Air Embolism-Induced Ischemic Stroke Following Orthognathic Surgery in a Patient With Goldenhar Syndrome.

Goldenhar syndrome, a rare congenital anomaly, manifests as craniofacial malformations often necessitating intricate surgical interventions. These procedures, though crucial, can expose patients to diverse postoperative complications, including hemorrhage or infection. A noteworthy complication is stroke, potentially linked to air embolism or local surgical trauma. We highlight a case of a male patient, aged 20 years, who experienced a significant postoperative complication of an ischemic stroke, theorized to be due to an air embolism, after undergoing orthognathic procedures for Goldenhar syndrome. The patient was subjected to LeFort I maxillary osteotomy, bilateral sagittal split ramus osteotomy of the mandible, and anterior iliac crest bone grafting to the right maxilla. He suffered an acute ischemic stroke in the left thalamus post-surgery, theorized to stem from an air embolism. Advanced imaging demonstrated air pockets within the cavernous sinus, a rare and concerning finding suggestive of potential air embolism. This case underscores the intricate challenges in treating Goldenhar syndrome patients and the rare but significant risk of stroke due to air embolism or surgical trauma. Limited literature on managing air embolism complications specific to Goldenhar syndrome surgeries exists. Generally, management includes immediate recognition, positional adjustments, air aspiration via central venous catheters, hyperbaric oxygen therapy, hemodynamic support, and high-flow oxygen administration to expedite air resorption. Our patient was conservatively managed post-surgery, and at a 3-month neurology follow-up, he showed significant improvement with only residual right arm weakness. It emphasizes the imperative of a comprehensive, multidisciplinary approach.

Prevention of postoperative nausea and vomiting after orthognathic surgery: a scoping review.

INTRODUCTION: Postoperative nausea and vomiting (PONV) is one of the most common adverse events following orthognathic surgery. It's a distressing feeling for patients and continues to be the cause of postoperative complications such as bleeding, delayed healing, and wound infection. This scoping review aims to identify effective PONV prophylaxis strategies during orthognathic surgery that have emerged in the past 15 years. METHODS: We searched Pubmed, Cochrane Controlled Register of Trials, and Embase from 2008 to May 2023. Studies meeting the following criteria were eligible for inclusion: (1) recruited patients undergo any orthognathic surgery; (2) evaluated any pharmacologic or non-pharmacologic method to prevent PONV. Studies meeting the following criteria were excluded: (1) case series, review papers, or retrospective studies; (2) did not report our prespecified outcomes. RESULTS: Twenty-one studies were included in this review. Pharmacological methods for PONV prevention include ondansetron and dexamethasone (3 studies), peripheral nerve block technique (4 studies), dexmedetomidine (1 study), pregabalin (2 studies), nefopam (2 studies), remifentanil (1 study), propofol (2 studies), and penehyclidine (1 study). Non-pharmacologic methods include capsicum plaster (1 study), throat packs (2 studies) and gastric aspiration (2 studies). CONCLUSIONS: Based on current evidence, we conclude that prophylactic antiemetics like dexamethasone, ondansetron, and penehyclidine are the first defense against PONV. Multimodal analgesia with nerve block techniques and non-opioid analgesics should be considered due to their notable opioid-sparing and PONV preventive effect. For the non-pharmacological methods, throat packs are not recommended for routine use because of their poor effect and serious complications. More prospective RCTs are required to confirm whether gastric aspiration can prevent PONV effectively for patients undergoing orthognathic surgery.

Artificial intelligence as a prediction tool for orthognathic surgery assessment.

INTRODUCTION: An ideal orthodontic treatment involves qualitative and quantitative measurements of dental and skeletal components to evaluate patients' discrepancies, such as facial, occlusal, and functional characteristics. Deciding between orthodontics and orthognathic surgery remains challenging, especially in borderline patients. Advances in technology are aiding clinical decisions in orthodontics. The increasing availability of data and the era of big data enable the use of artificial intelligence to guide clinicians' diagnoses. This study aims to test the capacity of different machine learning (ML) models to predict whether orthognathic surgery or orthodontics treatment is required, using soft and hard tissue cephalometric values. METHODS: A total of 920 lateral radiographs from patients previously treated with either conventional orthodontics or in combination with orthognathic surgery were used, comprising n = 558 Class II and n = 362 Class III patients, respectively. Thirty-two measures were obtained from each cephalogram at the initial appointment. The subjects were randomly divided into training (n = 552), validation (n = 183), and test (n = 185) datasets, both as an entire sample and divided into Class II and Class III sub-groups. The extracted data were evaluated using 10 machine learning models and by a four-expert panel consisting of orthodontists (n = 2) and surgeons (n = 2). RESULTS: The combined prediction of 10 models showed top-ranked performance in the testing dataset for accuracy, F1-score, and AUC (entire sample: 0.707, 0.706, 0.791; Class II: 0.759, 0.758, 0.824; Class III: 0.822, 0.807, 0.89). CONCLUSIONS: The proposed combined 10 ML approach model accurately predicted the need for orthognathic surgery, showing better performance in Class III patients.

Effects of orthognathic surgery on respiratory function during sleep: A prospective longitudinal study.

When treating patients with orthognathic surgery, there might be a risk of obstructive sleep apnoea (OSA) due to soft tissue changes in the upper airways, especially in patients treated with isolated mandibular setback or mandibular setback in combination with maxillary advancement. In the present study, we assessed respiratory function during sleep with home cardiorespiratory polygraphy in 62 patients who had not been previously been diagnosed with OSA at three times: prior to orthognathic surgery for aesthetic and functional indications, and then 3 months and 1 year after surgery. We evaluated surgical displacement based on measurements in three dimensions using pre- and post-operative computed tomography. There were only minor changes in the respiratory parameters such as the apnoea-hypopnoea index (AHI), the apnoea-hypopnoea index in the supine position (AHIsup), the oxygen saturation index (ODI) and the snore index. There was no significant correlation between surgical displacement and the AHI, AHIsup and ODI. There was a weak but significant correlation between vertical displacement of the anterior mandible and the snore index. Within the limitations of the present study, the risk for iatrogenic obstruction of the upper airways seems to be low in patients without OSA treated with orthognathic surgery.

Impact of protraction or orthognathic surgery for class III malocclusion on longitudinal quality of life in patients with cleft lip and palate.

OBJECTIVES: This study assessed overall quality of life (QoL) over time in youth with cleft lip and palate (CLP) undergoing maxillary protraction treatment or orthognathic surgery for class III malocclusion to identify any differences in QoL based on treatment group and outcome success. MATERIALS AND METHODS: A prospective longitudinal cohort study was conducted in two pediatric hospitals. The Short Form Health Survey (SF-12) measured physical and mental QoL prior to treatment, at maximal correction, at treatment completion, and at 1-year post treatment. Analyses included one-sample, two-sample, and paired t-tests and analyses of variance and covariance. RESULTS: Participants (N = 91) either completed protraction (n = 53) at age 11-14 or surgery (n = 38) at age 16-21. Participants were mostly Latinx (67%) males (55%) born with unilateral CLP (81%) and there were no demographic differences between the two groups other than age. The total sample's QoL was in the average range and significantly higher than national norms. No significant differences were found in QoL-based outcome success; however, the protraction group showed a gradual physical QoL improvement over time, while the surgery group experienced a temporary drop in physical QoL postoperatively. At treatment completion, higher physical QoL was associated with higher socioeconomic status. At a year post treatment, mental QoL was significantly higher for males. CONCLUSION: Both protraction and surgery appear to be acceptable treatment options in terms of overall QoL for youth with CLP. While treatment success did not impact QoL, there were some differences in physical QoL coinciding with the treatment phase as well as individual factors.

Impacts of mandibular setback with or without maxillary advancement for class III skeletal correction on sleep-related respiratory parameters: A systematic review and meta-analysis.

A systematic review and meta-analysis was conducted to evaluate the impacts of mandibular setback with or without maxillary advancement for class III skeletal correction on respiratory parameters measured by polysomnography (PSG) and to compare these respiratory parameters between these procedures for class III skeletal correction. Six electronic databases were searched up to June 2023. Studies comparing PSG parameters before and after orthognathic surgery for skeletal class III patients were selected for further analysis. The outcomes of interest were apnoea-hypopnea index (AHI), respiratory disturbance index (RDI), the lowest oxygen saturation (lowest SpO2), the average oxygen saturation (mean SpO2), and the 3% oxygen desaturation index (3% ODI). Data extraction, methodological quality assessment, risk of bias assessment, meta-analysis, and subgroup analysis were performed. Sixteen studies with a total of 476 patients who underwent orthognathic surgery for class III skeletal correction were included for meta-analysis. The risk of bias level was moderate for most studies. All PSG parameters before and after orthognathic surgery were not significantly different. The different surgical procedures also did not significantly affect post-operative PSG parameters. 5.8% of patients developed post-operative obstructive sleep apnoea (OSA). Most of them underwent a large distance of mandibular setback. There is a moderate level of evidence that mandibular setback with or without maxillary advancement for class III skeletal correction does not pre-dispose young and healthy patients to obstructive sleep apnoea when evaluated in the short term after surgery. However, post-operatively developed OSA was found in several isolated cases that underwent a large amount of mandibular setback with or without maxillary advancement.

3D analysis of condylar and mandibular remodeling one year after intra-oral ramus vertical lengthening osteotomy.

OBJECTIVES: Among the existing techniques for the correction of mandibular posterior vertical insufficiency (PVI), the intra-oral ramus vertical lengthening osteotomy (IORVLO) can be proposed as it allows simultaneous correction of mandibular height and retrusion. This study assessed the 3D morpho-anatomical changes of the ramus-condyle unit and occlusal stability after IORVLO. MATERIALS AND METHODS: This retrospective analysis compared immediate and 1-year post-operative 3D CBCT reconstructions. The analysis focused on the condylar height (primary endpoint) and on the changes in condylar (condylar diameter, condylar axis angle) and mandibular (ramus height, Frankfort-mandibular plane angle, gonion position, intergonial distance, angular remodeling) parameters. Additionally, this analysis investigated the maxillary markers and occlusal stability. RESULTS: On the 38 condyles studied in 21 included patients (mean age 23.7 ± 3.9 years), a condylar height (CH) loss of 0.66 mm (p < 0,03) was observed, with no correlation with the degree of ramus lengthening (mean 13.3 ± 0.76 mm). Only one patient presented an occlusal relapse of Class II, but a 3.4 mm (28%) condylar diameter loss and a 33% condylar volume reduction with loss of 1 mm and 3.4 mm in CH and condyle diameter, respectively. A mean 3.56 mm (p < 0.001) decrease in ramus height was noted, mainly due to bone resorption in the mandibular angles. CONCLUSION: This study confirms the overall stability obtained with IORVLO for the correction of PVI. CLINICAL RELEVANCE: This study aims to precise indication of IORVLO, and to validate the clinical and anatomical stability of results.

Facial asymmetry outcome of orthognathic surgery in mild craniofacial microsomia compared to non-syndromic class II asymmetry.

OBJECTIVES: To compare the facial asymmetry after bimaxillary surgery between mild craniofacial microsomia (CFM) and non-syndromic class II asymmetry. MATERIALS AND METHODS: Cone-beam computed tomography scans of adults with Pruzansky-Kaban types I and IIA CFM (CFM groups, n = 20), non-syndromic skeletal class II asymmetry (Class II group, n = 20), and normal controls (control group, n = 20) were compared. The area asymmetry of lower face and jaw bones was quantified. Landmark-based method was used to evaluate the lower facial asymmetry regarding midline, cants, and contour. RESULTS: There were no significant postoperative differences in the hemi-facial and hemi-jaw area asymmetry between CFM and Class II groups, both of which were significantly larger than the control group. No significant difference was found in the midline deviation and lip and occlusal cants between CFM and Class II groups. The vertical contour asymmetry in CFM group became significantly larger than Class II group. Compared to the control group, the deviation of pronasale, subnasale, and soft-tissue menton, lip and occlusal cants, and sagittal and vertical contour asymmetry in CFM group were significantly larger, as were the deviation of subnasale and soft-tissue menton and vertical contour asymmetry in Class II group. CONCLUSIONS: The vertical contour asymmetry of mild CFM was significantly larger than non-CFM class II after surgery, while the area asymmetry, midline deviation, cants, and sagittal contour asymmetry of lower face showed no significant difference. CLINICAL RELEVANCE: Be aware that correcting vertical asymmetry of contour, lip, and dentition in CFM is still challenging.

The effect of tongue reduction for preventing adverse effects in patients undergoing class III orthognathic surgery: a three-dimensional comparative analysis.

OBJECTIVES: This study aims to evaluate the potential benefits of combining tongue reduction with mandibular setback surgery in patients undergoing class III orthognathic surgery. Specifically, we investigated whether this combined approach reduced the risk of surgical relapse, condylar resorption, and airway space reduction by mitigating tongue pressure on the mandible. MATERIAL AND METHODS: The study retrospectively enrolled patients who had undergone bilateral sagittal split ramus osteotomy (BSSRO) with at least 5 mm of setback and met the criteria of a body mass index > 20 kg/m2 and tongue volume > 100 mm3. The study included 20 patients with 10 in the tongue reduction group (TR, n = 10) and 10 in the BSSRO only group (SO, n = 10). RESULTS: The volumetric changes of the total airway space were significantly different between the TR and SO groups (p = 0.028). However, no significant differences were observed in the condylar resorption and postoperative relapse between the groups (p = 0.927 and 0.913, respectively). The difference between the resorption of the anterior and posterior segments of the condyle was also statistically insignificant (p = 0.826). Postoperative counterclockwise rotation of the proximal segment only demonstrated a significant correlation with postoperative relapse (p = 0.048). CONCLUSIONS: The reduction in tongue volume demonstrated a preventive effect on the reduction of the airway space after mandibular setback, although it did not yield statistical significance concerning surgical relapse and condylar volume. The counterclockwise rotation of the proximal segment might be responsible for the forward displacement of the distal segment and postoperative relapse. However, the clinical implications of this finding should be interpreted with caution owing to the limited sample size CLINICAL RELEVANCE: Tongue reduction could potentially serve as a preventive measure in preserving the airway space and might be beneficial in mitigating the risk of obstructive sleep apnea in patients with class III deformity.

Site and severity of facial asymmetry after bimaxillary surgery for class III deformity: a case-control study.

OBJECTIVES: The study aimed (1) to evaluate the site and severity of facial asymmetry in Class III patients before and after bimaxillary surgery, and (2) to identify the influence of initial severity and positional jaw asymmetry on residual facial asymmetry. MATERIALS AND METHODS: Preoperative and postoperative cone-beam computed tomography of 65 patients with Class III facial asymmetry who underwent bimaxillary surgery were evaluated. Five midline and 14 paramedian facial soft tissue landmarks were identified to assess facial asymmetry. The outcomes were compared to a control group consisting of 30 age- and gender-matched Class I subjects. The postoperative positional jaw asymmetry (i.e., shift, roll, yaw) of each osteotomy segment (maxilla, mandible, chin, ramus) was also measured. RESULTS: Before surgery, the asymmetry was more severe at the chin, middle and lower contour. Bimaxillary surgery effectively corrected facial asymmetry, particularly in achieving normalization of chin deviation. However, significant asymmetry persisted postoperatively in the middle and lower contour (p < 0.001 and p < 0.01, respectively), which was affected by the positional ramus asymmetry in the roll and shift. CONCLUSIONS: Deviation of the chin, middle and lower contour contributed significantly to overall facial asymmetry in Class III asymmetry. Despite normalization of the chin deviation after bimaxillary surgery, asymmetry persisted at the middle and lower contour, primarily as the result of insufficient correction of the positional ramus asymmetry. CLINICAL RELEVANCE: Understanding the residual asymmetry after bimaxillary surgery is important for minimizing deviation and optimizing the surgical planning for its correction.