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.

Distracción osteogénica del tercio medio facial. Reporte de dos casos clínicos / Distraction osteogenesis of the midface. Two clinical cases report

La corrección quirúrgica de grandes asimetrías faciales son un desafío para el equipo quirúrgico. En dichos casos, los resultados de la corrección utilizando técnicas quirúrgicas convencionales son limitados, lo que hace necesario la utilización de otras herramientas terapéuticas. La distracción ósea (DO) es una de ellas, pues permite el estiramiento controlado del callo óseo previamente creado mediante osteotomías. La DO permite realizar cambios en el posicionamiento óseo de gran envergadura, favoreciendo el crecimiento óseo como mecanismo de acción. El objetivo de este artículo es describir los resultados quirúrgicos de DO intraoral del tercio medio facial utilizado en dos pacientes con severas asimetrías faciales asociadas a malformaciones de origen genético. Se relata el diagnóstico, la planificación, las herramientas tecnológicas utilizadas, técnica quirúrgica y los resultados obtenidos.

Surgical correction of major facial asymmetries is a challenge for the surgical team. In such cases, treatment results from conventional surgical techniques are limited, which requires using other therapeutic tools. Bone distraction is one of them, as it allows controlled stretching of the bone callus previously developed through osteotomies. Distraction osteogenesis allows making changes in large bone positioning, favoring bone growth as an action mechanism. This article aims to describe the surgical results of intraoral distraction osteogenesis of the midface used in two patients with severe facial asymmetries related to congenital malformations. Diagnosis, planning, technological tools, surgical techniques, and results obtained are explained.

Concepts, protocol, variations and current trends in surgery first orthognathic approach: a literature review

ABSTRACT In the current era of expedited orthodontics, among many clinicians, tertiary care hospitals and patients, surgery first orthognathic approach (SFOA) has gained popularity. The advantages of SFOA (face first approach) are the reduced overall treatment duration and the early improvement in facial esthetics. In SFOA, the absence of a presurgical phase allows surgery to be performed first, followed by comprehensive orthodontic treatment to achieve the desired occlusion. The basic concepts of surgery early, surgery last, SFOA and Sendai SFOA technique along with its variations are reviewed in the present article. The recent advancement in SFOA in the context of preoperative preparation, surgical procedures and post-surgical orthodontics with pertinent literature survey are also discussed.

RESUMO Na presente era da Ortodontia de resultados acelerados, a cirurgia ortognática com benefício antecipado (COBA) ganhou popularidade entre muitos clínicos, hospitais terciários e pacientes. A vantagem da COBA é a redução da duração total do tratamento, juntamente com a melhora precoce da estética facial. Na COBA, a ausência de uma fase pré-cirúrgica permite que a cirurgia seja realizada antes e, só então, venha o tratamento ortodôntico abrangente para se alcançar a oclusão desejada. Os conceitos básicos de cirurgia primeiro, cirurgia por último, COBA e a técnica COBA de Sendai, bem como suas variações, são aqui revistos. Também são discutidos no presente artigo, junto com a revisão da literatura pertinente, os recentes avanços da COBA no contexto do preparo pré-cirúrgico, dos procedimentos cirúrgicos e da Ortodontia pós-cirúrgica.

Soft tissue changes after anterior maxillary osteotomy by using 3D CBCT scanning / Cambios en los tejidos blandos después de la osteotomía maxilar anterior mediante el uso de la exploración 3D CBCT

The objective of this study was to evaluate the soft tissue changes after anterior maxillary osteotomy using cone beam computed tomography. The study included twelve patients diagnosed as suffering from an excess of the anterior part of maxilla and required surgical correction by anterior maxillary osteotomy. Assessment of Cone beam computed tomography in evaluation the soft tissue changes. All cases subjected to anterior maxillary osteotomy using modified Cuper technique. Follow up of cases was does clinically and radio- graphically by cone beam computed tomography. The results of the study proved that the statistically significant increase in mean Nasolabial angle after 6 months was 5.2 degrees, the mean value of nasal width after 6 months was 0,9mm. The mean value of Philtrum length was 3.3mm. In conclusion, Cone Beam Computed Tomography can be used to obtain dimensionally accurate linear and angular measurement from bony maxillofacial structure and landmarks and allows accurate, three-dimensional imaging of hard and soft tissues

El objetivo de este estudio fue evaluar los cambios en los tejidos blandos después de la osteotomía maxilar anterior mediante tomografía computarizada con haz cónico. El estudio incluyó a doce pacientes diagnosticados que sufrían un exceso de la parte anterior del maxilar y requirió corrección quirúrgica mediante osteotomía maxilar anterior. Evaluación de la tomografía computarizada del haz cónico en la evaluación de los cambios de tejidos blandos. Todos los casos sometidos a osteotomía maxilar anterior con la técnica de Cuper modificada. El seguimiento de los casos se realizó de forma clínica y radiográfica mediante tomografía computarizada de haz cónico. Los resultados del estudio demostraron que el aumento estadísticamente significativo en el ángulo Nasolabial medio después de 6 meses fue de 5,2 grados, el valor medio del ancho nasal después de 6 meses fue de 0,9mm. El valor medio de la longitud de Philtrum fue de 3,3mm. En conclusión, la tomografía computarizada Cone Beam se puede utilizar para obtener mediciones lineales y angulares dimensionales precisas a partir de la estructura ósea maxilofacial ósea y permite obtener imágenes precisas y tridimensionales de los tejidos duros y blandos

Abordagem cirúrgica do hiperteleorbitismo na displasia craniofrontonasal / Surgical approach of hypertelorbitism in craniofrontonasal dysplasia

RESUMO Objetivo: apresentar nossa experiência no tratamento cirúrgico do hiperteleorbitismo na displasia craniofrontonasal. Métodos: análise retrospectiva dos pacientes com displasia craniofrontonasal operados por orbital box osteotomy ou por bipartição facial entre os anos de 1997 e 2015. Informações sobre as intervenções cirúrgicas foram obtidas dos prontuários médicos, exames complementares, fotografias e entrevistas clínicas. Os resultados cirúrgicos foram classificados com base na necessidade de cirurgia adicional, e a recidiva orbital foi calculada. Resultados: sete pacientes do sexo feminino foram incluídas, três submetidas à orbital box osteotomy (42,86%) e quatro (57,14%) à bipartição facial. Houve uma recidiva orbital média de 3,71±3,73mm. A média global dos resultados cirúrgicos de acordo com a necessidade de novas cirurgias foi de 2,43±0,53. Conclusão: a abordagem cirúrgica do hiperteleorbitismo na displasia craniofrontonasal deve ser individualizada, respeitando, sempre que possível, a idade e as preferências dos pacientes, seus familiares e cirurgiões.

ABSTRACT Objective: to present our experience in the hypertelorbitism surgical treatment in craniofrontonasal dysplasia. Methods: retrospective analysis of craniofrontonasal dysplasia patients operated through orbital box osteotomy or facial bipartition between 1997 and 2015. Surgical data was obtained from medical records, complementary tests, photographs, and clinical interviews. Surgical results were classified based on the need for additional surgery and orbital relapse was calculated. Results: seven female patients were included, of whom three (42.86%) underwent orbital box osteotomy and four (57.14%) underwent facial bipartition. There was orbital relapse in average of 3.71±3,73mm. Surgical result according to the need for further surgery was 2.43±0.53. Conclusion: surgical approach to hypertelorbitism in craniofrontonasal dysplasia should be individualized, respecting the age at surgery and preferences of patients, parents, and surgeons.

Avanço maxilomandibular na Síndrome da Apneia Obstrutiva do Sono / Maxillomandibular advancement in the Obstructive Sleep Apnea Syndrome

A Síndrome da Apneia Obstrutiva do Sono (SAOS) é uma doença com alto índice de morbidade e mortalidade, que compromete 5% da população mundial, sendo 9% dos homens e 4% das mulheres da idade adulta. O avanço maxilomandibular (AMM) tem sido indicado como tratamento cirúrgico da doença nas formas moderada e grave. O objetivo deste estudo é descrever um relato de caso de um paciente 33 anos, gênero feminino, Classe II de Angle. Ao exame polissonográfico, foi constatada a ocorrência de 47 apneias/ hora de sono, e, na radiografia cefalométrica de perfil, observou se um estreitamento das vias áreas superiores. Foi realizado AMM e mentoplastia para aumentar o volume das vias aéreas. A paciente evoluiu com redução acentuada dos sintomas e consequente melhoria em sua qualidade de vida. Atualmente, o AMM é a opção cirúrgica mais bem sucedida para o tratamento da SAOS de moderada a grave... (AU)

Obstructive Sleep Apnea Syndrome (OSAS) is a disease with high morbidity and mortality, which commits 5% of the world population and 9% of men and 4% of women in adulthood. The maxilomandibular advancement (AMM) has been indicated as surgical treatment in moderate and severe forms. The aim of this study is to describe a case report of a patient 33 years old, female, Angle Class II. In polysomnography examination, it was found the occurrence of 47 apneas per hour during sleep and lateral cephalometric radiograph was observed a narrowing of the upper airway. It was performed AMM and genioplasty to increase the volume of the airways. The patient progressed with a significant reduction of symptoms and consequent improvement in their quality of life. Currently, the maxilomandibular advancement is the most successful surgical option for the treatment of moderate to severe OSAS... (AU)

Comparison of soft‑tissue changes in simultaneous maxillomandibular distraction with mandibular distraction with second‑stage maxillary osteotomy.

Background: The purpose of this study was to compare the frontal lip cant changes in common facial asymmetry (FA) cases after simultaneous maxillomandibular distraction osteogenesis (DO) and mandibular DO with maxillary orthognathic surgery. Materials and Methods: Retrospective analysis of FA cases at tertiary craniofacial referral was performed. Patients of either gender with all medical imaging records and pre‑ and post‑operative (1 year) facial photographs in natural head position were included in the study. The lip cant change was assessed by the ratio of the linear dimension between affected and unaffected side labial commissures and the bi‑pupillary reference line. Difference between the pre‑ and post‑operative ratio was analyzed. Statistical analysis was performed for the outcome. P ≤0.05 was taken as significant. Results: The mean preoperative measured value of the affected side was 0.845 ± 0.036 while the postoperative value was 0.95 ± 0.032. The effective change was 0.11 ± 0.044. The postoperative ratio compared with simultaneous DO case was 0.98 ± 0.06 while that of mandibular distraction with orthognathic surgery was 0.92 ± 0.08 (P = 0.048). The mean change of the simultaneous DO case was measured as 0.114 ± 0.041 while the same for the mandibular distraction with orthognathic surgery was 0.069 ± 0.035 (P = 0.013). Discussion and Conclusion: The results indicate that the simultaneous DO yields more better frontal lip cant change between both halves than the mono‑DO with orthognathic surgery. The mean change is much higher in the simultaneous DO cases indicating a more effective correction and desired result. The biological reason and lip musculature mechanism behind the response in both conditions are discussed.

Why segment the maxilla between laterals and canines?

Introduction: Maxillary surgery on a bone segment enables movement in the sagittal and vertical planes. When performed on multiple segments, it further provides movement in the transverse plane. Typical sites for interdental osteotomies are between laterals and canines, premolars and canines, or between incisors. Additionally, osteotomies can be bilateral, unilateral or asymmetric. The ability to control intercanine width, buccolingual angulation of incisors, and correct Bolton discrepancy are some of the advantages of maxillary segmentation between laterals and canines. Objective: This article describes important features to be considered in making a clinical decision to segment the maxilla between laterals and canines when treating a dentoskeletal deformity. It further discusses the history of this surgical approach, the indications for its clinical use, the technique used to implement it, as well as its advantages, disadvantages, complications and stability. It is therefore hoped that this paper will contribute to disseminate information on this topic, which will inform the decision-making process of those professionals who wish to make use of this procedure in their clinical practice. Conclusions: Segmental maxillary osteotomy between laterals and canines is a versatile technique with several indications. Furthermore, it offers a host of advantages compared with single-piece osteotomy, or between canines and premolars.

Introdução: a cirurgia de maxila em um segmento ósseo possibilita sua movimentação nos planos sagital e vertical. Quando realizada em múltiplos segmentos, contempla também o plano transversal. A localização das osteotomias interdentárias pode ser: entre incisivos laterais e caninos, entre pré-molares e caninos, ou entre os incisivos centrais - podendo ser bilateral, unilateral ou assimétrica. A possibilidade de controle da distância intercaninos, da angulação vestibulolingual dos incisivos e da correção da discrepância de Bolton é uma das vantagens da segmentação da maxila entre incisivos laterais e caninos. Objetivo: o presente artigo descreve aspectos importantes, no tratamento das deformidades dentoesqueletais, a serem considerados na decisão clínica de segmentar-se a maxila entre os incisivos laterais e os caninos. Serão discutidas, também, a história dessa abordagem cirúrgica, as indicações para seu emprego clínico, a técnica para sua utilização, bem como suas vantagens, desvantagens, complicações e estabilidade. Desse modo, espera-se contribuir para o aumento das informações disponíveis sobre o assunto, subsidiando a decisão dos profissionais que queiram considerar o uso dessa técnica em suas atividades clínicas. Conclusão: a osteotomia segmentar de maxila entre os incisivos laterais e os caninos corresponde a uma técnica versátil com diversos tipos de indicações, e apresenta uma série de vantagens, quando comparada com as osteotomias em um segmento ou entre caninos e pré-molares.

Midfacial measurement using occlusal maxillary CT and surgical implications of maxillary osteotomies

Reconstructions of Binder's Syndrome with Various Surgical Techniques: Photogrammetric Analysis of Nasomaxillary Bone

Binder's syndrome has some characteristic signs, such as orbital hypotelorism, shortened and flat noses, diminutive columella, crescent shaped nostrils, acute nasolabial angle, convex upper lip, class III malocclusion, absent anterior nasal spine, and maxillary hypoplasia. Binder's syndrome patients usually need the correction of the following three: the hypoplatic nose, the perialar flatness due to underdevelopment of the piriform margin, and the hypoplastic maxilla with its malocclusion. The authors treated eleven(n=14) patients through various surgical techniques depending on the clinical signs. In order to correct the nasomaxillary hypoplasia, the autogenous bones, the autogenous cartilages and the alloplastic implants were used. In three patients with severe nasomaxillary retrusion, the combined Le Fort I and II osteotomies and the perinasal osteotomy were performed. The results were analyzed using the proportion indices from the preoperative and postoperative lateral photographs of the patients. The postoperative values of all the proportion indices were significantly higher compared to the preoperative ones. For nasal dorsal augmentation, columellar lengthening and peripiriform augmentation, autogenous bone grafts were found to be very effective. The use of high-density porous polyethylene sheets for columellar lengthening was preferred over the use of nasal septal cartilages. Two types of osteotomy were the most effective for nasomaxillary augmentation in severe deformity.

A clinico-statistical study of soft tissue changes of upper lip & nose following Le Fort I maxillary movement

TOPOGRAPHY AND MORPHOMETRY OF THE STRUCTURES OF THE PTERYGOPALATINE FOSSA IN KOREANS

Maxillary osteotomy(LeFort I, II, III) is a commonly performed maxillary surgical procedure for the correction of dentofacial deformities. Maxillary osteotomy necessitate seperation of the skeleton of the middle third of the face from its posterior attachments to the cranium. With conventional techniques, an osteotome is placed between the maxilla and pterygoid plates and tapped medially and anteriorly to separate the pterygomaxillary junction. To separate the pterygomaxillary junction safely, knowledge on the anatomical structures of the pterygopalatine fossa area is very important to surgeons. So, to clarify the anatomical structures as it relates to the surgical approach of the pterygomaxillary junction area, Korean skulls (male 110 sides, female 44 sides) were used. And 30 sides of Korean hemisectioned heads were dissected to study about the anatomical and surgical structures of the pterygopalatine fossa area. Suggestions are given regarding the prevention of the complication during the maxillary osteotomy. Results of the studies indicate that with regard to the course of the maxillary artery and the morphology of the pterygomaxillary junction, pterygomaxillary dysjunction would be safely done with pterygomaxillary osteotome of 15mm width in Koreans. And osteotomy should be angled inferiorly from the zygomaticomaxillary crest. This will minimize the risk of the damaging the pterygopalatine fossa area because the mean distance form the inferior border of the pterygomaxillary junction to the furcation of the descending palatine artery was 24.8mm.