Are postoperative antibiotics required after orthognathic surgery?

The aim of this study was to investigate and compare the frequency of surgical site infection (SSI) between orthognathic patients who received only intraoperative antibiotics and patients who received intraoperative antibiotics plus postoperative antibiotics. A retrospective study was performed of patients treated by a single surgeon over the years 2006-2012 and 2016-2019. The primary predictor variable was antibiotic exposure. The control group received no postoperative prophylactic antibiotics. The study group received postoperative antibiotics. Both groups received prophylactic intraoperative antibiotics and performed postoperative chlorhexidine rinses. The primary outcome was SSI frequency. Univariate, bivariate, and multiple logistic regression analyses were performed; statistical significance was set at P ≤ 0.05. The sample comprised 333 patients. Their mean age was 30.7 ± 11.8 years. The study group included 129 patients (38.7%); the control group included 204 patients (61.3%). The frequency of SSI was 17.1% in the study group and 26.5% in the control group (P = 0.048). In the multivariable logistic regression, only alcohol consumption was significantly associated with an increased risk of SSI (odds ratio 2.46, 95% confidence interval 1.36-4.44; P = 0.003). In patients undergoing orthognathic surgery, postoperative antibiotic exposure in addition to intraoperative prophylaxis approached but was not statistically significant for a decreased risk of SSI (P = 0.067).

Maxillary stability in patients with skeletal class III malocclusion treated by bimaxillary orthognathic surgery: comparison of mandible-first and maxilla-first approaches in a randomised controlled study.

The maxilla-first approach has been the standard orthognathic sequence for many years, however, with the evolution of rigid internal fixation and to eliminate any errors that could be encountered during preoperative bite registration, the mandible-first approach has become an effective treatment modality for bimaxillary orthognathic surgery. Would the maxilla-first or mandible-first orthognathic sequence in bimaxillary orthognathic surgery result in more maxillary stability in patients with skeletal class III malocclusion? Twenty-four patients with skeletal class III malocclusion were selected from the outpatient clinic of the Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Cairo University. Patients were randomly divided into two equal-sized groups: the maxilla-first approach (group I), and the mandible-first approach (group II). All patients underwent cone-beam computed tomography before, immediately after (P1), and 6months after surgery (P2). Virtual planning included designing the virtual cuts and the intermediate and final splints. Both splints were three-dimensionally printed. In both approaches, hard and soft tissue landmarks were used as reference points to evaluate maxillary stability, which was calculated by subtracting P2 values from P1 values. All measures were statistically evaluated as numerical values of means and standard deviations. The differences between the radiographic measurements of the two groups were not statistically significant except for the soft tissue inclination at the nasal tip. The mandible-first approach in bimaxillary orthognathic surgery is a reliable method for achieving high maxillary stability.

An overview of surgery-first orthognathic approach: History, indications and limitations, protocols, and dentoskeletal stability.

The most common orthognathic surgery approach consists of three steps: presurgical orthodontic treatment, surgery, and postsurgical orthodontic treatment. Despite its advantages, this technique has some disadvantages, too, including a long treatment period, problems in mastication and articulation, temporary worsening of the patient's appearance, and psychological problems for the patient. The introduction of the surgery-first orthognathic approach has been an attempt to overcome these problems. In this article, we wish to provide a comprehensive overview on this approach. In this approach, which consists of surgery without orthodontic preparation and a short period of orthodontic treatment after it, the overall duration of treatment decreases and the patient's appearance improves. The skeletal anchorage, placed at the time of surgery, can be used to facilitate tooth movements after surgery. Despite the advantages of this technique, it is associated with some limitations; in particular, occlusion cannot have a guiding role during surgery. Therefore, correct diagnosis, prediction of the outcomes, and simulating correction with the model setup are of crucial importance. The surgeon's knowledge and expertise have a significant role in this respect.

Correction of Eyes and Lip Canting after Bimaxillary Orthognathic Surgery.

Patients who have a lower facial asymmetry with compensatory head posture (developmental facial asymmetry) may have minor temporomandibular (T-M) joint problems and tend to mask their asymmetry by tilting the head for camouflage of their chin deviation. However, this compensatory head posture can give the impression of orbital dystopia and c spine deviation. When these patients undergo bimaxillary orthognathic surgery, orbital canting and head tilting improves gradually without the need for camouflage, and bleary eyes become clearer. We evaluated 13 patients who underwent LeFort I osteotomy combined with bilateral sagittal split osteotomy of the mandible for developmental facial asymmetry to quantitatively observe whole facial postural changes after surgery. Pre-operative and post-operative 1:1 full-face photographs of the patients were analyzed to compare the degrees of head tilting and orbital canting and the sizes of the eye opening. After bimaxillary orthognathic surgery, eye canting decreased from 2.6° to 1.5°, eye and lip lines came closer to parallel, and the degree of head tilting decreased from 3.4° to 1.3°. The eyes also appeared to open wider. Correction of lower facial skeletal asymmetry through bimaxillary orthognathic surgery improved head tilting and orbital canting gradually by eliminating the need of compensatory head posture. Facial expressions also changed as the size of the eyes increased due to the reduction of facial muscle tension caused by T-M joint dysfunction.

Correction of Eyes and Lip Canting after Bimaxillary Orthognathic Surgery

Patients who have a lower facial asymmetry with compensatory head posture (developmental facial asymmetry) may have minor temporomandibular (T-M) joint problems and tend to mask their asymmetry by tilting the head for camouflage of their chin deviation. However, this compensatory head posture can give the impression of orbital dystopia and c spine deviation. When these patients undergo bimaxillary orthognathic surgery, orbital canting and head tilting improves gradually without the need for camouflage, and bleary eyes become clearer. We evaluated 13 patients who underwent LeFort I osteotomy combined with bilateral sagittal split osteotomy of the mandible for developmental facial asymmetry to quantitatively observe whole facial postural changes after surgery. Pre-operative and post-operative 1:1 full-face photographs of the patients were analyzed to compare the degrees of head tilting and orbital canting and the sizes of the eye opening. After bimaxillary orthognathic surgery, eye canting decreased from 2.6° to 1.5°, eye and lip lines came closer to parallel, and the degree of head tilting decreased from 3.4° to 1.3°. The eyes also appeared to open wider. Correction of lower facial skeletal asymmetry through bimaxillary orthognathic surgery improved head tilting and orbital canting gradually by eliminating the need of compensatory head posture. Facial expressions also changed as the size of the eyes increased due to the reduction of facial muscle tension caused by T-M joint dysfunction.

Augmented reality as an aid in maxillofacial surgery: validation of a wearable system allowing maxillary repositioning.

AIM: We present a newly designed, localiser-free, head-mounted system featuring augmented reality as an aid to maxillofacial bone surgery, and assess the potential utility of the device by conducting a feasibility study and validation. METHODS: Our head-mounted wearable system facilitating augmented surgery was developed as a stand-alone, video-based, see-through device in which the visual features were adapted to facilitate maxillofacial bone surgery. We implement a strategy designed to present augmented reality information to the operating surgeon. LeFort1 osteotomy was chosen as the test procedure. The system is designed to exhibit virtual planning overlaying the details of a real patient. We implemented a method allowing performance of waferless, augmented-reality assisted bone repositioning. In vitro testing was conducted on a physical replica of a human skull, and the augmented reality system was used to perform LeFort1 maxillary repositioning. Surgical accuracy was measured with the aid of an optical navigation system that recorded the coordinates of three reference points (located in anterior, posterior right, and posterior left positions) on the repositioned maxilla. The outcomes were compared with those expected to be achievable in a three-dimensional environment. Data were derived using three levels of surgical planning, of increasing complexity, and for nine different operators with varying levels of surgical skill. RESULTS: The mean error was 1.70 ± 0.51 mm. The axial errors were 0.89 ± 0.54 mm on the sagittal axis, 0.60 ± 0.20 mm on the frontal axis, and 1.06 ± 0.40 mm on the craniocaudal axis. The simplest plan was associated with a slightly lower mean error (1.58 ± 0.37 mm) compared with the more complex plans (medium: 1.82 ± 0.71 mm; difficult: 1.70 ± 0.45 mm). The mean error for the anterior reference point was lower (1.33 ± 0.58 mm) than those for both the posterior right (1.72 ± 0.24 mm) and posterior left points (2.05 ± 0.47 mm). No significant difference in terms of error was noticed among operators, despite variations in surgical experience. Feedback from surgeons was acceptable; all tests were completed within 15 min and the tool was considered to be both comfortable and usable in practice. CONCLUSION: We used a new localiser-free, head-mounted, wearable, stereoscopic, video see-through display to develop a useful strategy affording surgeons access to augmented reality information. Our device appears to be accurate when used to assist in waferless maxillary repositioning. Our results suggest that the method can potentially be extended for use with many surgical procedures on the facial skeleton. Further, our positive results suggest that it would be appropriate to proceed to in vivo testing to assess surgical accuracy under real clinical conditions.

Bimaxillary advancement as the initial treatment of obstructive sleep apnea: five years follow-up of the pori experience.

OBJECTIVES: Bimaxillary advancement surgery has proven to be effective treatment of obstructive sleep apnea syndrome. According to the Stanford protocol upper airway soft tissue surgery or advancement of tongue by chin plastic surgery is first carried out and if obstructive sleep apnea persists, then bimaxillary advancement is done. This study describes the 5 year outcome of 13 obstructive sleep apnea patients in whom the Stanford protocol was omitted and bimaxillary advancement was carried out as initial surgical treatment. MATERIAL AND METHODS: Patients were divided in two groups. Group A comprised patients with obstructive sleep apnea (OSAS) confirmed by polysomnography in whom ODI-4 (oxygen desaturation index) was 5 or more. Group B consisted of patients with occlusal problems needing orthognathic surgery and with OSAS symptoms but no clear disease on polysomnography, where the ODI-4 index was less than 5. Both groups were treated with bimaxillary advancement surgery (BAS) as initial therapy. RESULTS: In the group A mean ODI-4 was 17.8 (SD 12) before treatment and 3.5 (SD 3.4) at 5-year follow-up (P = 0.018 in paired differences t-test). In group B the ODI-4 remained below 5. In group A mean saturation improved from 94.3% (SD 1.6) to 96.3% (SD 2), P = 0.115 and in group B from 96.3% (SD 1.2) to 97.8% (SD 1.7), P = 0.056 (in paired differences t-test). The static charge sensitive bed evaluation showed improvement in all patients except one. CONCLUSIONS: Bimaxillary advancement surgery is safe and reliable as an initial surgical treatment of obstructive sleep apnea syndrome.

Postsurgical Orthodontic Treatment Planning: a Case Report with 20 Years Follow-up.

BACKGROUND: Traditionally, maxillofacial deformities are corrected surgically after an initial orthodontic treatment phase. However in, this article, the authors emphasize the postsurgical therapeutic protocol which is extremely important for determining the final and permanent retention of the corrected occlusion. METHODS: A 55 year old female with severe skeletal Class II malocclusion is presented. Combined surgical and orthodontic correction of the malocclusion was used. RESULTS: : The step-by-step procedure the authors followed for the postsurgical therapy is described. The goals of the postoperative therapy were to restore and rehabilitate neuromuscular function, obtain occlusal stabilization, grind teeth selectively, and final occlusion retention. The importance of a surgical occlusal splint for rehabilitating stomatognathic neuromuscular function postoperatively was demonstrated. Furthermore, the orthodontic-prosthodontic treatment ensured occlusion stability after the surgical correction. The long-term results confirmed the efficacy of the treatment protocol presented here from both functional and aesthetical perspectives. CONCLUSIONS: Postsurgical orthodontic treatment is an important step in the surgical and orthodontic therapy of maxillofacial deformities.