Effects of the multiple-piece maxillary osteotomy on the periodontium.

Clinical indications exist for both the surgically assisted rapid maxillary expansion (SARME) and the multiple-piece maxillary osteotomy (MPMO). Recent trends, however, imply that the SARME combined with a subsequent 1-piece osteotomy can supplant the use of the MPMO. Those favoring the SARME frequently site morbidities associated with the MPMO. Major reported complications include loss of dentoalveolar segments, teeth, and oronasal or oroantral communication. Relapse, tooth devitalization, and damage to the periodontium, including bone loss and soft tissue alteration, comprise the minor morbidities. If these can be avoided or minimized, then the use of the MPMO for its inherent advantages over the SARME in certain clinical situations may be indicated The purpose of our study was to critically evaluate the periodontium following the use of the MPMO to ascertain if minor morbidities are inherent to the procedure, and to quantify them. Records of 24 MPMO patients were reviewed, ranging from 3 to 24 months after surgery. A specific surgical technique was utilized for all patients, including bone grafting. The vertical segmental osteotomy sites varied and were recorded for comparison. Periodontal probing depths at the segmental osteotomy sites were compared with the adjacent interproximal spaces of each patient. Independent dental examiners were used to review photographs and periapical radiographs to compare the papillae and alveolar bone height, respectively, at the osteotomy site versus the neighboring interproximal areas. A paired t test was used to compare probing depth measurements at the vertical osteotomy site and neighboring interproximal sites. The mean difference between these two sites was 0.01 mm with a standard deviation of 0.25 mm. This was not statistically significant. Statistical analyses were also performed to compare these probing depth differences at varying sites in the maxilla, and to compare probing depth differences to gender, total number of osteotomies performed on each patient, estimated blood loss, and length of procedure. These results were not statistically significant. Independent examiners found no difference in gingival architecture or alveolar bone levels when comparing vertical osteotomy sites to neighboring interproximal sites. This study showed that damage to the periodontium at vertical osteotomy sites was minimal, and not a reason to avoid use of the multiple-piece maxillary osteotomy.

Evaluation of profile esthetic change with mandibular advancement surgery.

Our purpose was to investigate the impact of mandibular advancement surgery on profile esthetics and to attempt to define guidelines that could be of value to the clinician in predicting profile esthetic change. The sample consisted of 34 patients who had been treated with a combination of orthodontics and mandibular advancement surgery without genioplasty. Initial (pretreatment) and final (posttreatment) cephalometric radiographs of each patient were used to produce silhouette images and to quantify skeletal changes that occurred with surgery. The images were displayed randomly to lay persons and orthodontic residents who were asked to score the esthetics of each profile. On average, after mandibular advancement surgery, B point moved forward 5.0 mm (SD = 2.6 mm) and downward 4.7 mm (SD = 3.1 mm), and the ANB angle decreased 3.0 degrees (SD = 1.6 degrees ) Graphical analysis and results of paired t tests revealed that for patients with an initial ANB angle >/= 6 degrees, a consistent improvement in profile esthetics was seen following surgery (P

A comparative study of osseointegration of titanium implants in autogenous and freeze-dried bone grafts.

PURPOSE: This study was undertaken to compare the rate and degree of osseointegration of dental implants when placed into either autogenous corticocancellous chip or freeze-dried corticocancellous chip bone grafts. MATERIALS AND METHODS: The canine ilium was used as the model site. Thirty experimental and 15 control implants were placed in 15 dogs: autogenous versus freeze-dried corticocancellous chip bone grafts around the exposed implant surfaces. In addition to the placement of control implants, the apical portion of the grafted implants acted as their own control. The implants were harvested at 1, 2, and 3 months. The evaluation of the integration process was performed by means of light microscopy, microradiography, and histomorphometry. RESULTS: Using this model, the results indicate that at 1 month there was no statistical difference in the degree of osseointegration in the two bone grafts. At 2 months, there was a statistically greater degree of osseointegration noted in the autogenous corticocancellous chip sites than in the freeze-dried bone grafts. At 3 months, the degree of osseointegration in the two groups was 70% and 33%, respectively. At 3 months, there was virtually 100% integration with trabecular bone at the control implant sites. CONCLUSION: The results indicate that at 2 months postoperatively implants placed in an autogenous bone chip graft osseointegrate to a significantly greater degree than implants placed in a freeze-dried bone chip graft, and this difference remains at 3 months.

Titanium osseointegrated implants combined with hyperbaric oxygen therapy in previously irradiated mandibles.

STATEMENT OF PROBLEM: Treatment for head and neck malignancies commonly involves radiation therapy. As a result of this therapy the vascular supply to irradiated structures is altered and results in decreased tissue perfusion. In addition to vascular changes, bony structures undergo a reduction in osteoblastic and osteoclastic activity. These tissue alterations, especially in the mandible, enhance the risk of osteoradionecrosis. To avoid this occurrence, many patients who have undergone radiation therapy do not receive elective preprosthetic surgeries, including implant therapy. PURPOSE OF STUDY AND METHODS: This report presents the preliminary results of placing 18 titanium screw implants into previously irradiated mandibles in conjunction with hyperbaric oxygen therapy. RESULTS: Of the 18 implants placed, 17 (94%) were judged to be osseointegrated at the abutment connection. One implant did not receive an abutment and was "put to sleep." The remaining 16 (88%) were used for prosthetic rehabilitation. CONCLUSION: The use of implants in irradiated tissues may provide a means of enhancing prosthetic rehabilitation while reducing the risk of tissue trauma that may develop into osteoradionecrosis.

Genioplasty strategies for anterior facial vertical dysplasias.

The influence of anterior mandibular height is often overlooked when planning treatment of facial vertical excess or deficiency. Although treatment decisions tend to focus primarily on Le Fort I maxillary osteotomies, genioplasty remains a useful adjunctive surgical procedure. Components of anterior facial vertical dysplasia are reviewed, and six genioplasty strategies are described.

Prospective comparison of arthroscopy and arthrocentesis for temporomandibular joint disorders.

PURPOSE: A prospective, randomized study was undertaken to compare arthroscopy and arthrocentesis for treatment of temporomandibular joint disorders. PATIENTS AND METHODS: Nineteen patients with clinical and radiographic documentation of internal derangement of the temporomandibular joint(s) unresponsive to nonsurgical therapy were randomized to one of two surgical groups: arthroscopic lysis and lavage under general anesthesia or arthrocentesis, hydraulic distention, and lavage under intravenous sedation. Objective data were collected; including interincisal opening, lateral excursions, occlusal evaluation, deviation on opening, and tenderness to palpation. A questionnaire in the form of visual analog scales relating to pain, joint noise, jaw mobility, and dietary alterations was completed by each patient at 1 week, and 1, 3, 4, 12, and 26 months postoperatively. RESULTS: There was no statistically significant difference in outcome between the two groups for any parameter evaluated. Categorization of a particular subject into a successful outcome was based on statistically significant improvement in maximum incisal opening and pain scores; the overall success rate was 82% for arthroscopy and 75% for arthrocentesis. CONCLUSIONS: Therapeutic success was not significantly different for arthroscopy and arthrocentesis; both surgical modalities are useful for decreasing patient reports of pain while increasing functional mobility of the mandible.

Neurosensory recovery following the mandibular bilateral sagittal split osteotomy.

PURPOSE: This prospective study evaluated the neurosensory recovery pattern of the inferior alveolar nerve following the bilateral sagittal split osteotomy (BSSO). PATIENTS AND METHODS: Forty-two consecutive patients undergoing BSSO were studied using five neurosensory tests: 1) static light touch, 2) moving touch discrimination, 3) two-point discrimination, 4) nociception, and 5) thermoreception. Intraoperative assessment of inferior alveolar nerve damage was made; other variables recorded included type of fixation, age, concomitant procedures, advancement vs setback, and magnitude of the movement. A subjective questionnaire was completed by the patient. RESULTS: The variables that affected neurosensory function following BSSO were degree of nerve damage and the amount of time elapsed following surgery. Larger myelinated fibers (A-alpha) recovered slower and to a lesser degree at all time intervals up to 2 years when compared with small myelinated and unmyelinated nerve fibers. The magnitude of nerve damage directly correlated with early neurosensory deficit, but equalized over time. CONCLUSION: The long term (6 months and greater) chance for neurosensory recovery is good despite intraoperative nerve manipulation. Patients seem to adapt and report normal neurosensory function even though objective testing indicates continued neurosensory deficit.

Orthodontic considerations in orthognathic surgery.

It is important for the oral and maxillofacial surgeon to understand the orthodontic decision-making process as it pertains to the orthognathic surgery patient to facilitate interprofessional communication. The orthodontic diagnostic process integrates the needs of the dentition, the requirements of facial balance, and the constraints of orthodontic mechanics to arrive at the best collective recommendation in each case. The orthodontic treatment objectives, extraction patterns, and types of mechanics used in orthognathic surgery cases may vary from those used in nonsurgical orthodontic regimens, in which the dentition is considered in the context of the largely immutable skeletal pattern. The goal of presurgical orthodontic treatment is to prepare the dentition for maximal surgical correction so that, at the time of surgery, the dental arches are compatible with the postsurgical position and facial balance is achieved.

Coordination of the orthosurgical treatment program.

Health care reform, current changes in the third-party payer system, and the evolution of orthognathic surgery mandate superior communication between the oral and maxillofacial surgeon and orthodontist. This article describes a successful approach to coordinating the entire orthosurgical treatment program to improve treatment outcome and patient satisfaction.

Prospective analysis of antibiotic prophylaxis for orthognathic surgery.

A randomized prospective study of 30 patients was undertaken to evaluate antibiotic prophylaxis for orthognathic surgery. Perioperative, high-dosage antibiotic administration was compared to an existing prophylactic regimen employing longer intervals and continued postoperative antibiotics for 7 to 10 days. No significant difference was found between the two groups with respect to incidence of infection. Other variables studied included gender and age of patients, type of surgery performed, procedure length, and use of fixation.

Osseointegrated implants: a comparative study of bone thickness in four vascularized bone flaps.

Primary and secondary reconstruction of mandibular continuity defects with vascularized bone is currently the standard of care at many institutions. The most commonly utilized donor sites for such bone flaps include the scapula, iliac crest, fibula, and radius. Recently, interest has grown in the placement of osseointegrated implants into these flaps to facilitate functional dental rehabilitation. There are no studies comparing the bone available from each of these flaps into which osseointegrated implants can be placed. In this cadaver study, the dimensions of bone available for implant placement from the iliac crest, scapula, fibula, and radius osseous flaps were measured. The iliac crest and fibula flaps had bone dimensions consistently adequate for implant placement. Bone available for the safe placement of implants into the scapula flap was found in the majority of specimens. The radius flap group had the highest number of specimens that were inadequate for implant placement. The majority of the specimens with bone inadequate for implantation were from females. Clinical implications of this study regarding flap selection are discussed.

Changing trends with mandibular fractures: a review of 1,067 cases.

To evaluate current trends in facial trauma, records from 1,067 patients sustaining 1,515 mandibular fractures from 1979 to 1989 were reviewed. The greatest number of fractures occurred between the ages of 20 to 29 years. Sex distribution was approximately three males to one female. Altercations were found to have caused about half of the fractures, and motor vehicle accidents accounted for nearly one-third. Angle fractures were most common, constituting 26.7% of the total. The most common site of mandibular fracture resulting from altercation was the angle (39.1%); condylar, symphysis, and alveolar fractures less commonly resulted from altercations than from motorcycle and automobile accidents.

Dental implications in Ehlers-Danlos syndrome. A case report.

Ehlers-Danlos syndrome is an unusual disease entity afflicting many body systems. Temporomandibular joint dysfunction has been described in an isolated number of cases. Ensuing complications should be recognized and the treatment plan modified accordingly. The following is a case report and review of the literature.

Hemodilution in orthognathic surgery.

The patient population for elective orthognathic surgery usually comprises young, healthy patients, in whom homologous blood transfusions should be avoided. Homologous transfusion poses substantial, potentially preventable risks to this patient population. In addition to autologous predonation, acute intentional hemodilution is an alternative that potentially avoids the use of homologous blood. Indications and contraindications for its use as well as initial results in two patients are presented. Further data and experience are required before this technique can be recommended for routine use.

Closed-intraoral wound suction: a prospective analysis of 65 cases and a review of the literature.

Minimizing postsurgical swelling, edema, and pain are important to the patient because of the elective nature of orthognathic surgical procedures. Closed-intraoral wound suction was placed following mandibular osteotomies in 65 consecutive patients. The volume of drainage ranged from 35 to 285 mL (mean of 113 mL). The use of closed-intraoral wound suction only minimally increased the incidence of postsurgical infection and at the same time resulted in considerable subjective improvement in postoperative facial appearance and a decrease in tissue edema and pain.

Alveolar osteitis following surgical removal of mandibular third molars.

PIP: The purpose of this study was to evaluate 2 methods that could be used universally to reduce the incidence of alveolar osteitis. In addition, other variables including age and sex of patient, preoperative aspirin use and discomfort, and the use of oral contraceptives (OCs) were studied. A large controlled prospective study was completed with 952 surgical extraction sites in 476 patients. Postoperative dressings included lincomycin hydrochloride (Lincocin)/absorbable gelatin sponge (Gelfoam), oxytetracycline HCL-hydrocortisone acetate (Terra-Cortril)/absorbable gelatin sponge, and absorbable gelatin sponge/saline. Bilaterally impacted mandibular 3rd molars of similar surgical difficulty were selected. Standard accepted surgical technique was used. Patients were seen 1 and 7 days after surgery or as needed. Lincomycin hydrochloride/absorbable gelatin sponge and oxytetracycline HC1-hydrocortisone acetate/absorbable gelatin sponge were effective in reducing the incidence of alveolar osteitis. Lincomycin hydrochloride/absorbable gelatin sponge is preferred because of the increased morbidity associated with dressings containing petrolatum products. Absorbable gelatin sponge alone is not effective in reducing the incidence of alveolar osteitis. Age and OC use were found to be significant factors in the incidence of this problem.^ieng