Impact of counterclockwise rotation of the occlusal plane on the mandibular advancement, pharynx morphology, and polysomnography results in maxillomandibular advancement surgery for the treatment of obstructive sleep apnea patients.

PURPOSE: Evaluate the impact of counterclockwise rotation of the occlusal plane (CCWROP) on pharynx morphology and polysomnography in maxillomandibular advancement (MMA) surgery to treat obstructive sleep apnea (OSA) patients. METHODS: Prospective clinical trial of patients with OSA treated by MMA. Computed tomography and polysomnography were performed pre- and postoperatively and the parameters were compared. The surgery classified the patients into two groups: with (R) and without (NR) CCWROP. RESULTS: The study sample comprised 38 individuals: R (n = 19) and NR (n = 19). An anterior mandible advancement of 0.71 mm was identified for each degree of CCWROP (p < 0.001). As for polysomnography, the apnea-hypopnea index was reduced by 80% and 62% in R and NR, showing final values of 6.8 and 13.0, respectively. The apnea index changed equally in both groups. Reduction of 68 and 26% in the hypopnea index was observed for R and NR, respectively, with no statistically significant difference. Total volume increased by 45% in R and 30% in NR. Retropalatal and retrolingual volumes increased by 49% and 4% in R and 43% and 15% in NR, respectively. The minimum axial area increased by 92% in the retropalatal region and 97% in the retrolingual region in R, whereas these increases were of 76% and 31% in NR, respectively. CONCLUSION: Anterior mandibular advancement of 0.71 mm for each degree of CCWROP is of great importance for surgical planning. As a result of this resource, individuals in R presented better results than those in NR in all parameters assessed, especially regarding the retrolingual region.

The Effect of Surgical Timing on 30-Day Outcomes in Cleft Palate Repair.

BACKGROUND: The optimal age for cleft palate repair continues to be debated, with little discussion of surgical risk related to operative timing. This study of 3088 cleft palate patients analyzed the impact of surgical timing on perioperative and 30-day postoperative outcomes. METHODS: Primary cleft palate repairs were identified in the National Surgical Quality Improvement Program database from 2012 to 2015. Data were combed for total postoperative complications, rates of readmission and reoperation, operating room time, and length of stay. Bivariate analyses were performed comparing 3-month periods from months 6 to 18, and months 0 to 5, 18 to 23, 24 to 29, and 30 to 59. RESULTS: Despite a higher proportion of isolated soft palate closure, children operated on before 6 months had a higher complication rate than children at other ages (7.1 percent versus 3.2 percent; OR, 2.4; p = 0.04), and higher rates of both readmission (3.6 percent versus 1.4 percent; OR, 3.6; p = 0.02) and reoperation (2.4 percent versus 0.5 percent; OR, 4.7; p = 0.04). There were no differences in short-term outcomes for any other age group younger than 5 years, and no differences in hospital length of stay among any age groups. CONCLUSIONS: The authors' findings suggest a relative contraindication to operation before 6 months. As there were no differences between any other age groups, long-term speech optimization should continue to be the primary consideration for operative planning. These findings improve the current rationale for palatoplasty timing, and can aid surgeons and parents in the surgical decision-making process. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Standardized Schematics for Facial Trauma Planning: A Clinical Education Tool.

INTRODUCTION: Learning facial fracture management principles can be challenging for surgical trainees. Residents must assimilate nuances of fixation techniques, skeletal biomechanics, and hardware use while managing acute work-flow limitations. This study aims to design a standardized-schematic for teaching facial fracture management and evaluate its performance improving resident operative planning. METHODS: Printable schematics of the facial skeleton with soft-tissue overlay were developed. Instructions on depicting fracture pattern, incisions, plating sequence, loadbearing/sharing plates, locking/nonlocking screws, and mono/bicortical screws were given. Senior residents (n=5) evaluated computed tomography of 3 mandibular fractures and submitted 3 operative plans per case: first without guidance, then with written instruction, and finally using the schematic (n=45). Performance was graded on content and conceptual correctness. Data on time to completion was obtained. Likert-scale surveys assessing understanding, communication, and operative planning were given RESULTS:: Schematic use improved operative plan content and facilitated communication of resident operative schemes. Of 7 content domains spanning approach, plating strategy, and screw selection, a mean of 2.3, 3.7, and 6.5 were included with no guidance, written instruction, and schematic use respectively. Information on approach (P=0.001), plating type (P=0.02), screw location (P<0.000), screw depth (P=0.000), and screw locking status (P=0.000) were improved when comparing pre- and postintervention plans. Mean time to completion was 8 minutes and 54 seconds. All subjects "agreed" (n=2) or "strongly agreed" (n=3) that schematic use aided planning and communication. CONCLUSIONS: Simple, guided interventions can enhance surgical training by identifying knowledge gaps, improving visuospatial conceptualization, and facilitating targeted discussions with attendings.

Manejo de pacientes en cirugía oral y maxilofacial durante el periodo de crisis y de control posterior de la pandemia de COVID-19 / Management of patients in oral and maxillofacial surgery during the stage of crisis and subsequent control of COVID-19 pandemic

La pandemia por la nueva infección respiratoria conocida como enfermedad coronavirus 2019 (COVID-19), causada por el virus SARS-CoV-2, ha desencadenado una perturbación sin precedentes en la actividad habitual de los servicios de cirugía oral y maxilofacial en España, retrasando la atención rutinaria de pacientes e intervenciones quirúrgicas programadas. Los cirujanos orales y maxilofaciales son uno de los colectivos sanitarios con mayor riesgo de infección nosocomial por el estrecho contacto que se produce con los pacientes asintomáticos y sintomáticos con infección por SARS-CoV-2 a través de la cavidad oral y orofaringe. El propósito del presente documento ha sido actualizar la evidencia disponible para el manejo y tratamiento seguro y efectivo en consulta, cirugías ambulatorias, programadas y urgentes y hospitalización, minimizando al mismo tiempo, tanto como sea posible, el riesgo de contagio para el cirujano oral y maxilofacial, personal sanitario y pacientes. Este documento pretende esclarecer los aspectos más significativos y crear un protocolo común de manejo de pacientes con COVID-19 en cirugía oral y maxilofacial durante la fase aguda de propagación y de control posterior de la pandemia en nuestro país

The pandemic due to the new respiratory infection known as coronavirus 2019 disease (COVID-19), caused by the SARS-CoV-2 virus, has triggered an unprecedented disruption in the normal activity of oral and maxillofacial surgery departments in Spain, delaying routine patient care and elective surgical interventions. Oral and maxillofacial surgeons are one of the healthcare groups with the highest risk of nosocomial infection because of the close contact that occurs with asymptomatic and symptomatic patients with SARS-CoV-2 infection through the oral cavity and oropharynx. The purpose of this document has been to update the available evidence for the safe and effective management and treatment in outpatient clinic, ambulatory, elective and emergency surgeries, and hospitalization, while minimizing as much as possible the risk of infection for the oral and maxillofacial surgeon, health workers and patients. This document aims to clarify the most significant aspects and create a common protocol for the management of patients with COVID-19 in oral and maxillofacial surgery during the acute stage of spread and subsequent control of the pandemic in our country

Evaluation of the Accuracy of Virtual Planning in Orthognathic Surgery: A Morphometric Study.

BACKGROUND: The purpose of this study was to prospectively test the accuracy of computer-aided orthognathic surgery comparing the virtual surgical planning with the three-dimensional (3D) outcome. METHODS: Patients that underwent computer-assisted orthognathic surgery were retrospectively evaluated. The postoperative results were compared with the surgical plan, superimposing the postoperative computed tomography (CT) scan onto the virtual plan. Surface-based superimpositioning of the postoperative CT scan onto the 3D preoperative plan was carried out to visualize the discrepancy between preoperative virtual plan and postoperative 3D CT result. RESULTS: A total of 17 consecutive patients that underwent two-jaw computer-assisted orthognathic surgery were enrolled in the study.The average linear differences for selected points were <1 mm in 12 patients out of 17. In 5 patients out of 17, the average differences for selected points were <2 mm. CONCLUSIONS: An overall high degree of accuracy between the virtual plan and the postoperative result was found.

[The smile: a challenge in the treatment of class III]. / Le sourire : un enjeu dans la décision thérapeutique des classes III.

INTRODUCTION: The smile poses a challenge in the treatment of class III. Untreated, the class III patient presents excessive maxillary torque and a predominant display of the mandibular incisors, a sign that becomes more visible with age. Functional orthopedics restores the aesthetic appearance of the smile by maxillary protraction (sometimes temporarily because 20% of cases will still need surgery). Depending on the initial severity of the case (-4.5 mm AoBo would be the threshold value), the options are compensation or surgical correction. In both cases, the profile is improved but without normalising the cephalometric values. In recent years, the number of published cases treated by compensations (often using skeletal anchorage) has multiplied with broader indications, particularly for Asian patients in whom Le Fort I surgery gives questionable aesthetic results. Attention must be focused on the occlusal plane rotation which alters the smile by displaying the mandibular incisors. Nevertheless, surgery can handle the most severe cases with a greater degree of improvement. AIM: The aim of this article is to determine the cephalometric cut-off values for an acceptable smile in Class III patients. MATERIALS AND METHODS: We performed a search on Pubmed using the following keywords: Class III, anterior cross bite, smile, camouflage, orthognathic surgery; then secondarily, using references supplied by the articles found. We then analysed the data. RESULTS: The ortho-surgical protocol associated with extractions of maxillary first premolars appears to be the way to obtain the best results in terms of the smile (versus surgery without extractions and versus orthodontic compensations) because it is, in fact, the only way to restore the normal position and torque of the maxillary incisors, thus increasing their display during smiling.

Planificación clásica en cirugía ortognática / Classic planning in orthognatic surgery

La cirugía ortognática es una de las cirugías electivas realizadas más a menudo en cirugía maxilofacial. Su planificación debe ser minuciosa, asegurando un grado de precisión tal que el margen de error sea de menos de 1 mm. El método clásico de planificar una cirugía ortognática se basaba en una cefalometría realizada a partir de una telerradiografía de perfil. A partir de aquí se trazaba una STO (Surgical Treatment Objectives) que permitía imaginar y medir en la dirección sagital los cambios quirúgicos. Concomitantemente, la cirugía de modelos corroboraba los cambios previstos con la STO. El desarrollo de las tomografías de haz de cono (CBCT) y su posterior incorporación a nuestras respectivas clínicas ha facilitado el paso de una planificación 2D basada en radiografías convencionales de perfil y ortopantomografía, a una planificación 3D basada en CBCT. Existe más de un enfoque correcto en la planificación y tratamiento de pacientes de cirugía ortognática. Cada paciente debe ser planificado y tratado de forma personalizada, según una serie de criterios. Existen pruebas adyuvantes como el escáner de haz de cono, planificación guiada por el escáner, férulas quirúrgicas CAD-CAM, modelos 3D craneales de resina o incluso cirugía con navegación asistida por robot que pueden ser útiles para mejorar los resultados quirúrgicos y disminuir el riesgo quirúrgico. Esto puede ser especialmente importante en deformidades severas, con un crecimiento anómalo y requiriendo maniobras quirúrgicas especialmente complicadas. Además, la cirugía endoscópica y la cirugía asistida por robot para navegar, están en rápido desarrollo y pueden en casos seleccionados especialmente complejos estar justificados. El objetivo de este artículo es discernir cuando son necesarias tales herramientas en cirugía ortognática (AU)

Orthognathic surgery is one of the elective surgery most often performed in maxillofacial surgery. Their planning must be thorough, ensuring a degree of precision such that the margin of error is less than 1 mm. The classical method for planning orthognathic surgery was based on a cephalometric made from a teleradiography profile. From here outlines a STO (Surgical Treatment Objectives) allowing imagine and measured in the sagittal direction surgically changes. Concomitantly, the model surgery corroborated the expected changes with the STO. The development of cone-beam CT (CBCT) and its subsequent incorporation into our respective clinics has facilitated the transition from a 2D plan based on conventional radiographs and panoramic radiograph profile, a CBCT-based 3D planning. More than one correct approach and treatment planning for orthognathic surgery patients. Each patient should be planned and treated in a personalized way, according to a set of criteria. Evidence exists adjuvants such as cone beam scanner, scanner guided planning, splints, surgical CAD-CAM, 3D models resin or cranial surgery with robot-assisted navigation can be used to improve surgical outcomes and reduce the surgical risk. This may be especially important in severe deformities with abnormal growth and requiring particularly complex surgical procedures. In addition, endoscopic surgery and robotic-assisted surgery for navigation, are rapidly developing in selected cases may be justified particularly complex. The aim of this paper is to discern when such tools are necessary in orthognathic surgery (AU)

[Improving the esthetic results and patient satisfaction in orthognatic surgery]. / Améliorer le résultat esthétique et la satisfaction du patient en chirurgie orthognatique.

The objectives of dental and maxillary defect management have changed over the last decade. Occlusal improvement is required, but it is expected to come with a good esthetic result for patients, especially for adults, and mentioned or not preoperatively. Thus, the maxillofacial surgeon must include complementary data in his therapeutic scheme, beyond the one provided by the cephalometric analysis. This chapter was drafted in pluridisciplinary mode to this end. A psychological approach and post-operative satisfaction are crucial factors that were studied prospectively (MD Battini and Courtois) and are a part of this chapter. Esthetic labial standard are also described, based on the results of a retrospective study (MD Hardy, Laure and Goga). Doctor Belhaouari presents solutions to embellish lips with filling products, initially or later. Finally, the complementary surgical techniques that can be used during orthognatic surgery are listed: lipofilling, rhinoplasty, surgery of mandibular angles, apposition of piriform aperture.

Severity and outcome assessments of patients undertaking surgical orthodontic treatment.

BACKGROUND: Combined orthognathic-orthodontic treatment can be lengthy and expensive. It is therefore important to evaluate the effectiveness of proposed treatment and the likely outcomes. OBJECTIVES: To determine the demographic and surgical details of patients who received orthognathic-orthodontic treatment at Christchurch Hospital, New Zealand, and to assess treatment using the Severity and Outcome Index (SOI). METHODS: An observational and retrospective study was conducted of patients who received surgical orthodontic treatment between 2005 and 2012 at Christchurch Hospital. Pre- and post-treatment lateral cephalometric radiographs of 93 patients were evaluated. Seven cephalometric parameters were assessed using the Severity and Outcome Index. A severity score ranged from 0 for the most severe to 7 for the least severe, while the outcome score ranged from 0 for the worst to 7 for the best outcome. RESULTS: Class II patients had a severity score of 3.4 and the best outcome score of 6.2. Class III patients had a severity score of 3.3 and an outcome score of 6.1. Patients with an anterior open bite (AOB) had the worst severity score of 3.0, and the worst outcome score of 5.9. The overall treatment outcome scores for all groups were statistically significantly greater than the severity scores, which increased from 3.4 to 6.1 (p < 0.05). CONCLUSIONS: Favourable outcomes were achieved for a group of patients with a high need for treatment. Christchurch Hospital appeared to be treating cases of increased severity and gained better treatment outcomes when compared with a United Kingdom (UK) national audit.

Chief resident case experience and autonomy are associated with resident confidence and future practice plans.

PURPOSE: To measure oral and maxillofacial surgery (OMS) chief resident case experience, including autonomy, and discover the role of this experience in developing resident confidence and determining the scope of practice on completion of training. MATERIALS AND METHODS: A cross-sectional study was conducted using an online questionnaire made available to residents near the completion of their final year of training in United States OMS training programs. Predictors were the case numbers and autonomy level. Outcomes were the anticipated frequency of practice, confidence to meet the standard of care, and changes in anticipated practice scope. Each was measured in 10 domains within the scope of OMS. RESULTS: Eighty-four residents (44%) completed the 116-item questionnaire. All respondents were "very confident" in their ability to meet the standard of care in mandibular trauma and dentoalveolar surgery. Autonomy was associated with the confidence to meet the standard of care in midface trauma, temporomandibular joint, orthognathic, cosmetic, pathology, reconstructive, and craniofacial surgery. Associations were noted between primary surgeon cases and confidence in midface trauma, temporomandibular joint, orthognathic, cosmetic, and craniofacial surgery. Case numbers were associated with an anticipated frequency of practice within the domains of midface trauma, temporomandibular joint, cosmetic, and pathology surgery. CONCLUSIONS: Results of this study suggest an association between a resident's surgical case experience (overall exposure and autonomy) and that resident's future plans for practice and confidence to meet the standard of care in this specialty. OMS training curricula should evolve to incorporate an evaluation of competence and an appropriate transfer of responsibility and experience to residents, thus maximizing confidence and future practice opportunities.

In vitro evaluation of new approach to digital dental model articulation.

PURPOSE: The purpose of the present study was to evaluate the accuracy of our newly developed approach to digital dental model articulation. MATERIALS AND METHODS: Twelve sets of stone dental models from patients with craniomaxillofacial deformities were used for validation. All the models had stable occlusion and no evidence of early contact. The stone models were hand articulated to the maximal intercuspation (MI) position and scanned using a 3-dimensional surface laser scanner. These digital dental models at the MI position served as the control group. To establish an experimental group, each mandibular dental model was disarticulated from its original MI position to 80 initial positions. Using a regular office personal computer, they were digitally articulated to the MI position using our newly developed approach. These rearticulated mandibular models served as the experimental group. Finally, the translational, rotational, and surface deviations in the mandibular position were calculated between the experimental and control groups, and statistical analyses were performed. RESULTS: All the digital dental models were successfully articulated. Between the control and experimental groups, the largest translational difference in mandibular position was within 0.2 mm ± 0.6 mm. The largest rotational difference was within 0.1° ± 1.1°. The averaged surface deviation was 0.08 ± 0.07. The results of the Bland and Altman method of assessing measurement agreement showed tight limits for the translational, rotational, and surface deviations. In addition, the final positions of the mandibular articulated from the 80 initial positions were absolutely agreed on. CONCLUSION: The results of our study have demonstrated that using our approach, the digital dental models can be accurately and effectively articulated to the MI position. In addition, the 3-dimensional surface geometry of the mandibular teeth played a more important role in digital dental articulation than the initial position of the mandibular teeth.

An assessment of the quality of care provided to orthognathic surgery patients through a multidisciplinary clinic.

The quality of care delivered to 74 patients undergoing orthognathic surgery was assessed using a patient satisfaction questionnaire and data collected from hospital case records. Surgical complications, hospital services, patient satisfaction, and impact on quality of life, were the main aspects considered. The majority of patients reported that their treatment objectives had been achieved and that they were satisfied with the quality of care provided. The main concern of the patients regarding the clinic was the waiting time before an appointment could be offered. Eating and breathing difficulties and low mood after surgery were the main reported complications. Sixty-three patients experienced post-operative weight loss. The importance of a nutritious, high calorie soft diet should be emphasised and the use of menthol inhalations following maxillary osteotomies should be considered more frequently. Clinicians should be aware of post-operative low mood, which may require psychological support. We developed a sensitive assessment battery with comprehensive parameters to audit quality of orthognathic surgery service, and recommend that a similar approach should be considered by teams which undertake management of orthognathic patients.

Hemangiopericytoma - the need for a protocol-based treatment plan.

Hemangiopericytoma is a vascular tumor which comprises only 1% of all vascular tumors. The frequency of occurrence in the head and neck accounts for about 16-33% of all hemangiopericytomas. In this paper we discuss the surgical management, the difficulties in decision-making and treatment-planning in a case of a maxillary tumor in a five-year-old boy with a two-year follow-up. A five-year-old boy presented with a large unilateral maxillary tumor with nasal obstruction. Computed tomography revealed a heterogeneous mass completely occupying the right maxillary sinus and displacing the lateral wall of the nose and nasal septum. The lesion was diagnosed as hemangiopericytoma after histopathological confirmation. The option of surgical resection (total maxillectomy) was carried out after evaluating the available literature. Various treatment modalities like surgery, chemotherapy and radiotherapy were taken into consideration as the tumor has an aggressive nature. Due to the inadequate literature on definitive treatment options for these types of tumors, there was difficulty in arriving at a protocol-based treatment plan.

An overview of cleft care in Nigeria.

This is an overview of the present state of cleft lip and palate care in Nigeria. The aim is to stimulate further discussions on the need to improve standard of care and quality of life in patients with cleft lip and palate deformities. The number of cleft surgeries and surgeons involved in cleft repairs across Nigeria is increasing due to availability of free treatment grants provided by non-governmental organisation; therefore, it has become imperative to assess the quality of surgery and quality of cleft care. It is expected that as the number of repaired cleft lip/palate increases, more patients will require secondary repair, speech therapy, and orthodontics therapy and orthognathic surgery. The following recommendations are made to improve the standard of cleft care in Nigeria: establishment of multidisciplinary team approach, formulation of policy on quality control, establishment of fellowship training in cleft care and establishment of regional specialised cleft care centre.

Using a clinical protocol for orthognathic surgery and assessing a 3-dimensional virtual approach: current therapy.

Oral and maxillofacial surgeons who perform orthognathic surgery face major changes in their practices, and these challenges will increase in the near future, because the extraordinary advances in technology applied to our profession are not only amazing but are becoming the standard of care as they promote improved outcomes for our patients. Orthognathic surgery is one of the favorite areas of practicing within the scope of practice of an oral and maxillofacial surgeon. Our own practice in orthognathic surgery has completed over 1,000 surgeries of this type. Success is directly related to the consistency and capability of the surgical-orthodontic team to achieve predictable, stable results, and our hypothesis is that a successful result is directly related to the way we take our records and perform diagnosis and treatment planning following basic general principles. Now that we have the opportunity to plan and treat 3-dimensional (3D) problems with 3D technology, we should enter into this new era with appropriate standards to ensure better results, instead of simply enjoying these new tools, which will clearly show not only us but everyone what we do when we perform orthognathic surgery. Appropriate principles need to be taken into account when implementing this new technology. In other words, new technology is welcome, but we do not have to reinvent the wheel. The purpose of this article is to review the current protocol that we use for orthognathic surgery and compare it with published protocols that incorporate new 3D and virtual technology. This report also describes our approach to this new technology.