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.

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.

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.

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.

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.

Long-term stability of two-jaw surgery for treatment of mandibular deficiency and vertical maxillary excess.

Changes in cephalometric landmark positions and relationships were evaluated more than 5 years postsurgically in 26 patients whose long-face condition had been treated with a combination of superior repositioning of the maxilla and mandibular advancement. All the patients had a least 2-mm surgical intrusion of the maxilla and 2-mm lengthening of the mandible with wire osteosynthesis, maxillomandibular fixation, and skeletal suspension wires. On the average, a small amount of downward and backward rotation of the mandible occurred long term. The mean change in overjet was less than 1 mm. Most of the changes occurred in a minority of the patients: 20% of the group had 2 to 4-mm downward movement of menton, and the mandibular plane angle increased more than 2 degrees in 25% of the patients. On clinical evaluation, a tendency toward opening of the bite beyond 1 year postsurgery was noted in 5 of the 26 patients (19%), and one patient had a greater than 4-mm decrease in overbite. The condylion-pogonion distance decreased 2 to 4 mm in three patients, two of whom had shown greater than 4-mm shortening of this distance during the first postsurgical year. It appears that long-term shortening of the condylar process is not a highly prevalent problem, but changes of 2 to 4 mm in condylion-pogonion associated with modest clinical relapse may occur beyond 1 year postsurgery in 5 to 10% of these two-jaw surgery patients.

Stability following superior repositioning of the maxilla by Le Fort I osteotomy: five-year follow-up.

Changes in dental and skeletal relationships were evaluated 5 years postsurgically in 49 patients whose maxilla had been superiorly repositioned by a Le Fort I osteotomy. All of the patients had at least 2 mm of intrusion at the maxillary incisor and molar; none had a mandibular ramus osteotomy or other osteotomy except genioplasty. Only 6.5% had 2 mm or greater of net vertical change in skeletal or dental landmarks at 1 year postsurgery. From 1 to 5 years postsurgery, minimal changes in skeletal and dental landmarks occurred in the majority of the patients, but approximately 25% of the patients showed 2 mm or more of downward movement of the maxilla and/or eruption of maxillary teeth, leading to downward-backward rotation of the mandible. Only one patient had more than 1 mm of open bite on long-term follow-up. An increase in overbite, resulting from incisor eruption, was noted in 14%, and an increase in overjet occurred in 12% as the mandible rotated. It appears that modest long-term skeletal and dental changes occur in some surgically treated long-face patients. The likelihood of long-term change was not related to the age of the patient, stability during the first postsurgical year, or segmentation of the maxilla at surgery.

Recovery following orthognathic surgery: mandibular bilateral sagittal split osteotomy and Le Fort I osteotomy.

Thirty-eight patients, who underwent orthognathic surgery, reported their recovery period upon returning to work or school and returning to full activity. Twenty-six patients had isolated bilateral sagittal split osteotomies (BSSO) and 12 had isolated Le Fort I osteotomies (LFI). At 1 to 2 weeks postoperatively, 50% of the BSSO group had returned to work or school while none of the LFI group had returned. By 3 to 4 weeks, 81% of the BSSO group had returned to work or school while nearly one half of the LFI group still had not returned. The BSSO group returned to full activity earlier than the LFI group, although the differences were not statistically significant. Hemoglobin, hematocrit, weight, and vital signs were determined preoperatively and for 6 weeks postoperatively. The LFI group had a larger mean estimated blood loss, length of operation, and weight loss.

Superior repositioning of the maxilla combined with mandibular advancement: mandibular RIF improves stability.

Postsurgical changes in 24 patients who had rigid internal fixation (RIF) of the mandible with screws after combined superior repositioning of the maxilla and mandibular advancement were compared with 53 patients who underwent the same surgery but who had intraosseous wire fixation, skeletal suspension wires, and 8 weeks of maxillomandibular fixation (MMF). During the first 8 weeks after surgery, the mean posterior relapse of the mandible was greater in the MMF group than in the RIF group (for example, -1.1 mm versus 0.15 mm at B point), and the percentage of patients with clinically significant vertical and horizontal changes was greater in the MMF group. By 1 year, there had been slight additional mean relapse in the MMF group (-1.5 mm net relapse at B point, with 42% of the patients showing 2 mm or more relapse). In the RIF group, the mandible was more likely to be repositioned forward than posteriorly (net mean change at B point, 0.7 mm forward; 33% had 2 mm or more forward movement). In the RIF group, all but one of the patients (96%) were judged to have an excellent clinical result; in the MMF group, the corresponding figure was 60%.

Surgical-orthodontic correction of mandibular deficiency: five-year follow-up.

Changes in dental and skeletal relationships at 5 years postsurgery were evaluated in a group of 35 patients whose mandibular deficiency had been corrected by the same surgeon, using sagittal split osteotomy of the mandibular ramus. From 1 to 5 years postsurgery, there was a small (0.9-mm) but statistically significant mean decrease in mandibular length (condylion to point B). In six patients, the decrease in mandibular length was 2 to 4 mm, and in two it was more than 4 mm, but only one of these individuals had more than a 2-mm increase in overjet. There was no mean change in overjet, but three patients had a 2 to 4-mm increase. Of these, one had 3.2 mm shortening of the mandible, one had 1.4 mm shortening of the mandible, and one had no change in mandibular length but repositioning of the incisors. Most patients had a deep overbite initially, and there was a tendency for the bite to deepen between the first and fifth years postoperatively, more as a result of extrusion of incisors than of mandibular rotation. Remodeling of the gonial angle area, with vertical and/or horizontal repositioning of gonion, was noted in more than half the subjects. It appears that morphologic changes related to continued skeletal remodeling, often compensated for by small changes in mandibular posture or tooth positions, continue after 1 year postsurgery for many patients.