Nonunion in Orthognathic Surgery: A Case-Series of 15 Patients.

BACKGROUND: Bone nonunion is extensively studied in the orthopedic literature, but the knowledge in oral and maxillofacial surgery, specifically orthognathic surgery, is scarce. Since this complication has a significant negative impact on postoperative management of patients, more studies are needed. PURPOSE: To report the characteristics of patients presenting with bone nonunion after orthognathic surgery. STUDY DESIGN, SETTING, SAMPLE: This is a retrospective case-series study on subjects who underwent orthognathic surgery between 2011 and 2021 and developed nonunion. Inclusion criteria were mobility at the site of the osteotomy and the need for a second surgical intervention. Exclusion criteria were an incomplete medical chart; the absence of nonunion upon surgical exploration, or radiological evidence of nonunion; cleft lip/palate; or syndromic patients. MAIN OUTCOME VARIABLE: The outcome variable was bone healing after nonunion care. COVARIATES: Demographics (age, sex), medical/dental comorbidities, type of surgery (type of fixation, bone grafts, Botox injection), amplitude of movements, nonunion treatment. ANALYSES: Descriptive statistics were computed for each study variable. RESULTS: The sample was composed of 15 patients (11 females, mean age 40.4 years old) with nonunion (maxilla: 8 cases, mandible: 7 cases) out of 2036 patients who underwent orthognathic surgery during the period studied (incidence 0.74%). Nine (60%) were bruxers, three were smokers (20%) and one had diabetes. Mean forward movement of the maxilla was 6.55 mm (4-9 mm) and 7.71 mm (4.8-12 mm) for the mandible. All patients but one (who refused surgery) were treated by curettage of fibrous tissue and new hardware placement. In addition, 11 received a bone graft, and 4 had Botox injections. All osteotomies healed after the second surgical intervention. CONCLUSION: Curettage with or without grafting appears to be a good strategy for the cure of nonunion. Bruxism may be a risk factor (60% of patients were bruxers in this study).

Perioperative Systemic Corticosteroids in Orthognathic Surgery: A Systematic Review and Meta-Analysis.

PURPOSE: Perioperative systemic corticosteroids are broadly used in orthognathic surgery to prevent postoperative complications, but it is unclear whether this practice is beneficial and concerns about potential side effects have been raised. The purpose of this systematic review and meta-analysis was to assess the effects of perioperative systemic corticosteroids on clinically important outcomes in patients undergoing orthognathic surgery. MATERIALS AND METHODS: The authors conducted a systematic review of randomized controlled trials evaluating the effect of systemic corticosteroids in orthognathic surgery compared with placebo or any other intervention. The authors searched Medline, Embase, Cochrane Central, CINAHL, Lilacs, Scopus, and Web of Science and references of included trials. The primary outcome was the incidence of postoperative reintubation during the index hospitalization. The secondary outcomes were hospital length of stay, decreases in facial edema, and adverse events. Data were summarized using Mantel-Haenszel random-effects models. RESULTS: Of the 1,098 trials retrieved, 8 were included (n = 234). No trial evaluated the risk of postoperative reintubation. One trial evaluated the duration of hospital stay and showed no difference associated with the intervention. There was a decrease in facial edema with the use of systemic corticosteroids (n = 80; standardized mean difference, -1.07; 95% confidence interval, -1.99 to -0.16; I2 = 67%). Three trials reported side effects, such as postoperative surgical site bleeding, hypersensitivity, and stomach discomfort with intake of corticosteroids. The 8 trials had an unclear risk of bias. CONCLUSION: The authors observed no evidence of effect of systemic corticosteroids on the risk of reintubation and hospital length of stay in orthognathic surgery. Although facial edema decrease was observed to be improved with the intervention, adverse effects were inconsistently screened and reported. Thus, the use of systemic steroids in orthognathic surgery is not supported by strong evidence.

Open Reduction with Internal Fixation of Mandibular Angle Fractures: A Retrospective Study.

OBJECTIVE: The goal of this project was to report the complications associated with mandibular angle fractures and identify variables affecting their occurrence. METHODS: We retrospectively reviewed the charts of patients with a mandibular angle fracture treated at the Centre hospitalier universitaire de Québec between 2009 and 2013. RESULTS: Seventy-eight patients (73 males) aged 15-59 years (mean 25.2 years) met our inclusion criteria. A wisdom tooth was present in 85.9% (n = 67) of the cases and it was removed 62.7% (n = 42) of the time. Thirty-four patients (43.6%) had other mandibular fractures. Most fractures were fixated with a sagittal split osteotomy plate (n = 32; 41.0%) or a 2.0-mm plate on the lateral aspect of the mandible (n = 20; 25.6%). The overall complication rate was 42.3% (n = 33); of these 37.2% were infections, 26.9% involved plate removal and 6.4% were associated with non-union. Older patients had more infections (p = 0.03) and more plates removed (p = 0.03). When a wisdom tooth was extracted, more infections (p = 0.04) and overall complications (p = 0.02) were observed. CONCLUSION: This study confirms that, when treating a mandibular angle fracture in a healthy patient, it may be beneficial to leave a wisdom tooth in the line of fracture in place, if there is no indication to remove it.

Temporomandibular Lavage Versus Nonsurgical Treatments for Temporomandibular Disorders: A Systematic Review and Meta-Analysis.

PURPOSE: To investigate the efficacy of temporomandibular joint (TMJ) lavage (arthrocentesis or arthroscopy) for the treatment of temporomandibular disorders in reducing pain and improving jaw motion. PATIENTS AND METHODS: We performed a systematic review of the literature and meta-analysis of randomized controlled trials (RCTs) comparing TMJ lavage with conservative measures. The data sources were MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), Scopus, Web of Science, and reference lists of relevant articles. Two independent reviewers identified RCTs by using controlled vocabulary (MeSH, Emtree) and free text terms. Data extracted from the selected studies included population characteristics, interventions, outcomes, and funding sources. Risk of bias was assessed with the Cochrane Collaboration risk assessment tool for RCTs. RESULTS: Five studies met the inclusion criteria, for a total of 308 patients. Of these studies, 3 were categorized as having a high risk of bias and 2 had a low risk. The summary effect of the 5 studies showed a reduction in pain in the intervention group at 6 months (-0.63; 95% confidence interval [CI], -0.90 to -0.37; P < .00001; I2 = 88%) and 3 months (-0.47; 95% CI, -0.75 to -0.19; P = .001; I2 = 85%). This was not the case at 1 month. No difference in mouth opening was observed at 6 months (-0.21; 95% CI, -1.82 to 1.40; P < .80; I2 = 74%), 3 months (0.20; 95% CI, -1.81 to 2.20; P = .85; I2 = 68%), and 1 month (-1.18; 95% CI, -2.90 to 0.55; P = .18; I2 = 0%). CONCLUSIONS: Given the relatively small number of patients included in this meta-analysis, the high risk of bias in 3 studies, and the statistical and clinical heterogeneity of the included studies, the use of TMJ lavage for the treatment of temporomandibular disorders should be recommended with caution because of the lack of strong evidence to support its use.

Pediatric Vascular Tumors of the Head and Neck.

Oral and maxillofacial surgeons are often involved in the diagnosis and treatment of vascular neoplasms of the head and neck. An incorrect diagnosis may lead to improper or unnecessary treatment. This article reviews the diagnosis and management of vascular tumors.

Infections after sagittal split osteotomy: a retrospective analysis of 336 patients.

PURPOSE: The purpose of this study was to determine the rate of infection after bilateral sagittal split osteotomy. MATERIALS AND METHODS: The investigators implemented a retrospective case series study. To be included in this study, patients needed to have a complete medical chart and a postoperative follow-up of at least 3 months. The outcome variable was postoperative infections. The predicator variables were type of surgery, medical comorbidities, third molar extraction, smoking, type of fixation, and antibiotic prophylaxis. Descriptive and bivariate statistics were computed, and significance was set at P < .05. Multivariate analyses were performed with logistic regression. RESULTS: The sample was composed of 336 patients with ages ranging from 13 to 65 years (27.2 ± 10.6). The rate of infection was 11.3%, and plates, screws, or both were removed in 10 patients (3%). There was a statistically significant association between age and infections (odds ratio, 1.04; 95% CI, 1.01-1.07; P = .02). CONCLUSIONS: The results of this study suggest that infection after bilateral sagittal split osteotomy is within normal range for a clean-contaminated procedure. Rigid fixation of the osteotomy may decrease the need for hardware removal.

Intraoperative hypertensive crisis secondary to an undiagnosed pheochromocytoma during orthognathic surgery: a case report.

Increased blood pressure (BP) during orthognathic surgery may result in excessive blood loss, poor surgical field visualization, and longer surgical time and require blood transfusion. When uncontrollable high BP is encountered in an otherwise healthy patient during orthognathic surgery, the diagnosis of pheochromocytoma should be considered. Pheochromocytomas are rare neuroendocrine tumors of the chromaffin cells of the adrenal medulla or extra-adrenal paraganglia (sympathetic ganglia) that secrete catecholamine. They are present in approximately 0.05 to 0.2% of hypertensive patients. Patients can present with hypertension, tachycardia, headaches, and diaphoresis. The clinical presentation may vary and a wide spectrum of nonspecific symptoms may be encountered. The elevated BP can be intermittent (40%) or permanent (60%). About 10% of pheochromocytomas are hereditary and they can be a feature of multiple endocrine neoplasia type 2. This report describes the case of a 29-year-old patient with a large pheochromocytoma of the right adrenal gland undiagnosed before orthognathic surgery.

Postoperative complications associated with the retromandibular approach: a retrospective analysis of 118 subcondylar fractures.

PURPOSE: The purpose of this study was to evaluate the rate of complications associated with the retromandibular approach. MATERIALS AND METHODS: The design of this research was a retrospective case-series study. Included were patients who 1) underwent open reduction and internal fixation of the condylar or subcondylar area through a retromandibular approach and 2) had a complete and available medical chart. Excluded were 1) patients treated endoscopically or by other approaches and 2) patients with preoperative facial paralysis. The data collected were age, gender, medical comorbidities, tobacco use, mechanism of injury, anatomic location, concomitant facial fractures, follow-up time, antibiotic protocol, and complications. RESULTS: One hundred eight patients (81 male; 118 condyles; age, 13 to 82 yr; mean, 35.6 ± 15.8 yr) met the inclusion criteria. Six patients never returned for postoperative visits and the mean follow-up time for all other patients was 6.5 months (8 days to 5.5 years). Twenty-six cases (22%) of temporary paralysis and 1 case of permanent facial paralysis were noted. Eight patients (6.8%) had persistent partial facial paralysis at their last visit, but all had short postoperative follow-ups. Fourteen cases (11.9%) of infection, 4 salivary fistulas, 2 sialoceles, 1 case of Frey syndrome, and 2 seromas were observed. CONCLUSION: The retromandibular approach is a safe method for the treatment of condylar process fractures and major complications are rare.

Intraoperative use of a gamma probe for the treatment of condylar hyperplasia: description of a new technique.

PURPOSE: The purpose of this article is to describe a new technique to perform a high condylectomy using a γ-probe. MATERIALS AND METHODS: A 15-year-old female patient presented with right condylar hyperplasia. Because the condition was active, a high condylectomy was performed to stop the abnormal growth of the affected condyle. To resect an adequate amount of bone and prevent relapse, a γ-probe was used to guide bone removal. The patient was injected with technetium-99m methylene diphosphate 25 mCi 2 hours before she was brought to the operating room. Bone was removed from the superior aspect of the right condyle until the reading with the γ-probe was equivalent to normal bone. RESULTS: Seven millimeters of bone was removed from the top of the condyle before the γ-emission from the remaining condyle was equivalent to the mandibular parasymphysis used as a control. No relapse was noted 9 months after surgery. CONCLUSION: The γ-probe may help a surgeon remove the correct amount of bone when performing a high condylectomy, especially in type II (vertical pattern) condylar hyperplasia.

Precision of maxillary repositioning during orthognathic surgery: a prospective study.

The purpose of this study was to evaluate the accuracy of surgical splints and an external reference point to reposition the maxilla during orthognathic surgery. Before surgery, a radiological marker was inserted inside the orthodontic bracket of the first right maxillary molar. A surgical splint was utilized to reposition the maxilla in the sagittal and coronal planes after the osteotomy. The vertical position was established by measuring the distance between a Kirschner wire inserted at bony nasion and the orthodontic wire. Preoperative and postoperative cephalometric radiographs were obtained and manually traced. The radiological marker and the tip of the right maxillary incisor were used as specific landmarks. Their displacement on the pre- and postoperative radiographs was measured. The actual surgical movement of the maxilla was compared to the initial surgical planning. 23 patients met the inclusion criteria to participate in the study. The mean difference between the planned and executed movements of the maxilla was 0.1mm (p=0.71). The difference was not statistically significant for any given movements of the maxilla. The use of surgical splints made from model surgery combined with an external reference point at bony nasion is accurate methods for repositioning the maxilla during orthognathic surgery.

Three-dimensional computed tomographic airway analysis of patients with obstructive sleep apnea treated by maxillomandibular advancement.

PURPOSE: To evaluate changes in airway size and shape in patients with obstructive sleep apnea (OSA) after maxillomandibular advancement (MMA) and genial tubercle advancement (GTA). MATERIALS AND METHODS: This was a retrospective cohort study, enrolling a sample of adults with polysomnography-confirmed OSA who underwent MMA + GTA. All subjects who had preoperative and postoperative 3-dimensional computed tomography (CT) scans to evaluate changes in airway size and shape after MMA + GTA were included. Preoperative and postoperative sleep- and breathing-related symptoms were recorded. Descriptive and bivariate statistics were computed. For all analyses, P < .05 was considered statistically significant. RESULTS: During the study period, 13 patients underwent MMA + GTA, of whom 11 (84.6%) met the inclusion criteria. There were 9 men and 2 women with a mean age of 39 years. The mean body mass index was 26.3; mean respiratory disturbance index (RDI), 48.8; and mean lowest oxygen saturation, 80.5%. After MMA + GTA, there were significant increases in lateral and anteroposterior airway diameters (P < .01), volume (P = .02), surface area (P < .01), and cross-sectional areas at multiple sites (P < .04). Airway length decreased (P < .01) and airway shape (P = .04) became more uniform. The mean change in RDI was -60%. CONCLUSIONS: Results of this preliminary study indicate that MMA + GTA appears to produce significant changes in airway size and shape that correlate with a decrease in RDI.

Management of obstructive sleep apnea: role of distraction osteogenesis.

Distraction osteogenesis to expand the facial skeleton is an alternative to standard orthognathic surgery for selected patients with obstructive sleep apnea. For children with congenital micrognathia or midface hypoplasia, distraction osteogenesis allows large advancements without the need for bone grafting and with less risk of relapse. For later-onset obstructive sleep apnea, distraction osteogenesis may represent an alternative when acute bone movement is expected to be difficult (scarring from previous surgery or radiation therapy) or when the risk for inferior alveolar nerve damage is unacceptable (patients older than 40 years).

A protocol for management of temporomandibular joint ankylosis in children.

Temporomandibular joint (TMJ) ankylosis in children is a challenging problem. Surgical correction is technically difficult and the incidence of recurrence after treatment is high. The purpose of the present report is to describe the protocol currently used at the Massachusetts General Hospital for the management of TMJ ankylosis in children. It has been our observation that the most common cause of treatment failure is inadequate resection of the ankylotic mass and failure to achieve adequate passive maximal opening in the operating room. The 7-step protocol consists of 1) aggressive excision of the fibrous and/or bony ankylotic mass, 2) coronoidectomy on the affected side, 3) coronoidectomy on the contralateral side, if steps 1 and 2 do not result in a maximal incisal opening greater than 35 mm or to the point of dislocation of the unaffected TMJ, 4) lining of the TMJ with a temporalis myofascial flap or the native disc, if it can be salvaged, 5) reconstruction of the ramus condyle unit with either distraction osteogenesis or costochondral graft and rigid fixation, and 6) early mobilization of the jaw. If distraction osteogenesis is used to reconstruct the ramus condyle unit, mobilization begins the day of the operation. In patients who undergo costochondral graft reconstruction, mobilization begins after 10 days of maxillomandibular fixation. Finally (step 7), all patients receive aggressive physiotherapy. A case series of children with ankylosis treated using this protocol is presented.