Journal of Oral and Maxillofacial Surgery Special Contribution Predicting the Future Focus of Orthognathic Surgery: Outcome-Driven Planning and Treatment With Function, Esthetics, and Occlusion as Key Indicators.

As we reflect on the last 7 decades since the first descriptions of modern orthognathic surgery (OGS) by Trauner and Obwegeser, we ponder what the next "game-changers" will be over the upcoming decades. We certainly recognize the prior contributions of Hullihen in 1849 and others in the 1920s and 1930s, and the pioneering work of Tessier, Obwegeser, and Bell in the 1960s and 1970s. Although there have been some changes in osteotomy design, as well as the landmark game-changing introduction of rigid internal fixation in the 1970s and 1980s, many of the more recent major changes have occurred only in the past decade or 2. The use of personalized and precision medicine with virtual surgical planning, and patient-specific implants has been transformational. Certainly, there will be more advances in the realm of diagnosis, surgical techniques and protocols, biomaterials and tissue engineering, and surgeon and patient education. But, as an international group of orthognathic surgeons, we believe that the most significant "next big thing" will be a clinical and research focus on patient-oriented outcomes and an improved quality of life. This will require outcome-driven planning and treatment with function, esthetics, and occlusion as key outcome indicators. Here we identify some shared visions and objectives for OGS with the aim to delineate future advancements to enhance the care of patients with dentofacial deformities. While we have organized the sections to cover key areas, the fundamental concepts include advances in these areas: diagnosis and treatment planning (eg, imaging, virtual surgical planning, artificial intelligence, and point-of-care workflows); materials development (eg, patient-specific implant, three-dimensional printing, tissue engineering, biodegradable implants, bone cements, titanium and magnesium implants, and developmental and regenerative medicine); and patient management (eg, minimally-invasive surgery, clear aligner therapy, temporary anchorage devices, outpatient OGS, age-centered treatment, and augmented reality/virtual reality).

Does Open Reduction and Internal Fixation Yield Better Outcomes Over Closed Reduction of Mandibular Condylar Fractures?

PURPOSE: Despite decades of study, a consensus on therapeutic approaches to condylar fractures remains elusive, and the vexing question of invasive or noninvasive therapy remains to be definitively answered. This randomized clinical study aimed to compare the outcomes of mandibular condylar fractures (MCFs) treated by closed reduction (CR) with those treated by open reduction and internal fixation (ORIF). METHODS: The investigators designed and implemented a randomized controlled trial composed of patients with unilateral or bilateral MCFs. Patients were randomly allocated into the ORIF and CR groups. The primary predictor variable was treatment, either CR or ORIF. The primary outcome variable was temporomandibular joint function (pain and range of motion) assessed at 1 and 6 weeks and at 3, 6, and 12 months. The secondary outcomes included occlusion and complications (deviation, facial nerve injury, and scarring). Perioperative covariates included fracture displacement, ramus height loss, and associated mandibular fractures. The effect of treatment group on each of the 12-month outcomes was assessed using the χ2 test or the independent samples t test. A 5% significance level was used. RESULTS: A total of 116 patients with MCFs were included in the study. Sixty-eight (59%) and 48 (41%) patients were treated by CR and ORIF, respectively. No statistically significant differences were observed between the 2 groups for mouth opening (P = .073, protrusion (P = .71), laterotrusive movements toward fractured side (0.080), and nonfractured side (P = .28). The median pain scores decreased from 4 (interquartile range [IQR] 3 to 4) at 6 weeks to 0 (IQR 0 to 0) at 52 weeks and 6 (IQR 5 to 6) at 6 weeks to 0 (IQR 0 to 0) at 52 weeks in the CR and ORIF groups, respectively. Statistically significant differences between the groups were observed for the outcome of malocclusion (P = .040) and deviation (P < .0001). Ramal height loss (P = .013) and angle of displacement (P = .0084) were significantly associated with the presence of complications in the CR group. CONCLUSIONS: The results of the present study have shown that both treatment options for MCFs yield acceptable results. However, CR yielded more complications, especially in patients with bilateral MCFs, ramus height loss greater than 5 mm, and angle of displacement greater than 15°.

Surgical/Orthodontic Correction of Transverse Maxillary Discrepancies.

The transverse dimension is a critical component of comprehensive treatment in orthognathic surgery. Several treatment approaches exist and the team must consider the patient's needs, desires, and limitations when working to correct the malocclusion. Treatment approaches may include only orthodontic expansion or rapid palatal orthodontic expansion; however, in adults, the orthodontist may require surgical assistance to expand the bony maxilla. Segmental maxillary expansion may be indicated in severe transverse deficiencies of the maxillary arch or dentofacial deformity patients also requiring vertical and sagittal corrections. The various treatment options, advantages, and disadvantages, and indications for each surgical approach are discussed.

Reconstruction of 56 mandibular defects with autologous compressed particulate corticocancellous bone grafts.

We retrospectively evaluated the results of particulate corticocancellous bone grafting of mandibular defects. Patients with deficits of mandibular continuity as a result of injuries or resection of disease had the affected segment debrided or resected, followed by placement of a patient-specific reconstruction plate. Eight weeks after resection, it was reconstructed with an autotransplant from the posterior iliac crest. Grafts were deemed successful if the regenerated ossicle (after 6 months' maturation) was adequate to take an osseointegrated fixture at least 10mm long. Fifty-six patients were treated, of whom 5 were lost to follow-up. The remaining 51 patients were followed up for a mean (SD) of 29 (18) months. The mean (SD) length of the defect was 12.4 (8.4) cm. Of the 51 reconstructions, 43 healed uneventfully and the grafts were deemed successful. Two healed grafts developed recurrent tumour, which required resection of the entire reconstructed area in one, and partial resection in the other. Three patients lost the complete graft from sepsis, and five developed sepsis that required debridement with partial loss of the graft. Two patients in the latter group required a second graft. One patient required an augmentation graft, as the ossicle was not sufficient to take an implant. The technique of staged grafting with particulate corticocancellous bone after moulding of the recipient site with a spacer produces unmatched restitution of mandibular anatomy with low morbidity.

Unilateral sagittal split mandibular ramus osteotomy: indications and geometry.

Small mandibular asymmetries may be corrected by unilateral sagittal split ramus osteotomy (USSO). This study had two objectives: first to define the geometric changes in the mandibular condyle and the lower incisor teeth that result from the rotation of the major segment (n=26), and secondly to examine in a clinical study the temporomandibular joints (TMJ) of 23 patients after correction of mandibular asymmetry by USSO to find out if there were any long-term adverse effects. Small mandibular asymmetries (<5mm) can be corrected by USSO. Secondary anteroposterior changes as a result of setback or advancement on the operated side should be taken into account during the planning of treatment. The small rotational changes of the condyle did not adversely affect the TMJ.

Interim reconstruction and space maintenance of mandibular continuity defects preceding definitive osseous reconstruction.

The use of space maintenance in mandibular defects as an interim measure before definitive osseous reconstruction may prevent problems associated with delayed reconstruction including increased technical difficulty, contracture of soft tissues that limits the volume of the final reconstruction, and the potential for iatrogenic injury to adjacent anatomical structures. The use of a condyle/ramus spacer made of medical grade, ultrahigh-molecular-weight polyethylene, and a flexible body spacer made of high quality, inert, non-toxic medical and food grade silicone rubber, was tested in 38 patients with mandibular defects after the resection of benign but locally aggressive disease, advanced osteomyelitis, and injuries. The spacer was retained for a maximum of 8 weeks, and was then removed through an extraoral approach before definitive reconstruction with a particulate corticocancellous bone graft. One of the 38 patients failed to attend for follow up and returned 7 months later with severe, generalised sepsis that required removal of the spacer and exclusion from the study. Of the remaining 37 patients, 32 healed uneventfully, 1 required removal of the spacer 2 weeks after implantation for intraoral wound dehiscence, and 4 had mild to moderate disturbances of wound healing that required either minor revision or local wound care until removal at the time of reconstruction. The use of a spacer promotes wound healing and simplifies and expedites secondary reconstruction of mandibular defects.

Reoperative orthognathic surgery.

The best time to perform orthognathic surgery for the correction of dentofacial deformities is the first time. However, complications requiring reoperation do occur. A thorough understanding of how to avoid intra- and postoperative complications, and how to manage these problems successfully, is mandatory. This article discusses some of the most common complications, how to avoid these complications, and how to treat complications when they do occur. General surgical complications during and after surgery, such as hemorrhage and infection, are outside the scope of this article.

Comparison of titanium and resorbable copolymer fixation after Le Fort I maxillary impaction.

INTRODUCTION: Advances in skeletal stabilization techniques have led to the use of titanium devices for rigid fixation. Their advantages include strength and skeletal stability, but they also have disadvantages. The purpose of this study was to investigate the stability of a resorbable copolymer as a potential alternative to titanium for fixation of Le Fort I maxillary impaction. METHODS: Fifty consecutive patients underwent maxillary impaction with nonsegmental monopiece Le Fort I osteotomy. Twenty-five patients were treated with titanium fixation; 25 patients were treated with resorbable copolymer fixation (82% poly-L-lactic acid: 18% polyglycolic acid). Lateral cephalograms were obtained 1 week preoperatively, 1 week postoperatively, and a minimum of 8 months postoperatively. Linear and angular measurements were recorded digitally to evaluate 2-dimensional skeletal changes. RESULTS: Statistical analysis showed no significant radiographic differences (P <0.05) in long-term stability in or between the 2 groups. No clinical or radiographic evidence of wound healing problems was noted. CONCLUSIONS: These results support the use of resorbable copolymer fixation for Le Fort I impaction as a viable alternative to titanium fixation.

Anterior open bite correction by Le Fort I or bilateral sagittal split osteotomy.

Some of the most challenging dentofacial deformities facing surgeons and orthodontists are anterior open bite malocclusions. Determining the cause for the development of an anterior open bite and formulating a diagnosis are complicated by the role of neuromuscular and genetic influences. Long-term skeletal and dental stability has been a concern because of the influence that the neuromusculature has on the repositioned jaws and stability of teeth after vertical orthodontic mechanics required for closing open bites.

Basic guidelines for the surgical correction of mandibular anteroposterior deficiency and excess.

During the past decades, knowledge and understanding of all aspects of orthognathic surgery have increased greatly. Diagnostic skills and treatment planning have become more sophisticated and, through experience, surgical techniques have attained a level enabling the treatment of the most complex jaw deformities with confidence. In this article, guidelines for the treatment of mandibular anteroposterior dentofacial deformities are discussed. It should, however, always be kept in mind that the face and mouth are complex, three-dimensional structures and multifunctional in character. An artistic flair and the ability to think originally have become essential for the orthognathic surgeon, because no two dentofacial deformities are the same.

Maxillary sinus pathology in 119 patients--a histopathologic study.

INTRODUCTION: Information on histopathological changes within sinus mucosa is lacking, both in the general population, and in subjects with specific facial morphology and chronic respiratory obstruction. AIMS AND OBJECTIVES: To provide baseline data of the frequency and nature of pathological changes in the maxillary sinus in a specified group of patients. METHODS: 119 patients undergoing elective maxillary osteotomies were selected. These included patients with (70) and without (49) vertical maxillary excess (VME), and mouth and nasal breathers. The frequency and nature of the histopathological changes within the maxillary antral lining were recorded. RESULTS: Patients ranged from 13 to 47 years, with a M:F ratio of 1:2.4. The findings included congestion (95%), submucosal oedema (90%), retention cysts (26%), true polyps (4.6%) and inflammation. There was eosinophilia (68%), basement membrane thickening (28%), goblet cell hyperplasia (95%) and dystrophic calcification (59%). CONCLUSIONS: A significant degree of sinus pathology was found in this specified group of patients. This was probably due to their living in a polluted urban environment. In the presence of such widespread pathological changes and the virtual impossibility of obtaining "normal" control tissue, investigators may find it impossible to correlate maxillary sinus pathology with either facial form or breathing pattern.

Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy.

PURPOSE: To evaluate a method to identify condylar sag intraoperatively by clinical examination after bilateral sagittal split osteotomy (BSSO). METHODS: We prospectively studied 184 patients (121 female, 63 male) who had BSSO. The same surgeon operated all patients over a period of 15 months using the same technique. All patients had mandibular advancements. A standard condylar seating technique was used. The occlusion was evaluated at operation and 1 week later. RESULTS: Eighteen patients had an incorrect occlusion diagnosed during the operation after removal of the IMF. Peripheral condylar sag (type II) had developed in three of these patients. In 15 patients central sag was diagnosed. One-week postoperatively, three patients had a malocclusion as a result of condylar sag. CONCLUSION: Meticulous examination of the occlusion and an understanding of the occlusal changes secondary to condylar sag can reliably identify condylar sag intraoperatively. The use of suitable corrective measures during the primary operation can substantially reduce the postoperative complication rate of condylar sag.

Mandibular, sagittal split osteotomies fixed with biodegradable or titanium screws: a prospective, comparative study of postoperative stability.

OBJECTIVE: Comparison of skeletal stability following bilateral sagittal split osteotomy (BSSO) advancement of the mandible fixed with titanium or biodegradable bicortical screws. STUDY DESIGN: Forty consecutive patients underwent mandibular advancement by means of BSSO performed with a standardized technique. In 20 patients rigid fixation was achieved by means of titanium bicortical screws; the other 20 patients were fixed with biodegradable copolymer screws made of poly-L-lactic acid (82%) and polyglycolic acid (18%). Lateral cephalograms were obtained 1 week preoperatively, 1 week postoperatively and after a minimum of 6 months postoperatively. Relevant skeletal points were traced and digitized to evaluate 2-dimensional skeletal change. Changes at each time point were analyzed and compared statistically. RESULTS: There was no statistically significant difference in long-term stability between the 2 groups. No clinical or radiographic evidence of wound healing problems were noted. CONCLUSION: Resorbable poly-L-lactic/polyglycolic acid copolymer bicortical screw fixation of a BSSO is a viable alternative to titanium screws for the fixation of advancement BSSO.

Age as a factor in the complication rate after removal of unerupted/impacted third molars at the time of mandibular sagittal split osteotomy.

PURPOSE: This study was designed to investigate the effect that the presence of an unerupted third molar has on the mandibular sagittal split osteotomy (SSO). PATIENTS AND METHODS: One operator performed 139 SSOs (70 right side and 69 left side) in 70 patients during a period of 6 months. Data related to gender, age, presence or absence of unerupted third molar teeth, split difficulty during SSO, fracture complications of the segment, neurovascular bundle involvement at surgery, removal of unerupted third molar teeth, and the postoperative recovery of nerve function were recorded. RESULTS: The SSOs evaluated as technically difficult were significantly more prevalent in mandibles with unerupted third molar teeth. All fractures (4) occurred in the younger age group (<20 years) with unerupted third molars present at the time of surgery. Although inferior alveolar nerve recovery was slower in the patients in whom the unerupted third molar teeth were present at the time of surgery due to increased frequency of neurovascular bundle manipulation, the recovery rates at 1 year were equal. CONCLUSIONS: The presence of unerupted third molar teeth increases the degree of difficulty of the SSO. Fracture of proximal and/or distal segments during SSO tend to occur more frequently in the younger age group (<20 years) with an unerupted third molar present.