Morphological Profiling of Unilateral Condylar Hyperplasia: Implications for Surgical Decision-Making.

OBJECTIVE: Unilateral condylar hyperplasia (UCH) presents challenges with functional and esthetic concerns, including facial and chin asymmetry, prognathism, class III malocclusion, and temporomandibular joint symptoms. This study aims to precisely locate condylar and mandibular asymmetry in patients with UCH, aiding targeted surgical correction and addressing persistent skeletal changes. METHODS: This retrospective study analyzed data from patients with UCH and controls, utilizing high-quality cone beam computed tomography scans with 1 mm or fewer slices. Morphometric points were placed using Planmeca software, measuring linear distances on both affected and unaffected sides. RESULTS: In a cohort of 40 patients (29 UCH, 11 controls), significant differences in condylar head and neck lengths were observed between the affected and unaffected sides in patients with UCH (P = 0.0019). However, ramus length showed no significant variation (P = 0.65). When comparing differences in condylar head and neck length between controls and patients with UCH, a substantial contrast was evident (P = 1.98e-07), while ramus length differences were not significant (P = 1.00). The median condylar head and neck lengths were 20.3 mm for controls, 19.78 mm for the unaffected side in patients with UCH, and 23.48 mm for the affected side. CONCLUSION: Facial asymmetry in UCH primarily results from differences in condylar head and neck length, not ramus length. This emphasizes the importance of high condylectomy in addition to bilateral sagittal split osteotomy to achieve improved symmetry and reduced temporomandibular joint dysfunction. Understanding these regional skeletal changes is critical for effective UCH treatment.

Dorsal Augmentation With the Dorsal Extension Spreader Graft.

Spreader grafts traditionally are used to improve airflow through opening the internal nasal valve, as well as enhance the cosmetic appearance of the nose. The graft's versatility proves useful in surgical correction of several nasal profiles by enhancing dorsal aesthetic lines and by maintenance of the nasal pyramid at midline. The authors describe a modified spreader graft that adds an additional benefit of dorsal augmentation in patients with underprojected or saddle noses. This technique utilizes harvested septal cartilage and fixation of the graft that extends beyond the septal and upper lateral cartilage dorsal border to improve nasal dorsum height. Patients who received this operative technique by the senior author were identified and their operative courses and surgical outcomes were analyzed. Case examples are provided to illustrate indications and outcomes. This grafting technique allows for improved functionality, defined dorsal aesthetic lines, changes in nasal width, and a more balanced profile in patients with underprojected noses.

Postoperative Edema Resolution Post-Orthognathic Triple Jaw Surgery: A Three-Dimensional Volumetric Analysis.

PURPOSE: The final result following orthognathic surgery may be hidden for months due to postoperative swelling. However, no substantial evidence supports this time estimate. Our study aims to three-dimensionally quantify volumetric changes in facial edema following triple-jaw surgery. MATERIALS AND METHODS: This was a retrospective, three-dimensional (3D) study of patients who underwent primary orthognathic triple jaw surgery (Le Fort I, Bilateral Sagittal Split Osteotomy (BSSO), and osseous genioplasty) by the senior author (DMS). Vectra 3D Software (Canfield, Fairfield, NJ) was used to assess and quantify volumetric changes between serial 3D photos. An inverse line of best-fit was plotted to assess reduction in postoperative facial edema. The effects of gender, age, body mass index, and tranexamic acid administration on swelling resolution were analyzed through mixed linear model analysis. RESULTS: A total of 46 patients (198 images) met the study criteria. The equation for the inverse function line of best fit was y = -13.14ln (x) + 39.54 (P < 0.01). On average, 60% of the swelling resolved in 1 month, 84% after 6 months, and nearly 93% after 12 months. There were no significant differences in the rate of swelling resolution when accounting for age, gender, body mass index, or tranexamic acid administration. CONCLUSIONS: Most facial edema resolved during the first month following triple jaw surgery, with significant reduction in swelling between 6 and 12 months postoperatively. After 1 year, approximately 10% of the initial edema remained.

Major Complications and Associated Risk Factors for Osseous Genioplasty With Bimaxillary Orthognathic Surgery: An American College of Surgeons-National Surgical Quality Improvement Program Analysis.

PURPOSE: Patients with significant dentofacial deformities undergoing aesthetic and functional orthognathic surgery may often require genioplasty to advance the position of the pogonion relative to B point. No study to date has evaluated nationally registered data pertaining to addition of osseous genioplasty to bimaxillary orthognathic surgery and its associated clinical outcomes. METHODS: Data was extracted from the National Surgical Quality Improvement Program from 2010 to 2018 using current procedural terminology codes pertaining to Le Fort I osteotomy (LF), bilateral sagittal split osteotomy (BSSO), and osseous genioplasty (G) and divided into 2 cohorts: bimaxillary orthognathic surgery with and without osseous genioplasty. Thirty-day postoperative outcomes inherently recorded within National Surgical Quality Improvement Program were identified and recorded. Chi-squared analysis and unpaired 2-tail t tests were performed between the cohorts and their respective outcomes to determine significant relationships with significance set as P < 0.05. RESULTS: There were 373 patients double- or triple-jaw patients identified from the years 2010 to 2018. The most common recorded indication for LF/BSSO was maxillary hypoplasia (27.3%) and mandibular hypoplasia (6.8%). The most common indications for LF/BSSO/G were maxillary hypoplasia (16.1%) and maxillary asymmetry (16.1%). In comparison to LF/BBSO only, LF/BSSO/GP was not associated with any differences in the rate of surgical (0.0% versus 0.31%, P = 0.72) or medical complications (0.0% versus 0.63%, P = 0.60), in addition to unplanned readmissions (0.0% versus 1.56% versus P = 0.41) or reoperations (0.0% versus 1.25%, P = 0.46). However, osseous genioplasty addition was associated with increased overall operating time (271.77 versus 231.75 minutes, P = 0.04). CONCLUSIONS: Osseous genioplasty does not alter short-term, 30-day complication rate when performed with bimaxillary orthognathic surgery. As reoperation rates remained relatively unchanged, it can be inferred that immediate adverse events or patient dissatisfaction were not apparent within 30 days. Although mean operating time is slightly longer, cardiopulmonary resuscitation without medical comorbidity was achieved at the conclusion of the procedure.

Outcomes in Pediatric Maxillofacial Reconstruction With Vascularized Fibular Flaps: A Systematic Review.

BACKGROUND: The purpose of this study was to examine the complications and outcomes after maxillofacial reconstruction using the free fibular flap in the pediatric population. METHODS: A systematic review and descriptive analysis were conducted using data variables, including study characteristics; patient characteristics; postoperative complications (major and minor); surgical revision; and dental rehabilitation. RESULTS: The systematic review resulted in 1622 articles, 55 of which met inclusion criteria for this study. The 55 articles consisted of 17 case series and 38 case reports with level III/IV and level V of evidence, respectively. Of the 155 identified pediatric patients, the rate of major complications was 13.5% and minor complications was 24.5%. The most common complication was mild growth distortion (n = 7) at the recipient site. Complications at the donor site were less common. During follow-up, 29 patients (18.7%) underwent or awaited surgical revision, and 43 patients (27.7%) underwent or awaited dental rehabilitation. CONCLUSIONS: Our study suggests that the free fibular flap for pediatric maxillofacial reconstruction is safe and reliable. Additionally, surgical revision to correct the functional impairments resulting from primary reconstruction using the free fibular flap is relatively common.

A Comprehensive Single-Center Analysis of Postoperative Nausea and Vomiting Following Orthognathic Surgery.

BACKGROUND: Postoperative nausea and vomiting (PONV) remains a major clinical end-point for directing enhanced recovery after surgery (ERAS) protocols in facial plastic surgery. This study aimed to identify risk factors for PONV and evaluate strategies for PONV reduction in orthognathic surgery patients. METHODS: A retrospective cohort study was performed among patients receiving orthognathic surgery at our institution from 2011 to 2018. Patient demographics, surgical operative and anesthesia notes, medications, and nausea/vomiting were assessed for each patient. The amount of opioid analgesia given both perioperatively and postoperatively was recorded and converted into morphine equivalents (MEQ). Stepwise regression analysis was used to identify significant risk factors for PONV. Post hoc analyses were employed to compare PONV among patients based on MEQ dosage and antiemetic prophylaxis regimes. RESULTS: A total of 492 patients were included; mean age was 23.0 years (range: 13-60); 54.4% were female. The majority of patients received concurrent Le Fort I osteotomy, BSSO, and genioplasty (70.1%). During hospitalization, 59.4% of patients experienced nausea requiring antiemetic medications and 28.4% experienced emesis. Stepwise regression yielded Apfel scores (P = 0.003) and postoperative opioids (P = 0.013) as the strongest predictors of PONV. Post hoc analyses showed that undertreatment with prophylactic antiemetics (based on Apfel) predicted increased PONV (+12.9%, P = 0.020), and that lower postoperative MEQs (<28.0) predicted decreased PONV (-11.8%, P = 0.01). CONCLUSIONS: The study findings confirm the high incidence of PONV among orthognathic surgical patients and stratify previously reported PONV risk factors. More aggressive utilization of antiemetic medications and decreased dependence on opioid analgesia may decrease nausea/vomiting following orthognathic surgery.

Race-Based Differences in the Utilization and Timing of Secondary Cleft Procedures in the United States.

Primary CL/P repair, revisions, and secondary procedures-cleft rhinoplasty, speech surgery, and alveolar bone grafting (ABG)-performed from 2014-2018 were identified from the Pediatric National Surgical Quality Improvement Program (NSQIP) database. Utilization estimates were derived via univariable and multivariable logistic regression. A Kruskal-Wallis rank-sum test and multivariable linear regression were used to assess differences in timing for each procedure cohort.The primary outcome measures were the odds of a patient being a certain race/ethnicity, and the age at which patients of different race/ethnicity receive surgery.There were 23 780 procedures analyzed. After controlling for sex, diagnosis, and functional status, there were significant differences in utilization estimates across procedure groups. Primarily, utilization was lowest in patient who were Black for cleft rhinoplasty (OR = 0.70, P = .023), ABG (OR = 0.44, P < .001) and speech surgery (OR = 0.57, P = .012), and highest in patients who were Asian patients in all surgery cohorts (OR 2.05-4.43). Timing of surgery also varied by race, although differences were minimal. CONCLUSIONS: Estimates of utilization and timing of secondary cleft procedures varied by race, particularly among patients who were Black (poor utilization) or Asian (high utilization). Further studies should identify the causes and implications of underutilized and/or delayed cleft care.

Racial Disparities in Complications, Length of Stay, and Costs Among Patients Receiving Orthognathic Surgery in the United States.

INTRODUCTION: Black and Hispanic/Latino patients in the United States often experience poorer health outcomes in comparison to White patients. We aimed to assess the impact of race on complications, length of stay, and costs after orthognathic surgery. METHODS: Pediatric and young adult orthognathic surgeries (age <21) were isolated from the Kids Inpatient Database from 2000-2012. Procedures were grouped into cohorts based on the preoperative diagnosis: apnea, malocclusion, or congenital anomaly. T tests and χ2 analyses were employed to compare complications, length of stay (LOS), and costs among Black, Hispanic, Asian/Pacific Islander, and other patients in comparison to White patients. Multivariable regression was performed to identify associations between sociodemographic variables and the primary outcomes. Post-hoc χ2 analyses were performed to compare proportions of patients of a given race/ethnicity across the 3 surgical cohorts. RESULTS: There were 8,809 patients identified in the KID database (mean age of 16.3 years). Compared to White patients, complication rates were increased among Hispanic patients (2.1 vs 1.3%, P = .037) and other patients treated for apnea (8.7 vs 0.83%, P = .002). Hospital LOS was increased in both Black (3.3 vs 2.1 days, P < .001) and Hispanic (2.9 days, P < .001) patients. Costs were higher than Whites ($35,633.47) among Hispanic ($48,029.15, P < .001), Black ($47,034.41, P < .001), and Asian/Pacific-Islander ($44,192.49, P < .001) patients. White patients comprised a larger proportion of the malocclusion group (77.8%) than apnea (66.9%, P < .001) or congenital anomaly (59.1%, P < .001), while the opposite was true for Black, Hispanic, and Asian/Pacific-Islander patients. CONCLUSION: There are significant differences in complications, LOS, and costs after orthognathic surgery among patients of different race/ethnicity. Further studies are needed to better understand the causes of disparity and their clinical manifestations.

Morphological Basis for Airway Surgical Intervention in Apert Syndrome.

OBJECTIVE: Previous studies have explored the restricted nasopharyngeal airway in Apert syndrome patients. This study aims to investigate the segmented airway volume changes with age and directly analyze their correlations with subcranial dimensions and angulations. METHODS: Ninety-seven preoperative computed tomography scans (Apert, n = 44; control, n = 53) were included in this study, and divided into 5 age-related subgroups. Computed tomography scans were measured using Mimics and 3-matics software. RESULTS: Before 6 months of age, the nasal cavity in Apert syndrome is reduced by 47% (P = 0.002), which gradually approximates normal thereafter; however, there remained a 30% reduction, compared with controls. It is highly correlated with the anteroposterior length of subcranial space, and the position of maxilla and palate. The pharyngeal airway volume in Apert syndrome patients, younger than 6 months, was larger than normal by 129% (P = 0.013). However, between 2 and 6 years of age, the pharyngeal airway becomes smaller than normal, with a 57% (P = 0.010) reduction in childhood and 52% (P = 0.005) in adolescence. It is closely correlated with the intercondylar and intergonial widths. CONCLUSIONS: Airway compromise in Apert syndrome patients is attributable more to the nasal cavity in infants, but in the older child, it is the pharyngeal region. The restricted nasal airway in Apert syndrome is correlated with the subcranial space length and width, but independent of cranial base flexion. The pharyngeal airway volume in Apert syndrome is not as highly correlated with craniofacial morphology. Rather, it is impacted by the growth of mandible, which often requires surgical intervention later in childhood.

Orthognathic Surgery in Cleidocranial Dysplasia.

ABSTRACT: Optimal surgical correction of the craniofacial manifestations of cleidocranial dysplasia (CCD) has not been established due to the rarity of the condition. A 27-year-old female with CCD is presented. She underwent virtual surgical planning (VSP) followed by LeFort-I disimpaction, bone grafting, bilateral sagittal-split osteotomy, genioplasty, submental lipectomy, and targeted facial fat grafting. The patient necessitated 15-mm of vertical maxillary disimpaction centrally, stabilized with wide maxillary plates and interpositional allogenic fibula grafts. Six-month postoperative examination demonstrated improved appearance and functional symptoms. Skeletal relationships were normalized on computed tomography (CT) and there was minimal change between immediate and 6-month postoperative CT measurements, demonstrating a stable result. Orthognathic surgery used to establish dentofacial harmony in patients with CCD can test the extremes of single-stage facial skeletal expansion. Use of VSP, wide maxillary plates, and interpositional bone grafts can help optimize maxillary expansion and stability, while concurrent fat redistribution optimizes facial aesthetics.

Spatial Analysis of the Temporomandibular Joint and Condyle Following Mandibular Distraction in Robin Sequence.

ABSTRACT: To comprehensively assess changes in temporomandibular joint and mandibular condyle morphology in Robin sequence (RS) patients undergoing mandibular distraction osteogenesis (MDO). A retrospective analysis of pediatric patients with RS and functional temporomandibular joints who underwent MDO by a single surgeon was performed. Preoperative and postoperative computed tomography (CT) scans were morphometrically analyzed three-dimensional in 3-matic and Mimics (Materialise). Comparative analysis was performed using Wilcoxon signed-rank tests. Fourteen RS patients were included (28 condyles, 56 CT scans), 78% male and 22% females. The mean age at surgery was 9.4 weeks (range 1.6-46.7 weeks). The average age at initial CT was 5.3 days (range 0-11 days). The mean time interval for CT scan before MDO and after hardware removal were 8.8 ±â€Š6.4 days and 11.2 ±â€Š25.8 days, respectively. Rotatory changes of the condyle revealed a significantly decreased horizontal angle following MDO (-7.55°, 95% confidence interval -11.13° to -3.41°; P < 0.001). Anteroposteriorly, the angle between condylar process and ramus (incline) increased significantly (14.14°, 95% confidence interval 10.71°-19.59°; P < 0.001). Intragroup analysis revealed no difference between left versus right condylar position measurements. The condyle itself increased in size and length and the intercondylion distance increased post-MDO. There were no complications and all patients achieved relief of airway obstruction without tracheostomy. Morphologic and positional changes of the mandibular condyle following MDO in RS patients parallel changes that occur during normal development in non-RS patients. As a result, MDO may facilitate normal condylar morphology and function in RS patients.

Decreasing Inpatient Opioid Use Following Orthognathic Surgery.

PURPOSE: Strategies to decrease postoperative opioid use are important for mitigating the immediate and long-term risks associated with their use. We aimed to investigate the impact of perioperative various factors on inpatient opioid needs for patients undergoing orthognathic surgery. METHODS: This was a retrospective cohort study of all patients who underwent orthognathic surgery performed by the senior author from 2012 to 2018. Patients were grouped into intravenous (IV) acetaminophen and no-IV acetaminophen cohorts. Opioid medications received by patients during hospital stay were converted to mean morphine equivalents (MME) for comparison. Additional factors that influenced opioid consumption, such as transexamic acid (TXA) and postoperative nausea and vomiting (PONV), were identified using univariate analysis. Factors found to have statistical significance were added to a multivariate linear regression model. RESULTS: 319 patients were included. Those who received IV acetaminophen had lower rates of total opioid use (57.3 versus 74.8 MME; P = 0.002) and postoperative opioid use (24.0 versus 37.7 MME; P < 0.001). Perioperative prothrombotic agents, such as TXA, were associated with lower total and postoperative MME (P = 0.005, P = 0.002). Multivariate regression analysis showed that increased PONV resulted in increased postoperative opioid use, whereas perioperative acetaminophen lowered total and postoperative quantities. CONCLUSIONS: Perioperative IV acetaminophen is an effective method for decreasing inpatient opioid analgesia after orthognathic surgery. Intravenous TXA and PONV control may provide additional benefit to decreasing inpatient opioid consumption. More research as to the mechanisms and ideal clinical applications for both IV acetaminophen and TXA are warranted.

Concurrent High Condylectomy and Orthognathic Surgery for Treatment of Patients With Unilateral Condylar Hyperplasia.

BACKGROUND: Facial asymmetry from unilateral condylar hyperplasia (UCH) may be definitively treated in the presence of active disease (with high condylectomy and concurrent orthognathic surgery) or after waiting for disease inactivity (orthognathic surgery alone). There is currently no consensus on the standard of care. In this study, we sought to compare functional and esthetic outcomes, as well as treatment duration, between these 2 management options. METHODS: Patients who underwent treatment for UCH were identified through retrospective review. Pre- and postoperative 3-dimensional (3D) images were obtained. Short- and long-term operative outcomes of those treated during the active (group 1) were compared to those treated in the inactive phase (group 2). Total treatment time, operative time, and length of hospital stay were evaluated. Facial asymmetry was also assessed by laypersons using a Likert scale. RESULTS: Fifteen patients (mean 25.6 years, range 14-56) were included: 6 in group 1 and 9 in group 2. All surgical outcomes were statistically independent of procedure type. Treatment time was significantly longer in the group 2 (P = 0.03). Both groups demonstrated significant improvement in facial asymmetry scores postoperatively with no significant difference in pre- or postoperative asymmetry between groups (P = 0.64). CONCLUSIONS: In patients with active UCH, high condylectomy and orthognathic surgery is a procedure that restores facial symmetry and improves jaw function while halting mandibular growth. Good esthetic and functional outcomes, as well as reduced treatment time and disease burden, support the use of this treatment option for this population.

Vascularized Composite Parietal Bone Flap for Immediate Reconstruction of a Hemi-Maxillectomy Defect in an Infant.

BACKGROUND: Surgical resection of maxillary tumors can result in defects that can be difficult to reconstruct by conventional means due to the complex functional and anatomic nature of the midface and lack of regional bone flap options in the head and neck. Many reconstructive methods have been used to repair maxillary defects, but the ideal technique for the reconstruction of hemi-maxillectomy defects in growing pediatric patients has yet to be determined. METHODS: The authors present a rare pediatric patient with melanotic neuroectodermal tumor of infancy resulting in a hemi-maxillectomy defect after resection that was reconstructed using a pedicled vascularized composite flap consisting of temporalis muscle, pericranium, and parietal bone. RESULTS: The patient achieved successful long-term bony reconstruction of his right maxilla with this flap. Stable skeletal fixation with adequate orbital support was maintained over a >3-year follow-up period. CONCLUSION: A vascularized composite parietal bone flap is a reliable reconstructive option for reconstruction of large maxillectomy defects providing low donor-site morbidity, adequate globe support, excellent long-term skeletal stability, and malar symmetry in rapidly growing pediatric patients. Successful reconstruction for a rare patient with maxillary melanotic neuroectodermal tumor of infancy requiring hemi-maxillectomy was demonstrated with >3-year follow-up.

Orthodontic and surgical management of a patient with severe mandibular deficiency and asymmetry with condylar hypoplasia using 3-dimensional surgical planning in combination with a modified surgery-first approach.

Progressive improvements in digital technology and surgical techniques have synergized the speed, predictability, and favorable outcomes for patients undergoing surgical-orthodontic treatment with handicapping dentofacial deformities. This case report will demonstrate the management of a patient with severe mandibular hypoplasia, condylar hypoplasia, and mandibular asymmetry. The dentofacial deformity, and consequently, the unaesthetic facial appearance, led to psychosocial stress, symptoms of excessive daytime sleepiness, and functional limitations, especially related to mandibular movements. A modified surgery-first approach was used, which was successfully performed using computer-assisted surgical planning. Postsurgical orthodontics was accomplished with the aid of temporary skeletal anchorage mini-plates. An additional alloplastic enhancement of the chin addressed the severe microgenia, which the osseous advancement could not achieve. This resulted in a total advancement of the pogonion by 26 mm yielding a remarkable improvement in the patient's facial esthetics. Furthermore, a considerable improvement in mandibular function and reduction in daytime sleepiness occurred. The severe malocclusion with a discrepancy index value of 47 was treated to a successful final occlusion in 21 months of treatment time.

Segmental Maxillary Osteotomy to Close Wide Alveolar Clefts.

Wide alveolar clefts are challenging to treat and are often associated with a higher chance of failure requiring repeated bone grafts. Even if successful, an excessively large cleft leads to a wide edentulous space, and patients are faced with prolonged orthodontic treatment. We present a series of large alveolar clefts closed with the aid of segmental maxillary osteotomies. Cases of alveolar clefts treated by segmental maxillary osteotomy from 2014 to 2016 were reviewed. Preoperative and postoperative computed tomography scans were analyzed to assess the alveolar gap and bone filling. Demographic characteristics, diagnoses, and operative techniques were reviewed and described. A total of 10 alveolar fistulae were addressed, using 6 segmental osteotomies in 6 patients. Of the cases, 66% were bilateral. There were 4 female and 2 male patients with an average age of 12.6 years. The average preoperative cleft width was 14.2 mm on computed tomography scans. Postoperatively, all clefts were successfully closed and no adverse effects were observed. Segmental maxillary osteotomy with concurrent bone grafting and fistula closure is an effective approach to treat excessively wide alveolar clefts. This enables a prudent dental substitution or prosthodontic plan while minimizing prolonged orthodontia, in addition to achieving the traditional goals of alveolar bone grafting (stabilizing the maxillary arch, closing fistulae, and permitting canine eruption).

Mandibular Spatial Reorientation and Morphological Alteration of Crouzon and Apert Syndrome.

BACKGROUND: From infancy to adulthood, the mandible develops increased ramus height, prominence of the chin, and laterally widened gonial angles. In Crouzon and Apert syndromes, both relative retrognathia and prognathic jaws have been reported. Growth is influenced by a variety of factors, including the growth and relative position of the skull base, functional coordination, and the spatial influence of the laryngopharynx. Thus, this study aimed to explore in detail the evolution of the mandible in both syndromes and its relationship with the entire facial structure and skull base. METHODS: One hundred twenty-three preoperative computed tomographic scans (Crouzon, n = 36; Apert, n = 33; control, n = 54) were included and divided into 5 age subgroups. Computed tomographic scans were measured using Materialise software. Cephalometrics relating to the mandible, facial structures, and cranial base were collected. Statistical analyses were performed using t test and statistical power analysis. RESULTS: In Crouzon syndrome, the angle between the cranial base and gnathion was increased prior to 6 months of age by 10.29 degrees (P < 0.001) and by adulthood to 11.95 degrees (P = 0.003) compared with normal. After 6 months of age, the distance between bilateral mandibular condylions (COR-COL) was narrower by 15% (P < 0.001) in Crouzon syndrome compared with control subjects. Before 6 months of age, Apert COR-COL decreased 16% (P < 0.001) compared with control subjects and 13% (P = 0.006) narrower than Crouzon. During 2 to 6 years of age, Apert mandibular ramus height caught up to, and became longer than, Crouzon by 12% (P = 0.011). The nasion-sella-articulare angle of the Apert skull was 5.04 degrees (P < 0.001) less than Crouzon overall. CONCLUSIONS: In Crouzon syndrome, the changes of the spatial relationship of the mandible to the cranial base develop earlier than the mandibular shape deformity, whereas in Apert syndrome, the spatial and morphological changes are synchronous. The morphological changes of the mandible are disproportional in 3 directions, initially significant shortening of the mandibular width and length, and, subsequently, reduced height. Crouzon has more shortening in mandibular height compared with Apert, reflecting the more shortened posterior cranial base length. The narrowed angle between the mandible and the posterior cranial base in Apert skulls is consistent with the more limited nasopharyngeal and oropharyngeal airway space.

Effect of Fat Grafting on Postoperative Edema After Orthognathic Surgery.

BACKGROUND: Autologous fat grafting concurrent with orthognathic surgery is a powerful adjunctive aesthetic tool, and has been shown to have anti-inflammatory properties in prior studies. The purpose of this study is to evaluate the effect of fat grafting on postoperative edema following orthognathic surgery, and also consider the impact of age and BMI. METHODS: A retrospective cohort study was performed. Three-dimensional photos (Canfield, Fairfield, NJ) from a series of postprocedure time-points were analyzed using Geomagic Studio 2013 (3D Systems, Morrisville, NC). An unstructured covariance linear mixed model was created to analyze the effect and extent of the effect of age, BMI, and fat using SPSS Statistics 24.0 (IBM, Armonk, NY). RESULTS: One hundred thirty postoperative three-dimensional pictures were analyzed, from 31 patients. The linear mixed model demonstrates that the fat injected (P<0.001), age (P=0.001), and BMI (P<0.001) are significant factors in the postoperative volume. Age and BMI increase postoperative edema by 3.63 cm per year and 14.60 cm per kg/m, respectively. Fat injected reduces postoperative edema by 8.72 cm per 1 cc injected. CONCLUSION: Increasing age and BMI lead to greater postoperative edema (3.88 cm per year and 14.60 cm per kg/m, respectively). Fat grafting concurrent with orthognathic surgery reduces postoperative edema by 8.72 cm per 1 cc injected, and hastens return to steady state. This impact is more profound in patients with a greater age and BMI.

Fat Grafting in Orthognathic Surgery.

BACKGROUND: Fat grafting is widely utilized in craniofacial surgery. The authors describe a series of consecutive patients who underwent orthognathic surgery with fat grafting by the senior author and review relevant literature in the field; fat grafting technique is discussed in detail. The authors also highlight 3 patients to illustrate postoperative outcomes. METHODS: A retrospective cohort of consecutive orthognathic surgery patients was reviewed. Age, sex, BMI, procedure, area of harvest, location of injection, donor site complications, and need for repeat fat grafting were analyzed. Inclusion criteria included history of orthognathic surgery and concomitant fat grafting performed by the senior author in 2015. RESULTS: Fifty-three orthognathic surgery patients with concurrent fat grafting were reviewed. The cohort comprised 20 males (37.7%) and 33 females (62.3%). Thirty-three patients (62.3%) underwent Le Fort I operations either in conjunction with genioplasty and/or bilateral sagittal split osteotomies. Twenty-eight patients (52.8%) underwent second operations involving additional fat grafting. The majority of these patients (15/28, 53.6%) received additional fat grafting during ensuing rhinoplasty. There were no donor site complications (ie, infection, wound breakdown) recorded in the authors' patient cohort. Amount of fat injected averaged 13.1 cc (range 5-25 cc). Follow-up generally occurred through the 1-year mark. CONCLUSIONS: Fat grafting is a proven technique to facilitate optimal postoperative wound-healing in orthognathic surgery. The senior author uses Telfa processing and the Coleman system to deliver the fat atraumatically. The authors' cohort of consecutive patients corroborates the benefits of fat grafting in craniofacial surgery; the authors observe wound-healing benefits, enhanced aesthetic outcomes and an anti-inflammatory effect with this technique.

Comparing Outcomes in Orthognathic Surgery Using Clear Aligners Versus Conventional Fixed Appliances.

PURPOSE: Orthognathic surgery for dentofacial deformities is typically preceded and followed by orthodontic treatment. Traditionally, orthodontic hardware is secured to the dentition to allow dental movement and stabilization. Clear-aligner therapy (eg, Invisalign) provides an aesthetic alternative, consisting of a series of transparent trays. Its use has not been described in complex triple-jaw orthognathic surgery. The purpose of this study is to evaluate perioperative outcomes and 3-dimensionally quantify postoperative edema in Invisalign patients undergoing triple-jaw orthognathic procedures, comparing this to patients treated with conventional fixed appliances. The surgical approach to patients with clear-aligners is also outlined. METHODS: The authors conducted a retrospective chart review and 3-dimensional morphometric study of Invisalign patients undergoing triple-jaw surgery (LeFort I osteotomy, bilateral sagittal split osteotomy, and genioplasty). An identical assessment of demographically matched patients treated with conventional fixed appliances was performed and compared with the Invisalign group. RESULTS: Thirty-three patients, with a mean age of 19.99 years, were included: 13 with Invisalign and 20 with conventional fixed appliances. No significant difference was observed in operating time, concurrent extraction of teeth, fat grafting, duration of hospital stay, diet advancement, and use of narcotic analgesics between the 2 groups. Nine patients had sufficient 3-dimensional images for volumetric analysis (4 with Invisalign and 5 with conventional fixed appliances). Postoperative edema was not significantly different (P = 0.712) when comparing conventional fixed appliances (44.29 ±â€Š23.16 cm) to Invisalign (37.36 ±â€Š31.19 cm). CONCLUSION: The present study demonstrates that complex multiple-jaw orthognathic procedures can be successfully performed in Invisalign patients. Perioperative and short-term clinical outcomes are not compromised.