Osseous genioplasty versus chin implants: early complications and patient satisfaction.

Osseous genioplasty and chin augmentation with implants are the two main treatment options for retrognathia. This retrospective cohort study was performed to compare the prevalence of complications and patient satisfaction following osseous genioplasty and chin augmentation by implant. Eighty patients were included: 38 underwent advancement osseous genioplasty and 42 received chin implants (alloplastic, either Medpor or Silastic) intraorally or extraorally. The patients were assessed for complications 12 months after surgery, including neurosensory disturbances, infection or extrusion, wound dehiscence, and the need for reoperation. Patient satisfaction was evaluated using a visual analogue scale. The infection rate was significantly higher in the chin implant group than in the genioplasty group (P = 0.028). Moreover, dehiscence and the need for reoperation appeared to be more common following chin augmentation with implants. However, there was no significant difference in the prevalence of neurosensory disturbances between the two groups (P = 0.137). In the chin implants group, the extraoral approach resulted in a lower dehiscence rate than the intraoral approach. Patients in the genioplasty group had significantly higher satisfaction scores than those in the chin implant group (P = 0.001). Overall, the rates of the complications assessed were lower and patient satisfaction was higher after osseous genioplasty when compared to chin augmentation with implants.

Does mandibular osteotomy affect gonial angle in patients with class III deformity? Vertical ramus osteotomy versus sagittal split osteotomy.

The mandibular angle represents an important part of facial aesthetics. Mandibular osteotomy can affect the gonial angle. The aim of this study was to compare the effects of sagittal split osteotomy (SSO) and intraoral vertical ramus osteotomy (IVRO) on the gonial angle. This retrospective cohort study assessed subjects with mandibular prognathism who underwent SSO (group 1) or IVRO (group 2). Lateral cephalograms obtained before and 1 year after the osteotomies were analyzed. In this study, age, sex, the change in occlusal plane (OP) and mandibular plane (MP) angles, and the amount of mandibular setback were considered as variable factors, while the type of surgery (SSO or IVRO) was considered the predictive factor. Fifty-six subjects were studied: 26 in group 1 and 30 in group 2. The changes in MP angle and OP angle were not significantly different between the groups (P>0.05). The change in gonial angle was 6.07±4.46° in group 1 and 7.33±5.73° in group 2; assessment of the data did not demonstrate a significant difference between the two groups studied (P=0.53). Mandibular osteotomy (SSO or IVRO) may change the gonial angle, but a significant difference between SSO and IVRO was not detected.

Biomechanical effects of surgical cut direction in unilateral mandibular lengthening by distraction osteogenesis using a finite element model.

Although the precise prediction of the results before distraction is important, performing three-dimensional (3D) simulations for all distraction osteogenesis patients is not practical. Formulating general guidelines based on the factors affecting the 3D results of distraction treatment is recommended. This study was performed on a 3D mandible based on a finite element method. Three surgical cuts (oblique, vertical and horizontal) were made in the right side of the mandible. The amount and direction of movement of proximal and distal segments were evaluated after simulation of 15 mm of distraction. In the distal segment, the maximum displacement in the pogonion occurred in the vertical cut. In the proximal segment, the maximum displacement occurred in the coronoid process in horizontal and oblique cuts in a superior direction. The condylar process rotated in the clockwise direction when the vertical cut was used and the coronoid process moved inferiorly. To make the gonial angle more prominent the vertical cut should be used. A horizontal cut is used to lengthen the ramus. Vertical and oblique cuts can be used in patients with long anterior facial height, but all other conditions being equal horizontal cuts are better used in short faced patients.

Facial symmetry after distraction osteogenesis and orthodontic therapy.

The purpose of this study was to document changes in the facial symmetry of patients with severe hypoplastic mandibles treated with distraction osteogenesis and orthodontic therapy. Ten patients (5 males and 5 females), ages 7 to 22 years, underwent unilateral mandibular distraction osteogenesis with extraoral distracting devices. Orthodontic therapy was initiated after the completion of mandibular lengthening. The mean follow-up period was 25.5 months. Posteroanterior cephalograms were traced before distraction, 6 months after distraction, and at a later follow-up appointment. Displacement of the chin point (in millimeters) and the midpoint of the mandibular incisors, the piriform angle, the intergonial angle, the occlusal cant to the horizontal line (in degrees), the ratio of linear measurements (in millimeters) Co-Gn, Co-Go, and Go-Gn of the affected to the nonaffected side, CoA'-Mid to CoA-Mid, and GoA'-Mid to GoA-Mid were compared. At the latest follow-up appointment, patients defined as having a successful result had a mean occlusal cant of 1.25 degrees, an intergonial angle of 2.13 degrees, and a piriform angle of 2.63 degrees. The mean displacement of the chin point to the midline was 1.5 mm and that of the mandibular central incisors to the midvertical line was 1.38 mm. The results indicated improvement in all patients.

Surgical technique for the treatment of high-flow arteriovenous malformations of the mandible.

The high-flow intraosseous arteriovenous malformation is a problematic vascular lesion which may affect bone and the dentition. Variable clinical presentations of this anomaly have resulted in a gamut of treatment modalities being reported ranging from simple curettage, resection, radiotherapy, sclerosing injections, and various forms of embolization, to immediate replantation of the resected segments. Embolization techniques alone have not been universally successful and have often resulted in rapid development of collaterals from surrounding vessels. Definitive treatment has usually involved complete surgical resection (when feasible) either alone, or in combination with other modalities such as embolization. Jaw resection, however, is deforming and leaves a defect often requiring subsequent reconstruction of the hard and soft tissues and replacement of any teeth lost with the resected segment. We report a surgical technique to treat mandibular arteriovenous malformations, which permits ligation of the feeding vessels and provides access allowing for complete removal of the intraosseous lesion. At the same time it not only prevents facial deformity by preserving the mandibular bone and oral soft tissue, but also, and more importantly, may preserve the dentition as well.

Treatment of mandibular asymmetry by distraction osteogenesis and orthodontics: a report of four cases.

Distraction osteogenesis devices followed by hybrid functional appliance therapy and fixed orthodontic appliance therapy were used to correct a variety of maxillofacial skeletal and dental deformities in 4 patients. The patients underwent procedures to lengthen the mandibular ramus and body. Transcutaneous pins were used to activate the distraction devices. After achieving the desired skeletal position, the distraction devices were maintained for 2 to 3 months to allow ossification. Following distraction, functional orthodontic appliance therapy was initiated during growth to correct the cant of the occlusal plane by extrusion of teeth on the affected side for improved facial symmetry. Fixed orthodontic therapy was used for final occlusal adjustments. All patients achieved lengthening of their jaws and substantial improvement in facial symmetry and occlusion. The follow-up period for this group of 4 patients ranged from 18 to 36 months.

An anatomic study of the lingual nerve in the third molar region.

PURPOSE: The aim of this study was to determine the location of the lingual nerve in the lower third molar region. PATIENTS AND METHODS: In this study, 669 nerves from 430 fresh cadavers were examined. Measurements on each cadaver were made using a micrometer caliper to determine the horizontal and vertical position of the lingual nerve in the lower third molar region. RESULTS: In 94 cases (14.05%), the nerve was above the lingual crest, and in 1 case (0.15%), the nerve was in the retromolar pad region. In the remaining 574 cases (85.80%), the mean horizontal and vertical distances of the nerve to the lingual plate and the lingual crest 2.06 +/- 1.10 mm (range, 0.00 to 3.20 mm) and 3.01 +/- 0.42 mm (range, 1.70 to 4.00 mm), respectively. In 149 cases (22.27%), the nerve was in direct contact with the lingual plate of the alveolar process. CONCLUSIONS: This study confirms the relatively unsafe position of the lingual nerve in relation to some oral and maxillofacial surgery procedures.

Experience with regional flaps in the comprehensive treatment of maxillofacial soft-tissue injuries in war victims.

This article presents our experience with regional flaps in the treatment of facial soft-tissue defects and deformities in 33 patients with various facial injuries from warfare during the period from 1986 to 1999. Thirty-two males and 1 female aged between 8 and 53 years (mean 24.18 years) were treated with facial soft-tissue injuries from high velocity projectiles and varying degrees of associated hard-tissue injuries. Bullets were the most common cause (70%), followed by injuries from shrapnel (21%), land mines (6%), and breech blocks (3%). The perioral region was involved in 15 cases (45%), the midface and cheeks were involved in 13 cases (39%), and the periorbital area was involved in 5 cases (15%). All soft-tissue injuries were treated primarily by debridement and primary closure and by combining, modifying, and tailoring standard regional flap techniques to fit the location of the injury and compensate for the extent of tissue loss. These procedures consisted basically of local-advancement or rotation-advancement flaps, used in conjunction with pedicled fat or subcutaneous supporting flaps, nasolabial, cheek, cervical, Dieffenbach, and Abbe-type flaps. Scar revision, tissue repositioning, and lengthening procedures, such as W, V-Y, Z, or multiple Z-plasty techniques were also used both primarily and secondarily. Revisions and secondary operations were done in 48% of the patients. Initial healing of the flaps was favourable in 76% of the patients. Postoperative discharge from the suture sites was seen in 24% of the patients, but this usually resolved within several weeks using daily irrigation, and these cases underwent scar revision subsequently. None of the soft-tissue flaps sloughed or developed necrosis. Form and function of the soft-tissue reconstructed regions usually recovered within one year postoperatively. The aesthetic results obtained were favourable. None required facial nerve grafting as only the terminal branches were injured in our cases and functional recovery was acceptable. Application of local tissue transfer procedures in our series of facial warfare injuries yielded acceptable tissue form, texture, and colour match, especially when these procedures were used in combination, and tailored to surgically fit the individual case. Moreover, application of these procedures is relatively easy and postoperative morbidity is limited, provided the general condition of the patient is stable, and the surgical techniques used have good indications and flap principles.

Use of activator appliances in pediatric patients treated with costochondral grafts for temporomandibular joint ankylosis: analysis of 13 cases.

PURPOSE: The long-term outcomes and clinical results of costochondral transplants used for the treatment of condylar ankylosis of the mandible in children with and without application of postoperative activator appliances are evaluated and compared. MATERIALS AND METHODS: A nonrandomized, retrospective clinical study of 13 cases of condylar ankylosis (16 joints) of the mandible surgically treated during a 9-year period from 1988 to 1997 was performed. All 13 patients were treated by condylectomy and immediate costochondral rib grafts. Nine of these patients underwent long-term postoperative therapy using removable activator appliances. Four patients did not undergo activator therapy postoperatively. Casts, radiographs, photographs, computed tomography (CT) scans, magnetic resonance imaging (MRI) and 99Tc bone scans were used postsurgically to evaluate graft take, condylar growth and function, occlusion, and facial and condylar symmetry. RESULTS: The postoperative and long-term clinical results in both groups showed costochondral growth center transplants to be effective in restoring mandibular growth of the affected side. However, symmetry, arch coordination, correction of occlusal canting, mandibular deviation, facial growth, and prevention of reankylosis were obtained and better controlled only in those cases that underwent long-term orthodontic activator therapy postoperatively and were followed closely. CONCLUSIONS: Children with long-standing condylar ankylosis of the mandible and its resultant facial asymmetry and occlusal canting (secondary to a nonfunctional joint and maxillary compensation) treated with condylectomy and immediate costochondral rib graft reconstruction of the affected joint were treated more favorably when activators were used postsurgically. The patients that failed to comply with or continue activator therapy postsurgically developed complications relating to mandibular deviation, occlusal dysharmony, asymmetry and, in one case, reankylosis of the temporomandibular joint (TMJ).

Reconstruction and rehabilitation of short-range, high-velocity gunshot injury to the lower face: a case report.

War injuries can range from the most minor to the devastating and life-threatening. Multidisciplinary care is required for successful management of survivors. In the acute phase, care may involve emergency surgeons, anaesthetists, neurosurgeons, ophthalmic surgeons, vascular surgeons and ENT specialists in addition to the oral and maxillofacial surgeon. Afterwards, definitive treatment of facial hard and soft tissue gunshot injuries depends ultimately on the abilities and skills of the oral and maxillofacial surgeon and his appreciation of such injuries. The timing and sequence of the surgical procedures used for reconstruction and rehabilitation of maxillofacial gunshot injuries are crucial to a successful outcome and aesthetic result. If incorrect, they may lead indefinitely to infection, graft rejection, wound dehiscence with consequent multiple revisional operations and complications which will prolong hospital stay, and increase treatment costs and morbidity in these patients. In this article, we describe the treatment protocol for reconstruction and rehabilitation of a typical case of devastating gunshot injury to the lower face and propose a staged sequence of surgical treatment based on an 8-year experience gained in treating war casualties during the Iraq-Iran war (1980-1988).