Does the Rigid External Distraction Device Alter Maxillary Pitch in Cleft Maxillary Distraction?

The rigid external distraction (RED) device is reported to have the ability to three-dimensionally reposition the maxilla. The purpose of this study is to assess the ability of RED to intentionally alter the maxillary pitch.Retrospective cohort study.Institutional practice.A retrospective chart review was completed over the past 12 years and a total of 50 patients met the inclusion criteria.Cephalometric changes and alteration in palatal plane angle.Cephalometric analysis of standardized landmarks was completed on calibrated, standardized lateral cephalograms. Pre-distraction and post-consolidation variables were compared via a two-tailed paired t-test.The mean age at surgery of 12.2 ± 3.2 years. Through distraction osteogenesis (DO), the maxilla was moved anteriorly with a mean distraction distance of 8.4 ± 4.8 mm. The mean change in the angles sella-nasion-A-point angle (SNA), sella-nasion-B-point angle (SNB), and A-point-nasion-B-point angle (ANB) were 10.2 ± 4.8, 0.9 ± 2.7, and 9.3 ± 4.1, respectively. The mean change in the palatal plane angle was -4.4 ± 3.7. The mean change in the vertical position of the anterior nasal spine (ANS) and posterior nasal spine (PNS) in relation to the Frankfort horizontal (FH) were -2.0 ± 4.1 mm and 1.7 ± 3.8 mm, respectively.This study documents short-term findings of RED in a large cleft lip and palate (CLP) population. Despite positioning of distraction eyelets superior to the theoretical center of resistance, a counterclockwise (CCW) rotation of the palatal plane occurred. This suggests that adjunctive methods of vector control should be considered if clockwise (CW) rotation of the palatal plane is intended with the RED device.

Comparison of airway changes after maxillomandibular advancement with or without genial tubercle advancement in obstructive sleep apnea using cone-beam computed tomography.

INTRODUCTION: This study compared the airway changes of patients with obstructive sleep apnea (OSA) after maxillomandibular advancement (MMA) with or without genial tubercle advancement (GTA) using cone-beam computed tomography. METHODS: The authors retrospectively studied 26 patients with moderate to severe OSA who underwent MMA with or without GTA. Airway changes were determined from preoperative and postoperative 3-dimensional reconstructed cone-beam computed tomography images. The Wilcoxon signed rank test, Mann-Whitney U tests, and Spearman correlation coefficients were used in data analysis. RESULTS: Airway was changed in all dimensions significantly after MMA with or without GTA. There was no significant difference in horizontal surgical changes between MMA and MMA with the GTA group. The mean increase in total airway volume was 66.8% for MMA alone and 74.7% for MMA with GTA (P = 0.39). Patients who underwent MMA had a larger percentage change of segmented upper airway volume than patients with MMA and GTA (106.6% vs 85.3%; P = 0.65). The group with MMA and GTA had a greater percentage change of segmented lower airway volume than the MMA alone group (80.1% vs 56.3%; P = 0.42). CONCLUSIONS: Differences in airway changes between MMA alone and MMA with GTA were not statistically significant. Performing the GTA concomitantly with MMA may not cause greater improvement in the pharyngeal airway in patients with OSA compared with MMA alone.

Does Early Secondary Alveolar Bone Grafting Influence Need for Additional Maxillary Advancement Procedures in Cleft Lip and Palate?

OBJECTIVE: To determine if secondary alveolar bone grafting (SABG) timing in patients with cleft lip and palate (CLP) influences the future need for additional maxillary advancement procedures, particularly Le Fort I osteotomy with rigid external distraction (RED). DESIGN: Retrospective cohort study. Groups were separated by SABG timing: early mixed dentition (ages 68 years) or late mixed dentition (ages 9-11 years). The criterion for RED was negative overjet ≥8 mm, and sufficient dental development for RED. SETTING: Single tertiary care institution. PATIENTS: Patients with CLP that underwent SABG from 2010 to 2015. Exclusion criteria included syndromic conditions, SABG surgery at age >12 years, current age <12 years, and <2 years follow-up. 104 patients were included. MAIN OUTCOME MEASURES: The number of RED candidates and treated patients. RESULTS: There was no statistical difference in the number of RED candidates (P = .0718) nor treated patients (P = .2716) based on SABG timing; stratification by laterality was also insignificant. Early SABG is associated with higher odds of being a RED candidate (pooled, unilateral, bilateral) and treated patient (pooled and unilateral); however, there were no statistically significant associations between SABG timing and the number of RED candidates and treated patients as determined by logistic regression models. CONCLUSION: There is no statistically significant association between SABG timing and the odds of being a RED candidate or treated patient. Future prospective studies are recommended to assess the relationship between SABG timing and maxillary growth in patients with CLP.

Is Orthognathic Correction with TMJ Preservation A Stable Treatment Option for Patients with Juvenile Idiopathic Arthritis?

Purpose: The purpose of this study was to evaluate the long-term skeletal stability of orthognathic correction of dentofacial deformities secondary to juvenile idiopathic arthritis (JIA) in individuals without total alloplastic joint reconstruction. Materials and Methods: The investigators designed and implemented a retrospective case series of patients diagnosed with JIA who underwent bimaxillary orthognathic surgery. To evaluate the long-term skeletal changes, the maxillary palatal plane to mandibular plane angle, anterior facial height, and posterior facial height measurements were evaluated through cephalograms. Results: Six patients met inclusion criteria. All subjects were female (mean 16.2 years). Four patients demonstrated < 1° of change of the palatal plane to mandibular plane angle, and all patients had < 2° of change. Three patients had < 1% change in the anterior to posterior facial height ratio. Three patients demonstrated relative posterior facial shortening compared to anterior facial height (< 4%). No patients developed postoperative anterior open-bite malocclusion. Conclusion: Orthognathic correction of the JIA DFD deformity with TMJ preservation is a viable modality to improve facial esthetics, occlusion, upper airway and speech swallowing and chewing mechanisms in select patients. The measured skeletal relapse did not affect the clinical outcome.

A combined orthodontic / orthognathic approach in the management of obstructive sleep apnoea: Balancing treatment efficacy and facial aesthetics.

Obstructive sleep apnoea (OSA) is a prevalent condition and has been extensively managed with orthognathic surgery using a variety of surgical techniques. This case report describes the successful management of a 56-year-old Caucasian woman with a bimaxillary retrusive profile and macroglossia complicated by OSA and the combined use of orthodontics and orthognathic surgery to improve Apnoea-Hypopnoea Index while maintaining facial aesthetics. The non-extraction treatment plan included: (1) pre-surgical orthodontic treatment to maximise aesthetics and functional occlusion after surgery; (2) maxillomandibular advancement using down fracture of the maxilla (Le Fort 1 osteotomy) with counter-clockwise rotation as well as bilateral sagittal split osteotomy with septoplasty to aid increase in airway function; and (3) post-surgical orthodontic finishing and alignment with self-ligating fixed appliances. Optimum aesthetic and functional results as well as an increase in the airway volume were achieved, without compromising facial aesthetics, with the cooperation of two specialties and the use of state-of-the-art technology during the surgical planning stages.

Enhancing the Orthognathic Surgery Experience: Treatment in 10 Weeks "Surgery First" Approach.

This case report describes the successful treatment of a 25-year-old male with maxillary retrognathism, skeletal and dental Class III malocclusion, anterior and posterior crossbite, negative overjet and overbite, mild mandibular crowding, and lower midline deviation. The nonextraction treatment plan included: (1) maxillary and mandibular arch fixed appliance and (2) Le Fort 1 maxillary osteotomy and postsurgical orthodontic treatment. The orthodontic treatment was initiated with 0.022" preadjusted brackets bonded to all the teeth except the maxillary second molars, 2 days before the surgery without any archwires. Two weeks after the surgery, maxillary and mandibular arch alignment along with the occlusal adjustments was started with the use of 0.018" NiTi wires, in both arches. Optimum esthetic and functional results were achieved in 10 weeks after the surgery, with the cooperation of two specialties and the use of surgery first approach.

Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.

This case reports the unsuccessful first treatment and the subsequent retreatment of a 35-year old Asian female with a skeletal class II with bimaxillary protrusion, complicated by a deep bite and vertical maxillary excess. This case report highlights the multiple facets of a challenging treatment plan and discusses the ramifications of treatment when treatment does not go as planned. The initial treatment plan consisted of a surgical approach with a maxillary Le Fort I surgery to correct the malocclusion as per the patient's requests without mandibular surgery due to the inherent risk of paraesthesia. The second treatment plan consisted of a bimaxillary surgery with genioplasty. The surgical treatment utilized virtual surgical planning (VSP). The orthodontic treatment was concluded with a corrected overjet and overbite achieving optimum function and balancing the facial profile aesthetically. This case report highlights the need for clear communication of the treatment plan and also the unpredictability of certain treatment outcomes especially when the literature does not provide for definitive conclusions. In addition, it sheds light on the challenge of unpredictable response of soft tissue after surgical treatment and the importance of patient expectations of outcomes. It is hoped that the paper provides a platform for future discussions of difficult malocclusions.

Long-Term Postoperative Cone-Beam Computed Tomography Analysis of Secondary Bone Grafting in 79 Patients With Unrepaired Alveolar Clefts.

PURPOSE: This study used cone-beam computed tomography (CBCT) analysis to assess the long-term radiographic outcomes of early secondary alveolar bone grafting. PATIENTS AND METHODS: The most recent postoperative CBCT scans of 79 alveolar cleft patients who underwent anterior iliac crest bone grafting by a single surgeon over a 6-year period and met all inclusion criteria were analyzed using a modified assessment tool. Clefts were measured vertically, horizontally, and superiorly in terms of nasal support and then assigned corresponding scores of 0 to 4 to help determine radiographic success. The sites were deemed poor (score of 0 or 1), acceptable (score ≥ 2), or favorable (score ≥ 3). Similarly, overall clefts (vertical plus horizontal scores) were classified as poor (score of 0 to 3), acceptable (score ≥ 4), or favorable (score ≥ 5). Statistical analysis was used to characterize patient demographic characteristics, to perform subgroup comparisons, and to identify factors specifically predictive of favorable outcomes. RESULTS: The study included 79 patients with a total of 105 clefts. Male patients comprised 60.8% of patients, and 32.9% of patients had a bilateral cleft. The average age at the time of surgery was 8 years 0 months, and the average time until the most recent postoperative CBCT scan was 2 years 8 months. The average scores were as follows: vertical, 2.9 (maximum score possible, 4); horizontal, 3.1 (maximum score possible, 4); nasal support, 2.7 (maximum score possible, 4); and overall cleft, 6.0 (maximum score possible, 8). All 79 patients were discharged on postoperative day 1, and the regraft rate was 0%. Multivariate analysis showed that younger patients had a significantly higher chance of achieving favorable results in terms of vertical scores (P = .0081) and overall cleft scores (P = .0204). The association between younger age and horizontal scores was marginally significant (P = .0667), but no significant association was found between age and nasal support. CONCLUSIONS: Younger patients have improved long-term radiographic success with grafted alveolar clefts. This finding supports performing anterior iliac crest bone grafting at a younger age in cleft lip patients.

Virtual surgical planning: Balancing esthetics, practicality, and anticipated stability in a complex Class III patient.

The treatment of skeletal Class III malocclusion with anterior open bite is a complex and challenging aspect of orthodontics. Facial esthetic factors, practicality and the anticipated stability of a provisional surgical plan must all be factored into the final decision of the actual orthodontic-orthognathic treatment. This case report presents the multidisciplinary treatment of a 39-year-old female patient with skeletal Class III, severe open bite with first dental contact being on the second molars, lateral crossbite, and crowding in both arches. The nonextraction treatment started with aligning and leveling of the teeth in both arches followed by an initial surgical plan based on the clinical evaluation of the smile esthetics. Precise surgical planning information was imported into the Virtual Surgica (VSP Orthognathics) workflow to visualize the direction and amount of movement necessary. The final plan was adjusted because of anticipated practical limitations of the surgery as well as to insure the stability. LeFort I, bilateral sagittal split osteotomies, and setback genioplasty were thus performed. After the surgery, the treatment concluded with the fine adjustment of the occlusion. In the end, good esthetic and functional outcomes with long-term stability were achieved as a result of this delicate multidisciplinary approach.

Comprehensive treatment approach for bilateral idiopathic condylar resorption and anterior open bite with customized lingual braces and total joint prostheses.

This case report describes the successful treatment of a 14-year-old girl with severe bilateral idiopathic condylar resorption and resultant mandibular retrusion, increased overjet, and anterior open bite. The nonextraction treatment plan included (1) aligning and leveling the teeth in both arches, (2) performing Le Fort I maxillary osteotomy, bilateral condylectomy, and mandibular joint replacement, and (3) postsurgical correction of the malocclusion. The orthodontic treatment was initiated with the use of custom lingual appliances followed by orthognathic surgery planned with virtual surgical planning. Patient-fitted and customized temporomandibular joint implants were designed and manufactured based on the patient's stereolithic bone anatomic model. Treatment was concluded with detailed orthodontic finishing. Optimum esthetic and functional results were achieved with the cooperation of 2 specialties and the use of state-of-the-art technology.

Risk Factors for Intraarticular Heterotopic Bone Formation in the Temporomandibular Joint in Juvenile Idiopathic Arthritis.

OBJECTIVE: Intraarticular corticosteroid (IAC) injections are often used to treat temporomandibular joint (TMJ) arthritis associated with juvenile idiopathic arthritis (JIA). One potential complication of IA therapy is heterotopic bone formation (HBF). The purpose of our study was to evaluate risk factors for HBF development in children with JIA who received IA therapy for TMJ arthritis. METHODS: This was a retrospective study of children with JIA who had received ≥ 1 IAC injection into the TMJ. Survival regression analysis was performed to identify risk factors for the development of HBF. RESULTS: There were 238 children included, of whom 33 (14%) developed HBF. No cases of HBF were diagnosed prior to the initial injection. Univariate analysis revealed that the risk factors for development of HBF were the total number of injections received into the TMJ and age at diagnosis of JIA, while the length of time from diagnosis of JIA to the first injection was inversely associated with the risk of HBF formation. The total number of injections was no longer significant following adjusted survival models. Children with HBF had increased physical examination evidence of acute or chronic changes, namely decreased maximal incisal opening and increased likelihood of jaw deviation. CONCLUSION: HBF within the TMJ is relatively common in patients with JIA receiving IAC injections for TMJ arthritis. Future prospective studies are required to delineate the risks posed by the injections themselves as opposed to the underlying disease activity, as well as to evaluate alternative forms of local therapy to the TMJ.

Temporomandibular joint arthritis in juvenile idiopathic arthritis, now what?

BACKGROUND: Arthritis involving the temporomandibular joint (TMJ) complicates 40 - 96% of cases of juvenile idiopathic arthritis (JIA), potentially leading to devastating changes to form and function. Optimal evaluation and management of this joint remains a matter of ongoing discussion. METHODS: We performed a PubMed search for all articles with keywords "temporomandibular" and "arthritis", covering the dates 2002 through February 28, 2018. A separate PubMed search was performed for all articles with keywords "temporomandibular joint", "arthritis", and "treatment" covering the same dates. FINDINGS: The TMJ is a particularly challenging joint to assess, both clinically and with imaging studies. Clinical assessment of the TMJ is hampered by the low sensitivity of joint pain as well as the absence of physical exam findings early in the disease process. As with all joints, plain radiography and computed tomography only detect arthritic sequelae. Additionally, there is mixed data on the sensitivity of ultrasound, leaving magnetic resonance imaging (MRI) as the optimal diagnostic modality. However, several recent studies have shown that non-arthritic children can have subtle findings on MRI consistent with TMJ arthritis, such as joint effusion and contrast enhancement. Consequently, there has been an intense effort to identify features that can be used to differentiate mild TMJ arthritis from normal TMJs, such as the ratio of the enhancement within the TMJ itself compared to the enhancement in surrounding musculature. With respect to treatment of TMJ arthritis, there is minimal prospective data on medical therapy of this complicated joint. Retrospective studies have suggested that the response to medical therapy of the TMJ may lag behind that of other joints, prompting use of intraarticular (IA) therapy. Although most studies have shown short-term effectiveness of corticosteroids, the long-term safety of this therapy on local growth as well as on the development of IA heterotopic bone have prompted recommendations to limit use of IA corticosteroids. Severe TMJ disease from JIA can also be managed non-operatively with splints in a growing child, as well as with surgery. CONCLUSION: In this review, we summarize literature on the diagnosis and management of TMJ arthritis in JIA and suggest a diagnostic and therapeutic algorithm for children with refractory TMJ arthritis.

Maxillary Distraction Osteogenesis in Unilateral Cleft Lip and Palate Patients with Rigid External Distraction System.

AIM: Distraction osteogenesis (DO) is a treatment option for patients with maxillary hypoplasia secondary to cleft lip and palate (CLP). PURPOSE: The aim of this study is to present a technique for maxillary DO using Le Fort I osteotomy with rigid external distraction (RED) system. SUBJECTS AND METHODS: The patient presented in this paper was an Asian female with CLP aged 13 years and 6 months. She presented with severe midfacial deficiency with a Class III dental malocclusion with a negative overjet and concave facial profile. Cone-beam computed tomography images were recorded preoperatively and the operation performed involved a high Le Fort I osteotomy. The appliance fabricated was banded to upper first molars used for anchorage of the RED system. Distraction of the maxilla was initiated after 7-day latency period. RESULTS: Postoperative cephalometric analysis showed maxillary advancement anteriorly and superiorly, the total distraction treatment period was 10 days. The maxillary advancement was 10.5 mm and the SNA angle increased from 67.5° to 77.9°. Furthermore, the ANB angle changed from -9.8° to 1.6° and the occlusion changed from Class III to Class I. The profile of the face changed from concave to convex and a much better esthetic result was achieved. CONCLUSION: The study suggests RED system to be a reliable alternative procedure for the treatment of midfacial hypoplasia with or without cleft. Furthermore, it minimizes the risk of the surgical procedure and shortens the operating time.

The Surgical Management of Skeletal Disproportion with Lingual Orthodontics and Three-dimensional Planning.

This case report describes the successful treatment of a 26-year-old Caucasian male with skeletal and dental Class III malocclusion associated with mild maxillary and mandibular crowding. The patient had anteroposterior and transverse discrepancies with a reverse overjet and bilateral posterior crossbites. The nonextraction treatment plan included aligning and leveling of the teeth in both arches, Le Fort I and bilateral sagittal split osteotomies, and postsurgical correction of the malocclusion. Orthodontic treatment was initiated with custom lingual appliances followed by orthognathic surgery planned with virtual surgical planning. Treatment was concluded with detailed orthodontic finishing, achieving optimum esthetics and function.

Comprehensive treatment approach for condylar hyperplasia and mandibular crowding with custom lingual braces and 2-jaw surgery.

We report on the successful treatment of a 32-year-old woman with condylar hyperplasia and severe mandibular crowding. In addition, her maxilla was canted to the right, her mandibular midline and chin point deviated to the left, and her maxillary canines were missing. The treatment plan included (1) aligning and leveling the teeth in both arches, (2) correcting overbite and overjet, (3) performing LeFort I osteotomy and bilateral split osteotomies, and (4) correcting the malocclusion postsurgically. The orthodontic treatment was performed with custom lingual braces and clear brackets, and virtual surgical planning techniques were used to plan the orthognathic surgery. The condylar hyperplasia and the mandibular crowding were corrected. At the end of treatment, the patient's face appeared symmetrical. The results suggest that esthetic and functional results can be achieved with the cooperation of 2 specialties and the use of state-of-the-art technology.

Does Practice Type Determine the Complexity of Patients Encountered for Orthognathic Surgery?

PURPOSE: This study sought to determine whether the type of oral and maxillofacial surgery (OMS) practice dictated the complexity of patients encountered for orthognathic surgery and to determine whether there were meaningful differences in comorbidities between patient groups. MATERIALS AND METHODS: This was a retrospective cohort study of orthognathic surgical patients operated on by surgeons at an academic medical center (AMC; OMS department at the University of Alabama-Birmingham) compared with a private practice (PP) group that also operated at the AMC auxiliary facility. Surgical procedures included in this study were Le Fort osteotomy, bilateral sagittal split osteotomy, genioplasty, and combinations of these procedures. An experienced surgeon scrutinized the medical records of the AMC and PP groups for age, gender, medical history, American Society of Anesthesiologists (ASA) classification, and indications for surgical procedures. These data were statistically compared for differences in patient complexity. RESULTS: The average age of patients in the 2 groups was similar (AMC, 29 yr; PP, 27 yr). Many more females were treated in the PP setting (male-to-female ratio, 1.06:1 in the AMC group and 1:1.6 in the PP group). The AMC group had a larger percentage of patients with medical comorbidities, a larger proportion of patients with ASA class 2 or 3, and a larger proportion of patients who underwent procedures for reasons other than malocclusion or cosmetic purposes, and these proportions were statistically relevant. Average length of surgery and average length of stay were longer in the AMC group. CONCLUSION: This retrospective cohort study suggests that OMS departments in AMCs tend to treat orthognathic surgical patients with increased comorbidities and systemic illnesses and operate on a larger percentage of patients with concomitant dentofacial issues versus more routine dentofacial skeletal and occlusion deformities.

Effects of FGFR Signaling on Cell Proliferation and Differentiation of Apert Dental Cells.

The Apert syndrome is a rare congenital disorder most often arising from S252W or P253R mutations in fibroblast growth factor receptor (FGFR2). Numerous studies have focused on the regulatory role of Apert FGFR2 signaling in bone formation, whereas its functional role in tooth development is largely unknown. To investigate the role of FGFR signaling in cell proliferation and odontogenic differentiation of human dental cells in vitro, we isolated dental pulp and enamel organ epithelia (EOE) tissues from an Apert patient carrying the S252W FGFR2 mutation. Apert primary pulp and EOE cells were established and shown to exhibit normal morphology and express alkaline phosphatase under differentiation conditions. Similar to control cells, Apert dental pulp and EOE cells expressed all FGFRs, with highest levels of FGFR1 followed by FGFR2 and low levels of FGFR3 and FGFR4. However, Apert cells had increased cell growth compared with control cells. Distinct from previous findings in osteoblast cells, gain-of-function S252W FGFR2 mutation did not upregulate the expression of epidermal growth factor receptor (EGFR) and platelet-derived growth factor receptor (PDGFRα), but elevated extracellular signal-regulated kinase (ERK) signaling in cells after EGF stimulation. Unexpectedly, there was little effect of the S252W mutation on odontogenic gene expression in dental pulp and EOE cells. However, after inhibition of total FGFR signaling or ERK signaling, the expression of odontogenic genes was upregulated in both dental cell types, indicating the negative effect of whole FGFR signaling on odontogenic differentiation. This study provides novel insights on FGFR signaling and a common Apert FGFR2 mutation in the regulation of odontogenic differentiation of dental mesenchymal and epithelial cells.