Application of Orthognathic Surgery Principles and Techniques in the Management of Craniomaxillofacial Trauma.

BACKGROUND: Posttraumatic secondary deformities of facial skeleton may occur because of nonmanagement or ill management of primary injuries, whereas some unexpectedly occur even after dedicated management attempts. Orthognathic surgery (OGS) principles and techniques can be used as an efficient tool to correct posttraumatic craniomaxillofacial deformities or skeletal developmental deformities during trauma management. AIM AND OBJECTIVES: The aims of this study were to describe the different types of posttraumatic secondary deformity and address how to use the principles of orthognathic techniques to correct them. MATERIALS AND METHODS: Patients with orthognathic surgical osteotomies during primary or secondary management of facial trauma (referred to as trauma-OGS) during the period of 2010 to 2018 were retrospectively reviewed. Variables pertaining to patients and surgery were collected, including trauma diagnosis, etiology, duration between trauma/primary surgery and secondary presentation, suggested reason for secondary deformity, intervention undertaken to address, and the surgical outcome. RESULTS: Twenty-seven patients were eligible and extensively reviewed. Etiological categorization of trauma-OGS could be done into posttraumatic deformities (18) and developmental deformities (9). The former group was further categorized as OGS done as primary procedure (8) that included immobile Le Fort fractures and delayed initial treatment, and OGS done as secondary procedure (10) that included complex fractures and condylar fractures. The developmental deformity group was categorized into OGS done simultaneously during trauma management (5) or done as a secondary procedure after trauma management (4). CONCLUSIONS: Application of principles and techniques of OGS in indicated primary or secondary management of facial trauma patients should always be considered. The categorization of scenarios presented in this article relating facial trauma and OGS may further help to understand the application.

Symmetry of the Vermillion Height after Modified Rotation-Advancement Cheiloplasty.

(1) Background: This study aimed to determine the postoperative vermillion symmetry between the cleft and non-cleft sides of patients with unilateral cleft lip during the early and late postoperative periods. (2) Methods: 57 patients with complete and 38 with incomplete unilateral cleft lips operated on between 2010 and 2014 were retrospectively evaluated within 1 month (T1), 9 months to 1 ½ years (T2), and more than 4 years (T3). Vermilion heights of the cleft and non-cleft sides were measured from frontal photographs. The Cleft Lip Component Symmetry Index (CLCSI) was used to determine the symmetry of the cleft and non-cleft sides and was then analyzed. (3) Results: Among the 95 patients studied, vermilion height was excessive on the cleft side throughout the three time periods. There was a significant increase in CLCSI from T1 to T2 for both complete and incomplete types, and a significant increase from T1 to T3 only in the incomplete group and no difference from T2 to T3 for both the groups. (4) Conclusions: Even with efforts to obtain a symmetric vermilion height during the primary cheiloplasty, vermilion height excess was noted with time in complete and incomplete cleft types. Secondary revisional vermilion surgery may be performed to achieve symmetry.

Effects of maxillary advancement on maxillary incisor display in patients with skeletal Class III malocclusion and cleft lip and palate.

INTRODUCTION: The information on the hard- and soft-tissue factors correlated with tooth display after LeFort I osteotomy, especially in the surgery-first approach (SFA), are limited. This study aimed to correlate different parameters with the maxillary incisor display in patients with skeletal Class III malocclusion and those with cleft lip and palate (CLP) in SFA. METHODS: This study consisted of 35 patients with skeletal Class III malocclusion and 32 with cleft deformities who had undergone orthognathic surgery. Pretreatment and posttreatment lateral cephalometric analysis were obtained. Maxillary incisor display was measured in photographs. The intraclass correlation coefficient was used to assess the intraexaminer repeatability. The Student t test was used to compare the maxillary incisor display between 2 groups. Analysis of covariance was performed with pretreatment measurement as covariates, and the important determinants for maxillary incisor display were identified by adjusting the baseline measurements. RESULTS: The mean increase of maxillary advancement at point A was 5.25 mm and 1.28 mm downward movement for skeletal Class III malocclusion, whereas it was 4.59 mm advancement and 2.16 mm downward movement for patients with CLP. The resulting maxillary incisor display was 2.86 mm for skeletal Class III malocclusion and 2.56 mm for patients with CLP. The covariates for maxillary incisor display before intervention was significantly associated with the maxillary incisor display after intervention (P <0.001). However, the interaction effect of groups was not seen (P = 0.933). The horizontal position of A, vertical position of ANS, and upper lip length were the most predictable parameters (P <0.001, P <0.001, P = 0.048, respectively) for maxillary incisor display in both groups. CONCLUSIONS: Horizontal position of point A, vertical position of ANS, and upper lip length are the most important determinants for maxillary incisor display for patients with skeletal Class III malocclusion and those with CLP.

Association between Mandibular Angle Fracture with Third Molar Positioning and Residual Bone Height.

BACKGROUND: Mandibular angle fracture are frequently associated with presence of third molar. This study aimed at assessing the role of third molar with angle fracture in relation to its positioning and the remaining bone between the apex of third molar and inferior border of mandible. METHODS: A retrospective study of all patients who reported for treatment of mandibular fracture between January 2019 to January 2021 were undertaken. Patient's data and orthopantamogram radiographs were obtained from there medical records. The collected data included presence/absence of mandibular angle fracture, presence/absence of mandibular third molar, angulation and positioning of third molar along with residual bone height. Statistical analysis was done in SPSS version 20 with p-value set at p<0.05 Results: Total of 86 mandibular fracture reported in the study period, of which 34 (39.53%) had angle fracture. Third molar was present in 31 (45.6%) cases and was associated with angle fracture with statistical significance of p<0.026. Mesioangular impaction (86.4%) with class II (57%) ramus relation and position B (72.7%) in occlusal relation were associated with angle fracture in comparison to non-angle fracture group where angulation and occlusal position were statistically significant p<0.001 and p=0.002, respectively. Residual bone height was also found to be less in angle fracture group in comparison to other mandibular fracture group showing statistical significance (p<0.023). CONCLUSIONS: Patient with partially erupted mandibular third molar are more frequently associated with angle fracture and the residual bone height could also be a good predictor for risk of angle fracture.

Extensive Gingivoperiosteoplasty Versus Secondary Alveolar Bone Grafting in Patients With Complete Bilateral Cleft Lip and Palate During the Mixed Dentition Period: A Retrospective Outcome Analysis.

BACKGROUND: The concept of gingivoperiosteoplasty (GPP) in the mixed dentition stage as compared with secondary alveolar bone grafting (ABG) in management of alveolar cleft has not been much discussed upon. The authors present the experience with extensive GPP and ABG in the mixed dentition stage in complete bilateral alveolar cleft cases. METHODS: A retrospective review of nonsyndromic patients with complete bilateral alveolar cleft operated on with either GPP or ABG (iliac crest) in the mixed dentition stage with at least 1-year follow-up was performed. Dental occlusal radiographs were evaluated for level of bone gain using Bergland and Witherow scales. Statistical evaluation of clinical success and procedure-related complications was conducted using χ2 test and odds ratio. RESULTS: Twenty-four patients in the GPP group and 20 in the ABG group were comparatively studied. Clinical success rate as indicated by Bergland scales I and II (87.5% in GPP vs 82.5% in ABG; P = 0.731), complication rate (20.83% in GPP vs 30% in ABG; P = 0.484), and status of canine eruption showed no significant differences in clinical outcomes in both groups. CONCLUSIONS: The technique of extensive GPP as described by authors shows equal efficacy to secondary ABG for management of bilateral alveolar clefts during the mixed dentition period.

One-Year Craniofacial Surgery Fellowship at Chang Gung Memorial Hospital.

ABSTRACT: Residency trainings in oral and maxillofacial surgery, plastic surgery, or otolaryngology do not sufficiently cover all aspects of craniofacial surgery to enable fresh graduates to independently practice as craniofacial surgeons. Fellowship trainings are almost mandatory to gain added skills and knowledge in the subspecialty. There are limited number of fellowship centers around the globe that accept international fellows, provide an excellent hands-on experience, arrange free accommodation and pay stipend to the selected candidates. The author presents his critical review of 1-year craniofacial surgery fellowship at Chang Gung Memorial Hospital, Taiwan, sponsored by Noordhoff Craniofacial Foundation (NCF), during which he rotated in pediatric craniofacial surgery unit for five and half months, orthognathic surgery unit for 4 months and craniofacial trauma and reconstruction unit for two and half months. The surgical log is presented along with critical review of individual postings, pearls of the overall fellowship along with suggestions for interested candidates to join the fellowship.

Unilateral Cleft Lip Repair Using the Chang Gung Technique: An Outcome Analysis.

OBJECTIVE: This retrospective study analyzed the outcomes of patients undergoing complete or incomplete unilateral cleft lip repair using the Chang Gung technique. The goal was to compare the symmetry and change of the technique through the measurement of anthropometric points on digital photographs. METHODS: From 2010 to 2016, a total of 274 complete and incomplete cleft lip patients without other craniofacial deformities were included in the study. All included patients had a minimum 1-year follow-up with frontal view photographs taken. The vermilion area, lip width, vermilion height, lateral lip length, lip height, and Cupid's bow width of both cleft and noncleft sides were measured for all patients. The Cleft Lip Component Symmetry Index was used to determine the symmetry of the cleft and noncleft sides in both incomplete and complete cleft groups. RESULTS: A total of 152 complete and 122 incomplete cleft lip patients were included in the study. The mean Cleft Lip Component Symmetry Index values showed that the vermilion area, lip height, and Cupid's bow width were symmetric on both cleft and noncleft sides. Lip width and lateral lip length were noted to be shorter, whereas the vermilion height was thicker on the cleft side than on the noncleft side. Significant differences between the complete and incomplete cleft group measurements were found for lateral lip length and lip height, and complete cleft measurements were shorter than those for incomplete clefts. There were no significant differences in vermilion area, lip width, vermilion height, and Cupid's bow width. CONCLUSIONS: The outcome analysis showed that vermilion height reduction and modifications could be made for both complete and incomplete groups. The complete cleft lip has been found to have a significantly shorter lateral lip length and lip height, reflecting a more severe anatomical soft tissue deficiency in this group. A long-term outcome anthropometric point study may further verify the results of this surgical technique.

Videofluoroscopic Findings as Predictors of Velopharyngeal Insufficiency After Orthognathic Surgery in Patients With Cleft Lip and Palate.

BACKGROUND: Midface retrusion is a common problem in patients with cleft lip and palate owing to the lack of adequate growth of the maxilla. Midface advancement surgery is a definite treatment for midface retrusion; however, the subsequent oropharyngeal airway changes might result in velopharyngeal insufficiency (VPI) in affected patients. Determining the predictors of VPI beforehand and modifying the surgical procedure would be beneficial. MATERIALS AND METHODS: A retrospective review of 42 patients with cleft lip and palate who underwent orthognathic surgery from 2013 to 2014 was performed. A total of 25 patients met the inclusion criteria and had undergone complete pre- and postsurgery videofluoroscopy, nasopharyngoscopy (NPS), and speech assessment. We compared 2 groups of patients, those who showed NPS finding changes of more than 0.1 (8 patients) and those without changes (17 patients), by measuring the distances of the contact point to the tip of the velum, gap size at maximum closure (MC) and rest, contact area length, lateral wall closure rate, closure velocity, and 2 angles (from the velum to the hard palate and genu) at MC and rest. The amount of maxillary advancement was also recorded. RESULTS: Among the 8 patients with NPS finding changes, 3 underwent Furlow palatoplasty for VPI. No significant difference was found in the amount of maxillary advancement between the groups (5.8 vs 5.7 mm). Significant differences were found in the preoperative gap size at MC and angle at the genu at MC (P = 0.035 and .012). These could be considered as the predictors before surgery. After surgery, a significant difference was found in the contact area, lateral wall closure rate, and gap size at MC (P = 0.005, 0.018, and 0.01). CONCLUSION: Videofluoroscopy is a relatively applicable method of determining dynamic changes in the velum function. By performing videofluoroscopy before midface advancement surgery in patients with cleft lip and palate, we may predict the risk of VPI and consider alternative surgical strategies.

Effect of sandblasting on fracture load of titanium ceramic crowns.

PURPOSE OF THE STUDY: It is difficult to achieve a reliable bond between the titanium and veneering porcelain. The aim of this study was to evaluate the bond strength between titanium ceramic crowns. MATERIALS AND METHODS: The surfaces of titanium copings were divided in two groups. Group A sandblasted with 250 um (n = 10) and Group B without sandblasting (n = 10). Low-fusing porcelain was bonded over copings. A universal testing machine was used to determine the fracture load (N) of the crowns. All data were compared using Student's t-test. RESULTS: There was a significant difference in fracture toughness between two groups (P = 0.05). The mean value of fracture strength for Group A was 721.66 N and for Group B was 396.39 N. CONCLUSIONS: Sandblasting improves the bond strength between titanium, and ceramic, mechanical bonding plays a crucial role in the bonding between titanium and ceramic.

Primary cN0 lip squamous cell carcinoma and elective neck dissection: Systematic review and meta-analysis.

BACKGROUND: Management of clinically negative lymph nodes (cN0) in primary lip squamous cell carcinoma (SCC) has always been a controversial topic. METHODS: A systematic review of English-language electronic databases using Medline, Embase, Cochrane library, Google Scholar, SCI, and specific journals on the subject matter was done. Only the studies mentioning primary nonmetastatic lip SCC with cN0 neck treated by surgery only and having at least 2 years of follow-up data were selected. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for reporting systematic reviews and meta-analysis was followed. RESULTS: The pooled estimate of occult metastasis in neck dissected specimen was 0.17 (95% confidence interval [CI], 0.10-0.28) and that of delayed nodal metastasis in patients without neck dissection was 0.08 (95% CI, 0.01-0.18). CONCLUSION: The results do not prove sufficient to justify elective treatment of the neck in primary cN0 lip SCC and close observation would be a viable option in such cases. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1392-1400, 2015.

The chronological age estimation of third molar mineralization of Han population in southwestern China.

The purpose of the study was to estimate the chronology of third molar mineralization in Han population of southwestern China and find its unique characteristics so that it would provide a reference in several legal cases like forensic age estimation. The study used Demirjian's staging method to study 2192 orthopantomograms of 984 male and 1208 female subjects aged between 8 and 25 years. The statistical data was analyzed by Student's t test and ANOVA. The conclusions of the study are: (1) The chronological mineralization age of third molars of Han population in Southwestern China is similar to the Turkish and the Japanese, was earlier than the Austrian and Han of South China, but later than the Spanish. (2) The mineralization timing of the third molars between two sides in maxilla or mandible has no significant differences in the same gender group. (3) There is no significant difference in mineralization of third molars between male and female, except for tooth 48 in Demirjian's stage E. (4) The mineralization of third molar in maxilla is earlier than mandible.

Report of a case with 19 supernumerary teeth in a non-syndromic patient.

Supernumerary teeth occur frequently in human dentition, but presence of multiple supernumerary teeth in patients without any associated syndrome or systemic disorder is a rare phenomenon. Presence of supernumerary teeth in itself is not a problem and may not require removal in all cases but in certain conditions, they may be associated with several clinical complications and require removal. Here, we present a 14 year old female who complained of non emergence of permanent teeth. Orthopantomogram initially showed presence of fifteen impacted supernumerary teeth distributed in all quadrants, but later, cone-beam computed tomography further revealed four additional teeth, totaling to nineteen supernumerary teeth. Consultation with concerned specialists ruled out any syndromes or systemic disorders which led us to the diagnosis of "non-syndromic multiple supernumerary teeth" and this probably is the highest number of supernumerary teeth reported in a single non-syndromic patient till date.