Dual-degree Oral and Maxillofacial Surgery Training in the United States: "Back to the Future".

In the present report, we trace the history of education and training of oral and maxillofacial surgeons as it has evolved from the mid-19th century to the present. We consider the effects of the discovery of ether anesthesia, the separation of medicine and dentistry, and other milestones such as antisepsis (Lister), antibiotics (Fleming) and surgical progress during wartime. The main emphasis, however, is on the background, development, and implementation of current dual-degree oral and maxillofacial surgery training programs, the first 5 programs, the pioneer advocates for this training, and progress and challenges for the future.

Correlation of Cephalometric Analyses With Clinical Impression in Orthognathic Surgery Patients: Harvold and Steiner Analyses.

PURPOSE: A variety of linear (Harvold) and angular (Steiner) cephalometric analyses are used to identify the skeletal basis for a malocclusion; there is no universally accepted standard. The purpose of this study was to compare the concordance of Harvold and Steiner analyses with the clinicians' impression of maxillary and mandibular jaw position. PATIENTS AND METHODS: We conducted a retrospective cohort study of patients who underwent orthognathic surgery at Massachusetts General Hospital from 2012 through 2016. Patients were included if they had symmetrical deformities not related to trauma, clefts, or syndromes; complete records; and a clinical diagnosis documented at initial consultation. The predictor variables were Harvold- and Steiner-derived diagnoses of jaw position (hypoplasia, neutral, or hyperplasia). The outcome variables were maxillary and mandibular clinical impressions (hypoplasia, neutral, or hyperplasia). The concordance, sensitivity, specificity, positive predictive value (PPV), and negative predictive value relative to clinical diagnoses were calculated. RESULTS: During the study period 388 patients had orthognathic surgery and 222(112 females, mean age 26.4±9.9 years) met the inclusion criteria. Harvold and Steiner analyses were 82% and 33% concordant with the maxillary clinical impression, respectively (P < .001), and 62% and 52% concordant with the mandibular clinical impression, respectively (P = .044). Steiner analysis had greater concordance in females (P < .001). For maxillary hypoplasia, the maxillary unit length had a sensitivity of 87%, specificity of 36%, and PPV of 92% and the sell-nasion-A (SNA) point had 28%, 84%, and 93%, respectively. For mandibular hypoplasia, the mandibular unit length had a sensitivity of 52%, specificity of 96%, and PPV of 94% and the sell-nasion-B (SNB) point had 52%, 98%, and 97%, respectively. For mandibular hyperplasia, the mandibular unit length had a sensitivity of 46%, specificity of 93%, and PPV of 40% and the SNB point had 73%, 73%, and 23%, respectively. CONCLUSIONS: Harvold analysis was significantly more consistent with the clinical impression of the maxillary and mandibular sagittal position than Steiner analysis. Both analyses were highly specific and had high PPVs to confirm the clinical impression. Clinicians should consider incorporating Harvold analysis during treatment planning for orthognathic surgery.

Long-Term Stability of Condylectomy and Costochondral Graft Reconstruction for Treatment of Idiopathic Condylar Resorption.

PURPOSE: To assess and update long-term outcomes of endoscopic condylectomy and costochondral graft (CCG) reconstruction for treatment of active idiopathic condylar resorption (ICR). PATIENTS AND METHODS: This study is a continuation of a retrospective cohort study of patients with active ICR who underwent bilateral condylectomies and CCG reconstruction from 1999 to 2016. Predictor variables were demographic and operative factors. The primary outcome variable was occlusal stability, as defined by normal overbite (1 to 4 mm) at latest follow-up. Overbite; overjet; the angle formed by the sella, nasion, and B point (SNB); mandibular plane angle; and ramus-and-condyle unit height were measured. Time points were preoperative (T0) and immediate (T1), 1 year (T2), 2 years (T3), 3 to 5 years (T4), and at least 5 years (T5) postoperative. Descriptive and bivariate statistics were computed. A Firth logistic regression model was used to identify variables associated with occlusal instability. RESULTS: Twenty-six patients (25 female; mean age, 23.1 yr) who underwent bilateral endoscopic condylectomies and CCG reconstruction were included: 14 from the original cohort and 12 additional patients for the present analysis. Median follow-up was 3.65 years (range, 1.11 to 17.1 yr). Preoperatively, all patients had a Class II malocclusion with a mean overjet of 6.89 mm (range, 1.2 to 17.1 mm) and a mean anterior open bite of -2.12 mm (range, -0.4 to -7.9 mm). Normal overbite (1 to 4 mm) and overjet (2 to 4 mm) were achieved postoperatively in all patients. There were no significant changes in overjet, overbite, SNB, mandibular plane angle, and ramus-and-condyle unit height from T1 to T4. At latest follow-up, 88.5% of patients had a normal overbite. Three patients developed an anterior open bite postoperatively: 1 at 2 years (0.1 mm; preoperative, -3.4), 1 at 9 years (-0.8 mm; preoperative -7.9), and 1 at 11 years (-1.3 mm; preoperative -1.1). Subjects at T5 (n = 9 of 26) had mean overjet and overbite of 3.48 and 1.56 mm, respectively. Non-white race and follow-up time were significant predictors of occlusal instability in the regression model. CONCLUSIONS: Stable and predictable long-term outcomes can be achieved using endoscopic condylectomy and CCG reconstruction for treatment of active ICR.

Residency Interview Experiences in Oral and Maxillofacial Surgery Differ by Gender and Affect Residency Ranking.

PURPOSE: Resident interview experiences are crucial for applicants when ranking programs. The purpose of the present study was to evaluate the interview experience among current oral and maxillofacial surgery (OMS) residents to determine the factors that influenced their selection and ranking of training programs and whether these experiences differed between women and men. MATERIALS AND METHODS: We conducted a cross-sectional survey of OMS residents in 2018. The 12-question survey included demographics, reasons for selecting an interview and ranking programs, and positive and negative experiences during the interviews. Logistic regression models were constructed to evaluate the predictors of unprofessional or negative experiences. RESULTS: A total of 1134 surveys were emailed, with 165 completed questionnaires (14.6%) returned by 35 women (21.2%) and 130 men (78.8%). Their average age was 30.8 years (range, 25 to 42). The racial/ethnic distribution was as follows: white, 75.8%; Asian, 15.8%; and other, 8.4%. Of the 165 respondents, 52% were in MD and 48% in non-MD programs. The top factors in selecting an institution at which to interview were clinical scope and volume, and the reason for ranking a program high was resident friendliness, which was similar among the female and male respondents. Unprofessional behavior or negative experiences were reported by 62 respondents (38%) and occurred by both faculty and residents and during both interviews and social events. Demeaning behavior toward the applicant, residents, and colleagues was the most common negative experience overall, with the women experiencing more gender-specific inappropriate behavior. Female respondents and those who were in dual-degree programs were 2.4 and 2.1 times more likely to experience unprofessional conduct than their peers, respectively (P = .03). CONCLUSIONS: Female and male residents were influenced by the same factors when selecting interviews and ranking residency programs. Unprofessional and inappropriate conduct was reported by 38% of the respondents. Women and dual-degree respondents were 2.4 and 2.1 times more likely to experience unprofessionalism during interviews, respectively. This might have contributed to the low number of current female OMS residents.

An Algorithm for Management of Dentofacial Deformity Resulting From Juvenile Idiopathic Arthritis: Results of a Multinational Consensus Conference.

PURPOSE: Juvenile idiopathic arthritis (JIA) frequently affects the temporomandibular joints and may cause dentofacial deformity and dysfunction. The adverse effects of JIA on dentofacial growth, morphology, and function may be due to erosion of the existing mandibular condyle(s), the inhibitory effect of the arthritis on the growing mandible, or both. No algorithm exists for management of JIA-induced skeletal and dental abnormalities; treatment varies widely. MATERIALS AND METHODS: On the basis of the available literature and expert opinion obtained by a consensus conference held by the Temporomandibular Joint Juvenile Arthritis (TMJAW) group-a multidisciplinary and multinational clinical and research network dedicated to the diagnosis and management of temporomandibular joint arthritis caused by JIA-we present an algorithm to be used as a conceptual framework for management of dentofacial deformity resulting from JIA. RESULTS: An algorithm for management of dentofacial deformity resulting from JIA is presented and exemplified by 5 clinical cases. CONCLUSIONS: A standardized algorithm will improve clinical decision making and facilitate outcome research by allowing valid comparisons between published research studies. We emphasize the importance of multidisciplinary evaluation, management, and long-term follow-up.

Risk Factors for Cervical Spine Injury in Patients With Mandibular Fractures.

PURPOSE: Patients with mandibular fractures are known to be at risk of concomitant cervical spine injuries (CSIs). The purpose of this study was to determine the incidence of and risk factors for CSIs in these patients. PATIENTS AND METHODS: We conducted a retrospective cohort study of adult trauma patients with mandibular fractures from June 1, 2007, through June 30, 2017. Patients were identified through the Massachusetts General Hospital trauma registry and were included as study patients if they had a mandibular fracture and computed tomography or magnetic resonance imaging of the cervical spine. The primary predictor variable was the site of the mandibular fracture; the primary outcome variables were the presence of CSIs and death. The other variables were demographic characteristics (age, gender, alcohol use, and drug use), Injury Severity Score, Glasgow Coma Scale, presence of midface and extra-craniofacial injuries, and etiology. Data analysis consisted of univariate correlations and construction of a multivariate model to determine independent risk factors for CSIs. RESULTS: Of 23,394 patients in the trauma registry, 3,950 (17%) had craniomaxillofacial fractures and 1,822 (7.7%) had CSIs. The frequency of CSIs in the overall cohort of mandibular fracture patients (n = 1,147) was 4.4%, and for admitted patients (n = 495), it was 10%. The mean age of patients with mandibular fractures plus CSIs was 40 years (range, 19 to 93 years); 84% were men. Patients with a ramus-condyle unit fracture, mandibular fracture plus any midface fracture, non-craniomaxillofacial injury, and motor vehicle crash etiology had the highest frequency of CSIs. Ramus-condyle unit fractures and chest injuries were independent risk factors for CSIs in the multivariate model (P = .0334 and P = .0013, respectively). The mortality rate was 4-fold higher in patients with CSIs versus those without CSIs. CONCLUSIONS: The presence of ramus-condyle unit fractures and the presence of chest injuries were independent risk factors for CSIs. Oral and maxillofacial surgeons should be diligent in ruling out CSIs in mandibular fracture patients.

Long-Term Effects of Distraction Osteogenesis of the Mandible.

PURPOSE: 1) To assess the fate of the permanent teeth in and adjacent to the regenerate in pediatric patients who underwent mandibular distraction osteogenesis (DO) and 2) to compare the postoperative growth of the distracted mandible with age- and gender-matched controls. PATIENTS AND METHODS: This was a retrospective cohort study of children who underwent mandibular DO during the primary or mixed dentition period and before completion of somatic growth (boys aged ≤14 years and girls aged ≤12 years) at Massachusetts General Hospital from 1996 to 2014. From the DO registry, patients were selected who had complete clinical and radiographic records and at least 1 year of follow-up. Patients with disorders of dental development (eg, ectodermal dysplasia) were excluded. Panoramic radiographs were used to assess changes in morphology, eruption, and orientation of the dentition. Standardized digital lateral cephalograms were used to assess the mandible (sella-nasion-B point, mandibular unit length, ramus height, body length) preoperatively, at the end of distraction, at 1 year after device removal, and at longest follow-up. RESULTS: A total of 118 patients of all ages in the registry underwent some form of DO during the study period. For assessment of the effects on dentition, 26 subjects, who had 36 osteotomies and distraction wounds, met the inclusion criteria. In this sample, 22 of 26 subjects (85%) had 52 adverse effects in 38 of 90 permanent teeth (42.2%) assessed. Cephalometric measurements indicated that there was net mandibular growth at longest follow-up, after a period of skeletal relapse from the end of distraction to 1 year after device removal; however, only 2 of 25 subjects (8%) regained a growth rate in the vector of DO that matched or exceeded normal age- and gender-matched controls. CONCLUSIONS: DO commonly results in adverse effects on the dentition within and adjacent to the DO gap, with only a minority resolving over time. Net growth of the mandible occurs after DO but at a slower rate and lesser magnitude than that of age- and gender-matched controls.

Evaluation of Andrews' Analysis as a Predictor of Ideal Sagittal Maxillary Positioning in Orthognathic Surgery.

PURPOSE: There is no universally accepted method for determining the ideal sagittal position of the maxilla in orthognathic surgery. In "Element II" of "The Six Elements of Orofacial Harmony," Andrews used the forehead to define the goal maxillary position. The purpose of this study was to compare how well this analysis correlated with postoperative findings in patients who underwent bimaxillary orthognathic surgery planned using other guidelines. The authors hypothesized that the Andrews analysis would more consistently reflect clinical outcomes than standard angular and linear measurements. MATERIALS AND METHODS: This is a retrospective cohort study of patients who had bimaxillary orthognathic surgery and achieved an acceptable esthetic outcome. Patients with no maxillary sagittal movement, obstructive sleep apnea, cleft or craniofacial diagnoses, or who were non-Caucasian were excluded. Treatment plans were developed using photographs, radiographs, and standard cephalometric measurements. The Andrews analysis, measuring the distance from the maxillary incisor to the goal anterior limit line, and standard measurements were applied to end-treatment records. The Andrews analysis was statistically compared with standard methods. RESULTS: There were 493 patients who had orthognathic surgery from 2007 through 2014, and 60 (62% women; mean age, 22.1 ± 6.8 yr) met the criteria for inclusion in this study. The mean Andrews distances were -4.8 ± 2.9 mm for women and -8.6 ± 4.6 mm for men preoperatively and -0.6 ± 2.1 mm for women and -1.9 ± 3.4 mm for men postoperatively. For women, the Andrews analysis was closer to the goal value (0 mm) postoperatively than any standard measurement (P < .001). For men, the linear distance from the A point to a vertical line tangent to the nasion from the McNamara analysis performed best (P < .001), followed by the Andrews analysis. CONCLUSION: The Andrews analysis correlated well with the final esthetic sagittal maxillary position in the present sample, particularly for women, and could be a useful tool for orthognathic surgical planning.

Adjuvant Antiangiogenic Treatment for Aggressive Giant Cell Lesions of the Jaw: A 20-Year Experience at Massachusetts General Hospital.

PURPOSE: To document long-term outcomes using a standardized treatment protocol of enucleation with preservation of vital structures and adjuvant subcutaneous interferon for aggressive giant cell lesions (GCLs) of the jaws. MATERIALS AND METHODS: A retrospective cohort study was designed. We evaluated all patients treated at Massachusetts General Hospital from April 1995 through September 2015 by enucleation with preservation of vital structures and adjuvant daily subcutaneous interferon for aggressive GCLs. The sample included patients with complete medical records consisting of clinical, radiographic, histopathologic, and follow-up data. The exclusion criteria included patients with incomplete records, contraindications to interferon therapy, non-aggressive GCLs, and GCLs associated with syndromes or with hyperparathyroidism. The primary outcome variable was long-term progression-free survival (PFS). The secondary outcome variables were adverse effects and laboratory abnormalities classified by type, frequency, and severity. Predictor variables for recurrence or failure included age, gender, location and features of lesion, type of procedure, duration of interferon treatment, amount of bone fill at end of treatment, and adverse effects. Descriptive statistics, Kaplan-Meier survival analysis, and Cox proportional hazards regression analysis were computed. RESULTS: Of a total of 77 patients, 45 (mean age, 18.8 ± 12.5 years; 29 female patients; 36 in whom the mandible was affected) met the inclusion criteria. The mean duration of interferon therapy was 7.9 ± 2.3 months. After follow-up of 4.8 ± 3.9 years, 6 patients showed progression of the lesion, considered recurrence (13.3% failure rate, 82.6% PFS rate). Most patients had mild (n = 42; 93.3%) and/or moderate (n = 31; 68.8%) side effects, which were readily managed. Adverse effects required stoppage of interferon in 7 patients, whereas no patients had long-term toxicity. No variable was significantly associated with PFS. CONCLUSIONS: The results of this study indicate that enucleation with preservation of vital structures in combination with adjuvant interferon alfa is a reliable treatment for aggressive GCLs of the jaws associated with a low recurrence rate.

Unicystic Ameloblastoma Revisited: Comparison of Massachusetts General Hospital Outcomes With Original Robinson and Martinez Report.

PURPOSE: Robinson and Martinez established unicystic ameloblastoma (UA) as a distinct pathologic entity in 1977. Using their original description, the aims of this study were to compare the clinical presentation and outcomes of UA treated at Massachusetts General Hospital (MGH) with outcomes reported in the original article. PATIENTS AND METHODS: This was a retrospective cohort study of MGH patients treated for UA during a 15-year period. Patients were included if they had a confirmed clinical and histologic diagnosis of UA. The primary predictor variable was the source of the study sample (MGH vs Robinson and Martinez). Secondary variables included age, gender, radiographic appearance, treatment, and histologic subtype. The primary outcome variable was the number of recurrences over time comparing the 2 groups. RESULTS: There were 19 patients (10 female and 9 male patients) in the MGH group and 20 patients (10 female and 10 male patients) in the Robinson and Martinez study. The lesions were predominantly unilocular (13 in MGH group and 19 in Robinson and Martinez group), located in the mandible (18 in MGH group and 20 in Robinson and Martinez group), and tooth associated (12 in MGH group and 14 in Robinson and Martinez group). No statistically significant demographic differences were noted between the 2 groups. In the MGH group, 13 cases (68%) exhibited mural or intramural ameloblastic epithelium, 4 (21%) were luminal or intraluminal, and 2 were unknown. However, histologic configuration was not reported in the Robinson and Martinez group. MGH patients were treated by enucleation (n = 7, 37%) or resection (n = 12, 63%) compared with enucleation in 100% cases in the Robinson and Martinez group. Overall, the disease-free survival rate was higher in the Robinson and Martinez group, but the difference was not statistically significant (P = .089). Within the MGH group, 100% of recurrences occurred in patients with mural invasion treated by enucleation. CONCLUSIONS: The results of this study support UA as a distinct entity based on demographic, clinical, and radiographic criteria. Outcomes in the MGH group were influenced by the degree of ameloblastic epithelial invasion and suggest that this variable should be considered when planning treatment.

Evaluation of Oral and Maxillofacial Surgery Residents' Operative Skills: Feasibility and Engagement Study Using SIMPL Software for a Mobile Phone.

PURPOSE: There are no universally accepted tools to evaluate operative skills of surgical residents in a timely fashion. The purpose of this study was to determine the feasibility of using a smartphone application, SIMPL (System for Improving and Measuring Procedural Learning), developed by a multi-institutional research collaborative, to achieve a high rate of timely operative evaluations and resident communication and to collect performance data. The authors hypothesized that these goals would be achieved because the process is convenient and efficient. MATERIALS AND METHODS: This was a prospective feasibility and engagement study using SIMPL to evaluate residents' operative skills. SIMPL requires the attending surgeon to answer 3 multiple-choice questions: 1) What level of help (Zwisch Scale) was required by the trainee? 2) What was the level of performance? 3) How complex was the case? The evaluator also can dictate a narrative. The sample was composed of 3 faculty members and 3 volunteer senior residents. Predictor variables were the surgeons, trainees, and procedures performed. Outcome variables included number and percentage of procedures performed by faculty-and-resident pairs assessed, time required to complete assessments, time lapsed to submission, percentage of assessments with narratives, and residents' response rates. RESULTS: From March through June 2016, 151 procedures were performed in the operating room by the faculty-and-resident teams. There were 107 assessments submitted (71%). Resident response (self-assessment) to faculty evaluations was 81%. Recorded time to complete assessments (n = 75 of 107) was shorter than 2 minutes. The time lapsed to submission was shorter than 72 hours (100%). Dictations were submitted for 35 evaluations (33%). Data for the type of help, performance, and complexity of cases were collected for each resident. CONCLUSIONS: SIMPL facilitates timely intraoperative evaluations of surgical skills, engagement by faculty and residents, and collection of detailed procedural data. Additional prospective trials to assess this tool further are planned.

Frequency and Morbidity of Temporomandibular Joint Involvement in Adult Patients With a History of Juvenile Idiopathic Arthritis.

PURPOSE: Most patients with juvenile idiopathic arthritis (JIA) have temporomandibular joint (TMJ) involvement, but little is known about the natural history of TMJ disease as these children enter adulthood. The purpose of this study was to evaluate adults with a history of JIA to document the frequency and severity of TMJ abnormalities and morbidity. The authors hypothesized that most would have persistent TMJ disease as adults. MATERIALS AND METHODS: This cross-sectional study included adults (>19 years of age) with JIA who were managed at Boston Children's Hospital (BCH) as children and at Brigham and Women's Hospital (BWH) as adults. History of a TMJ problem was not considered for enrollment. Patients completed a questionnaire and underwent physical examination and maxillofacial cone-beam computed tomography (CBCT). Additional data were obtained from medical records. Associations between TMJ abnormalities at CBCT and arthritis history, TMJ pain and function, facial asymmetry, malocclusion, and cephalometric analysis were examined. RESULTS: Of 129 eligible patients contacted, 21 (42 TMJs) were enrolled. Mean age was 26.0 ± 6.1 years and mean duration of care for JIA at the BCH and BWH was 13.7 ± 6.5 years. TMJ pain was present in 62% of patients (n = 13); 43% (n = 9) had a TMJ functional limitation and 76% (n = 16) had lower facial asymmetry. Abnormalities were found in the TMJs on 55% of CBCT scans, with 79% showing bilateral deformities. There was at least 1 cephalometric measurement of mandibular size or position that was more than 1 standard deviation beyond normal in 81% of patients (n = 17). Only 4 patients (19%) had previously been evaluated for a TMJ problem. CONCLUSION: TMJ abnormalities and related morbidity are common in adult patients with a history of JIA. Therefore, an early screening protocol for TMJ involvement in children with a new diagnosis of JIA would be beneficial and long-term follow-up into adulthood should be routine.

Oral and Maxillofacial Surgery Foundation Research and Fellowship Awards: A 26-Year Review at Massachusetts General Hospital and Harvard School of Dental Medicine.

PURPOSE: The purpose of this study was to review outcomes of the Oral and Maxillofacial Surgery (OMS) Foundation's funding awards to members of the OMS department at Massachusetts General Hospital (MGH) in terms of projects completed, abstracts presented, peer-reviewed publications, and career trajectories of recipients. MATERIALS AND METHODS: Data were collected from MGH and OMS Foundation records and interviews with award recipients. Primary outcome variables included 1) number of awards and award types, 2) funding amount, 3) project completion, 4) number of presented abstracts, 5) conversion from abstracts to publications, 6) number of peer-reviewed publications, 7) career trajectories of awardees, and 8) additional extramural funding. RESULTS: Eleven Student Research Training Awards provided $135,000 for 39 projects conducted by 37 students. Of these, 34 (87.2%) were completed. There were 30 student abstracts presented, 21 peer-reviewed publications, and a publication conversion rate of 58.8%. Faculty research awards comprised $1,510,970 for 22 research projects by 12 faculty members and two research fellows. Of the 22 funded projects, 21 (95.5%) were completed. There were 110 faculty and research fellow abstracts presented and 113 peer-reviewed publications, for a publication conversion rate of 93.8%. In the student group, 17 of 37 (45.9%) are enrolled in or are applying for OMS residencies. Of the 10 students who have completed OMS training, 3 (30%) are in full-time academic positions. Of the 12 faculty recipients, 9 (75%) remain in OMS academic practice. During this time period, the department received $9.9 million of extramural foundation or National Institutes of Health funding directly or indirectly related to the OMS Foundation grants. CONCLUSIONS: The results of this study indicate that 90.2% of projects funded by the OMS Foundation have been completed. Most projects resulted in abstracts and publications in peer-reviewed journals. These grants encouraged students to pursue OMS careers and aided OMS faculty in developing their research programs.

Juvenile Mandibular Chronic Osteomyelitis: Role of Surgical Debridement and Antibiotics.

PURPOSE: To document outcomes of management of juvenile mandibular chronic osteomyelitis (JMCO) using a standardized treatment protocol including open biopsy, decortication, microbial culture, and long-term antibiotic therapy. MATERIALS AND METHODS: This was a retrospective case study of pediatric patients with JMCO treated at Massachusetts General Hospital for Children from 1996 through 2014. Inclusion criteria included age younger than 18 years, diagnosis of JMCO, management by the protocol, adequate clinical and radiographic data in the record, and follow-up of at least 1 year after initial treatment. Inpatient and outpatient records were reviewed for demographics, clinical and radiographic findings, and histologic and laboratory evaluations. The predictor variable was the standardized treatment protocol and the primary outcome variables were disease status at end of treatment and complications of treatment. RESULTS: Twenty patients (mean age at onset, 10.7 yr; range, 3 to 14 yr) were treated, 12 (11 girls) of whom met the inclusion criteria. Management of all patients consisted of biopsy (extraoral when feasible, n = 9; intraoral, n = 3), decortication, cultures, and long-term antibiotic therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) were administered only as needed for pain control. There was complete resolution of osteomyelitis with no recurrence in 7 of 12 patients (mean follow-up, 4.3 yr; range, 1 to 11 yr). Five patients had partial responses, with decreased frequency and severity of disease recurrence. These were well controlled with short courses of antibiotics (4 to 12 weeks) with NSAIDs only as needed for pain control (mean follow-up, 1.4 yr; range, 1 to 3 yr). There were no major complications related to antibiotic therapy. Minor complications included rash (n = 2), nausea and vomiting (n = 1), and vaginal candidiasis (n = 1). CONCLUSION: The results of this study indicate that 58.3% of patients were cured and had no recurrent symptoms (mean follow-up, 4.3 yr). The remaining patients continue on intermittent treatment with antibiotics for recurrent episodes of swelling and pain. Favorable responses to antibiotic therapy support the hypothesis that JMCO is an infectious disease and that negative cultures might represent a failure of standard culture techniques to isolate the responsible organisms.

Morbidity and Mortality Rates After Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea.

PURPOSE: To compare morbidity and mortality rates in obstructive sleep apnea (OSA) versus dentofacial deformity (DFD) patients undergoing equivalent maxillofacial surgical procedures. PATIENTS AND METHODS: Patients with OSA who underwent maxillomandibular advancement with genial tubercle advancement in the Massachusetts General Hospital Department of Oral and Maxillofacial Surgery from December 2002 to June 2011 were matched to patients with DFD undergoing similar maxillofacial procedures during the same period. They were compared regarding demographic variables, medical comorbidities, perioperative management, intraoperative complications, early and late postoperative complications, and mortality rate. RESULTS: A study group of 28 patients with OSA and a control group of 26 patients with DFD were compared. The patients with OSA were older (41.9 ± 12.5 years vs 21.7 ± 8.6 years), had a higher American Society of Anesthesiologists classification (2.0 ± 0.5 vs 1.3 ± 0.6), and had a higher body mass index (29.6 ± 4.7 kg/m(2) vs 23.0 ± 3.1 kg/m(2)). They also had a greater number of medical comorbidities (2.4 ± 2.3 vs 0.7 ± 1.0). More OSA patients than DFD patients had complications (28 [100%] vs 19 [73%], P = .003), and the total number of complications in the OSA group was higher (108 vs 33, P < .001). Of the complications, 13.9% in the OSA group and 3.0% in the DFD group were classified as major. The absolute risk of a complication was 3.9 for the OSA group versus 1.3 for the DFD group. The relative risk of complications in OSA patients compared with DFD patients was 3.0. No difference in mortality rate was found. CONCLUSIONS: The patients in the OSA group were older, had more comorbidities, and ultimately had a greater number of early, late, minor, and major complications than those in the DFD group. The incidence of death in both groups was zero. Maxillomandibular advancement appears to be a safe procedure regarding mortality rate, but OSA patients should be counseled preoperatively regarding the relative increased risk of complications.

Quantifying Synovial Enhancement of the Pediatric Temporomandibular Joint.

PURPOSE: The purposes of this study were to assess a novel method for quantifying temporomandibular joint (TMJ) synovial enhancement on gadolinium-enhanced magnetic resonance imaging (MRI) and to establish normative values to allow early detection of synovitis. MATERIALS AND METHODS: This is a retrospective cohort study of pediatric patients (aged 0 to 16 years) without jaw pathology who underwent MRI scans with contrast that included the TMJs. From a coronal T1-weighted image, the signal intensity within the superior and inferior joint spaces was divided by the signal intensity of the longus capitis muscle to establish a ratio by age. Intrarater reliability and inter-rater reliability were assessed. A mixed-model regression analysis was used to determine the 95% specificity threshold for normal ratios. RESULTS: Temporal and optic nerve MRI scans of 158 patients were included. Normative synovial enhancement ratios (95% specificity) thresholds were established: 1.52, 1.68, and 1.55 for superior joint space, inferior joint space, and average of both joint spaces, respectively. Intrarater and inter-rater agreement was excellent. CONCLUSIONS: A ratio of signal intensity of the TMJ synovium to the longus capitis is a reliable method to quantify enhancement controlling for time after contrast infusion and may be useful for diagnosis of TMJ synovitis.

Is There a Difference in Cost Between Standard and Virtual Surgical Planning for Orthognathic Surgery?

PURPOSE: Virtual surgical planning (VSP) and 3-dimensional printing of surgical splints are becoming the standard of care for orthognathic surgery, but costs have not been thoroughly evaluated. The purpose of this study was to compare the cost of VSP and 3-dimensional printing of splints ("VSP") versus that of 2-dimensional cephalometric evaluation, model surgery, and manual splint fabrication ("standard planning"). MATERIALS AND METHODS: This is a retrospective cohort study including patients planned for bimaxillary surgery from January 2014 to January 2015 at Massachusetts General Hospital. Patients were divided into 3 groups by case type: symmetric, nonsegmental (group 1); asymmetric (group 2); and segmental (group 3). All cases underwent both VSP and standard planning with times for all activities recorded. The primary and secondary predictor variables were method of treatment planning and case type, respectively. Time-driven activity-based micro-costing analysis was used to quantify the differences in cost. Results were analyzed using a paired t test and analysis of variance. RESULTS: The sample included 43 patients (19 in group 1, 17 in group 2, and 7 in group 3). The average times and costs were 194 ± 14.1 minutes and $2,765.94, respectively, for VSP and 540.9 ± 99.5 minutes and $3,519.18, respectively, for standard planning. For the symmetric, nonsegmental group, the average times and costs were 188 ± 17.8 minutes and $2,700.52, respectively, for VSP and 524.4 ± 86.1 minutes and $3,380.17, respectively, for standard planning. For the asymmetric group, the average times and costs were 187.4 ± 10.9 minutes and $2,713.69, respectively, for VSP and 556.1 ± 94.1 minutes and $3,640.00, respectively, for standard planning. For the segmental group, the average times and costs were 208.8 ± 13.5 minutes and $2,883.62, respectively, for VSP and 542.3 ± 118.4 minutes and $3,537.37, respectively, for standard planning. All time and cost differences were statistically significant (P < .001). CONCLUSIONS: The results of this study indicate that VSP for bimaxillary orthognathic surgery takes significantly less time and is less expensive than standard planning for the 3 types of cases analyzed.