The effect of mandibular nerve block on opioid consumption, nausea and vomiting in bilateral mandibular osteotomies.

UNLABELLED: The purpose of this study was to compare the efficacy of a mandibular nerve block to placebo, in patients undergoing mandibular osteotomy surgery, regarding opioid consumption and adverse opioid induced side effects. Forty healthy individuals with a mean age of 19.7 years participated in the study. All subjects received lidocaïn 2% + adrenaline 1/80,000 versus placebo for mandibular nerve block in a randomized double-blind manner. Opioid consumption and opioid related side effect such as postoperative nausea and vomiting (PONV), and respiratory depression were assessed. RESULTS: The placebo group received significantly more sufentanil during the surgical procedure than the lidocaïngroup. There were no significant differences in adverse opioid induced side effects. In the postoperative phase there was no difference in additional pain intervention between the two groups. CONCLUSION: The mandibular block during mandibular osteotomy reduces intra-operative opioid consumption but does not alternate the opioid related side-effects in the postoperative phase.

Perioperative complications in corrective facial orthopedic surgery: a 5-year retrospective study.

PURPOSE: Frequency and severity of complications have a profound impact on referral patterns for facial orthopedic surgery. Therefore, a retrospective study was undertaken to determine the incidence of such problems in a large series of patients, with the intent to use these data to make possible changes in the perioperative protocol used in our clinic. PATIENTS AND METHODS: The files of all patients operated on between 1992 and 1996 were studied. These comprised 1,108 patients with 1,872 osteotomy procedures. The following parameters were descriptively analyzed: airway obstruction, hemorrhage, hematoma, infection, neurosensory disturbances, unfavorable fractures, malposition of condyles and nasal septum, and vascularization problems. RESULTS: The most frequent complication was impairment of trigeminal nerve function. In 31.5% of the mandibular base osteotomies, 43.6% of the combined mandibular base and chin osteotomies, and 13% of the chin osteotomies, lip sensibility was decreased immediately postoperatively. After 1 year, this number was reduced to approximately 5%. The function of 17 lingual nerves and 45 infraorbital nerves was temporarily impaired. A wound infection was next in frequency. Fifty-three infections (mandible-to-maxilla ratio, 2.5:1) were treated with drainage under local anesthesia and antibiotic therapy. Loss of part or all of an osteotomized segment did not occur. Other complications were rare and/or temporary. CONCLUSIONS: The most frequent complication was impairment of inferior alveolar nerve function. Life-threatening complications were not encountered. The frequency of infections (<5%) requires further consideration regarding ways to reduce the incidence.

Proximal segment position after distraction with the MD-DOS device.

We investigated cephalometrically the movement of the proximal segment in the sagittal plane in patients treated with distraction (MD-DOS device) for mandibular lengthening. The proximal segment was anteriorly rotated, whilst the distal segment was posteriorly rotated after the lengthening procedure. Thus the angle of the jaw was advanced half the distance of the advancement of the distal segment. One possible reason for the anterior rotation of 3.3 degrees on average is the repositioning of the proximal segment during application of the anterior fixation unit in the cases where mobilization was complete. Another more plausible reason is the anterior pull by the masticatory muscles and elastic bands being greater than the reactive distraction vector component in concert with a flexible telescopic distraction module and a single posterior screw anchorage. The positional movements of both distal and proximal segments were similar to those observed after mandibular advancement with bilateral sagittal split osteotomies.

The nasal frame osteotomy: technical note.

In the practice of orthognathic surgery, a patient presenting with a gummy smile and lip incompetence is readily diagnosed as having vertical maxillary excess, and a maxillary impaction osteotomy is usually the proposed treatment. If a short nose, an arched and upwardly displaced upper lip, and a broad face accompany these 2 features, nasal lengthening and caudal repositioning of the central portion of the upper lip by a nasal frame osteotomy should be considered instead. The technique of the nasal "frame" osteotomy, which was used in 1 patient with a 4-year follow-up, is described.

Prediction of mandibular autorotation.

PURPOSE: The purpose of this investigation was to test the hypothesis that the mandible rotates around the same point during maxillary impaction surgery as during initial jaw opening. This point, called the center of mandibular autorotation (CAR), could then be used to predict mandibular position and to decide whether only maxillary impaction would be needed to correct the occlusion and the facial profile. PATIENTS AND METHODS: Preoperatively, two lateral cephalograms were obtained from a consecutive series of 20 patients who underwent maxillary impaction without concomitant mandibular ramus osteotomy. One cephalogram was taken with the mandible in centric relation using a wax bite wafer and another with a jaw opening of 10 mm using a fabricated acrylic bite block with the mandible manipulated to its most retruded position. The CAR was calculated before and after jaw opening using the Rouleaux method on the lower incisor and gonion point. A third lateral cephalogram was taken within 2 days postoperatively. The postoperative lower incisal point was then transferred to the first cephalogram using cranial base superimposition. RESULTS: When the preoperative and postoperative distances between CAR and incisal point were compared, there was no significant difference between these distances, proving the hypothesis. CONCLUSIONS: The method used is a practical and precise way to determine the center of mandibular autorotation on an individual basis. The center of rotation during initial jaw opening is the same as during impaction surgery.

Orthognathic surgery: patients' subjective findings with focus on the temporomandibular joint.

Two hundred and ninety-six patients who underwent various orthognathic surgery procedures were questioned, a minimum of 1 year postoperatively, on their overall subjective findings. Patient satisfaction, willingness to resubmit to surgery, self-confidence and subjective changes in their temporomandibular joints (TMJ) function and masticatory efficiency were evaluated. 87% would undergo the combined surgical-orthodontic treatment again. Self-confidence improved in 77% of the patients. There was a subjective improvement in TMJ function in 40% of the patients and a worsening in 11%; masticatory function was improved in 41% and worsened in 7% of the patients.

Reconstruction of the severely resorbed maxilla with a combination of sinus augmentation, onlay bone grafting, and implants.

PURPOSE: A new method of reconstruction of the atrophic maxilla by combining a bilateral sinus floor elevation and cancellous bone graft with buccal and labial onlay graft using L-shaped corticocancellous blocks from the posterior iliac crest is presented. PATIENTS AND METHODS: Seventeen patients were treated with this procedure. One hundred one IMZ implants were placed in 14 patients, and 22 Brånemark implants were placed in three patients. Patients were observed for 6 months after prosthetic rehabilitation. RESULTS: All patients were fully rehabilitated with fixed bridges except one, who preferred an overdenture. Only two implants were lost at the time of the abutment connection. Some bone resorption was seen around six implants. The success rate with this procedure was 92.7% 6 months after prosthetic rehabilitation if implants with bone resorption were considered failures. CONCLUSIONS: These preliminary results indicate that this surgical procedure is suitable for reconstruction of most atrophic maxillas.

An intra-operative technical aid to miniplating of mandibular fractures by fracture segment apposition.

Internal plate osteosynthesis and lag-screw osteosynthesis are currently the preferred methods of fixation in the treatment of mandibular fractures. Rigid internal fixation (RIF) provides for functionally stable immobilization of the segments, avoiding the need for postoperative intermaxillary fixation (IMF) by "dental wiring" in the majority of cases. Reduction and fixation can be provided by so-called compression plates (type AO/ASIF). Non compressive mini-plates are more extensively used, however, because their size and malleability facilitate their transoral application. Peroperative problems may arise with the anatomical reduction of the fragments. We present a simple fracture reduction-compression technique that can be used in combination with either compression and non-compression mini-plate fixation. Its use can be extended to reduction and fixation in selected areas of difficult surgical access.

The effect of the subspinal Le Fort I-type osteotomy on interalar rim width.

The postoperative increase in interalar rim width was measured in two groups undergoing Le Fort I impaction or advancement. In the control group, 19 patients with a conventional osteotomy, an absorbable alar cinch suture, and V-Y closure were followed for 20 months on average. In the experimental group, 12 patients with a "subspinal" Le Fort I osteotomy (without alar cinch or V-Y closure) were followed for 15 months on average. Interalar rim width was measured with a slide gauge preoperatively, at several times during surgery, and at the 6-month and late follow-up appointments. At surgery, the alar cinch suture decreased the interalar rim width by 50% in the control group. Still, after extubation, there was no statistical difference between groups. At the 6-month follow-up measurement, the interalar rim width was significantly (1.92 mm) smaller in the subspinal group. At the late follow-up, this difference had decreased by a mean of 0.61 mm.

High labial incisions for genioplasty.

Clinical experience in genioplasty has shown that high labial incisions heal with fewer scar bands than conventional deep labial incisions. In a prospective randomized trial, we compared 18 high labial curvilinear incisions with 27 high labial W-shaped ('royal') incisions for access and visibility during chin osteotomy. Both incisions were 3 cm wide. Maximal incision lengthening between two skin hooks was recorded with a ruler before closure, and there was no significant difference between the two. The maximum wound area between three skin hooks was photographed and computed, and showed a mean difference of 188.75 mm2 (t-test, P < 0.001), which corroborated the clinical findings that access and visibility were superior in the W-shaped incision group. Complications were few in both groups. We now use the high labial royal incision about 3.5 cm wide, with 90 degrees limb angle for complicated chin osteotomies and ostectomies. A smaller curvilinear high labial incision is used for simple advancement osteotomies.

Use of fibrin glue in lower blepharoplasties.

This prospective study investigates the long-term appearance of the scar following closure of lower blepharoplasty incisions with the fibrin adhesive Tissucol compared with the usual subciliary suturing. Eighteen eyelids closed with fibrin adhesive were compared with 12 eyelids where a 5-0 running suture was used for closure and to 10 eyelids that did not undergo surgery. The measurement team consisted of a panel, blind to patients and technique, that scored the scar morphology on a scale of 1-4. The Dunn test showed no difference between the group treated with the tissue adhesive and the group with conventional subciliary closure. There was a difference between the Tissucol treated group and the control group (P < 0.01). The surgical technique and the advantages in lower lid incision closure are discussed.

Creating lip seal by maxillo-facial osteotomies. A retrospective cephalometric study.

Lateral head films taken immediately pre-operatively and at least 6 months postoperatively were analysed in 99 selected orthognathic surgery patients to study soft and hard tissue ratios in relation to lip seal creation. The patients were grouped according to the osseous correction carried out. In maxillary advancement patients, the overall position of stomion superius was difficult to predict when important horizontal and vertical movements had been made. The vertical movement of stomion superius was 30% of that seen at the anterior palate point, and 25% of that at the upper incisal point, when the main vector of maxillary repositioning was vertical (either intrusion or extrusion). There was a weak linear correlation between mandibular advancement at pogonion and vertical changes at stomion inferius. The correlation increased if vertical movement at menton and mentolabial angle were added as independent variables. Good linear correlations between vertical changes at stomion inferius and vertical changes at lower incisal point and menton were observed in mandibular set-back surgery. In mandibular autorotation, the best linear correlation with single predictors was found between vertical changes at stomion inferius and those at menton (about 80% + 1 mm upward movement), and vertical changes at stomion inferius and horizontal changes at lower incisal point. Vertical changes at stomion inferius were mainly determined by vertical changes at menton in genioplasties, the change at stomion inferius being 40% of that at menton. The horizontal component at pogonion had almost no influence. In combined genioplasty and Le Fort I procedures, the vertical changes at stomion inferius were 50% of those at menton + 1 mm upward movement, this difference being due to mandibular autorotation.

Temporomandibular joint symptoms in an orthognathic surgery population.

The records of 317 consecutive patients who underwent orthognathic surgery in the Division of Maxillo-Facial Surgery of the General Hospital St. John, Bruges, Belgium, between 1.10.90 and 1.10.92 were evaluated for pre- and postoperative temporomandibular joint (TMJ) symptoms. Only 143 patients, with a normal/low angle mandibular deficiency deformity, treated by mandibular advancement, and 53 high angle absolute mandibular retrognathism patients having bimaxillary operations, were selected. Fewer TMJ symptoms were found postoperatively, than preoperatively in the total group (17.8% vs 26.5% p = 0.025, Mc Nemar). In the normal/low angle group, there was a decrease in TMJ symptoms after surgery from 30.0% to 14.6% (p = 0.0001, Mc Nemar). In the high angle group, however, more TMJ symptoms are seen postoperatively 26.4% versus 16.8% (p = 0.228, Mc Nemar). Possible hypothetical explanations are given.

Rhinoplasty with nasal bone disarticulation to deepen the nasofrontal groove. Experimental and clinical results.

Deepening of the nasofrontal groove is considered a fiddly task. The unwonted chisel ostectomy technique (Skoog, 1974; McCarthy, 1990; Aiach and Levignac, 1991) was therefore modified and evaluated both experimentally and clinically. The hump is removed in one piece together with the nasal bones up to the horizontal part of the frontonasal suture. To accomplish this, the reduction osteotomy has to be performed in a wave line fashion. The depth of resection in the sellion area depends upon the aesthetic planning. In cases with most severe hypertrophy, the osteotome enters the vertical frontonasal suture behind the nasal bones and in front of the nasal spine of the frontal bone. The nasal bones are disarticulated with a levering movement. Cadaver studies demonstrate the safety of the technique: no fracture lines were detected in the frontal process of the maxilla, ethmoid, frontal or lacrimal bones, by either clinical inspection, or by standardised radiological examination. The clinical cases show a convincing outcome.

The 'sandwich' zygomatic osteotomy: technique, indications and clinical results.

The classical approach to lateral midface hypoplasia is reconstruction with onlays. Dislocation and asymmetry, early and late infection, and extrusion are possible complications with alloplastic implant materials. Unpredictable resorption, irregular contours and asymmetry are problems that can arise with autogenous, homogenous and hetergenous onlay grafts. We describe a technique by which the zygomatic body is luxated laterally and ventrally after a combined oblique-horizontal and vertical osteotomy. The resultant greenstick fracture at the temporo-zygomatic suture together with minimal lateral degloving causes the malar body to return to its former position. An interpositional porous hydroxyapatite block acts as a space maintainer until the osteotomy sites are ossified. The restoration of contour is performed by the zygomatic body itself, not by the implants. The indications are discussed and the results of three year follow-up are illustrated.

Evaluation of the slot osteosynthesis technique in mandibular advancement. With focus on occlusion and lower lip sensibility.

The slot osteosynthesis technique (SLOT) was evaluated in 25 mandibular advancements. SLOT was successfully used to readjust skeletal and occlusal malpositioning in 48% of the cases. Neurosensory tests in the lower lip and chin region revealed a low disturbance rate (immediately postsurgery 20% of patients, at 7 months 8%). This may be due to the specific splitting and fixation techniques applied.

Brow and forehead lift with cranial suspension. Technical note.

Cranial suspension of the forehead skin in a coronal lift enables more precise modelling of the brows. The tension on the skin closure line, and consequently the risk of local alopecia, are considerably reduced.

Condylar resorption in orthognathic surgery: a retrospective study.

A retrospective study was performed to examine the occurrence of condylar atrophy in connection with orthognathic surgery. Patients with high-angle mandibular deficiency (n = 29) were selected from among those who underwent bimaxillary osteotomy (n = 93) during the period from January 1987 through December 1990. This group of 29 was examined for shortening of the ascending ramus of the mandible because of condylar resorption. In 9 of these 29 (31%), the ramus had resorbed more than 2 mm, or more than 6% of the total length of the ramus. All 9 of these patients were female. There was no correlation between resorption and age, the amount of retrognathism, or the presence of preoperative temporomandibular joint dysfunction. Female patients with high-angle retrognathism should be informed of the possibility of postoperative condylar resorption and should be followed with radiographic controls for at least 2 years after surgery.

The use of skull bone in maxillofacial reconstruction and its potential use in orthopedic surgery.

The calvarium provides a source of bone grafts that are widely applied in maxillofacial surgery, with minimal donor-site morbidity and less resorption than endochondral grafts. A technique of harvesting monocortical bone is described and possible indications in orthopedic surgery are proposed. Thus, we suggest that skull bone can be used in orthopedic surgery in some instances, resulting in less donor-site morbidity than when autogenous bone from other sources is used.