Midfacial Advancement Line-A Comparative Evaluation of a New Measurement Method in Orthognathic Surgery.

PURPOSE: In planning intraoral quadrangular Le Fort II osteotomy (IQLFIIO), simulation of hard and soft tissue changes will be important at the infraorbital, Le Fort I, and incisor level. The aim of our study was to evaluate a new method for visualization and quantification. MATERIALS AND METHODS: Three different methods of quantification were compared: the point-to-point (PTP) measurement, which has been viewed as the reference standard; part comparison analysis (PCA); and a new method, the midfacial advancement line (MFAL) measurement. We performed a measurement comparison study using the Bland-Altman method to measure agreement and enrolled patients with midfacial deficiency and Class III malocclusion who had undergone IQLFIIO. The primary predictor variable was the method of measurement. The primary outcome variable was the amount of midfacial advancement. We also investigated the time required, visualization quality, and interobserver agreement. RESULTS: The sample included 12 subjects with a mean age of 21.6 years; 7 patients were male. The PTP and MFAL showed no significant observer dependence. The advancement measured with PTP and MFAL showed no significant differences. However, the advancement measured using MFAL and PCA showed a significant difference. The highest rating of visualization was found for MFAL. The time requirements were similar for all 3 methods. CONCLUSIONS: Our results have shown that the MFAL is a suitable method for visualization and quantification of soft and hard tissue changes at all 3 face levels in 1 image. It could be a valuable tool for virtual planning of midfacial advancement surgery.

Soft Tissue Changes in Patients Undergoing Intraoral Quadrangular Le Fort II Osteotomy Versus Conventional Le Fort I Osteotomy.

PURPOSE: The aim of this study was to evaluate soft tissue changes after intraoral quadrangular Le Fort II osteotomy (IOQLFII) and correlate those changes to underlying osseous changes. MATERIALS AND METHODS: Twenty-six non-growing patients with midfacial deficiency and Class III malocclusion were analyzed. A study group of 13 patients who underwent IOQLFII was compared with 13 patients who underwent conventional Le Fort I osteotomy (LFI). After fusion of pre- and postoperative computed tomograms, each patient's hard and corresponding soft tissue changes were measured. Measurement points were defined at 3 levels in the IOQLFII group (infraorbital rim [IR], sinus floor [SF], and lateral incisor tip [LI]) and at 2 levels in the LFI group (SF and LI). Linear models were created to test for correlations between hard and soft tissues. RESULTS: The slope (a1 coefficient) between anteroposterior hard and soft tissue changes was found to be highly significant at each measurement point for all groups. In the IOQLFII group, soft tissue advancement was 69% (confidence interval [CI], 62 to 77%) of the hard tissue advancement at the IR, 90% (CI, 84 to 96%) at the SF, and 73% (CI, 64 to 82%) at the LI. In the LFI group, the corresponding percentages were 90% (83 to 97%) at SF and 84% (77 to 90%) at LI. CONCLUSION: IOQLFII results in predictable correction of midfacial deficiency. At the IR, bony advancement always resulted in markedly less soft tissue advancement than at the SF level. These results indicate that the planned infraorbital advancement should not be too conservative because soft tissue changes are smaller in this region.

Technical Modifications for Intraoral Quadrangular Le Fort II Osteotomy.

PURPOSE: The intraoral quadrangular Le Fort II osteotomy (IQLFIIO) represents a reliable surgical method in cases of midfacial deficiency with good functional, esthetic, and stable long-term results. PATIENTS AND METHODS: In this technical note, we present 3 surgical modifications to previous reports: 1) inferior orbital rim osteotomy by angulated piezosurgical instruments, thereby avoiding the use of chisels in the orbital region; 2) osteosynthetic fixation only laterally at the zygomatic buttress with 2 L-shaped miniplates, thus avoiding paranasal osteosynthesis; and 3) advancement step camouflage in the lateral infraorbital region with a compound mass of autologous bone chips and fibrin glue with the intention to reduce bone block-associated side effects. RESULTS: Thirteen consecutive patients presenting with midfacial deficiency and Class III malocclusion were treated by IQLFIIO and mandibular osteotomy. In all cases, osteotomy and consecutive down fracture could be conducted as planned using the piezotome. No atypical fractures were encountered. No cases of infraorbital nerve anesthesia developed. Midfacial hypesthesia was found in 54% of the operated sides after 3 months, in 23% after 6 months, and in 13% after 12 months. The 5-month postoperative 3-dimensional scans revealed osseous healing at the infraorbital advancement step. CONCLUSIONS: Our results suggest that IQLFIIO can be conducted fully without chisels in the orbital region. Implementation of piezosurgery in IQLFIIO allows for safe bone cutting in the orbital region. Two miniplates and step camouflage with fibrin glue-stabilized bone chips were sufficient for osseous healing. Future studies will focus on quantitative soft to hard tissue changes that occur with IQLFIIO advancement.

Maxillomandibular advancement for treatment of obstructive sleep apnea syndrome: a systematic review.

PURPOSE: To perform a systematic review of the published data concerning maxillomandibular advancement for the treatment of obstructive sleep apnea syndrome. MATERIALS AND METHODS: A systematic literature search was performed in the PubMed database. Original articles in the English language were reviewed to obtain information about patient data, success rates, and outcome measures. RESULTS: The systematic literature search yielded 1,113 citations, of which 101 articles met our inclusion criteria. After a review of the full text, 39 studies were included in the analysis. Most articles were classified as evidence level 4, and 5 met the inclusion criteria for level 2b. The only prospective randomized controlled study had been published in January 2010 and was assigned level 1b. CONCLUSIONS: A recommendation grade of A to B was achieved with regard to the levels of evidence-based medicine. Our results have shown that maxillomandibular advancement is the most successful surgical therapy, and the postoperative polysomnography results are comparable to those under ventilation therapy.

Staging and grading as prognostic factors in maxillary squamous cell carcinoma.

PURPOSE: This retrospective study was performed to present our long-term results in the treatment of maxillary squamous cell carcinoma and evaluate especially the influence of T staging and grading on patients' survival. PATIENTS AND METHODS: We performed a retrospective analysis of 93 consecutive patients with alveolar, gingival, or palatal maxillary SCC treated at our clinic with surgical resection and/or radiation therapy. Data were obtained from chart review and patients' records and were analyzed statistically using the log-rank test and Kaplan-Meier survival curves. The male:female ratio was 2:1 and the mean age was 63 years (range 35 to 94 yrs). Most patients showed a T4 stage (66%) and the most frequent staging was T4N0M0 (42%). The most common histopathological grading was G2 (57%), followed by G3 (22%) and G1 (21%). The 5-year overall survival rate was 71%, and the recurrence rate was 37%. Advanced T stage (T4) and grading did not significantly influence the cumulative survival rates. CONCLUSIONS: T-stage and grading do not have a significant impact on patients' long-term survival. The most crucial factor for recurrence prevention and therefore survival are free resection margins.

Complication rates in the operative treatment of mandibular angle fractures: a 10-year retrospective.

PURPOSE: Large-scale studies assessing complication rates and correlation of complications are still missing considering different fracture locations in the mandible. In the present retrospective study, complication rates of mandibular angle fractures treated by open reduction were assessed. MATERIALS AND METHODS: Three hundred twenty-two patients (259 men, 63 women) with 335 surgically treated mandibular angle fractures were included in this study. RESULTS: Fractures were caused by fights (46.6%), falls (19.2%), traffic accidents (14.6%), sports (11.9%), wisdom tooth removal (7.3%), and 0.9% other causes. Successful treatment occurred in 93.69% of fractures with 1 open reduction and in 6.31% with 2 open reductions. Of surgically treated patients, 71.47% (238) were completely free of complications. A detailed complication correlation matrix is given in the text. Ninety-five fractures treated with 1 miniplate, 170 with 2 miniplates, and 70 with other osteosynthesis concepts were compared regarding osteosynthesis failure and pseudarthrosis. CONCLUSION: Similar osteosynthesis failure rates were shown for 1 miniplate and 2 miniplates.

Three-dimensional measurement of the mandible after mandibular midline distraction using a cemented and screw-fixated tooth-borne appliance: a clinical study.

PURPOSE: The aim of this study was to analyze the 3-dimensional movement of the mandible segments after distraction of the mandibular midline by use of a cemented and screw-fixated tooth-borne appliance. PATIENTS AND METHODS: Twenty patients with transverse deficiencies of the lower arch were included in a consecutive study. Before surgical intervention, a custom-made appliance was cemented to the teeth and also fixed with 2 screws between the teeth on each side. The distraction appliance was activated after 5 days at a rate of 0.6 mm/d. After a consolidation period of 6 weeks, the appliance was removed and an orthodontic retainer was applied. Radiographs and cast models were taken preoperatively and postoperatively, and direct linear measurements were performed at the same intervals. RESULTS: Mean expansion (+/- SD) of the osteotomy line measured on the radiographs for the superior, middle, and inferior part of the mandible was 5.1+/-2.4, 5.9+/-2.8, and 5.7+/-2.9 mm, respectively. The mean overall expansion was 5.6+/-2.6 mm. The width increase of the models between the canines, first premolars, second premolars, first molars, and second molars was 4.2+/-1.8, 5.0+/-2.0, 4.7+/-2.0, 4.3+/-1.7, and 3.6+/-1.3, respectively, at the tooth level and 3.4+/-2.0, 3.6+/-1.8, 3.3+/-1.4, 3.2+/-1.5, and 2.2+/-1.8, respectively, at the bone level. CONCLUSIONS: Expansion of the osteotomy line in the vertical dimension showed a uniform pattern. Lateral movements of the mandibular segments decreased from the symphysis to the gonial angles. The positional changes of the teeth and the bone segments were proportionate. Minimal dental movement was observed.

Closure of oroantral communications with Bichat's buccal fat pad.

PURPOSE: The aim of the present study was to evaluate the use of the pedicled buccal fat pad for the closure of oroantral communications (OACs) and to describe our experience with this surgical procedure. PATIENTS AND METHODS: A retrospective review of 161 patients treated at the University Hospital for Cranio-Maxillofacial and Oral Surgery in Vienna, Austria, from 2000 to 2005, with the diagnosis of an OAC was performed. All defects were closed by application of a buccal fat pad. Data were obtained from chart review, a compiled database, and clinical follow-up and included the location of the defect, the cause of the OAC, the modality of anesthesia, intraoperative complications, any complications during the process of wound healing, and any late adverse effects. RESULTS: The buccal fat pad for closure of an OAC was successfully used in 161 patients at our department. In 12 patients (7.5%), the closure of the OAC was insufficient, and a second operation was necessary. Excluding all severe and complicating cases such as tumor-related defects or previously treated cases, the overall success rate for closure of the OAC was nearly 98%. No late complications occurred, and all patients were free of pain or any limitations after the 6-month follow-up period. CONCLUSIONS: According to the recommendations and anatomic limitations reported in published studies and discussed in the present report, the application of the buccal fat pad is a safe and reliable procedure for closing an OAC.

Surgical treatment of squamous cell carcinoma of the maxilla and nasal sinuses.

PURPOSE: In the treatment of oral squamous cell carcinoma of the maxilla and paranasal sinuses, radical surgery and reconstruction with free flaps is accepted among many clinics. Nevertheless, the treatment protocols vary considerably. This study was performed to present our experience in the treatment of maxillary squamous cell carcinoma with surgical means alone, and to try to identify crucial prognostic factors for the patients' survival. PATIENTS AND METHODS: Thirty-six patients with primary resectable squamous cell carcinoma were included in the study. The mean age was 63 years (43-87 years) and 50% presented in advanced tumor stage (T4). Five patients (14%) already had cervical metastases. All patients were treated by radical surgery alone, and the resulting defects were closed by means of local or free flaps or the use of an obturator, respectively. RESULTS: The overall 5-year survival rate was 64%; the recurrence rate was 33%. Only patients who presented in T3 or T4 stages or had no free resection margins died during the follow-up period. Sixty-nine percent of the patients who died passed away within the first 12 months of follow-up. The 5 patients with cervical metastases received therapeutic neck dissection and showed no regional recurrence. In cases of R1 resection, adjuvant radiotherapy was applied. CONCLUSIONS: The sole surgical treatment of squamous cell carcinomas of the maxillary region led to good results, and can therefore be seen as a valuable strategy. Free resection margins and early detection of the tumor are the most important factors for success.

Facial esthetics and the assignment of personality traits before and after orthognathic surgery rated on video clips.

Typically, before and after surgical correction faces are assessed on still images by surgeons, orthodontists, the patients, and family members. We hypothesized that judgment of faces in motion and by naïve raters may closer reflect the impact on patients' real life, and the treatment impact on e.g. career chances. Therefore we assessed faces from dysgnathic patients (Class II, III and Laterognathia) on video clips. Class I faces served as anchor and controls. Each patient's face was assessed twice before and after treatment in changing sequence, by 155 naïve raters with similar age to the patients. The raters provided independent estimates on aesthetic trait pairs like ugly /beautiful, and personality trait pairs like dominant /flexible. Furthermore the perception of attractiveness, intelligence, health, the persons' erotic aura, faithfulness, and five additional items were rated. We estimated the significance of the perceived treatment related differences and the respective effect size by general linear models for repeated measures. The obtained results were comparable to our previous rating on still images. There was an overall trend, that faces in video clips are rated along common stereotypes to a lesser extent than photographs. We observed significant class differences and treatment related changes of most aesthetic traits (e.g. beauty, attractiveness), these were comparable to intelligence, erotic aura and to some extend healthy appearance. While some personality traits (e.g. faithfulness) did not differ between the classes and between baseline and after treatment, we found that the intervention significantly and effectively altered the perception of the personality trait self-confidence. The effect size was highest in Class III patients, smallest in Class II patients, and in between for patients with Laterognathia. All dysgnathic patients benefitted from orthognathic surgery. We conclude that motion can mitigate marked stereotypes but does not entirely offset the mostly negative perception of dysgnathic faces.

Can dual-energy CT improve the assessment of tumor margins in oral cancer?

OBJECTIVES: The aim was to investigate the image quality of dual-energy computed-tomography (DECT) compared to single-energy images at 80 kV and 140 kV in oral tumors. MATERIALS AND METHODS: Forty patients underwent a contrast-enhanced DECT scan on a definition flash-CT. Four reconstructions (80 kV, 140 kV, mixed (M), and optimum-contrast (OC)) were assessed by four blinded readers for subjective image quality (10-point scale/10=best). For objective quality assessment, linear attenuation measurements (line density profiles (LDP)) were positioned at the tumor margin, and the difference between minimum and maximum was calculated. Signal-to-noise ratios (SNR) were measured in the tongue. RESULTS: The mean image quality for all readers was 5.1±0.3, 8.4±0.3, 8.1±0.2, and 8.3±0.2 for the 140 kV, 80 kV, M, and OC, respectively (P<001 between 140 kV and all others). The mean difference between the minimum and maximum within the LDP was 139.4±59.0, 65.7±29.5, 105.1±46.5, and 118.7±59.4 for the 80 kV, 140 kV, M, and OC, respectively (P<001). The SNR for the tongue was 3.8±2.1, 3.8±2.1, 4.2±2.4, and 4.1±2.3 for the 80 kV, 140 kV, M, and OC, respectively. DISCUSSION: DECT of oral tumors offers high image quality, with subjectively rated image quality and attenuation contrast at the tumor margin similar to that of 80 kV; DECT, however, provides a significantly higher SNR compared to 80 kV.

Long-term success of surgery in bisphosphonate-related osteonecrosis of the jaws (BRONJs).

OBJECTIVES: Bisphosphonates are associated with osteonecrosis of the jaw. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) may be treated conservatively or by surgery. PATIENTS AND METHODS: 108 patients underwent surgery and 88 patients were followed for a mean period of 337 days. Age, gender, dental procedures, underlying disease, and the role of bisphosphonate treatment in the success of surgery were evaluated retrospectively. RESULTS: Surgical treatment improved the stage distribution from 19% stage I, 56% stage II and 25% stage III to 59% intact mucosa, 19% stage I and 13% stage II and 8% stage III. The improvement in the stage of disease achieved by surgery was statistically significant. Further relevant parameters that favor a positive outcome of surgery were the event triggering the outbreak of BRONJ (p=0.05) and the underlying disease (p=0.05). BRONJ in the maxilla necessitated repeat surgery significantly earlier than did BRONJ in the mandible (p=0.03). CONCLUSION: Effective surgery might improve the outcome of BRONJ, although prevention still is the most important aspect of this condition.

Manifestation of an ameloblastic carcinoma ten years after follicular cyst enucleation in the mandibular ramus.

Ameloblastic carcinoma (AC) is a rare tumour which can emerge de novo or from an ameloblastoma. To our knowledge, malignant transformation from an odontogenic cyst into an AC has not been documented yet. This case report describes the manifestation of an AC 10 years after enucleation of a histologically confirmed follicular cyst in the angle of the mandible.

Factors influencing surgical treatment of bisphosphonate-related osteonecrosis of the jaws.

BACKGROUND: Bisphosphonates are known to be associated with osteonecrosis of the jaw. We assess factors underlying the success of surgical treatment in patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ). METHODS: Fifty-eight patients were investigated 6 months after having surgery. Outcome variables included the stage of disease. Factors underlying the success of surgery such as age, sex, dental procedures, underlying disease, and bisphosphonate therapy were subjected to statistical analysis. RESULTS: In all, 41 patients after surgery could be followed up. Twenty-four patients (58.5%) had an intact mucosa after surgical treatment. A statistically significant improvement was registered between preoperative and postoperative staging (p < .01). Routine dental procedures and the underlying illness influenced the outcome of surgery (p < .05). Patients with osteoporosis and multiple myeloma improved to a greater extent by surgery than those with cancer. Discontinuation of bisphosphonates was found to improve the outcome (p < .05). CONCLUSIONS: Surgery is more successful in patients with osteoporosis or multiple myeloma than in those with solid tumors. Discontinuation of bisphosphonate therapy favored the surgical outcome.

CROOMA, complication rates of operatively treated mandibular fractures, paramedian and body.

INTRODUCTION: This retrospective study comprises an exploratory analysis of 10 years of surgical treatment of symphysis (S) and parasymphysis/body (P/B). Correlations of complications, as well as dependencies of surgical concepts, are investigated. MATERIALS AND METHODS: All surgically treated patients in the period of 1995 to 2005 with at least one mandibular fracture mesial to the mandibular angle were included in this study. A total of 63 patients (46 men, 17 women) with 63 symphysis fractures were included and 497 patients (369 men, 128 women) with 553 P/B were included; 99.27% (549) of these fractures were included in the study, 4 had to be dismissed because of inconclusive documentation. RESULTS: Of patients with P/B, 96.04% were successfully treated with 1 open reduction, 3.76% had 2, and 0.20% had 3 surgeries. Of the surgically treated patients, 75.77% (416) were completely free of complications, whereas the other 24.23% of the P/B showed 1 or more complications. The main complication was mild nerve damage (24.8%). Osteosynthesis failure rate (OFR) was 2.4% (7 of 298) for 2 miniplates, 5.7% (3 of 53) for 1 tension screw, and 8.4% (9 of 107) for 1 miniplate. Regarding OFR, 2 miniplates showed to be superior in a Fisher exact test (P = .018, adjusted P = .132). Symphysis fractures were completely free of complications in 81.8% and showed 2 major complications, i.e., 1 severe nerve damage and 1 osteosynthesis failure. DISCUSSION: This study has the limitations of a retrospective study. CONCLUSION: A high success rate of open reduction and osteosynthesis with 2 miniplates can be guaranteed.

Antibiotic susceptibility and resistance of the odontogenic microbiological spectrum and its clinical impact on severe deep space head and neck infections.

OBJECTIVE: The purpose of this retrospective study was to identify the major pathogens responsible for deep space head and neck infections and their current resistance to routinely used antibiotics in a university hospital setting. STUDY DESIGN: A total of 206 patients suffering from odontogenic deep space infections were treated at our department by means of surgical intervention and intravenous administration of antibiotics. RESULTS: The predominant bacteria were viridans group streptococci (VGS), staphylococci, Prevotella, Peptostreptococcus, and Bacteroides. In the aerobic spectrum, resistance against clindamycin was found in 18%, against macrolides in 14%, and against penicillin G in 7%. The anaerobes were resistant to clindamycin in 11%, to metronidazole in 6%, and to penicillin G in 8%. CONCLUSION: The high resistance rate for clindamycin and macrolides was especially striking and may necessitate an adaptation of our antibiotic regime in the future.

Complication rates of operatively treated mandibular fractures--the mandibular neck.

BACKGROUND: Surgical treatment of mandibular neck fractures is frequently associated with postoperative complications. This study aims at an in-depth analysis of complication rates of surgically treated mandibular neck fractures. METHODS: All treated patients (264 male, 103 female patients, with 429 mandibular neck fractures) of the Vienna University Clinic of Maxillofacial Surgery in the period of 1995 to 2005 with at least 1 mandibular neck fracture were included. RESULTS: Of surgically treated fractures, 94.8% healed successfully after 1 open reduction, 4.4% had 2, and 0.8% had 3 open reductions. Osteosynthesis failure was 11.3% for 1 miniplate, 6.7% for 2 miniplates, and 8.5% for 1 lag screw. Of the surgically treated, 53 (21.3%) had 1 complication, 12 (4.8%) had 2, and 4 (1.6%) had 3 complications. Comparing isolated and mandibular neck fractures combined with other mandibular fractures the risk of suffering osteosynthesis failure is 3.59 in case of isolated (P = .004). CONCLUSIONS: Predominant causes of revision surgery are osteosynthesis failure, pseudarthrosis, and malposition.