Active Unilateral Condylar Hyperplasia Treated With Simultaneous Condylectomy and Orthognathic Surgery: A Clinical Report.

PURPOSE: To review and report the demographic and diagnostic data in a population with active unilateral condylar hyperplasia. The surgical intervention, sequencing of surgery, and treatment outcomes, including a quality-of-life survey, are described. MATERIALS AND METHODS: Eighty patients were diagnosed with active disease. Demographic, treatment, and treatment outcomes were assessed. Quality of life was assessed by a 21-question questionnaire. RESULTS: Women were affected more frequently than men (W - 52; 65%; P = .008). Hemimandibular elongation (HE) (49; 61%; P - .004) occurred more frequently than hemimandibular hyperplasia (HH) (24; 30%) and HH-HE (7; 9%). Right side was affected more than left (R - 49; 61%; P - .003) overall, and when stratified. All racial groups were represented. Of the 80 patients in the sample, 80 (100%) underwent condylectomy on the side of active growth, 70 (87%) underwent bimaxillary osteotomies, 53 patients (66%) had single-piece maxillary osteotomies, 17 (21%) underwent segmental maxillary osteotomies, and 38 (48%) genioplasties were performed. Four patients (5%) underwent a second operation within a year of the first surgery to adjust the position of the mandible. Four (5%) facial nerve deficits were recorded. Class I cuspid occlusion was achieved with coincident maxillary and mandibular midlines and resolution of crossbite in 70 (88%) patients. Twenty three of the 24 respondents (96%) reported that they were satisfied with the treatment. CONCLUSIONS: Both HH and HE are diagnosed through clinical and radiographic examinations. Our results showed that HE occurs more frequently, all deformity subclassifications occur more frequently in females, the majority present in adolescence, and all racial groups are affected. The right side predominated. This study suggests that simultaneous condylectomy and orthognathic surgery provides predictable and stable outcomes for patients with active unilateral condylar hyperplasia and associated dentofacial deformities with an improvement in quality of living.

Changes in scleral exposure following modified Le Fort III osteotomy.

OBJECTIVE: The Kufner modified Le Fort III osteotomy (LFIII) can be used to address midface deficiency, which is often accompanied by excessive scleral exposure. The purpose of this project is to analyze the changes in scleral exposure after a LFIII. METHODS: Thirteen patients with midface hypoplasia were treated with LFIII. Scleral surface area (SSA) was determined by pixel count and the distance from the inferior eyelid margin to the center of the pupil (MED) was measured pre- and postoperatively. Intraclass correlation coefficients were calculated to assess measurement reliability and repeated measures analysis of variance (ANOVA) were determined to assess systematic difference among the replicates. RESULTS: The interquartile range for change in SSA ranged from -31% to -7%, median 20% (P = .002) and the interquartile range for change in MED ranged from -21% to -12%, median -18% (P = .0002). CONCLUSIONS: SSA and MED can be reliably determined using the aforementioned method. The LFIII decreases scleral exposure.

Postdischarge Nausea and Vomiting Remains Frequent After Le Fort I Osteotomy Despite Implementation of a Multimodal Antiemetic Protocol Effective in Reducing Postoperative Nausea and Vomiting.

PURPOSE: To assess the prevalence of postdischarge nausea and vomiting (PDNV) after Le Fort I osteotomy with and without the use of a multimodal antiemetic protocol shown to decrease postoperative nausea and vomiting (PONV). MATERIALS AND METHODS: Consecutive patients undergoing Le Fort I osteotomy with or without additional procedures at a single academic institution formed the intervention cohort for an institutional review board-approved prospective clinical trial with a retrospective comparison group. The intervention cohort was managed with a multimodal antiemetic protocol. The comparison group consisted of consecutive patients who underwent similar surgical procedures at the same institution before protocol implementation. All patients were asked to complete a postdischarge diary documenting the occurrence of nausea and vomiting. Those who completed the diaries were included in this analysis. Data were analyzed with the Fisher exact test and the Wilcoxon rank sum test. A P value less than .05 was considered significant. RESULTS: Diaries were completed by 85% of patients in the intervention group (79 of 93) and 75% of patients in the comparison group (103 of 137). Patients in the intervention (n = 79) and comparison (n = 103) groups were similar in the proportion of patients with validated risk factors for PDNV, including female gender, history of PONV, age younger than 50 years, opioid use in the postanesthesia care unit (PACU), and nausea in the PACU (P = .37). The prevalence of PDNV was unaffected by the antiemetic protocol. After discharge, nausea was reported by 72% of patients in the intervention group and 60% of patients in the comparison group (P = .13) and vomiting was reported by 22% of patients in the intervention group and 29% of patients in the comparison group (P = .40). CONCLUSION: Modalities that successfully address PONV after Le Fort I osteotomy might fail to affect PDNV, which is prevalent in this population. Future investigation will focus on methods to minimize PDNV.

Unilateral mydriasis after maxillary osteotomy: a case series and review of the literature.

PURPOSE: To present 4 cases of unilateral mydriasis associated with orthognathic surgery and to review the differential diagnosis and management related to this condition. MATERIALS AND METHODS: Four cases of unilateral mydriasis associated with orthognathic surgery were identified from the authors' institutional experience. All maxillary osteotomies performed by the authors' department from 2001 to 2013 were identified based on Current Procedural Terminology codes; 4 cases of unilateral mydriasis were found. Cases are presented and the literature is reviewed. RESULTS: Two male and 2 female patients with an age range of 16 to 34 years developed unilateral mydriasis after maxillary osteotomy; the estimated prevalence is 0.004%. Although the precise cause can be difficult to determine, in this series 1 case was attributable to swelling affecting contents of the superior orbital fissure, 1 was related to edema or medications, and 2 were pharmacologically induced. CONCLUSION: Although rare, a review of the differential diagnosis for and management of unilateral mydriasis associated with orthognathic surgery is pertinent to those who perform corrective jaw surgery.

Multimodal protocol reduces postoperative nausea and vomiting in patients undergoing Le Fort I osteotomy.

PURPOSE: To assess the impact of a multimodal antiemetic protocol on postoperative nausea and vomiting (PONV) after Le Fort I osteotomy. MATERIALS AND METHODS: Consecutive patients undergoing Le Fort I osteotomy with or without additional procedures at a single academic institution were recruited as the intervention cohort for an institutional review board-approved prospective clinical trial with a retrospective comparison group. The intervention cohort was managed with a multimodal antiemetic protocol, including total intravenous anesthesia; prophylactic ondansetron, steroids, scopolamine, and droperidol; gastric decompression at surgery end; opioid-sparing analgesia; avoidance of morphine and codeine; prokinetic erythromycin; and fluids at a minimum of 25 mL/kg. The comparison group consisted of consecutive patients from a larger study who underwent similar surgical procedures before protocol implementation. Data, including occurrence of PONV, were extracted from medical records. Data were analyzed in bivariate fashion with the Fisher exact and Wilcoxon rank-sum tests. Logistic regression was used to compare the likelihood of nausea and vomiting in the 2 cohorts after controlling for demographic and surgical characteristics. A P value less than .05 was considered significant. RESULTS: The intervention (n = 93) and comparison (n = 137) groups were similar in gender (58% and 65% female patients; P = .29), race (72% and 71% Caucasian; P = .85), age (median, 19 and 20 years old; P = .75), proportion of patients with known risk factors for PONV (P = .34), percentage undergoing bimaxillary surgery (60% for the 2 groups), and percentage for whom surgery time was longer than 180 minutes (63% and 59%; P = .51). Prevalence of postoperative nausea was significantly lower in the intervention group than in the comparison group (24% vs 70%; P < .0001). Prevalence of postoperative vomiting was likewise significantly lower in the intervention group (11% vs 28%; P = .0013). The likelihood that patients in the comparison group would develop nausea was 8.9 and that for vomiting was 3.7 times higher than in the intervention group. CONCLUSION: This multimodal protocol was associated with substantially decreased prevalence of PONV in patients undergoing Le Fort I osteotomy.

Long-term 3-dimensional stability of mandibular advancement surgery.

PURPOSE: To evaluate 3-dimensional changes in the position of the condyles, rami, and chin from 1 to 3 years after mandibular advancement surgery. MATERIALS AND METHODS: This prospective observational study used pre- and postoperative cone-beam computed tomograms of 27 subjects with skeletal Class II jaw relation and normal or deep overbite. An automatic technique of cranial base superimposition was used to assess positional and bone remodeling changes that were visually displayed and quantified using 3-dimensional color maps. Analysis of covariance with presence of genioplasty, age at time of surgery, and gender as explanatory variables was used to estimate and test adjusted mean changes for each region of interest. RESULTS: The chin rotated downward and backward 1 to 3 years after surgery. Changes of at least 2 mm were observed in 17% of cases. Mandibular condyles presented with displacements or bone remodeling of at least 2 mm on the anterior surface (21% of cases on the left side and 13% on the right), superior surface (8% on right and left sides), and lateral poles (17% on left side and 4% on right). Posterior borders of the rami exhibited symmetric lateral or rotational displacements in 4% of cases. CONCLUSION: In the hierarchy of surgical stability, mandibular advancement surgery is considered one of the most stable surgical procedures. However, 1 to 3 years after surgery, approximately 20% of patients had 2- to 4-mm changes in horizontal and vertical chin positions or changes in condylar position and adaptive bone remodeling.

Changes in the pattern of patients receiving surgical-orthodontic treatment.

INTRODUCTION: The characteristics of patients who seek and accept orthognathic surgery appear to be changing over time but have not been well documented in the 21st century. METHODS: Records for patients who had orthognathic surgery at the University of North Carolina from 1996 to 2000 and from 2006 to 2010 were reviewed to collect data for changes in the prevalence of patients with mandibular deficiency (Class II), maxillary deficiency or mandibular prognathism (Class III), long face, and asymmetry problems. The changes were compared with those in previous time periods and at other locations. RESULTS: Between 1996 and 2000 and between 2006 and 2010, the percentage of Class III patients increased from 35% to 54%, and the percentage of Class II patients decreased from 59% to 41%, while the percentages for long face and asymmetry showed little change. The decrease in Class II patients was accentuation of a long-term trend; the increase in Class III patients occurred only after the turn of the century. CONCLUSIONS: A similar but less-marked change has been noted at some but not all other locations in the United States. It appears to be related primarily to an increase in the numbers of African Americans, Native Americans, Hispanics, and Asians who now are seeking surgical treatment, but it also has been affected by changes in where orthognathic surgery is performed, decisions by third-party payers (insurance and Medicaid) about coverage for treatment, and the availability of nonsurgical orthodontic treatment options for Class II patients.

Orbital anatomy for the surgeon.

An anatomic description of the orbit and its contents and the eyelids directed toward surgeons is the focus of this article. The bone and soft tissue anatomic nuances for surgery are highlighted, including a section on osteology, muscles, and the orbital suspensory system. Innervation and vascular anatomy are also addressed.

Stability after mandibular setback: mandible-only versus 2-jaw surgery.

PURPOSE: The objective of this study was to evaluate whether changes in the technique for mandibular setback surgery since the introduction of rigid internal fixation have improved postoperative stability in Class III correction with setback alone and 2-jaw surgery. PATIENTS AND METHODS: Cephalometric (skeletal and dental) outcomes for 17 patients with mandibular setback alone were compared with outcomes in 83 patients with 2-jaw surgery for Class III correction. Demographic characteristics in the 2 groups were similar, and the mean amount of setback (-4.7 mm) was the same; however, given a mean maxillary advancement of 4.9 mm, the 2-jaw patients had a greater total Class III correction. RESULTS: Greater than 4 mm of posterior movement of the gonion at surgery and a resulting significant change in ramus inclination were found in 8 of the mandible-only patients (47%) but only 1 of the 2-jaw patients (1%). Postoperatively, the mean changes for the 2 groups were similar, with mean forward movement of the chin (pogonion) of 2.8 mm in both groups, but the mechanism was different. In the mandible-only patients, the major reason for forward movement of the chin was recovery of ramus inclination. In the 2-jaw group, about half the change in chin position was because of forward movement of the gonion; the other half was because of small upward movement of the maxilla that allowed upward-forward rotation of the mandible. In both groups there was a significant correlation (r = 0.42, P < .0001) between postoperative change in the position of the chin and gonion. CONCLUSIONS: Despite improvements in surgical techniques for mandibular setback since 1995, postoperative stability still leaves something to be desired, but there is better control of the ramus position when 2-jaw surgery is performed.

Sensory retraining after orthognathic surgery: effect on patient report of altered sensations.

INTRODUCTION: The purpose of this analysis was to determine whether, over a 2-year period after bilateral sagittal split osteotomy, patients who received facial sensory-retraining exercises with standard opening exercises in the first 6 months after surgery were as likely to report an alteration in facial sensation as those who received standard opening exercises only. METHODS: 186 subjects were enrolled in a multi-center, double-blind, stratified-block, randomized clinical trial with 2 parallel groups. Patient reports of altered sensations were obtained before surgery, and 1, 3, 6, 12, and 24 months after surgery. A marginal model was fit to examine the effect of sensory retraining while controlling for potential explanatory effects related to demographic, psychological, and clinical factors on the odds of postoperative altered sensations being reported. RESULTS: Age (P <0.0001) and severity of presurgical psychological distress (P <0.0001) were significantly associated with the presence of altered sensations after controlling for the exercise training received. After controlling for age and psychological distress, patients who received opening exercises only were approximately 2.2 times more likely to report postoperative altered sensations than those who also received sensory-retraining exercises (P <0.03). CONCLUSIONS: These results suggest that a simple noninvasive exercise program started shortly after orthognathic surgery can lessen the likelihood that a patient will report altered sensations in the long term after orthognathic surgery.

Retained third molars with orthodontics and orthognathic surgery.

PURPOSE: The aim of this study was to document the prevalence of retained third molars after orthodontics and orthognathic surgery. PATIENTS AND METHODS: Inclusion criteria for these retrospective analyses included all subjects in a longitudinal trial at least 18 years old at enrollment with Class II skeletal problems, treated presurgery with orthodontics followed by orthognathic surgery. Panoramic or lateral cephalometric radiographs were analyzed to assess the presence and relationship to the occlusal plane of third molars and the presence or absence of premolars, recorded at enrollment, presurgery, and postsurgery for each subject. The primary outcome measure was the presence of third molars postsurgery. Explanatory variables included third molar position at the occlusal plane and missing premolars. Because of the few retained third molars postsurgery, analyses are limited to descriptive statistics only. RESULTS: The majority of the 372 subjects were female (80%) and Caucasian (91%). Median age at enrollment was 32.3 years (interquartile range, 27.0-39.6). At entry 145 subjects had at least 1 third molar; 57% of third molars present were at the occlusal plane, and 27% of quadrants in the 145 subjects had at least 1 missing premolar. Sixty subjects had at least 1 third molar postsurgery, 84% of third molars present were at the occlusal plane, and 44% of quadrants had at least 1 missing premolar. CONCLUSIONS: Third molars retained after treatment for dentofacial deformity with orthodontics and orthognathic surgery were more likely to be at the occlusal plane and tended to be in quadrants with missing premolars.

Sensory retraining after orthognathic surgery: effect on patients' perception of altered sensation.

PURPOSE: The primary research hypothesis was that the magnitude and duration of the perceived burden from altered sensation reported by patients after bilateral sagittal split osteotomy and trauma to the third division of the trigeminal nerve are decreased when facial sensory retraining exercises are performed in conjunction with standard opening exercises as compared with standard opening exercises alone. SUBJECTS AND METHODS: A total of 186 subjects were enrolled in a multicenter, double-blind, 2 parallel group-stratified block randomized clinical trial. Oral and facial pain, unusual sensations, numbness, and loss of sensitivity were scored from "no problem" to "serious problem" before surgery and 1 month, 3 months, and 6 months after surgery. A proportional odds model for the ordered multinomial response was used to compare the responses of the 2 exercise groups. RESULTS: The 2 exercise groups did not differ significantly at any postsurgical time in terms of perceived problem level from intraoral of facial pain. The difference between the 2 groups at each visit was not statistically significant for unusual sensations, although the trend was for the sensory retraining group to have a higher likelihood of reporting fewer problems. By 6 months, the likelihood of a subject reporting lower problem or interference level related to numbness or decreased lip sensitivity was significantly higher in the sensory-retraining group, approximately twice that of the opening exercise-only group. CONCLUSIONS: Our results support the premise that a simple noninvasive exercise program initiated shortly after orthognathic surgery can lessen the objectionable impression of negative altered sensations.

The hierarchy of stability and predictability in orthognathic surgery with rigid fixation: an update and extension.

A hierarchy of stability exists among the types of surgical movements that are possible with orthognathic surgery. This report updates the hierarchy, focusing on comparison of the stability of procedures when rigid fixation is used. Two procedures not previously placed in the hierarchy now are included: correction of asymmetry is stable with rigid fixation and repositioning of the chin also is very stable. During the first post-surgical year, surgical movements in patients treated for Class II/long face problems tend to be more stable than those treated for Class III problems. Clinically relevant changes (more than 2 mm) occur in a surprisingly large percentage of orthognathic surgery patients from one to five years post-treatment, after surgical healing is complete. During the first post-surgical year, patients treated for Class II/long face problems are more stable than those treated for Class III problems; from one to five years post-treatment, some patients in both groups experience skeletal change, but the Class III patients then are more stable than the Class II/long face patients. Fewer patients exhibit long-term changes in the dental occlusion than skeletal changes, because the dentition usually adapts to the skeletal change.

Self-reinforced biodegradable screw fixation compared with titanium screw fixation in mandibular advancement.

PURPOSE: This report compares the skeletal stability and treatment outcomes of 2 similar cohorts undergoing bilateral sagittal osteotomies of the mandible for advancement. The study groups included patients stabilized with 2-mm self-reinforced polylactate (PLLDL 70/30), biodegradable screws (group B), and 2-mm titanium screws placed in a positional fashion (group T). MATERIALS AND METHODS: Sixty-nine patients underwent bilateral sagittal osteotomies of the mandibular ramus for advancement utilizing an identical technique. There were 34 patients in group B and 35 patients in group T. Each patient had preoperative, immediate postoperative, splint out, and 1-year postoperative cephalometric radiographs available for analysis. The method of analysis and treatment outcomes parameters are identical to those previously used. Repeated measures analysis of variance was performed with means of fixation as the between-subject factor and time as the within subject factor. The level of significance was set at .01. RESULTS: There were no clinical failures in group T and a single failure in group B. The average difference in stability between the groups is small and subtly different at the mandibular angle. The data documented similarity of the postsurgical changes in the 2 groups with the only statistically significant difference being the vertical position of the gonion (P < .001) and the mandibular plane angle (P < .01) with greater upward remodeling at gonion in group T. CONCLUSIONS: Two-mm self-reinforced PLLDL (70/30) screws can be used as effectively as 2-mm titanium screws to stabilize the mandible after bilateral sagittal osteotomies for mandibular advancement. The difference in 1-year stability and outcome is minimal.

Mandibular distraction osteogenesis in children.

Distraction osteogenesis is currently considered a useful treatment option for the correction of specific facial skeletal deformities. Although it is apparent that distraction may have significant potential and broader application in the management of maxillofacial problems, very few comprehensive scientific data exist, making it difficult to describe its exact role in the reconstructive oral and maxillofacial surgeon's armamentarium. This article reviews the biological basis for distraction osteogenesis, potential applications, and current surgical approaches for mandibular distraction in children.

Perceptions of recovery and satisfaction in the short term after orthognathic surgery.

PURPOSE: A 2-arm, parallel-group, stratified-block, randomized clinical trial was designed to assess whether patients' perceptions of recovery and satisfaction 4 to 6 weeks after surgery were affected by 3 factors: preparation strategy (viewing a visual treatment simulation), attitudes (expectations about recovery), and psychologic distress (reported before surgery). PATIENTS AND METHODS: One hundred eighty-four patients with a dentofacial disharmony scheduled for orthognathic surgery were randomly assigned to 1 of 2 preparation strategy groups: a standard presurgical consultation with or without a computerized treatment simulation presentation. Psychologic well-being and expectations regarding recovery were obtained before surgery and perceptions of recovery, and satisfaction were assessed for 126 patients at 4 to 6 weeks after surgery. RESULTS: Viewing a treatment simulation before surgery did not affect patients' perceptions of postsurgical discomfort or satisfaction at 4 to 6 weeks after surgery. Patients who overestimated the discomfort or problems they would experience reported significantly lower average level of problems than those who did not overestimate. Patients who were psychologically distressed before surgery reported, on average, significantly more discomfort or difficulty with symptoms, social/self-concerns, general health, and overall recovery after surgery. CONCLUSION: Viewing a treatment simulation before surgery does not, on average, negatively affect perception of symptoms or satisfaction 4 to 6 weeks after surgery. Orthognathic surgery patients who are psychologically distressed before surgery tend to report a higher recovery burden overall and, on average, experience more difficulty with symptoms, social/self-concerns, and general health in the first 1 or 2 months after surgery.