Complete Reoperation in Orthognathic Surgery

A case series on a new reference in mandibular angles harmonization: the Frontozygomatic-Infraorbital Line (FZ-IOL)

the aim of this paper, is to propose a new reference line: the Frontozygomatic-Infraorbital Line (FZ-IOL). This reference line can guide the surgical team planning mandibular angle harmonization, based on the patient's skeletal proportion. The Frontozygomatic-Infraorbital Line has been adopted for symmetrization surgery, masculinization surgery, and in unsatisfactory results of previous orthognathic surgery. From March 2021 to December 2022, 3 patients were treated for severe facial asymmetry affecting mainly the lower third of the face. All cases were planned with the reference FZ-IOL. Patients were treated in the same center, at the Orthognathic Surgery Department of the Instituto Portugues da Face, Lisbon, Portugal. The Frontozygomatic-Infraorbital Line is designed virtually using software to reconstruct a 3D image from a digital imaging and communications in medicine (DICOM) file obtained from a cone beam computer tomography (CBCT). , connecting the two orbital rims. Then, a vertical line, the frontozygomatic line perpendicular to the IOL and passing through the outmost lateral portion of the frontozygomatic suture is drawn. The proposed line demonstrated how establishing appropriate reference lines is crucial for the success of the surgery. The selection of reference lines should be based on the patient's anatomy, the symmetrization process's complexity, and the surgery's desired outcome. The Frontozygomatic-Infraorbital Line represents an adequate reference line for managing mandibular angle lateral projection, improving lower third of the face symmetrization.

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

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

Average Three-Dimensional Skeletofacial Model as a Template for Bone Repositioning during Virtual Orthognathic Surgery

BACKGROUND

Virtual planning has revolutionized orthognathic surgery. This study presents a computer-assisted method for constructing average three-dimensional skeletofacial models that can be applied as templates for surgical planning for maxillomandibular repositioning.

METHODS

The authors used the images of 60 individuals (30 women and 30 men) who had never undergone orthognathic surgery to construct an average three-dimensional skeletofacial model for male participants and one for female participants. The authors validated the accuracy of the newly developed skeletofacial models by comparing their images with 30 surgical simulation images (ie, skulls) that had been created using three-dimensional cephalometric normative data. The comparison was conducted by superimposing surgical simulation images created using the authors' models with the previously created images to analyze their differences, particularly differences in the jawbone position.

RESULTS

For all participants, the authors compared the jaw position in the surgical simulation images created using the authors' average three-dimensional skeletofacial models with that in the images created using three-dimensional cephalometric normative data. The results revealed that the planned maxillary and mandibular positions were similar in both images and that the differences between all facial landmarks were less than 1 mm, except for one dental position. Most studies have reported less than 2 mm to be the success criterion for the distance difference between planned and outcome images; thus, the authors' data indicate high consistency between the images in terms of jawbone position.

CONCLUSION

The authors' average three-dimensional skeletofacial models provide an innovative template-assisted orthognathic surgery planning modality that can enhance the fully digital workflow for virtual orthognathic surgical planning.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Last 40 Years of Orthognathic Surgery: A Bibliometric Analysis

PURPOSE

Bibliometric analyses provide information on the effectiveness, performance, trends, and various other characteristics of research by using mathematical and statistical analysis methods for data related to scientific publications. This study aims to determine the focus of studies in the field of orthognathic surgery, map it, and present the results in a simplified manner through a comprehensive bibliometric analysis of the relevant literature.

METHODS

In this bibliometric analysis study, orthognathic surgery publications from 1980 to 2022 were retrieved from the Web of Science Core Collection database. The independent variables were co-citations, while the outcome variables included cross-country collaboration analysis, keyword analysis, co-citation analysis, and cluster analysis of the co-citation network. Covariates were the number of publications, number of citations, year range, centrality value, and silhouette value. The bibliometric analysis was conducted using CiteSpace, VOSviewer, and R-Studio software.

RESULTS

A total of 7,135 publications and 75,822 references were included in the analysis, and the annual growth rate of publications was 9.52%. The co-citation clustering analysis revealed that the orthognathic surgery literature was organized into 16 subject headings. Patient satisfaction was found to be the most widely published topic. The youngest clusters, representing new topics in the field, were virtual planning and examination of condylar changes after orthognathic surgery.

CONCLUSION

Bibliometric analysis methods were used to evaluate the 40-year history of the orthognathic surgery literature. The analysis identified the most influential publications, the topics in which the literature is divided, and hot spots in the field. By conducting similar bibliometric research studies in the future, the progress and future direction of the literature can be monitored based on evidence.

Causes of Reoperation Consultation and Clinical Review of Actual Reoperation After Previous Orthognathic Surgery

OBJECTIVE

To investigate the causes of reoperation consultation, and the actual percentage and procedures of reoperation after previous orthognathic surgery.

METHODS

The samples consisted of 30 patients who visited our clinic for reoperation consultation from October 2015 to September 2021 (6 males and 24 females; mean age at reoperation consultation, 28.4 y). Patient's causes of reoperation consultation were divided into "esthetic dissatisfaction," "airway changes," "temporomandibular disorders," "uncomfortable occlusion," and "other complications". In terms of esthetic dissatisfaction, the more detailed esthetic problem was evaluated by the clinical chart, facial photographs, and radiographs. In patients who actually underwent reoperation, the actual percentage and procedures of reoperation were investigated.

RESULTS

The most prevalent causes for reoperation consultation were "esthetic dissatisfaction" (n = 21, 70.0%), followed by "airway changes" (n = 11, 36.7%), "uncomfortable occlusion" (n = 8, 26.7%), "other complications" (n = 5, 16.7%), and "temporomandibular disorder" (n = 4, 13.3%). Less than half of patients actually underwent reoperation (n = 13, 43.3%). Actual reoperation procedures included minor revision surgery, reconstruction surgery, or complete reoperation according to the patient's need. In case of complete reoperation, more accurate and predictable results were obtained by using virtual surgical planning, customized surgical guides, titanium surgical plates made with computer-aided design and computer-aided manufacturing technique, and a 3-dimensional printing method.

CONCLUSION

It is important to communicate with patients about expectations for facial esthetic improvement by orthognathic surgery for obtaining the patient's postoperative satisfaction.

A retrospective analysis of redo orthognathic surgery: Underlying causes, strategy, and outcome

The aim of this study was to investigate the underlying causes of the need for redo orthognathic surgery, address surgical strategies, and evaluate postoperative outcomes. A retrospective chart review was conducted involving patients who underwent redo orthognathic surgery between January 2018 and April 2020. A total of 32 patients were included in this study. Prior to the procedures, patients' chief complaints were unfavorable facial profile, asymmetry, relapse, malocclusion, obstructive sleep apnea, and long face. To address these issues, we performed redo orthognathic surgery: this resulted in satisfactory aesthetic and functional outcomes in most cases. Considering the challenging nature of a redo orthognathic surgery, it is crucial for surgeons to accurately evaluate the patient's chief complaints and tailor individualized surgical plans to meet the patient's expectations.

Virtual Planning and 3D Printing in Contemporary Orthognathic Surgery

Orthognathic surgery is a powerful tool to improve facial balance, form, and function. Virtual planning and three-dimensional printing has improved our ability to visualize complex anatomy, consider various iterations and execute complex movements, and create accurate splints, plates, and cutting guides. This article will outline the distinct advantages of the use of virtual surgical planning over traditional planning, and it will explore the utility of computer-aided design and technology within contemporary orthognathic surgery, including its expanded applications and limitations.

Orthognathic correction and corticobasal implant-supported prostheses as a treatment modality for partial edentulism with mandibular prognathism: A case report and review of literature

Introduction

Mandibular prognathism manifests as elongation of the mandible in the anteroposterior direction, resulting in a sunken appearance of the middle third of the face and sad look of the eyes. It adversely affects esthetics, function, and oral health, reducing the patients' self-esteem. It therefore presents a significant challenge.

Presentation of case

A 23-year-old woman presented with prognathic features characterized by mandibular protrusion, maxillary retrusion, a prominent chin, and reduce self-esteem. Intraoral examination revealed multiple extracted teeth, severe fracture of the crown at 23, mobility of the fixed prosthesis on 13, 14, 15, and 16, a root stump of 18, and periodontally compromised teeth (31, 32, 33, 41, and 42).

A multidisciplinary team formulated the following treatment plan: stage 1, orthognathic osteotomy to retrude the mandible at 34 and 44; stage II, fabrication of transitional acrylic partial dentures; and stage III: fabrication of definitive corticobasal implant-supported prostheses. The patient was delighted with the treatment and complied with the oral hygiene instructions and follow-up program. After 7 years of function, the patient presented without complaints and exhibited significant improvement in oral health, self-esteem, and quality of life.

Discussion

The management of mandibular prognathism requires a multidisciplinary approach. The treatment implemented was considered the optimal option that aligned with the recommendations of several researchers to reduce facial disfigurement and rehabilitate the edentulous state.

Conclusion

The use of corticobasal implant-supported prostheses for the rehabilitation of patients with partial edentulism can significantly improve the treatment outcome following orthognathic surgery in cases with mandibular prognathism.

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Mandibular prognathism may adversely affect the patient’s esthetic and function and quality of life.

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Orthodontic surgery can improve the patient esthetic without replacing the missing dentition

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The patient was rehabilitated using corticobasal implant-supported prostheses.

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The esthetics, function, and oral hygiene improved significantly.

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This treatment modality enhances the patient’s self-esteem and improves the patient’s quality of life.

Current trends in orthognathic surgery

Orthognathic surgery has steadily evolved, gradually expanding its scope of application beyond its original purpose of simply correcting malocclusion and the facial profile. For instance, it is now used to treat obstructive sleep apnea and to achieve purely cosmetic outcomes. Recent developments in three-dimensional digital technology are being utilized throughout the entire process of orthognathic surgery, from establishing a surgical plan to printing the surgical splint. These processes have made it possible to perform more sophisticated surgery. The goal of this review article is to introduce current trends in the field of orthognathic surgery and controversies that are under active discussion. The role of a plastic surgeon is not limited to performing orthognathic surgery itself, but also encompasses deep involvement throughout the entire process, including the set-up of surgical occlusion and overall surgical planning. The authors summarize various aspects in the field of orthognathic surgery with the hope of providing helpful information both for plastic surgeons and orthodontists who are interested in orthognathic surgery.

Refining Orthognathic Surgery Results by Synchronous Cheek Fat Compartment Augmentation with Fat Grafting in Adult Females with Class III Skeletal Profiles

SUMMARY

Patients with maxillomandibular disharmony may present with a flat to concave midface. The effects of orthognathic surgery concomitant with midface fat grafting on facial appearance and midface volumetric and positional change have not formally been assessed to date. The authors' approach for synchronous orthognathic surgery and fat grafting is described and evaluated. Adult female patients (n = 20) who underwent synchronous two-jaw orthognathic surgery and cheek-specific fat grafting (1.9 ± 0.6 cm3 per side) for correction of skeletal class III deformity and anteromedial cheek deficiency were prospectively included. Preoperative and postoperative photographs were appraised by 42 blinded raters using facial appearance scales for beauty, attractiveness, and pleasantness parameters. The three-dimensional midface soft-tissue volume change and postoperative cheek mass position were computed. Facial imaging data from gender-, ethnic-, and facial pattern-matched adult patients (n = 20) who underwent isolated two-jaw orthognathic surgery (n = 20) were included for comparison. The three-dimensional facial norms database-derived cheek mass position information (2.19 ± 1.31mm) was also adopted for analysis. Patients treated with the synchronous procedure had significantly (p < 0.001) increased facial appearance-related perception change for beauty (2.9 ± 1.6), attractiveness (2.8 ± 1.8), and pleasantness (3.0 ± 1.5) parameters, three-dimensional midface volume change (1.8 ± 0.5 cm3), and postoperative cheek mass position (2.16 ± 0.47 mm) in comparison with those treated with the isolated procedure (2.0 ± 1.5, 1.9 ± 1.6, 2.3 ± 1.6, 0.6 ± 0.2 cm3, and 1.84 ± 0.43 mm, respectively). Healthy female individuals had similar and larger cheek mass position than patients treated with synchronous (p > 0.05) and isolated (p < 0.001) procedures, respectively. Synchronous orthognathic surgery and check-specific fat grafting resulted in superior enhancement of facial appearance and midface volume and position compared with isolated orthognathic surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Three-Dimensional Computer-Assisted Orthognathic Surgery: Traditional Hybrid Versus Full Digital Planning Models

PURPOSE

Three-dimensional (3D) computer-aided planning has truly revolutionized orthognathic surgery (OGS) treatment, but no study has compared the traditional hybrid and full 3D digital planning models. This study compared these virtual planning models in the treatment of asymmetric maxillomandibular disharmony.

METHODS

Young adult patients with an asymmetric skeletal class III deformity who underwent 3D computer-aided 2-jaw OGS using hybrid (alginate dental impression, 2D cephalometric tracings, manual-guided stone model surgery, occlusion setup, and splint fabrication; n = 30) or full digital (laser-scanned dentition, 3D cephalometric tracings, virtual-based occlusion setup and surgery, and computer-generated surgical splint; n = 30) planning models were consecutively recruited. Preoperative and postoperative 3D cephalometric analyses (dental relation, skeletal assessments based on sagittal and frontal views, and soft tissue evaluations) were adopted for intragroup and intergroup comparisons. Postoperative patient-perceived satisfaction with facial appearance was also recorded.

RESULTS

Both hybrid and full digital planning groups had significant (all P < 0.05) improvements after surgery with respect to facial convexity, incisor overjet, and frontal symmetry parameters. The full 3D digital planning-based OGS treatment had similar (all P > 0.05) 3D cephalometric-derived outcomes (preoperative, postoperative, and treatment-induced change data) and patient-perceived outcomes compared with the traditional hybrid 3D planning method.

CONCLUSIONS

For the decision-making process in selecting the planning model, multidisciplinary teams could consider additional parameters such as patient comfort, storage needs, convenience for data reuse, overall planning time, availability, and costs.

Comparison of Orthognathic Surgery Outcomes Between Patients With and Without Underlying High-Risk Conditions: A Multidisciplinary Team-Based Approach and Practical Guidelines

Orthognathic surgery (OGS) has been successfully adopted for managing a wide spectrum of skeletofacial deformities, but patients with underlying conditions have not been treated using OGS because of the relatively high risk of surgical anesthetic procedure-related complications. This study compared the OGS outcomes of patients with and without underlying high-risk conditions, which were managed using a comprehensive, multidisciplinary team-based OGS approach with condition-specific practical perioperative care guidelines. Data of surgical anesthetic outcomes (intraoperative blood loss, operative duration, need for prolonged intubation, reintubation, admission to an intensive care unit, length of hospital stay, and complications), facial esthetic outcomes (professional panel assessment), and patient-reported outcomes (FACE-Q social function, psychological well-being, and satisfaction with decision scales) of consecutive patients with underlying high-risk conditions (n = 30) treated between 2004 and 2017 were retrospectively collected. Patients without these underlying conditions (n = 30) treated during the same period were randomly selected for comparison. FACE-Q reports of 50 ethnicity-, sex-, and age-matched healthy individuals were obtained. The OGS-treated patients with and without underlying high-risk conditions differed significantly in their American Society of Anesthesiologists Physical Status (ASA-PS) classification (p < 0.05), Charlson comorbidity scores, and Elixhauser comorbidity scores. The two groups presented similar outcomes (all p > 0.05) for all assessed outcome parameters, except for intraoperative blood loss (p < 0.001; 974.3 ± 592.7 mL vs. 657.6 ± 355.0 mL). Comparisons with healthy individuals revealed no significant differences (p > 0.05). The patients with underlying high-risk conditions treated using a multidisciplinary team-based OGS approach and the patients without the conditions had similar OGS-related outcomes.

The outcome of skeletofacial reconstruction with mandibular rotation for management of asymmetric skeletal class III deformity: A three-dimensional computer-assisted investigation

The mandibular proximal ramus segments should be moved and rotated during orthognathic surgery-based skeletofacial reconstruction for the correction of challenging patients with facial asymmetry and malocclusion, but quantitative data regarding this rotation were not sufficient to date. This 3D computer-assisted study measured the proximal ramus segment rotation after 3D simulation-guided two-jaw surgery in patients with facial asymmetric deformity and class III malocclusion (n = 31). Using 3D mandible models and a reliable proximal ramus segment-related plane, angular changes in pitch, roll and yaw directions were measured before and one month after surgery. Significant rotational changes (p < 0.01) were observed in the left and right sides and overall proximal ramus segments after surgery, with absolute differences of 4.1 ± 3.0 (range −7.8 to 6.9), 2.8 ± 2.3 (−8.8 to 5.0), and 2.7 ± 2.4 (−6.6 to 9.9) degrees in pitch, roll, and yaw rotations, respectively. Numbness and mouth opening limiting occurred within the first 6 months after surgery but the patients had an unremarkable long-term postoperative course, with no revisionary surgery required. This study contributes to the multidisciplinary-related literature by revealing that proximal ramus segment rotation and rigid fixation with no postoperative intermaxillary immobilization was practicable in skeletofacial surgery for the successful treatment of asymmetric deformity and class III malocclusion.

[Secondary surgeries for facial osteotomies: 10 cases]

Orthognathic surgery, now well known to the general public, is becoming increasingly successful. It is the most predictable approach to the treatment of dento-maxillo-facial deformities. As with plastic surgery the number of indications increasing the number of difficult cases follows as well as the searching for perfection. The aim of these treatments must be triple and take into account the functional elements of the face, the dental occlusion and the aesthetic objectives of the patient and therapists. Orthognathic surgery procedures having become quite bearable patients who feel that the result is not up to their requirement easily require a reoperation to achieve their objective. PATIENTS AND METHODS: We studied 10 cases of facial redone osteotomies from 4 different surgeons. We looked at the initial indication, the type of surgery, the initial orofacial functions, the delay of the reoperation, the technique of redo and the result. RESULTS AND DISCUSSION: Like other authors, we found that there are surgeries and at-risk patients. The patients who were re-operated all had at least one of the three negative factors: OSAS, lingual dysfunction, oral ventilation. We have not been able to highlight an overall frequency of surgical resumption in the studied literature which is poor about reoperations after osteotomies of the face.