Orbital apex disorders: a case series.

Orbital apex syndrome is an uncommon disorder characterized by ophthalmoplegia, proptosis, ptosis, hypoesthesia of the forehead, and vision loss. It may be classified as part of a group of orbital apex disorders that includes superior orbital fissure syndrome and cavernous sinus syndrome. Superior orbital fissure syndrome presents similarly to orbital apex syndrome without optic nerve impairment. Cavernous sinus syndrome includes hypoesthesia of the cheek and lower eyelid in addition to the signs seen in orbital apex syndrome. While historically described separately, these three disorders share similar causes, diagnostic course, and management strategies. The purpose of this study was to report three cases of orbital apex disorders treated recently and to review the literature related to these conditions. Inflammatory and vascular disorders, neoplasm, infection, and trauma are potential causes of orbital apex disorders. Management is directed at the causative process. The cases described represent a rare but important group of conditions seen by the maxillofacial surgeon. A review of the clinical presentation, etiology, and management of these conditions may prompt timely recognition and treatment.

Three-dimensional regional displacement after surgical-orthodontic correction of Class III malocclusion.

OBJECTIVES: To investigate how displacements of maxillo-mandibular structures are associated with each other at splint removal and 1 year post-surgery following 1-jaw and 2-jaw surgeries for correction of Class III malocclusion. SETTING AND SAMPLE POPULATION: Fifty patients who underwent surgical correction with maxillary advancement only (n = 25) or combined with mandibular setback (n = 25) were prospectively enrolled in this study. METHODS: Cone-beam computed tomographies were taken pre-surgery, at splint removal and at 1 year post-surgery. Three-dimensional cranial base superimpositions and shape correspondence were used to measure the outcomes from pre-surgery to splint removal (surgical changes) and splint removal to 1 year post-surgery (post-surgical adaptations). Pearson's correlation coefficients were used to evaluate the association between the regional displacements. RESULTS: Both surgery groups presented mandibular clockwise rotation with surgery and post-surgical adaptive counterclockwise rotation. In patients treated with maxillary advancement only, the surgical changes of the maxilla were significantly correlated with chin changes. The amount and direction of chin autorotation were significantly correlated with right and left ramus autorotation. Right and left condylar displacements were significantly correlated. One year post-surgery, adaptive displacements and bone remodeling of both rami were correlated with the chin and condylar changes. For the 2-jaw group, the few correlations between the positional and remodeling changes in the anatomic regions of interest observed due to the surgery were different than those observed after post-surgical adaptations, suggesting that these changes occurred independently. CONCLUSION: Our results indicate that surgical displacements and post-surgical adaptations are often correlated in one-jaw surgery and are, in general, independent in two-jaw surgery.

Postoperative nausea and vomiting following orthognathic surgery.

The purpose of this study was to assess the incidence and risk factors associated with postoperative nausea (PON) and vomiting (POV) after orthognathic surgery. A review of the clinical records of consecutively enrolled subjects (2008-2012) at a single academic institution was conducted between 9/2013 and 3/2014. Data on the occurrence of PON and POV and potential patient-related, intraoperative, and postoperative explanatory factors were extracted from the medical records. Logistic models were used for the presence/absence of postoperative nausea and vomiting separately. Data from 204 subjects were analyzed: 63% were female, 72% Caucasian, and the median age was 19 years. Thirty-three percent had a mandibular osteotomy alone, 27% a maxillary osteotomy alone, and 40% had bimaxillary osteotomies. Sixty-seven percent experienced PON and 27% experienced POV. The most important risk factors for PON in this series were female gender, increased intravenous fluids, and the use of nitrous oxide, and for POV were race, additional procedures, and morphine administration. The incidence of PON and POV following orthognathic surgery in the current cohort of patients, after the introduction of the updated 2007 consensus guidelines for the management of postoperative nausea and vomiting, has not decreased substantially from that reported in 2003-2004.

Are bioresorbable polylactate devices comparable to titanium devices for stabilizing Le Fort I advancement?

The purpose of this study was to evaluate whether skeletal and dental outcomes following Le Fort I surgery differed when stabilization was performed with polylactate bioresorbable devices or titanium devices. Fifty-seven patients with preoperative records and at least 1 year postoperative records were identified and grouped according to the stabilization method. All cephalometric X-rays were traced and digitized by a single operator. Analysis of covariance was used to compare the postsurgical change between the two stabilization methods. Twenty-seven patients received bioresorbable devices (group R), while 30 received titanium devices (group M). There were no statistically significant differences between the two groups with respect to gender, race/ethnicity, age, or dental and skeletal movements during surgery. Subtle postsurgical differences were noted, but were not statistically significant. Stabilization of Le Fort I advancement with polylactate bioresorbable and titanium devices produced similar clinical outcomes at 1 year following surgery.

One-year assessment of surgical outcomes in Class III patients using cone beam computed tomography.

The purpose of this study was to apply a novel method to evaluate surgical outcomes at 1 year after orthognathic surgery for Class III patients undergoing two different surgical protocols. Fifty patients divided equally into two groups (maxillary advancement only and combined with mandibular setback) had cone beam computed tomography (CBCT) scans taken pre-surgery, at splint removal, and at 1-year post-surgery. An automatic cranial base superimposition method was used to register, and shape correspondence was applied to assess, the overall changes between pre-surgery and splint removal (surgical changes) and between splint removal and 1-year post-surgery at the end of orthodontic treatment (post-surgical adaptations). Post-surgical maxillary adaptations were exactly the same for both groups, with 52% of the patients having changes >2mm. Approximately half of the post-surgical changes in the maxilla for both groups were vertical. The two-jaw group showed significantly greater surgical and post-surgical changes in the ramus, chin, and most of the condylar surfaces (P<0.05). Post-surgical adaptation on the anterior part of the chin was also more significant in the two-jaw group (P<0.05). Regardless of the type of surgery, marked post-surgical adaptations were observed in the regions evaluated, which explain the adequate maxillary-mandibular relationship at 1-year post-surgery on average, with individual variability.

Soft tissue response to mandibular advancement using 3D CBCT scanning.

This prospective longitudinal study assessed the 3D soft tissue changes following mandibular advancement surgery. Cranial base registration was performed for superimposition of virtual models built from cone beam computed tomography (CBCT) volumes. Displacements at the soft and hard tissue chin (n = 20), lower incisors and lower lip (n = 21) were computed for presurgery to splint removal (4-6-week surgical outcome), presurgery to 1 year postsurgery (1-year surgical outcome), and splint removal to 1 year postsurgery (postsurgical adaptation). Qualitative evaluations of color maps illustrated the surgical changes and postsurgical adaptations, but only the lower lip showed statistically significant postsurgical adaptations. Soft and hard tissue chin changes were significantly correlated for each of the intervals evaluated: presurgery to splint removal (r = 0.92), presurgery to 1 year postsurgery (r = 0.86), and splint removal to 1 year postsurgery (r = 0.77). A statistically significant correlation between lower incisor and lower lip was found only between presurgery and 1 year postsurgery (r = 0.55). At 1 year after surgery, 31% of the lower lip changes were explained by changes in the lower incisor position while 73% of the soft tissue chin changes were explained by the hard chin. This study suggests that 3D soft tissue response to mandibular advancement surgery is markedly variable.

Biodegradable fixation for craniomaxillofacial surgery: a 10-year experience involving 761 operations and 745 patients.

Patient acceptance, safety, and efficacy of poly-l/dl-lactic acid (PLLDL) bone plates and screws in craniomaxillofacial surgery are reported in this article. Included in the sample are 745 patients who underwent 761 separate operations, including more than 1400 surgical procedures (orthognathic surgery (685), bone graft reconstruction (37), trauma (191) and transcranial surgery (20)). The success (no breakage or inflammation requiring additional operating room treatment) was 94%. Failure occurred because of breakage (14) or exuberant inflammation (31). All breakage occurred at mandibular sites and the majority of inflammatory failure occurred in the maxilla or orbit (29), with only two in the mandible. Failures were evenly distributed between the two major vendors. PLLDL 70/30 bone plates and screws may be used successfully in a variety of craniomaxillofacial surgical applications. The advantages include the gradual transference of physiological forces to the healing bone, the reduced need for a second operation to remove the material and its potential to serve as a vehicle to deliver bone-healing proteins to fracture/osteotomy sites. Bone healing was noted at all sites, even where exuberant inflammation required a second surgical intervention.

Sensory retraining: burden in daily life related to altered sensation after orthognathic surgery, a randomized clinical trial.

OBJECTIVE: Assess the long-term effect of sensory retraining exercises, age, gender, type of surgery, and pre-surgical psychological distress on patients' perception of the interference related to altered sensation 2 years after orthognathic surgery. SETTING AND SAMPLE POPULATION: A total of 186 subjects with a developmental dentofacial disharmony were enrolled in a multicenter randomized clinical trial: one center was a community-based practice and the other a university-based center. METHODS AND MATERIALS: Subjects were randomly allocated to two groups: standard of care mouth opening exercises after BSSO or a progressive series of sensory retraining facial exercises in addition to the opening exercises. At 1, 3, 6, 12, and 24 months after surgery, subjects scored unusual feelings on the face, numbness, and loss of lip sensitivity from 'no problem (1)' to 'serious problem (7)'. A marginal proportional odds model was fit for each of the ordinal outcomes. RESULTS: Up to 2 years after surgery, the opening exercise only group had a higher likelihood of reporting interference in daily activities related to numbness and loss of lip sensitivity than the sensory retraining exercise group. The difference between the two groups was relatively constant. Older subjects and those with elevated psychological distress before surgery reported higher burdens related to unusual facial feelings, numbness, and loss of lip sensitivity (p < 0.02). CONCLUSION: The positive effect of sensory retraining facial exercises observed after surgery is maintained over time. Clinicians should consider the patient's age and psychological well-being prior to providing pre-surgical counseling regarding the impact on daily life of persistent altered sensation following a mandibular osteotomy.

Long-term stability of adolescent versus adult surgery for treatment of mandibular deficiency.

In mandibular deficient patients, mandibular growth is not expected after the adolescent growth spurt, so mandibular advancement surgery is often carried out at 13 years. To test if the long-term stability for younger patients is similar to that for adult patients, the authors compared cephalometric changes from 1-year postsurgery (when changes due to the surgery should be completed) to 5-year follow up. 32 patients who had early mandibular advancement with or without simultaneous maxillary surgery (aged up to 16 for girls and 18 for boys), and 52 patients with similar surgery at older ages were studied. Beyond 1-year postsurgery, the younger patients showed significantly greater change in the horizontal and vertical position of points B and pogonion, the horizontal (but not vertical) position of gonion, and mandibular plane angle. 50% of younger patients had 2-4mm backward movement of Pg and another 25% had >4mm. 15% of older patients had 2-4mm change and none had >4mm. Long-term changes in younger patients who had two-jaw surgery were greater than for mandibular advancement only. Changes in younger groups were greater than for adult groups. Satisfaction with treatment and perception of problems were similar for both groups.

Facial altered sensation and sensory impairment after orthognathic surgery.

The aim of this study was to determine whether impairment of sensory functions after trigeminal nerve injury differs in severity among patients who report qualitatively different altered sensations. Data were obtained from 184 patients. Before and at 1, 3 and 6 months after orthognathic surgery, patients were grouped as having no altered sensation, negative sensations only (hypoaesthetic), mixed sensations (negative+active), or active sensations only (paraesthetic or dysaesthetic). Bias-free estimates of contact detection and two-point discrimination were obtained to assess, via ANOVA, whether patients in the four groups exhibited different levels of sensory impairment. Impairment in contact detection and two-point discrimination was found to differ significantly among the groups at 6 months but not at 1 month. At 6 months, patients who reported negative sensations only exhibited the greatest impairment, on average, in contact detection; in contrast, patients who reported mixed sensations exhibited the greatest impairment in two-point discrimination. The least residual impairment at 6 months was observed in patients who reported no altered sensation. It is recommended that clinical judgments regarding nerve injury-associated sensory dysfunction should not be based on threshold testing results without consideration of patients' subjective reports of altered sensation.

Superimposition of 3D cone-beam CT models of orthognathic surgery patients.

OBJECTIVES: To evaluate the registration of 3D models from cone-beam CT (CBCT) images taken before and after orthognathic surgery for the assessment of mandibular anatomy and position. METHODS: CBCT scans were taken before and after orthognathic surgery for ten patients with various malocclusions undergoing maxillary surgery only. 3D models were constructed from the CBCT images utilizing semi-automatic segmentation and manual editing. The cranial base was used to register 3D models of pre- and post-surgery scans (1 week). After registration, a novel tool allowed the visual and quantitative assessment of post-operative changes via 2D overlays of superimposed models and 3D coloured displacement maps. RESULTS: 3D changes in mandibular rami position after surgical procedures were clearly illustrated by the 3D colour-coded maps. The average displacement of all surfaces was 0.77 mm (SD=0.17 mm), at the posterior border 0.78 mm (SD=0.25 mm), and at the condyle 0.70 mm (SD=0.07 mm). These displacements were close to the image spatial resolution of 0.60 mm. The average interobserver differences were negligible. The range of the interobserver errors for the average of all mandibular rami surface distances was 0.02 mm (SD=0.01 mm). CONCLUSION: Our results suggest this method provides a valid and reproducible assessment of craniofacial structures for patients undergoing orthognathic surgery. This technique may be used to identify different patterns of ramus and condylar remodelling following orthognathic surgery.

Skeletal advancement for the treatment of obstructive sleep apnea in children.

OBJECTIVE: Maxillomandibular advancement is curative for some adult patients with obstructive sleep apnea (OSA). Little is known, however, about the efficacy of this treatment in children. The purpose of this retrospective analysis is to assess the clinical outcomes of children with medically refractory OSA who were treated with a variety of procedures to advance the maxillofacial skeleton. METHODS: The records of eight children with OSA (five boys and three girls; mean age, 8.6 years; range, 2 to 17 years) were reviewed. Six children had identifiable syndromes associated with micrognathia, one child had mandibular ankylosis, and one child was nonsyndromic. In five of the children, conventional medical and surgical treatment of OSA had failed; therefore, these children were considered tracheostomy candidates. The remaining three children had had tracheostomies placed in infancy. Specific signs and symptoms with regard to each patient's OSA were identified and recorded. Bronchoscopy was performed preoperatively to evaluate the airway and localize the site of obstruction and again postoperatively if the patient's signs and symptoms recurred. Oxygen saturation and sleep patterns were monitored overnight in the five patients without tracheostomies, revealing a mean apnea index of 25.3 (range, 2.0 to 60.0) and mean lowest desaturation of 73% (range, 62% to 77%). All patients underwent a variety of skeletal procedures to advance the mandible, maxilla, and/or chin. OUTCOME MEASURES: Criteria for success after treatment were twofold: (1) decannulation and (2) cessation or improvement in symptoms facilitating avoidance of tracheostomy. Criteria for failure, likewise, were (1) inability to decannulate and (2) recurrence or nonimprovement in symptoms necessitating tracheostomy. RESULTS: To date, with a mean follow-up time of 7.2 years (range, 19 months to 19 years), the treatment of four of the eight children in our population can be considered a success. Two of the three children with previously placed tracheostomies were able to be decannulated within days of surgery and experienced no further signs or symptoms of OSA. Two other children experienced complete cessation of clinical signs and symptoms and elimination of previous oxygen requirements. Of the four patients in whom treatment failed, three had transient improvement (mean, 6 months) and, despite skeletal stability, eventually experienced relapse of symptoms: one patient with Down syndrome and tracheobronchomalacia required subsequent tracheostomy; the second had a central obstructive component and underwent a ventriculoperitoneal shunt for treatment of a Chiara I malformation; and the third experienced relapse of symptoms due to lack of mandibular growth. The fourth child could not be decannulated because of accompanying tracheal and laryngeal malacia. CONCLUSIONS: Skeletal advancement can be an effective treatment for medically refractory OSA in children. Success, however, is dependent not only on skeletal position but also on neuromuscular adaptation. Bronchoscopy is the most valuable diagnostic and predictive tool.

Long-term stability of surgical open-bite correction by Le Fort I osteotomy.

Skeletal changes greater than those observed in untreated adults have been noted beyond 1 year post-surgery in adult patients who had surgical correction of a long face deformity. The stability of skeletal landmarks and dental relationships from 1 to >3 years post-surgery was examined in 28 patients who had undergone surgery of the maxilla only, and in 26 patients who had undergone 2-jaw surgery to correct >2 mm anterior open bite. Although the average changes in almost all landmark positions and skeletal dimensions were less than 1 mm, point B moved down >2 mm and face height increased >2 mm in one-third of the maxilla-only group and in 40% of the 2-jaw group (>4 mm in 10% and 22% respectively). Overbite decreased 2-4 mm in only 7% of the maxilla-only and 12% of the 2 groups, with no changes >4 mm, because in three-fourths of the patients with an increase in anterior face height, further eruption of the incisors maintained the overbite relationship. In the maxilla-only group, mandibular length (Co-Pg) showed >2 mm long-term change in 45% of the patients, two-thirds of whom showed an increase rather than a decrease in length. In the 2-jaw group, no patients showed a decrease in Co-Pg length and one-third had an increase. For both groups, changes in overjet were smaller and less frequent than changes in mandibular length.

Osseous remodeling after inferior border osteotomy for chin augmentation: an indication for early surgery.

PURPOSE: This study investigated the relationship of age at surgery and type of fixation to the pattern and extent of bone remodeling associated with inferior border osteotomy for chin augmentation. PATIENTS AND METHODS: Four groups of patients with similar chin advancement were established by age at the time of surgery: younger than 15, 15 to 19, 20 to 24, and older than 39 years. Cephalometric radiographs for immediate preoperative, immediate postoperative, and at least 9 months postoperative times were traced, digitized, and superimposed. RESULTS: The pattern of osseous remodeling was similar for all age-groups. This consisted of resorption of the superior-buccal aspect of the distal segment, bone apposition on the buccal surface of the proximal segment, and modest resorption at pogonion (mean change, 1 mm or less). There was no significant difference in stability of the chin advancement between wire and rigid (screw) fixation. There was a marked difference in the symphysis thickness regeneration of the youngest group (92% of the original symphysis thickness) compared with the rest of the groups (< or =66%, P < .001). CONCLUSIONS: Minimal remodeling at pogonion occurs in all age-groups with both wire and rigid fixation. Regeneration of symphysis thickness is much more complete in patients younger than 15 years at the time of surgery. This is potentially important for early treatment of severe chin deficiency, because it permits additional advancement of the chin later in life, if necessary.

A retrospective analysis of lingual nerve sensory changes after mandibular bilateral sagittal split osteotomy.

PURPOSE: The purpose of this retrospective study was to determine the patient-reported incidence, duration, and perceived deficit in daily activities associated with lingual nerve (LN) sensory changes after bilateral sagittal split osteotomy (BSSO) of the mandible and to compare them with inferior alveolar nerve (IAN) sensory changes in the same study population. MATERIALS AND METHODS: Questionnaires were mailed to 316 patients who had undergone BSSO procedures between 1980 and 1993. The patients were queried for perceived sensory changes in the distribution of the IAN and LN; duration of these sensory changes; and alteration in daily activities caused by these sensory changes. The same questionnaire was mailed to 47 patients who had undergone isolated genioplasty (GP) to control for the normal variance of non-BSSO surgery on perceived LN sensory changes. RESULTS: Forty-three percent of the BSSO patients and 38% of the GP patients returned the questionnaires. Within the BSSO group, 19.4% reported LN sensory changes, of which 69.3% reported that these changes resolved within 1 year; 88% reported altered daily activities. By comparison, 95.5% reported a perceived IAN sensory change, of which 27.3% reported that these changes resolved within 1 year; 57% reported altered daily activities. Within the GP control group, 11% reported LN sensory changes; none of the reported sensory changes lasted longer than 1 month. CONCLUSIONS: A small percentage of patients report LN sensory changes after BSSO. When compared with IAN reported sensory changes, LN sensory changes resolve more frequently and sooner, but they are associated with greater perceived deficits in daily activity. The interpretation of the reported incidence of LN change must be critically reviewed because control subjects also responded positively.

A community needs assessment: the care needs assessment pack for dementia (CarenapD)--its development, reliability and validity.

OBJECTIVE: To develop and evaluate a multidisciplinary needs assessment tool for people with dementia living in the community and their carers. DESIGN: The measure was developed through applying a theory of need, generating content, consultation with potential users and refinement and evaluation. Validity was established incrementally through the development process. SETTING: The development and evaluation was conducted in a variety of settings, including multidisciplinary dementia community care teams, social work departments, day hospitals, and inpatient and residential care. PATIENTS: The evaluation included community patients with a formal diagnosis of dementia (N = 34) and consultation with a multidisciplinary group of potential users (N = 23). The development process included inpatients with a formal diagnosis of dementia (N = 157) and consultation with potential users (N = 170) from a range of professions including both health and social care. MEASURES: Interrater reliability was assessed using the kappa statistic. Social validity was estimated using a measure developed for this purpose as part of the development process. RESULTS: The evaluation of interrater reliability demonstrated that three-quarters of assessors agreed on at least 85% of items in the CarenapD. The kappa statistic demonstrated that agreement for 76.2% of items in the CarenapD was 'good' or better (ie kappa >0.75), for 12.4% of items it was 'fair' or 'moderate' (ie kappa 0.35-0.60) and for the remaining 12 (11.4%) items for which kappa could not be calculated there was low intra-item variance and high agreement (>90%). There was good evidence for social validity. CONCLUSIONS: The CarenapD is a reliable and valid multidisciplinary assessment of need for people with dementia living in the community and their carers.

Assessing continuing care needs: findings from the Fife Healthcare Assessment for Placement Project for elderly people.

Previous surveys of elderly patients in different continuing care settings suggest considerable overlap between settings. However, re-analysis of this data in terms of patients' profiles of dependency reveals a somewhat different picture, suggesting that overlap is not such a general phenomenon. Further data from new surveys in Fife confirm this view. The findings of these studies raise questions about some of the previous research on "misplacement' of people in long-stay care, and suggest that planners may need to be more discriminating in their analysis of which types of patient to transfer and what continuing care resources might be required. Failure to address these issues may lead to undue pressure on many of the continuing care placements.

Orthognathic surgery: a hierarchy of stability.

The stability and predictability of orthognathic surgical procedures varies by the direction of surgical movement, the type of fixation, and the surgical technique employed, largely in that order of importance. The most stable orthognathic procedure is superior repositioning of the maxilla, closely followed by mandibular advancement in patients in whom anterior facial height is maintained or increased. (If facial height is decreased by upward rotation of the chin, stability is compromised). The combination of moving the maxilla upward and the mandible forward is significantly more stable when rigid internal fixation is used in the mandible. Forward movement of the maxilla is reasonably stable, with or without rigid internal fixation, but mandibular setback often is not stable, and downward movement of the maxilla that creates downward rotation of the mandible is unstable. For mandibular setback, the inclination of the ramus at surgery appears to be an important influence on stability. It has been suggested that both interpositional synthetic hydroxyapatite grafting and simultaneous ramus osteotomy improve the stability of downward movement of the maxilla, but this has not been well documented. In two-jaw Class III surgery, the stability of each jaw appears to be quite similar to that of isolated maxillary advancement or mandibular setback. The least stable orthognathic procedure is transverse expansion of the maxilla. Although surgically assisted rapid palatal expansion has been suggested as a more stable alternative to segmental Le Fort I osteotomy, the patterns of movement resulting from the two procedures are different, and differences in stability have not been established.