Comparing Outcomes in Orthognathic Surgery Using Clear Aligners Versus Conventional Fixed Appliances.

PURPOSE: Orthognathic surgery for dentofacial deformities is typically preceded and followed by orthodontic treatment. Traditionally, orthodontic hardware is secured to the dentition to allow dental movement and stabilization. Clear-aligner therapy (eg, Invisalign) provides an aesthetic alternative, consisting of a series of transparent trays. Its use has not been described in complex triple-jaw orthognathic surgery. The purpose of this study is to evaluate perioperative outcomes and 3-dimensionally quantify postoperative edema in Invisalign patients undergoing triple-jaw orthognathic procedures, comparing this to patients treated with conventional fixed appliances. The surgical approach to patients with clear-aligners is also outlined. METHODS: The authors conducted a retrospective chart review and 3-dimensional morphometric study of Invisalign patients undergoing triple-jaw surgery (LeFort I osteotomy, bilateral sagittal split osteotomy, and genioplasty). An identical assessment of demographically matched patients treated with conventional fixed appliances was performed and compared with the Invisalign group. RESULTS: Thirty-three patients, with a mean age of 19.99 years, were included: 13 with Invisalign and 20 with conventional fixed appliances. No significant difference was observed in operating time, concurrent extraction of teeth, fat grafting, duration of hospital stay, diet advancement, and use of narcotic analgesics between the 2 groups. Nine patients had sufficient 3-dimensional images for volumetric analysis (4 with Invisalign and 5 with conventional fixed appliances). Postoperative edema was not significantly different (P = 0.712) when comparing conventional fixed appliances (44.29 ±â€Š23.16 cm) to Invisalign (37.36 ±â€Š31.19 cm). CONCLUSION: The present study demonstrates that complex multiple-jaw orthognathic procedures can be successfully performed in Invisalign patients. Perioperative and short-term clinical outcomes are not compromised.

Three-Dimensional Imaging in Rhinoplasty: A Comparison of the Simulated versus Actual Result.

PURPOSE: Computer imaging has become increasingly popular for rhinoplasty. Three-dimensional (3D) analysis permits a more comprehensive view from multiple vantage points. However, the predictability and concordance between the simulated and actual result have not been morphometrically studied. The purpose of this study was to aesthetically and quantitatively compare the simulated to actual rhinoplasty result. METHODS: A retrospective review of 3D images (VECTRA, Canfield) for rhinoplasty patients was performed. Images (preop, simulated, and actual) were randomized. A blinded panel of physicians rated the images (1 = poor, 5 = excellent). The image series considered "best" was also recorded. A quantitative assessment of nasolabial angle and tip projection was compared. Paired and two-sample t tests were performed for statistical analysis (P < 0.05 as significant). RESULTS: Forty patients were included. 67.5% of preoperative images were rated as poor (mean = 1.7). The simulation received a mean score of 2.9 (good in 60% of cases). 82.5% of actual cases were rated good to excellent (mean 3.4) (P < 0.001). Overall, the panel significantly preferred the actual postoperative result in 77.5% of cases compared to the simulation in 22.5% of cases (P < 0.001). The actual nasal tip was more projected compared to the simulations for both males and females. There was no significant difference in nasal tip rotation between simulated and postoperative groups. CONCLUSION: 3D simulation is a powerful communication and planning tool in rhinoplasty. In this study, the actual result was deemed more aesthetic than the simulated image. Surgeon experience is important to translate the plan and achieve favorable postoperative results. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pharmacological Management of Insomnia.

Insomnia is a highly prevalent condition associated with significant morbidity, reduction in quality of life, and increase in healthcare costs, and is a risk factor for multiple physical and mental disorders. The primary treatment modality is cognitive behavioral therapy for insomnia (CBT-I) but this is associated with difficulties with access and higher cost as well as poor response in some patients. Therefore, pharmacotherapy for insomnia is common and hypnotic agents are among the most frequently prescribed medications in the United States. Older medications for insomnia are limited by their side effect burden and narrow therapeutic window. Newer hypnotics, on the other hand, have been shown to have a better safety profile and longer term efficacy. While some studies have shown that long-term hypnotic use is associated with adverse outcomes, the current evidence is equivocal. The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations. This clinical review discusses the currently available medication options to treat insomnia, their mechanisms of action, dosing, and side effect profiles. This review also provides guidance on long-term management of hypnotics and the use of these medications in the elderly, those with medical comorbidities, and other special populations.

Control of Nasal Tip Position: Quantitative Assessment of Columellar Strut versus Caudal Septal Extension Graft.

BACKGROUND: Control and maintenance of nasal tip position are critical in rhinoplasty. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft. However, no quantitative data exist comparing the two methods over time. The purpose of this study was to analyze maintenance of tip projection and rotation following either columellar strut or septal extension graft. METHODS: A retrospective cohort study of patients undergoing rhinoplasty was reviewed. Three-dimensional photogrammetric evaluation of patients with either columellar strut or septal extension graft to increase tip projection was performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection, nasal length, the Goode ratio, and tip rotation. Results were stratified based on technique and compared statistically. RESULTS: One hundred six patients were included. Overall, 66 percent were female, with an average age of 34.5 years. A columellar strut was used in 42 percent of cases (n = 45), and a septal extension graft was used in 57 percent (n = 61). Analysis showed greater maintenance of tip rotation over time with the septal extension graft compared with the columellar strut [-1.01 percent change (p = not significant versus -5.08 percent change (p = 0.009)]. Tip projection, nasal length, and the Goode ratio decreased over time for both groups, but the differences were not statistically different. CONCLUSIONS: Nasal tip projection and rotation appear to decrease from the immediate postoperative position. In this study, both septal extension graft and columellar strut exhibit similar changes in tip projection with time; however, septal extension graft is better able to preserve tip rotation compared with the columellar strut. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Conformity of the Actual to the Planned Result in Orthognathic Surgery.

BACKGROUND: Virtual surgical planning has facilitated preoperative planning, splint accuracy, and intraoperative efficiency in orthognathic surgery. The translation of the virtual surgical plan to the actual result has not been adequately examined. The authors examined the conformity of the virtual surgical plan to the postoperative result. They hypothesize that the greatest conformity exists in the anteroposterior dimensions. METHODS: The authors examined patients who underwent Le Fort I maxillary advancement, bilateral sagittal split osteotomy, and genioplasty. The preoperative virtual surgical planning file and postoperative cone beam computed tomographic scan were registered in Mimics using unchanged landmarks. The conformity to the virtual surgical plan was quantified using linear and angular measurements between bone surface landmarks. Results were compared using t tests, with p < 0.05 considered statistically significant RESULTS:: One hundred patients who underwent Le Fort I maxillary advancement, bilateral sagittal split osteotomy, and genioplasty were included. Three-dimensional analysis showed significant differences between the plan and outcome for the following landmarks: A point (y, p = 0.04; z, p = 0.04), B point (y, p = 0.02; z, p = 0.02), pogonion (y, p = 0.04), menton (x, p = 0.02; y, p = 0.01; z, p = 0.03), and anterior nasal spine (x, p = 0.04; y, p = 0.04; z, p = 0.01). Angular measurements sella-nasion-A point, sella-nasion-B point, and A point-nasion-B point were not statistically different. CONCLUSIONS: There is a high degree of conformity comparing the orthognathic virtual surgical plan to the actual postoperative result. However, some incongruency is seen vertically (maxilla) and sagittally (mandible, chin). Departures of the actual position compared with the plan could be the result of condylar position changes, osteotomy locations, aesthetic intraoperative decisions, and/or play in the system.

Facial Malformation in Crouzon's Syndrome Is Consistent with Cranial Base Development in Time and Space.

BACKGROUND: In Crouzon's syndrome, cranial base deformities begin sequentially in the anterior cranial fossa initially, and later to the posterior cranial base. Facial characteristics are likely related to cranial base development. The temporal correlation between cranial base development and facial features is in need of clarification in Crouzon's patients, to clarify initial sites of deformity, which may impact surgical decision making. METHODS: Thirty-six computed tomography scans of unoperated Crouzon's syndrome patients and 54 controls were included and divided into 5 age-subgroups. All the planes used for analysis were set as perpendicular to a defined "midplane" to offset the confounding factor caused by potential asymmetry. RESULTS: The angle between Sella-Nasion plane and Frankfort horizontal plane was significantly increased before 6 months of age (P = 0.014), with an average 70% (P < 0.001) increase ultimately into adulthood. The angle between SN and maxillary plane and the angle between Sella-Nasion and occlusal planes increased consistently through infancy to adulthood (124% and 42%, respectively, both P < 0.001). The relative angle of mandibular plane to Frankfort horizontal plane increased before 6 months (28%, P = 0.007) with a peak timeframe from 2 to 18 years. Facial lateral curvature related measurements indicate the whole face is inclined posteriorly and inferiorly direction in relation to the anterior cranial base. CONCLUSION: Crouzon's facial malformation development is synchronous and positionally correlational with cranial base deformity. It transmitted from orbit to mandible, with the most evident morphologic changes are in the orbit and midface.