One-Stage Computer-Guided Customized Management of Skeletal Asymmetry by Concomitant Proportional Condylectomy and Orthognathic Surgery in Patients With Unilateral Condylar Hyperplasia

A proposed protocol for correlation between bone density in hemimandibular hyperplasia radiography and histopathological findings - A retrospective study

The role of low-dose computed tomography (LDCT) in surgical planning can be assessed based on the correlation among bone density (BD/HU), radiographic values, and the histopathological appearance of hyperplastic overgrowth in mandibular condyles (hemimandibular hyperplasia/osteochondroma). The aim of this study was to evaluate the correlation between LDCT indices of bone-density measurements in surgical planning and histopathological specimens. The patients incuded in this study underwent detailed radiological evaluation as preparation for further clinical procedures. Excised condyles were evaluated in terms of bone density index using LDCT, and then histopathologically to investigate the accuracy of surgical procedures and set the basis for future surgical planning. An index value between both condyles' bone densities represented the relative difference between the healthy condyle and the side with hemimandibular hyperplasia (HH). Patients with unilateral condylar hyperplasia (UCH) showed a statistical correlation between condyle heads with increased bone density (BD) and scintigraphic (SCI) values (p < 0.001). On the other hand, correlation between BD and histopathological studies alone was significant (p < 0.001). With the increase in BD measured in HU in UCH condyles, the overall value of fibrous cartilage layer thickness decreased (p < 0.001). Furthermore, histopathological evaluation indicated that increased bone density on the UCH side resulted in increased total thickness (p > 0.001). The proposed index measurements in the mandibular condyles based on LDCT/BD can be used to estimate the degree of required surgical resection. Results from LDCT radiographic studies correlate with histopathological specimens more than scintigraphy.

The Role of Digital Surgical Planning and Surgical Guides in the Treatment of Unilateral Condylar Hyperplasia

Unilateral condylar hyperplasia (UCH) results in facial asymmetry, malocclusion, and temporomandibular joint dysfunction. Treatment consists of both surgical and orthodontic intervention. A review was performed for 4 patients with UCH who underwent digital surgical planning (DSP)-assisted condylectomy. All patients were female, aged 14 to 35 years at the time of operation with facial asymmetry and class III malocclusion. None of the patients had prior treatment and all had perioperative orthodontic appliances to provide fixation and postoperative elastic therapy. All patients underwent DSP-guided condylectomy, and intraoperative surgical cutting guides were used for 3 of the patients. All had significant improvement in facial symmetry and occlusion. None had recurrence, and additional intervention has not been required. If UCH is recognized before marked secondary changes in the maxilla, mandible, and occlusion, future orthognathic surgery may be potentially obviated. Craniomaxillofacial surgeons should consider using DSP and surgical guides in the treatment of UCH.

Methods of Definitive Correction of Mandibular Deformity in Hemimandibular Hyperplasia Based on Radiological, Anatomical, and Topographical Measurements-Proposition of Author's Own Protocol

In order to fully evaluate and establish the degree of bone overgrowth, various radiological studies are essential in the careful planning of the amount of surgical excision. In the presented paper, the authors use self-designed anatomo-topographical reference points for planning the surgeries. Routine panoramic radiographs and low-dose computed tomography based on anatomical landmarks help in measuring the proportions of mandibular bone overgrowth with the following preoperative anatomical landmarks: (Go-Go), (Go(Right)-Gn), (Go(Left)-Gn), and (Me−Gn). Measurements taken at selected points and landmarks (gonion-gnathion/gnathion-menton) are easy to conduct. In the authors’ proposal, the main key factor is total chin correction, which is necessary in cases of severe overgrowth; when F0 > C and Go-Gn>, there is >7 mm of vertical bone overgrowth, and the mandibular canal is positioned <5 mm from the inferior mandibular border—MIB. Larger overgrowths (>7 mm) have a greater outcome on the final symmetry than smaller overgrowths. As no guidelines are known, the authors present their own proposal.

What Features on Routine Panoramic Radiographs Could Help Orthodontists to Estimate the Occurrence of Condylar Hyperplasia from Other Mandibular Asymmetries—Retrospective Analysis Study

Hemimandibular hyperplasia (HH) and elongation (HE) are the most common pathologies present in the mandible. Presented condylar hyperplasias have their own radiological and clinical features. In most cases, patients suffer from various forms of malocclusion. From a total of 150 asymmetrical jaw radiographs evaluated, 46 were evaluated and included in this study. A retrospective study on the data of 46 selected patients treated, diagnosed, and consulted from various forms of mandibular and skeletal asymmetry based on routine diagnostic panoramic radiographs evaluated typical and atypical radiological and anatomical symptoms of condylar hyperplasia. The presented evaluation focused on mandibular, maxillary, and other bones, in order to distinguish condylar hyperplasia from other forms of mandibular asymmetry. The degree of maxillary downward growth followed by the occurrence of an open bite on the affected side estimate the degree/presence or cessation of growth in the affected condyle. Mandibular asymmetry with incisor teeth inclination remains the most typical characteristic of condylar hyperplasia. Increased height of mandibular ramus differentiates between condylar hyperplasia and elongation, which also influences the position of the inferior alveolar nerve. Mentioned symptoms, described as the acronym “Go Moira!”, are useful in a quick and simple “glimpse of an eye” differential diagnostic approach. It is possible to quickly and accurately establish the first diagnosis simply by a careful evaluation of patients’ panoramic radiographs.

Application of optimized three-dimensional digital surgical guide plates for complex midfacial fractures

INTRODUCTION

The treatment of midfacial fractures is always difficult. The purpose of this study was to verify whether optimized three-dimensional (3D) digital surgical guide plates combined with preformed titanium plates improved the treatment effect in complex midfacial fractures.

PATIENTS AND METHODS

Twenty-six patients with complex midfacial fractures were recruited and randomized into three groups: ten for Group A, eight for Group B, and eight for Group C. Group A was treated with a combination of preformed titanium plates and optimized 3D digital surgical guide plates. Group B was treated with preformed titanium plates only. Group C was treated conventionally. Clinical effects, patient-reported outcome measures (PROMs), midfacial contour, facial symmetry, surgical accuracy, △orbital volume (the absolute value of the bilateral orbital volume difference), and maximum deviation were evaluated in each of the three groups.

RESULTS

Group A had the best postoperative clinical effects and patient-reported outcomes. Significant improvements in midfacial contour (L1[0.72±0.29 mm, P = 0.001], L2[1.04±0.46 mm, P < 0.001]), facial symmetry (S1[0.71±0.30 mm, P < 0.001], S2[0.96±0.58 mm, P < 0.001], S3[0.86±0.40 mm, P < 0.001], S5[0.81±0.16 mm, P = 0.003], S8[0.95±0.30 mm, P < 0.001], S9[1.03±0.38 mm, P < 0.001], S11[0.64±0.46 mm, P < 0.001]) and surgical accuracy (M1[R, 0.82±0.31 mm, P < 0.001], M2[R, 0.87±0.44 mm, P < 0.001], M3[L, 0.88±0.22 mm, P = 0.004], M3[R, 1.06±0.31 mm, P = 0.003], M4[L, 0.96±0.45 mm, P = 0.008], M4[R, 1.11±0.57 mm, P = 0.003], M5[R, 0.76±0.26 mm, P < 0.001], M6[L, 1.00±0.46 mm, P = 0.003], M6[R, 1.00±0.58 mm, P = 0.001], M7[0.87±0.53 mm, P = 0.001], M8[R, 0.91±0.53 mm, P < 0.001], M9[R, 0.81±0.32 mm, P = 0.010], M10[R, 1.19±0.42 mm, P = 0.009], M11[L, 0.85±0.51 mm, P = 0.021], M11[R, 0.96±0.49 mm, P = 0.003]) were found in Group A compared with the other two groups. The results of △orbital volume and maximum deviation analysis showed an ideal surgical treatment effect in Group A.

CONCLUSION

Optimized 3D digital guide plates can accurately locate preformed titanium plates and effectively improve the treatment effect in complex midfacial fractures.

The need for secondary orthognathic surgery after high condylectomy in patients with active unilateral condylar hyperplasia

The need for secondary orthognathic surgery (OS) after a high condylectomy (HC) in patients with active unilateral condylar hyperplasia was assessed in 25 patients, reviewing patient characteristics and treatment planning. At 6-12 months after HC, 13 patients (52%) required secondary OS. The amount of mandibular dental midline shift before the HC (P=0.037), and a dental crossbite that was present before the HC (P=0.017) were significantly associated with the need for secondary OS. Overall, the mandibular dental midline coincided with the facial midline in eight patients (32%) at 2 weeks after HC. In 16% of the patients, no additional OS was needed despite this being the initial treatment plan. Additionally, the initially planned type of secondary OS was modified in six other patients. Early HC in skeletally immature patients provided very good results, both aesthetic and functional, with only two of them needing supplementary OS at 6-12 months after HC. The HC remains a valuable treatment in patients with active unilateral condylar hyperplasia, as it can eliminate the need for secondary OS and is very well tolerated by most patients.

Patient Specific Implants to Solve Structural Facial Asymmetry After Orthognathic Surgery

ABSTRACT

Facial asymmetry is a challenge for surgeons. Some surgical strategies could be used involved soft or hard tissue of the face. The aim of this report is to show the use of patient specific implants (PSI) in a puzzle strategy based on computer aided design/computer aided manufacturer to solve a complex structural facial asymmetry after orthognathic surgery. Twenty-five-year-old male patient complain for facial asymmetry after orthognathic surgery; main deformity was related to the shape of mandibular bone in the ramus, angle, and body. After mirror image, was chose an augmentation in the right side using 2-pieces patient specific implants and the bone reduction in the vertical high of the mandibular body in the left side. Surgical technique was realized by intra oral approach installing the ramus segment at first approach and the body segment as second to obtain stability in the fitting implant-bone-implant; the left side was treated using a guide for osteotomy; after 1-year follow-up no infection or complication was observed and facial symmetry was obtained. It is possible to conclude that the puzzle technique using polyetheretherketone can be applied to obtain predictable results in a simple strategy to solve a complex problem.