Surgeons and the Nobel Prize for Medicine.

The Nobel Prize in Medicine or physiology has been awarded yearly since 1901. Of the 111 awards given, only 3 have been bestowed to surgeons for their accomplishments in the field of clinical surgery. They came from different countries, eras, and cultures, but they shared several common traits.

Is a Final Splint Necessary in Bimaxillary Orthognathic Surgery?

For bimaxillary orthognathic surgery, a splint is commonly used to achieve the final occlusion and is then maintained through initial skeletal healing. The purpose of this study is to document how often a final splint is used to achieve the planned intraoperative occlusion, and how often is the final splint retained after surgery to maintain the occlusion during the initial skeletal healing phase.The investigators developed a retrospective case series. The study variables were demographic and operative. The outcome variables were the use of a final splint to achieve the desired intraoperative occlusion; the frequency and clinical indication for maintaining the final splint during the 5-weeks of initial skeletal healing; and the occlusion achieved after initial healing (5 weeks) compared to that planned from model surgery. Descriptive statistics were reported.The study sample was composed of 41 consecutive subjects. The mean age at operation was 26.9 ±â€Š11.8 years and 51% of the subjects were male. Twenty-five subjects required segmental maxillary surgery. The final splint was used in 39% of subjects to achieve final occlusion and maintained postoperatively in only 10%. No subjects developed transverse relapse during the initial healing phase (5-weeks). All subjects with planned immediate mid-arch open-bites (n = 8) showed vertical improvement or closure during the initial healing when the splint was not maintained.The use of a final occlusal splint and then maintenance of the splint through initial skeletal healing is not required in the majority of bimaxillary orthognathic surgery cases to achieve the planned occlusion.

Short Face Dentofacial Deformities: Changes in Social Perceptions, Facial Esthetics, and Occlusion After Bimaxillary and Chin Orthognathic Correction.

The purpose of this study was to document changes in social perceptions and facial esthetics, and document occlusion outcomes in a series of short face (SF) dentofacial deformity (DFD) subjects. The investigators hypothesized that subjects would achieve positive change in social perceptions and facial esthetics, and maintain a long-term corrected occlusion after undergoing bimaxillary and chin osteotomies.A retrospective cohort study was implemented. Photographic records and occlusion parameters were studied preoperatively and >2 years after surgery. The first outcome variable was social perceptions of SF subjects, judged by laypersons. The second outcome variable was facial esthetics, judged by professionals. The third outcome variable was occlusion maintained long-term.Fifteen subjects met inclusion criteria. Mean age at operation was 33 years. Consistent facial contour deformities at presentation included deficient maxillary dental show and downturned oral commissures. As a group, there was improvement (P < 0.05) in 11 of 12 social perceptions, judged by laypersons, all subjects achieved correction of the facial esthetic parameters studied by professionals, and all subjects maintained a favorable occlusion long-term.In SF DFD subjects, bimaxillary and chin surgery proved effective to improve social perceptions, to correct facial contour deformities, and in achieving a long-term corrected occlusion.

Orthognathic Surgery Has a Significant Positive Effect on Perceived Personality Traits and Perceived Emotional Expressions in Long Face Patients.

PURPOSE: Crowdsourcing is increasingly being used in medical research to obtain the opinion and perception of laypeople. We hypothesized that a layperson's perception of a patient with long face dentofacial deformity is more favorable after orthognathic surgery than before surgery regarding perceived personality traits and emotional facial expressions. MATERIALS AND METHODS: We implemented a survey, distributed through Amazon.com's Mechanical Turk crowdsourcing platform, to compare 6 perceived personality traits and 6 perceived emotional traits before and after (>6 months) orthognathic surgery in patients through standardized photographs (3 facial views). The sample was composed of 20 patients randomly selected from our long face dentofacial deformity database, treated by 1 surgeon, all having undergone bimaxillary and chin orthognathic surgery. The outcome variable was change in each of the 12 perceived personality and emotional traits studied. Descriptive and bivariate statistics were computed. P < .05 was considered significant. RESULTS: A total of 500 respondents (raters) completed the survey in less than 10 hours. The respondents were mostly men (60%), aged 25 to 34 years (57%), white (71%), and college graduates (53%) with an annual income between $20,000 and $50,000 (48%). After jaw reconstruction and completion of orthodontic treatment, long face patients as a group were perceived to be significantly more trustworthy, more friendly, more intelligent, more attractive, and more dominant and also perceived as happier and less angry, sad, afraid, or disgusted than they were before surgery (P < .05). CONCLUSIONS: We confirmed that laypersons consistently report positive changes in a long face patient's perceived personality traits and perceived emotional expressions after bimaxillary and chin orthognathic surgery.

Orthognathic Surgery Has a Significant Positive Effect on Perceived Personality Traits and Perceived Emotional Facial Expressions in Subjects With Primary Mandibular Deficiency.

This study tested the hypothesis that a layperson's social perceptions of a dentofacial deformity (DFD) patient with primary mandibular deficiency (PMD) are more positive after bimaxillary orthognathic surgery.A survey was implemented comparing layperson's social perceptions of emotional expressions and personality traits before and >6 months after orthognathic surgery when viewing standardized facial photographs. The study sample comprised 20 patients selected randomly from a larger primary mandibular deficiency database, treated by 1 surgeon after orthognathic surgery. The outcome variable was change in 6 perceived emotional expressions and 6 personality traits studied. Descriptive and bivariate statistics were computed (P < .05).Five hundred respondents (raters) completed the survey. The respondents were 52% male with 44% aging from 25 to 34. After bimaxillary and chin orthognathic surgery, primary mandibular deficiency patients were perceived to be significantly more dominant, trustworthy, friendly, intelligent, attractive, and less threatening (P < .05). They were also perceived as happier and less angry, surprised, sad, afraid, or disgusted than before surgery (P < .05).Laypeople consistently report improved social traits in primary mandibular deficiency patient's perceived emotional expressions and perceived personality traits after bimaxillary and chin orthognathic surgery.

Primary Maxillary Deficiency Dentofacial Deformities: Occlusion and Facial Esthetic Surgical Outcomes.

PURPOSE: The purpose of this study was to document the malocclusion and facial dysmorphology in patients with primary maxillary deficiency (PMD) and chronic obstructive nasal breathing before treatment and the outcomes after bimaxillary orthognathic, genioplasty, and intranasal surgery. MATERIALS AND METHODS: A retrospective cohort study of patients with PMD undergoing bimaxillary orthognathic, chin, and intranasal surgery was implemented. The predictor variables were grouped into demographic, anatomic, operative, and longitudinal follow-up categories. The primary outcome variables were the initial postoperative occlusion achieved (T2; 5 weeks postoperatively) and that maintained long-term (T3 or T4; >2 years after surgery). Six occlusion parameters were assessed: overjet, overbite, coincidence of dental midlines, Angle classification, and molar vertical and transverse positions. A second outcome variable was facial esthetic results. Photographs were analyzed to document 7 facial contour characteristics. RESULTS: Sixty-six patients met the inclusion criteria. Age at operation averaged 22 years (15 to 55 yr). The study included 18 women (27%). Most patients (57 of 66; 86%) achieved and maintained a favorable occlusion for each parameter studied long-term (mean, 5 yr). The need for a 3-segment Le Fort I was strongly associated with long-term posterior malocclusion. Facial dysmorphology before surgery included the appearance of a prominent chin (56%), flat labiomental fold (61%), prominent lower lip (88%), prominent nose (77%), sunken midface (100%), flat cheekbones (82%), and recessed upper lip (73%). Before surgery, 82% of patients exhibited at least 5 of the 7 key facial contour deformities. Correction of all 7 facial contour deformities was confirmed in 92% of patients in the long-term. In 8% of patients, an overly prominent-appearing chin persisted. CONCLUSION: Using orthognathic techniques, most patients with PMD achieved and maintained a corrected occlusion long-term. In unoperated patients, a "facial esthetic type" was identified. Bimaxillary orthognathic and chin surgery proved effective in correcting associated facial dysmorphology in most patients.

Long-Face Dentofacial Deformities: Occlusion and Facial Esthetic Surgical Outcomes.

PURPOSE: The purpose of this study was to document malocclusion and facial dysmorphology in a series of patients with long face (LF) and chronic obstructive nasal breathing before treatment and the outcomes after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery. MATERIALS AND METHODS: A retrospective cohort study of patients with LF undergoing bimaxillary, chin, and intranasal (septoplasty and inferior turbinate reduction) surgery was implemented. Predictor variables were grouped into demographic, anatomic, operative, and longitudinal follow-up categories. Primary outcome variables were the initial postoperative occlusion achieved (T2; 5 weeks after surgery) and the occulsion maintained long-term (>2 years after surgery). Six key occlusion parameters were assessed: overjet, overbite, coincidence of dental midlines, canine Angle classification, and molar vertical and transverse positions. The second outcome variable was the facial esthetic results. Photographs in 6 views were analyzed to document 7 facial contour characteristics. RESULTS: Seventy-eight patients met the inclusion criteria. Average age at surgery was 24 years (range, 13 to 54 yr). The study included 53 female patients (68%). Findings confirmed that occlusion after initial surgical healing (T2) met the objectives for all parameters in 97% of patients (76 of 78). Most (68 of 78; 87%) maintained a favorable anterior and posterior occlusion for each parameter studied long-term (mean, 5 years 5 months). Facial contour deformities at presentation included prominent nose (63%), flat cheekbones (96%), flat midface (96%), weak chin (91%), obtuse neck-to-chin angle (56%), wide lip separation (95%), and excess maxillary dental show (99%). Correction of all pretreatment facial contour deformities was confirmed in 92% of patients after surgery. Long face patients with higher preoperative body mass index levels were more likely to have residual facial dysmorphology after surgery (P = .0009). CONCLUSION: Using orthognathic surgery techniques, patients with LF dentofacial deformity achieved the planned occlusion and most maintained the corrected occlusion long-term. In unoperated patients with LF, a "facial esthetic type" was identified. Orthognathic surgery proved effective in correcting associated facial dysmorphology in most patients.

Primary Mandibular Deficiency Dentofacial Deformities: Occlusion and Facial Aesthetic Surgical Outcomes.

PURPOSE: The purpose of the present study was to document the malocclusion and facial dysmorphology in primary mandibular deficiency (PMD) subjects with chronic obstructive nasal breathing before treatment and the outcomes after bimaxillary orthognathic, genioplasty, and intranasal surgery. PATIENTS AND METHODS: A retrospective cohort study of PMD subjects undergoing bimaxillary, chin, and intranasal surgery was implemented. The predictor variables were grouped into demographic, anatomic, operative, and longitudinal categories. The primary outcome variables were the initial postoperative occlusion achieved at 5 weeks postoperatively (T2) and that maintained long-term more than 2 years after surgery (T4). Six occlusion parameters were assessed: overjet, overbite, coincidence of dental midlines, Angle classification, molar vertical, and transverse positions. A second outcome variable was the facial esthetic results. Photographs were analyzed to document 7 facial contour characteristics. RESULTS: Forty subjects met the inclusion criteria. Their age at surgery averaged 32 years (range 13 to 63). The study included 25 females (63%). The findings confirmed that the occlusion after initial surgical healing (T2) met the objectives for all parameters in 39 of the 40 patients (98%). Most patients (35 of 40; 88%) achieved and maintained a favorable occlusion for each parameter in the long-term (mean 5 years, 3 months). Subjects requiring counterclockwise rotation of the maxillomandibular complex were more likely to a have recurrent anterior open bite in the long-term. Facial contour deformities on presentation included weak chin (80%), deep labiomental fold (90%), everted lower lip (100%), short neck-to-chin length (88%), obtuse neck-to-chin angle (85%), weak mandible angles (93%), and "bunching" of the neck soft tissues (85%). Before surgery, 88% of the subjects exhibited a minimum of 5 of the 7 facial deformities. Correction of all 7 facial deformities was confirmed in 86% of the subjects in the long-term. CONCLUSIONS: Most PMD subjects achieved and maintained a corrected occlusion in the long-term. In the untreated subjects, a "facial type" was identified. Orthognathic surgery proved effective in correcting the associated facial dysmorphology in most patients.

"Silent" Sleep Apnea in Dentofacial Deformities and Prevalence of Daytime Sleepiness After Orthognathic and Intranasal Surgery.

PURPOSE: The purposes of this study were to determine the occurrence of undiagnosed "silent" obstructive sleep apnea (OSA) in dentofacial deformity (DFD) patients at initial surgical presentation and to report on the level of daytime sleepiness in DFD patients with OSA and chronic obstructive nasal breathing (CONB) after undergoing bimaxillary, chin, and intranasal surgery. MATERIALS AND METHODS: A retrospective cohort study of patients with a bimaxillary DFD and CONB was implemented. Patients were divided into those with no OSA (group I) and those with OSA (group II). Group II was further subdivided into patients referred with polysomnogram (PSG)-confirmed OSA (group IIa) and those with a diagnosis of OSA only after surgical consultation, airway evaluation, and a positive PSG (group IIb). Group II patients were analyzed at a minimum of 1 year after surgery (range, 1 to 10 years) for daytime sleepiness with the Epworth Sleepiness Scale. Patients with postoperative excessive daytime sleepiness were assessed for risk factors and continued need for OSA treatment. Patients in group II were studied to determine which DFD patterns were most associated with OSA. We compared the prevalence of OSA between our study population and the general population. RESULTS: Two hundred sixty-two patients met the inclusion criteria. Of these, 23% (60 of 262) had PSG-confirmed OSA (group II). This rate was much higher than that found in the general population. Of the patients, 7% (19 of 262) were known to have OSA at initial surgical consultation (group IIa). An additional 16% (41 of 262) were later confirmed by PSG to have OSA (group IIb). Patients with primary mandibular deficiency and short face DFDs were most likely to have OSA (P < .001 and P = .001, respectively). In group II, 91% (55 of 60) rated their daytime sleepiness as "not sleepy" at a minimum of 1 year after surgery. A significant association was found between group II patients with postoperative excessive daytime sleepiness ("sleepy" or "very sleepy") and a preoperative body mass index category of overweight (P = .026). CONCLUSIONS: Our study found silent OSA to be frequent in the DFD population. The prevalence of OSA in DFD patients exceeded that estimated in the general population, with retrusive jaw patterns most affected. In DFD patients also presenting with OSA and CONB, we confirmed low levels of daytime sleepiness long-term after simultaneous bimaxillary orthognathic, chin, and intranasal surgery.

Hemimandibular Elongation: Is the Corrected Occlusion Maintained Long-Term? Does the Mandible Continue to Grow?

PURPOSE: The purpose of this study was to assess for the maintenance of a corrected occlusion and ongoing mandibular growth in a group of patients younger than 26 years with hemimandibular elongation (HME) who underwent bimaxillary orthognathic reconstruction. MATERIALS AND METHODS: We conducted a retrospective cohort study of HME patients operated on by a single surgeon at 1 institution between 1999 and 2013. At a minimum, all patients underwent Le Fort I and bilateral sagittal ramus osteotomies. Study exclusions included patients aged 26 years or older; those with clefts, craniofacial disorders, or tumors; and those with a history of temporomandibular joint or orthognathic surgery. The study variables included age, gender, side of condylar hyperactivity, premolar extractions, extent of mandibular deformity and malocclusion, planned surgical change, and longitudinal follow-up. The outcome variables studied were the achievement and maintenance of a corrected occlusion and the occurrence of continued mandibular growth after surgery. We compared the occlusion at intervals including the following: before surgery (T1), 5 weeks postoperatively (T2), and either 6 to 24 months after surgery (T3) or more than 2 years after surgery (T4). Anterior occlusion assessment included evaluation of overjet, overbite, and dental midline position. Posterior occlusion assessment included the Angle classification, first molar vertical position, and first molar transverse position. If the corrected anterior occlusion remained stable and no posterior open bite occurred, then no clinically significant condylar hyperactivity and/or ongoing mandibular growth was judged to have occurred. RESULTS: Seventy-six consecutive patients met the inclusion criteria. Age at operation averaged 18 years (range, 14.5 to 25 years), and the study included 44 female patients (58%). T3 patients (10 of 76, 13%) had documentation of occlusion at a mean of 19 months after surgery. T4 patients (66 of 76, 87%) had documentation of occlusion at a mean of 5 years 8 months after surgery. Only 1 of the 76 study patients (1%) was judged to have clinically significant ongoing mandibular growth after reconstruction. For all other patients, a corrected anterior occlusion was maintained long-term, and a posterior open bite did not develop in any. In 7 of the 76 patients (9%), there was a recurrent posterior crossbite by 1 year after completion of orthodontics but without the need for retreatment. An association was confirmed between mandibular setback and long-term posterior malocclusion even with simultaneous maxillary advancement (P = .05). CONCLUSIONS: In HME, a favorable occlusion can be reliably achieved and maintained long-term in most cases using standard bimaxillary orthognathic technique. The need for mandibular setback, even in the presence of simultaneous maxillary advancement, proved to be a factor in the recurrence of long-term posterior malocclusion, although the risk remains low. The results clarify that in patients with HME, by use of the described techniques and timing for surgery, there is no need for an ablative open joint procedure to arrest condylar growth.

Surgical Site Infections Following Bimaxillary Orthognathic, Osseous Genioplasty, and Intranasal Surgery: A Retrospective Cohort Study.

PURPOSE: Frequency estimates of surgical site infection (SSI) after orthognathic surgery vary considerably. The purpose of this study was to determine the incidence and site of SSIs and associated risk factors after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery. MATERIALS AND METHODS: The authors executed a retrospective cohort study of patients with a bimaxillary developmental dentofacial deformity (DFD) and symptomatic chronic obstructive nasal breathing. All patients underwent at a minimum Le Fort I osteotomy, bilateral sagittal ramus osteotomies (SROs), septoplasty, inferior turbinate reduction, and osseous genioplasty. The primary outcome variable studied was the incidence and site of SSI. Predictor variables were type and extent of prophylactic antibiotic used, demographic (age and gender), and anatomic (pattern of DFD, surgical site, and presence of third molar). RESULTS: Two hundred sixty-two patients met the inclusion criteria. Their average age at surgery was 25 years (range, 13 to 63 yr) and there were 134 female patients (51%). The major presenting patterns of DFD included long face (30%) and maxillary deficiency (25%). Forty percent of patients undergoing an SRO and 47% of those undergoing a Le Fort I osteotomy underwent simultaneous removal of a third molar. Ninety percent of patients received cefazolin or cephalexin antibiotics. Overall, 5 of 1,048 (0.5%) osteotomy sites sustained an infection, including 1 chin and 4 ramus SSIs. There were no delays in bone healing. Fixation hardware removal was not required in any patient who developed an infection. Two of the 25 patients (8%) given clindamycin prophylaxis developed an SSI, whereas 3 of 237 patients (1%) receiving cefazolin did. Three of the 4 patients who developed an SRO SSI underwent simultaneous removal of an erupted or partially erupted mandibular third molar (P < .05). CONCLUSIONS: In this study, the incidence of SSI was limited to 1% of patients who were given cefazolin or cephalexin extended for 5 days. The removal of an erupted or partially erupted mandibular third molar in conjunction with an SRO was associated with risk of SSI, but the incidence remains low.