Early Surgery: Le Fort I Advancement in a 6-Year-Old Patient-A Therapeutic Approach Using a Modified Le Fort I Osteotomy.

Orthognathic surgery in young patients before completion of skeletal growth is still sharply discussed today. In the following case report of a 6-year-old patient, however, there was a vital indication for treatment. The main clinical symptoms were characterized by impaired hearing as a result of constantly recurring seromucotympanum and adenoids, persistent rhinorrhea and otorrhea, chronic tonsillitis and chronic otitis media. ENT interventions such as the partial C-tonsillectomy, paracentesis with tympanic drainage, adenotomy and tube dilation with balloon catheter did not bring lasting success. Despite antibiotic therapy with aminopenicillins and cephalosporins in ß-hemolytic streptococci, no improvement in the symptoms could ultimately be achieved, so that there was a life-threatening risk of endocarditis with previous pulmonary valve replacement. In our orthognathic consultation, a maxillary retrognathism with a frontal crossbite was diagnosed. With an interdisciplinary consideration of the risks and side effects, an early surgical treatment in the sense of an upper jaw advancement with dilatation of the airways and evacuation of the maxillary sinuses was carried out. The operative challenge consisted of determining an ideal osteotomy line so as not to damage permanent tooth structures. Furthermore, the patient and his family had to understand the expected outcomes, potential risks, and possible complications that might arise from early surgical interventions, such as a subsequent maxillary growth discrepancy. After successful surgery the patient could already be discharged on the 2nd postoperative day and soon no longer showed any complaints or symptoms with regard to the tube ventilation disorder and the seromucotympanum-also no dental or skeletal recurrence has been evident up to now. With 25 years of experience in "Early surgery," we have learned that orthognathic operations in children and adolescents might have decisive effects on life quality.

Upper airway changes following high oblique sagittal split osteotomy (HSSO).

The aim of this study was to evaluate volumetric changes of the posterior airway space (PAS) following bimaxillary surgery using a high oblique sagittal split osteotomy (HSSO) of the mandibular ramus. The cone beam CTs of Class II and Class III patients taken before (T0) and 6-12 months after surgery (T1) were analyzed using 3D software (Mimics® Innovation Suite 18.0). The PAS was divided into three segments (superior, middle, inferior) by three planes parallel to the Frankfurt horizontal plane intersecting at the posterior nasal spine, the velum palatinum and the epiglottis. Total (TPAS) and partial volumes (SPAS = superior, MPAS = middle, IPAS = inferior) were calculated. For the 25 Class II patients, a highly significant increase (p<0.001) of the total, middle and inferior airway space (TPAS: +33.6%, MPAS: +43.1%, IPAS: +55.9%) was found, while the increase of the upper airway space was statistically not significant (+5.4%, p = 0.074). For the 28 Class III patients, the total, middle and inferior airway space increased statistically insignificantly (TPAS: +4.6%, p = 0.265, MPAS: +2.7%, p = 0.387, IPAS: +2.8%, p = 0.495), while the increase of the upper airway space was statistically significant (+9.7%, p = 0.010). Bimaxillary orthognathic surgery using the HSSO technique led to a significant increase of PAS for Class II patients and could conserve the PAS for Class III patients.

Moving the mandible in orthognathic surgery - A multicenter analysis.

Orthognathic surgery has always been a classical focus of maxillofacial surgery. Since more than 100 years, various surgical techniques for mandibular repositioning have been developed and clinically tested. Since the establishment of plate and screw osteosynthesis, orthognathic surgery became more stable and safe. Nowadays, different surgical methods for mobilising the mandible are existing. This international multicenter analysis (n = 51 hospitals) is providing first evidence based data for the current use of different surgical methods. The dominating techniques were Obwegeser/dal Pont (61%) followed by Hunsuck/Epker (37%) and Perthes/Schlössmann (29%). The main osteosynthesis materials were plates (82%), bicortical screws (23.5%), or a combination of both (5.9%). 47% of all centers reported to use several surgical methods at the same time, depending on the anatomical problem and the surgeon's preference. This shows that different surgical methods seem to work as comparable, safe, and reliable procedures in everydays clinical practise. On this basis, further prospective studies could evaluate possible advantages for our patients.

[Short sagittal osteotomy]. / Ostéotomie sagittale courte.

Bilateral sagittal split osteotomy has become the standard mandibular surgery for the treatment of dento-facial deformities. Even patients with less important deformities may undergo surgery. The morbidity must be as low as possible. We describe a technique with reduced split surfaces. The osseous section follows an oblique line since the thorn of Spix below and outside towards the supra-angular region. This section is completed by an osteotomy of the posterior border of the mandible. This split never reaches the inferior alveolar nerf tunnel. The protection of the alveolar nerve is increased what decreases considerably the risk of nervous complications of this intervention. The majority of the mandibular movements are possible by this technique with the exception of the important advancements and the increase of the height of the ramus.

Influence of maxillary advancement surgery on skeletal and soft-tissue changes in the nose - a retrospective cone-beam computed tomography study.

OBJECTIVES: Surgical correction of skeletal maxillary retroposition is often associated with changes in the morphology of the nose. Unwanted alar flaring of the nose is observed in many cases. The aim of the present study was therefore to investigate the influence of surgical advancement of the maxilla on changes in the soft-tissue morphology of the nose. Having a coefficient that allows prediction of change in the nasal width in Caucasian patients after surgery would be helpful for treatment planning. MATERIALS AND METHODS: All 33 patients included in this retrospective study were of Caucasian descent and had skeletal Class III with maxillary retrognathia. They were all treated with maxillary advancement using a combination of orthodontic and maxillofacial surgery methods. Two cone-beam computed tomography (CBCT) datasets were available for all of the study's participants (16 female, 17 male; age 24.3 ± 10.4 years): the first CBCT imaging was obtained before the planned procedure (T0) and the second 14.1 ± 6.4 months postoperatively (T1). Morphological changes were recorded three-dimensionally using computer-aided methods (Mimics (Materialise NV, Leuven/Belgium), Geomagic (Geomagics, Morrisville/USA)). Statistical analysis was carried out using SPSS 21 for Mac. RESULTS: The mean sagittal advancement of the maxilla was 5.58 mm. The width of the nose at the alar base (Alb) changed by a mean of + 2.59 mm (±1.26 mm) and at the ala (Al) by a mean of + 3.17 mm (±1.32 mm). Both of these changes were statistically highly significant (P = 0.000). The increase in the width of the nose corresponded to approximately half of the maxillary advancement distance in over 80 % of the patients. The nasolabial angle declined by an average of -6.65° (±7.71°). CONCLUSIONS: Maxillary advancement correlates with a distinct morphological change in nasal width. This should be taken into account in the treatment approach and in the information provided to patients.

Evaluation of surgically assisted rapid maxillary expansion with piezosurgery versus oscillating saw and chisel osteotomy - a randomized prospective trial.

BACKGROUND: Ultrasonic bone-cutting surgery has been introduced as a feasible alternative to the conventional sharp instruments used in craniomaxillofacial surgery because of its precision and safety. The piezosurgery medical device allows the efficient cutting of mineralized tissues with minimal trauma to soft tissues. Piezoelectric osteotome has found its role in surgically assisted rapid maxillary expansion (SARME), a procedure well established to correct transverse maxillary discrepancies. The advantages include minimal risk to critical anatomic structures. The purpose of this clinical comparative study (CIS 2007-237-M) was to present the advantages of the piezoelectric cut as a minimally invasive device in surgically assisted, rapid maxillary expansion by protecting the maxillary sinus mucosal lining. METHODS: Thirty patients (18 females and 12 males) at the age of 18 to 54 underwent a surgically assisted palatal expansion of the maxilla with a combined orthodontic and surgical approach. The patients were randomly divided into two separate treatment groups. While Group 1 received conventional surgery using an oscillating saw, Group 2 was treated with piezosurgery. The following parameters were examined: blood pressure, blood values, required medication, bleeding level in the maxillary sinus, duration of inpatient stay, duration of surgery and height of body temperature. RESULTS: The results displayed no statistically significant differences between the two groups regarding laboratory blood values and inpatient stay. The duration of surgery revealed a significant discrepancy. Deploying piezosurgery took the surgeon an average of 10 minutes longer than working with a conventional-saw technique. However, the observation of the bleeding level in the paranasal sinus presented a major and statistically significant advantage of piezosurgery: on average the bleeding level was one category above the one of the remaining patients. CONCLUSION: This method of piezoelectric surgery with all its advantages is going to replace many conventional operating procedures in oral and maxillofacial surgery. TRIAL REGISTRATION: CIS 2007-237-M.

Root trauma and tooth loss through the application of pre-drilled transgingival fixation screws.

UNLABELLED: Transgingival fixation screws are used for intermaxillary fixation in different situations. The aim of this study was to evaluate the risk of root trauma and tooth loss using pre-drilled transgingival fixation screws. MATERIAL AND METHODS: 521 patients with mean age 26.9 (SD 9.9) years who had orthognathic surgery or trauma to the maxilla or mandible were selected for the study. Postoperative orthopantomographs (OPT) taken before and after screw removal were examined. The location of the screws and dental-root "hits" were recorded. RESULTS: 1663 screws were inserted either to the maxilla or to the mandible. 285 teeth (17.1%) showed radiologically proven contact between the dental roots and the screws or the dental roots were hit by the screw (screw inserted with more than the screws radius into the root). In three cases (0.2%) teeth were lost due to apical or periradicular inflammation, four teeth (0.2%) had to be root filled and five teeth (0.3%) were persistent painful at the follow-up examination before miniplate removal 10.3 (SD 8.1) months post-surgery. CONCLUSION: Dental problems occurred in 0.7% at the screw insertions sites. The use of transgingival fixation screws showed a low risk of tooth loss. Root defects healed without any incident. However surgeons must be aware of possible consequences to provide a safe treatment.

Use of stereolithographic drilling and cutting guides in bilateral mandibular distraction.

Mandibular distraction osteogenesis is used in the treatment of patients with syndromic and nonsyndromic class II mandibular hypoplasia. The three-dimensional distraction of the mandible is extremely complex. Past experience with mandibular distraction has demonstrated the indispensability of solid presurgical planning to achieve predictable results. We report a method for a virtual three-dimensional planning of the bilateral mandibular distraction with intraoperative transfer by stereolithographic guides. Five patients (mean age, 22.8 years) with bilateral mandibular hypoplasia were examined with preoperative and postoperative computed tomographic scans. The direction and dimension of the distraction were planned on the three-dimensional computed tomographic scans. Tooth- and bone-borne stereolithographic guides for transferring the planning were then applied intraoperatively. It was feasible to transfer and perform the surgery as planned by the use of the stereolithographic drilling and cutting guides. The mean distraction width was 11.33 (SD, 8.32) mm. The mean difference of the distraction width between the planning and the achieved final mandibular position was 1.80 (SD, 0.43) mm. The intercondyle distance decreased by 3.28 (SD, 1.01) mm. A parallel distraction within the planned vectors was achieved. Mandibular distraction osteogenesis in the treatment of severe mandibular hypoplasia needs careful presurgical planning. Parallel distraction and fast placement of the distractors are provided by the planning. The method provides a useful tool for both planning and intraoperative transfer of the virtually preplanned distraction vectors.

Changes after surgically-assisted maxillary expansion (SARME) to the dentoalveolar, palatal and nasal structures by using tooth-borne distraction devices.

Different devices are available to aid surgically-assisted maxillary expansion. In this study we have evaluated the changes to the anchoring teeth, the hard palate, and the lower nasal passage made by tooth-borne distraction devices. Thirty-one patients (mean (SD) age 28 (2) years) with deficiencies in the transverse width of the maxilla were examined by computed tomography and cone beam scans before and after operation. The data were analysed with the help of Wilcoxon's signed rank test and Spearman's r correlation. The mean (SD) distraction width was 6.5 (2.3) mm. All anchorage teeth were tilted (p<0.01). The axes changed by a mean (SD) of 4.8 (0.9)° in the first premolar and 3.1 (0.8)° in the first molar. The nasal isthmus increased by a mean (SD) of 2.5 (0.3) mm. The hard palate adjacent to the anchoring teeth increased anteriorly by a mean (SD) of 2.8 (0.4) mm and posteriorly by 2.7 (0.4) mm. The hard palate was lowered by 1.2 (0.8) mm. There was a significant correlation in the distraction width, with changes in the intercoronal and interapical distances of the anchoring premolars (p<0.05) and with the interapical distance of the anchoring molars (p<0.01). There was also a correlation between the distraction width and the overall gain in width of the lower nasal passage (p<0.05). The results suggested that surgically-assisted maxillary expansion with tooth-borne devices has significant effects on the anchoring teeth, the nasal floor, and the hard palate. Both tilting of the teeth and an evenly distributed movement of the segments were seen.

Changes in the mandibular and dento-alveolar structures by the use of tooth borne mandibular symphyseal distraction devices.

PURPOSE: Different devices to perform a mandibular symphyseal distraction osteogenesis (MSDO) are available. This study evaluates how tooth borne distraction devices change to the teeth, the mandible and the condyles. MATERIALS AND METHODS: 19 patients (mean age 27.1) with anterior width deficiencies of the mandible were examined with routine pre- and postoperative CT-scans 1 month before and 4 months after a mean distraction width of 5.68 mm (SD 0.88). The anchorage teeth of the tooth borne device were examined concerning displacement of their axes as well as the movement of the condyles and the mandibular symphysis. The data were evaluated using Wilcoxon signed rank test and Spearman rho correlation. RESULTS: Significant tilting of the anchorage teeth was observed (p<0.01). The axes changed by 3.32° (SD 1.57) in the first premolar and by 2.63° (SD 1.75) in the first molar. A total of 2.67 mm (SD 1.17) of bone was formed on the symphysis. A significant correlation was found between distraction width and intercoronal distance changes of the anchorage teeth (p<0.01). No significant change of the intercondylar distance was found pre- and postoperatively in the Wilcoxon test. CONCLUSION: MSDO with tooth borne devices has strong effects on the anchorage teeth. No severe effects on the condyles were observed. The postoperative width gain is a result of newly generated bone in the symphysis and tooth tilting. Nevertheless stable postoperative bite corrections are achievable.

Long term effects of surgically assisted rapid maxillary expansion without performing osteotomy of the pterygoid plates.

PURPOSE: Surgically assisted rapid maxillary expansions (SARME) are commonly used to widen the maxilla. This study evaluates long term stability of surgically assisted rapid palatal expansion without performing osteotomy of the pterygoid plates and its effects on nasal airway volume. MATERIALS AND METHODS: 13 patients (mean age 31, 23+/-6, 11) with a maxillary transverse deficit of at least 5mm were examined 1 month before and on average 63 months after a mean palatal distraction of 8.29+/-1.68mm by acoustic rhinometry. Profiles of the nasal airway volumes were collected. A cast model analysis was performed. The data were evaluated using Wilcoxon signed rank test. RESULTS: A V-shaped movement of the segments was observed. The gain for total nasal volume was 23.25%. Findings indicate a significant enhancement of nasal volume in all patients (P<0.01) as result of the maxillary expansion. No relapse occurred in the study group. CONCLUSION: SARME provides a long term stable orthodontic bite correction and permanently enhances the nasal airways. A transverse shift of the segments can be achieved over the whole bony palate even when no osteotomy of the pterygo-maxillary suture is performed.

Complications during mandibular midline distraction.

OBJECTIVE: To analyze the number and type of complications during mandibular midline distraction. MATERIALS AND METHODS: The records of 100 consecutive patients who underwent mandibular midline distraction were evaluated, and complications which occurred up to 2 weeks after surgery were recorded. RESULTS: Fourteen patients had complications during the distraction period. In four cases the screw of the appliance rotated back between the activations. In three cases the osteotomy had to be repeated because the symphysis did not open; two cases developed scar strictures, in another two a lower incisor fractured. One case developed an abscess, one a mandibular swelling, and one a large gingival recession. CONCLUSIONS: Complications during or shortly after mandibular midline distraction surgery are relatively rare and mostly mild or transient. Only 3% of the patients presented irreversible damage. Thus, mandibular midline distraction appears to be a relatively safe method of expanding the mandible.