Biocompatibility Analyses of HF-Passivated Magnesium Screws for Guided Bone Regeneration (GBR).

Background: Magnesium (Mg) is one of the most promising materials for human use in surgery due to material characteristics such as its elastic modulus as well as its resorbable and regenerative properties. In this study, HF-coated and uncoated novel bioresorbable magnesium fixation screws for maxillofacial and dental surgical applications were investigated in vitro and in vivo to evaluate the biocompatibility of the HF coating. Methods: Mg alloy screws that had either undergone a surface treatment with hydrofluoric-acid (HF) or left untreated were investigated. In vitro investigation included XTT, BrdU and LDH in accordance with the DIN ISO 10993-5/-12. In vivo, the screws were implanted into the tibia of rabbits. After 3 and 6 weeks, degradation, local tissue reactions and bony integration were analyzed histopathologically and histomorphometrically. Additionally, SEM/EDX analysis and synchrotron phase-contrast microtomography (µCT) measurements were conducted. The in vitro analyses revealed that the Mg screws are cytocompatible, with improved results when the surface had been passivated with HF. In vivo, the HF-treated Mg screws implanted showed a reduction in gas formation, slower biodegradation and a better bony integration in comparison to the untreated Mg screws. Histopathologically, the HF-passivated screws induced a layer of macrophages as part of its biodegradation process, whereas the untreated screws caused a slight fibrous tissue reaction. SEM/EDX analysis showed that both screws formed a similar layer of calcium phosphates on their surfaces and were surrounded by bone. Furthermore, the µCT revealed the presence of a metallic core of the screws, a faster absorbing corrosion front and a slow absorbing region of corroded magnesium. Conclusions: Overall, the HF-passivated Mg fixation screws showed significantly better biocompatibility in vitro and in vivo compared to the untreated screws.

Complicaciones perioperatorias y postquirúrgicas tempranas en cirugía ortognática / Intraoperative and immediate post surgical complications in orthognathic surgery

Objetivos: La cirugía ortognática ha experimentado un desarrollo significativo en las últimas décadas que la ha convertido en una técnica segura, pero no está exenta de presentar complicaciones. El objetivo del estudio es evaluar las complicaciones perioperatorias y postquirúrgicas inmediatas (durante el ingreso del paciente) asociadas a la cirugía ortognática en pacientes intervenidos de deformidades dentofaciales en nuestro hospital, analizando las características epidemiológicas de los pacientes y las posibles asociaciones entre el sexo, la edad, el tipo de osteotomía realizada y las complicaciones más frecuentes. Material y métodos: Realizamos un estudio descriptivo retrospectivo que comprende 284 intervenciones de cirugía ortognática realizadas consecutivamente entre el 1 de enero del 2000 y el 31 de diciembre del 2016 en el Hospital Povisa de Vigo. Resultados: La media de edad de los pacientes intervenidos fue de 28,72 años. El 64,4 % eran mujeres. La deformidad dentofacial más frecuentemente tratada fue la maloclusión clase III de Angle, y la osteotomía con mayor incidencia fue la osteotomía tipo Le Fort I del maxilar superior. La mayoría de los pacientes fueron clasificados como ASA I. El tiempo operatorio promedio fue de 174 minutos y el tiempo medio de hospitalización fue de 3,26 días. Las náuseas o vómitos en el postoperatorio inmediato (NVPO) fue la complicación más frecuentemente registrada. Se encontraron correlaciones estadísticamente significativas entre el tipo de osteotomía realizada y la hemorragia, las NVPO, la ansiedad, la necesidad de transfusión sanguínea y el dolor postoperatorio. Conclusión: El bajo índice de complicaciones encontradas en el presente estudio sugiere que la cirugía ortognática es un procedimiento quirúrgico seguro

Objectives: Orthognathic surgery has undergone a significant development in recent years becoming a safe surgical technique. However, different complications can occur after orthognathic surgery. The purpose of this study is to analyze the possible complications found during surgery and immediately after orthognatic surgery, at our institution. Material and methods: A retrospective descriptive study comprising 284 consecutive orthognathic surgical procedures performed between January 1, 2000 and December 31, 2016 at Povisa Hospital, Vigo, Spain, were studied. Results: Mean age of the treated patients was 28.72 years. 64.4 % were women. The most frequent dentofacial deformity diagnosed was Angle class III malocclusion and the most frequent performed osteotomy was Le Fort I maxillary osteotomy. The majority of patients were classified as ASA I. Mean operative time was 174 minutes and mean hospitalization time was 3.26 days. Postoperative nausea or vomiting (PONV) was the most frequent complication found. Statistically significant correlations were found between the type of osteotomy performed and postoperative bleeding, PONV, anxiety, need of blood transfusion and postoperative pain. Conclusions: The low rate of complications found in the present study suggests that orthognathic surgery is a safe surgical procedure

Concepts, protocol, variations and current trends in surgery first orthognathic approach: a literature review.

In the current era of expedited orthodontics, among many clinicians, tertiary care hospitals and patients, surgery first orthognathic approach (SFOA) has gained popularity. The advantages of SFOA (face first approach) are the reduced overall treatment duration and the early improvement in facial esthetics. In SFOA, the absence of a presurgical phase allows surgery to be performed first, followed by comprehensive orthodontic treatment to achieve the desired occlusion. The basic concepts of surgery early, surgery last, SFOA and Sendai SFOA technique along with its variations are reviewed in the present article. The recent advancement in SFOA in the context of preoperative preparation, surgical procedures and post-surgical orthodontics with pertinent literature survey are also discussed.

Concepts, protocol, variations and current trends in surgery first orthognathic approach: a literature review

ABSTRACT In the current era of expedited orthodontics, among many clinicians, tertiary care hospitals and patients, surgery first orthognathic approach (SFOA) has gained popularity. The advantages of SFOA (face first approach) are the reduced overall treatment duration and the early improvement in facial esthetics. In SFOA, the absence of a presurgical phase allows surgery to be performed first, followed by comprehensive orthodontic treatment to achieve the desired occlusion. The basic concepts of surgery early, surgery last, SFOA and Sendai SFOA technique along with its variations are reviewed in the present article. The recent advancement in SFOA in the context of preoperative preparation, surgical procedures and post-surgical orthodontics with pertinent literature survey are also discussed.

RESUMO Na presente era da Ortodontia de resultados acelerados, a cirurgia ortognática com benefício antecipado (COBA) ganhou popularidade entre muitos clínicos, hospitais terciários e pacientes. A vantagem da COBA é a redução da duração total do tratamento, juntamente com a melhora precoce da estética facial. Na COBA, a ausência de uma fase pré-cirúrgica permite que a cirurgia seja realizada antes e, só então, venha o tratamento ortodôntico abrangente para se alcançar a oclusão desejada. Os conceitos básicos de cirurgia primeiro, cirurgia por último, COBA e a técnica COBA de Sendai, bem como suas variações, são aqui revistos. Também são discutidos no presente artigo, junto com a revisão da literatura pertinente, os recentes avanços da COBA no contexto do preparo pré-cirúrgico, dos procedimentos cirúrgicos e da Ortodontia pós-cirúrgica.

Current Concepts in Orthognathic Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify skeletal differences that are treated with orthognathic surgery; describe the goals of orthognathic surgery; and understand modern virtual surgical planning of orthognathic movement of the mandible, maxilla, and chin. 2. Appreciate the surgical principles of maxilla- versus mandible-first surgery, and orthognathic surgery before orthodontic correction; and understand when an osseous genioplasty may be beneficial, and the potency of this bony movement. 3. Appreciate the utility of fat grafting as an adjunct to orthognathic bony movements, and demonstrate understanding of the utility of orthognathic surgery in the treatment of obstructive sleep apnea. 4. Be aware of associated complications and be able to critically assess outcomes following orthognathic surgery. SUMMARY: This CME article outlines the goals of orthognathic surgery, highlighting advances in the field and current controversies. The principles of the sequencing of osteotomies are discussed and literature is reviewed that may assist in decision-making as to maxilla-first versus mandible-first surgery. The emergence of "surgery first," in which surgery precedes orthodontics, is discussed and important parameters for patient candidacy for such a procedure are provided. The emerging standard of virtual surgical planning is described, and a video is provided that walks the reader through a planning session. Soft-tissue considerations are highlighted, especially in the context of osseous genioplasty and fat grafting to the face. The utility of orthognathic surgery in the treatment of obstructive sleep apnea is discussed. The reader is provided with the most current data on complications following orthognathic surgery and advice on avoiding such pitfalls. Finally, outcome assessment focusing on the most current trend of patient-reported satisfaction and the psychological impact of orthognathic surgery are discussed.

Antifibrinolytic Agents in Plastic Surgery: Current Practices and Future Directions.

BACKGROUND: Prevention of blood loss is a chief consideration in plastic and reconstructive surgery. The antifibrinolytic drugs tranexamic acid and ε-aminocaproic acid have emerged as promising agents to reduce both perioperative blood loss and transfusion requirements. However, published reports in the plastic surgery literature are lacking. The authors sought to summarize the current knowledge of the use of antifibrinolytics in plastic surgery by reviewing the existing literature for clinical outcomes and recommendations. METHODS: A systematic review of the PubMed, Cochrane, and Google Scholar databases was conducted for publications examining the use of antifibrinolytics in plastic surgery. Studies were abstracted for procedure type, antifibrinolytic dose, time and mode of administration, blood loss, transfusion requirements, and complications. RESULTS: Thirty-three studies were deemed eligible for inclusion, comprising a total of 1823 patients undergoing plastic surgical procedures with tranexamic acid (n = 1328) and/or ε-aminocaproic acid (n = 495). CONCLUSIONS: Tranexamic acid and ε-aminocaproic acid are widely used to reduce blood loss and transfusion requirements in craniofacial and orthognathic surgery, without an increased risk of adverse events. Intravenous administration is most commonly used, although topical formulations show similar efficacy with a reduced systemic distribution. Tranexamic acid has also emerged as a promising agent in aesthetic surgery and burn care, due to its favorable safety profile and role in reducing blood loss, achieving an improved surgical field, and reducing edema and ecchymosis. Further investigation of these agents in the fields of burn care, aesthetic surgery, and microsurgery is warranted to standardize protocols for clinical use.

Cleft Palate Repair: Description of an Approach, Its Evolution, and Analysis of Postoperative Fistulas.

BACKGROUND: Fistulas following cleft palate repair impair speech, health, and hygiene and occur in up to 35 percent of cases. The authors detail the evolution of a surgical approach to palatoplasty; assess the rates, causes, and predictive factors of fistulas; and examine the temporal association of modifications to fistula rates. METHODS: Consecutive patients (n = 146) undergoing palatoplasty during the first 6 years of practice were included. The technique of repair was based on cleft type, and a common surgical approach was used for all repairs. RESULTS: The fistula rate was 2.4 percent (n = 125) after primary repair and 0 percent (n = 21) after secondary repair. All complications occurred in patients with type III or IV clefts. Cleft width and cleft-to-total palatal width ratio were associated with fistulas, whereas syndromes, age, and adoption were not. Most complications could also be attributed to technical factors. During the first 2 years, modifications were made around specific anatomical features, including periarticular bony hillocks, maxillopalatine suture, velopalatine pits, and tensor insertion. The fistula rate declined by one-half in subsequent years. CONCLUSIONS: The authors describe a surgical approach to cleft palate repair, its evolution, and surgically relevant anatomy. Fistulas were associated with increasing cleft severity but could also be attributed to technical factors. A reduction in frequency and severity of fistulas was consistent with a learning curve and may in part be associated with modifications to the surgical approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cleft-Palate Repair: Does Hospital Case-Volume Impact Outcomes or Cost?

BACKGROUND: How hospital case-volume affects operative outcomes and cost continues to grow in importance. The purpose of this study was to examine the relationship of case volume with operative outcomes and cost in cleft palate repair. METHODS: Subjects undergoing cleft palate repair between 2004 and 2015 were identified in the Pediatric Health Information System. Outcomes were compared between two groups: those undergoing treatment at a high-volume institution, and those undergoing treatment at a low-volume institution. Primary outcomes were as follows: any complication, prolonged length of stay, and increased total cost. RESULTS: Over 20,000 patients (n = 20,320) from 49 institutions met inclusion criteria. On univariate analysis, those subjects who underwent treatment at a high-volume institution had a lower rate of overall complications (3.4 percent versus 5.1 percent; p < 0.001), and lower rates of prolonged length of stay (4.5 percent versus 5.8 percent; p < 0.001) and increased total cost (48.6 percent versus 50.9 percent; p = 0.002). In multivariate regression analyses, subjects treated in high-volume centers were less likely to experience any complication (OR, 0.678; p < 0.001) and were less likely to have an extended length of stay (OR, 0.82; p = 0.005). Subjects undergoing palate repair at a high-volume institution were no less likely to incur increased total cost (OR, 1.01; p = 0.805). CONCLUSION: In institutions performing a high volume of cleft palate repairs, subjects had significantly decreased odds of experiencing a complication or prolonged length of stay. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Modern trends in Class III orthognathic treatment: A time series analysis.

OBJECTIVE: To examine the current trends in surgical-orthodontic treatment for patients with Class III malocclusion using time-series analysis. MATERIALS AND METHODS: The records of 2994 consecutive patients who underwent orthognathic surgery from January 1, 2004, through December 31, 2015, at Seoul National University Dental Hospital, Seoul, Korea, were reviewed. Clinical data from each surgical and orthodontic treatment record included patient's sex, age at the time of surgery, malocclusion classification, type of orthognathic surgical procedure, place where the orthodontic treatment was performed, orthodontic treatment modality, and time elapsed for pre- and postoperative orthodontic treatment. RESULTS: Out of the orthognathic surgery patients, 86% had Class III malocclusion. Among them, two-jaw surgeries have become by far the most common orthognathic surgical treatment these days. The age at the time of surgery and the number of new patients had seasonal variations, which demonstrated opposing patterns. There was neither positive nor negative correlation between pre- and postoperative orthodontic treatment time. Elapsed orthodontic treatment time for both before and after Class III orthognathic surgeries has been decreasing over the years. CONCLUSION: Results of the time series analysis might provide clinicians with some insights into current surgical and orthodontic management.

[Temporo-mandibular joints and orthognathic surgery]. / Articulations temporo-mandibulaires et chirurgie orthognathique.

Temporo-Mandibular Joints (TMJ) and orthognathic surgery are closely linked. In the past, some authors have even described (with mixed results) the correction of some dysmorphosis through direct procedures on the TMJs. Nowadays, performing orthognathic surgery involves the TMJ in three different occasions: (1) TMJ disorders potentially responsible for dento-maxillary dysmorphosis, (2) effects of orthognathic surgery on TMJs, and (3) condylar positioning methods in orthognathic surgery. These three chapters are developed in order to focus on the close relationships between TMJ and orthognathic surgery. Some perspectives close this article.

Combined surgical-orthodontic treatment: how did it evolve and what are the best practices now?

It has been 50 years since the landmark presentation by Hugo Obwegeser at Walter Reed Army Hospital. At that conference, Professor Obwegeser offered American surgeons techniques to correct facial skeletal deformities with access through intraoral incisions. As important advances in surgical technique and anesthesia evolved for the surgical procedures, a major contribution by American orthodontists in collaboration with surgeons was the creation of a common diagnostic, planning, and treatment scheme for use by both clinician groups in the treatment of dentofacial deformities, the skeletal and dental problems of the most severely affected 5% of the population. This article summarizes what American orthodontists and surgeons have learned in the late 20th and early 21st centuries, and forecasts what might be the future of treatment for patients with dentofacial deformities.

Mandibular surgery: technologic and technical improvements.

The ability of surgeons to use advanced techniques can significantly improve both surgical outcome and patient satisfaction. Surgical evolution in mandibular orthognathic surgery is no exception, because advancements have aided both surgical planning and technique. It is important for clinicians to be aware of the historical progression of improvements in this technique and appreciate the technologic advancements as they are happening. Computer-driven surgical planning is becoming increasingly popular, providing surgeons and patients with the ability to adjust to intraoperative and postoperative variations. By using these capabilities, clinicians are now able to give patients the best possible outcomes.

Maxillary orthognathic surgery.

Maxillary surgery to correct dentofacial deformity has been practiced for almost 100 years. Significant advances have made maxillary surgery a safe and efficient means of correcting midface deformities. Anesthetic techniques, specifically hypotensive anesthesia, have allowed for safer working conditions. Landmark studies have proven manipulation and segmentalization of the maxilla is safe and allowed this surgery to become a mainstay in corrective jaw surgery. This article provides an overview of surgical techniques and considerations as they pertain to maxillary surgery for orthognathic surgery. Segmental surgery, openbite closure, vertical excess, grafting, and a technology update are discussed.

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)

Regenerative medicine: implications for craniofacial surgery.

Craniofacial reconstruction of cases with complex anatomy challenges surgeons. The recently emerging field of tissue engineering and regenerative medicine has resulted in a variety of novel therapeutic concepts particularly in the craniofacial area. However, researchers still face significant problems when translating scientific concepts from the bench to the bedside. Reconstruction procedures depend on sustainability, aesthetic outcome, and functionality. Tissue engineering approaches yield powerful tools for long-term satisfying results enabling customized reconstruction and supporting natural healing processes. In conclusion, further advances of tissue-engineered reconstruction need multidisciplinary research to create complex tissue structures and make satisfactory outcomes clinically achievable for most patients. This review highlights clinical advances in the field and gives an overview about current scientific concepts.

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.