Impact of the Distance of Maxillary Advancement on Horizontal Relapse After Orthognathic Surgery.

BACKGROUND: The maxillary horizontal relapse following Le Fort I advancement has been estimated to be 10% to 50%. This retrospective review examines the direct association between the amounts of maxillary advancement and relapse. We hypothesize that the greater the advancement, the greater the relapse amount. METHOD: Patients with class III skeletal malocclusion underwent maxillary advancement with either a Le Fort I or a Le Fort I with simultaneous mandibular setback (bimaxillary surgery) from 2008 to 2015. Patients were assessed for a history of cleft lip or cleft palate. Patients with known syndromes were excluded. Cephalometric analysis was performed to compare surgical and postsurgical changes. RESULTS: Of 136 patients, 47.1% were males and 61.8% had a history of cleft. The mean surgery age was 18.9 (13.8-23) years and 53.7% underwent a bimaxillary procedure. A representative subgroup of 35 patients had preoperative, immediate postoperative, and an average of 1-year postoperative lateral cephalograms taken. The mean maxillary advancement was 6.3 mm and the horizontal relapse was 1.8 mm, indicating a 28.6% relapse. A history of cleft and amount of maxillary advancement were directly correlated, whereas bone grafting of the maxillary osteotomy sites was inversely correlated with the amount of relapse ( P < .05). CONCLUSIONS: Our data suggest positive correlation between amount of maxillary advancement and horizontal relapse as well as a positive correlation between history of cleft and horizontal relapse. Bone grafting of the maxillary osteotomy sites has a protective effect on the relapse.

Randomized controlled trial of personalized motivational interventions in substance using patients with facial injuries.

PURPOSE: The proximate use of illicit drugs or alcohol (substance use) is the most common precipitator of facial injuries among socioeconomically disadvantaged populations. Reducing these risky behaviors could minimize adverse health sequelae and potential reinjury. The objective of our study was to test whether a culturally competent, personalized motivational intervention incorporated into surgical care could significantly reduce existing substance use behaviors in facial injury patients. PATIENTS AND METHODS: Substance-using subjects (n = 218) presenting with facial injuries to a level 1 trauma center were randomly assigned to either a personalized motivational intervention (PMI) condition or a health-information (HI) control condition. After a brief assessment of the individual's substance use severity and willingness to change these behaviors, both groups attended 2 counseling sessions with a trained interventionist. The PMI subjects (n = 118) received individualized, motivational interventions, whereas the HI subjects (n = 100) received only general health information. Both groups were reassessed at 6 and 12 months postinjury, and changes in substance-use patterns were measured to assess the effects of intervention. RESULTS: The PMI and HI groups were closely matched on their sociodemographic and substance use characteristics. Subjects in the PMI group showed statistically significant declines in drug use at both the 6- and 12-month assessments. The intervention's effect on lowering illicit drug use was greatest at the 6-month assessment but had weakened by the 1-year follow-up. The efficacy of the PMI was moderated by an individual's initial drug use severity; individuals with greater drug use dependency at baseline were seen to have larger intervention effects, as did individuals who were most aware of their drug problem and willing to change their substance use behaviors. Unlike illicit drug use, changes in alcohol use did not differ significantly between the intervention and control groups, irrespective of an individuals' recognition of the alcohol problem or willingness to take steps to address it. CONCLUSION: A culturally competent, motivational intervention integrated into the care of vulnerable patients with facial injury can reduce illicit drug use behaviors. Subgroups of injured patients appear to benefit most from such personalized motivational interventions. A better articulation of target populations, intervention content, and delivery would allow for directed interventions and an appropriate focusing of limited time and health care resources.

Willingness of facial injury patients to change causal substance using behaviors.

Many injuries due to interpersonal violence among patients presenting to urban trauma centers for treatment are preventable, with alcohol and illicit drug use presenting as common antecedent risk factors. However, many patients with such problems do not seek treatment. Substance use patients were surveyed to determine how many recognized they had a problem and whether they had previously received treatment for substance use problems. Almost 60% of the patients treated for a facial injury screened for problem alcohol use, and slightly more than 25% screened for problem drug use. Only approximately one third of patients indicated any movement towards dealing with these problems and of these, only 20% had actually sought treatment. Employment had an effect on treatment seeking, with fewer employed patients seeking help. Utilizing the critical window of opportunity for emergency department (ED) personnel to make referrals may have an impact on treatment seeking for problem level substance use.

Adolescent orofacial injury: association with psychological symptoms.

Ethnic minority youth living in urban areas experience disproportionately high rates of violent intentional injuries. This study investigates the association of violent intentional injuries with psychological distress and alcohol use among adolescents treated in trauma centers for facial injuries. Interviews were conducted with 67 adolescents treated at two urban trauma centers (predominantly males [86%], and minority [Latino, 72%; African American, 19%]). Adolescents reported experiencing several different types of accidental and assault-related injuries that required medical attention in the past six months. About half (53%) reported experiencing only unintentional injuries (e.g. car accidents, falls, sports injury); 23% experienced one type of intentional injury resulting from either fighting or being attacked; and 24% experienced two types of intentional injuries resulting from both fighting and being attacked. Measures of alcohol use and psychological distress were examined in relation to these three types of injuries. Overall, 30% of study participants reported they had been drinking alcohol at the time of injury. Compared to adolescents without intentional injuries, those who experienced a physical fight and/or attack had higher levels of alcohol problems, depression, paranoia and somatic symptoms, and were more likely to have family members with alcohol problems. There is a considerable need for adolescents with intentional assault-related injuries to be screened for alcohol and mental health problems, and to be referred for appropriate treatment interventions if they score at problem levels.

Substance use in vulnerable patients with orofacial injury: prevalence, correlates, and unmet service needs.

BACKGROUND: A large portion of the injuries treated at urban trauma centers are preventable with alcohol and substance use presenting as common antecedent risk factors. METHODS: Alcohol and drug use characteristics of vulnerable adults treated for intentional orofacial injury at a regional trauma center were investigated. Patients (N = 154) presenting with intentional facial injury were recruited. Patients were considered eligible for recruitment if they were adults, recently used alcohol or drugs, and had a fracture within the 30 days preceding recruitment that involved the jaw, orbit, nose, or cheekbone as determined by clinical history, examination, and radiographic findings and that injury was due to interpersonal violence. RESULTS: This patient cohort evidenced significant levels of alcohol use, with 58% of our patient cohort meeting the criteria for problem drinking. Although lower than alcohol use rates, the reported use of illicit drugs was substantial. Almost half of the sample reported other substance use in the previous month, with 24% meeting the criteria for problem drug use. CONCLUSIONS: Despite the very high percentage of individuals needing alcohol or drug treatment, only a small proportion of the patient sample reported having seen a professional for alcohol or drug treatment. Integrating substance use services into trauma care is discussed.

Factors associated with orofacial injury and willingness to participate in interventions among adolescents treated in trauma centers.

PURPOSE: Assault is the most common cause of facial injuries in adolescents treated at inner-city trauma centers, yet little is known about the behavioral and environmental antecedents of these injuries or the willingness of such at-risk adolescents to participate in behavioral interventions to minimize reinjury. The purpose of this study was to identify possible risk and protective factors among adolescents with assault-related facial injury and to assess their willingness to participate in prospective observational research and behavioral interventions. PATIENTS AND METHODS: Interviews were conducted with 67 adolescents (range 14 to 20 yrs) who were treated in trauma centers for facial injuries. Most of these injuries were assault-related (59%), followed by motor vehicle or other accidents (29%), gunshot wounds (9%), and sports injuries (3%). The subjects were predominantly male (86%) and of ethnic minorities (91%). RESULTS: The adolescents showed high rates of intentional injuries in the past 6 months (56%), unhealthy alcohol use, and in more than half (55%) problem levels of substance use. Compared with those with unintentional injuries, adolescents who experienced assault-related injuries were more likely to report using alcohol, tobacco, and other substances. Although a significant segment of the sample (55%) had been arrested previously, no differences in arrest rates or types of crimes for which adolescents were arrested were observed by injury type. Most subjects were unwilling to participate in interventions that involved multiple sessions; however, greater family cohesion predicted the likelihood of being willing to participate. CONCLUSIONS: Most facial injuries in inner-city adolescents result from assault. Unhealthy alcohol use, problem levels of substance use behaviors, and family history of alcohol problems are associated markers of assault-related injuries that can be useful for risk assessment and targeted intervention. Interventions need to be brief if they are to engage these at-risk youth.

Implant-supported distraction osteogenesis: a technique to advance the deficient maxilla.

We describe a technique in which osseointegrated implants are used as anchors to support a custom-fabricated distraction device to advance the deficient anterior maxilla. The absolute rigidity of osseointegrated implants in bone provides stable anchorage for successful distraction.

Tisssue responses in corticotomy- and osteotomy-assisted tooth movements in rats: histology and immunostaining.

INTRODUCTION: The purpose of this histologic study was to examine underlying cellular responses to corticotomy- and osteotomy-assisted tooth movements. METHODS: Thirty-six rats were divided into 5 groups: corticotomy-assisted tooth movement (CO + TM), sham corticotomy without tooth movement (CO alone), osteotomy-assisted tooth movement (OS + TM), sham osteotomy without tooth movement (OS alone), and unassisted tooth movement (TM alone). Standard orthodontic springs were activated to produce mesial tooth movement. The rats were killed at 3, 21, and 60 days after activation for osteoclast and blood vessel counts, and immunostaining with proliferating cell nuclear antigen (PCNA), transforming growth factor beta 1 (TGF beta 1), vascular endothelial growth factor (VEGF), and osteocalcin were performed. RESULTS: The CO + TM group had significantly more osteoclasts at 3 days (P <0.005) compared with the OS + TM group. The alveolar bone surrounding the dental roots was replaced with multicellular tissue at 21 days in the CO + TM group but was intact in the OS + TM group with the exception of a distal distraction site. At day 21, immunostaining with PCNA, TGF beta 1, VEGF, and osteocalcin occurred at the mesial border of bone in the CO + TM group, whereas a diffuse pattern was observed in the distal distraction sites at 21 and 60 days in the OS + TM group. CONCLUSIONS: Corticotomy-assisted tooth movement produced transient bone resorption around the dental roots under tension; this was replaced by fibrous tissue after 21 days and by bone after 60 days. Osteotomy-assisted tooth movement resembled distraction osteogenesis and did not pass through a stage of regional bone resorption.

Barriers to seeking mental health care after treatment for orofacial injury at a large, urban medical center: concordance of patient and provider perspectives.

BACKGROUND: Patients with orofacial injury face significant mental health issues, yet few obtain mental health services. The goals of this study were twofold: (1) compare the perspectives of providers and patients with documented mental health service needs regarding psychosocial aftercare; and (2) identify factors that impede or facilitate aftercare participation. METHODS: Patients with orofacial injury in a large, urban medical center who met the screening criteria for probable mental health disorder (n = 25) and trauma service providers (n = 35) were queried about their perceptions of psychosocial aftercare and beliefs regarding potential barriers to seeking care. Bivariate analyses and Fisher's exact tests were used to describe and compare patient and provider responses. RESULTS: Patient participants generally expressed interest in receiving aftercare services for psychological problems. For patients, lack of information about services, financial cost, and availability of transportation emerged as the most salient barriers to care. The providers also rated these barriers as among the most salient; however, important provider- patient discrepancies emerged during barrier ratings. The most potentially challenging area of divergence concerned provider beliefs that patients are disinterested in addressing psychological problems, lack faith in the effectiveness of psychosocial services, and do not regard solving these problems as a priority. CONCLUSIONS: A substantial proportion of patients have unmet psychosocial needs after facial trauma. Patients desire these services but endorse key barriers to care seeking. Providers are not necessarily aware of either the extent of interest in psychosocial services or the nature of the barriers that would impede care utilization. Implications for improving access to care are discussed.

Dental implant reconstruction in a patient with ectodermal dysplasia using multiple bone grafting techniques.

Ectodermal dysplasia is a syndrome in which 2 ectodermally derived structures fail to develop. Patients have a reduced number of teeth, and dental implant reconstruction is the preferred method of replacing teeth. We report the use of the tent pole technique in the severely resorbed mandible with sinus lifts and block grafting in the maxilla to restore the maxillofacial complex of a female patient with ectodermal dysplasia. The treatment sequence and techniques are discussed.

Accuracy of data collected by surgical residents.

PURPOSE: Clinician records are the primary information source for assessing the quality of facial injury care, billing, risk management, planning of health services, and health-system management and reporting. Inaccuracies obscure outcomes assessment and affect the planning of health services. We sought to determine the accuracy of the clinician collected data by comparing them to similar information elicited by professional interviewers. MATERIALS AND METHODS: We abstracted admissions data from the medical records of 185 patients treated for orofacial injury between January 2005 and January 2007. Clinician data on sociodemographics and substance use were compared with similar information elicited by trained research staff as part of a prospective study. RESULTS: The accuracy of the clinician data sets varied considerably depending on the variable. Concordance with the interviewer data sets was highest for age (paired t test P = .09), gender (kappa = 1), and ethnicity (kappa = .84) but dropped off considerably for marital status (kappa = .22) and alcohol (kappa = .18) and drug use (kappa = .16). The missing data per variable ranged from 4.5% (gender) to 46.9% (employment and education). CONCLUSIONS: Although more research is needed to evaluate the cause of inaccuracies and the relative contributions of patient, provider, and system level effects, it seems that significant inaccuracies in administrative data are common. In particular, patient information collected by surgical residents under-reports substance use behaviors. Interventions aimed at identifying the sources and correcting these errors are necessary.

Survivors of violence-related facial injury: psychiatric needs and barriers to mental health care.

OBJECTIVE: This study examined mental health needs, receptivity to psychosocial aftercare, and barriers to care among survivors of violence-related facial injuries. METHODS: Face-to-face interviews were conducted with 25 consecutively treated individuals at a hospital-based specialty outpatient clinic one month after a violence-related facial injury. To participate in the study, patients had to screen positive for an alcohol use disorder (AUD), major depression or posttraumatic stress disorder (PTSD). Participants were questioned about receptivity to an aftercare program and perceived barriers to care. RESULTS: Of those screened for study eligibility (n=62), a substantial proportion met probable criteria for AUD (31%), PTSD (34%) and major depression (35%). Among those completing the core interview (n=25), 80% met probable criteria for two or more psychiatric disorders. The majority (84%) expressed interest in psychosocial aftercare. However, barriers such as cost, insufficient information about counseling and obtaining services, transportation and preferences for self-reliance were commonly endorsed. CONCLUSIONS: Survivors of violence-related facial injuries have substantial mental health needs and appear receptive to psychosocial aftercare. However, significant treatment barriers must be addressed. Findings underscore the value of a collaborative care model for treating violence-related facial trauma patients seeking care in specialty outpatient oral and maxillofacial clinics.

Missense mutation in the PTEN promoter of a patient with hemifacial hyperplasia.

The cellular mechanisms involved in the asymmetric facial overgrowth syndrome, hemifacial hyperplasia (HFH), are not well understood. This study was conducted to compare primary cell cultures from hyperplastic and normal HFH bone for cellular and molecular differences. Primary cultures developed from biopsies of a patient with isolated HFH showed a twofold difference in cell size and cell number between hyperplastic and normal bone. Microarray data suggested a 40% suppression of PTEN (phosphatase-tensin homolog) transcripts. Sequencing of the PTEN gene and promoter identified novel C/G missense mutation (position -1053) in the regulatory region of the PTEN promoter. Western blots of downstream pathway components showed an increase in PKBa/Akt1 phosphorylation and TOR (target of rapamcyin) signal. Sirolimus, an inhibitor of TOR, when added to overgrowth cells reversed the cell size, cell number and total protein differences between hyperplastic and normal cells. In cases of facial overgrowth, which involve PTEN/Akt/TOR dysregulation, sirolimus could be used for limiting cell overgrowth.

Bilateral maxillary duplication: case report and literature review.

Accessory maxillary jaws are extremely rare occurrences. Currently, there is only 1 report of bilateral accessory maxillary jaws in the English-language literature. We present a case of a 7-year-old girl with bilateral bony exostoses extending from the maxillary tuberosities. The patient also had restricted protrusive and lateral excursive movements of the mandible. The histologic report revealed teeth in various developmental stages within the bony exostoses. We concluded that these structures were an isolated form of bilateral accessory maxillary jaws.

Complications of local anesthesia used in oral and maxillofacial surgery.

Local anesthetics are used routinely in oral and maxillofacial surgery. Local anesthetics are safe and effective drugs but do have risks that practitioners need to be aware of. This article reviews the complications of local anesthesia. A brief history is provided and the regional and systemic complications that can arise from using local anesthesia are discussed. These complications include paresthesia, ocular complications, allergies, toxicity, and methemoglobinemia. Understanding the risks involved with local anesthesia decreases the chances of adverse events occurring and ultimately leads to improved patient care.

Clinical applications of orthodontic microimplant anchorage in craniofacial patients.

Microimplant anchors, also known as temporary anchorage devices, mini- and micro-screws, have been used to enhance orthodontic anchorage for difficult tooth movements. Here, the authors describe how microimplants can be used to help treat craniofacial patients by supporting distraction osteogenesis procedures, maxillary protraction procedures, cleft segment expansion and stabilization, and tooth movement into narrow alveolar cleft sites. While most craniofacial patients are treated without microimplants, it would be worthwhile to identify which cases could benefit from microimplant anchorage. As an adjunct to orthodontic treatment, the microimplant offers a potential method for solving troublesome orthodontic and surgical problems such as guiding distraction procedures with orthodontics when primary teeth are exfoliating, addressing residual maxillary cants after vertical distraction osteogenesis of a ramus, stabilizing an edentulous premaxilla, and moving teeth into atrophic alveolar ridges. These cases are presented to open a dialogue on their possible uses in craniofacial patients.

Manipulating the mandibular distraction site at different stages of consolidation.

PURPOSE: The purpose of this study was to define optimal timing and conditions for correcting an open bite side effect by manipulating the distraction site with orthodontic springs after mandibular distraction. MATERIALS AND METHODS: At 0, 1, 2, 3, and 8 weeks postdistraction, interarch springs were attached for 2 weeks to close distraction-produced open bites in 45 rabbits. Distractors were removed in half of the animals receiving spring treatment. Segment position was recorded by weekly direct measurements and radiographs. Tissue samples were collected at the end of spring application for microcomputerized tomography analysis and measurements of lateral symmetry. RESULTS: Orthodontic springs closed the open bite with or without distractors in place immediately after distraction and partially corrected the bite at later stages of bone consolidation. Distractor removal produced more rapid bite closure but also introduced lateral buckling of the distraction site during early consolidation. The lateral buckling was not observed if springs were applied after 2 weeks of consolidation. The amount of bite correction with orthodontic springs correlated with mineralization of the distraction site. CONCLUSION: During the consolidation period, a distraction site can be callus manipulated with orthodontic springs to correct an open bite. The amount of correction depended on when springs were placed and whether distractors were removed at the time of spring application.