The effect of soft palate reconstruction with the da Vinci robot on middle ear function in children: an observational study.

Cleft palate is associated with a high prevalence of middle ear dysfunction, even after palatal repair. The aim of this study was to evaluate the effects of robot-enhanced soft palate closure on middle ear functioning. This retrospective study compared two patient groups after soft palate closure with a modified Furlow double-opposing Z-palatoplasty technique. Dissection of the palatal musculature was performed using a da Vinci robot in one group and manually in the other. Outcome parameters were otitis media with effusion (OME), tympanostomy tube use, and hearing loss during 2 years of follow-up. At 2 years post-surgery, the percentage of children with OME had reduced significantly to 30% in the manual group and 10% in the robot group. The need for ventilation tubes (VTs) decreased significantly over time, with fewer children in the robot group (41%) than those in the manual group (91%) needing new VTs during postoperative follow-up (P = 0.026). The number of children presenting without OME and VTs increased significantly over time, with a faster increase in the robot group at 1 year post-surgery (P = 0.009). Regarding hearing loss, significantly lower hearing thresholds were recorded in the robot group from 7 to 18 months postoperatively. To conclude, beneficial effects of robot-enhanced surgery were recorded, suggesting a faster recovery when the soft palate was reconstructed using the da Vinci robot.

The effect of subspinal Le Fort 1 corticotomy on nasal morphology in surgically assisted rapid palatal expansion.

The purpose of this retrospective study was to evaluate the influence of subspinal Le Fort 1 corticotomy (SLF1C) on nasal morphology in patients treated with surgically assisted rapid palatal expansion (SARPE) using three-dimensional (3D) stereophotogrammetry images. A total of 64 patients were enrolled in the study and divided into two groups according to the surgical approach that was used: in group 1 (n = 32) SARPE was performed using a conventional Le Fort 1 corticotomy (CLF1C), and in group 2 (n = 32) SARPE was performed using a subspinal Le Fort 1 corticotomy (SLF1C). Measurements of alar and columellar width, and nasolabial angle were taken on 3D stereophotogrammetry images before and after SARPE using Vectra 3D camera system. Both surgical groups showed a statistically significant increase in alar and columellar width, and nasolabial angle postoperatively (p<0.05). SLF1C resulted in significantly smaller changes of the columellar base postoperatively (p=0.0456). The data suggests that SARPE with an osteotomy of the anterior nasal spine as an additional step to the conventional Le Fort 1 corticotomy results in a smaller increase of the columellar base.

A novel instrument for the prevention of condylar torque in bilateral sagittal ramus osteotomy when using bicortical screw fixation.

When using the bilateral sagittal split osteotomy (BSSO) technique, rigid internal fixation (RIF) remains the standard method to accurately fix the distal and proximal osteotomy fragments. A concern with the use of RIF, especially with bicortical screws, is the increased risk of condylar torque and its functional consequences. This technical note introduces a new method for preventing torque of the mandibular condyles after BSSO, using a sagittal split space maintainer.

Orthodontic - Surgical management in a Class II case with idiopathic root resorption.

Patients with root resorption and malocclusion can benefit from orthodontic treatment with or without surgery. However, orthodontics has a risk of inducing or aggravating root resorption, therefore the duration of the treatment is of utmost importance. In this paper, a surgery-first protocol with lower jaw advancement and precise interdental alveolar osteotomies was conducted to accelerate the treatment of a 14-year-old female patient who presented with a Class II division 2 malocclusion, anterior dental crowding and idiopathic root resorption. One week after the surgery, the patient received postoperative orthodontic treatment for 6 months with weekly activation the first month. The clinical outcome was satisfactory with complete clinical resolution and no tooth loss. This surgery approach allowed an 'en bloc' tooth movement and induced an increased bone remodelling, which resulted in an accelerated tooth movement. The reduction of treatment time was beneficial and no aggravation of the root resorption was seen.

Impact of oral clefts on the oral health-related quality of life of preschool children and their parents.

OBJECTIVE: To assess the oral health-related quality of life (OHRQoL) of preschool children with cleft lip and palate (CLP) and their relatives. MATERIALS AND METHODS: In this cross-sectional study, 55 2-5-year-old children with the history of CLP were randomly selected from those referred to Shiraz Lip and Palate Cleft Research Center and treated with single-stage closure (Push back palatoplasty). Furthermore, same number of children with the same age who attended the Shiraz School of Dentistry for routine dental care were selected as control group using randomized sampling. Children's demographic data were obtained from their parents. Farsi version of the Early Childhood Oral Health Impact Scale (F-ECOHIS) was used for evaluating these children's QoL. RESULTS: We found a significant difference in OHRQoL between children with CLP and children without CLP in the overall score of F-ECOHIS and all of subscales. In the impact on children subscale, the difference between these groups was remarkable in limitations' domain. As for difficulties faced by children, question on "difficulty in pronouncing words" had the highest average score. Furthermore, in impact on family, in parental distress domain, the difference between these groups was remarkable. For difficulties faced by family, financial impact got the highest average score. No significant difference was found between boys and girls with CLP in all subscales. While according to the score of total F-ECOHIS in unilateral and bilateral CLP children, there was statistically significant difference in these groups. CONCLUSION: Since oral clefts affect the QoL of children and their families even after the usual treatments, the implementation and maintenance of multidisciplinary interventional strategies are required for establishment of facial esthetics, oral function, and psychological support for such individuals.

Mandibular midline distraction using a tooth-borne device and a minimally invasive surgical procedure.

In this technical note we share our experience of mandibular midline distraction, a powerful tool in orthognathic surgery. The use of a tooth-borne distractor and a minimally invasive surgical procedure to perform the midline osteotomy is discussed.

Two-stage palatoplasty using a modified Furlow procedure.

A two-stage palatal repair using a modification of Furlow palatoplasty is presented. The authors investigate the speech outcome, fistula formation and maxillary growth. In a prospective, successive cohort study, 40 nonsyndromic patients with wide cleft palate were operated on between March 2001 and June 2006 by a single surgeon. 10 patients in the first cohort underwent a Furlow palatoplasty (control group). In 30 patients in the second cohort a unilateral myomucosal cheek flap was used in combination with a modified Furlow palatoplasty (study group). The hard palate was closed in both groups 9-12 months later. The Bzoch speech quality score was superior in the study group, and the hypernasality was significantly reduced in the study group. Overall fistula formation was 0%. At the time of hard palate reconstruction palatal cleft width was significantly reduced. Relative short-term follow up of maxillary growth was excellent. There were no postoperative haematomas, infections, or episodes of airway obstruction. This technique is particularly encouraging, because of better speech outcome, absence of raw surfaces on the soft palate, no fistula formation, and good maxillary growth. Further follow-up is necessary to determine the long-term effects on facial development.

Virtual occlusion in planning orthognathic surgical procedures.

Accurate preoperative planning is mandatory for orthognathic surgery. One of the most important aims of this planning process is obtaining good postoperative dental occlusion. Recently, 3D image-based planning systems have been introduced that enable a surgeon to define different osteotomy planes preoperatively and to assess the result of moving different bone fragments in a 3D virtual environment, even for soft tissue simulation of the face. Although the use of these systems is becoming more accepted in orthognathic surgery, few solutions have been proposed for determining optimal occlusion in the 3D planning process. In this study, a 3D virtual occlusion tool is presented that calculates a realistic interaction between upper and lower dentitions. It enables the surgeon to obtain an optimal and physically possible occlusion easily. A validation study, including 11 patient data sets, demonstrates that the differences between manually and virtually defined occlusions are small, therefore the presented system can be used in clinical practice.

Predicting soft tissue deformations for a maxillofacial surgery planning system: from computational strategies to a complete clinical validation.

In the field of maxillofacial surgery, there is a huge demand from surgeons to be able to pre-operatively predict the new facial outlook after surgery. Besides the big interest for the surgeon during the planning, it is also an essential tool to improve the communication between the surgeon and his patient. In this work, we compare the usage of four different computational strategies to predict this new facial outlook. These four strategies are: a linear Finite Element Model (FEM), a non-linear Finite Element Model (NFEM), a Mass Spring Model (MSM) and a novel Mass Tensor Model (MTM). For true validation of these four models we acquired a data set of 10 patients who underwent maxillofacial surgery, including pre-operative and post-operative CT data. For all patient data we compared in a quantitative validation the predicted facial outlook, obtained with one of the four computational models, with post-operative image data. During this quantitative validation distance measurements between corresponding points of the predicted and the actual post-operative facial skin surface, are quantified and visualised in 3D. Our results show that the MTM and linear FEM predictions achieve the highest accuracy. For these models the average median distance measures only 0.60 mm and even the average 90% percentile stays below 1.5 mm. Furthermore, the MTM turned out to be the fastest model, with an average simulation time of only 10 s. Besides this quantitative validation, a qualitative validation study was carried out by eight maxillofacial surgeons, who scored the visualised predicted facial appearance by means of pre-defined statements. This study confirmed the positive results of the quantitative study, so we can conclude that fast and accurate predictions of the post-operative facial outcome are possible. Therefore, the usage of a maxillofacial soft tissue prediction system is relevant and suitable for daily clinical practice.

Trans-sinusoidal maxillary distraction in three cleft patients.

The trans-sinusoidal maxillary distractor (TS-MD) was used to achieve maxillary advancement in three patients with repaired cleft lip and palate. After preoperative computer-aided planning of the distraction vectors, each TS-MD was bent on a stereolithographic model of the maxilla of the patient. The devices were intraoperatively positioned using a methyl-methacrylate template. After standard Le Fort I osteotomy the devices were intraorally activated. After distraction the devices remained in situ for 3 months as rigid internal fixation of the maxilla. All patients were successfully distracted according to protocol. Maxillary advancement was 12, 8 and 11 mm. In two patients, additional maxillary widening of 6 and 8 mm was achieved by choosing divergent distraction vectors. After distraction a clockwise rotation of the maxilla was observed in two patients. There was no relapse during the 3 months of consolidation and 12-month follow-up. The TS-MD allows not only distraction but also rigid internal fixation after distraction. It was easy to apply but difficult to remove. Owing to preoperative 3D planning of the distraction vectors, the results were predictable, but clockwise rotation of the maxilla during distraction should be considered in planning. The distractor did not interfere with function or social activities during distraction and retention periods. After removal it left no extraoral scars.

Trans-sinusal maxillary distraction for correction of midfacial hypoplasia: long-term clinical results.

Maxillary distraction osteogenesis is indicated in severe angle class III malocclusions, and severe maxillary hypoplasia among some cleft patients and other craniofacial deformities. Twenty patients, aged 8-48 years (mean 17.8+/-10.5 SD) with maxillary and midfacial hypoplasia were treated. The follow-up period was 13-65 months (mean 35+/-16.3 SD). A trans-sinusal maxillary distractor was placed intraorally at each side of the maxilla. The distraction vector was predicted using specialist software, and was transferred to the patients using stereolithographic models and individual templates. A (high) Le Fort I type osteotomy was performed. The amount of activation varied from 8 to 17.5 mm (mean 13.1+/-2.9 SD). Soft and hard tissue formation resulted in complete healing across the distraction gaps. The distractors are almost completely submerged, and can be left in place as long as necessary to avoid relapse. Wit's appraisal was used to measure the stability of the long-term distraction results. Results up to 5 years after distraction showed considerable maxillary advancement with long-term stability. Ongoing growth of the facial skeleton must be considered when distraction osteogenesis is chosen in growing patients.

[Predictability of maxillary distraction with the trans-sinusoidal distractor]. / Prédictibilité de la distraction du maxillaire supérieur avec distracteur trans-sinusien.

INTRODUCTION: This work was conducted to evaluate a new maxillary distractor with an activating system introduced into the maxilary sinus. PATIENTS AND METHOD: Fourteen patients age 8 to 55 Years with severe maxillary and midfacial hypoplasia were treated in our center. A trans-sinusoidal maxillary distractor (TS-MD, developed by Dr. N. Nadjmi in cooperation with Martin, Tuttlingen, Germany) was placed intra-orally at each side of the maxilla. The distraction vector was predicted with devoted software (Medicim N.V Belgium), and was transferred to the patients using stereolithographic models and individual templates. A high Lefort I type osteotomy was performed. RESULTS: Forward maxillary movement at distractor level varied from 7 to 22 mm. Soft and hard tIssue formation resulted in complete healing across the distraction gaps. The maxillary movements and new bone formation in the sagittal, horizontal, and vertical planes could be predicted and achieved. Distractors were designed to allow clockwise rotation of the maxilla during the distraction phase allowing the correction of the anterior open-bite in all patients with this skeletal deformity. The distractors were almost completely submerged, and could be left in place as long as necessary to avoid relapse. DISCUSSION: The TS-MD distractor has the advantage of good tolerance since the most voluminous part is placed within the maxilary sinus. Implantation via an exclusively oral approach is a further advantage. The devise does not interfere with the patient's social life and does not require alveolodental fixation. The TS-MD distractor can also aleviate the need for bone grafting in cases with major advancement. Correct position of the vector is crucial but one-sided catch-up distraction is possible.

Cephalometric evaluation of maxillary advancement with an internal distractor in an adult boxer dog.

OBJECTIVE: The aim of the study was to evaluate cephalometrically the effects of distraction of the maxilla over a 1-year period by means of an internal distractor applied in a boxer dog. DESIGN: Internal distractors were placed bilaterally in the internal cavity of the maxillary sinus of a 2-year-old boxer dog after a Le Fort I osteotomy. Distraction was started 5 days after surgery and activations were continued for 14 days at a rate of 1 mm/day. Standardized lateral cephalograms were taken with an extemal source of 90 kV, 60 mS immediately pre-surgery, at day 1 after the start of the distraction (dp) and at day 5 dp, day 7 dp, day 10 dp, day 14 dp (end of distraction), at 14 days of consolidation period (cp), at 28 days cp and at 56 days cp (removal of the distractors). One year after the removal of the distractor, a final lateral cephalogram was taken. Cephalometric analysis was performed and superimpositions were used for the evaluation of the sagittal position of the maxilla. RESULTS: The linear measurements, as well as the superimposition showed evidence for a significantly advanced position of the maxilla, which was stable 1 year after removal of the distractor. CONCLUSION: The application of the internal maxillary distractor in a boxer dog resulted in a sagittal advancement of the midface that was still present after 1 year.

Full-thickness skin graft in the secondary repair of bilateral cleft lip. A case report.

A 13-week-old boy with bilateral complete cleft lip and palate is presented. He had three attempted repairs of his lip elsewhere over a period of four weeks, and all of these broke down. Consequently, a substantial amount of his prolabium became necrotic. After a preoperative orthodontic realignment of the cleft segments, a secondary lip/nose repair was performed. The mucosa was reconstructed by advancement flaps. The orbicularis muscle was dissected out from its abnormal insertion and reconstructed in the midline. The philtrum was reconstructed with a full-thickness skin graft from the right postauricular area. The six-month postoperative result was satisfactory. This technique could be considered as an alternative to primary Abbé flap in secondary reconstruction of the cleft lip, although long-term follow-up must be obtained.

Six year's experience with the zygomatic "sandwich" osteotomy for correction of malar deficiency.

PURPOSE: This study discusses the rationale, modifications, and complications of an osteotomy technique used to increase malar projection. PATIENTS AND METHODS: Seventy "sandwich" zygomatic osteotomies were performed in a 6-year period. Hydroxyapatite (HA) blocks were used to stabilize the anterolateral rotation of the zygomatic body in 44 osteotomies, calcium carbonate blocks were used in 23, calvarial bone grafts in three, a piece of bovine cartilage in one, and a bone graft from a chin ostectomy procedure combined with mesh osteosynthesis in one procedure. Fifty-six zygomatic osteotomies were combined with Le Fort I-type osteotomies (eight with a midline split). Nineteen zygomatic osteotomies were performed simultaneously with a Le Fort I-type osteotomy and a rhinoplasty with lateral osteotomies. RESULTS: The increase of malar projection and the stability of the procedure could not be measured on conventional three-plane cephalograms. However, patient's and surgeon's satisfaction were high and remained so during the follow-up period (maximum, 6.5 years; minimum, 6 months). Three patients developed maxillary sinusitis. In two of them, this was clearly related to fragmentation of an HA block. A Treacher-Collins patient developed a chronic fistula in the upper vestibule, caused by leakage of infraorbitally placed HA granules. In two cases, a fracture of the zygomatic arch occurred. Osteosynthesis was performed in one of them. CONCLUSION: With proper technique and care not to fracture the interpositional HA block, complications are rare. The procedure is expedient and provides predictable and stable correction of malar deficiency.

Prediction of mandibular autorotation.

PURPOSE: The purpose of this investigation was to test the hypothesis that the mandible rotates around the same point during maxillary impaction surgery as during initial jaw opening. This point, called the center of mandibular autorotation (CAR), could then be used to predict mandibular position and to decide whether only maxillary impaction would be needed to correct the occlusion and the facial profile. PATIENTS AND METHODS: Preoperatively, two lateral cephalograms were obtained from a consecutive series of 20 patients who underwent maxillary impaction without concomitant mandibular ramus osteotomy. One cephalogram was taken with the mandible in centric relation using a wax bite wafer and another with a jaw opening of 10 mm using a fabricated acrylic bite block with the mandible manipulated to its most retruded position. The CAR was calculated before and after jaw opening using the Rouleaux method on the lower incisor and gonion point. A third lateral cephalogram was taken within 2 days postoperatively. The postoperative lower incisal point was then transferred to the first cephalogram using cranial base superimposition. RESULTS: When the preoperative and postoperative distances between CAR and incisal point were compared, there was no significant difference between these distances, proving the hypothesis. CONCLUSIONS: The method used is a practical and precise way to determine the center of mandibular autorotation on an individual basis. The center of rotation during initial jaw opening is the same as during impaction surgery.