Orthognathic surgery. Review of mandibular body procedures.

In a clinical diagnostic approach to orthognathic deformities, the patient's past medical and dental histories and the indications and potential complications of mandibular body ostectomy and osteotomy are important considerations. The need for a team approach in the diagnostic, orthodontic, and surgical phase of the treatment is also important. The mandibular body procedure has a definite place in the armamentarium of the oral surgeon because certain mandibular deformities can be corrected only by this method. Predictable and stable results can be expected in indicated cases if one adheres to the principles of exacting surgical technique, precision immobilization, and neuromuscular balance. Presurgical and postsurgical orthodontic treatment enhances the functional and esthetic correction and furnished indispensable surgical fixation appliances for precision segment immobilization.

Surgical correction of the acromegalic face. A one stage procedure with a team approach.

The features of acromegaly are presented with special reference to facial deformity. A one-stage procedure with careful pre-operative planning is advocated. The operating team is composed of a plastic surgeon and an oral surgeon. The frontal protrusion is corrected by osteotomy, the vertical and anteroposterior facial disproportion by bimaxillary procedures, the nasal deformity by rhinoplasty or skull bone grafting, and the macroglossia by tongue resection. This results in an improvement of the patient's psyche and frequently improvement in speech.

Topical fluoride in orthodontic bonding.

Neutral and acidified sodium fluoride solutions were topically applied to enamel etched in a manner typical for orthodontic bonding procedures. Enamel fluoride levels were greater with the acidified solutions.

Intraoral quadrangular Le Fort II osteotomy.

The technical aspects of the intraoral quadrangular Le Fort II osteotomy are described, and the anesthetic technique, blood loss, operating time, intraoperative and postoperative complications, length of hospitalization, and length of fixation in seven cases are reported. This procedure was predictable and reproducible with few complications, had low surgical and postsurgical morbidity, exhibited excellent initial skeletal stability, provided esthetics superior to those achieved with lower osteotomy and onlay bone grafting techniques, and demonstrated versatility within limits.

Quadrangular Le Fort I osteotomy: surgical technique and review of 54 patients.

Technical aspects and indications for the quadrangular Le Fort I osteotomy are described. The records of 54 consecutive patients who underwent this procedure for primary correction are reviewed in general terms, and those of 3 patients with significant follow-up are presented in some detail. The procedure gave predictable results, provided acceptable midfacial aesthetic improvement, and was surgically reproducible with few complications. Low surgical and postoperative morbidity was documented. This procedure was used in a similar patient population as the quadrangular Le Fort II osteotomy, and the rationale for choosing between these two procedures is discussed.

Determinants of facial attractiveness in a sample of white women.

Esthetic evaluation of a photographic profile slide of a random sample of 130 adult white women was made by six judges. The esthetic evaluation included vertical and anteroposterior evaluation and an attractiveness score on a visual analog scale. Additionally, the judges were asked to give specific reasons for their scores. Profiles with increased vertical features or convex or Class II tendency profiles were judged as being the most unattractive. Judgment of facial appearance was consistently related to certain regions of the face: the chin, upper lip, and nose having the greatest effect on the overall judgment of appearance. Orthodontic and surgical treatment planning should focus primarily on these regions to obtain the best esthetic result.

Validity and reliability of facial profile evaluation in vertical and horizontal dimensions from lateral cephalograms and lateral photographs.

Esthetic profile evaluation was performed by six judges on a random sample of 130 white women. Vertical and horizontal profile evaluations of the subjects' cephalograms were compared with vertical and horizontal profile evaluations of the same subjects' photographic slides. Statistically significant differences were found: Judges sometimes favored the photographic profile and sometimes favored the cephalographic profile. Esthetic treatment goals should be based on facial shortcomings as they are observed clinically or seen on a patient's photograph.

The effect of Le Fort I maxillary impaction on nasal airway resistance.

To evaluate the effect of maxillary superior movement via Le Fort I osteotomy on nasal airway resistance, eleven Caucasian patients whose surgical orthodontic treatment included Le Fort I impaction (range 2 to 8 mm, mean 5.3 mm) were selected. Nasal airway resistance in these patients was determined a few days before and approximately 8 weeks after the Le Fort I surgical procedure. Nasal airway resistance was determined by means of a uninasal active mask rhinomanometric technique. Contrary to the predicted negative effects of maxillary superior movement on nasal airway function, there was a statistically significant improvement in nasal airway resistance (P less than 0.01) after maxillary superior movement. This rather unexpected finding can be explained by examining the effect of maxillary superior movement on the nasal valve area in the anterior nose. The nasal valve area is a teardrop-shaped area bordered by the nasal septum, the caudal end of the upper lateral nasal cartilage, the floor of the nose, and the soft fibrofatty tissue on the lateral aspect of the nose. The apex of the teardrop-shaped area (the angle between the nasal septum and the upper lateral cartilage) is called the nasal valve. In the Caucasian type of nose, the nasal valve accounts for most of the inspiratory resistance to airflow. Maxillary superior movement increases the alar width. It is proposed that this increase in alar width is transmitted at least partially to the nasal valve angle, causing it to widen slightly, paradoxically reducing nasal airway resistance while reducing skeletal intranasal dimensions.

A biplanar cephalometric stereoradiography technique.

A biplanar cephalometric stereoradiography (BCSR) technique was developed for accurate three-dimensional assessment of structures that can be identified by markers or anatomical landmarks that are visible on both lateral closed and posteroanterior cephalometric radiographs. The accuracy and precision of the technique were determined by means of a phantom and clinical radiographs. On the phantom, three-dimensional coordinates were determined by the BCSR technique and were measured directly with an electronic digital caliper. The accuracy of the BCSR technique was found to be within 0.5% of the measured distances. On clinical radiographs, the lengths of plates and screws, used as rigid fixation devices, were measured on two subsequent sets of biplanar radiographs and were found to be within the accuracy of our current digitizer (+/- 0.381 mm). The stability of interosseous wires was tested against implants and other interosseous wires on two subsequent sets of biplanar radiographs through a comparison of the distances between two devices. These comparisons confirmed the stability of interosseous wires. The BCSR technique proved to be an accurate method for measurements in three dimensions.

The effect of topical fluorides, after acid etching of enamel, on the bond strength of directly bonded orthodontic brackets.

This study tests the hypothesis that the beneficial effects of topical fluoride can be realized without reducing the bond strength of the resin adhesive. Twenty-eight groups of four teeth (third molars and premolars) were extracted from twenty-eight patients and stored in distilled water. Twin brackets on Ormesh pads were bonded to all teeth with Endur adhesive. One tooth from each group was bonded according to the manufacturer's instructions. These teeth, Subgroup I, served as controls. Subgroup II teeth were etched for 4 minutes with 50% phosphoric acid containing 2 percent sodium fluoride. Subgroup III teeth received a 3-minute application of a basic phosphate fluoride solution (10(-2)M NA3PO4, 10(3) ppm F) after 1 minute of etching with 50 percent phosphoric acid. Subgroup IV teeth received a 4-minute application of 8 percent stannous fluoride solution after 1 minute of etching with 50 percent phosphoric acid. Each tooth was mounted in a block of improved dental stone; guide wires were used to reproduce bracket orientation. The M.T.S. materials-testing apparatus was used to generate a torsional moment on the bracket at a rate of 1 degree per second. Fluoride uptake by enamel has been shown to be greater in an acid medium or after acid etching. The application of directly bonded orthodontic brackets and pit-and-fissure sealants requires acid etching of the enamel surface. This study supports the use of topical fluoride after acid etching, a procedure that achieves the benefits of increased fluoride uptake without changing the bond strength of the resin adhesive.

Stability after inferior or anterior maxillary repositioning by Le Fort I osteotomy: a biplanar stereocephalometric study.

A biplanar cephalometric stereoradiographic system was used to measure maxillary positional changes during and after Le Fort I procedures for inferior or anterior repositioning of the maxilla. Of the 29 patients studied, 25 had undergone surgical maxillary advancement, and 15 had undergone inferior repositioning. These cases were divided into subgroups based on fixation technique, presence or absence of bone grafts, age, and surgeon. The postsurgical follow-up period was at least 11 months for each patient. The landmarks used to measure maxillary positional changes consisted of skeletal features and points on wire or rigid fixation devices. Mean magnitudes of postsurgical maxillary landmark displacement were insignificant for all subgroups examined except the advancement group with wire fixation. Individual patients exhibiting the greatest postsurgical displacements tended to have had large surgical advancements and received wire fixation. Magnitudes of surgical and postsurgical change did not seem correlated on the whole, except in the maxillary advancement cases in which bone grafts had not been used. Error analysis results suggest that digitizing consistency was acceptable for maxillary landmarks; however, methodologic improvements with regard to provision of cranial reference landmarks may further minimize errors in future studies.

Multidisciplinary management of acromegaly and its deformities.

The skeletal deformities associated with acromegaly are not reversed by correction of abnormal growth hormone dynamic. We describe a patient with acromegaly in whom facial reconstruction was undertaken after successful removal of a pituitary adenoma.