Virtual surgical planning in orthognathic surgery: A prospective evaluation of postoperative accuracy.

OBJECTIVES: The development of 3D computer-assisted technologies over the past years has led to vast improvements in orthognathic surgery. The aim of the present study was to evaluate differences in maxillary position between 3D virtual surgical planning (VSP) and surgical results. MATERIALS AND METHODS: We assessed data from 25 patients who underwent bimaxillary non-segmented orthognathic surgery with 3D VSP. Each patient underwent a postoperative CT scan within 40 days after surgery. We compared the STL (Standard Triangulation Language) file from the VSP with that obtained from the postoperative CT. RESULTS: According to our comparative analysis, the postoperative and VSP 3D models did not statistically differ. The Lin concordance correlation coefficient was always >0.95 for each landmark, but in 21 patients (84 % of the sample) we identified at least one point with a difference of more than 1.5 mm between the postoperative and VSP 3D model on at least one axis. The most frequently observed differences corresponded to sagittal translation and pitch rotation. CONCLUSIONS: An intraoperative clinical and aesthetic evaluation of the consequences of bone movements on patient face is strongly recommended, also when we use VSP because we may have clinically significant differences from the planning.

Nebulized hyaluronic acid improves nasal symptoms after orthognathic surgery: a randomized clinical trial.

PURPOSE: After maxillary osteotomy in orthognathic surgery, patients report nasal breathing discomfort in early postoperative period. Topical hyaluronic acid (HA) has been proven to have beneficial effects on the upper airway tract mucosa. This prospective randomized controlled study was designed to analyze the effect on nasal obstruction of nebulized HA during the recovery process after maxillary osteotomy. METHODS: Patients were randomized to control and treatment groups. The postoperative treatment differed only for additional nebulized HA provided to the treatment group. The level of nasal obstruction, and its impact on quality of life, was assessed every 3 days for the first 15 days postoperatively using a questionnaire. Demographic and other variables (maxillary osteotomy type and surgical movements) were analyzed. Differences in quantitative data were tested using Student's t-test, the Mann-Whitney U test, and mixed repeated measures ANOVA. RESULTS: Twenty-four subjects were included in each group; differences in age, sex, type of maxillary osteotomy, and movements were non-statistically significative. At the beginning of treatment (T0), the two groups had comparable questionnaire scores regarding nasal breathing discomfort (p >0.05), whereas statistically significant differences were found at days 3, 6, 9, and 12 (p <0.05). A significant decrease in nasal breathing discomfort over time was observed in both groups, with trends that differed between the two, indicating faster improvement in the treatment group. CONCLUSION: Nebulized HA can be a useful additional treatment in early postoperative period after orthognathic surgery. Patients reported more rapid improvement of nasal respiratory symptoms, indicating a potential role for HA in reducing recovery time and patient discomfort after maxillary surgery.

Duplication of the Pituitary Gland (DPG)-Plus Syndrome Associated With Midline Anomalies and Precocious Puberty: A Case Report and Review of the Literature.

Duplication of the pituitary gland (DPG)-plus syndrome is a very rare developmental disorder with few cases described in the literature and characterized by multiple midline and central nervous system malformations. The hypothalamus and hypophysis involvement may be clinically associated with endocrine abnormalities. A 5.9-year-old female child was admitted to our Clinic for premature thelarche and acceleration of growth. DPG-plus syndrome with paired infundibula and pituitary glands was diagnosed after birth, when she appeared small for gestational age and she presented with lingual hypoplasia, cleft palate, right choanal stenosis, nasopharyngeal teratoma, and facial dysmorphisms. Neuroimaging revealed a duplication of the infundibula, the pituitary gland, and the dens of the epistropheus despite surgical removal of a rhino-pharyngeal mass performed at the age of two months. An array-CGH revealed a 2p12 deletion. At our evaluation, bone age assessment resulted advanced and initial pubertal activation was confirmed by Gonadotropin-Releasing Hormone stimulation test. Hormonal suppression treatment was started with satisfactory results. This case shows that DPG-plus syndrome must be considered in presence of midline and craniofacial malformations and endocrinological evaluations should be performed for the prompt and appropriate management of pubertal anomalies.

Virtual Planning of a Complex Three-Part Bimaxillary Osteotomy.

In maxillofacial surgery, every patient presents special problems requiring careful evaluation. Conventional methods to study the deformities are still reliable, but the advent of tridimensional (3D) imaging, especially computed tomography (CT) scan and laser scanning of casts, created the opportunity to better understanding the skeletal support and the soft tissue structures. Nowadays, virtual technologies are increasingly employed in maxillofacial surgery and demonstrated precision and reliability. However, in complex surgical procedures, these new technologies are still controversial. Especially in the less frequent cases of three-part maxillary surgery, the experience is limited, and scientific literature cannot give a clear support. This paper presents the case of a young patient affected by a complex long face dentofacial deformity treated by a bimaxillary surgery with three-part segmentation of the maxilla. The operator performed the surgical study completely with a virtual workflow. Pre- and postoperative CT scan and optical scanning of plaster models were collected and compared. Every postoperatory maxillary piece was superimposed with the presurgical one, and the differences were examined in a color-coded map. Only mild differences were found near the osteotomy lines, when the bony surface and the teeth demonstrated an excellent coincidence.

How does the mandible grow after early high condylectomy?

The early high condylectomy (HC), removing the overgrowing area of the condyle, may be indicated for condylar hyperplasia. However, in young patients, when the HC removes the pathological overgrowing tissue the contralateral condyle is still growing. May this surgical procedure, in these growing patients, stop the operated side growth creating the conditions for an opposite asymmetry? Authors investigate the way the operated mandible develops after the early HC, both as a symmetry percentage and in an absolute value related to the unaffected side. A sample of 8 consecutive growing patients, 1 male and 7 females, referred to the Maxillofacial Surgery Department of Parma University for HC were investigated. Patients were longitudinally studied with 3 orthopantomographies at: T0 (diagnosis: mean age, 13 years; range, 11 years 2 months to 13 years 8 months), T1 (after surgery: mean age, 15; range, 13-18 years) and T2 (follow-up: mean age, 18 years; range, 17-20 years). The x-ray is used to study the condyle, ramus, and total vertical structures length by Mattila tracing method. The data were analyzed by the Student t test and Wilcoxon matched pairs test; P value was set at 0.5. The operated side was overcorrected by HC and; during the investigated period, its growth decreased from T0 to T1 and restarted from T1 to T2. The whole T0-T2 growth of the operated side was not statistically different from the one of the healthy side (P < 0.05). These results suggest that the operated side growth may continue in a more normal way after condylectomy.

Mandibular distraction in neonates: indications, technique, results.

BACKGROUND: The Pierre Robin Sequence features were first described by Robin in 1923 and include micrognathia, glossoptosis and respiratory distress with an incidence estimated as 1:8,500 to 1:20,000 newborns. Upper airway obstruction and feeding difficulties are the main concerns related to the pathology. Mandibular distraction should be considered a treatment option (when other treatments result inadequate). PATIANTS AND METHODS: Ten patients between the ages of 1 month and 2 years with severe micrognathia and airway obstruction were treated with Mandibular Distraction Osteogenesis (MDO).All patients underwent fibroscopic examination of the upper airway and a radiographic imaging and/or computed tomography scans to detect malformations and to confirm that the obstruction was caused by posterior tongue displacement. All patients were evaluated by a multidisciplinary team. Indications for surgery included frequent apneic episodes with severe desaturation (70%). Gavage therapy was employed in all patients since oral feeding was not possible. The two tracheotomy patients were 5 months and 2 years old respectively, and the distraction procedure was performed to remove the tracheotomy tube. All patients were treated with bilateral mandibular distraction: two cases with an external multivector distraction device, six cases with an internal non-resorbable device and two cases with an internal resorbable device. In one case, the patient with Goldenhar's Syndrome, the procedure was repeated. RESULTS: The resolution of symptoms was obtained in all patients, and, when present, tracheotomy was removed without complications. Of the two patients with pre-existing tracheotomies, in the younger patient (5 months old) the tracheotomy was removed 7 days postoperatively. In the Goldenhar's syndrome case (2 years old) a Montgomery device was necessary for 6 months due to the presence of tracheotomy-inducted tracheomalacia. Patients were discharged when the endpoint was obtained: symptoms and signs of airway obstruction were resolved, PAS and maxillomandibular relationship improved, and tracheotomy, when present, removed. During the follow-up, no injury to the inferior alveolar nerve was noted and scarring was significant in only the two cases treated with external devices. CONCLUSION: Mandibular Distraction Osteogenesis is a good solution in solving respiratory distress when other procedures are failed in paediatric patients with severe micrognatia.

Tessier 3 cleft with bilateral anophthalmia: case report and surgical treatment.

Tessier clefts type 3 and 4 are rare. In this paper the authors report on the management of a wide Tessier 3 cleft. There is no standardized protocol or timing of the surgical procedures in this rare disfiguring condition. Generally speaking, the aim is to preserve the function of important anatomical structures (e.g., a seeing eye.) and reconstruct, as best as possible, harmonic facial features. The authors present a "step by step" solution of the malformation pointing out the limitations of the surgical procedures they used and the goals they wanted to obtain. Despite of the uniqueness and the complexity of the pathology, the authors think they obtained reasonable results both in term of function and aesthetics, permitting the patient to be accepted in the social environment.

Simultaneous management of the enophthalmos and sinus pathology in silent sinus syndrome: a report of three cases.

Silent sinus syndrome is a rare disorder affecting the maxillary sinus unilaterally, characterized by ipsilateral enophthalmos and hypoglobus. The treatment is surgical: the endoscopic approach represents the gold standard for the restoration of normal sinus aeration, but there is no consensus in the management of the enophthalmos. Most authors suggest a two stage procedure consisting of endoscopic sinus surgery initially and a delayed secondary operation for the restoration of the orbital floor. We present our experience with three cases treated with a single-stage procedure, focusing on the advantages of this one-step approach.