Endoscopically assisted Le Fort I osteotomy

Minimally invasive orthognathic surgery: a systematic review

Minimally invasive techniques are currently applied in many oral and maxillofacial surgical procedures, including orthognathic surgery. A systematic review on the application of potentially minimally invasive procedures in orthognathic surgery was performed to provide a clear overview of the relevant published data. Articles in English on minimally invasive orthognathic procedures, published in the scientific literature, were obtained from the PubMed, Embase, and Cochrane Library databases, and an additional manual search (revised 31 December 2016). After screening the abstracts and applying the eligibility criteria, 403 articles were identified. All articles reporting the potential for minimally invasive orthognathic surgery were included (n=44). The full papers were evaluated in detail and categorized as articles on a minimally invasive surgical approach (n=4), endoscopically assisted orthognathic procedures (n=17), or the use of a piezoelectric device in orthognathic surgery (n=25); two articles were each included in two categories. Although a small incision and minimal dissection is the basic principle of a minimally invasive technique, most articles (90.9%) reported the endoscope and piezoelectric instrument as important tools in minimally invasive orthognathic surgery. Evidence from available studies suggests that patients undergoing minimally invasive orthognathic surgery have less morbidity and make a faster recovery. Further research should aim to obtain higher levels of evidence.

Endoscopically-Assisted Zygomatic Implant Placement: A Novel Approach

BACKGROUND

Zygomatic implants (ZIs) have been proposed as a valid alternative to advance bone-grafting procedures in the rehabilitation of the severe atrophied upper maxilla, with a reported overall success rate of more than 95 %. Otherwise, the use of the endoscope has been described for the treatment of maxillofacial trauma, orthognatic surgical procedures, sinonasal pathology, salivary gland disease, and TMJ internal derangement. A careful identification of anatomical landmarks is of utmost importance while trying to avoid potential complications during the insertion of ZIs. Several approaches for ZI insertion have been reported, such as the classical approach; the sinus slot technique; and the exteriorized approach.

MATERIALS AND METHODS

The authors first introduce in the literature the endoscopically-assisted approach for the insertion of ZIs in the extremely severe atrophic maxilla.

RESULTS

Optimal results in terms of ZIs positioning with no damage to surrounding structures were obtained.

CONCLUSIONS

By means of this new technique the surgeon may minimize the risk of complications related to the damage of neighbouring anatomic structures, such as orbital disruption or infraorbitary nerve damage, while ensuring an adequate drill positioning and angulation for the placement of one or two implants into the zygomatic bone.

Removal of impacted mandibular third molars using an inward fragmentation technique (IFT) - Method and first results

PURPOSE

Conventional surgical extraction of impacted mandibular third molars (M3M) requires a lateral flap reflection in conjunction with lateral bone removal for outward mobilization of the tooth. The aim of this report is to outline a novel inward fragmentation technique (IFT) in conjunction with an occlusal miniflap approach to reduce the amount of bone removal to a minimum.

PATIENTS AND METHODS

Seventeen consecutive patients (7 men and 10 women; mean age 24.4 years, range 18-36 years) required the extraction of 21-impacted M3M with a close relationship to the inferior alveolar nerve (IAN). Occlusal miniflaps were used and only occlusal bone removal was performed to expose the M3M under endoscopic vision. A central space-making cavity was created followed by inward fragmentation and mobilization of the crown and subsequent root removal through the space created.

RESULTS

20 of 21 sites healed uneventfully, one late infection was observed, no permanent neurosensory lesion occurred. The mean preoperative buccal bone height was 15.5 (11-18) mm and the postoperative buccal bone height 14.7 (11-17) mm. On the 2nd day, the mean swelling level was 1.38 (0-2) on a 4 point scale, the pain level was 2.30 (0-5) on a 10 cm VAS, mean pain duration was 2.04 days.

CONCLUSION

An inward fragmentation technique allows preservation of >90% of the buccal bone height adjacent to mandibular third molars and may reduce postoperative morbidity without raising the risk of IAN lesions.

Delayed progressive haematoma after Le Fort I osteotomy: A possible severe complication in orthognatic surgery

Although the Le Fort I osteotomy is a safe surgical technique, many complications have been reported. We present a case of an extended cervico-facial haematoma due to delayed bleeding from the terminal branches of the maxillary artery after orthognatic surgery. A 23-year-old man was referred to our observation for the surgical correction of a class III asymmetric malocclusion. The patient underwent a Le Fort I osteotomy, with impaction of the maxilla, associated with an Epker mandibular bilateral sagittal split osteotomy, with maxillary advancement and rigid internal fixation of the mandible with four miniplates and another four for the upper maxilla as well. The first post-surgery day, the patient developed a gradual dispnea together with neck swelling. By second postoperative day, the patient's general condition improved with a progressive normalization of laboratory tests values. The Computerised Axial Tomography (CAT) scan confirmed a decrease in the parapharyngeal thickening. Total recovery was achieved within two months, the final clinical check showed a healthy appearance with good occlusion. An increased knowledge of the basic biology of the Le Fort I osteotomy, the development of instruments specially designed for the Le Fort I procedure and the use of hypotensive anaesthesia could reduce the morbidity and duration of this procedure.

Endoscopic assistance in the diagnosis and treatment of odontogenic maxillary sinus disease

PURPOSE

Endoscopic sinus surgery has become an increasingly popular treatment for most surgical cases of chronic sinusitis. However, in some cases, a modification of the classic Caldwell-Luc operation is unavoidable. The purpose of this paper is to present the outcome of 20 cases with pathology of the maxillary sinus which was approached endoscopically on diagnostic or interventional purpose. The primary indication for endoscopy for 11 cases was acute or chronic odontogenic sinusitis. For six cases, endoscopy was performed for removing a foreign body from the sinus cavity and for the remaining three cases, for diagnostic purpose only.

METHODS

A 4-mm rigid endoscope was used through the middle nasal meatus (eight cases) or via a puncture at the canine fossa (seven cases). A combined endoscopic approach was used in five cases. In three cases, endoscopy was combined with Caldwell-Luc technique. For the majority of the patients, the operation was performed under local anesthesia (16 cases).

RESULTS

The mean follow-up period was 9.1 months. No major complications were observed. One patient died 18 months after an endoscopically assisted detection of malignancy. Results were depended on the surgical procedure pursued and the underlying sinus pathology. Laborious surgery and chronic sinusitis gave the less satisfactory results.

CONCLUSIONS

Endoscopy of the maxillary sinus can be applied in a variety of indications. Alone or in combination with conventional surgery, it is a minimally invasive and highly diagnostic tool.

Endoscopically assisted Le Fort I osteotomy using an ultrasonic scalpel: a feasibility study in cadavers

PURPOSE

Drawbacks to conventional Le Fort I osteotomy include bleeding, infection, and relapse. The open approach predisposes itself to each of these complications through various means. We performed an endoscopically assisted Le Fort I osteotomy with an ultrasonic scalpel in cadavers to develop a new technique that minimizes such complications.

MATERIALS AND METHODS

Endoscopically assisted Le Fort I osteotomy was performed in 4 fresh adult human cadavers. Two 1-cm gingivobuccal sulcus incisions were used to approach the maxilla. Osteotomies were carried out with an ultrasonic scalpel from within the maxillary sinus under endoscopic visualization after a small antrostomy was made in its anterior wall. The external periosteal sleeve to the maxilla remained intact, eliminating the risk of massive hemorrhage and preserving bony vascularity. A stab incision was made with a 2-mm osteotome above the anterior nasal spine to separate the caudal septum from the Le Fort I segment. Pterygomaxillary disjunction was also performed with classic osteotomes. Disimpaction was completed with minor digital pressure inferiorly.

RESULTS

Each of the 4 Le Fort I osteotomies was complete, and mobility was checked by manual examination. There was a steep learning curve to the operation, but the final cadaveric dissection took 37 minutes to complete. At no time did the ultrasonic scalpel violate the maxillary periosteum as judged by postoperative direct examination.

DISCUSSION

This cadaveric study shows the feasibility of an endoscopically assisted Le Fort I osteotomy by use of an ultrasonic scalpel. Further experimental work combined with refinements in technique and equipment will help bring this advancement into clinical application.

Morbidity related to "endo-corticotomies" for transpalatal osteodistraction

INTRODUCTION

The objective of this study was to evaluate morbidity arising from transnasal, endoscopically assisted corticotomies for transpalatal osteodistraction. This minimally invasive technique utilizes three 1-cm incisions in the nasal vestibule instead of the classical, two lateral and one medial oral vestibule incisions of 2-3 cm and 1cm long, respectively.

MATERIAL AND METHODS

Fifty-nine patients (33 females and 26 males; age range: 9-50 years, mean 20 years) who underwent surgery in the hub hospital by the senior surgeon were included in a prospective registry. Patients with congenital maxillary hypoplasia were excluded. Difficulties were systematically recorded.

RESULTS

Mean operative time was 68 min (SD: 15 min) when no other procedures were combined with the transpalatal osteodistraction. Ten difficulties unrelated to either the device or oral hygiene were encountered: rhinorrhoea and minor nasal obstruction (1), nasal bleeding with hospital admission (1), periostitis at the piriform aperture that necessitated revision using local anaesthesia (1), periostitis with spontaneous healing (1), postoperative pain (2), dermatitis (1), infraorbital ecchymosis (1), excessive postoperative oedema (1), and prolonged cheek hyperaesthesia (1).

DISCUSSION AND CONCLUSION

Operative time as well as both percentage and nature of complications was similar to those experienced with "open-sky TPD" (transpalatal distraction), with less pronounced oedema and patient surgical threshold decreased.

Pterygomaxillary separation in Le Fort I osteotomy UK OMFS consultant questionnaire survey

Pterygomaxillary osteotomy or leverage alone is commonly used to achieve separation of the posterior maxilla from the pterygoid process in the Le Fort I osteotomy. An osteotomy of the tuberosity is less often used. No published data exist on the extent to which surgeons in the UK have adopted these techniques or on the incidence of technique-related vascular complications. We aimed to investigate techniques that are currently used for pterygomaxillary separation and maxillary mobilisation, and the incidence of serious vascular complications among orthognathic surgeons in the UK in 2004. A questionnaire was sent to 301 oral and maxillofacial (OMFS) consultant surgeons in the UK and 205 were returned (response rate 68%). Most of these surgeons (78%) reported that they use an osteotome or a micro-oscillating saw for pterygomaxillary separation. The others use leverage alone or osteotomy of the tuberosity. Eleven (8%) of the surgeons who use a pterygomaxillary osteotome reported that they had had a serious vascular complication in the past year. There were no vascular complications reported by surgeons who use leverage alone or osteotomy of the tuberosity.

Endoscopic Approaches to Maxillary Orthognathic Surgery

Endoscopically assisted surgery has become an essential component in many fields of surgical specialties. The implementation of this technique to craniofacial and maxillofacial surgery is a recent development. Endoscopic approach to subcondylar mandible fractures has been established as reliable surgical method.

[Comparative study of spatial imaging techniques in stereo-endoscopy]

PURPOSE

This study compares the two-dimensional presentation of stereo-endoscopic video data with three-dimensional presentation using polarization glasses and three-dimensional presentation with an autostereoscopic display. The aim of this study was to evaluate possible advantages of the three display technologies.

MATERIAL AND METHODS

Fifty-nine test persons untrained in endoscopy had to complete three endoscopic tasks with different levels of difficulty. Each test involved a new presentation method. Different measurements were noted such as speed of task completion, accuracy of task performance, and quantity of solved tasks. The data collected were statistically evaluated.

RESULTS

Neither sex, handedness, nor level of stereopsis had any statistically significant impact on the test results. The differences between the three presentation methods of stereo-endoscopic pictures were not statistically significant.

CONCLUSION

Similar results were achieved with all three presentation methods. None of the presentation methods was significantly superior in the values measured. A final assessment of the possibilities of spatial endoscopy should await future technological developments in endoscopic devices (e.g., picture acquisition).