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.

Perioperative management and complication control of Le Fort Ⅲ osteotomy in children with syndromic craniosynostosis / 中华口腔医学杂志

Objective: To summarize the preliminary efficacy, perioperative management and complications of Le Fort Ⅲ osteotomy and midface distraction in patients with syndromic craniosynostosis by retrospective analysis, and to provide clinical experience for reference. Methods: From October 2017 to January 2020, 20 patients with syndromic craniosynostosis underwent Le Fort Ⅲ osteotomy and distraction in The Department of Oral and Maxillofacial Surgery of Peking University International Hospital, including 11 males and 9 females, were involved. The median age was 7 years (1.5 to 15 years). Preoperative risk prevention plan was put forward by multidisciplinary evaluation, and preoperative intervention was carried out. The diagnostic data of SNA, airway volume, polysomnography (PSG), ophthalmology and occlusal relationship were obtained through specialized examination, and osteotomy and distraction surgical plan was formulated through virtual surgical planning. CT was taken 1 week and 3, 6, 12 months after operation, PSG and eye protrudence examination were conducted to evaluate the therapeutic effect, syndrome type, multiple disciplinary treatment (MDT) intervention, occurrence and outcome of complications were summarized. Results: There were 15 cases of Crouzon syndrome and 5 cases of Pfeiffer syndrome. Sleep apnea was the first complaint in 18 cases and exophthalmia in 2 cases. Preoperative interventional therapy included 4 cases of adenoid surgery, 2 cases of continuous positive airway pressure and 2 cases of maxillary expansion. The most common surgical complications were accidental fracture (14/20 cases, 70%), cerebrospinal fluid fistula (2 cases), internal carotid cavernous sinus fistula (1 case), postoperative hyponatraemia (5 cases), crying syndrome (2 cases), wound infection (2 cases), trichiasis of lower eyelid (4 cases), and nasal malformation (1 case). Three cases underwent unplanned secondary surgery. SNA, airway volume and mean percutaneous arterial oxygen saturation (SpO2) six months after operation were significantly higher than those before operation (F=10.09, P=0.001; F=5.13, P<0.001; F=10.78, P=0.001), and the protrusion and apnea hypopnea index were significantly lower than those before surgery (F=6.73, P=0.010; F=18.47, P<0.001). There were no significant differences in SNA, airway volume, mean SpO2, ophthalmology between 6 months after surgery and 1 year after surgery (P>0.05). Conclusions: Perioperative safety assessment and early intervention of MDT is an effective diagnosis and treatment model of Le Fort Ⅲ osteotomy and distraction for syndromic craniosynosis. The operative complications are mainly local, and systemic complications are controllable.

Osteotomía Le Fort III modificada en un paciente no sindrómico / Modified Le Fort III osteotomy in a non-syndromic patient

Las discrepancias dento-esqueletales severas presentan un reto para el cirujano maxilofacial, existe una versatilidad de osteotomías para las diferentes anomalías del crecimiento y desarrollo, sin embargo, son pocas las que permiten mejorar la proyección malar. La osteotomía Le Fort III modificada fue utilizada en un principio en pacientes con algún síndrome craneofacial, pero actualmente es una alternativa útil para discrepancias severas en pacientes no sindrómicos, ya que permite un avance cigomático-maxilar, favorece la proyección malar y disminuye la exposición escleral con un número limitado de complicaciones. Se presenta el caso de un paciente masculino de 33 años con antecedente de fractura orbitocigomática y piso orbitario izquierda con una discrepancia dento-esqueletal severa, la que fue tratada mediante osteotomía Le Fort III modificada, osteotomías sagitales mandibulares para un avance máxilo-malar y retroceso mandibular respectivamente y una genioplastia de avance; logrando un resultado funcional y estético adecuado.

The dento-skeletal severe discrepancies present a challenge for the maxillofacial surgeon, there is a versatility of osteotomies for the different growth and development anomalies, however, a few of them make possible to improve malar projection. The modified Le Fort III osteotomy was originally used in patients with some craniofacial syndrome, but now it is a useful alternative for severe discrepancies in non-syndromic patients, since it allows a zygomatic-maxillary advance, favors malar projection and reduces scleral exposure with a limited number of complications. The case of a 33-year-old male patient with a history of orbitozygomatic fracture and left orbital floor with a severe dento-skeletal discrepancy is presented, who was treated by modified Le Fort III osteotomy, mandibular sagittal osteotomies for maxillo-malar advancement and retrogression mandibular respectively and geniplasty for advance; achieving a suitable functional and aesthetic result.

Anatomical control of the lower nasal width in Le Fort I osteotomy / Control anatómico del ancho nasal inferior en osteotomía Le Fort I

SUMMARY: The aim of this research is to show a simple technique to obtain control in the alar base width in Le Fort I osteotomy. The technique was used in eighteen patients submitted to maxillary impaction and/or advancements (≥ 3 mm). Inter-alar width, alar base width and right/left nostril were studied before surgery and 6 months of follow-up. Data were reported as means and standard deviations; statistical analysis was realized by t test considering a p-value <0.05. Left nostril was modified 0.33 ± 1.03 mm, right nostril was modified 0.39 ± 0.98 mm after 6 months and inter-alar width show a decrease of 0.17 ± 1.15 mm. No statistical differences were observed between the preoperative and the postoperative measurements. Our results show this technique as effective in to obtain a stable position in nasal width.

RESUMEN: el objetivo de esta investigación es presentar una técnica simple para obtener el control en el ancho de la base alar en la ejecución de una osteotomía de Le Fort I. La técnica fue usada en 18 sujetos sometidos a cirugía maxilar de ascenso y/o avance maxilar mayor (≥ 3 mm). El ancho inter-alar, el ancho de la base alar y el orificio nasal derecho e izquierdo fueron estudiados antes de la cirugía y seis meses después de la misma. Los datos fueron presentados en promedios y desviación estándar; el análisis estadístico fue realizado utilizando el t test considerando un valor de p <0,05. El orificio izquierdo fue modificado en 0,33 ± 1,03 mm, el orificio izquierdo fue modificado en 0,39 ± 0,98 mm des- pués de 6 meses y el ancho inter alar mostro una reducción de 0,17 ± 1,15 mm. No se observaron diferencias estadísticas entre las mediciones obtenidas previo a la cirugía y después de la cirugía. Nuestros resultados muestran que la técnica es efectiva para obtener una posición estable del ancho nasal.

Tratamento cirúrgico de fratura Le Fort II: relato de caso / Surgical Treatment of Le Fort II Fracture: Case Report

Fraturas faciais geralmente resultam traumas, e podem ocorrer de forma isolada ou concomitante a outras lesões. O trauma na região facial resulta em danos não só em tecido ósseo, mas também em tecido mole e dentição, causando um prejuízo na função e na estética do paciente. Os acidentes automotores permanecem sendo uma das causas mais significativas de traumas faciais. As fraturas do terço médio da face incluem a maxila, zigoma e o complexo naso órbito etimoidal; podem ser classificadas em: fraturas Le Fort I, II ou III, fraturas do complexo zigomático maxilar, fraturas de arco zigomático ou fraturas naso órbito etimoidais. Elas podem ser unilaterais ou bilaterais, simétricas ou assimétricas. Este estudo objetiva-se em relatar o caso clínico de um paciente do sexo masculino, 31 anos, vítima de acidente automobilístico (carro/ anteparo). O paciente foi diagnosticado com fratura do tipo Le Fort II e nasal onde foi realizado o tratamento de redução e fixação interna rígida das fraturas de maxila e redução incruenta de fratura nasal, resultando em melhora da condição do paciente. As fraturas Le Fort são predominantemente causadas por colisões de alta energia. Portanto o tratamento é imprescindível para a devolução da função, estética e autoestima do paciente... (AU)

Facial fractures usually result from trauma, and may occur in isolation or concomitantly with other injuries. Trauma in the facial region results in damage not only to bone tissue but also to soft tissue and dental elements, which causes a loss in the patient's function and esthetics. Automotive accidents remain one of the most significant causes of facial trauma. Fractures of the middle third of the face include maxilla, zygoma and the nasoorbitoethmoid; may be classified as: Le Fort I, II or III fractures, maxillary zygomatic complex fractures, zygomatic arch fractures, or nasoorbitoethmoid. They can be unilateral or bilateral, symmetrical or asymmetric. The present study aims to report the clinical case of a 31 years, male patient, victim of an automobile accident (car/fixed shield). The patient was diagnosed with le Fort II and nasal fracture, where the treatment of reduction and rigid internal fixation of maxilla fractures and reduction of nasal fracture were performed, resulting in improvement of the patient's condiction. Le Fort fractures are predominantly caused by high energy collisions. Therefore the treatment is essential for the return of the function, aesthetics and increase of the patient's self-esteem... (AU)

Orthognathic surgery with anterior segmental osteotomy as alternative of treatment in patients with dento-skeletal deformity class III AP maxillary deficiency with dental compensation: case report / Cirugía ortognática con osteotomía segmentaria anterior como alternativa de tratamiento en pacientes con deformidades dento esqueletales (DDE) clases III por deficiencia AP maxilar compensados dentalmente: caso clínico

Introduction: Orthognathic surgery is a routine procedure carried out by maxillofacial surgeons in patients with dento-skeletal deformations (DSD) with the objective of achieving functional and esthetical satisfactory results. However, some in cases, due to the decision of the patient or the orthodontic team, the occlusion is tried to be compensated with the intention of avoiding surgery, without optimal results. As a consequence, some extra procedures are required in the surgery to correct and obtain better results. Objective: The aim of this case is to propose the anterior segmental osteotomy (ASO) as alternative of treatment in patients with dento-skeletal deformity class III with maxillary and para-nasal deficiency which have been orthodontically compensated. Material and methods: A 18 years old female with DED Class III due anterior-posterior (AP) maxillary and paranasal deficiency and AP mandibular excess. The surgery was carried out through Le Fort I osteotomy in combination with a segmentary osteotomy at the expense of first premolars and bilateral setback sagittal split osteotomy (BSSO). Clinical and imageology post operatory controls were made during the first 6 months and at two years. Results: Through the realization of the anterior segmental osteotomy the correction of occlusal and transversal alterations of the patient maxilla were performed and additionally favorable facial changes were obtained. Conclusion: The initial orthodontic management of patients with DSD will influence the surgical procedures and the achievement of a balance between esthetics and function. This illustrates why the treatment of these patients must be multidisciplinary; the treatment that was chosen in this case was innovative and could be an alternative for the treatments of patients with DED Class III.

Introducción: La cirugía ortognática es un procedimiento de rutina que realizan los cirujanos bucomaxilofaciales en pacientes con deformidades dento esqueletales (DDE) con la finalidad de lograr un resultado funcional y estético satisfactorio. Sin embargo, hay casos en los cuales, ya sea por decisión del paciente o por el ortodoncista, se intenta compensar la oclusión con el fin de evitar la fase quirúrgica no obteniendo los resultados más óptimos; y como consecuencia, se requiere de procedimientos adicionales a los convencionales en la cirugía para corregir y lograr el mejor resultado. Objetivo: El propósito de este caso es proponer la osteotomía segmentaria anterior (OSA) como alternativa de tratamiento en pacientes con Deformidad Dento Esqueletal clase III con deficiencia maxilar y paranasal los cuales han sido compensados ortodonticamente. Material y Métodos: Paciente femenina de 18 años de edad con Deformidad Dento Esqueletal Clase III por deficiencia AP maxilar y paranasal y exceso AP mandibular. Se realiza cirugía mediante osteotomía Le Fort I en combinación con osteotomía segmentaria a expensas de primeros premolares, osteotomía sagital de rama bilateral de retroposición. Se realizan controles post-operatorios clínico e imagenológicos durante los primeros 6 meses. Resultados: Por medio de la realización de la osteotomía segmentaria anterior se pudo realizar la corrección de las alteraciones oclusales y transversales del maxilar de la paciente, además de producir cambios faciales favorables. Conclusión: El manejo inicial de los pacientes con deformidades dento-esqueletales por parte del ortodoncista va influir en los procedimientos quirúrgicos y en lograr un balance entre lo estético y lo funcional, por lo que el tratamiento en estos pacientes es multidisciplinario; el tratamiento realizado en este caso en una solución innovadora y puede llegar a tomarse como alternativa en los tratamientos de las clases III.

Una revisión de la cirugía ortognática y su relación con la ortodoncia a través del tiempo. Cambiemos de paradigma , ¡el futuro es / A review of Orthognatic Surgery and its relationship with Orthodontics over time. Let's change the paradigm... the future is today!

La cirugía ortognática no siempre estuvo relacionada con la ortodoncia. Sin embargo, hoy en día, es fundamental la interrelación de estas dos especialidades odontológicas. Es importante que el ortodoncista se interiorice y se capacite en las nuevas técnicas quirúrgicas para poder llevar a cabo con éxito el tratamiento. La tecnología que, actualmente, está al alcance de nuestras manos, hace más accesibles y seguros los tratamientos. La comunicación y el trabajo en equipo entre ortodoncista y cirujanos, es clave para lograr los objetivos planteados. La actualización profesional constante nos da la llave para hacer esto posible. Por eso, ¡cambiemos de paradigma!(AU)

Orthognatic Surgery was not always related to Orthodontics. Yet today, interrelation of these two specialties is fundamental. It is important that orthodontists become internalized and trained in the new surgical techniques in order to successfully carry out the treatment. The technology that is currently at our fingertips makes treatments more accessible and safe. Communication and teamwork between orthodontist and surgeons are key to achieve the proposed objectives. The continuing professional updating brings us the key for making this possible.That is why let's change the paradigm!(AU)

Removal of odontogenic keratocyst in maxilla through the Le Fort i osteotomy / Eliminación de queratoquiste odontogénico en el maxilar mediante la osteotomía Le Fort

The odontogenic keratocyst is a lesion with specific clinical and histopathological aspects. The World Health Organization (WHO) in 2017 reclassified it from a tumor to a cyst. It is characterized as a cyst of epithelial development of the jaws, arising from the remains of the dental blade. It represents 3 % to 11 % of all odontogenic cysts and 7 to 11 % of cysts of the gnatic bones. It stands out for its aggressive nature and high relapsing potential. Most of the cases are diagnosed in individuals between 10 and 40 years old, with a mild preference for the masculine gender, occurring more in the mandible. Radiographically, it is radiolucent and well delimited, predominantly unilocular, and may cause displacement of adjacent teeth. The present study aims to report a clinical case of a female 25 years old patient, presenting an intra-osseous lesion in the maxilla (posterior, left side), asymptomatic, with a slight increase in intraoral buccal volume, containing the tooth 28, with a diagnostic hypothesis of Odontogenic Keratocyst. The patient was submitted to the surgical decompression treatment, with cystic fluid puncture, biopsy of the lesion and posterior anatomopathological examination. The enucleation of the tumor was performed using LeFort I osteotomy of maxilla and reconstruction with titanium mesh. There is radiographic evidence of bone repair and lesion reduction. The patient is in periodic follow-up of 4 years and does not present clinical and radiographic signs of relapse. Due to the aggressiveness of the odontogenic keratocyst, the relapse rate is high. The knowledge of the techniques recommended for the treatment of Odontogenic Keratocysts and the clinical and radiographic follow-up of the patient demonstrate a gradual decrease of the lumen of the lesion and suggest local bone neoformation, favoring the prognosis of the case.

El queratoquiste odontogénico es una lesión con aspectos clínicos e histopatológicos específicos. La Organización Mundial de la Salud (OMS) en 2017 lo reclasificó de un tumor a un quiste. Se caracteriza como un quiste de desarrollo epitelial de las mandíbulas, que surge de los restos de la lámina dental. Representa del 3 % al 11 % de todos los quistes odontogénicos y del 7 al 11 % de los quistes de los huesos gnáticos. Se destaca por su naturaleza agresiva y su alto potencial de recaídas. La mayoría de los casos se diagnostican en individuos de entre 10 y 40 años, con una leve preferencia por el sexo masculino, que ocurre más en la mandíbula. Radiográficamente, es radiotransparente y bien delimitado, predominantemente unilocular, y puede causar el desplazamiento de los dientes adyacentes. El presente estudio tiene como objetivo reportar el caso clínico de una paciente de 25 años, que presenta una lesión intraósea en el maxilar (posterior, lado izquierdo), asintomática, con un ligero aumento en el volumen bucal intraoral, que contiene el diente 28, con una hipótesis diagnóstica de queratoquiste odontogénico. El paciente fue sometido al tratamiento quirúrgico de descompresión, con punción de líquido quístico, biopsia de la lesión y examen anatomopatológico posterior. La enucleación del tumor se realizó con osteotomía LeFort I de maxilar y reconstrucción con malla de titanio. Existe evidencia radiográfica de reparación ósea y reducción de la lesión. El paciente se encuentra en seguimiento periódico de 4 años y no presenta signos clínicos ni radiográficos de recaída. Debido a la agresividad del queratoquiste odontogénico, la tasa de recaída es alta. El conocimiento de las técnicas recomendadas para el tratamiento de los queratoquistes odontogénicos, y el seguimiento clínico y radiográfico del paciente, demuestran una disminución gradual del lumen de la lesión y sugieren neoformación ósea local, favoreciendo el pronóstico del caso.

Avaliação mecânica de diferentes tipos de fixação para osteotomia Le Fort I após grande avanço maxilar / Evaluation biomechanical of different types of fixation for Le Fort I osteotomy after major maxillary advancement

Objetivo: Avaliar a estabilidade mecânica de quatro métodos de osteossíntese na maxila após um avanço linear de 11mm. Materiais e Métodos: Foram realizadas osteotomias Le Fort I em 20 modelos de resinas da região do terço médio da face e divididos em quatro grupos que receberam diferentes tipos de osteossíntese na região anterior, pois todos os grupos receberam uma placa "L" (PL) do sistema 2.0 de quatro furos na região posterior, sendo eles: grupo I, placas Lindorf (PLf), grupo II: placas Lindorf modificada (PLfM), grupo III placas em "T" invertido (PTi) e grupo IV: placas PL. Uma máquina universal de testes mecânicos (EMIC ­ Linha DL) foi usada para o ensaio mecânico. As amostras foram acopladas a um suporte metálico, especialmente desenvolvido para o teste, e foram posicionadas na máquina EMIC e submetidas a uma carga linear axial na linha média entre os incisivos centrais com velocidade de 1 mm/min, até o deslocamento em 5mm. Os dados obtidos em newtons (N), tempo de aplicação da força e quantidade de deformação foram computados pelo software Bluehill 2 (2004) interligado à EMIC e então, foram calculados os dados de energia exigida para deslocamento e rigidez de cada material que foram submetidos à análise estatística pelo software SPSS/PC 20.0 (Chicago, USA) e foi realizado o teste t para amostra independentes (ANOVA) e o limite de significância estatística foi P<0,05. Resultados: O grupo I e II apresentaram maior resistência ao deslocamento (P< 0,05) quando comparado aos demais grupos. Sendo assim, o sistema de fixação dos grupos I e II promoveu uma melhor estabilidade dos segmentos em comparação com os demais sistemas de fixação no avanço maxilar de 11mm, quando submetido a uma carga axial linear na linha média dos incisivos centrais. Conclusão: Para grandes avanços lineares da maxila o sistema de fixação com maior resistência à deformação é com a utilização de placas do tipo PLfM seguido PLf na região anterior e do tipo PL na região posterior bilateralmente(AU)

Objective: The aim of the study was evaluate the mechanical stability of four methods of osteosynthesis in the maxilla after a linear advance of 11mm. Materials and Methods: Le Fort I osteotomies were performed on 20 resin models in the middle third of the face and divided into four groups that received different types of osteosynthesis in the anterior region, as all groups received an "L" (PL) plate of the 2.0 system with four holes in the posterior region, which are: group I, Lindorf plates (PLf), group II: modified Lindorf plates (PLfM), group III inverted "T" plates (PTi) and group IV: PL plates. A universal mechanical testing machine (EMIC - DL Line) was used for the mechanical test. The samples were attached to a metallic support, specially developed for the test, and were positioned on the EMIC machine and subjected to an axial linear load in the midline between the central incisors at a speed of 1 mm / min, until the displacement at 5 mm. The data obtained in newtons (N), force application time and amount of deformation were computed by the software Bluehill 2 (2004) connected to EMIC and then, the data of energy required for displacement and stiffness of each material that were submitted were calculated. statistical analysis using SPSS / PC 20.0 software (Chicago, USA) and the t test for independent samples (ANOVA) was performed and the limit of statistical significance was p<0.05. Results: Group I and II showed greater resistance to displacement (p<0.05) when compared to the other groups. Thus, the fixation system of groups I and II promoted a better stability of the segments in comparison with the other fixation systems in the maxillary advance of 11mm, when subjected to a linear axial load in the midline of the central incisors. Conclusion: For large linear advances of the maxilla, the fixation system with greater resistance to deformation is with the use of PLfM plates followed by PLf in the anterior region and PL type in the posterior region bilaterally(AU)

Avanço cirúrgico de maxila e ressonância de fala: comparação entre os tipos de fissura / Surgical maxillary advancement and speech resonance: comparison among cleft types

RESUMO Objetivo Investigar a influência do tipo de fissura sobre o aparecimento da hipernasalidade após o avanço cirúrgico da maxila (AM). Método A nasalidade foi determinada por meio da medida de nasalância (correlato acústico da nasalidade) utilizando-se a nasometria. Foi realizada a análise dos escores de nasalância de 17 indivíduos com fissura isolada de palato (FP), 118 com fissura de lábio e palato unilateral (FLPU) e 69 com fissura de lábio e palato bilateral (FLPB), de ambos os sexos, com idades entre 18 e 28 anos, submetidos ao AM. Apenas indivíduos com escores de nasalância indicativos de ressonância equilibrada previamente ao AM foram incluídos neste estudo. A nasometria foi realizada, em média, três dias antes e 15 meses após o AM. A proporção de pacientes que apresentaram escores de nasalância indicativos de hipernasalidade após o AM foi calculada por meio do teste ANOVA e a comparação entre os diferentes tipos de fissura foi realizada utilizando-se o teste Qui-quadrado (p < 0,05). Resultados Não foi observada diferença significante entre as proporções de indivíduos com hipernasalidade, de acordo com o tipo de fissura. Conclusão A nasometria mostrou que o aparecimento da hipernasalidade após o AM, em indivíduos com fissura de palato envolvendo ou não o lábio, ocorreu em proporções similares independentemente do tipo de fissura.

ABSTRACT Purpose This study investigated the influence of the cleft type on the appearance of hypernasality after surgical maxillary advancement (MA). Methods Nasality was determined by measurement of nasalance (acoustic correlate of nasality) by nasometry. The study involved analysis of the nasalance scores of 17 individuals with isolated cleft palate (CP), 118 with unilateral cleft lip and palate (UCLP) and 69 with bilateral cleft lip and palate (BCLP), of both sexes, aged 18 to 28 years, after MA. Only individuals with normal nasalance scores indicating balanced resonance before MA were included in this study. Nasometry was performed 3 days before and 15 months after MA, on average. The proportion of patients who presented nasalance scores indicating hypernasality after surgery was calculated by the ANOVA test, and comparison among the different cleft types was evaluated by the chi-square test (p < 0.05). Results No significant difference was found in the proportions of individuals with hypernasality among the cleft types. Conclusion Nasometry showed that the appearance of hypernasality after MA in individuals with cleft palate with or without cleft lip occurred in similar proportions, regardless of the cleft type.

Tratamiento ortodóncico-quirúrgico con cirugía monomaxilar y ortodoncia correctiva de autoligado / Orthodontic-surgical treatment with surgery monomaxillary and self-ligating corrective orthodontics

En el presente artículo tenemos como objetivo presentar un caso clínico en el cual se realizó quirúrgicamente avance del maxilar superior con osteotomía de Lefort I, y ortodóncicamente se trató a la paciente con aparatología fija de baja fricción con prescripción Roth.

Cambios Faciales y su Estabilidad en el Tiempo en Pacientes con Fisura Labiopalatina no Sindrómica Sometidos a Distracción Osteogénica Maxilar con Distractor Externo Rígido. Revisión Narrativa / Facial Changes and their Stability over Time in Non-Syndromic Cleft Lip and Palate Patients Undergoing Maxillary Distraction Osteogenesis Through Rigid External Distractor. Narrative Review

RESUMEN: Las fisuras labiopalatinas corresponden a las malformaciones de cabeza y cuello de mayor prevalencia a nivel mundial; dentro de las cuales, aquellas que no están asociadas a síndrome son las más frecuentes. Los pacientes que sufren estas malformaciones presentan en muchos casos hipoplasia maxilar. La distracción osteogénica maxilar mediante distractor externo rígido constituye una alternativa de tratamiento para la corrección de esta deficiencia esqueletal. Describir los cambios faciales y su estabilidad en el tiempo, en pacientes con fisura labio palatina no sindrómica sometidos a distracción osteogénica maxilar con distractor externo rígido. Se realizó una búsqueda estratégica en las bases de datos PubMed, Epistemonikos, EBSCO, BEIC y The Cochrane Library a través de las palabras clave cleft palate; cleft lip and palate; distraction osteogenesis; osteodistraction; callotasis; callotases; callus distraction, maxillary hypoplasia; midface hypoplasia; hypoplastic maxilla; maxillary deficiency; retromaxilla y maxillary retrognatism; con los términos booleanos AND y OR. Se seleccionaron 20 artículos: 2 revisiones sistemáticas, 3 ensayos clínicos, 14 estudios observacionales descriptivos y 1 estudio observacional analítico. La distracción osteogénica maxilar con distractor externo rígido corresponde a una alternativa efectiva en el tratamiento de la retrusión del tercio medio en pacientes con fisura labiopalatina no sindrómica. Esta técnica, sin embargo, no consigue cambios completamente estables, existiendo múltiples factores relacionados con su recidiva.

ABSTRACT: Cleft lip and palate is the world's most prevalent head and neck malformation, within which, nonsyndromic is the most frequent. Patients with this malformation in many cases present maxillary hypoplasia. Maxillary distraction osteogenesis through a rigid external distractor constitutes an alternative to correct this skeletal deficiency. The objective of this study was to describe facial changes and their stability over time in non-syndromic cleft lip and palate patients undergoing distraction osteogenesis through rigid external distractor. An electronic search was carried out in PubMed database, Epistemonikos, EBSCO, BEIC and The Cochrane Library through the keywords cleft palate; cleft lip and palate; distraction osteogenesis; osteodistraction; callotasis; callotases; callus distraction, maxillary hypoplasia; midface hypoplasia; hypoplastic maxilla; maxillary deficiency; retromaxilla and maxillary retrognatism, related to each other with the Boolean terms AND and OR. For this analysis 20 articles were selected: 2 systematic reviews, 3 clinical trials, 14 descriptive observational studies and 1 analytic observational study. Maxillary distraction osteogenesis through rigid external distractor is an effective alternative in the treatment of midface retrusion in non-syndromic cleft lip and palate patients. However, this technique does not completely achieve stable changes, due to multiple factors related to its recurrence.

Análise morfométrica maxilar aplicada a osteotomia Le Fort I / Morphometric analysis of maxilla applied to Le Fort I osteotomy

Introdução: A osteotomia Le Fort I é uma técnica cirúrgica utilizada para a correção de deformidades dentofaciais e para que ocorra a mobilização da maxila é necessária a disjunção da sutura pterigomaxilar. Durante esse procedimento, complicações podem ocorrer, como hemorragia resultante da injúria da artéria maxilar interna ou de seus ramos terminais, na qual a artéria palatina descendente é mais comum de ser lesionada. Objetivo: O objetivo deste estudo foi contribuir para o estabelecimento de parâmetros cirúrgicos seguros para realizar osteotomia le fort I com disjunção pterigomaxilar, por meio da obtenção de medidas das regiões maxilar e pterigomaxilar. Material e métodos: Foram selecionados quarenta crânios secos dos sexos masculino e feminino do Departamento de Anatomia de uma instituição pública e realizadas as medidas pelo método de inspeção direta com o uso de um paquímetro digital Mitutoyo® e um compasso Staedtler®. Foram medidas a altura e espessura da junção pterigomaxilar (JPM), a distância da sutura pterigomaxilar até o pilar zigomático, a distância desde o ponto mais inferior da sutura pterigomaxilar até a fissura orbital inferior (FOI), a extensão da parede lateral da cavidade nasal até o canal palatino descendente e o comprimento do septo nasal, bilateralmente. Para análise estatística dos resultados, utilizou-se o teste t para amostras independentes, com nível de significância de 5%. Resultados: Observou-se que para o lado direito, as médias das respectivas medidas foram de 14,88mm, 9,17mm, 27,60mm, 34,47mm e 36,86; e o lado esquerdo, as médias foram, respectivamente, 15,18mm, 9,08mm, 26,50mm, 34,70mm e 36,02mm. O valor médio do comprimento do septo nasal foi de 49,10mm. Conclusão: com base nos valores obtidos é possível estabelecer parâmetros operatórios para a osteotomia Le Fort I.

Introduction: The Le Fort I osteotomy is a surgical technique used for correction of dentofacial deformities and dislocation of the pterygomaxillary suture for mobilization of maxilla. During this procedure, complications may happen, such as hemorrhage resulting from the injury of the internal maxillary artery or its terminal branches, in which the descending palatine artery is more common to be injured. Objective: The aim of this study was to contribute for establishment of safe surgical parameters to improve osteotomy with pterygomaxillary disjunction, through the measurement of the maxillary and pterygomaxillary regions. Material and Method: Forty dry skulls (male and female) of the Department of Anatomy of a public institution were selected and the measurements were made by the direct inspection method using a Mitutoyo® digital caliper and a Staedtler compass ®. The height and thickness of the pterygomaxillary junction, the distance from the pterygomaxillary suture to the zygomatic pillar, the distance from the lower point of the pterygomaxillary suture to the inferior orbital fissure, the extension of the lateral wall of the nasal cavity to the descending palatine canal, and the length of the nasal septum, bilaterally, were measured. For the statistical analysis of the results, the t-test was used for independent samples, with a significance level of 5%. Results: We found that on the right side, the averages of the respective measurements were 14.88mm, 9.17mm, 27.60mm, 34.47mm and 36.86; and on the left side, the averages were, respectively, 15.18mm, 9.08mm, 26.50mm, 34.70mm and 36.02mm. The mean value of nasal septum length was 49.10 mm. Conclusion: Based on the values obtained it is possible to establish operative parameters for the Le Fort I osteotomy.

Efficacy of minimal invasive cardiac output and ScVO₂ monitoring during controlled hypotension for double-jaw surgery

BACKGROUND: Controlled hypotension (CH) provides a better surgical environment and reduces operative time. However, there are some risks related to organ hypoperfusion. The EV1000/FloTrac system can provide continuous cardiac output monitoring without the insertion of pulmonary arterial catheter. The present study investigated the efficacy of this device in double jaw surgery under CH.METHODS: We retrospectively reviewed the medical records of patients who underwent double jaw surgery between 2010 and 2015. Patients were administered conventional general anesthesia with desflurane; CH was performed with remifentanil infusion and monitored with an invasive radial arterial pressure monitor or the EV1000/FloTrac system. We allocated the patients into two groups, namely an A-line group and an EV1000 group, according to the monitoring methods used, and the study variables were compared.RESULTS: Eighty-five patients were reviewed. The A-line group reported a higher number of failed CH (P = 0.005). A significant correlation was found between preoperative hemoglobin and intraoperative packed red blood cell transfusion (r = 0.525; P < 0.001). In the EV1000 group, the mean arterial pressure (MAP) was significantly lower 2 h after CH (P = 0.014), and the cardiac index significantly decreased 1 h after CH (P = 0.001) and 2 h after CH (P = 0.007). Moreover, venous oxygen saturation (ScVO2) decreased significantly at both 1 h (P = 0.002) and 2 h after CH (P = 0.029); however, these values were within normal limits.CONCLUSION: The EV1000 group reported a lower failure rate of CH than the A-line group. However, EV1000/FloTrac monitoring did not present with any specific advantage over the conventional arterial line monitoring when CH was performed with the same protocol and same mean blood pressure. Preoperative anemia treatment will be helpful to decrease intraoperative transfusion. Furthermore, ScVO2 monitoring did not present with sufficient benefits over the risk and cost.

Le Fort I osteotomy as treatment for traumatic class III malocclusion caused by Le Fort III fracture: A case report

Trauma in the modern society is characterized by multiple injuries, and the several comorbidities are often accompanied by facial bone fracture. The types of multiple facial bone fractures vary from Le Fort to panfacial fracture. Le Fort fracture, which can cause problems, such as facial disfigurement, functional impairment of mastication, malocclusion and speech abnormalities, is a challenging case for plastic surgeons. The purpose of treatment for patients with malocclusion due to Le Fort fracture is to maintain and restore both function and aesthetics. The author reports a case of Le Fort I osteotomy as a surgical correction of traumatic class III malocclusion due to Le Fort III fracture.

Cirugía ortognática para el tratamiento de las anomalías dentoesqueletales / Orthognathic surgery for the treatment of dentoskeletal abnormalities

Las anomalías dentoesqueletales se presentan en el 2-3% de la población. Las mismas afectan el complejo maxilomandibular como también la relación entre las arcadas dentarias. Estas alteraciones producen problemas fonéticos, deglutorios, respiratorios y estéticos. Existe una tendencia en corregir las alteraciones dentarias sin tratar las discrepancias esqueletales, dificultando la corrección quirúrgica, si esta fuera necesaria. Actualmente, la cirugía ortognática ha tenido mayor aceptación como el tratamiento ideal para pacientes con estas anomalías. Se presentará una revisión de la literatura sobre las características que esta alteración presenta, junto a la resolución de casos clínicos (AU)

Facial asymmetry: virtual planning to optimize treatment predictability and aesthetic results

Abstract Facial asymmetry is a condition that compromises function and social interactions and, consequently, the quality of life. Orthodontic-surgical treatment may be indicated to achieve a stable occlusion and significant improvement in facial aesthetics. The virtual planning of the maxillary, mandibular and chin movements can be done prior to surgery. These movements can be successfully performed with the use of prototyped guides obtained from virtual planning. The aim of this article is to show the state of the art of treatments of facial asymmetries, and emphasize how important is the multi-disciplinary approach to achieve predictable aesthetic and functionally stable results in a patient with facial asymmetry and chin protrusion.

Resumo A assimetria facial é uma condição capaz de comprometer a função oclusal e as interações sociais e, consequentemente, a qualidade de vida dos indivíduos. Nessas condições, para se obter oclusão estável e melhora significativa na estética facial, o tratamento ortodôntico-cirúrgico pode estar indicado. A simulação virtual da cirurgia permite planejar de forma adequada, e antecipada, os movimentos cirúrgicos a serem efetuados na maxila, mandíbula e mento. Esses movimentos são, então, realizados com sucesso graças ao uso de guias prototipados obtidos a partir do planejamento virtual. Assim, os objetivos do presente artigo consistem em relatar o estado da arte no planejamento virtual do tratamento de um paciente com assimetria facial e protrusão do mento, e enfatizar a importância da abordagem multidisciplinar para se atingir resultados estéticos previsíveis e funcionalmente estáveis.

Osteosíntesis Bioreabsorbible Bioactivo (Hidroxiapatita/Poly L-lactido) en Osteotomía Le Fort I Segmentada / Bioresorbable Bioactive Osteosynthesys (Hidroxiapatite/Poly L-lactide) in Le Fort I Segmented Osteotomy

RESUMEN: El objetivo de este artículo es presentar un caso clínico con la utilización de un innovador sistema de osteosíntesis basado en la mezcla de hidroxiapatita (HA) y acido poliláctico (PLLA). La paciente fue admitida en el Hospital Abraham González Peña de Lautaro (Chile) debido a una deformidad facial que exigió realizar una cirugía ortognática monomaxilar para avance y aumento transversal del maxilar; se utilizaron placas de tipo L y tornillos de HA/PLLA de 5 mm para la fijación maxilar, realizando la cirugía sin complicaciones; el proceso técnico y alta hospitalaria se ejecutó de forma convencional. Se realizó un análisis de la literatura donde se analiza la versatilidad, la seguridad y la estabilidad de segmentos cuando se utiliza este innovador material y se concluye que este tipo de osteosíntesis es aplicable a cirugía maxilofacial, exigiendo una curva de aprendizaje por parte del cirujano, necesaria para obtener resultados adecuados.

ABSTRACT: The aim of this paper is to show a clinical case, where was used an innovative osteosynthesys system based on the mixture of hidroxiapatite (HA) and polilactic acid (PLLA). The patient was admitted into Abraham González Peña Hospital (Chile), showing a facial deformity to treat with monomaxillary orthognathic surgery for advance and transversal increase of the maxilla.; were used type L plates and 5 mm screws of HA/PLLA for the internal fixation, performing the surgery without complications; the technical process and the ALTA hospital was realized in a conventional strategy. Was realized a literature review showing the versatility, safe and stability of bone segment when used this innovative material and it´s concluded that this osteosynthesis system can be used normally in maxillofacial surgery; a learning curve to learn about this material is needed by surgeons.

Long-term stability of surgical-orthodontic open bite treatment: Le Fort I versus 4-piece segmental Le Fort I osteotomy / Estabilidade em longo prazo do tratamento cirúrgico da mordida aberta anterior por osteotomia tipo Le Fort I com e sem segmentação maxilar

Introduction: This vertical malocclusion has the potential of causing functional and esthetic impairment, impacting patients´ quality of life negatively. The long-term stability of anterior open bite surgical-orthodontic treatment is an important and controversial issue. A variety of factors such as surgery type, surgery fixation, and the anteroposterior discrepancy is related to and can influence long-term overbite stability. The controversy of stability arises in the inherent difficulty of collecting a homogeneous sample, with considerable sample size and adequate long-term followup, leading the current literature to an inconclusive status. Therefore this thesis aimed to test 2 null hypotheses: 1- There is no difference in the long-term stability of the surgical-orthodontic correction of anterior open bite when comparing Le Fort I to 4-piece segmental Le Fort I osteotomies. 2- To test the null hypothesis that there is no difference in the long-term stability of the surgical-orthodontic correction of anterior open bite when comparing Class II to Class III patients. Materials and Methods: The sample of the first investigation comprised the lateral cephs of 29 open bite subjects treated with 1-piece Lefort I osteotomy compared to the lateral cephs of 24 open bite subjects treated with 4-piece Lefort I osteotomy; in both groups Class I, II and III subjects were included. The groups were matched regarding age and were compared with t-tests. To test the second null hypothesis, lateral cephs of 21 Class II open bite subjects were compared to lateral cephs of 25 Class III open bite subjects. Overbite changes were compared at 3-time points: T1 (pretreatment), T2 (posttreatment) and T3 (follow-up) by using t-test. Overbite clinical stability percentage at T3 was assessed with the chi-square test. Results: In 1-piece Le Fort I Group 65.52% of patients presented with clinically significant overbite stability, while in 4-piece Group 83.33% remained stable in the long-term, however it was not statistically significant. In Class II Group 57.14% of patients presented with clinically significant overbite stability, while in Class III Group 88% remained clinically stable, and it was statistically significant. Conclusions: The first null hypothesis regarding maxillary segmentation was accepted because there was no significant intergroup difference regarding the percentage of clinically stable patients. The type of fixation seems to influence the long-term stability of open bite surgical-orthodontic correction more than maxillary segmentation. The second null hypothesis was rejected because clinical stability of Class II malocclusion open bite surgical-orthodontic treatment was significantly smaller than in Class III malocclusions.(AU)

Introdução: A estabilidade em longo prazo do tratamento orto-cirúrgico da mordida aberta anterior é um assunto relevante e controverso. Esta má oclusão vertical tem o potencial de causar importantes alterações tanto funcionais quanto estéticas, impactando negativamente a qualidade de vida dos pacientes. Vários fatores, como o tipo de cirurgia, a fixação cirúrgica e a discrepância ântero-posterior, estão relacionados e podem influenciar a estabilidade da sobremordida em longo prazo. A controvérsia na estabilidade surge na dificuldade inerente de coletar uma amostra homogênea, com um tamanho de amostra considerável e acompanhamento adequado em longo prazo, levando esse assunto na literatura atual a um status inconclusivo. Portanto, esta tese teve como objetivos testar 2 hipóteses nulas: 1- Não há diferença na estabilidade em longo prazo da correção orto-cirúrgica da mordida aberta anterior ao comparar as osteotomias tipo Le Fort I com e sem segmentação maxilar. 2- Não há diferença na estabilidade em longo prazo da correção orto-cirúrgica da mordida aberta anterior ao comparar pacientes com má oclusão de Classe II e Classe III. Materiais e Métodos: A amostra da primeira investigação compreendeu as telerradiografias de 29 indivíduos com mordida aberta tratados por osteotomia Lefort I sem segmentação maxilar, às quais foram comparadas às telerradiografias laterais de 24 indivíduos com mordida aberta tratados por osteotomia Lefort I com segmentação maxilar; pacientes Classe I, II e III foram incluídos. Os grupos foram compatibilizados pela idade e foram comparados com testes t e qui-quadrado. Para testar a segunda hipótese nula, telerradiografias laterais de 21 indivíduos com mordida aberta e má oclusão de Classe II foram comparadas às telerradiografias laterais de 25 indivíduos com mordida aberta e má oclusão de Classe III. As alterações do overbite foram comparadas em três tempos: T1 (pré-tratamento), T2 (pós-tratamento) e T3 (longo-prazo) usando o teste t. A taxa de estabilidade clínica em T3 foi avaliada com teste de qui-quadrado. Resultados: No Grupo Le Fort I sem segmentação maxilar 65,52% dos pacientes apresentaram estabilidade clínica da sobremordida, enquanto que no Grupo Le Fort I com segmentação maxilar, 83,33% mantiveram-se estáveis em longo prazo, porém essa diferença não se apresentou estatisticamente significante. No Grupo Classe II, 57,14% dos pacientes permaneceram clinicamente estáveis, enquanto que no Grupo Classe III, a porcentagem clínica de estabilidade foi de 88%, e a diferença apresentou significância estatística. Conclusões: A primeira hipótese nula em relação à segmentação maxilar foi aceita porque não houve diferença estatisticamente significante entre os grupos em relação à porcentagem de pacientes clinicamente estáveis. O tipo de fixação parece influenciar a estabilidade em longo prazo da correção orto-cirúrgica da mordida aberta mais do que a segmentação maxilar. A segunda hipótese nula foi rejeitada porque a estabilidade clínica do tratamento orto-cirúrgico da mordida aberta em pacientes com má oclusão de Classe II foi significativamente menor do que nos pacientes com má oclusão de Classe III.(AU)