Immunohistochemical Analysis on Cortex-to-Cortex Healing After Mandibular Vertical Ramus Osteotomy: A Preliminary Study.

PURPOSE: The present study analyzed the expression of specific cytokines in the transforming growth factor (TGF)-ß superfamily postoperatively after mandibular vertical ramus osteotomy (VRO). MATERIALS AND METHODS: Four beagle dogs were enrolled and euthanized at 1, 2, 4, and 8 weeks postoperatively for immunohistochemical analysis using 6 specific antibodies (bone morphogenetic protein [BMP]-2/4, BMP-7, TGF-ß2, TGF-ß3, matrix metalloproteinase-3, and vascular endothelial growth factor [VEGF]). The results from the surgical site and control (adjacent area) were compared. RESULTS: Generalized upregulation of BMP-2/4 was observed in all healing periods, and the strongest expression of BMP-7 was observed at 1 week postoperatively. The strongest expression of TGF-ß2 was observed at 8 weeks with increasing pattern. The strong expression of TGF-ß3 was observed at 1 and 4 weeks, with the strongest expression of VEGF at 1 week, with a decreasing pattern. No notable uptake was detected with the 6 specific antibodies in the adjacent bone (control). CONCLUSIONS: The absence of internal fixation after VRO led to dynamic healing with a specific expression pattern of BMP-7 and TGF-ß2. The anatomic factors, including sufficient preexisting vascularity, led to the earlier expression pattern of VEGF.

Nasal Soft Tissue Change Following Bimaxillary Orthognathic Surgery.

OBJECTIVE: The purpose of this study is to identify the correlation between maxillary movement and nasal soft tissue changes on three-dimensional reconstructed cone beam computed tomography (CBCT) images after Le Fort I osteotomy. MATERIALS AND METHODS: The authors also investigate the long-term change of alar base width (ABW) to determine the effect of cinch suture. The authors retrospectively studied 52 subjects (14 males and 38 females) who were treated by bimaxillary orthognathic surgery including Le Fort I osteotomy and mandibular ramus surgery. The landmarks and planes were established on three-dimensional reconstructed CBCT images. The authors measured each parameters preoperatively, 1 month postoperatively, and 1 year postoperatively. RESULTS: There was no significant correlation between the horizontal movement of A-point and the widening of ABW (P < 0.038), nor was there a significant correlation between the vertical movement of A-point and the change of ABW (P < 0.61). There was no significant correlation between horizontal and vertical movement of anterior nasal spine and the widening of ABW, nor was there a significant correlation between the nasal tip length and the vector of maxillary movement. CONCLUSION: There was no significant correlation between the ABW widening and the vector of surgical maxillary movement. The effect and stability of the alar base cinch suture is difficult to determine and require further investigation.

Transport distraction osteogenesis combined with orthodontic treatment in a patient with unilateral temporomandibular joint ankylosis.

Temporomandibular joint ankylosis manifests a range of clinical characteristics dependent upon the age of onset, the affected side, and the severity. When it occurs during development, mandibular growth is affected, resulting in severe retrusion or asymmetry as well as limitation of mandibular movements. Progressive asymmetric mandibular growth in unilateral ankylosis causes canting of the occlusal plane. In this case report, we present a successful temporomandibular joint reconstruction using transport distraction osteogenesis combined with camouflage orthodontic treatment for occlusal canting correction of a patient with unilateral temporomandibular joint ankylosis and severe facial asymmetry.

Intraoral Vertical Ramus Osteotomy Results in Good Long-Term Mandibular Stability in Patients With Mandibular Prognathism and Anterior Open Bite.

PURPOSE: Few studies have evaluated the outcomes of intraoral vertical ramus osteotomy (IVRO) for the correction of skeletal Class III malocclusion with an anterior open bite and the potential for postoperative relapse. Therefore, this study evaluated the stability of outcomes of IVRO for mandibular prognathism with and without an anterior open bite. MATERIAL AND METHODS: This retrospective cohort study included consecutive patients with skeletal Class III malocclusion with (AOB group) and without (NAOB group) an anterior open bite who underwent IVRO at Yonsei Dental Hospital (Seoul, Korea). Lateral cephalograms were analyzed for predictor (open bite, yes or no) and outcome (horizontal and vertical relapse in the mandible) variables before and 7 days, 1 year, and 2 years after surgery. Other variables included the patients' demographic characteristics. Data were analyzed using independent t tests, repeated measures analysis of variance, Pearson correlation coefficients, and multiple linear regression analysis. RESULTS: The 2 groups (n = 15 each) were matched for baseline demographic characteristics. During the 2-year postoperative period, anterior and superior mandibular movements were observed in the NAOB group, whereas posterior and superior movements were observed in the AOB group. However, there were no meaningful intergroup differences in horizontal and vertical relapses of the mandible at all time points, although the amount of postoperative inferior relapse increased with a decrease in the amount of initial overbite. CONCLUSIONS: IVRO for the correction of skeletal Class III malocclusion resulted in good postoperative stability over time, regardless of the presence of a preoperative open bite, although the amount of postoperative inferior relapse showed a weak negative correlation with the initial overbite. Thus, IVRO can be a clinically acceptable treatment for skeletal Class III malocclusion with an anterior open bite.

Unilateral mandibular advancement with bilateral intraoral vertical ramus osteotomy.

Intraoral vertical ramus osteotomy (IVRO) is an effective surgical procedure that is used for the correction of mandibular prognathism. However, application of IVRO for mandibular advancement has been limited because of the instability of the proximal segments caused by the gap between the distal and proximal segments. We report a case of unilateral mandibular advancement with bilateral IVRO for the correction of facial asymmetry. This case shows possible application of bilateral IVRO for unilateral mandibular advancement without any means of fixation.

Recovery pattern of mandibular movement by active physical therapy after bilateral transoral vertical ramus osteotomy.

PURPOSE: The purpose of the present study was to evaluate the effect of an active physical therapy (PT) protocol after transoral vertical ramus osteotomy and to investigate the rehabilitation patterns of mandibular movement. MATERIALS AND METHODS: The study included 187 patients diagnosed with mandibular prognathism with or without facial asymmetry who had undergone bilateral transoral vertical ramus osteotomy from 2001 to 2009. The subjects were evaluated preoperatively and 1, 3, 6, 12, 18, and 24 months postoperatively in terms of the periods of PT and range of mandibular movement. The data were analyzed using 1-way analysis of variance (significance level, P < .05). RESULTS: Of the 187 patients, 108 (57.8%) did not receive repeat intermaxillary fixation (IMF) during the PT period, 58 (31.0%) received it once, 15 (8.0%) twice, and 6 patients more than 3 times. The average PT period for all was 10.9 days (range 5 to 45). The mean maximal mouth opening was 50.7 mm before surgery, decreasing to 33.9 mm at 1 month postoperatively. This was followed by an increase to 46.3 mm at 6 months postoperatively, with the maximal mouth opening thereafter showing 93.9% to 95.7% recovery compared with the preoperative state. CONCLUSIONS: About 88% of the patients with transoral vertical ramus osteotomy responded well to the reduced IMF duration and active PT protocols, receiving repeat IMF less than twice. It required about 6 months to recover 90% of the preoperative maximal mouth opening and 12 months to recover near preoperative levels statistically. The benefits of reduced IMF duration and the PT protocols seem to promote rehabilitation of the masticatory muscles and prevention of mandibular hypomobility.

Stability of maxillary position after Le Fort I osteotomy using self-reinforced biodegradable poly-70L/30DL-lactide miniplates and screws.

PURPOSE: The purpose of this study was to evaluate the stability of Le Fort I osteotomy using self-reinforced biodegradable poly-70L/30DL-lactide miniplates and screws. PATIENTS AND METHODS: Nineteen patients who had Le Fort I osteotomy and internal fixation using self-reinforced biodegradable poly-70L/30DL-lactide miniplates and screws were evaluated both radiographically and clinically. Changes in maxillary position after operation were documented 1 week, 1, 3, 6 mo, and/or 1-yr postoperatively with lateral cephalometric tracings. Complications of the self-reinforced biodegradable poly-70L/30DL-lactide miniplates and screws were evaluated by follow-up roentgenograms and clinical observation. A mixed model analysis for repeated measures was used for statistical analysis. RESULTS: Maxillary position was stable after operation with no change between time points (P > .05). There were no complications with the self-reinforced biodegradable poly-70L/30DL-lactide miniplates and screws. CONCLUSIONS: Internal fixation of the maxilla after Le Fort I osteotomy with self-reinforced biodegradable poly-70L/30DL-lactide miniplates and screws is a reliable method for maintaining the postoperative maxillary position after Le Fort I osteotomy.

The chronologic prevalence of temporomandibular joint disorders associated with bilateral intraoral vertical ramus osteotomy.

PURPOSE: The purpose of this study was to evaluate the long-term stability of the improvement of symptoms associated with temporomandibular joint (TMJ) disorders after intraoral vertical ramus osteotomy for the treatment of mandibular prognathism. MATERIALS AND METHODS: A total of 217 patients who had undergone bilateral intraoral vertical ramus osteotomy (BIVRO) from 1998 to 2005 were evaluated preoperatively and 1, 3, 6, 12, 18, and 24 months postoperatively regarding mouth opening, clicking, and pain of the TMJ. A retrospective study was conducted based on the results. RESULTS: Remarkable improvement of TMJ symptoms after BIVRO was reliable. Preoperative TMJ sounds disappeared after BIVRO in 94.3% of joints, and most of the joints that were sound free preoperatively remained without TMJ sounds postoperatively (98.2%). However, 19 joints exhibited recurrence, and transient TMJ sounds were observed in 35 joints. Preoperative TMJ pain had improved in 97.9% of joints at 1 month postoperatively, and TMJ pain was not observed in any joints at 18 months after surgery. Joints that were pain free before surgery remained without pain, although there were 20 joints that exhibited transient TMJ pain. The mean mouth opening was 50.0 mm before surgery, which decreased to 34.92 mm at 1 month postoperatively. This was followed by an increase to 44.44 mm to 48.75 mm at 6 months postoperatively, and thereafter mouth opening showed 94.72% to 97.5% recovery compared with the preoperative state. CONCLUSIONS: BIVRO can be used as a method of choice for relieving undesirable TMJ symptoms such as sound and pain, as well as for repositioning the condyle head to its physiologic position. Such favorable effects of BIVRO on the TMJ were not remarkably affected with time.

Clinical implications of the topography and distribution of the posterior superior alveolar artery.

The aim of this study was to clarify the arrangement of the anatomic courses and distribution of the intraosseous branch (IObr) of posterior superior alveolar artery. The anatomic variations in the topographic relationships were described to provide beneficial data to minimize injury to the IObr during surgical procedure of the buccal wall of the maxillary sinus. The IObrs in 42 hemifaces of embalmed Korean cadavers were examined. The courses of the IObr of the posterior superior alveolar artery were classified into 2 categories: the straight (type 1) and the U-shaped (type 2). The type 1 was the most common (78.1%), and the type 2 was observed in 21.9% of the specimens. The minimum mean height from the cervix to the IObr was 21.1 mm in the first molar region. The IObr ran at the lowest level from the maxillary sinus floor at the first premolar region. These anatomic findings in the current study could represent useful information for the various surgical procedures of the maxilla.

Intraosseous lesion in mandibular condyle mimicking temporomandibular disorders: report of 3 cases.

Pain and dysfunction in the temporomandibular joint (TMJ) region represent a diagnostic challenge. Temporomandibular disorders (TMD) are usually diagnosed by means of a thorough patient history and comprehensive clinical examination. However, additional diagnostic tests, such as imaging of the TMJ area, are necessary in cases where the signs do not explain the symptoms. Neoplasms and pseudotumors of the TMJ are quite uncommon, but their early recognition is necessary in order prevent the delay of correct treatment. This report describes 3 cases of different intraosseous lesions of the mandibular condyle in which the patient was erroneously first treated for a TMD.

Major factors contributing to anterior and posterior relapse after intraoral vertical ramus osteotomy.

The aim of this retrospective cohort study was to investigate the factors contributing to mandibular relapse after intraoral vertical ramus osteotomy (IVRO) while controlling for possible confounders. Forty-seven patients who underwent bimaxillary surgery were divided into three groups according to the direction of horizontal mandibular relapse: a stable group (group S), a posterior relapse group (group P), and an anterior relapse group (group A). Lateral cephalograms were analysed 1 month before and at 7 days and 12 months after surgery. One month before surgery, the pogonion in group A was positioned about 13 mm more anteriorly than in group P (P < 0.05). Immediately after surgery, the mandibles in groups A and S had moved about 6 mm more posteriorly than in group P. At 12 months, both the mandibles (point B) and the maxillae (point A) had moved posteriorly in group P (P < 0.05). A multivariate linear regression analysis showed that the amount of setback was the one key factor predicting postoperative mandibular changes 12 months after IVRO. As the amount of setback decreased, mandibular posterior horizontal relapse increased after IVRO. These findings suggest that the amount of setback can be a key factor predicting postoperative mandibular relapse.

Orthognathic surgery and temporomandibular joint symptoms.

The aim of this article is to review temporomandibular joint symptoms as well as the effects of orthognathic surgery(OGS) on temporomandibular joint(TMJ). The causes of temporomandibular joint disease(TMD) are multifactorial, and the symptoms of TMD manifest as a limited range of motion of mandible, pain in masticatory muscles and TMJ, Joint noise (clicking, popping, or crepitus), myofascial pain, and other functional limitations. Treatment must be started based on the proper diagnosis, and almost symptoms could be subsided by reversible options. Minimally invasive options and open arthroplasty are also available following reversible treatment when indicated. TMD manifesting in a variety of symptoms, also can apply abnormal stress to mandibular condyles and affect its growth pattern of mandible. Thus, adaptive developmental changes on mandibular condyles and post-developmental degenerative changes of mandibular condyles can create alteration on facial skeleton and occlusion. The changes of facial skeleton in DFD patients following OGS have an impact on TMJ, masticatory musculature, and surrounding soft tissues, and the changes of TMJ symptoms. Maxillofacial surgeons must remind that any surgical procedures involving mandibular osteotomy can directly affect TMJ symptoms, thus pre-existing TMJ symptoms and diagnoses should be considered prior to treatment planning and OGS.

Purification and characterization of acidic proteo-heteroglycan from the fruiting body of Phellinus linteus (Berk. & M.A. Curtis) Teng.

Phellinus linteus is a well-known oriental medicinal fungus that has various biological activities such as stimulation of humoral and cell mediated immunity, anti-mutagenicity activity, and anti-cancer activity. The process of isolating and purifying a water-soluble glycan from P. linteus was achieved by hot water extraction, filtration, solvent precipitation, dialysis, and freeze-drying. Acidic fractions of the polysaccharide were separated from crude polysaccharides by DEAE-cellulose anion exchange chromatography at 0.4 M NaCl. The molecular weight of the proteo-heteroglycan after Sepharose CL-4B gel filtration chromatography was about 150,000. The acidic proteo-heteroglycan consisted of 72.2% polysaccharide and 22.3% protein. The sugar of the proteo-heteroglycan was composed of mannose, galactose, glucose, arabinose, and xylose. The amino acid pattern showed that the fractions contained large amounts of aspartic acid, glutamic acid, alanine, glycine, and serine. The fractions for both alpha-glycan at 860 cm(-1) and beta-glycan at 910 cm(-1) had the characteristics of IR spectrum absorption as compared to those for beta-glucan derived from Lentinus edodes. A 13C and 1H NMR spectroscopy showed that the acidic proteo-heteroglycan was a noble biomolecule mixed both alpha- and beta-linkages, and a (1,6) branched type (1,3) glycan.

Comparative analysis of the amount of postoperative drainage after intraoral vertical ramus osteotomy and sagittal split ramus osteotomy.

OBJECTIVES: The purpose of this retrospective study was to compare the amount of postoperative drainage via closed suction drainage system after intraoral vertical ramus osteotomy (IVRO) and sagittal split ramus osteotomy (SSRO). MATERIALS AND METHODS: We planned a retrospective cohort study of 40 patients selected from a larger group who underwent orthognathic surgery from 2007 to 2013. Mean age (range) was 23.95 (16 to 35) years. Patients who underwent bilateral IVRO or SSRO were categorized into group I or group II, respectively, and each group consisted of 20 patients. Closed suction drainage system was inserted in mandibular osteotomy sites to decrease swelling and dead space, and records of drainage amount were collected. The data were compared and analyzed with independent t-test. RESULTS: The closed suction drainage system was removed at 32 hours postoperatively, and the amount of drainage was recorded every 8 hours. In group I, the mean amount of drainage was 79.42 mL in total, with 31.20 mL, 19.90 mL, 13.90 mL, 9.47 mL, and 4.95 mL measured at 0, 8, 16, 24, and 32 hours postoperatively, respectively. In group II, the mean total amount of drainage was 90.11 mL, with 30.25 mL, 25.75 mL, 19.70 mL, 8.50 mL, and 5.91 mL measured at 0, 8, 16, 24, and 32 hours postoperatively, respectively. Total amount of drainage from group I was less than group II, but there was no statistically significant difference between the two groups (P=0.338). There was a significant difference in drainage between group I and group II only at 16 hours postoperatively (P=0.029). CONCLUSION: IVRO and SSRO have different osteotomy design and different extent of medullary exposure; however, our results reveal that there is no remarkable difference in postoperative drainage of blood and exudate.

Anatomic study to determine a safe surgical reference point for mandibular ramus osteotomy.

OBJECTIVE: The purpose of this study was to identify a surgical reference point on the mandibular ramus that can be used during ramus osteotomy to prevent injury to the inferior alveolar nerve. MATERIALS AND METHODS: A total of 125 subjects' mandibles were analyzed and compared on a three-dimensional (3D) model constructed from computed tomography (CT). 25 volunteer subjects with normal class I occlusion (group I, control), 50 consecutive subjects (25 females and 25 males) diagnosed with mandibular retrognathism (group II), and 50 consecutive subjects (25 females and 25 males) with prognathism (group III) were included. This study created a landmark (the midwaist point) at the halfway point on a horizontal plane between the most concave points on the anterior and posterior borders of mandibular ramus, with the vertical plane bisecting the horizontal plane. The midwaist point was compared to other anatomic landmarks including antilingula, lingula, and mandibular foramen for correlation. RESULTS: The distance from the midwaist point to lingula and mandibular foramen along the horizontal plane was not significantly different among three groups. Lingula and mandibular foramen were mostly located within 2 mm posterior of the midwaist point, whereas the locations of lingula and mandibular foramen along the vertical plane to the midwaist point were highly variable. CONCLUSION: The midwaist point is an excellent intraoperative reference point that can help surgeons to identify the position of the lingual and the mandibular foramen, thus preventing inferior alveolar nerve injury.

Fracture of the clivus as an unusual complication of LeFort I osteotomy: case report.

LeFort I osteotomy is a standard technique for the surgical correction of dentofacial deformities. Despite its low morbidity, it can lead to various complications at the base of the skull. We report the case of a fractured clivus as an unusual complication.

A simple classification of facial asymmetry by TML system.

This study proposes a system for classifying facial asymmetry with accompanying mandibular prognathism to facilitate choice of surgical method. We examined hard and soft tissue measurements obtained from posterior-anterior cephalometric radiographs and clinical facial photographs of 153 patients (86 male, 67 female), classifying them according to menton deviation with transverse asymmetry (T), maxillary cant (M), and lip cant (L). The T-group is subclassified according to direction of transverse asymmetry (H). Statistical analysis of menton deviation, cant and transverse asymmetry was performed for each group. The various relationships observed among the groups indicate that most cases (85%) were not effectively correctable using conventional surgical methods. As such, the authors believe that analysing facial asymmetry in terms of the classification system presented in this study and employing surgical methods appropriate to each case will help achieve more harmonious aesthetic outcomes.

Oral foregut cyst in the ventral tongue: a case report.

An oral foregut cyst is a rare congenital choristoma lined by the respiratory and/or gastrointestinal epithelium. The exact etiology has not been fully identified, but it is thought to arise from misplaced primitive foregut. This lesion develops asymptomatically but sometimes causes difficulty in swallowing and pronunciation depending on its size. Thus, the first choice of treatment is surgical excision. Surgeons associated with head and neck pathology should include the oral foregut cyst in the differential diagnosis for ranula, dermoid cyst, thyroglossal duct cyst and lymphangioma in cases of pediatric head and neck lesions.

Postoperative stability for surgery-first approach using intraoral vertical ramus osteotomy: 12 month follow-up.

The aim of this study was to evaluate the postoperative stability of the surgery-first approach using intraoral vertical ramus osteotomy (IVRO). We retrospectively studied a sample derived from the patients who were treated by the surgery-first approach using a LeFort I osteotomy and IVRO for correction of class III dentofacial deformity from 2008 to 2012. Lateral cephalograms taken preoperatively and 2 days, 6 months, and 12 months postoperatively were traced, and the skeletal and dental variables at different time points were analysed. The study sample comprised 37 subjects, mean (SD) age 23 (4) years. The mean (SD) total duration of treatment including postoperative orthodontics was 14 (6) months, and surgical movement of the maxillary A point was 0.75 (1.3)mm anteriorly, and 0.21 (1.79)mm superiorly. The surgical change in the position of the maxillary first molar was 1.01 (1.57)mm superiorly. The mean (SD) movement of mandible was 11.15 (5.4)mm posteriorly at pogonion and 1.02 (1.79)mm inferiorly at menton. There were no significant change in maxillary skeletal variables during the first year postoperative period. The surgical relapse of mandible at pogonion was 0.63 (2.31) mm anteriorly (p=0.01), however, the relapse in superior direction at menton was 2.86 (1.39) mm with statistical significance (p=0.01). The total duration of orthodontic treatment with surgery-first was roughly 5 months shorter than conventional preoperative and postoperative orthodontic treatment. The surgery-first approach using IVRO is effective and predictable, and shortens the overall duration of treatment. Anterior relapse of the mandible was less than 1mm, and increased superior relapse can be compensated for with appropriate preoperative planning to provide a reliable outcome. This study was limited to 12 months' follow-up, and a long term follow-up study is indicated.

The stability following advancement genioplasty with biodegradable screw fixation.

The purpose of this study was to compare postoperative stability using biodegradable screws with that of metal plates for fixation of advancement genioplasty. We studied patients who had advancement genioplasty alone or at the same time as other orthognathic surgery including mandibular setback. We assessed the lateral cephalographs at different time points (preoperatively, and 7 days, 3 months, 6 months, and 12 months postoperatively). A total of 54 patients were enrolled and 27 patients were assigned to each group. The position of pogonion was stable 12 months postoperatively, and the amount of skeletal advancement was reflected in soft tissue close to 100%. There were no clinical differences between biodegradable screws and conventional metal plates used for fixation. Biodegradable fixation for advancement genioplasty is a good option for patients who would require a second operation for removal of the plates.