Gender-dependent impact of aging on facial proportions.

PURPOSE: Facial proportions in younger people have been evaluated in several studies. However, the number of older people who need orthognathic surgery is growing steadily. The aim of this study was to evaluate facial morphology in Caucasians accounting for age and gender. METHODS: Three-dimensional facial scans of 240 healthy volunteers were taken. The subjects were divided into males and females, then into three groups by age (21-35, 36-50 and 51-65 years). Landmarks and artificial planes were placed in the scans. Distances, relations and angles between them and the artificial frontal plane were recorded. RESULTS: Nearly all distances between the tragion and the landmarks in the middle of the face increased with the age of the volunteers. Therefore, the soft tissue of the face grows horizontally with increasing age. Also, the length of the upper lip increased with age. The percentage of subnasale-stomion and stomion-menton distances of the total subnasale-stomion-menton measurement changed significantly (men: p = 0.149; women: p < 0.001) during aging in females but not in males. The landmarks in the upper and middle third of the face were closer to the frontal plane in women than in men. CONCLUSION: Using the created frontal plane for evaluating landmarks in the sagittal plane facilitates measuring positions of soft tissue. There are significant changes in distances, angles and relations during aging which can be very important for planning orthognathic surgery.

A non-language-specific speech test to evaluate the speech of cleft patients from different language and cultural backgrounds - A pilot study.

Cleft speech tests are not universally available. We developed a tool to fill this gap, especially in the context of a cleft mission setting. We performed a pilot study to evaluate the test's ability to differentiate between the speech of cleft patients and healthy individuals from three different language backgrounds. We used 78 made-up, nonsensical syllables to evaluate hypernasality, nasal emissions, and consonant errors. Cleft (n = 41) and non-cleft (n = 39) individuals from three countries were included in this study. Two speech and language pathologists, blinded to the examination, rated the audio recording independently. Patients from Germany (n = 12; mean age 15.2), Iran (n = 14; mean age 7), and India (n = 15; mean age 14.7 years) were evaluated. We observed a significant difference in each category (p < 0.05) between patients and control subjects of the same language and cultural background. Hypernasality was affected the most. The test proved to possess the correct phonetic characteristics to reveal and provoke relevant cleft speech pathologies independent of cultural and language backgrounds. The test sounds posed no articulatory difficulties to non-cleft individuals, with some exceptions regarding non-specific consonant errors. A comparison with other existing tests will further illuminate its value as a speech test.

Use of anterior maxillary distraction osteogenesis in two cleft lip and palate patients.

Distraction osteogenesis (DO) has become a mainstream surgical technique for patients with jaw deformities. The aim of this study was to report the effect of DO done by a hyrax screw incorporated in an acrylic plate in the treatment of two maxillary deficient cases with cleft lip and palate. Two patients, a 24-year-old female and a 29-year-old male who suffered from maxillary deficiency and cleft lip and palate, were treated by DO. After making vertical cuts between the premolars on both sides and horizontal cuts similar to Le Fort 1, a hyrax screw was mounted on an acrylic plate for the slow anteroposterior expansion of maxillary arch. The expansion was achieved by turning the hyrax screw 0.8 mm per day after the latency period. Treatment was discontinued after achieving satisfactory over jet and occlusion. This study showed that anterior maxillary distraction is a reliable technique for correction of midfacial deformity arising out of cleft lip and palate. Incidences of complications are negligible compared to total maxillary distraction.

Effect of maxillary advancement on the change in the soft tissues after treatment of patients with class III malocclusion.

The aesthetic outcome of treatment has become increasingly important to patients having orthognathic surgery. The aim of this observational cohort study based on clinical records was to evaluate the effect of maxillary advancement on changes to the soft tissues. We studied 53 patients with class III malocclusion (29 women and 24 men, mean (SD) age 28 (11) years). We identified all patients treated between 1 January 2002 and 30 December 2013 who could be monitored postoperatively for 6 months. To study the effect of maxillary advancement on changes to the soft tissue we distinguished between patients who had had less than 6mm, and those with 6mm advancement or more. In those who had had less than 6mm, we found no significant changes in the soft tissue in the region of the nasolabial angle. However, the lip-chin- throat angle (p=0.016), cervical length (p=0.002), lower lip (p=0.007) and upper lip distance (p=0.0001) from the aesthetic line changed significantly. On the other hand, the changes to the soft tissue in the submental and nasolabial regions were significant in patients with 6mm advancement or more, and indicated a clear improvement in the aesthetic outcome of this region. This aesthetic change for the good in the submental and nasolabial regions after maxillary advancement of 6mm or more should be considered when planning treatment, and reduction in the mandibular setback will reduce the risk of development of a double chin.

The short-term effects of face mask and fixed tongue appliance on maxillary deficiency in growing patients--a randomized clinical trial.

BACKGROUND: The purpose of this single blind, prospective, parallel randomized trial study was to compare the effects of face mask and fixed tongue appliance in treatment of Class III malocclusion with maxillary deficiency in growing patients. METHODS: 88 patients with maxillary deficiency were selected. 60 fulfilled the study requirements. The patients were randomly assigned to 2 groups by computer generated tables. One group was treated with removable face mask and the other group was treated by fixed tongue appliance. 4 of the patients dropped out of study leaving a final number of 56 patients. Thus, the face mask group included 30 patients (13 males, 17 females) with the mean age of 8.5 (SD 1.4) years and the fixed tongue appliance group included 26 patients (13 males, 13 females) with the mean age of 8.9 (SD 1.7) years. The patients Lateral cephalograms obtained at the beginning and end of the study were analyzed. RESULTS: Paired t-tests showed that SNA increased by 1.3° (SD 1.1°) in face mask group (P<0.001) and it increased by 1.8° (SD 0.9°) in fixed tongue appliance group (P<0.001). T-test showed that there were no statistically significant differences between the two groups except for SNB. IMPA decreased significantly in both groups. CONCLUSIONS: Both treatment modalities were successful in moving the maxilla forward and improving the profile of the patients; however, the bulky size of face masks might reduce patients' compliance and make them less favorite choice of treatment.

Use of aesthetic rhinoplasty procedures in reconstructive nasal surgery.

Resection of cancer often involves the excision of underlying hard tissue, and some procedures in aesthetic rhinoplasty can be used in reconstructive nasal surgery to increase the margin of safety while still achieving an acceptable aesthetic and functional outcome. We have used techniques from aesthetic rhinoplasty to shape the nasal framework. Osteotomy and formation of the tip were used in 17 patients with defects (ranging from 1 to 3.5 cm in size) from the nasal root to the tip of the nose. After the underlying bony or cartilaginous framework, or both, had been removed, the resulting open roof deformity had to be corrected by osteotomy of the bony nasal wall and the tip shaped by excision and suturing, including insertion of the tip graft and columellar strut graft. After this, and narrowing of the nose, the defect was smaller and could be closed with local tissue without tension. There were no deformities in the contour, and patency of the airway was maintained. Patients were satisfied with both the aesthetic and functional results. Although the margin of safety was increased, shaping the nasal framework reduced the size of the defect, which allowed tension-free closure with a local flap. The operation requires a thorough knowledge of procedures used in aesthetic rhinoplasty.

Noninvasive 3-dimensional evaluation of periorbital asymmetry in isolated unilateral orbital floor fractures.

OBJECTIVE: The study was carried out to evaluate the degree of asymmetry between the injured and contralateral periorbital region in isolated orbital floor fractures after surgery. STUDY DESIGN: The periorbital asymmetry of 35 patients with medium-sized orbital floor fractures that were surgically treated with alloplastic resorbable implants was evaluated and compared with that of a healthy control group using an optical 3-dimensional facial scanner. Distance measurements between facial surface landmarks, as well as volume measurements between the original image and an automatically generated mirror image, were performed using commercially available software. RESULTS: There were no statistically significant differences in the distance measurements (P > .05) and volume measurements (P > .05) within the groups or when the study group and control group were compared using the Student t test. CONCLUSIONS: Alloplastic resorbable implants can restore medium defects of the orbital floor without significant periorbital asymmetry. Automatically constructed mirror images can be a helpful tool for detecting asymmetries in faces.

Soft-tissue changes associated with different surgical procedures for treating class III patients.

OBJECTIVE: The aim of this study was to evaluate the effects of different surgical procedures on soft tissue and skeletal changes. PATIENTS AND METHODS: Pre- and postoperative lateral cephalograms of 191 class III patients aged 16-58 years were retrospectively analyzed and divided into three groups according to the surgical therapy they had undergone. Group I had undergone maxillary advancement (n=51), group II a bimaxillary (n=102) procedure, and group III mandibular setback (n=38). Cephalometric assessments were made at the beginning of orthodontic treatment (T1) and at least 8 weeks after surgical correction of the class III malocclusion (T2). Nasolabial angle and the distance between the lower lip and the esthetic line were evaluated as soft-tissue parameters, while the skeletal parameters included the SNA and SNB angles, Wits value, gonial angle, and relative position of the maxilla to mandible. Mean values and standard deviations were calculated and any significant difference between soft and hard tissue in association with surgery methods was determined applying the Wilcoxon test using SAS statistical software. RESULTS: Compared to mandible setback, the number of bimaxillary procedures and maxilla advancements has increased significantly in recent years (0.04). SNA values measured at T2 were an average of 84° in group I, 83° in group II, and 82° in group III, thus, revealing a tendency to return to the normal range. SNB values measured at T2 averaged 81° in group I, 80° in group II, and 81° in group III. We observed significant changes in the nasolabial angle according to the surgical approach taken (p=0.018). Changes in the distance between the lower lip and the esthetic line were only slightly significant (p=0.050). No significant differences were noted among the surgical approaches in terms of SNA and SNB angles. CONCLUSION: The two groups that underwent advancement of the maxilla (groups I and II) revealed marked improvements in soft-tissue esthetics.

The accuracy of computer-assisted primary mandibular reconstruction with vascularized bone flaps: iliac crest bone flap versus osteomyocutaneous fibula flap.

BACKGROUND: The intention of mandibular reconstruction is to restore the complex anatomy with maximum possible functionality and high accuracy. The aim of this study was to evaluate the accuracy of computer-assisted surgery in primary mandibular reconstruction with an iliac crest bone flap compared with an osteomyocutaneous fibula flap. MATERIALS AND METHODS: Preoperative computed tomography data of the mandible and the iliac crest or fibula donor site were imported into a specific surgical planning software program. Surgical guides were manufactured using a rapid prototyping technique for translating the virtual plan, including information on the transplant dimensions and shape, into real-time surgery. Using postoperative computed tomography scans and an automatic surface-comparison algorithm, the actual postoperative situation was compared with the preoperative virtual simulation. RESULTS: The actual flap position showed a mean difference from the virtual plan of 2.43 mm (standard deviation [SD] ±1.26) and a surface deviation of 39% <2 mm and 15% <1 mm for the iliac crest bone flap, and a mean difference of 2.18 mm (SD ±1.93) and a surface deviation of 60% <2 mm and 37% <1 mm for the osteomyocutaneous fibula flap. The position of the neomandible reconstructed with an osteomyocutaneous fibula flap indicated a mean difference from the virtual plan of 1.25 mm (SD ±1.31) and a surface deviation of 82% <2 mm and 57% <1 mm, in contrast to a mean difference of 1.68 mm (SD ±1.25) and a surface deviation of 63% <2 mm and 38% <1 mm for the neomandible after reconstruction with an iliac crest bone flap. For shape analysis, a similarly high accuracy could be calculated for both flaps. CONCLUSION: Virtual surgical planning is an effective method for mandibular reconstruction with vascularized bone flaps, and can help to restore the anatomy of the mandible with high accuracy in position and shape. It seems that primary mandibular reconstruction with the osteomyocutaneous fibula flap is more accurate compared with the vascularized iliac crest bone flap.

Consideration of effect of the amount of mandibular setback on the submental region in the planning of orthodontic-orthognathic treatment.

Aesthetic outcome has gained in importance in the treatment of patients with orthognathic problems. Historically, Class III malocclusions have historically been treated by isolated mandibular setback and maxillary advancement, whereas bimaxillary procedures have recently become the more common option. Functional outcome and stability have been discussed previously. The aim of this observational study was to evaluate the effect of mandibular setback (BSSO) on the cervical region. We studied 38 Class III patients (20 women and 18 men, mean (SD) age 25 (0.8) years) who we identified from our clinical records and who were treated between 1 January 2002 and 30 December 2012 with mandibular setback procedures and followed up for 6 months. To study the effect of the amount of mandibular setback on the aesthetic outcome we have distinguished between patients with less than 5mm setback and those with 5mm or more. In patients whose mandibular setback was less than 5mm there was no significant change in cervical length. However, it decreased significantly in patients in whom the movement was 5mm or more. Postoperatively the lip-chin-throat angle (p=0.02), the length of the lower lip (p=0.002), and the length of the upper lip (p=0.003) from the aesthetic line also differed significantly between the 2 groups. Our observations strongly suggest that all these relations should be considered when treatment is being planned to avoid an unpleasant aesthetic impact on the chin region.

Evaluation of soft and hard tissue changes after bimaxillary surgery in class III orthognathic surgery and aesthetic consideration.

AIMS: The aim of this study was to evaluate hard and soft tissue change after bimaxillary surgery in class III patients by focusing on sella, nasion, A point (SNA) and sella, nasion, B point (SNB) angle and aesthetic outcome. MATERIALS AND METHODS: The sample consisted of 96 skeletal Class III patients (42 women, 54 men) with a mean age of 25 years with standard deviation (SD) of 8.4. The youngest patient was 16-years-old and the oldest 51-years-old at the time of surgery. In total, seven skeletal parameters, eight soft tissue parameters, and two dental parameters were evaluated on the cephalograms. RESULT: At the beginning of the treatment 49 Patients had SNA between 80° and 84°, 34 had SNA of less than 80° and 13 had SNA of more than 84°. Post surgically, 25 patients had SNA of 78°-84°, 19 had SNA less than 78° and 52 patients had SNA of more than 84°. Out of 96 patients 22 had SNB of 78°-82° before surgery, 16 had less than 78° and 58 had SNA of more than 84°. Postoperatively, we measured SNB of 78°-80° in 42, less than 78° in 18 and of more than 82° in 36 patients. The inclination of the maxilla relative to the cranial base changed from 7.2° (SD = 4)-8° (SD = 5.1) and the mandible changed from 35.7° (SD = 6.6) to 36° (SD = 6.3) postoperatively which was not significant. The distance from upper lip to E-line increased by 2.6 mm (SD = 3.9) after surgery (P < 0.001), while, the lower lip distance to E-line decreased slightly by 0.9 mm (SD = 3.2) (P < 0.01). Nasolabial angle was decreased by 9.5° (SD = 9.4) after surgery (P < 0.001). The nose prominence also decreased from 18.2 mm (SD = 3.5) -16.5 mm (SD = 3.3). CONCLUSION: Although in many cases we did not have a SNA angle or SNB angle in normal range but a good aesthetic outcome have been observed. Consequently our study showed that soft tissue change and aesthetic aspects should be considered in surgical planning and achieving SNA angle or SNB angle of norm range should not be the only goal. As we could show the advancement of maxilla will result in a better lip and nose profile and this should be considered in treatment planning.

Maxillary deficiency treatment by fixed tongue appliance--a case report.

This case illustrates orthopaedic treatment of a 12.1-year-old girl with class III malocclusion and maxillary deficiency. The patient was treated by a fixed tongue appliance in the upper jaw. First maxillary molars and premolars were banded and a hyrax was mounted on them in order to achieve lateral expansion. A fixed tongue appliance comprising of a few cribs was soldered to the anterior side of the hyrax with the purpose of pushing the maxilla in forward position. The orthopaedic stage of treatment lasted for 5 months after which favourable correction of the malocclusion was observed. The SNA angle increased by 2 degrees, the IMPA decreased by 10 degrees and mandibular plane angle (GoGn-SN) increased by 20. After this time, the fixed tongue appliance and Hyrax remained in the mouth for 3 more months as retention. This case demonstrates that fixed tongue appliance might be an alternative method to extra oral appliances in class III and maxillary deficient cases.

Functional long-term results after the harvest of vascularised iliac bone grafts bicortically with the anterior superior iliac spine included.

The aim of this study was to evaluate the postoperative morbidity at the donor site and the long-term outcome after the harvest of bicortical iliac bone grafts, including the iliac crest and the anterior superior iliac spine (ASIS), by using a confirmed score. We retrospectively examined 54 consecutive patients who had had vascularised iliac bone grafts harvested to reconstruct different parts of the mandible. We used the Harris Hip Score to evaluate objectively the long-term postoperative morbidity at the donor site. Of 54 patients, 20 were female (37%) and 34 male (63%), with a mean age of 49 years (range 12-81). The causes of the bony defects were malignancy (n=37, 69%), benign tumours (n=7, 13%), osteomyelitis (n=9, 17%), and atrophy of the alveolar ridge (n=1, 2%). All transplants healed adequately. A total of 38/52 patients (73%) had a score of more than 80 points, which defines clinical success. Vascularised iliac bone grafts offer excellent bony dimensions with optimal shape to be used for reconstruction of different parts of the mandible. They can be harvested bicortically, including the iliac crest and the ASIS, with acceptable morbidity at the donor site. The Harris Hip Score is an appropriate tool for the evaluation of long-term impairment at the donor site after the harvest of vascularised iliac bone grafts, and it could be used to compare the results of different studies.

The effects of facemask and reverse chin cup on maxillary deficient patients.

INTRODUCTION: The aim of this randomized clinical trial was to assess differences in the effects of face mask and reverse chin cup therapy on maxillary deficient growing patients. METHODS: The sample consisted of 42 class III patients with maxillary deficiency randomly divided into two equal groups. Twenty-one patients (10 males and 11 females) with a mean age of 8.9 (SD: 1.4) years were treated with a face mask for 18 (SD: 2) months. Twenty-one patients (9 males and 12 females) with the mean age of 9.2 (SD: 1.1) years were treated with a reverse chin cup for 19 (SD: 4) months. Cephalometric radiographs were taken at the beginning and end of treatment and the cephalometric measurements were analysed. Paired t-tests and a Wilcoxon test were used for intra-group evaluations. Mann-Whitney test was used for inter-group evaluations. RESULTS: Sella-Nasion-A point (SNA) was increased by 1° (SD: 1.7°) (P<0.003) and 1.8° (SD: 1.7°) (P<0.001) in the face mask and reverse chin cup groups, respectively. The IMPA decreased by 4.1° (SD: 6.5°) in face mask group (P<0.009) and 3.1° (SD: 4.7°) in the reverse chin cup group (P<0.008). However, no statistically significant differences were seen in changes between the two groups. CONCLUSION: Both face mask and reverse chin cup appliances are successful at moving the maxilla forward.

Bone remodeling to correct maxillary deficiency after growth cessation.

This case report presents a 22-year-old girl with class III malocclusion due to maxillary deficiency. The patient was referred for presurgical orthodontics; however, she rejected the surgery. This case was treated by means of Tongue appliance and slow palatal expansion, followed by lower fixed appliance, reverse chin cup, and upper fixed appliance. Tongue appliance and slow palatal expansion were used at the beginning of the treatment. After 6 months, reverse chin cup and lower fixed appliance were added. Six months later reverse chin cup was removed and upper fixed appliance was mounted. Positive overbite and over jet were achieved after 24 months of active treatment. Nasolabial angle also showed improvement. Nonsurgical treatment of adult class III patients is a difficult procedure; however, this patient was treated nonsurgically.

Orthodontic treatment after autotransplantation.

Autotransplantation is an alternative method to replace a missing tooth. This study reports a 17-year-old man who had autotransplantation of the left upper third molar with the congenitally missing left lower second premolar. No signs of inflammation, root resorption, ankylosis, mobility, sensitivity, pocket problems, or pulp destructions were found after 2-year follow up. Autotransplantation can lead to shorter treatment time and an improved treatment result in certain cases. It also eliminates the need for implants or prosthetic therapy.

Comparison of donor-site engraftment after harvesting vascularized and nonvascularized iliac bone grafts.

PURPOSE: The objective of this study is to characterize the donor-site morbidity after harvesting of nonvascularized and vascularized iliac bone grafts. PATIENTS AND METHODS: Clinical data of 353 patients were collected for analysis. In addition, a questionnaire was sent to all patients asking about their perceptions of different parameters. In an individual age-matched layout, we compared 34 patients with nonvascularized iliac bone grafts with 34 patients with vascularized iliac bone grafts. RESULTS: Transplantation of vascularized bone grafts has been increasingly performed at our institution. The mean age was 41.5 years in the nonvascularized group and 48.6 years in the vascularized group. The main reason for the bony defect in the vascularized group was malignancy. The majority of postoperative functional problems were observed in obese patients. No patient had serious or long-term complications at the donor site. The amount of bone graft taken affected postoperative sensitivity disturbance and caused postoperative functional problems and pain. CONCLUSIONS: We conclude that the iliac crest is a suitable site for harvesting both vascularized and nonvascularized bone grafts measuring up to 10 x 3 cm. For larger defects that require a larger bone graft, a vascularized bone graft is more suitable with a better predictable healing capability. No significant differences in donor-site morbidity were found between the vascularized and nonvascularized bone grafts if a similar amount of bone was taken for transplant.