Surgical Treatment of a Borderline Skeletal Class III Patient: an Interdisciplinary Approach.

INTRODUCTION: Class III malocclusion is considered the most challenging discrepancies in orthodontic diagnosis and treatment planning. It is often difficult to classify borderline cases as surgical or non-surgical. The following case report is of a borderline Class III case with several missing maxillary premolars treated via an interdisciplinary approach. AIM: This clinical case highlights the importance of meticulous diagnosis to obtain optimal results in borderline Class III cases. The significance of an interdisciplinary approach in complex adult orthodontic cases was also discussed. CASE REPORT: Given the complexity of the case, the treatment required a comprehensive interdisciplinary approach with the intervention of multiple specialties including periodontics, prosthodontics, orthodontics, oral surgery and maxillofacial surgery. The presurgical orthodontic stage was achieved in preparation for LeFort I maxillary advancement. Third molars extractions along with implant placement were implemented. Finally, crown placement and connective tissue graft were completed to achieve an optimal result. Total treatment time was 1.7 years (20 months). Patient's profile and facial appearance were dramatically enhanced, and a stable functional Class II occlusion was attained despite the preexisting skeletal Class III. CONCLUSION: Borderline adult Class III cases require a delicate diagnostic approach to be able to distinguish a surgical from a non-surgical approach. Complex adult orthodontic cases require a diplomatic interdisciplinary approach from all required specialties in order to attain the most favorable results.

Evidence-Based Performance Measures for Rhinoplasty: A Multidisciplinary Performance Measure Set.

SUMMARY: The American Society of Plastic Surgeons, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Facial Plastic and Reconstructive Surgery commissioned the multidisciplinary Rhinoplasty Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing both functional and aesthetic rhinoplasty. One outcome measure and three process measures were identified. The outcome looked at patient satisfaction with rhinoplasty procedures. The process measures look at motivations and expectations of the procedure, airway assessment, and nonnarcotic shared decision-making strategies for pain management. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Facial Plastic and Reconstructive Surgery, The Rhinoplasty Society, and the American Association of Oral and Maxillofacial Surgeons. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

A New Software Suite in Orthognathic Surgery : Patient Specific Modeling, Simulation and Navigation.

Orthognathic surgery belongs to the scope of maxillofacial surgery. It treats dentofacial deformities consisting in discrepancy between the facial bones (upper and lower jaws). Such impairment affects chewing, talking, and breathing and can ultimately result in the loss of teeth. Orthognathic surgery restores facial harmony and dental occlusion through bone cutting, repositioning, and fixation. However, in routine practice, we face the limitations of conventional tools and the lack of intraoperative assistance. These limitations occur at every step of the surgical workflow: preoperative planning, simulation, and intraoperative navigation. The aim of this research was to provide novel tools to improve simulation and navigation. We first developed a semiautomated segmentation pipeline allowing accurate and time-efficient patient-specific 3D modeling from computed tomography scans mandatory to achieve surgical planning. This step allowed an improvement of processing time by a factor of 6 compared with interactive segmentation, with a 1.5-mm distance error. Next, we developed a software to simulate the postoperative outcome on facial soft tissues. Volume meshes were processed from segmented DICOM images, and the Bullet open source mechanical engine was used together with a mass-spring model to reach a postoperative simulation accuracy <1 mm. Our toolset was completed by the development of a real-time navigation system using minimally invasive electromagnetic sensors. This navigation system featured a novel user-friendly interface based on augmented virtuality that improved surgical accuracy and operative time especially for trainee surgeons, therefore demonstrating its educational benefits. The resulting software suite could enhance operative accuracy and surgeon education for improved patient care.

Clinical and Cephalometric Analysis of Facial Soft Tissue.

OBJECTIVE: This study aimed to provide average of standard values in planning orthognathic surgery in Asians. MATERIALS AND METHODS: Thirty-three Asians with well-balanced facial profile, combined with class I occlusion and stabilized condylar head were evaluated using lateral cephalograms. RESULTS: Facial length (Nasion'-Menton') was 138.8 and 127.0 mm in male and female, respectively. Upper and lower lip length were 24.5 and 49.8 mm for male, and 22.2 and 45.1 mm for female, and maxillary incisor exposure was 2.0 and 4.0 mm in male and female, respectively. Nasolabial angle was 77.7° and 84.1° in male and female, respectively. Alar base, A point', and maxillary incisor were placed posteriorly to true vertical line by 10.6, 1.0, and 8.0 mm for male and 9.0, 0.8, and 6.9 mm for female. The horizontal distance between upper lip anterior and lower lip anterior was 2.1 mm for male and 2.6 mm for female, and the horizontal distance between A point' and B point' was 5.3 mm for male and 3.9 mm for female. Orbital rim' to A-point' was 12.4 and 11.3 mm in male and female, respectively. Pogonion' located posteriorly to glabella' by 2.7 mm for male and anteriorly to glabella' by 3.2 mm for female, and facial angle was 156.7° and 147.0° in male and female, respectively. CONCLUSIONS: This quantitative analysis of facial profile in Asian will be helpful in evaluation of facial soft tissue and establishment of treatment plans for orthognathic surgery.

Guías y miniplacas personalizadas: un protocolo guiado para cirugía ortognática / Customised guides and mini-plates: a guided-protocol for orthognathic surgery

Introducción. Los avances tecnológicos en planificación e impresión 3D permiten sinterizar productos sanitarios personalizados mediante un flujo de trabajo completamente digital. El objetivo de este trabajo es presentar y evaluar un nuevo sistema posicionador para cirugía ortognática (SPO), basado en el uso de una guía hueso-soportada y una miniplaca personalizada, que permite posicionar el fragmento maxilar sin la necesidad de una férula oclusal intermaxilar. Material y métodos. Se trata de un estudio prospectivo observacional sobre 10 casos de cirugía bimaxilar en los que se ha seguido un protocolo de planificación inversa. Tanto la guía como la miniplaca personalizada fueron diseñadas con tecnología computer aided-desing/manufacturing (CAD-CAM) y fabricadas por sinterizado láser de polvo de titanio puro comercial. Para analizar la precisión obtenida, se realizó un estudio comparativo superponiendo la planificación con una tomografía computarizada realizada un mes posterior a la cirugía. Resultados. El SPO se pudo aplicar con éxito en todos los casos sin observarse fenómenos de intolerancia al material. Permitió simplificar notablemente el procedimiento y reducir los tiempos quirúrgicos, al evitar la fijación intermaxilar, el moldeado de la miniplaca y la necesidad de realizar mediciones intraoperatorias. En el estudio postoperatorio se obtuvo una precisión media del 68,1% ±1mm. Conclusiones. Los sistemas de posicionamiento para cirugía ortognática que incluyan sistemas personalizados de osteosíntesis pueden ser una opción de futuro que permita incrementar la precisión y la seguridad del procedimiento, así como reducir los tiempos quirúrgicos (AU)

Introduction. Technological advances in preoperative planning and 3D printing allow custom-made biomedical devices to be synthesised using a completely digital workflow. The aim of this paper is to present and critically evaluate a new Orthognathic Positioning System (OPS) for Orthognathic Surgery. The OPS used bone-supported guides and a custom mini-plate to allow maxillary fragment positioning and fixation without the need for an inter-maxillary occlusal splint. Materials and methods. A prospective observational study was conducted on 10 cases of bimaxillary surgery using an inverse planning protocol. The guide and the custom-made mini-plate were designed using CAD-CAM software and synthesised by laser from commercially pure titanium powder. Accuracy was evaluated by overlap comparison of the virtual planning and 1-month postoperative CT scan. Operation times, complications, and overall safety profile were analysed. Results. The OPS was successfully applied to all cases, and was well tolerated. Operation times were reduced by avoiding inter-maxillary fixation, mini-plate bending, and obviating the need for intra-operative measurements. A mean postoperative accuracy of 1mm was obtained in 68.1% of cases. Conclusions. The positioning systems for orthognathic surgery that involve custom made systems of osteosynthesis, can be a future option that could increase accuracy and the safety of the procedure, as well as the surgical times. We believe this novel technology is a step forward in optimising and improving the delivery of orthognathic surgery care (AU)

An assessment of the compliance of systematic review articles published in craniofacial surgery with the PRISMA statement guidelines: A systematic review.

CONTEXT: Systematic review evidence is increasing within craniofacial surgery. Compliance with recognised reporting guidelines for systematic review evidence has not been assessed. OBJECTIVE: To assess the compliance of systematic reviews published in craniofacial journals with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting criteria. DATA SOURCES, SEARCH TERMS AND STUDY SELECTION: Thomson Reuters impact factor was used to identify three top craniofacial journals. A search for all systematic review articles published in these journals from 1st May 2010 to 30th April 2015 was conducted using MEDLINE PubMed. DATA EXTRACTION: Two independent researchers assessed each study for inclusion and performed the data extraction. Data included the article reference information; the pathology and interventions examined and compliance of each review article with the PRISMA checklist. DATA SYNTHESIS AND RESULTS: 97 studies were returned by the search. 62 studies proceeded to data extraction. The mean percentage of applicable PRISMA items that were met across all studies was 72.5% (range 28.6-96.2%). The area of poorest compliance was with the declaration of a study protocol (19.4% of studies). Only 37.1% of studies declared their source of funding. CONCLUSIONS: Compliance of systematic review articles within craniofacial surgery with areas of the PRISMA checklist could be improved.

Precisión en la planificación quirúrgica 3D en un paciente con síndrome de Goldenhar / Precision in 3D surgical planning in a patient with Goldenhar syndrome

Objetivo. Presentar un caso clínico de una paciente con síndrome de Goldenhar en el cual se utilizó, para la planificación de la corrección de su asimetría facial, el software Materialise CMF® (Leuven, Bélgica). Caso clínico. aciente de sexo femenino de 27 años que padece síndrome de Goldenhar. Se le realizó cirugía ortognática para corregir su asimetría facial. Para el diagnóstico, planificación y simulación quirúrgica del caso se utilizó el software 3D Materialise CMF® (Leuven, Bélgica). Conclusión. El método de planificación tradicional no es preciso, y estas imprecisiones producen una acumulación de errores en todo el proceso. Estos conceptos cobran gran relevancia en los casos de deformidades asimétricas, en donde los métodos bidimensionales son insuficientes, dejando un gran margen para la intuición, para la habilidad del profesional y, por lo tanto, para el error. El método de planificación 3D facilita el estudio, la planificación y la transferencia de lo planificado a la cirugía, minimizando los errores y logrando la máxima precisión (AU)

Aim. Submit a case of a patient with Goldenhar syndrome. The Materialise CMF® (Leuven, Belgium) software was used for planning her facial asymmetry correction. Case report. Female patient aged 27 who suffers from Goldenhar syndrome. He underwent orthognathic surgery to correct facial asymmetry. For diagnosis, surgical planning and simulation case 3D Materialise CMF® software (Leuven, Belgium) was used. Conclusions. The traditional method of planning is not necessary, these inaccuracies are an accumulation of errors in the whole process. These concepts assume great importance in cases of asymmetric deformities where the 2-dimensional methods are insufficient, leaving much room for intuition, for the professional ability and therefore for error. The method of 3D planning facilitates the study, planning and transfer of what is thought to surgery, minimizing errors and achieving maximum accuracy (AU)

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)

Planificación tridimensional y utilización de férulas Computer Aided Design/Computed Aided Manufacturing en cirugía ortognática / 3D planning and use of Computer Aided Design/Computed Aided Manufacturing surgical splints in orthognathic surgery

El presente trabajo se centra en explicar las ventajas que aporta la planificación tridimensional (3D) y la confección de férulas quirúrgicas Computer Aided Design/Computed Aided Manufacturing (CAD/CAM) en cirugía ortognática. La digitalización del entorno laboral es una realidad imparable en nuestra sociedad y, en nuestra especialidad, nos proporciona ventajas desde un punto de vista logístico, de precisión diagnóstica y en la confección de férulas quirúrgicas. Las tradicionales férulas quirúrgicas siguen un método de fabricación casi artesanal sometido a errores sistemáticos que se van acumulando a lo largo del proceso. Las férulas CAD/CAM se crean directamente a partir de imágenes que obtenemos de la tomografía computarizada o de la tomografía de haz cónico con lo que acortamos, digitalizamos y estandarizamos el proceso de confección disminuyendo la posibilidad de cometer errores derivados de la confección manual. Las imágenes 3D sobre las que podemos trabajar nos aportan ventajas respecto a la visualización bidimensional (2D) ya que no hay una pérdida de información ni una superposición de estructuras anatómicas. En 3D podemos ver con mayor detalle puntos de referencia difíciles de visualizar en 2D y son imágenes idóneas para el estudio de asimetrías en el plano frontal (AU)

The aim of this work is to present the advantages of 3D planning and CAD/CAM (Computer Aided Design/Computed Aided Manufacturing) surgical splints in orthognathic surgery. Digitalization of the working environment is an unstoppable reality in our society and, in our specialty it gives us advantages from a logistics, accuracy and diagnostic point of view, as well as in the manufacture process of surgical splints. The conventional surgical splints have an artisanal manufacturing process subjective to systematic errors. CAD/CAM surgical splints are built from computed tomography or cone beam computed tomography, which makes manufacturing process shorter, digitalized and standardized, thus decreasing the errors of the hand made manufacture. The 3D images that we can work with, give us advantages compared to two-dimensional (2D) visualization because there is no loss of information or overlapping anatomical structures. More detailed points of references can be seen in 3 D images, which are very difficult to see in two-dimensional images, and are ideal images for the study of frontal plane asymmetry (AU)

Periodontal management in orthognathic surgery: early screening of periodontal risk and its current management for the optimization of orthodontic and surgical treatments.

Orthodontic preparation for orthognathic surgery requires correcting mal-occlusions and coordination of arcades. In addition to improving the aesthetics, these treatments can ensure the achievement and sustainability of prosthetics and/or implants. Nevertheless, periodontal structures are easily damaged. Orthodontic displacement can only be applied in the absence of inflammation or weakened periodontal structure. An early detection of periodontal risk should be achievable by prescribers of a surgical-orthodontic treatment. Simplified periodontal examination, with easily detectable warning signs, will help to identify the periodontal risk. Although periodontal treatment follows current "non invasive" trend, some procedures remain necessary to prevent and/or remedy periodontal defects or diseases, such as mineral periodontal reinforcement corticotomy. It is essential that the patient meets all the practitioners to plan and assess the extent of the constraints necessary to optimize results, before starting orthodontic treatment combined with orthognathic surgery. Any periodontal complication (even minor) will be considered as a failure, regardless of good aesthetic and functional results.

¿Podemos predecir la pérdida de sangre en la cirugía ortognática utilizando parámetros preoperatorios? / Can we predict blood loss during orthognatic surgery using pre-operative paramenters?

El presente artículo estudia la posibilidad de restringir la inclusión de los pacientes sometidos a intervenciones de cirugía ortognática en el protocolo de autotransfusión con predepósitos utilizando parámetros preoperatorios (la mayor edad, el sexo femenino, el tipo de cirugía más invasiva) y valora la necesidad cuantitativa de sangre (número de bolsas utilizadas). Material y método. Realizamos un estudio descriptivo retrospectivo que comprende 91 de intervenciones de cirugía ortognática realizadas entre el junio del 2007 y el diciembre de 2010 en el Hospital de La Princesa - Madrid que describe en términos analíticos el manejo de las pérdidas sanguíneas y busca una relación entre varios parámetros como: edad, tipo de cirugía, tiempo de cirugía, los valores de hemoglobina pre-, intra- y postoperatoria, el número de bolsas de sangre recibidas y el sexo. Resultados. No se han encontrado correlaciones estadísticamente significativas entre la necesidad de transfusión y: la mayor edad (p = 0,23), el sexo femenino (p = 0,11), el mayor tiempo de cirugía (p = 0,93), el tipo de cirugía más invasiva (p = 0,284) con lo cual estos parámetros no suponen un mayor riesgo de sangrado ni de ser transfundido. Conclusión. En nuestro grupo de estudio los parámetros enumerados no sirven en el preoperatorio para delimitar un grupo de pacientes para los cuales la inclusión en el protocolo de autotransfusión sería beneficiosa. Los resultados indican la posibilidad de reducir la cantidad de sangre ahorrada por protocolo e indican una probable sobreindicación del procedimiento(AU)

Objectives: The present article studies the possibility of restricting the inclusion of patients undergoing orthognathic surgical procedures in the autologous transfusion protocol with pre-deposited blood using preoperative parameters (age, female gender, more invasive type of surgery), as well as assessing the amount of blood required (number of bags used). Material and Methods: We conducted a retrospective study comprising 91 orthognathic surgery interventions performed between June 2007 and December 2010 at the La Princesa Hospital - Madrid, which describes, in analytical terms, the management of blood loss and looks for a relationship between various parameters such as age, type of surgery, duration of surgery, pre-, intra- and postoperative haemoglobin values, number of blood bags used and gender. Results: No statistically significant correlationswere found between the need for transfusion and: older age (p = .23), female gender (p = .11), increased duration of surgery (p = .93), the more invasive type of surgery (p = .284), thus these parameters do not pose an increased risk of bleeding or of being transfused. Conclusion: In our study group, the parameters listed in the preoperative evaluation do not serve the purpose of restricting a group of patients for whom the inclusion in the autotransfusion protocolwould be beneficial. The results showthe possibility of reducing the amount of blood saved per protocol and indicate a probable over-recomendation of the procedure(AU)

Compliance with the minimum dataset of the British Orthodontic Society/British Association of Oral and Maxillofacial Surgeons for record keeping for orthognathic patients: retrospective comparative multicentre audit.

Accurate and timely collection of clinical records is of utmost importance in planning, evaluating, and auditing orthognathic operations. The minimum dataset guidelines of the British Orthodontic Society (BOS) and the British Association of Oral and Maxillofacial Surgeons (BAOMS) were published in an attempt to standardise the collection of clinical records of patients having orthognathic operations. This multicentre retrospective audit aimed to assess and compare compliance with the guidelines in 3 maxillofacial units over a 1-year period. A total of 105 cases were reviewed. Compliance varied. Documentation of altered sensation was consistently poor and too many unnecessary radiographs were taken. There may be a need to circulate the guidelines again to increase awareness and reduce variability between centres.

Soft tissue cephalometric norms for orthognathic and cosmetic surgery.

PURPOSE: Proportionality of the lower and middle thirds of the face is a key determinant of successful orthognathic treatment. A flatter profile and marked variance of the soft tissue envelope in the Japanese population complicates the accurate assessment of these proportions. This study aimed to identify gender differences and establish norms for Japanese young adults using the method of soft tissue cephalometric analysis (STCA) by Arnett et al (Am J Orthod Dentofacial Orthop 116:239, 1999). MATERIALS AND METHODS: Lateral cephalograms of 49 young normal Japanese subjects (19 men, 30 women) were selected from the archival records and analyzed with STCA. The Student t test was used to compare mean values of the male and female groups. RESULTS: Significant differences were found between women and men. Men had a flatter occlusal plane and a more acute nasolabial angle than women. Men showed larger values for upper and lower lip thickness, menton soft tissue thickness, and vertical face length, especially in the lower third of the face. Women had a more projected midface than men. Compared with established STCA norms, the Japanese have more midfacial projection. CONCLUSIONS: Significant gender differences were found in the thickness, lower third length, and midface projection in Japanese young adults, which should be taken into account when interpreting measurements for orthognathic surgical planning. These differences can serve as norms for STCA in young Japanese adults. Differences were noted between the reference values of Arnett et al and Japanese subjects.

Osteotomía distal mandibular y fractura en tallo verde / No disponible

No disponible

Consent for orthognathic surgery: a UK perspective.

Obtaining consent to undertake orthognathic surgery is a legal requirement that starts at the initial visit when treatment is being considered and continues until the operation itself. The process includes discussion of the benefits, risks, and potential complications of the proposed procedure, and any alternative (including doing nothing), but there is no consensus about how much information should be disclosed. Guidance is provided on the basis of case law, which is itself evolving. The purpose of this study was to look at the current practice of obtaining consent for orthognathic surgery by oral and maxillofacial surgeons in the UK to act as a benchmark and potentially to stimulate further debate. We also review common and serious complications that might be included in the process.

[Mediсo-organizational principles of orthopedic stomatological care rendering to patients with postoperative maxillofacial defects].

Complex research in which result key problems are revealed is done and the medico-organizational substantiation is given modern principles of rendering of the orthopedic care to the patients with maxillofacial defects.