Challenges of computer-assisted orthognathic surgery in clinical application / 口腔疾病防治

@#After years of development, the advantages of computer-assisted orthognathic surgery have been widely recognized. However, the clinical application of this technology is challenging. Each step may generate errors from data acquisition, computer-assisted diagnosis, and computer-assisted surgical design, causing errors to be transferred from the virtual surgical plan to the operation. The accumulation and amplification of errors will affect the final surgical effect. Currently, digital devices, such as intraoral scanners, are being explored for error control, utilizing automation methods and algorithms, and implementing personalized bone positioning methods. Moreover, there are still many problems that have not been fully resolved, such as precise simulation of postoperative soft tissue, functional assessment of mandibular movement, and absorbable internal fixation materials. Fully understanding computer-assisted orthognathic surgery's limitations could provide direction for optimizing existing methods while helping clinicians avoid risks and maximize its advantages to achieve the best outcome. Many emerging and cutting-edge technologies, such as personalized titanium plates, artificial intelligence, and surgical robots, will further promote the development of this discipline. We can expect future optimization of digital orthognathic surgical technology by innovations in automation, intelligence, and personalization.

Relationship between bite force, occlusal contact area, and three-dimensional facial soft tissue in dentofacial deformities

ABSTRACT Purpose This study aimed to investigate three-dimensional facial soft tissue dimensions, maximum bite force (MBF), and occlusal contact area in patients with DFD. In addition, we analyzed the relationship between MBF and the three-dimensional facial measurements. Methods Thirty-two patients with skeletal Class III DFD and 20 patients with Class II DFD underwent a soft tissue evaluation using surface laser scanning, as well as MBF and occlusal contact area assessments. The DFD groups were compared with each other and with 25 healthy subjects. Results Significant morphological differences were found in the transversal, vertical, and anteroposterior dimensions between Class II DFD and Class III DFD. Both DFD groups presented an increased linear distance of chin height, which was strongly related with decreased MBF magnitude. The DFD groups exhibited lower MBF and occlusal contact area, with no significant differences between Class II and Class III DFD. Conclusion The presence of DFD affected 3D measurements of facial soft tissue, causing variations beyond normal limits, lower MBF, and occlusal contact area in both Class II and Class III DFD patients. The vertical dimension might have influenced the lower MBF magnitude in the studied skeletal deformities.

O uso do planejamento virtual na cirurgia ortognática / The use of virtual planning in orthognathic surgery

Introdução: A cirurgia ortognática envolve manipulação da arquitetura óssea facial, através de osteotomias, para restaurar a forma e a função, corrigindo a má oclusão, as desproporções maxilomandibulares e assimetrias faciais. O planejamento virtual em cirurgia ortognática é realizado com ajuda de softwares que utilizam as medidas reais do esqueleto craniofacial e registros da oclusão do paciente, através de uma análise 3D. Método: Foram avaliados 18 pacientes com deformidades dentofaciais, de acordo com a classificação de Angle submetidos a cirurgia ortognática com o uso do planejamento virtual, entre 2018 e 2019. Os critérios de inclusão foram pacientes entre 16 e 60 anos com desproporções maxilo-mandibulares nas quais o tratamento ortodôntico isolado não era suficiente. Os critérios de exclusão foram a presença de lesões císticas ou tumorais nos maxilares e comorbidades clínicas que contraindicavam a cirurgia. O planejamento virtual foi realizado em todos os pacientes, utilizando o software Dolphin® Imaging 11 e os guias cirúrgicos confeccionados em impressora 3D. Resultados: O guia cirúrgico intermediário apresentou adaptação perfeita nas faces oclusais promovendo grande estabilidade para o reposicionamento e fixação da maxila na oclusão intermediária. Os 18 pacientes operados responderam como "totalmente satisfeitos" em relação ao resultado estético-funcional nessa série estudada. Foi encontrada uma semelhança muito grande da posição do esqueleto maxilofacial no planejamento virtual préoperatório e o obtido no pós-operatório, através da avaliação das telerradiografias. Conclusão: O planejamento virtual em cirurgia craniomaxilofacial possui inúmeras vantagens, como diminuição do tempo laboratorial pré-operatório, maior precisão na confecção dos guias cirúrgicos e melhor reprodutibilidade dos resultados simulados.

Introduction: Orthognathic surgery involves the manipulation of facial bone architecture through osteotomies to restore form and function, correcting malocclusion, maxillomandibular disproportions, and facial asymmetries. Virtual planning in orthognathic surgery is carried out with the help of software that uses real measurements of the craniofacial skeleton and records of the patient's occlusion through 3D analysis. Method: 18 patients with dentofacial deformities were evaluated, according to Angle's classification, who underwent orthognathic surgery using virtual planning between 2018 and 2019. The inclusion criteria were patients between 16 and 60 years old with maxylo-mandibular disproportions in which orthodontic treatment alone was not sufficient. Exclusion criteria were the presence of cystic or tumoral lesions in the jaw and clinical comorbidities that contraindicated surgery. Virtual planning was carried out on all patients, using Dolphin® Imaging 11 software and surgical guides made with a 3D printer. Results: The intermediate surgical guide presented perfect adaptation on the occlusal surfaces, promoting great stability for the repositioning and fixation of the maxilla in intermediate occlusion. The 18 operated patients responded as "completely satisfied" in relation to the aesthetic-functional result in this series studied. A very great similarity was found between the position of the maxillofacial skeleton in the preoperative virtual planning and that obtained post-operatively through the evaluation of teleradiography. Conclusion: Virtual planning in craniomaxillofacial surgery has numerous advantages, such as reduced pre-operative laboratory time, greater precision in the creation of surgical guides, and better reproducibility of simulated results.

Anatomical Conditions in Simultaneous Orthognathic Surgery and Structural Rhinoplasty. A Clinical Series / Condiciones Anatómicas en Cirugía Ortognática y Rinoplastia Estructural Simultanea. Una Seria Clínica

SUMMARY: Orthognathic surgery and rhinoplasty show synergy in terms of function and aesthetic results. The aim of this research is to analyze variables related to simultaneous orthognathic surgery and rhinoplasty and to discuss the surgical sequence. Male and female subjects between 18 and 45 years old were included in this research. Diagnosis related to nasal morphology (nasal tip bifid, rotate, square and others as well as the alae morphology and columella), facial deformity (sagittal and vertical deformity), type of surgery (rhinoplasty techniques and orthognathic techniques) and complications were included. The minimum follow-up was 12 months; Chi- Square and t test were used to define correlations, considering a value of p<0.05 for statistical significance. Class III facial deformity was observed in 40 % of subjects and class II facial deformity was present in 43 %. For the nasal deformities, the tip and nasal bridge were most prevalent; primary nasal deformity was observed in the 83 % of subjects and was significant more than secondary nasal deformity (p=0.042). Bimaxillary surgery was performed in 31 cases (88 %). In 10 cases a change of the original plan for rhinoplasty due to previous maxillary surgery was realized, mainly in class III facial deformity, with no statistical differences. Revision rhinoplasty was realized in 5 cases (14 %) and was not related to surgical variables; revision for orthognathic surgery was not necessary in this series. Rhinoplasty and orthognathic surgery simultaneously show low complications and predictable results. We can conclude that maxillary mandibular osteotomies and rhinoplasty could be performed safely. However, larger studies are necessary to understand the best choice and variables involved in simultaneous procedures and soft tissue response.

La cirugía ortognática y la rinoplastia muestran sinergia en términos de resultados funcionales y estéticos. EL objetivo de esta investigación es analizar variables relacionadas con la cirugía ortognática y rinoplastia ejecutada de forma simultanea. Fueron incluidos hombres y mujeres entre 18 y 45 años de edad. EL diagnóstico fue en base a la morfología nasal (punta bífida, rotada, cuadrada u otras así como alteraciones del ala nasal y columela), deformidad facial (deformidad sagital y vertical), tipo de cirugía (técnica de rinoplastia y cirugía ortognática) y complicaciones asociadas. El seguimiento mínimo fue de 12 meses; se utilizo las prueba t test y chi cuadrado para definir relaciones estadísticas considerando un valor de p< 0,05 para obtener diferencias significativas. La deformidad clase III fue observada en el 40 % de los sujetos y la deformidad facial de clase II se presento en el 43 %. Para la deformidad nasal, las alteraciones de a punta nasal y nasal fueron mas prevalentes; la deformidad nasal primaria se presentó en el 83 % de los sujetos y fue significativamente mayor que la deformidad nasal secundaria (p=0,042). La cirugía bimaxilar se realizó en 31 casos (88 %); en 10 casos se realizó el cambio del plan quirúrgico inicial de la rinoplastia debido a cambios generados en la cirugía maxilar previa, mayormente en deformidad facial de clase III, sin presentar diferencias significativas. La rinoplastia de revisión fue realizada en 5 casos (14 %) y no fue relacionada con ninguna variable de tipo quirúrgica; la revisión de cirugía ortognática no fue realizada en ningún caso de esta serie. La rinoplastia y la cirugía ortognática simultanea mostraron bajas complicaciones y resultados predecibles. Se puede concluir que la osteotomía maxilo mandibular y la rinoplastia son seguras; sin embargo, estudios de mayor volumen son necesarios para entender la mejor opción y variables relacionadas con procedimientos simultáneos y la respuesta de tejidos blandos faciales.

Avaliação da fixação dos avanços maxilares pela técnica de osteotomia Le Fort I / Evaluación de la fijación de avances maxilar mediante la técnica de osteotomía Le Fort I / Evaluation of the fixation of maxillary advancements by the Le Fort I osteotomy technique

Introdução: A osteotomia Le Fort I possibilita a correção de deformidades dentofaciais que envolvem o terço médio da face. Para sua fixação, convencionou-se o emprego de quatro mini-placas nos pilares zigomático-maxilar e nasomaxilar. Propôs-se então, a dispensa da fixação do segmento posterior, surgindo questionamentos relacionados à capacidade biomecânica do sistema. Objetivos: Comparar o estresse biomecânico gerado em três meios distintos de fixação da osteotomia Le Fort I frente ao movimento de avanço sagital linear maxilar de 7mm. Metodologia: Trata-se de uma pesquisa experimental laboratorial, utilizando-se da análise de elementos finitos como ferramenta analítica, a fim de constatar qual das técnicas sofrerá maior estresse biomecânico. Resultados: Constatou-se que o estresse biomecânico gerado é maior quando aplicado em 4 pontos do que quando aplicado em apenas 2 pontos. Conclusão: Os resultados obtidos fornecem informações aos cirurgiões sobre a real necessidade do uso de fixação adicional de acordo com o método de fixação planejado. No entanto, deve ser interpretado de forma cautelosa, considerando-se as limitações deste estudo. Sendo assim, uma análise incipiente, que tem como intuito o fornecimento de evidência científica de grande significância.

Introducción: La osteotomía Le Fort I permite la corrección de deformidades dentofaciales que involucran el tercio medio de la cara. Para su fijación se acordó utilizar cuatro miniplacas en los pilares cigomaticomaxilar y nasomaxilar. Entonces se propuso prescindir de la fijación del segmento posterior, planteando interrogantes relacionados con la capacidad biomecánica del sistema. Objetivos: Comparar el estrés biomecánico generado en tres medios diferentes de fijación de la osteotomía Le Fort I frente a un movimiento de avance sagital lineal maxilar de 7mm. Metodología: Se trata de una investigación experimental de laboratorio, utilizando como herramienta analítica el análisis de elementos finitos, con el fin de comprobar cuál de las técnicas sufrirá un mayor estrés biomecánico. Resultados: Se encontró que el estrés biomecánico generado es mayor cuando se aplica en 4 puntos que cuando se aplica solo en 2 puntos. Conclusión: Los resultados obtenidos brindan información a los cirujanos sobre la necesidad real de utilizar fijación adicional de acuerdo al método de fijación planificado. Sin embargo, debe interpretarse con cautela, considerando las limitaciones de este estudio. Por tanto, un análisis incipiente, que pretende aportar evidencias científicas de gran trascendencia.

Introduction: The Le Fort I osteotomy allows the correction of dentofacial deformities involving the middle third of the face. For its fixation, it was agreed to use four mini plates on the zygomaticomaxillary and nasomaxillary pillars. It was then proposed to dispense with the fixation of the posterior segment, raising questions related to the biomechanical capacity of the system. Objectives: To compare the biomechanical stress generated in three different means of fixation of the Le Fort I osteotomy against a 7mm maxillary linear sagittal advancement movement. Methodology: This is an experimental laboratory research, using finite element analysis as an analytical tool, in order to verify which of the techniques will suffer greater biomechanical stress. Results: It was found that the biomechanical stress generated is greater when applied to 4 points than when applied to only 2 points. Conclusion: The results obtained provide information to surgeons about the real need to use additional fixation according to the planned fixation method. However, it should be interpreted with caution, considering the limitations of this study. Therefore, an incipient analysis, which aims to provide scientific evidence of great significance.

Tratamento orto-cirúrgico de mordida aberta anterior: um relato de caso / Ortho-surgical treatment of anterior open bite: a case report / Tratamiento ortoquirúrgico de la mordida abierta anterior: reporte de un caso

Objetivo: discorrer sobre um caso clínico de mordida aberta anterior com uma abordagem de tratamento orto-cirúrgica. Relato de caso: Paciente, leucoderma, sexo feminino, 21 anos, ASA 1, buscou tratamento cirúrgico, após a recomendação do ortodontista. Esta já havia realizado tratamento ortodôntico no período de dois anos, mas sem alcançar resultados satisfatórios. Ao exame clínico, se concluiu uma ausência de assimetria facial significativa e uma paciente face longa. Além de um padrão esquelético classe II, com uma bi-protusão dos incisivos caracterizando uma mordida aberta anterior, no qual, posteriormente foi solicitada a cirurgia para a correção da deformidade dentofacial e maloclusão. Conclusão: Em síntese, após todo o tratamento orto-cirúrgico houve uma melhora significativa da oclusão da paciente, com o posterior ganho da sua autoconfiança e estética facial e, consequentemente, o reestabelecimento da sua função mastigatória, respiratória e fonação.

Objective: discuss a clinical case of anterior open bite with an ortho surgical treatment approach. Case report: Patient, Caucasian, female, 21 years old, ASA 1, sought surgical treatment after orthodontist recommendation. The patient already went through orthodontic treatment for two years, not achieving satisfactory results. On clinical examination, there was an absence of significant facial asymmetry and a long-face. In addition to a class II skeletal pattern, with a bi-protrusion of the incisors characterizing an anterior open bite, in which surgery was later requested to correct the dentofacial deformity and malocclusion. Conclusion: In summary, after ortho-surgical treatment, there was a significant improvement in the patient's occlusion, with substantial increase of her self-confidence and facial aesthetics and consequently, the reestablishment of patient's masticatory, respiratory and phonation function.

Objetivo: discutir un caso clínico de mordida abierta anterior con abordaje de tratamiento ortoquirúrgico. Reporte de caso: Paciente, caucásica, sexo femenino, 21 años, ASA 1, buscó tratamiento quirúrgico, por recomendación del ortodoncista. Ya se había sometido a un tratamiento de ortodoncia durante dos años, pero sin lograr resultados satisfactorios. En el examen clínico, había ausencia de asimetría facial significativa y una cara alargada. Además de un patrón esquelético clase II, con biprotrusión de los incisivos caracterizando una mordida abierta anterior, en la que, posteriormente, se solicitó cirugía para corregir la deformidad dentofacial y maloclusión. Conclusión: En resumen, después de todo el tratamiento ortoquirúrgico, hubo una mejoría signifi cativa en la oclusión de la paciente, con la consiguiente ganancia en su confi anza en sí misma, en su estética facial y en consecuencia, el restablecimiento de su función masticatoria, respiratoria y fonatoria.

Effect of Bimaxillary Orthognathic Surgery on Pharyngeal Airway Volume / Efecto de Cirugía Ortognática Bimaxilar en el Volumen de la Vía Aérea Faríngea

SUMMARY: Subjects with maxillary skeletal classes II and III not only express alterations in the hard and soft maxillofacial tissues, but also in the morphology and dimensions of the upper airway. A small space in the upper airway has been associated with sleep disorders, such as snoring and mainly obstructive sleep apnea/hypopnea syndrome (OSAHS). Consequently, interest has increased due to the influence of orthognathic surgery in the airway space. Although there are studies in the literature that have compared upper airway spaces, most have evaluated the changes using two-dimensional images, mainly lateral skull X-rays. The present study aimed to determine the airway volume in subjects with skeletal classes II and III who underwent bimaxillary orthognathic surgery. 80 CBCT exams from 40 subjects obtained before and 6 months after surgery were used. There were 20 class II and 20 class III subjects. For the volumetric analysis, a 3D rendering of the upper airway was made in previously established segments, and then the airway volume was calculated using the 3D Slicer® software version 4.11 (Slicer, USA). The statistical analysis by t-test of related samples revealed statistically significant volumetric increases in the nasopharynx, laryngopharynx, and total volume in class II patients. However, in class III patients, there were significant increases in the nasopharynx and total volume, while the volume was maintained in the oropharynx and laryngopharynx.

Sujetos con clases esqueletales II y III maxilares, no solamente expresan alteraciones en los tejidos duros y blandos maxilofaciales, sino también en la morfología y dimensiones de la vía aérea superior. Un espacio reducido a nivel de la vía aérea superior se asocia a trastornos del sueño como ronquidos y principalmente el síndrome de apnea/hipoapnea obstructiva del sueño (AOS); debido a esto, ha aumentado el interés por la influencia de la cirugía ortognática en el espacio de la vía aérea. Si bien existen en la literatura estudios que han comparado los espacios de la vía aérea superior, la mayoría de los estudios han evaluado los cambios utilizando imágenes bidimensionales, principalmente radiografías laterales de cráneo. El objetivo del presente estudio fue determinar el volumen de la vía aérea en sujetos con clases esqueletales II y III sometidos a cirugía ortognática bimaxilar. Se utilizaron 80 exámenes CBCT pertenecientes a 40 sujetos obtenidos previo a la cirugía y 6 meses después de realizada. Veinte sujetos clase II y 20 clase III. Para el análisis volumétrico se realizó un renderizado 3D de la vía área superior en segmentos previamente establecidos y posteriormente se calculó el volumen de dicha vía aérea con la utilización del software 3D Slicer ®versión 4.11 (Slicer, USA). El análisis estadístico realizado por t-test de muestras relacionadas, arrojó en pacientes clase II aumentos volumétricos estadísticamente significativos en nasofaringe, laringofaringe y volumen total. Mientras que en pacientes clase III, se observó aumentos significativos en Nasofaringe y volumen total y mantención de volumen en orofaringe y laringofaringe.

Plication of the Suprahyoid Muscles Concomitant with Genioplasty to Improve the Aesthetics of the Submandibular Region / Plicatura de los Músculos Suprahioideos Concomitante con Genioplastia para Mejorar la Estética de la Región Submandibular

In addition to functionally correcting skeletal facial deformities, orthognathic surgery also has a great impact on aesthetics and facial proportions. However, patients who have soft tissue changes, such as tissue flaccidity, may not achieve an ideal result, and require complementary surgical techniques that promote aesthetic refinement. The literature on less invasive techniques is limited, and therefore, this work aims to report a surgical technique performed concomitantly with genioplasty to refine the harmony of the submandibular region, in a simple and effective way. Patient with skeletal class II deformity, with lack of mandibular definition and submandibular flaccidity, underwent bimaxillary advancement orthognathic surgery with advancement genioplasty to correct chin retrusion. Due to limited results with bone repositioning alone, plication of the suprahyoid musculature was performed in association with the same approach used in the genioplasty. As a result, there was traction in the cervical region, with a consequent decrease in the submental-cervical angle and improvement in submandibular aesthetics. Furthermore, there was no need for extensive surgical intervention and no impairment of the functional results of the orthognathic surgery itself. Therefore, it can be concluded that plication of the suprahyoid musculat ure concomitantly with genioplasty is a technique that promotes aesthetic gains in the cervical region.

Además de corregir funcionalmente las deformidades faciales esqueléticas, la cirugía ortognática también tiene un gran impacto en la estética y las proporciones faciales. Sin embargo, los pacientes que tienen cambios en los tejidos blandos, como la flacidez, pueden no lograr un resultado ideal y requieren técnicas quirúrgicas complementarias que promuevan el refinamiento estético. La literatura sobre técnicas menos invasivas es limitada, por lo que este trabajo tiene como objetivo reportar una técnica quirúrgica realizada concomitantemente con la genioplastia para refinar la armonía de la región submandibular, de manera simple y efectiva. Se trató a un paciente con deformidad esquelética clase II, con falta de definición mandibular y flacidez submandibular, intervenida de cirugía ortognática de avance bimaxilar con genioplastia de avance para corregir la retrusión del mentón. Debido a los resultados limitados solo con el reposicionamiento óseo, se realizó la plicatura de la musculatura suprahioidea en asociación con el mismo abordaje utilizado en la genioplastia. Como resultado, hubo tracción en la región cervical, con la consiguiente disminución del ángulo submentoniano-cervical y mejoría en la estética submandibular. Además, no hubo necesidad de una intervención quirúrgica extensa ni deterioro de los resultados funcionales de la cirugía ortognática en sí. Por lo tanto, se puede concluir que la plicatura de la musculatura suprahioidea concomitantemente con la genioplastia es una técnica que promueve ganancias estéticas en la región cervical.

Comparação da fragilidade gerada por 3 diferentes osteotomias sagitais de mandíbula: estudo in vitro / Comparison of fragility generated by 3 different sagittal mandible osteotomies: in vitro study / Comparación de la fragilidad generada por 3 osteotomías mandibulares sagitales diferentes: estudio in vitro

A osteotomia sagital bilateral de mandíbula (OSBM) foi publicada por Trauner e Obwegeser em 1957, desde então sofreu várias modificações a fim de diminuir as complicações e tornar o procedimento mais simples e previsível. Sendo assim objetivo do presente trabalho foi avaliar e comparar a fragilidade causada na mandíbula por 3 tipos de OSBM. Para isso, foram realizadas as osteotomias propostas por Trauner e Obwegeser modificada por Hunsuck e Epker (I), a de Sant'Ana (II) e de Wolford (III), em 24 hemimandibulas de poliuretano e foi realizado o ensaio mecânico para gerar a fratura sagital. Os dados foram coletados e tabulados, e obteve como resultado que, a maior quantidade de força máxima aplicada foi observada no grupo III, e a menor quantidade no grupo II; com relação à deflexão, apresentou significância estatística entre o grupo II e grupo III; com relação à rigidez, a maior média, foi encontrada no grupo I. Sendo assim, foi possível concluir que dentro deste modelo de estudo a osteotomia II foi capaz de gerar maior fragilidade à hemimandibula de poliuretano com menor quantidade de força. As OBMD dos grupos I e a III também apresentaram ótimos resultados, entretanto necessitaram mais força para alcançar a fratura... (AU)

The bilateral sagittal split osteotomy of the mandible (BSSO) was published by Trauner and Obwegeser in 1957, since then it has undergone several modifications in order to reduce complications and make the procedure simpler and more predictable. Therefore, the objective of this study was to evaluate and compare the fragility caused in the mandible by 3 types of BSSO. For this, the osteotomies proposed by Trauner and Obwegeser modified by Hunsuck and Epker (I), Sant'Ana (II) and Wolford (III) were performed on 24 polyuretha ne hemimandibles, a mechanical test to generate the sagittal fracture. Data were collected and tabulated, and the result was that, the highest amount of maximum force applied was observed in group III, and the lowest amount in group II; with regard to deflection, it was statistically significant between group II and group III; with regard to stiffness, the highest average was found in group I. Therefore, it was possible to conclude that within this study model, osteotomy II was able to generate greater fragility to the polyurethane hemimandible with less force. The BSSO of the groups I and III also showed excelent results, however they required more force to reach the fracture... (AU)

La osteotomía sagital bilateral de la mandíbula (OSBM) fue publicada por Trauner y Obwegeser en 1957, desde entonces ha sufrido varias modificaciones con el fin de reducir las complicaciones y hacer el procedimiento más simple y predecible. Por lo tanto, el objetivo de este estudio fue evaluar y comparar la fragilidad causada en la mandíbula por 3 tipos de OSBM. Para eso, se realizaron las osteotomías propuestas por Trauner y Obwegeser modificadas por Hunsuck y Epker (I), Sant'Ana (II) y Wolford (III) en 24 hemimandíbulas de poliuretano y se realizó un ensayo mecánico para generar la fractura sagital. Los datos fueron recolectados y tabulados, obteniendo como resultado que, la mayor cantidad de fuerza máxima aplicada se observó en el grupo III, y la menor cantidad en el grupo II; en cuanto a la deflexión, fue estadísticamente significativa entre el grupo II y el grupo III; en cuanto a la rigidez, la media más alta se encontró en el grupo I. Por lo tanto, se pudo concluir que, dentro de este modelo de estudio, la osteotomía II logró generar mayor fragilidad a la hemimandíbula de poliuretano con menor fuerza. El OSBM de los grupos I y III también mostró excelentes resultados, pero requirieron mayor fuerza para llegar a la fractura... (AU)

Evidence gaps in orthognathic surgery, a Delphi study protocol

Aim: To assess the research gaps identified in a recent mapping review of orthognathic surgery through their evaluation by clinical experts, leading to a clinically relevant list of research gaps. This will guide future investigations of the topic, focusing on the outcomes of blood loss, infection, and relapse. Methods: The Delphi technique will be used to appraise the identified research gaps. The expert panel will include maxillofacial surgeons who regularly perform orthognathic surgery. Potential participants will be identified through various methods, including contact information from articles in the mapping review, nominations from peers, and social media platforms. Two rounds of surveys will be undertaken with Likert-type and open-ended questions to assess the clinical relevance of research gaps. For the second round, participants will receive a report of the results of the first round. Questions will be modified depending on the answers obtained in the first round. A consensus of 60% will be considered valid. Conclusions: Through this Delphi study, in a collaborative effort between researchers and clinical experts, a comprehensive understanding of the clinical relevance of research gaps in orthognathic surgery will be achieved. The outcomes will guide future investigations, ultimately improving the outcomes and practices in this field.

Fatores importantes da cirurgia mandibular minimamente invasiva: técnica, instrumentos e implantes / Important factors of minimally invasive mandibular surgery: technique, instruments and implants / Factores importantes de la cirugía mandibular mínimamente invasiva: técnica, instrumentos e implantes

O tratamento das deformidades faciais passou por algumas modificações nessas últimas décadas empregando princípios da cirurgia minimamente invasiva na osteotomia maxilar e mandibular. A utilização de diferentes formatos de osteotomia tem por objetivo um melhor contorno, preenchimento e simetria da região de ângulo e corpo mandibular, e além disso, permitir menor edema e parestesia em comparação a técnica clássica. Nesse relato de caso e revisão integrativa temos por objetivo apresentar uma modificação ao procedimento convencional, bem como sua aplicabilidade e execução... (AU)

The treatment of facial deformities has undergone some changes in recent decades employing principles of minimally invasive surgery in maxillary and mandibular osteotomy. The use of different osteotomy formats aims a better contour, filling and symmetry of the mandibular angle and body region, and in addition to this, allowing less edema and paresthesia compared to the classic technique. In this case report and integrative review, we aim to present a modification to the conventional procedure, as well as its applicability and execution... (AU)

El tratamiento de las deformidades faciales ha sufrido algunos cambios en las últimas décadas utilizando principios de cirugía mínimamente invasiva en osteotomía maxilar y mandibular. El uso de diferentes formatos de osteotomía tiene como objetivo proporcionar un mejor contorno, relleno y simetría del ángulo mandibular y de la región corporal, y además, permitir un menor edema y parestesia en comparación con la técnica clásica. En este reporte de caso y revisión integrativa pretendemos presentar una modificación al procedimiento convencional, así como su aplicabilidad y ejecución... (AU)

Localização topográfica da emergência do condóito nasolagrimal medido em tomografia como reparação anatômica para procedimentos de cirurgia maxilofacial / Topographic location of the nasolagrimal conduit emergence measured on ct scans as an anatomical repair for maxillofacial surgery procedures / Ubicación topográfica de la emergencia del conducto nasolagrimal medida en tomografías como reparo anatómico para procedimientos de cirugía maxilofacial

Contexto: Na cirurgia maxilofacial existem procedimentos que envolvem o ducto nasolacrimal, pelo que esta medida é um ponto de referência para evitar a sua lesão. Artigos anteriores tomam como referência o fenótipo anglo-saxão e não a população latino-americana, o que é uma grande limitação quando se extrapola para a cirurgia maxilofacial. Objetivo: Medir a distância do ducto nasolacrimal às estruturas anatômicas adjacentes em uma amostra de tomografias computadorizadas do Hospital Universitário San Ignacio em Bogotá, Colômbia, em 2021. Métodos: Foi realizado um estudo observacional retrospetivo com base em tomografias computadorizadas do HUSI. Foi utilizada uma amostragem não probabilística, na qual foram identificadas 150 tomografias computadorizadas. Informações sobre sexo, idade e distância do ducto nasolacrimal em milímetros foram coletadas em um banco de dados em planilha Excel, tendo como marcos anatômicos o entalhe piriforme, o forame infraorbitário e o assoalho da fossa nasal em cortes axiais, sagitais e coronais. Resultados: A análise das medidas mostrou que nenhuma das distribuições de medidas se comportou de forma diferente da distribuição normal. Em relação à comparação das medidas por sexo, a idade foi semelhante entre homens e mulheres, enquanto nas comparações por idade foram evidenciadas diferenças significativas. Conclusão: Os resultados são consistentes com os dados publicados em estudos anteriores. Em termos de distribuição por sexo, o comprimento do ducto nasolacrimal é maior nos homens do que nas mulheres, e a distribuição por idade indica que, à medida que a idade aumenta, a distância do ducto a estas estruturas diminui... (AU)

Background: In maxillofacial surgery there are procedures that involve the nasolacrimal duct, so this measure is a reference point to avoid its injury. Previous articles take as reference the Anglo-Saxon phenotype and not the Latin American population, which is a great limitation when extrapolating it to maxillofacial surgical procedures. Objective: To measure the distance of the nasolacrimal duct to adjacent anatomical structures in a sample of CT scans from the Hospital Universitario San Ignacio in Bogotá- Colombia in 2021. Methods: A retrospective observational study was performed based on CT scans from HUSI. A non-probabilistic sampling was used in which 150 CT scans were identified. Information on sex, age and distance of the nasolacrimal duct in millimeters was collected in an Excel spreadsheet database, taking as anatomical landmarks the piriform notch, the infraorbital foramen and the floor of the nasal fossa in axial, sagittal and coronal sections. Results: The analysis of the measurements showed that none of the measurement distributions had a behavior different from the normal distribution. In relation to the comparison of the measurements by sex, age was similar in men and women, while significant differences were evidenced in the comparisons by age. Conclusion: The results coincide with the data published in previous studies. Regarding the distribution by sex, the length of the nasolacrimal duct is greater in men than in women, and the distribution by age indicates that as age increases the distance of the duct to these structures decreases... (AU)

Antecedentes: En cirugía maxilofacial existen procedimientos que involucran el conducto nasolagrimal, por lo cual esta medida es un punto de referencia para evitar su lesión. Artículos previos toman como referencia el fenotipo anglosajón y no la población Latinoamericana, lo cual supone una gran limitante al extrapolarlo a intervenciones quirúrgicas maxilofaciales. Objetivo: Medir la distancia del conducto nasolagrimal a estructuras anatómicas adyacentes en una muestra de tomografías del Hospital Universitario San Ignacio en BogotáColombia en 2021. Métodos: Se realizó un estudio observacional retrospectivo basado en tomografías del HUSI. Se utilizó un muestreo no probabilístico en el que se identificaron 150 tomografías. En una base de datos en hoja de cálculo en Excel se recolectó información sobre sexo, edad y distancia del conducto nasolagrimal en milímetros, teniendo como reparo anatómico la escotadura piriforme, el agujero infraorbitario y el piso de la fosa nasal en los cortes axial, sagital y coronal. Resultados: El análisis de las mediciones realizadas mostró que ninguna de las distribuciones de medición tuvo un comportamiento distinto a la distribución normal. En relación con la comparación de las medidas por sexo la edad fue similar en los hombres y mujeres, mientras que se evidenciaron diferencias significativas en las comparaciones por edad. Conclusión: Los resultados coinciden con los datos publicados en estudios previos. En cuanto a la distribución por sexo, la longitud del conducto nasolagrimal es mayor en hombres que en mujeres, y la distribución por edad indica que conforme aumenta la edad la distancia del conducto a estas estructuras disminuye... (AU)

Manejo multiprofissional na Cirurgia Ortognática minimamente invasiva / Multidisciplinary Management in Orthognathic Surgery minimally invasive / Manejo Multidisciplinario en Cirugía Ortognática mínimamente invasiva

O manejo multiprofissional na Cirurgia Ortognática minimamente invasiva envolve a colaboração de diversos profissionais para proporcionar uma abordagem abrangente e personalizada ao paciente e consequentemente uma recuperação pós-operatória mais célere. A integração eficiente dos profissionais assegura uma abordagem holística "princípio da cirurgia segura", maximizando os resultados e a experiência do paciente durante todas as fases da Cirúrgia Ortognática minimamente invasiva... (AU)

Multidisciplinary management in minimally invasive Orthognathic Surgery involves the collaboration of several professionals to provide a comprehensive and personalized approach to the patient and consequently a faster postoperative recovery. The efficient integration of professionals ensures a holistic "safe surgery principle" approach, maximizing results and patient experience throughout all phases of minimally invasive Orthognathic Surgery... (AU)

El manejo multidisciplinar en Cirugía Ortognática mínimamente invasiva implica la colaboración de varios profesionales para proporcionar un abordaje integral y personalizado del paciente y en consecuencia una recuperación postoperatoria más rápida. La integración eficiente de profesionales garantiza un enfoque holístico del "principio de cirugía segura", maximizando los resultados y la experiencia del paciente en todas las fases de la cirugía ortognática mínimamente invasiva... (AU)

Avanços na Cirurgia Ortognática Minimamente Invasiva / Advances in Minimally Invasive Orthognathic Surgery

Entrevista com o Dr. Jonathas Claus, especialista em Técnicas Inovadoras e perspectivas futuras na Odontologia Maxilofacial.

Manejo quirúrgico de bad split bilateral en cirugía ortognática / Surgical management of bilateral bad split during orthognathic surgery

El bad split es un término clínico que refiere a una fractura no planificada que ocurre al momento de realizar una osteotomía sagital de rama mandibular (OSRM). Afecta aproximadamente al 2,3% de los pacientes y se han descrito factores de riesgo tales como la presencia de terceros molares mandibulares, edad avanzada al momento de la cirugía, técnica de osteotomía inadecuada, entre otros. Se recomienda efectuar manio-bras preventivas para evitar la aparición de patrones de fractura no deseados al realizar la OSRM. Sin embargo, al momento de pesquisar un bad split, éste debe ser tratado por un equipo capacitado y de manera oportuna para evitar retardo en la consolidación, infecciones y secuestros óseos que puedan comprometer los resultados de la cirugía. En este artículo se presenta el manejo de un caso clínico de bad split bilateral intraoperatorio por el Servicio de Cirugía Maxilofacial del Hospital San José, enfatizando su tratamiento quirúrgico.

Bad Split is a clinical term referring to an unplanned fracture that occurs during the bilateral sagittal split osteotomy (BSSO). It affects approximately 2,3% of the patients undergoing orthognathic surgery and several risk factors have been described such as the presence of mandibular third molars, advanced age at the moment of orthognathic surgery, inadequate osteotomy technique, etc. Preventive maneuvers are recommended in order to avoid the appearance of undesired fracture patterns during BSSO. However, if a bad split is detected it must be managed and treated by a qualified team to avoid further complications such as delayed bone consolidation, bone infection and necrosis. In this article we present the management of a case of bilateral bad split by the Maxillofacial Surgery Service of Hospital San José, emphasizing on its surgical treatment.

Uso de Sistema Vivostat® como hemoderivado sellador de abordajes en cirugía ortognática y reconstrucciones de los maxilares, reporte de 23 casos / Use of the Vivostat® system as a sealing blood product for approaches in orthognathic surgery and maxillary reconstructions, report of 23 cases

El presente trabajo tiene como propósito presentar 23 casos operados en distintas prácticas privadas, donde se utilizaron adhesivos de fibrina para: cirugía ortognática bimaxilar, expansión palatina rápida asistida quirúrgicamente (SARPE), y reconstrucciones de rebordes atróficos maxilares y mandibulares empleando injertos e implantes. El uso del adhesivo de fibrina del sistema Vivostat® permitió no solo sellar los abordajes quirúrgicos, sino también fue un excelente complemento en estas cirugías para la cobertura de la mucosa de fosas nasales y mucosa antral que se dañan durante las osteotomías y accesos quirúrgicos. Junto con adquirir ventajas, como variabilidad de factores de crecimiento y protección de los injertos subyacentes en las regiones operadas, se obtienen asimismo una posible disminución de la incidencia en los sangramientos postoperatorios, principalmente epistaxis; con lo cual se brinda al paciente una mejor recuperación en el postoperatorio y evita la posibilidad de dehiscencias y, o aperturas de heridas operatorias con exposición de injertos y de elementos de osteosíntesis subyacentes.

The purpose of this paper is to present 23 operative cases in different private practices, where fibrin adhesives were used for: bimaxillary orthognathic surgery, surgically assisted rapid palatal expansion (SARPE), and maxillary and mandibular atrophic ridge reconstructions using grafts and implants. The use of the fibrin adhesive of the Vivostat® system allowed not only sealing the surgical approaches, but was also an excellent complement in these surgeries for covering the mucosa of the nasal passages and antral mucosa that are damaged during osteotomies and surgical accesses. Along with acquiring advantages, as well as growth factors and protection of the underlying grafts in the operated regions, a possible decrease in the incidence of postoperative bleeding was obtained, mainly epistaxis; with which the patient is given a better recovery in the postoperative period and avoids the possibility of dehiscences and/or openings of surgical wounds with exposure of grafts and underlying osteosynthesis elements.

Volumetric Evaluation of the Upper Airways in Relation to the Gonial Angle / Avaliação Volumétrica das Vias Aéreas Superiores com Relação ao Ângulo Goníaco

The upper airspace is essential to understand the physiology and pathogenesis of its obstruction, complementary exams based on images have been used to evaluate the upper airspace. The objective of this study was to evaluate, by means of computed tomography, the upper airways (UAS), in relation to anatomical variables, emphasizing the gonial angle and comparing it with volume in mm³, sex and age. A total of 124 computed tomography scans were analyzed using DICOM files (digital image communication in medicine) made available by a radiology clinic using the ITK-snap program (version 3.6.0), upper airway volumes, sex, age and gonial angle values on both the right and left sides were tabulated in a table in the Excel 2010 program of the Microsoft Office 2010 package, and subsequently analyzed in the SPSS software with statistical analysis using the Levene Test and also the ANOVA test, to obtain of the results. The values found for the gonial angle did not indicate a significant difference. However, the present work confirms that within each of these groups there is a homogeneity of variances, corroborating the results reported in the literature. However, regarding the volume of the upper airways, we found that in men and in individuals aged over 34 years, the volume is greater.(AU)

O espaço aéreo superior é essencial para compreender a fisiologia e a patogênese de sua obstrução, exames complementares baseados em imagens têm sido empregados para avaliar o espaço aéreo superior. O objetivo desse estudo foi avaliar por meio de tomografia computadorizada, as vias aéreas superiores (VAS), com relação a variáveis anatômicas, dando ênfase ao ângulo goníaco e comparando com volume em mm³, sexo e idade. Foram analisados 124 exames de tomográfica computadorizada, por meio dos arquivos DICOM (comunicação de imagens digitais em medicina) disponibilizados por uma clínica radiológica, através do programa ITK-snap (versão 3.6.0), os volumes das vias aéreas superiores, o sexo, a idade e os valores do ângulo goníaco tanto do lado direito como do lado esquerdo foram tabulados em tabela no programa Excel 2010 do pacote Microsoft Office 2010, e analisados posteriormente no software SPSS com análise estatística pelo Teste de Levene e também teste ANOVA, para obtenção dos resultados. Os valores encontrados para o ângulo goníaco não indicaram diferença significativa. Contudo, o presente trabalho confirma que dentro de cada um desses grupos há uma homogeneidade das variâncias e corroborando com os resultados relatados na literatura. No entanto com relação ao volume das vias aéreas superiores encontramos que em homens e em indivíduos com idade superior a 34 anos o volume é superior.(AU)

Soft tissue changes in midfacial healthy and affected sides of unilateral cleft lip and palate patients after orthognathic surgery / 中华医学美学美容杂志

Objective:To investigate the alterations in soft tissue morphology and thickness in the mid-face region of patients with cleft lip and palate (UCLP) secondary to maxillofacial deformity following Le Fort I osteotomy.Methods:A total of 22 patients (16 males and 6 females aged from 17 to 28 years with an average of 20 years) diagnosed with cleft lip and palate secondary to maxillofacial deformity were collected from the Wuhan University Hospital of Stomatology from July 2012 to August 2020. All patients underwent Le Fort I osteotomy. CBCT scans were obtained at T0 (3 days before surgery), T1 (7 days after surgery), and T2 (1 year after surgery). The Dolphin11.95 software and 3D Slicer software were utilized to measure and analyze the soft tissue near the mid-face osteotomy line. Differences in soft tissue thickness before and after surgery were compared.Results:Before and after the operation, the soft tissue thickness at P3, P5, P6, and P8 on the affected side was thicker than that on the healthy side, and the difference was statistically significant, with a P-value of <0.05. At P5, P6, P7, P8, and P9 below the osteotomy line at T2-T0, the degree of postoperative thinning on the affected side was more apparent than that on the healthy side, and there was statistical significance at P6 ( P<0.05). The postoperative soft tissue asymmetry in the Ck region was improved compared with the preoperative one. The preoperative average protruding of the affected side was 0.63 compared with the healthy side, and the postoperative value was 0.17. The preoperative and postoperative Mann-Whitney U tests showed significantly statistical difference. Conclusions:After Le Fort I osteotomy, the facial asymmetry of patients with unilateral cleft lip and palate secondary to maxillofacial deformity is improved. However, there is still a difference in the soft tissue thickness between the healthy side and the affected side, and the change in soft tissue thickness on the affected side is more significant than that on the healthy side.

Application and development of orthognathic surgery in treatment of syndromic craniosynostosis / 中国修复重建外科杂志

OBJECTIVE@#To summarize the application and recent development of orthognathic surgery in treating syndromic craniosynostosis.@*METHODS@#The related literature at home and abroad in recent years was extensively reviewed, and the indications, routine procedures, and protocols of orthognathic surgery in the treatment of syndromic craniosynostosis were summarized and analyzed.@*RESULTS@#Craniosynostosis is a common congenital craniofacial malformation. Syndromic craniosynostosis usually involves premature fusion of multiple cranial sutures and is associated with other deformities. Orthognathic surgery is the necessary and effective means to improve the midfacial hypoplasia and malocclusion. Le Fort I osteotomy combined with sagittal split ramus osteotomy are the common surgical options. Orthognathic surgery should combine with craniofacial surgery and neurosurgery, and a comprehensive long-term evaluation should be conducted to determine the best treatment plan.@*CONCLUSION@#Orthognathic surgery plays an important role in the comprehensive diagnosis and treatment of syndromic craniosynostosis. The development of digital technology will further promote the application and development of orthognathic surgery in the treatment of syndromic craniosynostosis.

From "Empirical Surgery" to "Precision Surgery": establishment and clinical application of precision orthognathic surgery system / 华西口腔医学杂志

Orthognathic surgery, which involve osteotomy and repositioning of the maxillomandibular complex, has recently emerged as a crucial method of correcting dentofacial deformities. The optimal placement of the maxillomandibular complex holds utmost significance during orthognathic surgery because it directly affects the surgical outcome. To accurately achieve the ideal position of the maxillomandibular complex, with the rapid advancements in digital surgery and 3D-printing technology, orthognathic surgery has entered an era of "Precision Surgery" from the pervious "Empirical Surgery." This article provides comprehensive insights into our extensive research and exploration of the treatment modality known as "precision orthognathic surgery" over the years. We also present the technical system and application in"Ortho+X" treatment modality to offer valuable references and assistance to our colleagues in the field.