Delayed Presentation of Actinomycosis Following Orthognathic Surgery: An Old Nemesis and a Difficult Diagnosis: Case Presentation and Review of the Literature.

Study Design: Review of the literature with report of Case. Objective: To review the presentation of Actinomycosis specifically as it occurs with mandibular osteotomies. Methods: A review of the literature and report of an additional case. Results: While minor infections secondary to local factors are usually seen 2-3 weeks after surgery, late infections are rare. Host factors may play a role. When actinomycosis is diagnosed, long-term antibiotics are necessary. Conclusions: Actinomycosis is very rare following orthognathic surgery. It usually occurs in the mandible and following a sagittal split. Time of presentation for actinomycosis can vary from 6 weeks to 4 months as in our case. Infections occurring this late after surgery should be treated with suspicion of actinomycosis obtaining both cultures and tissue biopsies. Treatment involves an incision and drainage and long-term antibiotics.

Use of a custom plate after large maxillary advancements with internal maxillary distraction: a novel approach.

OBJECTIVE: To present a technique of placing custom patient specific bone plates (PSI) in patients after large maxillary advancement by distraction. STUDY DESIGN: Two cases are used illustrating plate design with a single plate or 2 plates when an anterior pedicle is required. RESULT: Both patients went on to heal after large maxillary advancements and continued orthodontic management shortly after the PSIs were placed. CONCLUSIONS: . Virtual planning is the gold standard for planning a maxillary distraction. Placement of custom plates 1 month after distraction can shorten the period of consolidation, ensure stability, and improve the occlusal results.

Historical evolution of surgical approaches to the face-part I: head and upper face.

Surgical approaches to the head and maxillofacial area have been described and modified by many authors throughout history. It was, however, during the nineteenth and twentieth centuries due in large part to improvements in the delivery of anesthesia and antibiotic therapy when most of the techniques were described. Currently, a myriad of surgical techniques are employed to access the maxillofacial complex with advantages and disadvantages for each one. Although each approach is described in many text and articles, few describe the circumstances or the historical context under which they were designed. In a series of three articles, a historical perspective will be provided on the evolution of some of the most commonly employed today. Descriptions will enumerate the advantages and disadvantages of as well as later modifications. The purpose of the present article (1/3) is to review the approaches to the head and upper face.

Historical evolution of surgical approaches to the face-part II: midface.

Surgical approaches to the head and maxillofacial area have been described and modified by multiple authors throughout history. It was during nineteenth and twentieth century when most of the techniques evolved due to advances in anesthesia and antibiotic therapy. Currently, a myriad of surgical approaches are employed to gain access to the maxillofacial complex, with each of them having advantages and disadvantages. Although the approaches are presented in numerous textbooks and articles, few texts describe the circumstances or historical context under which they were developed. In a series of three articles, we will provide a historical perspective of the evolution of the most common surgical approaches to the head and face employed today. Descriptions contain advantages and disadvantages of the approaches and modifications are also provided. The purpose of the present article (2/3) is to review the approaches to the midface.

Historical evolution of surgical approaches to the face-part III: lower face.

Surgical approaches to the head and maxillofacial area have been described and modified by many authors throughout history. It was, however, during the nineteenth and twentieth centuries when most of the techniques were described, mainly thanks to the advent of anesthesia and antibiotic therapy. Currently, a myriad of surgical techniques are employed to access the maxillofacial complex, with each of them having advantages and disadvantages. Although the approaches are the subject of textbooks and articles, most do not describe the circumstances or the historical context under which they were designed. In a series of three articles, we will provide a historical perspective of the most common surgical approaches to the head and face employed today. Descriptions contain advantages and disadvantages and modifications are provided. The purpose of the present article (3/3) is to review the approaches to the lower face.

Third molar surgery: Past, present, and the future.

Third molar surgery is the most common ambulatory procedure done by oral and maxillofacial surgeons. Surgical approaches for the removal of third molars have been published since the 20th century. This article reviews the history and development of extraction techniques through a literature review. The literature was selected through a search of an electronic database. Key words for the Medline search were "mandibular/maxillary third molar," "impacted mandibular/maxillary third molar," "mandibular/maxillary third molar flap design," and "mandibular/maxillary third molar incision." The search was restricted to English-language articles. Additionally, a manual search in the major oral surgery journals and books was performed. The aim of this article is to examine the evolution of third molar surgery, recognize pioneering techniques, and compare these techniques to current approaches. Common approaches employed today are discussed and treatment philosophies with thoughts for future therapies are provided.

Resorbable Versus Nonresorbable Membranes: When and Why?

Guided bone-regeneration techniques use either resorbable or nonresorbable membrane. Ideal membrane material should be biocompatible with tissue integration, be able to create and maintain space, be occlusive with selective permeability, and have good handling properties. Commercially available nonresorbable membranes are Gor-tex (e-PTFE), Cytoplast (d-PTFE), and titanium mesh. Resorbable membranes are available as natural and synthetic. Clinical trials, a systematic review and meta-analysis have shown no statistically significant difference in most clinical indications between both types of membrane. The choice of membrane varies according to the choice of grafting materials and nature of defect.

Tissue Engineering: What is New?

Soft and hard tissue engineering has expanded the frontiers of oral/maxillofacial augmentation. Soft tissue grafting enhancements include improving flap prevascularization and using stem cells and other cells to create not only the graft, but also the vascularization and soft tissue scaffolding for the graft. Hard tissue grafts have been enhanced by osteoinductive factors, such as bone morphogenic proteins, that have allowed the elimination of harvesting autogenous bone and thus decrease the need for other surgical sites. Advancements in bone graft scaffolds have developed via seeding with stem cells and improvement of the silica/calcium/phosphate composite to improve graft characteristics and healing.

Zygoma Implants or Sinus Lift for the Atrophic Maxilla with a Dentate Mandible: Which is the Better Option?

Rehabilitation of maxillary atrophy with dental implants is challenging to the clinician despite the wide variety of surgical techniques available. Finding the right indication for a procedure is highly important for the long-term stability of dental implants. With the introduction of the concept of "teeth-in-a-day," clinicians have explored innovative techniques to attain the goal of immediate implant-supported provisional prosthesis. However, costs and comorbidities are limitations to advancing these techniques. This article focuses on algorithms to rehabilitate the atrophic maxilla with the purpose of providing immediate provisional prosthetic teeth regardless of the mandibular dentition.

Nasal Alar Pressure Ulcer After Orthognathic Surgery: Clinical Presentation and Preventive Recommendations.

Nasotracheal intubation is routinely used in patients undergoing oral and maxillofacial surgery when intermaxillary fixation is needed either intraoperatively or postoperative. Various complications can occur such as epistaxis, turbinectomy, retropharyngeal dissection, tympanites, and nasal alar pressure sores or necrosis, especially when there is a prolonged nasotracheal intubation. The first report of a nasal alar necrosis after prolonged nasotracheal intubation was published by Hatcher et al in 1968. Since then several reports of skin necrosis of the nasal alar region have been published and attributed to a prolonged operation or the technique used in tube placement. Pressure ulcers are a localized damage to the skin and underlying soft tissue and usually appear immediately after the procedure. They start with nonblanchable erythematous intact skin and can evolve to partial thickness loss of skin with exposed dermis and scab formation during the healing process. They may be painful and can cause a cosmetic problem for patients. The literature has several studies of nasal alar necrosis after nasotracheal intubation for head and neck reconstructive surgery, but there is no description of this complication after orthognathic surgery. This paper describes the occurrence of skin nasal alar necrosis following a bimaxillary jaw correction and highlights recommendations for its management and prevention.

A Straightforward Technique to Repair a Residual Oronasal Fistula in Bilateral Cleft Lip and Palate Patients.

PURPOSE: An anterior palatal oronasal fistula in a bilateral cleft lip and palate is a challenging clinical dilemma. The purpose of this article is to present a 2-stage technique to repair the fistula in consistent fashion. The technique was developed to avoid more complicated procedures that had greater morbidity for larger oronasal defects that could not be treated in a single procedure. MATERIALS AND METHODS: This is a retrospective study performed over 15 years using this technique in a private practice setting. From 2002 to 2017, 15 7- to 12-year-old patients (11 boys and 4 girls) were treated. They were seen in a multispecialty clinic for anterior residual fistulae, and impressions were obtained. Then, they were scheduled for first-stage closing of the fistulae. Data were retrospectively analyzed. The first stage started with closing the central portion of the fistulae. For the second stage 6 months later, the residual nasoalveolar cleft was closed and grafted in standard fashion. The first stage involved posteriorly reflecting a full-thickness mucoperiosteal flap and inserting it into the palatal soft tissue and stabilizing the segment with a splint for 3 weeks. The premaxillary segment was left denuded. RESULTS: Fourteen of 15 patients (93%) had the central portion of the oronasal fistulae successfully closed. One patient had partial breakdown when the splint was prematurely removed at 2 weeks. The patient underwent successful closure by the same procedure at a later date. All patients had successful second-stage grafting of their nasoalveolar clefts. CONCLUSIONS: An alternative technique is presented to treat clinically challenging oronasal fistulae. This 2-stage closure of a palatal fistula is straightforward, allows consistent closure of soft tissue defects, and avoids complex alternative procedures with serious surgical morbidities.

Dysphagia Requiring Nasogastric Feeding Following Orthognathic Surgery: An Unusual Complication, Case Report, Literature Review, and Recommendations.

PURPOSE: To report on dysphagia following orthognathic surgery, to review the literature on this topic, and to make recommendations for the management of this highly unusual problem. PATIENTS AND METHODS: Two cases of dysphagia requiring nasogastric feeding tubes following two-jaw surgery are presented adding to the two already reported in the English language. Similarities and possible causes are discussed and the management of this entity is proposed. RESULTS: Both of our patients required nasogastric feeding tubes be placed to facilitate enteral nutrition. Similar to cases reported in the literature, none of the patients had neurological deficits other than to the second and third division of the trigeminal nerve. All patients recovered the ability to swallow. CONCLUSIONS: While less than 2% of patients undergoing orthognathic surgery may report difficulty with swallowing following jaw surgery, most will recover in a short period of time. For those with prolonged dysphagia, a neurologic examination, a swallow study, and a nasogastric feeding may be required until normal swallowing returns.

A historical perspective with current opinion on the management of atrophic mandibular fractures.

The management of atrophic mandibular fractures has been a challenge for maxillofacial surgeons for decades. During the past 70 years, various techniques for treating edentulous mandibular fractures have been advocated. These techniques have been praised, criticized, abandoned, improved, and used in combination with other methods. Although some of the principles of management outlined before the end of World War II are still valid in today's technological era, other concepts did not survive the test of time. The aim of this paper is to examine the evolution of treatment modalities for the management of atrophic mandibular fractures that have been employed over the years. Debates and discussions generated by this topic are included. Current techniques and treatment philosophies with thoughts for future therapies are provided.

Atrophic Mandible Fractures: Are Bone Grafts Necessary? An Update.

PURPOSE: The management of atrophic mandibular fractures poses a challenge because of anatomic variations and medical comorbidities associated with elderly patients. The purpose of this article is to review and update the literature regarding the management of atrophic mandible fractures using load-bearing reconstruction plates placed without bone grafts. MATERIALS AND METHODS: We performed a review of the English-language literature looking for atrophic mandibular fractures with or without continuity defects and reconstruction without bone grafts. Included are 2 new patients from our institution who presented with fractures of their atrophic mandibles and had continuity defects and infections. Both patients underwent reconstruction with a combination of a reconstruction plate, recombinant human bone morphogenetic protein 2, and tricalcium phosphate. This study was approved as an "exempt study" by the Institutional Review Board at the University of Kentucky. This investigation observed the Declaration of Helsinki on medical protocol and ethics. RESULTS: Currently, the standard of care to manage atrophic mandibular fractures with or without a continuity defect is a combination of a reconstruction plate plus autogenous bone graft. However, there is a need for an alternative option for patients with substantial comorbidities. Bone morphogenetic proteins, with or without additional substances, appear to be a choice. In our experience, successful healing occurred in patients with a combination of a reconstruction plate, recombinant human bone morphogenetic protein 2, and tricalcium phosphate. CONCLUSIONS: Whereas primary reconstruction of atrophic mandibular fractures with reconstruction plates supplemented with autogenous bone graft is the standard of care, in selected cases in which multiple comorbidities may influence local and/or systemic outcomes, bone morphogenetic proteins and tricalcium phosphate can be used as a predictable alternative to autogenous grafts.

Secondary reconstruction of maxillofacial trauma.

PURPOSE OF REVIEW: Craniomaxillofacial trauma is one of the most complex clinical conditions in contemporary maxillofacial surgery. Vital structures and possible functional and esthetic sequelae are important considerations following this type of trauma and intervention. Despite the best efforts of the primary surgery, there are a group of patients that will have poor outcomes requiring secondary reconstruction to restore form and function. The purpose of this study is to review current concepts on secondary reconstruction to the maxillofacial complex. RECENT FINDINGS: The evaluation of a posttraumatic patient for a secondary reconstruction must include an assessment of the different subunits of the upper face, middle face, and lower face. Virtual surgical planning and surgical guides represent the most important innovations in secondary reconstruction over the past few years. Intraoperative navigational surgery/computed-assisted navigation is used in complex cases. Facial asymmetry can be corrected or significantly improved by segmentation of the computerized tomography dataset and mirroring of the unaffected side by means of virtual surgical planning. Navigational surgery/computed-assisted navigation allows for a more precise surgical correction when secondary reconstruction involves the replacement of extensive anatomical areas. The use of technology can result in custom-made replacements and prebent plates, which are more stable and resistant to fracture because of metal fatigue. SUMMARY: Careful perioperative evaluation is the key to positive outcomes of secondary reconstruction after trauma. The advent of technological tools has played a capital role in helping the surgical team perform a given treatment plan in a more precise and predictable manner.

Stability of large maxillary advancements using a combination of prebent and conventional plates for fixation.

OBJECTIVE: The purpose of this study was to determine the stability of one and two jaw maxillary advancements fixed with prebent plates and "L"-shaped plates. STUDY DESIGN: Twenty-six patients met the inclusion criteria (group 1: one jaw [14]; group 2: two jaws [12]). Radiographs were digitized before surgery (T1), immediately after surgery (T2), at 6 weeks (T3), and at 6 months (T4). Stability was assessed comparing A-point movement and change in palatal plane. t tests were used for comparisons between groups, and linear regression analysis was used to assess the stability of A-point T2-T4 versus A-point movement T1-T2 and changes in the palatal plane T1-T2. RESULTS: Initial A-point movement between the two groups was significant (group 1 = 7.61 ± 1.73; group 2 = 5.22 ± 1.67) (P = .0002). Both showed relapse (group 1 = 0.78 ± 0.95; group 2 = 0.04 ± 0.49). Although there was no significant relationship between initial A-point movement and relapse, there was a significant negative relationship between change in palatal plane and relapse in group 1. When initial A-point movement and change in palatal plane were combined, as both increased, relapse also increase (P = .007; R2 = 0.41). CONCLUSIONS: Prebent plates used with "L" plates are a stable fixation technique. Relapse increases with large advancements and change in palatal plane (posterior impaction).

Correlational study of impacted and non-functional lower third molar position with occurrence of pathologies.

BACKGROUND: Lower third molar (M3) eruption is unpredictable. The purpose of this study was to correlate radiographic position of M3 on a preexistent film with the current clinical, histopathological, and radiographic findings. METHODS: A retrospective cohort study was performed. The sample was collected from a database of patients covered by Medical Fund of Brazilian Army. Radiographs were obtained a minimum of 5 years prior to the presurgical visit and after their clinical exam. The primary outcome variables were the teeth positions using Pell and Gregory/Winter classifications on panoramic X-rays. Those variables were analyzed at both the beginning (T0) and end of the study (T1). Clinical assessments and histopathological study of the thirds that were extracted were performed only at T1. Correlation between the teeth positions were related to the clinical, histopathological, and radiographic parameters using statistical analysis tests with significance set at p < 0.05. RESULTS: Twenty-six patients with 49 M3 were assessed over 10 months. Mean age was 14.92 years at T0 and 21.87 years at T1. The average time between T0 and T1 was 6.77 years. A significant relationship (p = 0.024) was found between the presences of root resorption on the second molar if M3 presented in an IB horizontal position at T1. There was also a significant correlation (p = 0.039) between dental crowding of the anterior lower teeth with IIIB position at T0 and if the patient finished orthodontic treatment without lingual retainers. CONCLUSIONS: Lower M3 in position IIIB seen in a teenager and IB seen in an adult is more likely to have negative consequences and should be followed closely.

Simultaneous removal of third molars and completion of a sagittal split osteotomy: effects of age and presence of third molars.

OBJETIVES: The risk of removal of third molars (M3) during a sagittal split osteotomy (SSO) is controversial. The purpose of this study was to review our experience with removal of mandibular M3 during versus before SSO. STUDY DESIGN: A chart and radiographic review was completed in all patients who underwent an SSO from April 2010 until September 2014. The presence or absence of M3, degree of impaction, age, sex, and occurrence of bad splits were noted. The variables were analyzed using the Pearson χ(2), ANOVA, and Fisher's exact tests set to a significance of 5%. RESULTS: For the 215 patients, the mean age was 23.28 years with an increase in the incidence of bad splits in older patients (P = .013). Sixty-six (30.70%) of them had at least 1 M3 present at the time of surgery. There were 6 (2.79%) bad splits. Paradoxically, looking at the occurrence of bad splits and presence of third molar, when the data were analyzed by the number of patients undergoing the procedure, there was slight evidence of a difference (P = .073), but when the data were analyzed by the surgical site, there was a statistically significant association (P = .05). CONCLUSION: The discrepancy between the 2 ways of analyzing the data may be related to there being double the number of observations when analyzed by surgical site and thus the analysis being more powerful.

The nasal lift technique for augmentation of the maxillary ridge: technical note.

Placement of dental implants in a severely resorbed anterior maxillary alveolar ridge is limited by the fact that implants may penetrate the nasal cavity. However, when the maxilla shows unusual anatomical changes, reconstruction with implants can be a challenge. Options to increase the bone in this region to permit placement of implants include: maxillary onlay bone graft, Le Fort I interpositional bone graft, and augmentation of the nasal floor, which is a procedure where only the piriform rim and the anterior nasal spine are exposed through an intraoral approach. In our case we modified this to what we call the nasal lift technique, which is a combination of turbinectomy followed by lifting of the anteroposterior nasal floor through a lateral window using autogenous bone or bone substitutes to augment the space.