases for randomized clinical trials (RCTs) published up to September 2020. After evaluating eligibility, 15 RCTs were selected. None of the studies reported an evaluation of all of the outcomes within the same publication. It was possible to determine the effect of LLLT in controlling pain following orthognathic surgery. Of the three studies evaluating this outcome, all observed a positive effect. Of the four studies that evaluated oedema, two found a positive effect. Of the 11 studies that evaluated neurosensory disorders of the IAN, all of them observed a positive effect, at least in one of the sensory evaluation tests. A meta-analysis was not possible due to the heterogeneity across studies. Considering the limitations of this review, but given the fact that LLLT is a minimally invasive intervention, its use merits consideration in immediate postoperative orthognathic surgery.

Three-dimensional virtual planning in mandibular advancement surgery: Soft tissue prediction based on deep learning

The study aimed at developing a deep-learning (DL)-based algorithm to predict the virtual soft tissue profile after mandibular advancement surgery, and to compare its accuracy with the mass tensor model (MTM). Subjects who underwent mandibular advancement surgery were enrolled and divided into a training group and a test group. The DL model was trained using 3D photographs and CBCT data based on surgically achieved mandibular displacements (training group). Soft tissue simulations generated by DL and MTM based on the actual surgical jaw movements (test group) were compared with soft-tissue profiles on postoperative 3D photographs using distance mapping in terms of mean absolute error in the lower face, lower lip, and chin regions. 133 subjects were included - 119 in the training group and 14 in the test group. The mean absolute error for DL-based simulations of the lower face region was 1.0 ± 0.6 mm and was significantly lower (p = 0.02) compared with MTM-based simulations (1.5 ± 0.5 mm). CONCLUSION: The DL-based algorithm can predict 3D soft tissue profiles following mandibular advancement surgery. With a clinically acceptable mean absolute error. Therefore, it seems to be a relevant option for soft tissue prediction in orthognathic surgery. Therefore, it seems to be a relevant options.

Electromyographic, Ultrasonographic, and Ultrasound Elastographic Evaluation of the Masseter Muscle in Class III Patients Before and After Orthognathic Surgery

PURPOSE

The aim of this study was to examine changes in the electromyographic activity, thickness, width, and hardness of the masseter muscle from before to after orthognathic surgery.

MATERIAL AND METHODS

The study included 15 patients with Class III dentofacial deformities who were treated with combined orthodontic and orthognathic surgery. Fifteen individuals with normal occlusion and no signs or symptoms of temporomandibular joint dysfunction were used as controls. All records were obtained bilaterally in the study group before surgery (T1), at 3 months after surgery (T2), and in the control group (CG) while at rest and in maximum voluntary contraction (MVC).

RESULTS

There was no difference in resting masseter muscle activity between T1, T2, and CG. Resting thickness and width of the masseter muscle did not differ significantly between T1 and T2. MVC masseter muscle activity and thickness increased significantly and width decreased significantly from T1 to T2 but did not reach CG values. Muscle hardness increased from T1 to T2.

CONCLUSIONS

The authors' findings indicate that despite improved muscle activity and dimensions, postoperative 3 months is still early period for adaptation of the masseter muscles to the new occlusion and skeletal morphology.

Hyperbaric CO2 Cryotherapy for Managing Swelling After Mandibular Angle Ostectomy

ABSTRACT

Postoperative facial swelling after mandibular angle ostectomy is a concern for patients as it affects their quality of life. This study aimed to evaluate the effect of hyperbaric CO2 cryotherapy in relieving postoperative swelling. Thirty-seven patients (mean age: 22.95 ± 3.49 years) who underwent bilateral mandibular angle ostectomy from April to October 2019, were included in this study. A split-mouth design was adopted and through a random sequence, either side of the face was designated as the experimental side. Both received routine nursing care, while the experimental side underwent an additional hyperbaric CO2 cryotherapy treatment. The facial structure was recorded by a 3-dimensional laser scanner pre- and postoperatively. Geomagic Studio was used for alignment, visualization, and quantification of the swelling. The largest deviation value on each side was adopted to assess the overall swelling. Parameters were compared using the paired t-test, and P<0.05 was considered statistically significant. No necrosis of the skin and adjacent structures or other complications occurred in these patients. After the first day of cryotherapy, the deviation in the experimental and the control groups was (8.40 ± 1.95) mm and (10.42 ± 2.03) mm, respectively. The next day, after cryotherapy, the value further reduced to (5.42 ± 1.36) mm and (8.24 ± 2.22) mm for the experimental and control groups, respectively. And the effect remained till the seventh day. No difference was observed in terms of volume of drainage. Hyperbaric CO2 cryotherapy is safe and effective in relieving postoperative swelling and seems to be more effective than the traditional cold-pack treatment after mandibular angle ostectomy.

Maxillary sinus haziness and facial swelling following suction drainage in the maxilla after orthognathic surgery

Background

We investigated the efficacy of a maxillary Jackson-Pratt (J-P) suction drain for preventing maxillary sinus hematoma and facial swelling after maxillary Le Fort I osteotomy (LF1).

Methods

We retrospectively evaluated 66 patients who underwent LF1 at a single institution. Of these, 41 had a J-P suction tube inserted in the mandible and maxilla (maxillary insertion), and 25 had a J-P drain inserted in the mandible only (no maxillary insertion). Facial CT was obtained before and 4 days after surgery. We compared mean midfacial swelling and maxillary sinus haziness by t test and examined correlations between bleeding amount and body mass index (BMI).

Results

For the maxillary-insertion group, the ratio of total maxillary sinus volume to haziness (57.5 ± 24.2%) was significantly lower than in the group without maxillary drain insertion (65.5% ± 20.3; P = .043). This latter group, however, did not have a significantly greater midfacial soft tissue volume (7575 mm³) than the maxillary-insertion group (7250 mm³; P = .728). BMI did not correlate significantly with bleeding amount or facial swelling.

Conclusions

Suction drainage in the maxilla reduced maxillary sinus haziness after orthognathic surgery but did not significantly reduce midfacial swelling.

The effect of manual lymphatic drainage on patient recovery after orthognathic surgery-A qualitative and 3-dimensional facial analysis

OBJECTIVE

The aim of this study was to investigate the effect of manual lymphatic drainage (MLD) on postoperative facial swelling and pain.

STUDY DESIGN

A randomized, single-center, prospective, 2-arm clinical trial with blinded endpoint assessment was set up. Patients were enrolled from the Maxillofacial Department of the Ghent University Hospital (Belgium) between January 2015 and March 2018. Both the intervention group (n = 13) and the control group (n = 13) received the same postoperative care; in addition, the intervention group underwent 6 sessions of MLD after orthognathic surgery. Three-dimensional facial scans were performed and questionnaires administered on postoperative days 3, 7, 14, 30, 90, and 180. A linear mixed model was performed, and statistical significance was assumed at the 5% level.

RESULTS

In total, 26 patients (mean age 29 years; range 16-57 years) were included for statistical analysis. A faster decrease in swelling in the intervention group was observed on 3-dimensional scans. Furthermore, patients receiving MLD reported reduction in swelling and pain within the first month after surgery. However, no statistically significant difference could be detected in these observations (P > .05).

CONCLUSIONS

Within the limitations of this study, no statistically significant difference could be found between patients treated with or without MLD after orthognathic surgery with regard to swelling and pain.

Postoperative complications after bimaxillary orthognathic surgery: A retrospective study with focus on postoperative ventilation strategies and posterior airway space (PAS)

PURPOSE

The aim of this study was to evaluate the impact of extubation time on postoperative complications in patients undergoing bimaxillary orthognathic surgery. We therefore retrospectively compared the effect of early extubating (EE) in the operating room versus delayed extubating (LE) on the intensive care unit (ICU) regarding postoperative complications and length of ICU/hospital stay (LOICUS/LOHS). Furthermore, we analyzed the influence of the PAS change on postoperative complications.

METHODS

The clinical data of 117 patients were retrospective analyzed regarding postoperative complications using Clavian-Dindo Classification. Volumetric calculations of the pre- and postoperative PAS were conducted using ITK-SNAP software. The Fisher's exact test was performed to evaluate the significance of differences between categorical variables. Continuous variables were analyzed using the Mann-Whitney U-Test or the Kruskal-Wallis one-way analysis of variance. Regression analysis was used estimating predictors for postoperative complications.

RESULTS

EE led to significant shortening of LOICUS (p < 0.001) and LOHS (p = 0.023). In total, we recorded 38 complications (minor n = 30; major n = 8) within the hospital stay. Complication rates were without significant differences with respect to the postoperative ventilation strategy. Large changes in PAS volume led to an increase in the major complication rates (p = 0.031). Increase or decrease of PAS was independent from postoperative complication rates (p = 1.000). Higher body mass index (p = 0.04) and a higher ASA PS score (p = 0.016) were associated with increased major complication rates.

CONCLUSION

Early extubation after surgery is a safe procedure and is associated with a reduced LOICUS and LOHS. Complications seem to occur more frequently in marked changes of the PAS and should be considered in perioperative risk stratification.

Three-Dimensional Nasal Alterations in Le Fort I Advancement: Linear Measurements, Angles, Nasal Indices, and Volume Differences

The maxillary advancement obtained by the Le Fort I osteotomy can also generate significant changes in the soft tissue of the nose and lips. The aim of this study was to compare the alterations in the soft tissue of the nose following the Le Fort I osteotomy maxillary advancement technique in a population of young adults submitted to orthognathic surgery. Seven men and 8 women aged between 23 and 45 underwent orthognathic surgery using the Le Fort I osteotomy and bilateral mandibular sagittal osteotomy. Sixty 3-dimensional images were analyzed (Vectra M3, Canfield, NJ) after labeling landmarks on the face and determining linear and angular measurements, proportion, and volume difference indices at the following intervals: preoperatively (baseline), then 2 months, 6 months, and 1 year after surgery. Following Le Fort I, there was an increase in the alar base, and reduction of nasal tip protrusion, nasal angles, and the nasal tip protrusion index (P < 0.05). There were no differences in the facial thirds, the nasal index, and angles of nasal and mentolabial convexity (P > 0.05). There was a difference in the volume of the nose only 2 months after surgery. The Le Fort I osteotomy caused significant alterations in linear, angular, and nasal proportion measurements. The volume differences were reversible in the early postoperative period and probably associated with edema. The possibility of variations in the size and shape of the nose should be presented to prospective patients preoperatively.

Difference in Degrees of Satisfaction with Orthognathic Surgery and Orthodontic Treatment between Skeletal Class III and Cleft Patients

OBJECTIVE

The aim of this study was to compare the degrees of satisfaction with orthognathic surgery and orthodontic treatment between skeletal Class III and cleft patients.

MATERIALS AND METHODS

The samples consisted of Class III group (N = 25) and Cleft group (N = 16). The Modified Orthognathic Quality of Life Questionnaires, which had 5 domains (oral function [OF], awareness of dentofacial deformity [ADD], social relationship [SR], facial esthetics [FE], and nose/lip esthetics [NLE]), were evaluated with 5 rates (0 [very satisfactory] to 4 [very unsatisfactory]) at initial visit (T1), just before surgery (T2), 3 to 6 months after surgery (T3), and at debonding or 1 year after surgery (T4). The scores at each stage, amount of change between stages, and effect size (ES) in the 5 domains were investigated.

RESULTS

Compared to Class III group, Cleft group exhibited lower satisfaction scores of NLE domain during all stages (all P < 0.001) and of SR domain and total domains at T4 stage (P < 0.05, P < 0.01). Cleft group showed significant improvement of satisfaction scores in FE domain during T1-T2 (P < 0.01), in SR, FE, NLE, and total domains during T2-T3 (all P < 0.01), in OF, SR, and total domains during T3-T4 (P < 0.05, P < 0.01, P < 0.01), and in all domains during T1-T4 (ADD, P < 0.05; OF, SR, and NLE, P < 0.01; FE and total, P < 0.001). Cleft group exhibited large improvement of ES only at SR and FE domains during T2-T3 (-0.81 and -1.09, respectively).

CONCLUSIONS

Owing to lower satisfaction of NLE domain at all stages in cleft patients, clinicians should recommend adjunctive cosmetic surgery for nose and lip after completion of treatment.

Silent Changes in Sleep Quality Following Mandibular Setback Surgery in Patients with Skeletal Class III Malocclusion: A Prospective Study

Mandibular setback surgery (MSS) for skeletal class III patients can result in a relative reduction of pharyngeal airway space (PAS). Consequently, there is a possibility of the decline of sleep quality after surgery. We investigated changes in sleep quality measured by overnight polysomnography (PSG) and the three-dimensional (3D) volumes of PAS following MSS with or without Le Fort I osteotomy (LF I) in class III patients (N = 53). Overnight PSG and cone beam computed tomography were conducted at preoperative stage (T0) and postoperative 3 months (T1). Measurements of PAS volumes were performed, and the subjective symptoms of sleep were evaluated by self-questionnaires. There were significant increases in respiratory disturbance index (RDI) and total respiratory effort-related arousal (RERA) index during T0-T1. The 3D volumes of PAS showed significant decreases in the oropharyngeal airway, hypopharyngeal airway, and total airway spaces. No significant changes were observed in subjective symptoms of sleep. MSS with or without LF I for class III patients could worsen sleep quality by increasing sleep parameters such as the RDI and RERA in PSG, and reduce volumes of PAS at postoperative 3 months. Although subjective symptoms may not show significant changes, objective sleep quality in PSG might decrease after MSS.

Thermographic assessment of facial temperature in patients undergoing orthognathic surgery

This study was conducted to assess the usefulness of thermography for quantifying facial temperature before and after orthognathic surgery and intermaxillary fixation, and the effects of these orthognathic procedures on facial temperature. Facial thermograms of 10 patients who underwent bilateral sagittal split ramus osteotomy (SSRO, one-jaw group) and another 10 patients who underwent Le Fort I osteotomy and bilateral SSRO (two-jaw group) were taken 1 day before orthognathic surgery (T1) and at release of intermaxillary fixation 7 days later (T2). Two thermograms taken 30 s (TG1) and 3 min (TG2) after the start of recording at T1 and T2 were used. A square (26 × 26 pixels) was marked on each thermogram and the mean facial temperature for each square was measured. Three-way analysis of variance was used for statistical comparisons. Facial temperatures were significantly higher at T2 than at T1 on TG1 and TG2, and were significantly higher on TG2 than on TG1 at T1 and T2. The two-jaw group had a significantly higher facial temperature than the one-jaw group. Thermography was useful for quantitative assessment of facial temperature in patients undergoing orthognathic surgery. Changes in facial temperature were due predominantly to inflammation after surgery, rather than to sarcopenia.