Medical necessity of orthognathic surgery for the treatment of dentofacial deformities associated with temporomandibular disorders.

This retrospective study assessed the medical necessity of orthognathic surgery for the treatment of dentofacial deformities associated with temporomandibular joint disorders from a perspective of cost effectiveness, myofascial and masticatory function, and quality of life. Questionnaires were mailed to 385 orthognathic surgical patients from one oral and maxillofacial surgery practice. Each questionnaire consisted of three sections: medical costs associated with the patient's orofacial symptoms, symptoms associated with the patient's condition, and the patient's quality of life. One hundred fifty patients responded to the questionnaire. On average, patients spent less money per month on costs associated with their orofacial problem after surgery, and there were fewer visits to the doctor postoperatively. All temporomandibular symptoms were significantly reduced postoperatively, with the exception of facial pain. Quality of life also showed improvement postoperatively. Although orthognathic surgery may be of slightly greater benefit to specific groups of patients based on occlusal relationship and age, all patients in this study showed significant postoperative improvement.

Average blood loss and the risk of requiring perioperative blood transfusion in 506 orthognathic surgical procedures.

PURPOSE: This study quantifies the estimated blood loss in seven groups of orthognathic surgical procedures and the risk of requiring perioperative blood transfusion, and identifies the factors relating to blood loss and need for transfusion. PATIENTS AND METHODS: The records of 506 consecutive patients who underwent various orthognathic surgical procedures under hypotensive anesthesia from 1987 to 1990 were analyzed retrospectively. All procedures were performed by the authors in the same hospital setting. Patients were placed in seven groups based on the operation(s) performed, including single-jaw and double-jaw procedures. Estimated blood loss was calculated for each group and was correlated with patients' sex, age, and year of surgery, and whether they autodonated blood. The volume of intravenous (IV) fluids given was also recorded. RESULTS: Average estimated blood loss for all groups was 273.23 mL. Double-jaw procedures resulted in more blood loss than single-jaw procedures. Men and boys had a higher average blood loss than women and girls, but average blood loss was not affected significantly by patients' age or year of surgery. Only four patients (0.8%) received blood transfusions, and their average estimated blood loss was 975 mL. The percentage of patients autodonating increased from 10.4% in 1987 to 54.9% in 1990. There was no significant difference in the percentage of autodonators by surgical procedure. CONCLUSIONS: The need for blood transfusion in this study was extremely low. Factors contributing to this are believed to be use of hypotensive anesthesia; a single surgical team; and a constant surgical setting. Patients having double-jaw surgery are at greater risk for blood loss than those having single-jaw procedures, and should be so advised, along with the risks of blood transfusion. The authors believe that under the conditions of this study the use of autodonation is not necessary, with the possible exception of complex double-jaw procedures involving small patients.

Utilization of 3-D computer tomographs in oral surgery.

Imaging is essential in the diagnosis and treatment of maxillofacial abnormalities. CT scans are but one type of imaging studies available to the practitioner. Computers have recently enhanced the traditional CT scan so that it can now be viewed in a three-dimensional reconstruction. Essentials of 3-D imaging and its uses will be presented by the authors, with various case reports to illustrate their value in the dental office.

Comparison of relapse in bilateral sagittal split osteotomies for mandibular advancement: rigid internal fixation (screws) versus inferior border wiring with anterior skeletal fixation.

A retrospective study of 28 patients treated by bilateral sagittal split ramus osteotomies for mandibular advancement and stabilized by two different methods of fixation was performed. Fourteen patients received rigid fixation, and 14 patients had inferior border wiring with anterior skeletal fixation. The postoperative and long-term cephalograms (greater than 6 months) were analyzed in a horizontal and vertical direction for relapse. In the horizontal direction, the rigid group experienced a 1.5% relapse in point B and a 3.2% relapse in pogonion. In the vertical direction, the rigid group experienced a 4% relapse in point B and a 9% relapse in pogonion, while the wire osteosynthesis group had a 13% relapse in point B and a 6% relapse in pogonion. These results support the belief that rigid fixation is more stable than is wire osteosynthesis and that it helps prevent relapse in the long-term results.

Early screw removal for correction of occlusal discrepancies following rigid internal fixation in orthognathic surgery.

Occlusal discrepancies that occur after orthognathic surgery in which rigid internal fixation was used are technically difficult to correct. These discrepancies often lead to prolonged postoperative orthodontics and possibly to compromised results. The effectiveness of the removal of rigid internal fixation in correcting these changes was studied retrospectively. Of 169 patients who underwent bilateral sagittal osteotomies of the mandible, 13 developed postoperative malocclusions, and their rigid internal fixation was removed (an average of 21 days postoperatively). Occlusion was improved in 11 of the patients. In the two patients who showed no improvement in occlusion, fixation had been removed at 5 weeks in one and at 6 weeks in the other. One patient had a slight relapse 6 months postoperatively. All other patients had stable occlusions and experienced no complications. Recommendations for use of the technique and potential complications are discussed.

Diagnosis and treatment planning for mandibular subapical osteotomies with new surgical modifications.

Mandibular anterior subapical osteotomies have been used for many years and have usually included vertical interdental osteotomies and submandibular horizontal osteotomies stabilized with intraosseous wires, splints, and bridle wires around the teeth adjacent to the interdental osteotomies. This article presents pertinent diagnostic criteria, orthodontic and surgical treatment planning considerations, and new surgical modifications to alter the position of the mandibular anterior teeth.

The microbiology and chemotherapy of odontogenic infections.

This article reviews the complexity of the microbiological environment of odontogenic infections. With an understanding of the organisms involved, the appropriate antibiotic can be chosen. A review of current antibiotic choices and the rationale for their selection is also presented.

Chin augmentation with various alloplastic materials: a comparative study.

This retrospective study of 62 patients compared three alloplastic materials used in chin augmentation: Proplast I (PI), Proplast II (PII), and porous block hydroxyapatite (PBHA). There were 25 patients with PI implants (average follow-up of 44.8 months), 25 patients with PII implants (average follow-up of 32.8 months), and 12 patients with PBHA implants (average followup of 19.1 months). Average bone resorption was 1.25 mm (range 0.00 to 3.30 mm) beneath the PI and PII implants and 0.00 mm beneath the PBHA implants. Average posterior settling was 0.46 mm (range 0.00 to 2.00 mm) for the PI and PII implants and 0.03 mm (range 0.00 to 0.17 mm) for the PBHA implants. The percentage of soft tissue change at pagonion relative to the size of the implant was 83.0% (range 66.7% to 100.0%) for PI and PII and 86.8% (range 77.3% to 100.0%) for the PBHA implants. When PI or PII implants were used, younger patients had more resorption than older patients. Slightly more resorption was found with PI and PII implants when maxillary surgery was performed. The size of the PI or PII implants made no difference in the amount of bone resorption, although there was slightly less soft tissue change when larger implants were used. Males had slightly more bone resorption than did females. The bone resorption beneath the PI and PII implants occurred within the first 12 months postsurgery. It can be concluded from this study that PI and PII implants are acceptable materials for chin implants, but some resorption can be expected during the first 12 months postsurgery. The absence of detectable resorption and the excellent soft tissue change make PBHA an attractive alternative as a chin implant material, although it is technically more difficult to use.

Coralline porous hydroxyapatite as a bone graft substitute in orthognathic surgery: 24-month follow-up results.

A 24-month postsurgical follow-up evaluation was performed on 49 patients (20 males and 29 females; mean age 26 years [range 9 to 52 years]) who had undergone orthognathic surgery in which coralline porous block hydroxyapatite (PBHA) was used as a bone graft substitute. Followup ranged from 23 to 45 months (average 27 months). One surgeon implanted all 215 blocks: 189 blocks to the maxilla, 19 blocks to the mandible, and seven blocks to the midfacial region. Of the 215 implants, 135 were positioned directly adjacent to the maxillary sinus. Nine patients had postsurgical complications: three developed sinusitis, which was treated with antibiotics and decongestants, four had midpalatal implants exposed intraorally during surgery that later required removal, one had a slight displacement of a mandibular implant that has remained in place, and one had an interdental implant exposed that was recontoured and covered with tissue. At the 24-month followup or later, only one of the 49 patients had complications or symptoms associated months postsurgery. These results strongly support the use of coralline PBHA along with bone plate fixation to provide predictable stability in orthognathic surgery.

Elimination of mandibular labial undercut with autogenous bone graft from a maxillary tuberosity.

A brief review of various grafts and implants that may be used to eliminate labial undercuts was described. A technique for elimination of the mandibular labial undercut with autogenous bone from the maxillary tuberosity was presented.