Iatrogenic retroposition of the lips sequel after bicuspid extraction-a retrospective study.

AIM: This study aims to explore the prevalence of Iatrogenic retroposition of the lips sequel (IRLS) after bicuspid extraction, associated dentofacial characteristics and the effectiveness of surgical treatment. MATERIAL: and methods: Patients with bicuspid extraction as part of an orthodontic treatment plan were retrospectively included. IRLS was identified by clinical evaluation and cephalometric Legan and Burstone analysis. Association of demographic and cephalometric variables were assessed. The effectiveness of combined orthodontic-orthognathic correction of the retroposition of the lips was evaluated. RESULTS: Out of 144 patients with extracted bicuspids, eight Class I patients, nine Class II patients and five Class III patients were seeking treatment because their lips had retruded as a consequence of compensating orthodontic treatment. Lower jaw bicuspid extraction and a decreased vertical facial height in Class II patients correlated significantly more with IRLS development. Postoperative cephalometric analysis of orthodontic-orthognathic treated patients reported improvement in lip projection and naso-labial angle. Only two Class I patients reported postoperative normalization of the lip position according to Legan and Burstone. CONCLUSION: The consequence of bicuspid extractions on soft tissue profile differs according to skeletal jaw relation. The impact of orthognathic surgery on IRLS is beneficial, although insufficient to completely correct the facial profile when judged on cephalometric standards.

Belgian consensus guideline on the management of hemorrhoidal disease.

Introduction: Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking. Methods: A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020. Results: Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids. Conclusions: The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

The use of Medpor implants for midface contouring in cleft patients.

Three-dimensional midfacial deficiency in cleft patients is common and is frequently connected to impairment of the aesthetic facial appearance. Different approaches to augment relevant facial regions are available. Alloplastic facial implants have been established as a viable alternative to autologous tissue augmentation in various circumstances. However, in cleft patients, the application of facial implants has rarely been reported. This retrospective study aimed to evaluate the use of Medpor implants for midfacial contouring in cleft patients. Fifty-one patients with orofacial clefts were assessed with regard to defined parameters. A range of Paranasal, Malar and Nasal Dorsum Medpor implants had been used. Unilateral cleft lip and palate (UCLP) represented the most common indication, followed by bilateral cleft lip and palate (BCLP). Bilateral implant insertion was performed as a general rule with few exceptions. Insertion of implants was frequently combined with other cleft-related surgical procedures. Even after orthognathic surgery, midfacial augmentation was implemented to specifically address residual volume deficiency, particularly in the malar region. The complication rate amounted to 4.9% (6/122 implants). Based on our findings, Medpor implants are reliable and long-term stable materials to successfully augment paranasal, subnasal and malar areas as well as a solid nasal dorsum material with few complications in cleft patients.

Comparison of three methods of facial measurement.

The aims of this study were to assess the accuracy of measurements recorded by 3D stereophotogrammetry and to compare three methods of facial measurement: manual anthropometry, 3D stereophotogrammetry and 2D photography. Measurements were taken from 14 landmarks on each of six volunteers and compared. In addition, the variability of the methods was assessed. Three-dimensional measurements were shown to compare well with manual measurements on volunteers as well as test objects for which the mean difference was 0.23 mm (shortest distance) and 0.13 mm (surface). All the three methods of measurement were found to have good levels of repeatability. Two-dimensional measurements were more variable than manual measurements (P=0.021). Three-dimensional stereophotogrammetric measurements were shown to compare well with manual measurements although the values obtained were mostly slightly larger. Stereophotogrammetry allows images to be taken in a Medical Photography Department, facilitating the accurate measurement of facial morphology from digitized data, including changes associated with treatment or growth. There are clear potential benefits of using 3D measurements in the assessment of facial deformity.

Biodegradable self-reinforced poly-L/DL-lactide plates and screws in bimaxillary orthognathic surgery: short term skeletal stability and material related failures.

Biodegradable self-reinforced poly-L/DL-lactide plates and screws were used for osteosynthesis in 10 consecutive cases of bimaxillary procedures with simultaneous genioplasties, without postoperative rigid intermaxillary fixation. During surgery, data were gathered concerning failure of the osteosynthesis material. Clinical examination was carried out weekly until the sixth postoperative week. Cephalometric analysis of standardized cephalograms was performed to evaluate the short-term skeletal stability pattern, which was compared with similar reports in the literature. Six weeks postoperatively, all jaws were clinically stable and there was no clinical evidence of foreign body reactions. For the whole group (n = 10), the mean maxillary advancement at point A was 2.9 mm with a mean postoperative relapse of 0.0 mm. The mean advancement at point B was 2.8 mm with a mean additional advancement postoperatively of 1.1 mm. The mean vertical surgical displacement at point A was directed inferiorly with a value of 1.8 mm and a relapse of -0.4 mm. At point B the corresponding values were 1.9 mm and -0.4 mm. In the Angle Class III group (n = 4), the mean advancement at A was 5.9 mm with an additional postoperative advancement of 0.3 mm. In the Angle Class II group (n = 6), mean advancement at point B was 4.0 mm, with an additional postoperative advancement of 1.1 mm. In the group with short face deformity (n = 3), the mean inferior movement in ANS was 6.6 mm with a relapse of -0.2 mm. At menton the vertical surgical movement was 13.0 mm with a relapse of -0.2 mm. None of the plates, which were bent at room temperature, broke. The screw heads broke or had an insufficient fit in the bone in 12 of 305 (3.9%) screws. It can be concluded that the tested system of biodegradable self-reinforced poly-L/DL-lactide screws and plates has a small material-related failure rate, and that their application in orthognathic surgery leads to a predictable short-term skeletal stability pattern which is comparable to the 'gold standard' of titanium plates and screws.

The Le Fort I osteotomy as a surgical approach for removal of tumours of the midface.

Tumours of the midface and maxillary sinuses have been removed via multiple approaches. The most common approaches are those using incisions in the facial skin, especially in the case of malignant tumours. The Le Fort I procedure via an intraoral incision as described by Sailer in 1986 is a versatile alternative. Combined with a coronal approach and various osteotomies of the upper face it also allows removal of tumours extending into the orbits, the nasoethmoidal complex and the skull base. The versatility of the Le Fort I osteotomy as a surgical approach was analysed in 17 cases. This method is reliable and gives excellent access. Further advantages are the wide surgical exposure and the clear visibility of the resection margins, the absence of visible scars, the feasibility of combining this approach with reconstruction using the buccal fat pad and the possibility of simultaneous placement of bone grafts, insertion of endosseous implants or other preprosthetic procedures via the same incision.

Biodegradable polylactide plates and screws in orthognathic surgery: technical note.

In orthognathic surgery, the bone fragments are usually fixed with metallic plates and screws. Metallic devices other than titanium plates are usually removed after the osteotomy has consolidated, which often requires general anaesthesia. Titanium plates, supposed to be biotolerable, have been introduced in order to overcome this need for secondary intervention. However, due to corrosion, titanium particles have been found in scar tissue covering these plates and in locoregional lymph nodes. Therefore, their removal is also advocated. Self-reinforced poly (L-lactide) homopolymer (PLLA) and poly (L/D-lactide) stereocopolymers with a L/D molar ratio up to 85/15 have sufficient strength to overcome the need for additional support for the fixation of fractures. The plates can be bent at room temperature. The surgical technique and early results of a case of bimaxillary surgery and genioplasty fixed with bioresorbable material without postoperative rigid maxillomandibular fixation are reported.

The role of a posteriorly inclined condylar neck in condylar resorption after orthognathic surgery.

Recently, it has been reported that a posteriorly inclined condylar neck is associated with condylar resorption following orthognathic surgery, although its role in resorption remains unknown. By cephalometric screening of 240 patients with Angle Class II occlusion 2 years after orthognathic surgery, 11 patients with postoperative condylar resorption were identified. The preoperative posterior inclination of the condylar neck and the surgical risk factors mentioned in the literature, particularly surgically induced counterclockwise rotation of the mandibular proximal segment were evaluated. In all 11 cases, the condylar neck was clearly inclined posteriorly. Counterclockwise rotation of the proximal segment was also observed in all cases, and it amounted to 6.7 degrees (2.5-12 degrees) on average. The contributing role of a posteriorly inclined condylar neck in connection with surgical mandibular movement in postoperative condylar resorption is discussed.

Development of the frontal sinus following bilateral fronto-orbital osteotomies.

The presence of frontal sinuses following bilateral fronto-orbital advancement is discussed controversially in the literature. In a retrospective study, 33 patients (18 male and 15 female) were operated on between 1982 and 1993, with at least one year postoperative follow-up and with a minimum age of 6 years at the end of the follow-up period following bilateral fronto-orbital remodelling, were included. The average age at which the procedure was performed was 29 months with a minimum of 3 months and a maximum of 7.8 years. The study presented shows a pneumatization of the frontal sinus in 72.7% of 33 patients following bilateral fronto-orbital advancement. The first radiographic signs of sinus development were detected between the ages of 4 and 11, average 8.3 years. There were no statistically proven correlations between frontal sinus pneumatization and age at operation or the amount of advancement or sex of the patients. Surgical enlargement of the cranium by frontal advancement with adequate stabilization results in an enlargement of the neurocranium, thereby decreasing pressure on the inner frontal cortex and allowing frontal sinus pneumatization to proceed normally. Hence, the development of a frontal sinus may be a reflection of the effectiveness of the surgical therapy.

Mandibular resorption due to systemic sclerosis. Case report of surgical correction of a secondary open bite deformity.

Systemic sclerosis (SSc) is a connective-tissue disorder of unknown origin causing a multisystem disease. While erosions of the distal phalanges are commonly described, resorption of the mandible has been considered an unusual finding. However, systematic radiographic screening of different groups of patients suffering from SSc revealed a resorption incidence of 20-33% of the examined mandibles. Women especially seem to be affected, and the male/female ratio is 1/7. Bilateral condylysis due to SSc has been described in seven cases, or 13.7% of the reported cases. To the best of our knowledge, this is the fourth report of surgical correction of secondary dysgnathia due to systemic sclerosis and the first with a 2-year follow-up period.

The bilobed myocutaneous pectoralis major flap in closure of combined intra- and extraoral defects.

Oral carcinomas may eventually invade the perioral soft tissues. In such cases, tumor resection creates through and through defects. Similar defects are seen in patients with gunshot wounds. The versatility of the bilobed myocutaneous pectoralis major flap in closure of these defects is emphasized. The results in nine patients treated by this method are discussed.

The unilateral hockey-stick incision for neck dissection in oral carcinoma. Technical note.

In 42 patients, a hockey-stick incision was used as standard approach in unilateral neck dissection. This approach permits a good overview of all structures in the neck and allows en bloc resection with intraoral tumor removal. The incision does not interfere with simultaneous reconstruction by pedicled or free flaps, and results in a scar which is barely visible and easily covered.

The value of stereolithographic models for preoperative diagnosis of craniofacial deformities and planning of surgical corrections.

The purpose of this study was to assess the importance of stereolithographic models (SLMs) for preoperative diagnosis and planning in craniofacial surgery and to examine whether these models offer valuable additional information as compared to normal CT scans and 3D CT images. Craniofacial SLMs of 20 patients with craniomaxillofacial pathology were made. A helical volume CT scan of the anatomic area involved delivered the necessary data for their construction. These were built with an SLA 250 stereolithography apparatus (3D-Systems, Valencia, CA, USA), steered by FORM-IT/DCS software (University of Zurich, Switzerland). The stereolithography models were classified according to pathology, type of surgery and their relevance for surgical planning. Though not objectively measurable, it was beyond doubt that relevant additional information for the surgeon was obtained in cases of hypertelorism, severe asymmetries of the neuro- and viscerocranium, complex cranial synostoses and large skull defects. The value of these models as realistic "duplicates" of complex or rare dysmorphic craniofacial pathology for the purpose of creating a didactic collection should also be emphasized. The models proved to be less useful in cases of consolidated fractures of the periorbital and naso-ethmoidal complex, except where there was major dislocation.

Multimodal strategy for reduction of homologous transfusions in cranio-maxillofacial surgery.

The transfusion of homologous blood carries well-known risks that have prompted efforts to develop alternative techniques. Such measures are of particular interest to patients undergoing elective procedures. A total of 204 patients, out of 1470 patients who consecutively underwent major craniomaxillofacial procedures under general anesthesia over a two-year period, were enrolled in a prospective protocol to reduce homologous transfusion requirements when a blood loss in excess of 500 ml was anticipated. The data were compared with the results of a retrospective control group (n=2890) covering major procedures during the previous four years, when blood-saving measures were applied occasionally, but not based on a global strategy. Techniques for the reduction of homologous transfusions were acute normovolemic hemodilution, controlled moderate hypotension, cell saver and predeposit autologous blood. In addition, preoperative administration of human recombinant erythropoietin was introduced during the last year of the study. These techniques were applied individually or in combination, depending on contraindications specific for each technique, using invasive monitoring in order to maintain intraoperative hemodynamic stability. The goal of this study was to examine the extent to which homologous transfusions may be reduced with the systematic application of transfusion-sparing techniques. Of 204 patients qualifying for the transfusion-sparing protocol, 30 received homologous transfusions. In comparison to the control group, utilization of transfusion-sparing techniques had doubled. The overall reduction in the use of homologous transfusions was highly significant. When acute normovolemic hemodilution, controlled moderate hypotension and the cell saver were used in combination, a greater reduction in homologous transfusions was achieved than with the use of either a single modality or combination of any two. No transfusions were required in patients pretreated with erythropoietin.

Reconstruction of the severely resorbed mandible prior to vestibuloplasty or placement of endosseous implants. A 2 to 5 year follow-up.

Ninety-two patients underwent augmentation of the severely resorbed mandible using corticocancellous bone grafts in the symphysis and a mixture of autogenous cancellous bone chips and hydroxylapatite particles in the posterior area. This study, extending from 2 to 5 years, shows that predictable and stable results were achieved. The average loss of height measured at 3 reference points was approximately 20%. Slight sensory disturbance was present in 19 patients (23%). Benefits derived from augmentation of the atrophic mandible include: improvement of facial form due to the renewed support of the collapsed circumoral muscles, a decrease in the intermaxillary distance, and restoration of mandibular bone bulk that will accommodate endosseous implants of maximum size.

Late management of secondarily grafted clefts.

34 patients (40 sides) received alveolo-palatal bone grafts for closure of the residual cleft, thus guiding a lateral incisor or canine into the arch. Long-term follow-up shows that in 41% of the patients uninterrupted arches were achieved with a normal relationship by orthodontic treatment only. 38% needed segmental osteotomies to eliminate the edentulous space, and in only 20% were bridges made to restore the dental arch. 9 (25%) patients still required a Le Fort I advancement osteotomy, despite optimal orthodontic treatment. The use of segmental osteotomies for eliminating edentulous spaces in cleft palate patients is discussed, and their advantage in relation to nasal base support is emphasized. It should be the aim to achieve in every cleft palate patient a complete archform without the need for bridges or removable prostheses. A rational orthodontic-surgical approach to the cleft, lip and palate patient is suggested with respect to naso-maxillary growth and development.

Surgical risk factors for condylar resorption after orthognathic surgery.

OBJECTIVE: The purpose of this study was to look for surgical risk factors for condylar resorption after orthognathic surgery. STUDY DESIGN: Seventeen patients of a group of 452 patients who had undergone orthognathic surgery consecutively and who were in accordance with the inclusion criteria of this study showed postoperative condylar resorption (group I). Preoperative cephalometric characteristics and surgically induced movements of this group were compared with a control group of 17 of 452 patients (group II) in whom postoperative condylar resorption and skeletal relapse did not develop, despite mandibular retrognathism (ANB angle >4 degrees) and high mandibular plane angle (>40 degrees). RESULTS: The kind of osteosynthesis used was not significantly different between the 2 groups. The amount of surgical advancements and the vertical movements of the jaws were not significantly different between the 2 groups. However, the distal (P =.005) and proximal (P =.007) mandibular segments were rotated significantly further counterclockwise in group I. Surgically induced posterior condylar displacement occurred significantly more frequently (P =.007) in group I. CONCLUSIONS: Counterclockwise rotation of the distal and proximal mandibular segments and surgically induced posterior condylar displacement seem to be important surgical risk factors for postoperative condylar resorption. Therefore, these movements seem to be contraindicated in patients who are at high risk.

Mandibular reconstruction with full thickness calvarial bone and temporal muscle flap.

Eleven patients underwent mandibular reconstruction with pedicled temporal muscle flaps combined with vascularised or free full thickness calvarial bone grafts. Six were primary and five secondary reconstructions. The indications were squamous cell carcinoma (n = 6), radio-osteonecrosis (n = 4), and gunshot wound (n = 1). Five patients also had endosseus implants, either simultaneously or delayed. The only major complications were necrosis of the whole calvarial bone (n = 1) and permanent facial nerve palsy (n = 1). The advantages of using full thickness calvarial bone are that it is thick enough to take an endosseous implant, morbidity is low, there is virtually no postoperative pain, the scar is invisible, and there is only one donor area for both hard and soft tissue. Transplantation of full thickness calvarial bone and temporal muscle is a viable alternative to an osseomyocutaneous microvascularised free flap for reconstruction of the mandible when the neck has been previously operated on or irradiated, and anastomosis may be critical.