Piriform Rim Asymmetry in Unilateral Cleft Lip and Palate Patients Before Orthognathic Surgery.

BACKGROUND: Complete unilateral cleft lip and palate (UCLP) creates a continuity defect on the nasal floor, which contributes to nasal asymmetry. Traditionally, piriform rim symmetry has been evaluated by comparing cleft and noncleft sides. No study has compared the magnitude of perinasal asymmetry in UCLP patients with a control group of patients without clefts. PURPOSE: To address the following question: In UCLP patients, whose alveolar clefts are reconstructed with alveolar bone grafts (ABGs), is the magnitude of remaining piriform rim asymmetry similar to that of patients without UCLP? STUDY DESIGN SETTING, SAMPLE: This is a retrospective cohort study that used the cone beam computed tomography of UCLP and non-UCLP patients to evaluate the piriform rim symmetry. The sample was derived from patients who presented for orthognathic surgery between January 2015 and December 2022. To be included, patients had to have a maxillary deficiency. The cleft group had ABG performed with symphyseal bone harvest and bone morphogenetic protein application. Patients were excluded from the control group if they had clinical asymmetry and nasal septum deviation. Patients from the UCLP group were excluded if they failed the first attempt of ABG or had a syndrome. Preorthognathic cone beam computed tomography was used to measure the distance from the inferior and lateral aspects of the piriform rim to reference lines. PREDICTOR VARIABLE: UCLP status grouped as present or absent (control). OUTCOME VARIABLES: The magnitude of piriform rim asymmetry defined as the millimetric distance from the inferior and lateral aspects of the piriform rim to reference lines. COVARIATES: The covariates were age, sex, tissue thickness at the level of the alar base, and turbinate size. ANALYSIS: Welch's two-sample t-test was utilized to compare means. A level of significance of 5% (P < .05) was used for all analyses. To analyze the reliability of the measurements intraexaminer and interexaminer errors were tested using the Weir method. RESULTS: A total of 60 patients were included, 30 in each group. The mean age of UCLP patients was 16.76 (range 13 to 25), and the control group was 17 (range 13 to 25), P = .71. The UCLP group had 12 girls, and the control had 18 girls (P = .12). In the UCLP group, the mean discrepancy between affected and unaffected sides at the inferior aspect of the piriform rim was 3.9 mm (range 0.9 to 7 mm, P < .01), and in the control group the discrepancy between right and left sides was 0.1 mm (0-2.1 mm, P = .87). The mean discrepancy between affected and unaffected sides at the lateral aspect of the piriform rim was 3.6 mm (range 0.7 to 7.6 mm, P < .01) in the UCLP group, and in the control group the discrepancy between right and left sides was 0.1 mm (range 0.1 to 5.8 mm, P = .78) in the control group. The mean alar base soft tissue thickness discrepancy was 3.1 mm (range 0.9 to 7.9 mm, P < .01) in the UCLP group and 0 mm (range -1.8 to 1.9 mm, P = .97) in the control group. The mean difference in the turbinate area in the UCLP group was 314 mm2 (range 797 to 2,898) and in the control group 35 mm2 (range 702 to 2,302) (P = .19). CONCLUSION: ABG with symphyseal bone and bone morphogenetic protein was not able to provide the same level of piriform symmetry observed in patients without a cleft. Alar base tissue was thicker on the cleft side, and the turbinate size demonstrated greater variability in the UCLP patients.

Spontaneous Palatal Cleft Closure.

This case report presents a palatal cleft that healed spontaneously, with complete formation of mucosa and bone. Even though the nasal structures could initially be observed through the cleft palate, a thin membrane sealed any communication between the oral and nasal cavities. The origin of this tenuous membrane cannot be fully understood with current discernment of palate formation, but it probably served as a basis for the formation of the other tissues. No previous record of nonintervened spontaneous closure of a cleft palate has been reported.

Regenerative Engineering of a Biphasic Patient-Fitted Temporomandibular Joint Condylar Prosthesis.

Regenerative medicine approaches to restore the mandibular condyle of the temporomandibular joint (TMJ) may fill an unmet patient need. In this study, a method to implant an acellular regenerative TMJ prosthesis was developed for orthotopic implantation in a pilot goat study. The scaffold incorporated a porous, polycaprolactone-hydroxyapatite (PCL-HAp, 20wt% HAp) 3D printed condyle with a cartilage-matrix-containing hydrogel. A series of material characterizations was used to determine the structure, fluid transport, and mechanical properties of 3D printed PCL-HAp. To promote marrow uptake for cell seeding, a scaffold pore size of 152 ± 68 µm resulted in a whole blood transport initial velocity of 3.7 ± 1.2 mm·s-1 transported to the full 1 cm height. The Young's modulus of PCL was increased by 67% with the addition of HAp, resulting in a stiffness of 269 ± 20 MPa for etched PCL-HAp. In addition, the bending modulus increased by 2.06-fold with the addition of HAp to 470 MPa for PCL-HAp. The prosthesis design with an integrated hydrogel was compared with unoperated contralateral control and no-hydrogel group in a goat model for 6 months. A guide was used to make the condylectomy cut, and the TMJ disc was preserved. MicroCT assessment of bone suggested variable tissue responses with some regions of bone growth and loss, although more loss may have been exhibited by the hydrogel group than the no-hydrogel group. A benchtop load transmission test suggested that the prosthesis was not shielding load to the underlying bone. Although variable, signs of neocartilage formation were exhibited by Alcian blue and collagen II staining on the anterior, functional surface of the condyle. Overall, this study demonstrated signs of functional TMJ restoration with an acellular prosthesis. There were apparent limitations to continuous, reproducible bone formation, and stratified zonal cartilage regeneration. Future work may refine the prosthesis design for a regenerative TMJ prosthesis amenable to clinical translation.

Arthrocentesis versus nonsurgical methods in the management of temporomandibular joint closed lock and pain: a double-blind randomized controlled trial.

OBJECTIVE: The present double-blind randomized clinical trial aimed to compare the efficacy of conservative treatment and articular lavage, either alone or combined, to reduce joint pain and improve mandibular opening. STUDY DESIGN: The sample consisted of patients presenting with limited mouth opening and joint pain. The diagnosis was made according to the diagnostic criteria for temporomandibular disorders guideline and confirmed by magnetic resonance imaging. Sixty patients were selected and randomly allocated to 4 groups of 15 patients each with different treatments: group A (conservative), group B (conservative + medication), group C (arthrocentesis), and group D (arthrocentesis + medication). The groups were compared in terms of maximal interincisal opening and pain. RESULTS: The average age of the patients was 34.17 ± 13.1 years, 88.1% were women, 72.9% had internal derangement, 54% had joint sounds, and 55.9% presented with locking. Clinical improvement was noted in all parameters compared with baseline in all groups (P < .005), but no significant differences were observed when the groups were compared (P > .05). CONCLUSIONS: Both arthrocentesis and conservative modalities were efficient treatments to reduce joint pain and increase mandibular opening.

Three-segment versus 2-segment surgically assisted rapid maxillary expansion.

OBJECTIVE: To compare the 2 surgically assisted rapid maxillary expansion (SARME) techniques, the conventional 2-segment osteotomy between maxillary central incisors and the 3-segment osteotomy between maxillary lateral incisors and canines bilaterally. Authors hypothesized that the 3-piece would provide better bone expansion. STUDY DESIGN: A pilot study was conducted; 19 patients were divided into 2 groups: conventional 2-segment osteotomy (10 patients) and 3-segment osteotomy (9 patients). Dental and skeletal measurements of the preoperative and postoperative cone beam computed tomography images were analyzed. Pre- and postoperative periodontal probing was performed, patients' cosmetic perception was evaluated in a colored visual analog scale (VAS), and surgical time was measured with a regular chronometer. RESULTS: Three-segment SARME resulted in greater bone expansion (5.12 vs 6.20 mm; P = .016), less molar inclination (7.16 vs 3.57 degrees; P = .028), better patient cosmetic perception (3.13 vs 7.68 in a VAS; P = .000), and longer surgical time (43 vs 52 minutes; P = .026). Furthermore, the 2-segment group presented necrosis of 1 central incisor. CONCLUSIONS: Results suggest that 3-piece SARME is more effective for bone expansion of the maxilla.

Impact of orthognathic surgery on quality of life and comparison of patients' postoperative experience after single- and double-jaw surgery: a longitudinal study.

OBJECTIVE: To evaluate the impact of orthognathic surgery on quality of life (QoL) and to compare single- and double-jaw surgeries in terms of ratio and patient perceptions of the postoperative period. STUDY DESIGN: A prospective, longitudinal observational study was conducted. The short form Oral Health Impact Profile (OHIP-14) and the Orthognathic Quality of Life Questionnaire (OQLQ) were applied preoperatively and 6 months postoperatively to evaluate oral health-related QoL (OHRQoL). Additionally, patient perceptions of the immediate postoperative period were assessed at the first and fourth week after surgery. RESULTS: One hundred consecutive patients were recruited and assigned to the single-jaw group (n = 24) or the double-jaw group (n = 76) according to the characteristics of each facial or occlusal deformity. The questionnaires showed lower scores for both groups after surgery, indicating significant benefits to OHRQoL. The whole sample OHIP-14 mean total scores decreased from 10.5 to 2.8 (P < .001, d = 1.35), whereas OQLQ showed a decrease from 48.4 to 11.6 (P < .001, d = 1.75). CONCLUSIONS: Orthognathic surgery can improve OHRQoL, and long-term benefits outweigh the risks and discomfort associated with the treatment.

Rehabilitation of an adolescent with ectodermal dysplasia. Two-stage orthognathic, graft, and implant surgery: case report.

A 16-year-old girl presenting with ectodermal dysplasia has undergone double jaw orthognathic surgery to correct mandibular prognathism and maxillary anteroposterior deficiency. Ten months later the patient had a second surgery that included the placement of 11 implants along with bone grafting to the maxilla and mandible. Fourteen months after the second surgery, the definitive ceramic work was fabricated and screw retained. Even though the patient was still an adolescent at the time of the first surgery, psychological effects of the deformity may require an early solution for this kind of patient.

Accuracy of maxillary positioning after standard and inverted orthognathic sequencing.

OBJECTIVE: This study aimed to compare the accuracy of maxillary positioning after bimaxillary orthognathic surgery, using 2 sequences. STUDY DESIGN: A total of 80 cephalograms (40 preoperative and 40 postoperative) from 40 patients were analyzed. Group 1 included radiographs of patients submitted to conventional sequence, whereas group 2 patients were submitted to inverted sequence. The final position of the maxillary central incisor was obtained after vertical and horizontal measurements of the tracings, and it was compared with what had been planned. The null hypothesis, which stated that there would be no difference between the groups, was tested. RESULTS: After applying the Welch t test for comparison of mean differences between maxillary desired and achieved position, considering a statistical significance of 5% and a 2-tailed test, the null hypothesis was not rejected (P > .05). Thus, there was no difference in the accuracy of maxillary positioning between groups. CONCLUSIONS: Conventional and inverted sequencing proved to be reliable in positioning the maxilla after LeFort I osteotomy in bimaxillary orthognathic surgeries.

Comparative analysis of two different alar base sutures after Le Fort I osteotomy: randomized double-blind controlled trial.

OBJECTIVE: The aim of this prospective study was to analyze the efficacy of a new alar base cinch suture by comparing it with the commonly used cinch suture described by Schendel and Delaire in Dr. William Bell's book. STUDY DESIGN: Thirty-five patients submitted to maxillary impaction and/or advancements of ≥ 3 mm were randomly divided into 2 groups. Group 1 received an extra oral alar base cinch suture, and patients from group 2 received the classic intraoral suture. Alar and alar base width were measured before and after surgery in digital photographs, with the patient's head in a submental oblique view. Data were reported as means and standard deviations, and difference between groups were determined using Welch t test. A P value of <.05 was considered to be statistically significant. RESULTS: Mean alar base widening was 1.38 mm in group 1 and 2.5 mm in group 2, and mean alar widening was 1.40 mm in group 1 and 2.31 mm in group 2. The difference was statistically significant (P < .05). CONCLUSION: Extraoral alar base cinch suture was more effective in maintaining preoperative Alar and alar base width compared with classic intraoral nasal suture.

Conduta cirúrgica em terceiro molar incluso com geminação / Surgical conduct for impacted third molar with gemination

Este trabalho objetiva apresentar o relato de paciente, sexo feminino, 29 anos de idade que compareceu para exodontia do elemento 38 parcialmente erupcionado. Na radiografia panorâmica observa-se o 38 associado a elemento dentário extranumerário, que se estende do rebordo a bem próximo a basilar, ultrapassando os limites do canal mandibular. Na tomografia cone beam observa-se coroa com diâmetro mesiodistal comproporções elevadas, sendo uma coroa dentária, uma câmara pulpar ampliada e três raízes, compatível com geminação. Duas das raízes estavam acima do canal mandibular e uma abaixo. A conduta cirúrgica proposta foi remoção da coroa e das raízes superiores e sepultamento da inferior, para evitar fratura mandibular e parestesia. Realizou-se acesso, osteotomia para exposição da coroa dentária até a região das furcas, seguida odontosecção para separação da coroa das raízes, clivagem e remoção da coroa. Na remoção do fragmento coronário observa--se presença da raiz mais profunda aderida a coroa, não sendo possível realizar clivagem total. As raízes superiores ao canal foram removidas sem maiores problemas. O alvéolo foi curetado, o retalho reposicionado na sua posição, seguido de sutura. Ressalta-se a importância da solicitação de exames de imagem e do planejamento de modo a evitar possíveis complicações no ato cirúrgico.

This paper reports the case of a 29-year-old female patient who visited the dental clinic for the extraction of partially eruption tooth 38. The panoramic radiograph revealed that tooth 38 was associated with an extranumerary tooth extending from the rim to near the basal lamina, surpassing the limits of the mandibular canal. Cone-beam tomography revealed a dental crown with a large mesio-distal diameter, large pulp chamber and three roots, compatible with gemination. Two of the rootswere above the mandibular canal and one was below. The proposedsurgical conduct was the removal of the crown and upper roots and burying of the lower root to avoid mandibular fracture and paresthesia. The region was accessed and osteotomy was performed to expose the dental crown to the furcation region, followed by sectioning for the separation of the crown from the roots, cleavage and removal of the crown. During this procedure, it was noted that the deepest root was adhered to the crown and complete cleavage was not possible. The roots above the canal were removed without incident. The alveolus was curetted and the flap was repositioned and sutured. This case underscores the importance of imaging exams and adequate planning toavoid possible complications during the act of surgery.