Morphological Variation of the Mandible in the Orthognathic Population-A Morphological Study Using Statistical Shape Modelling.

The aim of this study was to investigate the value of 3D Statistical Shape Modelling for orthognathic surgery planning. The goal was to objectify shape variations in the orthognathic population and differences between male and female patients by means of a statistical shape modelling method. Pre-operative CBCT scans of patients for whom 3D Virtual Surgical Plans (3D VSP) were developed at the University Medical Center Groningen between 2019 and 2020 were included. Automatic segmentation algorithms were used to create 3D models of the mandibles, and the statistical shape model was built through principal component analysis. Unpaired t-tests were performed to compare the principal components of the male and female models. A total of 194 patients (130 females and 64 males) were included. The mandibular shape could be visually described by the first five principal components: (1) The height of the mandibular ramus and condyles, (2) the variation in the gonial angle of the mandible, (3) the width of the ramus and the anterior/posterior projection of the chin, (4) the lateral projection of the mandible's angle, and (5) the lateral slope of the ramus and the inter-condylar distance. The statistical test showed significant differences between male and female mandibular shapes in 10 principal components. This study demonstrates the feasibility of using statistical shape modelling to inform physicians about mandible shape variations and relevant differences between male and female mandibles. The information obtained from this study could be used to quantify masculine and feminine mandibular shape aspects and to improve surgical planning for mandibular shape manipulations.

Effects of Upper Blepharoplasty Techniques on Headaches, Eyebrow Position, and Electromyographic Outcomes: A Randomized Controlled Trial.

The aim of this study was to assess changes in headaches, eyebrow height, and electromyographic (EMG) outcomes of the frontalis and orbicularis oculi muscles, after an upper blepharoplasty with or without resecting a strip of orbicularis oculi muscle. In a randomized controlled trial, 54 patients received an upper blepharoplasty involving either only removing skin (group A) or removing skin with an additional strip of orbicularis muscle (group B). Preoperative, and 6 and 12 months postoperative headache complaints were assessed using the HIT-6 scores and eyebrow heights were measured on standardised photographs. Surface EMG measurements, i.e., electrical activity and muscle fatigue, were assessed for the frontalis and orbicularis oculi muscles preoperatively and 2, 6, and 12 months postoperatively. Significantly fewer headaches were reported following a blepharoplasty. The eyebrow height had decreased, but did not differ between groups. Regarding the surface EMG measurements, only group A's frontalis muscle electrical activity had decreased significantly during maximal contraction 12 months after surgery (80 vs. 39 mV, p = 0.026). Fatigue of both the frontalis and the orbicularis oculi muscles did not change significantly postoperatively compared to baseline. EMG differences between groups were minor and clinically insignificant. The eyebrow height decreased and patients reported less headaches after upper blepharoplasty irrespective of the used technique.

Adjunctive Aesthetic Procedures in Orthognathic Surgery.

An important aesthetic goal in orthognathic planning is to improve facial balance, harmony, volume, and symmetry. It is therefore logical that adjunctive aesthetic procedures become a part of the overall orthognathic treatment plan and that their possibilities are discussed with orthognathic candidates. Such procedures help to improve the final outcome of the orthognathic treatment and enhance patient satisfaction. Training and experience are of utmost importance when offering and performing aesthetic facial surgery. This article discusses various facial aesthetic procedures that can be combined with orthognathic surgery, to the patient's benefit, to help them become the most beautiful version of themselves.

Traditional versus Laterally Extended Upper Blepharoplasty Skin Excisions: Objective and Patient-Reported Outcomes.

BACKGROUND: Different skin excision shapes may result in different aesthetic outcomes after upper blepharoplasty. METHODS: Two skin-only excision shapes were evaluated objectively and subjectively in 28 matched patients with laterally extended skin excision (group A) or traditional elliptical skin excision (group B). The pretarsal show, lateral eyebrow height, amount of scarring (evaluated with the Patient and Observer Scar Assessment Scale), and patient-reported aesthetic results (evaluated using FACE-Q) were scored and compared at 6 and 12 months postoperatively. RESULTS: In both groups, pretarsal show improved significantly after blepharoplasty. The homogeneity of pretarsal show improved significantly in the lateral extension group (group A) together with slightly more pretarsal show (0.5 to 0.8 mm at central pupil region) at 6 and 12 months of follow-up compared with group B ( P = 0.004). A trend was observed in the exocanthion 45-degree measurement, in which group A had 0.6 mm greater pretarsal show 6 months postoperatively. Homogeneity of the pretarsal show had improved significantly in group A, but not in group B, at 12 months after blepharoplasty. No other significant differences were observed between the groups regarding pretarsal show measurements or FACE-Q scores. Both groups showed descent of the lateral eyebrow, but this was only significant in group B. Group B showed 1.4 to 2.0 mm more descent compared with group A. Scarring and adverse effects scores were low in both groups and did not differ. CONCLUSION: Laterally extended skin excision and traditional elliptical skin excision both result in positive aesthetic results, but the laterally extended skin excision technique is accompanied by a slightly more favorable outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Volumetric Effect and Patient Satisfaction after Facial Fat Grafting.

BACKGROUND: Facial fat grafts decrease in volume after transplantation. This observation is based on overall facial three-dimensional analyses, because there is sparse information on volume changes in well-defined aesthetic areas. The authors aimed to assess the overall and, more specifically, the local volumetric effects of facial fat grafting and relate these effects to patient satisfaction up to 1 year after treatment. METHODS: All consecutive adult female patients who were scheduled for facial fat grafting without additional surgical procedures were asked to participate. All patients underwent the same fat grafting method. An algorithm-based personalized aesthetic template was applied to define specific aesthetic areas on the preoperative three-dimensional image. Objective outcome parameters [i.e., three-dimensional volume differences, patient satisfaction (FACE-Q questionnaire)] were measured at baseline and at 6 weeks, 6 months, and 12 months after fat grafting. RESULTS: Of 33 female patients who underwent a facial fat graft procedure, 23 patients had complete three-dimensional data and were eligible for analysis. The highest volume gain was observed 6 weeks after grafting and was followed by a gradual loss thereafter. Overall and in the zygomatic area, a substantial gain in volume was still present 1 year after grafting, whereas this effect was lost in the lip area. FACE-Q scales Satisfaction with Facial Appearance Overall and Satisfaction with Cheeks improved too, whereas scores for Lines: Lips returned to baseline levels. The improvement in FACE-Q scales was in agreement with the objective change in volume. CONCLUSION: Gain in overall and local volumetric effects is accompanied by comparable changes in patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Supplementation of Facial Fat Grafting to Increase Volume Retention: A Systematic Review.

BACKGROUND: For decades, facial fat grafting has been used in clinical practice for volume restoration. The main challenge of this technique is variable volume retention. The addition of supplements to augment fat grafts and increase volume retention has been reported in recent years. OBJECTIVES: The aim of this systematic review was to investigate which supplements increase volume retention in facial fat grafting as assessed by volumetric outcomes and patient satisfaction. METHODS: Embase, Medline, Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar were searched up to November 30, 2020. Only studies assessing volume after facial fat grafting with supplementation in human subjects were included. Outcomes of interest were volume or patient satisfaction. The quality of the studies was assessed with the Effective Public Health Practice Project tool. RESULTS: After duplicates were removed 3724 studies were screened by title and abstract. After reading 95 full-text articles, 27 studies were eligible and included for comparison. Supplementation comprised of platelet-rich plasma, platelet-rich fibrin, adipose tissue-derived stromal cells or bone marrow-derived stromal cells, cellular or tissue stromal vascular fraction, or nanofat. In 13 out of 22 studies the supplemented group showed improved volumetric retention and 5 out of 16 studies showed greater satisfaction. The scientific quality of the studies was rated as weak for 20 of 27 studies, moderate for 6 of 27 studies, and strong for 1 study. CONCLUSIONS: It remains unclear if additives contribute to facial fat graft retention and there is a need to standardize methodology.

Impact of upper blepharoplasty, with or without orbicularis oculi muscle removal, on tear film dynamics and dry eye symptoms: A randomized controlled trial.

PURPOSE: Upper blepharoplasty may be related to dry eye symptoms since the function of the orbicularis oculi muscle may affect the tear film. We aimed to assess the effect of blepharoplasty with or without the removal of a strip of orbicularis oculi muscle on tear film dynamics and dry eye symptoms. METHODS: A double-blind, randomized, controlled trial comparing upper blepharoplasty without (group A) or with (group B) orbicularis oculi muscle excision was performed on 54 healthy Caucasian patients. Tear film dynamics and dry eye symptoms were evaluated using multiple dry eye parameters, i.e. tear osmolarity, Schirmer test I, corneal/conjunctival staining, tear break-up time (TBUT), Oxford Scheme, Sicca Ocular Staining Score and Ocular Surface Disease Index questionnaire. All the parameters were assessed preoperatively and 6 and 12 months after upper blepharoplasty. All the groups' outcomes were compared. RESULTS: The differences were not significant between the two upper blepharoplasty techniques regarding most of the above-mentioned outcomes. Subjective symptoms of ocular irritation, consistent with dry eye disease and vision-related impairment, were reduced after upper blepharoplasty independent of the type of the technique applied, while the pre and postoperative outcomes of the objective tear dynamics did not differ 12 months after surgery. However, group B demonstrated a significant increase in tear osmolarity and TBUT at the 6-month follow-up visit. CONCLUSION: An upper blepharoplasty alleviates subjective dry eye complaints in the long term, while not changing the tear dynamics. The improvement was independent of the blepharoplasty technique used.

A functional MRI study of presurgical cognitive deficits in glioma patients.

BACKGROUND: The main goal of this functional MRI (fMRI) study was to examine whether cognitive deficits in glioma patients prior to treatment are associated with abnormal brain activity in either the central executive network (CEN) or default mode network (DMN). METHODS: Forty-six glioma patients, and 23 group-matched healthy controls (HCs) participated in this fMRI experiment, performing an N-back task. Additionally, cognitive profiles of patients were evaluated outside the scanner. A region of interest-based analysis was used to compare brain activity in CEN and DMN between groups. Post hoc analyses were performed to evaluate differences between low-grade glioma (LGG) and high-grade glioma (HGG) patients. RESULTS: In-scanner performance was lower in glioma patients compared to HCs. Neuropsychological testing indicated cognitive impairment in LGG as well as HGG patients. fMRI results revealed normal CEN activation in glioma patients, whereas patients showed reduced DMN deactivation compared to HCs. Brain activity levels did not differ between LGG and HGG patients. CONCLUSIONS: Our study suggests that cognitive deficits in glioma patients prior to treatment are associated with reduced responsiveness of the DMN, but not with abnormal CEN activation. These results suggest that cognitive deficits in glioma patients reflect a reduced capacity to achieve a brain state necessary for normal cognitive performance, rather than abnormal functioning of executive brain regions. Solely focusing on increases in brain activity may well be insufficient if we want to understand the underlying brain mechanism of cognitive impairments in patients, as our results indicate the importance of assessing deactivation.

Three-dimensional facial volume analysis using algorithm-based personalized aesthetic templates.

Three-dimensional stereophotogrammetry is commonly used to assess volumetric changes after facial procedures. A lack of clear landmarks in aesthetic regions complicates the reproduction of selected areas in sequential images. A three-dimensional volumetric analysis was developed based on a personalized aesthetic template. The accuracy and reproducibility of this method were assessed. Six female volunteers were photographed using the 3dMDtrio system according to a clinical protocol, twice at baseline (T1) and twice after 1year (T2). A styrofoam head was used as control. A standardized aesthetic template was morphed over the baseline images of the volunteers using a coherent point drift algorithm. The resulting personalized template was projected over all sequential images to assess surface area differences, volume differences, and root mean square errors. In 12 well-defined aesthetic areas, mean average surface area and volume differences between the two T1 images ranged from -7.6mm2 to 10.1mm2 and -0.11cm3 to 0.13cm3, respectively. T1 root mean square errors ranged between 0.24mm and 0.62mm (standard deviation 0.18-0.73mm). Comparable differences were found between the T2 images. An increase in volume between T1 and T2 was only observed for volunteers who gained in body weight. Personalized aesthetic templates are an accurate and reproducible method to assess changes in aesthetic areas.

When Right Is on the Left (and Vice Versa): A Case Series of Glioma Patients with Reversed Lateralization of Cognitive Functions.

We report a case series of four patients operated on for a glioma in awake conditions and in whom task-based functional magnetic resonance imaging (fMRI) demonstrated right-dominant activity during a language production task. Language functional sites were identified intraoperatively by electrical stimulations only in the patient with a right-sided lesion. Furthermore, the pre- or postoperative cognitive evaluations in the three patients operated on for a left-sided glioma revealed right spatial neglect and dysexecutive syndrome, hence demonstrating that, in patients with right-dominant activity on language fMRI, the left hemisphere is implicated in spatial consciousness and cognitive control. This study supports the interest of presurgical task-based language fMRI to identify patients with a reversed lateralization of cognitive functions and to make an adequate selection of the battery of intraoperative cognitive tasks to be monitored in those rare outliers.

Volumetric Effect of Pregnancy on a Unilateral Facial Fat Graft.

Weight gain can affect the volume of a facial fat graft, resulting in unfavorable asymmetries. Weight gain during pregnancy is more complex and does not just entail an increase in adipose tissue. This case report objectifies whether pregnancy results in volume changes of a facial fat graft. A 24-year-old woman received a fat graft (7 ml) in the mandibular area to mask a volume deficiency. This deficiency occurred after a fibula reconstruction of a mandibular defect resulting from the removal of an ameloblastoma. The patient became pregnant 3 weeks after the fat graft procedure. Standardized 3-dimensional photographs (3dMD) were available preoperatively and at 7 weeks (first trimester), 6 months (second trimester), 9 months (third trimester), and 14 months (4 months after delivery) postoperatively. Three-dimensional analysis revealed that no substantial volume changes of the fat graft occurred during pregnancy other than the overall proportional gain in facial volume. Pregnancy apparently does not affect the volume of a small unilateral fat graft applied in the facial region.

Bone-borne surgically assisted rapid maxillary expansion: A retrospective three-dimensional evaluation of the asymmetry in expansion.

PURPOSE: Asymmetrical expansion occurs in patients treated with Surgically Assisted Rapid Maxillary Expansion (SARME). In the clinical setting, this asymmetrical expansion is seen in multiple directions. However, the frequency, actual directions and amount of asymmetry are unclear. Hence, the aim of this study was to analyze the directions and amount of asymmetrical lateral expansion in non-syndromic patients with transversal maxillary hypoplasia on employing bone-borne transpalatal distraction by means of SARME. Treatment involved corticotomies of all four bony supports, including pterygomaxillary disjunction. MATERIALS AND METHODS: A retrospective case series was formed from patients treated with SARME. Pre- and postdistraction Cone Beam Computed Tomography scans were superimposed. A reference frame was created to analyze lateral expansion asymmetries in five directions. RESULTS: Clinical relevant asymmetries (>3.0 mm) in at least one of the investigated directions occurred in 55% of the patients. Lateral expansion asymmetries occurred mostly in the inferior-anterior part between the left and right segment and asymmetry in total expansion was noted between the anterior and posterior part of the maxilla. CONCLUSION: This study confirms the clinical suspicion that using SARME with a bone-borne distractor and pterygomaxillary disjunction to treat non-syndromic patients with transversal maxillary hypoplasia, results in regular asymmetrical lateral expansion.

What is the current optimal fat grafting processing technique? A systematic review.

BACKGROUND: With the advents of new processing techniques and new graft survival theories in fat grafting, the question is: Which processing technique is of preference? This study systematically reviewed literature regarding current techniques for processing fat grafts. METHODS: PubMed, Embase, Cinahl, and Cochrane databases were searched until August 2015. Studies comparing different fat grafting processing techniques were included. Outcomes were viability of adipocytes, number of adipose-derived stromal/stem cells (ASC) and growth factors in vitro, volume and quality of the graft in animal studies, and satisfaction and volume retention in human studies. RESULTS: Thirty-five studies were included. Adipocyte viability and ASC numbers were the best using the gauze/towel technique (permeability principle) compared to centrifugation. With regard to centrifugation, the pellet contained more ASCs compared to the middle layer. The animal studies' and patients' satisfaction results were not distinctive. The only study assessing volume retention in humans showed that a wash filter device performed significantly better than centrifugation. CONCLUSION: In this study, processing techniques using permeability principles proved superior to centrifugation (reinforced gravity principle) regarding viability and ASC number. Due to the variety in study characteristics and reported outcome variables, however, none of the processing techniques in this study demonstrated clinical evidence of superiority.

Computer-aided planning and surgical guiding system fabrication in premolar autotransplantation: a 12-month follow up.

This case report describes the autotransplantation of maxillary right second premolar into the contralateral position in a 14-year-old female using computerized tomographic data and a customized guiding system produced by computer-aided design/computer-assisted manufacture technology. Using innovative surgical guides and keys with navigation features, modification of the recipient socket and handling of the transplant were facilitated without harming the periodontal membrane. Postoperative clinical and radiographic examination showed periodontal and pulp healing earlier than 6 months after surgery.

Surgically facilitated orthodontic treatment: a systematic review.

INTRODUCTION: Corticotomy and dental distraction have been proposed as effective and safe methods to shorten orthodontic treatment duration in adolescent and adult patients. A systematic review was performed to evaluate the evidence supporting these claims. METHODS: PubMed, Embase, and Cochrane databases were searched until April 2013 for randomized controlled trials, controlled clinical trials, and case series with 5 or more subjects that focused on velocity of tooth movement, reduction of treatment duration, or complications with various surgical protocols. There were no language restrictions during the search phase. Publications were systematically assessed for eligibility, and 2 observers graded the methodologic quality of the included studies with a predefined scoring system. RESULTS: Eighteen articles met the inclusion criteria. Seven studies were clinical trials, with small investigated groups. Only studies of moderate and low values of evidence were found. Surgically facilitated treatment was indicated for various clinical problems. All publications reported temporarily accelerated tooth movement after surgery. No deleterious effects on the periodontium, no vitality loss, and no severe root resorption were found in any studies. However, the level of evidence to support these findings is limited owing to shortcomings in research methodologies and small treated groups. No research concerning long-term stability could be included. CONCLUSIONS: Evidence based on the currently available studies of low-to-moderate quality showed that surgically facilitated orthodontics seems to be safe for the oral tissues and is characterized by a temporary phase of accelerated tooth movement. This can effectively shorten the duration of orthodontic treatment. However, to date, no prospective studies have compared overall treatment time and treatment outcome with those of a control group. Well-conducted, prospective research is still needed to draw valid conclusions.

Risk of bleeding after dentoalveolar surgery in patients taking anticoagulants.

To avoid increasing the risk of thromboembolic events, it is recommended that treatment with anticoagulants should be continued during dentoalveolar operations. We have evaluated the incidence of bleeding after dentoalveolar operations in a prospective study of 206 patients, 103 who were, and 103 who were not, taking anticoagulants. Seventy-one were taking thrombocyte aggregation inhibitors and 32 vitamin K antagonists. Patients were treated according to guidelines developed at the Academic Centre for Dentistry Amsterdam (ACTA), The Netherlands. The operations studied included surgical extraction (when the surgeon had to incise the gingiva before extraction), non-surgical extraction, apicectomy, and placement of implants. Patients were given standard postoperative care and those taking vitamin K antagonists used tranexamic acid mouthwash postoperatively. No patient developed a severe bleed that required intervention. Seven patients (7%) taking anticoagulants developed mild postoperative bleeds. Patients taking vitamin K antagonists reported 3 episodes (9%) compared with 4 (6%) in the group taking thrombocyte aggregation inhibitors. Among patients not taking anticoagulants, two (2%) developed mild bleeding. The differences between the groups were not significant. All bleeding was controlled by the patients themselves with compression with gauze. We conclude that dentoalveolar surgery is safe in patients being treated with anticoagulants provided that the conditions described in the ACTA guidelines are met.

Maxillomandibular advancement surgery as alternative to continuous positive airway pressure in morbidly severe obstructive sleep apnea: a case report.

Obstructive sleep apnea syndrome (OSAS) is a sleep-related breathing disorder, characterized by disrupted snoring and repetitive upper airway obstructions. Oral appliance therapy is an effective alternative to continuous positive airway pressure (CPAP) and is especially effective in mild and moderate OSAS cases. Successful oral appliance therapy has been suggested as a predictor for successful maxillomandibular advancement (MMA) surgery in OSAS patients. MMA surgery has gained increasing popularity in this field since this procedure is associated with an enlargement of the entire velo-oro-hypopharyngeal airway. The authors present an unusual case of a CPAP-intolerant morbidly obese female (body mass index (BMI) = 40) with morbidly severe OSAS (apnea-hypopnea index (AHI) = 139, lowest oxyhemoglobin saturation level = 73%), who underwent a successful combination of MMA surgery, a modified genioplasty and cervicomental liposuction after oral appliance therapy. The post-surgical AHI was 6, and the lowest oxyhemoglobin saturation level increased to 86%. The authors suggest that this surgical combination should be seriously considered in obese patients with severe OSAS and CPAP intolerance.

Oral rehabilitation with implant-based prostheses of two adult patients treated for childhood rhabdomyosarcoma.

BACKGROUND: Rhabdomyosarcoma is the most common malignant tumor in the nasal and paranasal sinus area at childhood. Multimodal treatment for this disorder has severe side effects due to normal tissue damage. As a result of this treatment, facial growth retardation and oral abnormalities such as malformation of teeth and microstomia can cause esthetic and functional problems. CASE REPORTS: Two cases are presented of patients with severe midfacial hypoplasia and reduced oral function as a result of treatment of rhabdomyosarcoma of the nasopharyngeal and nasal-tonsil region. With a combined surgical (osteotomy, distraction osteogenesis, implants) and prosthetic (implant-based overdenture) treatment, esthetics and function were improved.