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.

Orthognathic surgery in patients over 40 years of age: indications and special considerations.

PURPOSE: To assess indications, incidence, patient experience, and outcomes of orthognathic surgery in patients over 40 years of age. PATIENTS AND METHODS: This was a retrospective cohort study of all patients who underwent orthognathic surgical procedures at Massachusetts General Hospital from 1995 to 2012. Demographic variables, including age, gender, indications, date, and type of operation, were documented. Patients were divided into 2 groups by date of operation: 1) 1995 to 2002 and 2) 2003 to 2012. The predictor variable was age (>40 vs <40 yr). Outcome variables included indications for treatment, date of operation, length of hospital stay, and removal of hardware. RESULTS: During the study period, 1,420 patients underwent 2,170 procedures; 911 patients (1,343 procedures) met the inclusion criteria. Group 1 consisted of 260 subjects (346 procedures, 35 patients ≥40 yr old, 13.5%) and group 2 consisted of 651 subjects (997 procedures, 89 patients ≥40 yr old, 13.8%). Subjects over 40 had longer hospital stays (P ≤ .0001) than those under 40. Indications for men were more frequently functional problems, whereas women sought esthetic improvements (P = .0001). Subjects over 40 were 2.51, 2.44, and 2.72 times more likely to require hardware removal 6 months (P = .0245), 12 months (P = .0073), and 24 months (P = .0003) postoperatively than those younger than 40. CONCLUSION: Motivation to undergo orthognathic surgery varies by age and gender. Older patients, particularly men, tend to seek treatment for functional rather than esthetic reasons. Patients older than 40 years had longer hospital stays and an increased rate of postoperative hardware removal.

Vascularized treatment options for reconstruction of the ascending mandible with introduction of the femoral medial epicondyle free flap.

Reconstruction of the ascending portion of the mandible, including the angle, ramus, and condyle, can be a challenging surgical problem. Many treatment options are available, but no single procedure has been able to restore long-term form and function in every case. Currently, autologous nonvascularized bone grafts are the most common treatment, with the costochondral graft as the historic leader. Nonvascularized grafts can often restore vertical height and normal function but may face the challenge of long-term durability secondary to bone resorption. Emerging techniques in microvascular surgery may offer an alternative approach with the benefits of resistance to resorption and infection by maintaining a viable blood supply to the graft. Vascularized grafts may thus be used to full advantage in cases where prior surgery, scarring, disrupted vasculature, or radiation damage may compromise the long-term surgical success of a nonvascularized graft. This article reviews the literature and summarizes key points regarding nonvascularized and vascularized treatment modalities for reconstruction of the ascending mandible. In addition, we present the use of the femoral medial epicondyle free flap based on the descending genicular vascular pedicle as a novel reconstruction of the ascending portion of the mandible with minimal donor-site morbidity. Knowledge of all available options will aid the surgeon in achieving the optimal reconstruction for their patient and improve long-term outcomes.

Longitudinal treatment of cleft lip and palate in developing countries: dentistry as part of a multidisciplinary endeavor.

Cleft lip and palate affects roughly 1 in 600 children and predisposes patients to a lifetime of functional and esthetic discrepancies. Disparities in access as well as quality of care exist worldwide, with many children in developing countries unable to receive treatment. In the late 20th century, humanitarian medical missions emerged as a means of delivering surgical expertise to patients in resource-limited settings. These early missions took on a patient-centered approach focused solely on cleft repair, with little emphasis on treating the dental abnormalities that arose after the initial surgery. However, modern cleft care is characterized by a multidisciplinary, team-based approach with significant dental involvement. Recent cleft lip and palate endeavors have shifted from a mission-based approach to a developmental approach facilitating growth of an independent care center. This strategy focuses on creating an institution with expanded access to dental services, thus facilitating the long-term treatment inherent in modern cleft care. One clinic in a developing country that has experienced successful transitioning from a mission site to an independent craniofacial clinic is Operation Smile's Cleft Comprehensive Care Clinic in Guwahati, India. This article will summarize the rationale and planning of the clinic, underscore the team-based approach required in longitudinal treatment of cleft lip and palate, and demonstrate how treatment methodology may differ in resource-limited settings by outlining the therapeutic considerations of each provider in the Guwahati Clinic.