Iatrogenic retroposition of the lips sequel after bicuspid extraction-a retrospective study.

AIM: This study aims to explore the prevalence of Iatrogenic retroposition of the lips sequel (IRLS) after bicuspid extraction, associated dentofacial characteristics and the effectiveness of surgical treatment. MATERIAL: and methods: Patients with bicuspid extraction as part of an orthodontic treatment plan were retrospectively included. IRLS was identified by clinical evaluation and cephalometric Legan and Burstone analysis. Association of demographic and cephalometric variables were assessed. The effectiveness of combined orthodontic-orthognathic correction of the retroposition of the lips was evaluated. RESULTS: Out of 144 patients with extracted bicuspids, eight Class I patients, nine Class II patients and five Class III patients were seeking treatment because their lips had retruded as a consequence of compensating orthodontic treatment. Lower jaw bicuspid extraction and a decreased vertical facial height in Class II patients correlated significantly more with IRLS development. Postoperative cephalometric analysis of orthodontic-orthognathic treated patients reported improvement in lip projection and naso-labial angle. Only two Class I patients reported postoperative normalization of the lip position according to Legan and Burstone. CONCLUSION: The consequence of bicuspid extractions on soft tissue profile differs according to skeletal jaw relation. The impact of orthognathic surgery on IRLS is beneficial, although insufficient to completely correct the facial profile when judged on cephalometric standards.

Belgian consensus guideline on the management of hemorrhoidal disease.

Introduction: Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking. Methods: A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020. Results: Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids. Conclusions: The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

The use of Medpor implants for midface contouring in cleft patients.

Three-dimensional midfacial deficiency in cleft patients is common and is frequently connected to impairment of the aesthetic facial appearance. Different approaches to augment relevant facial regions are available. Alloplastic facial implants have been established as a viable alternative to autologous tissue augmentation in various circumstances. However, in cleft patients, the application of facial implants has rarely been reported. This retrospective study aimed to evaluate the use of Medpor implants for midfacial contouring in cleft patients. Fifty-one patients with orofacial clefts were assessed with regard to defined parameters. A range of Paranasal, Malar and Nasal Dorsum Medpor implants had been used. Unilateral cleft lip and palate (UCLP) represented the most common indication, followed by bilateral cleft lip and palate (BCLP). Bilateral implant insertion was performed as a general rule with few exceptions. Insertion of implants was frequently combined with other cleft-related surgical procedures. Even after orthognathic surgery, midfacial augmentation was implemented to specifically address residual volume deficiency, particularly in the malar region. The complication rate amounted to 4.9% (6/122 implants). Based on our findings, Medpor implants are reliable and long-term stable materials to successfully augment paranasal, subnasal and malar areas as well as a solid nasal dorsum material with few complications in cleft patients.

Midfacial augmentation in teenage cleft patients using malar and paranasal Medpor implants.

Malar and paranasal implants offer a way to augment and reconstruct midfacial deformities, and can be used across a broad spectrum of craniofacial deformities. Three patients aged between 13 and 15 years underwent such a procedure. Access was achieved via a labial mucosal approach; 'super petite' and 'petite' malar and paranasal Medpor implants were inserted in a subperiosteal plane and secured with titanium screws. All patients underwent an uneventful postoperative recovery and have remained pleased with their reconstruction at follow-up. In carefully selected patients, Medpor implants may have a role in teenage cleft patients with subtle midfacial hypoplasia, where formal osteotomies are not felt to be required, or where the lengthy preparation period might not be tolerated. In the cases described, they were used as a bridging or temporizing measure as there was not yet the skeletal maturity for definitive osteotomies. These patients may otherwise face a lengthy wait during their teenage years, in which they may struggle to manage what they may perceive as a significant facial deformity.

An investigation into the variables associated with length of hospital stay related to primary cleft lip and palate surgery and alveolar bone grafting.

This retrospective study evaluated variables associated with length of stay (LOS) in hospital for 406 admissions of primary cleft lip and palate and alveolus surgery between January 2007 and April 2009. Three patients were treated as day cases, 343 (84%) stayed one night, 48 (12%) stayed 2 nights and 12 (3%) stayed > 2 nights. Poisson regression analysis showed that there was no association between postoperative LOS and age, distance travelled, diagnosis and type of operation, with a p value > 0.2 for all variables. 60/406 patients stayed 2 nights or more postoperatively mostly due to poor pain control and inadequate oral intake. Patients with palate repair were more likely to have postoperative LOS > 1 night, compared to patients with lip repair, p value = 0.011. Four patients (1%), all of whom had undergone cleft palate surgery, were readmitted within 4 weeks of the operation due to respiratory obstruction or haemorrhage. Using logistic regression, evidence showed that these readmissions were related to a longer original postoperative LOS. This study shows that length of stay for primary cleft lip, palate and alveolus surgery can in most cases be limited to one night postoperatively, provided that adequate support can be provided at home.

Cystic change in alveolar bone graft.

The authors report a cystic lesion within a previous unilateral cleft lip and alveolus bone graft site in a 15-year-old girl, 5 years after the secondary bone graft. The cyst comprised respiratory epithelial lining, which is thought to be a remnant of the nasal mucosal lining of the primary cleft.

Comparison of three methods of facial measurement.

The aims of this study were to assess the accuracy of measurements recorded by 3D stereophotogrammetry and to compare three methods of facial measurement: manual anthropometry, 3D stereophotogrammetry and 2D photography. Measurements were taken from 14 landmarks on each of six volunteers and compared. In addition, the variability of the methods was assessed. Three-dimensional measurements were shown to compare well with manual measurements on volunteers as well as test objects for which the mean difference was 0.23 mm (shortest distance) and 0.13 mm (surface). All the three methods of measurement were found to have good levels of repeatability. Two-dimensional measurements were more variable than manual measurements (P=0.021). Three-dimensional stereophotogrammetric measurements were shown to compare well with manual measurements although the values obtained were mostly slightly larger. Stereophotogrammetry allows images to be taken in a Medical Photography Department, facilitating the accurate measurement of facial morphology from digitized data, including changes associated with treatment or growth. There are clear potential benefits of using 3D measurements in the assessment of facial deformity.

The role of a posteriorly inclined condylar neck in condylar resorption after orthognathic surgery.

Recently, it has been reported that a posteriorly inclined condylar neck is associated with condylar resorption following orthognathic surgery, although its role in resorption remains unknown. By cephalometric screening of 240 patients with Angle Class II occlusion 2 years after orthognathic surgery, 11 patients with postoperative condylar resorption were identified. The preoperative posterior inclination of the condylar neck and the surgical risk factors mentioned in the literature, particularly surgically induced counterclockwise rotation of the mandibular proximal segment were evaluated. In all 11 cases, the condylar neck was clearly inclined posteriorly. Counterclockwise rotation of the proximal segment was also observed in all cases, and it amounted to 6.7 degrees (2.5-12 degrees) on average. The contributing role of a posteriorly inclined condylar neck in connection with surgical mandibular movement in postoperative condylar resorption is discussed.

Surgical risk factors for condylar resorption after orthognathic surgery.

OBJECTIVE: The purpose of this study was to look for surgical risk factors for condylar resorption after orthognathic surgery. STUDY DESIGN: Seventeen patients of a group of 452 patients who had undergone orthognathic surgery consecutively and who were in accordance with the inclusion criteria of this study showed postoperative condylar resorption (group I). Preoperative cephalometric characteristics and surgically induced movements of this group were compared with a control group of 17 of 452 patients (group II) in whom postoperative condylar resorption and skeletal relapse did not develop, despite mandibular retrognathism (ANB angle >4 degrees) and high mandibular plane angle (>40 degrees). RESULTS: The kind of osteosynthesis used was not significantly different between the 2 groups. The amount of surgical advancements and the vertical movements of the jaws were not significantly different between the 2 groups. However, the distal (P =.005) and proximal (P =.007) mandibular segments were rotated significantly further counterclockwise in group I. Surgically induced posterior condylar displacement occurred significantly more frequently (P =.007) in group I. CONCLUSIONS: Counterclockwise rotation of the distal and proximal mandibular segments and surgically induced posterior condylar displacement seem to be important surgical risk factors for postoperative condylar resorption. Therefore, these movements seem to be contraindicated in patients who are at high risk.

Alternative methods for reduction of blood loss during elective orthognathic surgery.

Bimaxillary orthognathic surgery and genioplasty are frequently performed to correct dentoskeletal anomalies in otherwise healthy young patients. Until 1990 homologous blood transfusions were routinely necessary for these procedures. The present study describes a protocol of blood-saving measures that was adopted and tested on a continuous sample of 127 patients treated between 1994 and 1997. The protocol comprises acute normovolemic hemodilution, controlled moderate hypotension, positioning the surgical field above the heart level, cell saving, intraoperative homeostasis, preoperative autologous blood donation, administration of recombinant erythropoietin, and acceptance of a low hematocrit perioperatively. This study shows that homologous blood transfusions may be avoided intraoperatively by following the protocol described.

Multimodal strategy for reduction of homologous transfusions in cranio-maxillofacial surgery.

The transfusion of homologous blood carries well-known risks that have prompted efforts to develop alternative techniques. Such measures are of particular interest to patients undergoing elective procedures. A total of 204 patients, out of 1470 patients who consecutively underwent major craniomaxillofacial procedures under general anesthesia over a two-year period, were enrolled in a prospective protocol to reduce homologous transfusion requirements when a blood loss in excess of 500 ml was anticipated. The data were compared with the results of a retrospective control group (n=2890) covering major procedures during the previous four years, when blood-saving measures were applied occasionally, but not based on a global strategy. Techniques for the reduction of homologous transfusions were acute normovolemic hemodilution, controlled moderate hypotension, cell saver and predeposit autologous blood. In addition, preoperative administration of human recombinant erythropoietin was introduced during the last year of the study. These techniques were applied individually or in combination, depending on contraindications specific for each technique, using invasive monitoring in order to maintain intraoperative hemodynamic stability. The goal of this study was to examine the extent to which homologous transfusions may be reduced with the systematic application of transfusion-sparing techniques. Of 204 patients qualifying for the transfusion-sparing protocol, 30 received homologous transfusions. In comparison to the control group, utilization of transfusion-sparing techniques had doubled. The overall reduction in the use of homologous transfusions was highly significant. When acute normovolemic hemodilution, controlled moderate hypotension and the cell saver were used in combination, a greater reduction in homologous transfusions was achieved than with the use of either a single modality or combination of any two. No transfusions were required in patients pretreated with erythropoietin.

The Le Fort I osteotomy as a surgical approach for removal of tumours of the midface.

Tumours of the midface and maxillary sinuses have been removed via multiple approaches. The most common approaches are those using incisions in the facial skin, especially in the case of malignant tumours. The Le Fort I procedure via an intraoral incision as described by Sailer in 1986 is a versatile alternative. Combined with a coronal approach and various osteotomies of the upper face it also allows removal of tumours extending into the orbits, the nasoethmoidal complex and the skull base. The versatility of the Le Fort I osteotomy as a surgical approach was analysed in 17 cases. This method is reliable and gives excellent access. Further advantages are the wide surgical exposure and the clear visibility of the resection margins, the absence of visible scars, the feasibility of combining this approach with reconstruction using the buccal fat pad and the possibility of simultaneous placement of bone grafts, insertion of endosseous implants or other preprosthetic procedures via the same incision.

Update on bioresorbable plates in maxillofacial surgery.

Biodegradable materials, mainly polymers and copolymers of polylactide and polyglycolide, are today routinely used as fixation materials in craniomaxillofacial surgery. Several research groups have shown that these materials can adequately fix osteotomies and fractures of the craniofacial skeleton. Although there are some differences between polymers, in general their biocompatibility is good. They gradually lose their strength, enabling the underlying bone to take up the stress. Secondary procedures for removal of the material causing discomfort and pain are not needed. An overview of the development of biodegradable materials, their characteristics, and illustrations of different applications in craniomaxillofacial surgery are presented. More than 200 patients have been treated successfully so far in our units, the longest follow-up time being now over 7 years. The good results indicate that the use of bioresorbable fixation can be considered routine and will be definitely state of art at the beginning of the new millennium.

The value of stereolithographic models for preoperative diagnosis of craniofacial deformities and planning of surgical corrections.

The purpose of this study was to assess the importance of stereolithographic models (SLMs) for preoperative diagnosis and planning in craniofacial surgery and to examine whether these models offer valuable additional information as compared to normal CT scans and 3D CT images. Craniofacial SLMs of 20 patients with craniomaxillofacial pathology were made. A helical volume CT scan of the anatomic area involved delivered the necessary data for their construction. These were built with an SLA 250 stereolithography apparatus (3D-Systems, Valencia, CA, USA), steered by FORM-IT/DCS software (University of Zurich, Switzerland). The stereolithography models were classified according to pathology, type of surgery and their relevance for surgical planning. Though not objectively measurable, it was beyond doubt that relevant additional information for the surgeon was obtained in cases of hypertelorism, severe asymmetries of the neuro- and viscerocranium, complex cranial synostoses and large skull defects. The value of these models as realistic "duplicates" of complex or rare dysmorphic craniofacial pathology for the purpose of creating a didactic collection should also be emphasized. The models proved to be less useful in cases of consolidated fractures of the periorbital and naso-ethmoidal complex, except where there was major dislocation.

Development of the frontal sinus following bilateral fronto-orbital osteotomies.

The presence of frontal sinuses following bilateral fronto-orbital advancement is discussed controversially in the literature. In a retrospective study, 33 patients (18 male and 15 female) were operated on between 1982 and 1993, with at least one year postoperative follow-up and with a minimum age of 6 years at the end of the follow-up period following bilateral fronto-orbital remodelling, were included. The average age at which the procedure was performed was 29 months with a minimum of 3 months and a maximum of 7.8 years. The study presented shows a pneumatization of the frontal sinus in 72.7% of 33 patients following bilateral fronto-orbital advancement. The first radiographic signs of sinus development were detected between the ages of 4 and 11, average 8.3 years. There were no statistically proven correlations between frontal sinus pneumatization and age at operation or the amount of advancement or sex of the patients. Surgical enlargement of the cranium by frontal advancement with adequate stabilization results in an enlargement of the neurocranium, thereby decreasing pressure on the inner frontal cortex and allowing frontal sinus pneumatization to proceed normally. Hence, the development of a frontal sinus may be a reflection of the effectiveness of the surgical therapy.

[Preoperative diagnosis of complex craniofacial syndromes]. / Präoperative Diagnostik komplexer kraniofazialer Syndrome.

The aim of this study was to evaluate stereolithography as a tool in craniofacial surgery. The indications were classified according to the usefulness of stereolithography for different craniofacial pathologies. Stereolithography models of 21 patients were built; in three cases two models were made. The age of the 7 male and 14 female patients was 17 years on average (range: 15 months-44 years). First a helical volume CT scan of the anatomical region was performed. After transformation of the data set, the models were built by an SLA 250 stereolithography apparatus (3D-Systems, Valencia, Calif., USA), steered by FORM-IT/DCS-Software (University of Zurich, Switzerland). The stereolithography models were constructed by superposition of epoxy resin slices of 0.05 mm thickness, which were polymerized by a helium-cadmium laser. These models were classified according to the indication for stereolithography, the operation performed, the relevance for surgical planning and the usefulness for the fabrication of implants and protheses. In craniofacial syndromes, severe asymmetries of the viscerocranium, large skull defects and before surgical correction of hypertelorism these models provided important additional information for the surgeon. Before complex interventions in these fields the construction of a stereolithography model should be considered. In multiple fractures consolidated in dislocation, the models proved to be less useful.

[Fronto-orbital corrections and development of the frontal sinus]. / Frontoorbitale Korrekturen und Stirnhöhlenentwicklung.

The development of frontal sinuses following bilateral fronto-orbital advancement is a topic of controversial discussion in the literature. In a retrospective study on 33 patients (15 girls and 18 boys) the development of the frontal sinus was examined radiologically. Only patients with a minimum age of 6 years and with at least 1 year of postoperative follow-up were included. The radiological reference for the frontal sinus development consisted of pneumatisation at or above the level of the supraorbital rims, as projected din postero-anterior cephalograms. According to these criteria a frontal sinus development was seen in 72.7% of our patients. There was no statistically proven correlation between sinus development and the sex of the patient, age at surgery or the amount of advancement. With the exception of severe cases of Crouzon's disease we usually expect normal development of the frontal sinus following bilateral fronto-orbital correction.