Does Tranexamic Acid Reduce the Need for Hypotensive Anesthesia Within Orthognathic Surgery? A Retrospective Study.

Background: Tranexamic acid (TXA) is utilized frequently in orthognathic surgery to limit blood loss and improve surgical field visualization. This antifibrinolytic has been proven effective with use of concomitant hypotensive anesthesia. Despite proven efficacy, there is a recent push to avoid perioperative hypotensive anesthesia due to risks of organ hypoperfusion, cardiac ischemia and postoperative nausea. Aims: The aim is to study the efficacy and safety of utilizing TXA without controlled hypotensive anesthesia. Methods: The authors identified two cohorts of subjects that underwent bimaxillary orthognathic surgery both with and without TXA administration and compared operative and perioperative variables. A retrospective analysis was completed evaluating intraoperative MAP measurements in subjects treated both with and without TXA using descriptive and bivariate analysis. Results and conclusion: Sixty-three subjects met inclusion criteria. The TXA cohort experienced 11.5% less time under hypotensive anesthesia when compared to the group that did not receive TXA. Additionally, surgical length was decreased by more than 28 min when subjects received TXA. No subjects required a blood transfusion or experienced any TXA-related complications. Given the recommendations to limit hypotensive anesthesia perioperatively, TXA is a useful adjunct in orthognathic surgery to limit controlled hypotensive anesthesia.

What Is Health Literacy Among Orthognathic Surgery Patients?

BACKGROUND: Health literacy of orthognathic surgery patients has not been thoroughly evaluated. PURPOSE: The purpose of this study was to estimate health literacy and identify risk factors associated with inadequate health literacy in orthognathic surgery patients. STUDY DESIGN, SETTING, SAMPLE: A cross-sectional study was implemented utilizing patients ages 14-80 years who presented for orthognathic surgery evaluation between September 2021 and December 2022. Subjects were excluded from the study if they did not complete the orthognathic surgery evaluation, were not between the ages of 14-80 years old, or did not complete the Brief Health Literacy Screening Tool (BRIEF) questionnaire during intake. Subjects who have not undergone orthognathic surgery but completed the initial evaluation for orthognathic surgery were included in the study. PREDICTOR VARIABLES: The predictor variables were a set of risk factors for inadequate health literacy: age, sex, primary language, race, estimated household income, and diagnosis. MAIN OUTCOME VARIABLE: The main outcome variable was health literacy assessed using the BRIEF questionnaire. During intake, subjects completed the BRIEF questionnaire consisting of four questions scored on an ordinal scale of 1-5. Inadequate health literacy was defined as a BRIEF score ≤16. COVARIATES: Not applicable. ANALYSES: Bivariate and multivariate analyses were performed. P < .05 was considered statistically significant. RESULTS: Of 150 patients presenting for orthognathic surgery, fifteen percent of patients had inadequate health literacy via the BRIEF test. The mean age of those with adequate health literacy was 27.9 years (standard deviation, ±12.5) compared to 18.5 years (standard deviation, ±5.7) for those with inadequate health literacy (P = <.001). After adjusting for sex, language, race, estimated household income, and diagnosis via multivariate analysis, increasing age was associated with decreased odds of inadequate health literacy (adjusted odds ratio = 0.81; confidence interval, 0.72-0.92; P = <.001). CONCLUSION AND RELEVANCE: In the complex process of orthognathic surgery, it is essential to identify patients with inadequate health literacy that may require additional health literacy interventions. Ultimately, 15% of orthognathic surgery subjects had inadequate health literacy, and younger patients were the most susceptible as the odds of inadequate health literacy decreased with increasing age.

Are Patients with Syndromic Craniosynostosis at Greater Risk for Epilepsy than Patients with Nonsyndromic Craniosynostosis?

OBJECTIVE: The aim of this study was to determine whether patients with syndromic craniosynostosis (SCS) are at increased risk for epilepsy relative to patients with nonsyndromic craniosynostosis (NSCS). METHODS: A retrospective cohort study was completed using the Kids' Inpatient Database (KID). All patients diagnosed with craniosynostosis (CS) were included. The primary predictor variable was study grouping (SCS vs. NSCS). The primary outcome variable was a diagnosis of epilepsy. Descriptive statistics, univariate analyses and multivariate logistic regression were performed to identify independent risk factors for epilepsy. RESULTS: The final study sample included a total of 10,089 patients (mean age, 1.78 years ± 3.70; 37.7% female). 9278 patients (92.0%) had NSCS, and the remaining 811 patients (8.0%) had SCS. A total of 577 patients (5.7%) had epilepsy. Not controlling for other variables, patients with SCS were at increased risk for epilepsy relative to patients with NSCS (OR 2.1, P < 0.001). After controlling for all significant variables, patients with SCS were no longer at increased risk for epilepsy relative to patients with NSCS (OR 0.73, P = 0.063). Hydrocephalus, Chiari malformation (CM), obstructive sleep apnea (OSA), atrial septal defect (ASD), gastro-esophageal reflux disease (GERD) were all independent risk factors (P < 0.05) for epilepsy. CONCLUSIONS: Syndromic craniosynostosis (SCS) in itself is not a risk factor for epilepsy relative to NSCS. The greater prevalence of hydrocephalus, CM, OSA, ASD, and GERD, all of which were risk factors for epilepsy, in patients with SCS relative to patients with NSCS likely explains the greater prevalence of epilepsy in SCS relative to NSCS.

What factors influence the cost of orthognathic surgery among patients in the US?

OBJECTIVE: The purpose of our study was to analyze what factors influence the cost of orthognathic surgery performed within the US. STUDY DESIGN: This retrospective cohort study was completed using the Kids' Inpatient Database (KID) from 2000 to 2012 on all patients aged 14 to 20 years who had undergone orthognathic surgery. The predictor variables included patient and hospitalization characteristics. The primary outcome variable was hospital charge ($). Multivariate linear regression was conducted to determine independent predictors for increased/decreased hospital charge. RESULTS: The final sample consisted of 14 191 patients (mean age, 17.4 ± 1.6 years; females, 59.2%). Each additional day in the hospital added $8123 in hospital charges (P < .01). Relative to mandibular osteotomy, maxillary osteotomy (+$5703, P < .01) and bimaxillary osteotomy (+$9419, P < .01) were each associated with increased hospital charges. Genioplasty (+$3499, P < .01), transfusion of packed cells (TPC) (+$11 719, P < .01), continuous invasive mechanical ventilation (CIMV) <96 hours (+$23 502, P < .01), and CIMV ≥96 hours (+$30 901, P < .01) were each associated with significantly increased hospital charges. Obstructive sleep apnea (OSA) added $6560 in hospital charges (P < .01). CONCLUSIONS: Maxillary osteotomy and bimaxillary surgery were each associated with significantly increased charges relative to mandibular osteotomy. Concomitant genioplasty, TPC, CIMV, and OSA each significantly increased the charges. Each additional day to the length of stay significantly increased the charges.

Validation of Andrews Analysis in the Virtual Environment.

BACKGROUND: Andrews analysis is a tool to establish the aesthetic anteroposterior position of the maxilla. Andrews analysis has not been evaluated through computer-aided surgical simulation (CASS). PURPOSE: The purpose of this study was to evaluate the accuracy of Andrews profile analysis when performed in the virtual environment. STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study was implemented with consecutive patients undergoing orthognathic surgery between February 2020 and February 2022 at the University of Alabama, Birmingham. Traditional Andrews analysis with lateral smiling photographs were taken during the presurgical appointment in adjusted natural head position (aNHP). The standard cone-beam CT obtained for CASS and archived on the KLS Martin (Jacksonville, Florida) database was accessed for retrospective measurement. Lateral facial photographs in aNHP were imported into the virtual environment and the three dimensional (3D) composite model was then oriented into aNHP. The software engineer, blinded to the traditional measurements, then performed the Andrews analysis in the virtual environment by placing a vertical glabella line on the 3D composite model in aNHP. The linear horizontal distance of the maxillary central incisor perpendicular to the vertical glabella line was recorded. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: Method of Andrews analysis measurement (traditional photographic evaluation vs CASS) MAIN OUTCOME VARIABLE: Linear Andrews analysis measurement. COVARIATES: Additional covariates evaluated were sex, age at surgery, and dentofacial deformity diagnosis. ANALYSES: Descriptive statistics were computed to compare photographic analysis versus CASS analysis. A P value of <.05 was considered statistically significant. RESULTS: The average age was 25.7 years old and 54% of patients were female. For the photographic analysis, the mean incisor-goal anterior limit line distance was -0.44 ± 7.12 mm (95% CI, -1.13 to 0.37 mm; P = .46). For the virtual analysis, the mean incisor-goal anterior limit line distance was 0.13 ± 7.21 (95% CI, -0.004 to 0.30; P = .89). The Pearson correlation coefficients between the photograph and 3D analysis were very strong (0.93). The root mean square deviation between the photographic and 3D analysis cohorts was 2.7 mm. CONCLUSION AND RELEVANCE: Given the high correlation coefficients between all demographics, CASS can be utilized for Andrews analysis to determine ideal anteroposterior maxillary position to streamline data collection and the planning process.

Current Orthognathic Surgery Practice Patterns Among Academic OMS.

OBJECTIVE: Currently there is variation in perioperative care of orthognathic surgery patients and limited clinical practice guidelines. The current orthognathic surgery practice patterns among US academic OMFS training centers have not been described. The purpose of this study is to describe the practice patterns among US academic OMFS training centers. DESIGN: The study design is cross-sectional. Data was collected through a survey of the sample. SETTING: OMFS programs in the US. PARTICIPANTS: Academic OMFS. 573 surgeons were contacted and 85 responses were received. MAIN OUTCOME MEASURE: Descriptive and bivariate statistics were reported. RESULTS: Respondents were 87% male and worked in full-time academic (80%), part-time academic (19%), or military settings (1%). Thirty-one percent have practiced for 30 years or more and then 29% with 11-20 years, 18% with 21-30 years, 12% with 6-10 years and 11% with 1-5 years. Twenty-six percent of respondents perform 20-40 orthognathic surgeries a year, 22% perform less than 20 surgeries a year, 21% perform 40-60 surgeries per year, and 19% perform more than 100 surgeries per year. Intraoperatively, 48% of surgeons request a mean arterial pressure of 60-64 mmHg, 25% utilize tranexamic acid (TXA), 85% report a blood loss of less than 400 milliliters, and 93% report a blood transfusion rate of <1%. CONCLUSION: There are variations in orthognathic surgery practice patterns with limited clinical practice guidelines. Only 13 of the 32 survey questions had a single response holding a simple majority. This study demonstrates the need for further research and evidence-based protocols and decision making.

Does the Rigid External Distraction Device Alter Maxillary Pitch in Cleft Maxillary Distraction?

The rigid external distraction (RED) device is reported to have the ability to three-dimensionally reposition the maxilla. The purpose of this study is to assess the ability of RED to intentionally alter the maxillary pitch.Retrospective cohort study.Institutional practice.A retrospective chart review was completed over the past 12 years and a total of 50 patients met the inclusion criteria.Cephalometric changes and alteration in palatal plane angle.Cephalometric analysis of standardized landmarks was completed on calibrated, standardized lateral cephalograms. Pre-distraction and post-consolidation variables were compared via a two-tailed paired t-test.The mean age at surgery of 12.2 ± 3.2 years. Through distraction osteogenesis (DO), the maxilla was moved anteriorly with a mean distraction distance of 8.4 ± 4.8 mm. The mean change in the angles sella-nasion-A-point angle (SNA), sella-nasion-B-point angle (SNB), and A-point-nasion-B-point angle (ANB) were 10.2 ± 4.8, 0.9 ± 2.7, and 9.3 ± 4.1, respectively. The mean change in the palatal plane angle was -4.4 ± 3.7. The mean change in the vertical position of the anterior nasal spine (ANS) and posterior nasal spine (PNS) in relation to the Frankfort horizontal (FH) were -2.0 ± 4.1 mm and 1.7 ± 3.8 mm, respectively.This study documents short-term findings of RED in a large cleft lip and palate (CLP) population. Despite positioning of distraction eyelets superior to the theoretical center of resistance, a counterclockwise (CCW) rotation of the palatal plane occurred. This suggests that adjunctive methods of vector control should be considered if clockwise (CW) rotation of the palatal plane is intended with the RED device.

Is Orthognathic Correction with TMJ Preservation A Stable Treatment Option for Patients with Juvenile Idiopathic Arthritis?

Purpose: The purpose of this study was to evaluate the long-term skeletal stability of orthognathic correction of dentofacial deformities secondary to juvenile idiopathic arthritis (JIA) in individuals without total alloplastic joint reconstruction. Materials and Methods: The investigators designed and implemented a retrospective case series of patients diagnosed with JIA who underwent bimaxillary orthognathic surgery. To evaluate the long-term skeletal changes, the maxillary palatal plane to mandibular plane angle, anterior facial height, and posterior facial height measurements were evaluated through cephalograms. Results: Six patients met inclusion criteria. All subjects were female (mean 16.2 years). Four patients demonstrated < 1° of change of the palatal plane to mandibular plane angle, and all patients had < 2° of change. Three patients had < 1% change in the anterior to posterior facial height ratio. Three patients demonstrated relative posterior facial shortening compared to anterior facial height (< 4%). No patients developed postoperative anterior open-bite malocclusion. Conclusion: Orthognathic correction of the JIA DFD deformity with TMJ preservation is a viable modality to improve facial esthetics, occlusion, upper airway and speech swallowing and chewing mechanisms in select patients. The measured skeletal relapse did not affect the clinical outcome.

Current Concepts in Prophylactic Antibiotics in Oral and Maxillofacial Surgery.

Antibiotic prophylaxis is the use of antibiotics in the perioperative period to prevent surgical site infections from local flora. Specific guidelines and criteria exist to prevent these infections while also practicing antimicrobial stewardship. Most dentoalveolar procedures do not require antibiotic prophylaxis. For nondentoalveolar procedures, the decision to provide antibiotic prophylaxis is based on involvement of the respiratory, oral, or pharyngeal mucosa. Special considerations exist for patients at high risk for infective endocarditis, patients with head and neck cancer, and temporomandibular joint replacement procedures. This article discusses indications for antibiotic prophylaxis during oral and maxillofacial surgical procedures.

Comparison of the condyle-fossa relationship and resorption between patients with and without Juvenile Idiopathic Arthritis (JIA).

PURPOSE: The purpose of this study was 1) to compare condyle - fossa relationships in the temporomandibular joint (TMJ), and 2) to score condylar resorption by using a TMJ indexing system in patients with JIA and without JIA. METHODS: The present retrospective cross-sectional study included cone-beam computed tomography (CBCT) images obtained from the sagittal, coronal, and axial slices. In the multidisciplinary Pediatric Rheumatology Outpatient Clinic at The University of Alabama at Birmingham (UAB) children with JIA are also examined by a group of orthodontists working in the same institute from October 2018 to July 2019. The predictor variable consists of patients with JIA and without JIA. The primary outcome variables are the depth of the mandibular fossa, joint spaces, axial angles, medio-lateral width, and condyle resorption. Other study variables were age and sex. In this study, the measurements obtained from 2 different groups (with JIA and without JIA) are compared using a t-test, where Tukey is utilized to adjust for multiple comparisons. The left and right joints are analyzed separately as the paired t test conducted showed a significant difference between the 2 joints (P < .05). RESULTS: The study was comprised of 34 patients diagnosed with JIA and 34 healthy subjects. The depth of the mandibular fossa, the anterior joint spaces, the axial angles, and the resorption index showed statistically significant differences between the JIA and healthy groups in both left and right sides (P < .05). However, there was no statistically significant difference in the posterior joint spaces and mediolateral width between JIA and healthy groups in both sides (P > .05). CONCLUSIONS: The results of our study presented the destructive potential of juvenile idiopathic arthritis by using CBCT. CBCT scanning is a helpful tool in the evaluation of the radiographic result of TMJ.

Management of juvenile idiopathic arthritis: Preliminary qualitative findings from the National Dental Practice-Based Research Network.

INTRODUCTION: Juvenile idiopathic arthritis (JIA) is the most common chronic arthritis in childhood and represents a series of chronic inflammatory arthritides that develop before 16 years of age. METHODS: In 2020, investigators with an interest in the management of JIA engaged the National Dental Practice-Based Research Network by conducting a preliminary qualitative questionnaire ("Quick Poll") that comprised 6 questions about JIA management. RESULTS: A total of 604 persons responded. Results suggested that there was an interest in the management of JIA, but many clinicians did not feel that they had the necessary knowledge or experience to treat these patients. CONCLUSIONS: The study clearly highlights a distinct gap in awareness and understanding of JIA among clinicians polled. Future work in this area should focus on education and awareness across multiple specialties, clinical guidelines for the management of JIA, and a data repository of long-term outcomes.

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.

Endotracheal Tube Fixation via a Modified Ivy Loop in a Pediatric Patient With Facial Burns: A Technical Note.

Securing an endotracheal tube in a child with a facial burn is crucial but often challenging. The traditional method of using a facial apparatus or tape tied around the lower face is not suitable in the setting of open facial wounds as it limits wound care and, if necessary, skin grafting. We describe a straightforward, quick method to secure the endotracheal tube by means of a modified ivy loop in a pediatric patient.

Challenges in the Successful Reconstruction of Cleft Lip and Palate: Managing the Nasomaxillary Deformity in Adolescence.

The surgical techniques and execution of primary cleft lip and palate repair are no longer the greatest challenge to achieving successful rehabilitation for those born with facial clefting (i.e., bilateral and unilateral cleft lip and palate). Despite a surgeon's best efforts, when cleft palate repair is carried out during infancy, by the mixed dentition, a majority will demonstrate nasomaxillary deficiency. The cleft team's commitment to a family under their care is to ensure that the newborn reaches adulthood reconstructed without need for special regard to their original birth malformation. Guiding principles are provided for the accurate diagnosis and reliable reconstruction of the bilateral and unilateral cleft lip and palate adolescent/adult who presents with nasomaxillary deficiency and any residual oronasal fistula, bony defects, cleft dental gap(s), nasal obstructions, and associated facial dysmorphology. Successful orthognathic surgery provides a stable foundation on which any remaining soft-tissue cleft lip or cleft nasal deformities can be accurately assessed and then reconstructed.

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.

The Effect of Cleft Orthognathic and Nasal Reconstruction on Perceived Social Traits.

BACKGROUND: The investigators hypothesized that a layperson's social perceptions of an adolescent cleft lip and palate (CL/P) patient are more favorable after orthognathic surgery and definitive nasal reconstruction. METHODS: The investigators implemented a survey comparing layperson's perception of specific social traits before and >6 months after jaw and nasal reconstruction in CL/P adolescent subjects by viewing standardized facial photographs. The sample was composed of 10 consecutive subjects treated by 1 surgeon from birth through completion of their staged reconstruction. The outcome variable was changed in 6 perceived personality, 6 emotional expression traits, and 7 perceptions of likelihood of positive interpersonal experiences. Descriptive and bivariate statistics were computed (P < 0.05). RESULTS: Five hundred respondents (raters) completed the survey. The respondents were 58% male with 53% age 25-34. After cleft reconstruction, study subjects were perceived to be significantly more dominant, trustworthy, friendly, intelligent, attractive, and less threatening (P < 0.05). They were also perceived as happier and less angry, surprised, sad, afraid, or disgusted than before surgery (P < 0.05). The subjects were also perceived to be more likely to have positive interpersonal experiences (P < 0.05). CONCLUSION: We confirmed that laypeople consistently report positive changes in adolescent CL/P subject's perceived social traits after bimaxillary and chin orthognathic surgery followed by definitive nasal reconstruction.

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.