Cleft lip and palate: a review for dentists.

The goals of primary closure of cleft lip and palate include not only re-establishing normal insertions for all of the nasolabial muscles but also restoring the normal position of all the other soft tissues, including the mucocutaneous elements. Conventional surgical wisdom, which recommends waiting until growth is complete before undertaking surgical correction of the postoperative sequelae of primary cheiloplasty, carries with it many disadvantages. If, after primary surgery of the lip, orolabial dysfunctions remain, they will exert their nefarious influences during growth and will themselves lead to long term dentofacial imbalances. These imbalances can significantly influence facial harmony. Unless accurate, symmetric and functional reconstruction of the nasolabial muscles is achieved during the primary surgery, not only will the existing dentoskeletal imbalances be exaggerated, but other deformities will be caused during subsequent growth, among which the most important are nasal obstruction and mouth breathing, reduced translation of the maxilla, dysymmetry of the nose and inability of the patient to symmetrically project the upper lip

Presence of impacted teeth as a determining factor of unfavorable splits in 1256 sagittal-split osteotomies.

OBJECTIVES: The purpose of this study was to determine the incidence of unfavorable mandibular fracture in sagittal-split osteotomies in the presence or absence of impacted third molar teeth. STUDY DESIGN: This retrospective study evaluated 1256 mandibular sagittal-split osteotomies in two groups of patients: Group I had impacted third molar teeth removed during sagittal-split osteotomy; in Group II, the third molar teeth had been removed at least 6 months before the sagittal-split osteotomy. Statistical testing consisted of chi-square analysis of contingency table for p < 0.05. RESULTS: In 1256 mandibular sagittal-split osteotomies there were 24 (1.9%) with unfavorable fractures. Five of 24 occurred when third molar teeth were removed at the time of osteotomy and 19 of 24 mandibular fractures occurred when no impacted third molar tooth was present at the time of osteotomy. However, no significant difference was demonstrated between the groups. CONCLUSION: The result of this study suggests that mandibular fractures may occur with greater frequency when the impacted third molar teeth have been removed at least 6 months before sagittal-split osteotomy as compared with that when third molar teeth are removed concomitant with sagittal-split osteotomy.

Effect of primary surgery for cleft lip and palate on mid-facial growth.

Surgery for cleft lip and palate is known to have an effect on growth and development of the mid-face. This paper studies the outcomes in 34 consecutive 10-year-old patients with unilateral cleft lip and palate. Clinical observations of the importance of both surgical technique and the influence of cranial base morphology on maxillo-mandibular position are discussed.

A comparison of patient-controlled and fixed schedule analgesia after orthognathic surgery.

PURPOSE: The purpose of this prospective study was to compare the effectiveness of patient-controlled intravenous (i.v.) opioid analgesic administration (PCA) with fixed schedule and dosage oral/rectal administration of naproxen, and opioid analgesics intramuscularly/orally as needed (i.m./p.o. prn) for postoperative analgesia over a period of 48 to 56 hours after surgery. PATIENTS AND METHODS: There were 75 orthognathic patients aged 25.73 +/- 8.01 years, subdivided into three study groups of 25: codeine group (8 males, 17 females); naproxen group (5 males, 20 females) and PCA group (8 male, 17 females). The degree of analgesia was assessed every 4 hours from 8:00 AM to 8:00 PM hours on days 1 and 2 postsurgery using a visual analog scale (VAS). Mean daily and mean overall VAS scores were treated as parametric data and were analyzed accordingly. Mean daily VAS scores also were categorized as comfort days when mean scores were less than 3.0 cm, and as discomfort days when mean scores were equal to or greater than 3.0 cm. ANOVA were used to analyze patient demographics, pain scores, surgical time, fentanyl used during general anaesthesia, analgesic morphine equivalents, and vital signs. Chi-square tests were used to analyze sex, comfort (discomfort) days, and nausea and vomiting. Mean VAS ratings were analyzed using independent t-tests. RESULTS: The three groups were matched in demographics, surgical time, fentanyl used, and sex. The PCA group used less than half the amount of morphine equivalent as the codeine group (P = .0001). Both the naproxen and the PCA groups were significantly more comfortable than the codeine group during day 1 and day 2 postsurgery. The codeine group had significantly more episodes of nausea than either the naproxen or the PCA groups. CONCLUSION: In patients undergoing orthognathic surgery, the naproxen and PCA regimens provided better analgesia than the codeine regimen.

Induced hypotensive anesthesia for adolescent orthognathic surgery patients.

PURPOSE: This study compared blood loss, quality of surgical field, and duration of procedure with and without induced hypotensive anesthesia in adolescent orthognathic surgery patients. PATIENTS AND METHODS: Fifty orthognathic surgery patients were studied in a prospective, randomized, blocked, stratified, and single-blind fashion. All patients underwent either sagittal ramus split osteotomy or Le Fort I osteotomy or genioplasty. One group of patients (n = 25) had induced hypotension; the other group (n = 25) received anesthesia with no attempt to deliberately reduce blood pressure during the operation. The surgeon, unaware of to which group the patient had been assigned, rated the surgical field every 15 minutes. At completion of surgery, three different methods were used to estimate or calculate blood loss. Duration of the procedure was recorded from time of first incision to time of last suture placement. The data were analyzed using ANOVA, chi-squared, and linear regression, where appropriate. RESULTS: Estimated blood loss was significantly less when induced hypotensive anesthesia was used. The surgical field was better, but there was no significant difference in duration of the procedure with induced hypotensive anesthesia. CONCLUSION: Induced hypotensive anesthesia results in both reduced blood loss and improvement in surgical field.

Orthognathic surgery and the family dentist.

In general, orthognathic surgery is a reliable, appropriate and prudent treatment option to correct maxillofacial deformities that cannot be managed by nonsurgical means alone. Unfavorable outcomes are relatively rare, but the statistical frequency of these complications loses its meaning in those cases where they occur. If a complication happens to an individual patient, it represents a one-hundred per cent incidence for that individual. For this reason, prior to the provision of treatment it is vitally important to obtain informed consent, ideally by establishing the widest possible information base on which meaningful communication can be built for the patient, the orthodontist, the surgeon, and the family dentist.

[Class II dento-skeletal dysmorphism. Observations apropos of orthodontic-surgical treatment]. / Dysmorphoses dento-squelettiques de Classe II. Réflexions à propos du traitement orthodontico-chirurgical.

The Classe II maxillofacial deformities are common, varied in their expression and most frequently have both dental and skeletal components. For this reason, combined orthodontic-surgical treatment is well suited to correction of problems from which the patient suffers. Several clinical deductions are presented which pertain to diagnosis and treatment of Class II vertical excess deformities.

Prophylactic extraction of third molars in cancer patients.

Most studies on third molar extractions focus on the potential of tooth-associated pathoses when justifying or questioning the extraction. Scant attention is paid to potential medical problems of the patient "attached" to the third molar. This study presents 28 consecutive cancer cases seen by one dentist over a 2-year period in which third molars had a significant impact on the health of the patient and on their course of cancer therapy. In 15 patients on whom extractions were performed, 40% experienced postoperative complications. Prophylactic extraction of partially erupted or impacted third molars in cancer patients before their cancer therapy is recommended on the basis of the following observations: (1) the increased risks and difficulties associated with post-cancer-treatment extraction, (2) the potential for third molars to produce pathoses in immunocompromised patients before, during, or immediately after their anticancer treatment, and (3) the management of third molars may interfere with the patient's cancer treatment.

Pterygoid plate fracture in Le Fort I osteotomy with and without pterygoid chisel: a computed tomography scan evaluation of 58 patients.

The incidence of pterygoid plate fracture as determined by computed tomography (CT) scan is much higher than that determined at surgery. This observation is irrespective of whether a chisel is used to effect pterygo-maxillary separation.

Clinical observations of cleft lip and palate.

In surgical management of cleft lip and palate, appreciation of the special anatomy and physiology of the human premaxilla is more important than the question of whether it is a separate bone. To take advantage of the potential of the premaxilla, both primary and secondary surgical procedures must strive to establish a nearly normal medial septal system and nasolabial musculature. To complement accurate muscle surgery of the lip and soft palate, the characteristics and functions of the mucoperiosteum that covers the palate must be respected. The quality of subsequent facial growth can be monitored with the architectural craniofacial cephalometric analysis. By adopting a physiologic approach to cephalometrics, the clinician can avoid some common errors of interpretation.

[Risks and benefits of extraction of impacted third molars: A critical review of the literature. 2]. / Risques et bénéfices de l'ablation des troisième molaires incluses: revue critique de la littérature--Partie 2.

In part I of this critical review of the literature on the risks and benefits of removing impacted third molars, we have dealt with: I--Risks of non-intervention. This second part is about: II--Risks of intervention, III--Benefits of non-intervention, and, finally, IV--Benefits of intervention.

Steroid acne after orthognathic surgery.

Steroid acne is a common unwanted effect in patients undergoing corticosteroid therapy. Eight women in a series of 1276 adult patients had acne after orthognathic surgery in which short-course parenteral corticosteroid therapy was used to reduce postoperative swelling. Steroid-induced acneiform eruption is different from acne vulgaris in that the former usually resolves on its own, without scar formation, after withdrawal of the drug.

[Risks and benefits of removal of impacted third molars: critical review of the literature. 1]. / Risques et bénéfices de l'ablation des troisième molaires incluses: revue critique de la littérature--Partie 1.

Because of the ever-increasing enthusiasm that new graduates have demonstrated for practising minor oral surgery procedures, the authors believed that it would be useful to translate the results of a research project done in 1990 by Drs. David S. Precious and Paul Mercier, who are well-known oral and maxillofacial surgeons. This paper is about the risks and benefits associated with the removal of impacted third molars.

The use of mandibular symphyseal bone in maxillofacial surgery.

Mandibular symphyseal bone (MSB) is useful in alveolar cleft grafting and orthognathic surgery. This paper reports on the application and techniques using MSB.

Function: the basis of facial esthetics.

Inadequate primary surgery, or a failure to establish muscular balance of the anterior face, causes muscular dysfunction. Muscular dysfunction has a nefarious effect on subsequent facial growth. Establishment of muscular balance, as early as possible, provides the best foundation for good esthetics.

[Lefort 1 osteotomy. The proposal of an outline modification]. / Ostéotomie de Lefort 1. Proposition de modification du tracé.

A modified outline of Lefort 1 osteotomy using an "inverse step" design is proposed which ensures simple and effective down-fracture and pterygo-maxillary separation. Osteosynthesis of the mobilized fragment is facilitated due to the improved contact of bone surfaces, particularly laterally. Combined rigid and supple osteosyntheses allow some degree of post-operative adjustment.

Anatomic placement of fixation devices in genioplasty.

The form of the anterior mandible in 45 patients was assessed before, immediately after, and 1 year after genioplasty. A specific, consistent pattern of bone apposition and resorption was observed after advancement genioplasty. A consistent but inverse apposition-resorption pattern was observed after reduction genioplasty. In view of the observed pattern of bony change, it is recommended that fixation devices for genioplasty be placed in areas of future bone deposition.