A conceptual framework for treating jaw deformities in patients with abnormal condyles: preservation versus replacement of the glenoid fossa-disc-condyle-ramus.

This article outlines a conceptual approach to the reconstruction of jaw deformities associated with abnormalities in the mandibular condyle. The authors describe a hierarchy of reconstruction, emphasizing use of the least invasive and progressing to the most complex and invasive techniques, depending on the nature and severity of the underlying deformity, prior operations, patient age, and stage of growth. Consider joint preservation orthognathic surgical correction, followed by biological techniques for replacement of the condyle, and avoid replacing a functional temporomandibular joint based only on radiographic remodeling and concerns about potential future flare-ups of disease based on anecdotal data.

Use of a 'low and short' medial cut limits sagittal ramus osteotomy interferences.

The traditional 'high and short' medial cut of the sagittal ramus osteotomy (Hunsuck modification) is a frequent cause of lingual plate interferences in patients undergoing mandibular yaw or cant corrections. We describe how the modified 'low and short' medial cut of the sagittal ramus osteotomy reduces lingual plate interferences with improved passive alignment of the osteotomy segments.

Method of osteotomy fixation and need for removal following bimaxillary orthognathic, osseous genioplasty, and intranasal surgery: a retrospective cohort study.

The purpose of this study was to determine the incidence and causes of fixation hardware removal after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery. A retrospective study was performed, involving subjects with a bimaxillary developmental dentofacial deformity (DFD) and symptomatic chronic obstructive nasal breathing. At a minimum, subjects underwent Le Fort I osteotomy, bilateral sagittal ramus osteotomies (SROs), septoplasty, inferior turbinate reduction, and osseous genioplasty. The primary outcome variable studied was fixation hardware removal. Demographic, anatomical, and surgical predictor variables were assessed. Two hundred sixty-two subjects met the inclusion criteria. Their mean age at operation was 25 years (range 13-63 years); 134 were female (51.1%). Simultaneous removal of a third molar was performed in 39.9% of SROs. Three of 262 Le Fort I procedures (1.1%) and two of 524 SROs (0.4%) required hardware removal. There were four cases of ramus wound dehiscence, four of ramus surgical site infection (SSI), one of chin SSI, two of maxillary sinusitis, and one of lingual nerve injury; none of these subjects underwent hardware removal. A limited need for fixation hardware removal after orthognathic procedures was confirmed. There was no statistical correlation between hardware removal and patient sex, age, pattern of DFD, simultaneous removal of a third molar, or occurrence of wound dehiscence, SSI, or lingual nerve injury.

Lingual nerve injury in association with sagittal ramus osteotomy and bicortical screw fixation: a review of 523 procedures in 262 subjects.

The purpose of this study was to assess the frequency of irreversible lingual nerve (LN) injury in patients undergoing sagittal ramus osteotomies (SRO) with bicortical screw fixation. A retrospective cohort study of patients treated by a single surgeon was performed (follow-up 2-11 years). The sample consisted of a series of subjects with a bimaxillary dentofacial deformity (DFD). The SRO and bicortical screw fixation techniques were consistent. The primary outcome variable was the prevalence of irreversible LN injury. Two hundred sixty-two subjects undergoing 523 SROs with bicortical screw fixation met the inclusion criteria. Average age at operation was 25 years (range 13-63 years) and there were 134 females (51%). The majority of SROs were fixated with three bicortical screws (92%). Simultaneous third molar removal was done in 209 of the 523 SROs (40%). For primary mandibular deficiency subjects (n=40), the mean mandibular advancement was 11.0mm (range 5-17mm), with 42.5% undergoing counter-clockwise rotation. In the study group (n=523 SRO's) there was one irreversible LN injury (<1%). This study confirmed a lack of association of LN injury at the time of SRO with sex, age at operation, simultaneous removal of a third molar, use of bicortical screw fixation, pattern of DFD, and extent of mandibular advancement.

Occurrence of a 'bad' split and success of initial mandibular healing: a review of 524 sagittal ramus osteotomies in 262 patients.

The purpose of this study was to assess the prevalence of a 'bad' split after sagittal ramus osteotomies (SRO) and report the results of initial mandibular healing. A retrospective cohort study derived from patients treated by a single surgeon at one institution between 2004 and 2013 was performed. An index group consisting of a series of subjects with a spectrum of bimaxillary dentofacial deformities also involving the chin and symptomatic chronic obstructive nasal breathing was identified. The SRO design, bicortical screw fixation technique, and perioperative management were consistent. Outcome variables included the occurrence of a 'bad' split and the success of initial SRO healing. Two hundred sixty-two subjects undergoing 524 SROs met the inclusion criteria. Their average age was 25 years (range 13-63 years) and 134 were female (51%). Simultaneous removal of a third molar was performed during 209 of the SROs (40%). There were no 'bad' splits. All subjects achieved successful bone union, the planned occlusion, and return to a chewing diet and physical activities by 5 weeks after surgery. The presence of a third molar removed during SRO was not associated with an increased frequency of a 'bad' split or delayed mandibular healing.

Osseous genioplasty in conjunction with bimaxillary orthognathic surgery: a review of 262 consecutive cases.

The purpose of this study was to evaluate the results of osseous genioplasty with bimaxillary orthognathic surgery. A retrospective consecutive case series of patients treated by a single surgeon between 2004 and 2013 was studied. All underwent Le Fort I, sagittal ramus osteotomies, septoplasty, inferior turbinate reduction, and osseous genioplasty. The outcome variables included the presenting chin dysmorphology, complications, and assessment of morphologic change. A Steiner analysis was completed for each subject's interval cephalogram. Two hundred sixty-two subjects met the inclusion criteria. Their mean age at operation was 25 (range 13-63) years. Chin osteotomy complications included one wound infection (0.4%), and two of the 1572 mandibular anterior teeth at risk sustained a pulpal injury. None of the subjects required revision. For subjects undergoing chin advancement, the mean change was +3.5 (range +3 to +6) mm. A majority also underwent counterclockwise rotation of the mandible (62%). For those undergoing chin lengthening, the mean change was +5 (range +3 to +12mm) mm, and for those undergoing vertical shortening, the mean change was -3.5 (range -3 to -7) mm. Osseous genioplasty is confirmed to be a safe method to reshape the chin. When osseous genioplasty is performed in conjunction with bimaxillary orthognathic surgery, only a modest horizontal change is required to achieve the preferred pogonion projection.

Accuracy of analytic model planning in bimaxillary surgery.

The purpose of this study was to assess our method of analytic model planning in achieving a planned maxillary advancement for the correction of a dentofacial deformity. A consecutive series of 20 patients who underwent bimaxillary orthognathic surgery, at a minimum, were included in the study group. For each study subject, consistent analytic model planning with splint fabrication was used to establish the desired horizontal repositioning of the maxilla. Using preoperative and 5-week postoperative lateral cephalometric radiographs, an analysis was designed to assess the difference between the planned and actual advancement of the maxilla. The average difference between the planned and actual 5-week postsurgical advancement of the maxilla was 0.6 mm (range 0.2-1.0, P>0.05). There was a strong correlation between the two data sets (R=0.96). The results of the study indicate that the described method of analytic model planning is reliable (within 1mm) in achieving the planned level of maxillary advancement in bimaxillary orthognathic procedures.

The craniofacial dysostosis syndromes: current surgical thinking and future directions.

Craniofacial dysostosis is the term applied to familial forms of craniosynostosis in which the sutural involvement generally includes the cranial vault, cranial base, and midfacial skeletal structures. The syndromic forms of craniofacial dysostosis were initially described by Carpenter, Apert, Crouzon, Saethre and Chotzen, Pfeiffer, and others. In addition to the dysmorphic cranial features, affected individuals may have profound alterations in facial skeletal development. Surgical reconstruction requires thoughtfully sequenced and staged procedures with consideration for the individual's specific malformations, craniofacial growth patterns, and psychosocial needs. Management of the craniofacial dysostosis syndromes is surgical, but the indications and the timing, type, and effectiveness of each stage of reconstruction have not been well evaluated and remains as much an art as a science. This article reviews the specific characteristic clinical features of the craniofacial dysostosis syndromes and presents current philosophy and rationale for the staging of reconstruction.

Treacher Collins syndrome: current evaluation, treatment, and future directions.

OBJECTIVE: Treacher Collins syndrome (TCS) is an inherited disorder in which there are general bilateral symmetric anomalies of the structures within the first and second branchial arches. In general, there is complete penetrance and variable expressivity of the trait. The craniofacial rehabilitation of a child with TCS is tailored to the extent of the deformities involved: the orbitozygomatic region, the maxillomandibular region, the nose, facial soft tissues, and external and middle ear structures. CONCLUSION: This article reviews the range of clinical features and specific dysmorphology observed in TCS. Functional and aesthetic objectives are discussed, and a comprehensive staged reconstructive approach is outlined, which may be used as a roadmap for treatment planning.

Fibrous dysplasia of the craniomaxillofacial region: current clinical perspectives.

Fibrous dysplasia is a benign fibro-osseous disease of bone of unknown etiology. Its occurrence in the craniomaxillofacial skeleton is frequent and varies in severity from an asymptomatic monostotic lesion to polyostotic involvement resulting in progressive functional deficit and aesthetic problems. With the advent of refined instrumentation and craniofacial surgical techniques, a more aggressive, non-disabling approach to these benign yet deforming fibro-osseous growths is possible. In some patients, complete excision of the involved bone with graft reconstruction of the resultant defect with primary autogenous bone may be possible. Lifelong continuous ongoing monitoring of the involved region is required throughout the patient's life.

Craniosynostosis and skull molding.

On February 20-23, 1997 in Scottsdale, Arizona, a symposium was held that was sponsored by the Plastic Surgery Educational Foundation, the American Society of Maxillofacial Surgeons, and the Joint Section on Pediatric Neurological Surgery of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. The chairs of the meeting were Jeffrey C. Posnick and Harold L. Rekate. The symposium examined issues relating to craniosynostosis and skull molding. The program consisted of three parts. Day 1 focused on the basic concepts of craniosynostosis and skull molding. Day 2 focused on evaluation and treatment of craniosynostosis. Day 3 focused on the diagnosis and treatment of craniofacial syndromes. The symposium was significant because it brought craniofacial and pediatric neurosurgeons together for the first time at a combined meeting to discuss important aspects of craniosynostosis and skull molding. This article summarizes the presentations made at the meeting.

The craniofacial dysostosis syndromes. Staging of reconstruction and management of secondary deformities.

During the past several decades, since the introduction of craniofacial surgery by Dr. Tessier in 1967, craniomaxillofacial surgery has advanced in many ways. Craniosynostosis is a common craniofacial malformation and requires a thoughtful team approach to select the preferred timing and technical aspects of reconstruction. The current approach to the correction of the deformities associated with the craniofacial dysostosis syndromes is to stage the reconstruction to coincide with facial growth patterns, visceral function, and psychosocial development. Recognition of the need for a staged reconstructive approach serves to clarify the objectives of each phase of treatment both for the clinicians and family. By continuing to define our rationale for the timing, method, and extent of surgical intervention and then objectively evaluating both functional and morphologic outcomes, we will improve the outlook for patients affected by these disorders.

The treatment of secondary and residual dentofacial deformities in the cleft patient. Surgical and orthodontic therapy.

The methods described to manage secondary jay deformities, resulting malocclusion, residual oronasal fistulas, and bony defects in adolescents born with a cleft are safe and reliable when carried out by an experienced cleft surgeon and team. They enhance the patient's quality of life and well-being. They also provide a stable foundation in which final soft-tissue lip and nose revisions may be carried out.

Binder syndrome: staging of reconstruction and skeletal stability and relapse patterns after LeFort I osteotomy using miniplate fixation.

The present study prospectively assesses the skeletal stability in a consecutive series of Binder syndrome patients (n = 7), aged 16 to 20 years, who underwent LeFort I osteotomy fixed with miniplates and the associated morbidity. All patients underwent a one-piece LeFort I osteotomy fixed with four miniplates in conjunction with orthodontic treatment during the period of 1986-1992. Five of seven patients underwent iliac grafting to their deficient premaxilla and interpositionally at their osteotomy sites. Six of seven patients underwent bone graft augmentation of their deficient nose (four costochondral, one cranial, and one iliac). Serial cephalometric radiographs were taken at standard intervals after surgery (1 week, 6-8 weeks, 1 year). Horizontal, anterior vertical, and posterior vertical directional changes were then measured at each interval. With the radiographs superimposed, the amount of change was measured by the method of anatomic best fit. The 1-year postoperative cephalograms also were assessed for overjet and overbite. The medical records were reviewed for morbidity. Each patient had a complete set of longitudinal records. Follow-up ranged from 1.5 to 5.5 years at the close of the study. Perioperative morbidity was unremarkable, other than one patient whose cranial bone graft dehiscence through the nasal skin required regrafting. The mean (effective) maxillary advancement for the group was 6.0 mm, with 5.9 mm maintained 1 year later. The mean anterior vertical change of the maxilla was 4.2 mm, with 3.1 mm maintained; whereas the mean posterior vertical change was 2.8 mm, with 2.2 mm maintained. All patients maintained a positive overjet and overbite at 1 year. In our series, a staged reconstructive approach for Binder syndrome was carried out in the teenage years and included orthodontic treatment, orthognathic surgery, and nasal augmentation. The extent of skeletal relapse of the LeFort I osteotomy fell within a range that could be managed effectively to maintain a long-term positive overjet and overbite.

Symposium "Implantable Materials in Facial Aesthetic and Reconstructive Surgery: Biocompatibility and Clinical Applications". American Society of Maxillofacial Surgeons. Montreal, Quebec, October 6, 1995.

On October 6, 1995, the American Society of Maxillofacial Surgeons sponsored a 1-day symposium entitled "Implantable Materials in Facial Aesthetic and Reconstructive Surgery: Biocompatibility and Clinical Applications." The symposium examined issues relating to the biocompatibility and clinical role of alloplastic materials commonly used for facial bone and soft-tissue replacement and augmentation. It provided a forum for the interaction of basic scientists, clinicians, and manufacturers. Clinical and laboratory data concerning a variety of implantable materials were presented and discussed. The program consisted of three parts. The first session was designed to provide historical and scientific background as well as perspective on legal issues surrounding the use of implantable biomaterials. The second session involved the presentation of clinical data on bone and bone substitutes for augmentation of the facial skeleton. The third session was devoted to clinical reports of bone and bone substitutes used for the reconstruction of cranial vault and cranial base skull defects.