Retrospective Cohort Studies in Craniofacial Outcomes Research: An Epidemiologist's Approach to Mitigating Bias.

Retrospective cohort studies, defined as a follow-up study in which outcome occurred prior to study onset, are common in craniofacial outcomes research and will continue to be prevalent given the increasing availability of secondary datasets and inherent prospective study limitations. However, if available data are not adequately measured, or necessary variables are absent, retrospective cohort studies can be particularly prone to bias. This brief communication aims to highlight the primary sources of bias, including measurement error, selection bias, and confounding. Each source is clearly defined, examples pertinent to craniofacial outcomes are provided, and mitigation strategies are discussed.

Eyeing Risks: A Critical Analysis of the Use of Periorbital Steroids in Fronto-orbital Advancement.

OBJECTIVE: To evaluate the outcomes associated with two techniques of periorbital steroid administration in bilateral fronto-orbital advancement (FOA). DESIGN: Multi-institutional retrospective chart review. SETTING: Two high volume, tertiary US craniofacial centers. PATIENTS, PARTICIPANTS: Patients who underwent FOA between 2012 and 2021. INTERVENTIONS: Patients were divided into three cohorts based on method of steroid administration. Groups GEL and INJ represent those who received steroids in the form of triamcinolone soaked gelfoam or direct injection of dilute triamcinolone to the frontal/periorbital region, respectively. Group NON did not receive any periorbital steroids. MAIN OUTCOME MEASURE(S): Peri-operative outcomes including hospital length of stay and complications were evaluated based on method of periorbital steroid administration. Variables predictive of infectious complications were assessed using stepwise logistic regression. RESULTS: Four hundred and twelve patients were included in our sample (INJ:249, GEL:87, NON:76). Patients in the INJ group had a higher ASA class (P < .001) while patients in the NON group were significantly more likely to be syndromic (P < .001) and have multisuture craniosynostosis (P < .001). Rate of infectious complications for each cohort were NON: 2.6%, INJ: 4.4%, and GEL: 10.3%. There was no significant difference between groups in hospital length of stay (P = .654) or rate of post-operative infectious complications (P = .061). Increased ASA class (P = .021), increased length of stay (P = .016), and increased intraoperative narcotics (P = .011) were independent predictors of infectious complications. CONCLUSIONS: We identified a dose-dependent relationship between periorbital steroids and rate of postoperative infections, with key contributions from ASA class, hospital length of stay, and dose of intraoperative narcotics.

Factors Contributing to Canine Impaction in Patients With Unilateral Cleft Lip and Palate Undergoing Alveolar Bone Grafts.

BACKGROUND: Patients with unilateral cleft lip and palate (UCLP) undergo alveolar bone grafting (ABG) to unite the bony segments before eruption of the maxillary permanent canine. PURPOSE: This study assessed the frequency of canine impaction after ABG in the UCLP patient population and identified associated demographic, anatomical, and operative factors. STUDY DESIGN, SETTING, SAMPLE: This retrospective cohort study included 257 patients with UCLP who received ABG surgery at a single craniofacial center. PREDICTOR VARIABLES: The variables were cleft characteristics, pre-ABG procedures, operative factors, and dental anomalies identified through electronic health records, radiographs, and intraoral photographs taken before ABG and at least 2 years after ABG. MAIN OUTCOME VARIABLE: The primary outcome variable was the presence of an impacted maxillary canine, defined as malposition of a fully developed canine following ABG with full eruption of the contralateral canine. ANALYSES: The t tests, χ2 tests, and logistic regression analysis were used to evaluate frequency of canine impaction and test for associations with the predictor variables. RESULTS: Of 257 patients, 56% were male with a mean age of 9.2 years at the time of ABG. The frequency of canine impaction was 27% (n = 69, 95% confidence interval 22 to 33%). Significant associations were found for: complete clefts (30 vs 12%, P = .017), hypodivergent facial patterns (low angle: 46%; high angle: 29 vs 22% normal angle, P = .042), females (adjusted odds ratio [aOR] = 2.1, P = .015), early grafting with less than 1/3 developed canine root (aOR = 3.36, P = .024), pregraft extraction of primary canine (aOR = 2.3, P = .009) and greater permanent canine angulation (odds ratio = 1.1, P < .0001). No significant associations with pregraft orthodontic expansion or regrafting were detected. CONCLUSION AND RELEVANCE: In this study, about one in four patients with UCLP had an impacted canine. Multiple factors including pregraft extraction of the primary canine and increased canine angulation were associated with impaction of the permanent canine.

Current Trends in Orthognathic Surgery.

Orthognathic surgery has evolved significantly over the past century. Osteotomies of the midface and mandible are contemporaneously used to perform independent or coordinated movements to address functional and aesthetic problems. Specific advances in the past twenty years include increasing fidelity with computer-assisted planning, the use of patient-specific fixation, expanding indications for management of upper airway obstruction, and shifts in orthodontic-surgical paradigms. This review article serves to highlight the contemporary practice of orthognathic surgery.

Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. METHODS: A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. RESULTS: The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. CONCLUSIONS: This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.

Defining the Safe Zone for the Low Medial Horizontal Cut in the Sagittal Split Osteotomy.

PURPOSE: A recent modification of the sagittal split osteotomy (SSO) utilizes a medial cut placed at the level of the mandibular occlusal plane (low) and terminating anterior to the retrolingular fossa (short). The purpose of this work was to evaluate the position of the inferior alveolar nerve (IAN) relative to the medial mandibular ramus cortex in patients undergoing SSO utilizing a low medial cut. METHODS: This was a retrospective, cross-sectional evaluation of patients evaluated at a tertiary-care center for facial skeletal deformities who were candidates for mandibular orthognathic surgery. Patients were included as study subjects if they had medical-grade computed tomography (CT) scans as part of preoperative planning. The measure of interest was the closest distance from the medial cortex to the IAN for a horizontal osteotomy placed at the level of the mandibular occlusal plane, as measured on CT scans using an automated process. Descriptive statistics were computed to identify the proximity of the IAN to the medial cortex as a function of the length of the medial horizontal osteotomy. RESULTS: Forty-seven patients (94 SSO sites) with a mean age of 18.7 ± 3.3 years were included as study subjects. Twenty-six subjects had a primary diagnosis of congenital craniofacial anomaly; 21 subjects had a primary dentofacial deformity. For medial ramus osteotomy lengths of 7.5 mm, 10 mm, 12.5 mm, 15 mm, and 20 mm, the closest distances to the IANs were 9.8 ± 2.5 mm, 8.3 ± 2.5 mm, 6.5 ± 2.4 mm, 4.8 ± 2.1 mm, and 2.9 ± 1.6 mm, respectively. CONCLUSION: When utilizing the low medial cut in the SSO, the IAN is reliably found ≥ 5 mm away from the medial cortex of the ramus when the osteotomy length is < 15 mm.

CT-Based Modeling of the Dentition for Craniomaxillofacial Surgical Planning.

ABSTRACT: Historically, the accuracy of imaging teeth by computed tomography (CT) has been suboptimal and deemed inadequate for surgical planning of orthognathic procedures. However, recent advances in CT hardware and software have significantly improved the accuracy of imaging occlusal anatomy. This technical note describes a quantitative means of evaluating the accuracy of CT-based modeling of teeth. Three-dimensional models of the dentition were created from a CT scan obtained of a craniomaxillofacial skeleton. Multiple reconstruction algorithms and modeling parameters were applied. The dentition of the same skeleton was scanned using a handheld optical scanning device to serve as the "gold standard." Semi-automated registrations of CT and optically acquired models were performed and deviation analysis was conducted. On average, the deviation of the CT model with the optical scan measured 0.19 to 0.25 mm across the various reconstruction and modeling parameters, with a mean of 0.22 mm. Computed tomography underestimated contours at cusp tips, while overestimating contours in occlusal groves. The use of bone reconstruction algorithms and decreased model smoothing resulted in more accurate models, though greater surface noise. Future studies evaluating the clinical effectiveness of CT-based occlusal splints should take this finding into account.

Does Distraction Lower Risk of VPI Compared to Conventional Maxillary Advancement? A Retrospective Cohort Study of Adolescents with Cleft Palate.

OBJECTIVE: To determine whether method of maxillary advancement in adolescents with cleft palate with or without cleft lip (CP ± L) influences post-operative velopharyngeal function. DESIGN: Retrospective cohort. SETTING: Pediatric Tertiary Care Hospital. PARTICIPANTS: One hundred and ninety-nine patients with CP ± L after LeFort I osteotomy for maxillary advancement at our institution between January 2007 and June 2019. INTERVENTIONS: LeFort I osteotomy via distraction osteogenesis (DO) or conventional osteotomy (CO). MAIN OUTCOME MEASURES: Patients who underwent DO or CO were compared for the presence of new velopharyngeal insufficiency (VPI), as measured by perceptual rating by a craniofacial speech-language pathologist.Of the 199 patients who underwent maxillary advancement, 126 were available for analysis. The DO group was younger, male, and had more severe maxillary hypoplasia. Following surgery, 17/41 (41.5%) of the DO group had new VPI, compared to just 23/85 (27.1%) of the CO group. After adjusting for cleft type and predicted maxillary advancement, however, there was not sufficient evidence to reject the null hypothesis of no difference in risk of post-operative VPI between the two surgical groups (prevalence ratio [PR] 1.40, 95% CI 0.68-2.90). Increased prevalence of VPI after DO versus CO was primarily observed among patients with a pre-operative velopharyngeal need ratio < 0.8 (PR = 2.01, 95% CI 0.79-5.10) and patients with normal velopharyngeal function pre-operatively (PR = 2.86, 95% CI 0.96-8.50).Our results suggest an increased rather than decreased risk of VPI following DO relative to CO. This association is primarily seen among those with a smaller velopharyngeal ratio or perceptually normal velopharyngeal function pre-operatively.

Mandibular Foramen Position Predicts Inferior Alveolar Nerve Location After Sagittal Split Osteotomy With a Low Medial Cut.

PURPOSE: To evaluate whether the distance between the mandibular occlusal plane and mandibular foramen predicts inferior alveolar nerve (IAN) position after the sagittal split osteotomy (SSO) when using a low medial horizontal osteotomy (Posnick's modification). METHODS: This was a retrospective cohort study of patients undergoing bilateral SSOs with the medial osteotomy placed at the level of the mandibular occlusal plane. The primary predictor variable was the vertical distance between the mandibular foramen and mandibular occlusal plane. The primary outcome was IAN position after SSO: contained within the proximal segment or freely entering the distal segment. Secondary predictor variables were age, gender, primary diagnosis, and type of surgery. Descriptive, bivariate, and regression statistics were computed. RESULTS: Thirty-one patients underwent 62 SSOs using a low medial cut; the sample's mean age was 19.6 ± 3.0 years, and 16 subjects were female. Twenty-three subjects had a primary diagnosis of craniofacial anomaly, and 26 subjects underwent bimaxillary surgery. The IAN was contained within the proximal segment in 28 SSOs (45.2%). The distance between the mandibular occlusal plane and mandibular foramen was greater in SSOs where the nerve was contained within the proximal segment (6.9 ± 2.5 mm) versus freely entering the distal segment (4.5 ± 2.7 mm, P < .001). A receiver-operator characteristic curve identified a threshold distance of greater than 5 mm as predictive of the IAN being contained within the proximal segment (sensitivity, 0.89; specificity, 0.85; area under the curve, 0.84; P < .001). When the mandibular foramen was greater than 5 mm above the mandibular occlusal plane, there was an increased odds of the IAN being contained within the proximal segment (odds ratio, 48.3; 95% confidence interval, 10.5, 222.8; P < .001). CONCLUSIONS: The distance between the mandibular occlusal plane and mandibular foramen predicts the position of the IAN after SSO when using a low medial horizontal osteotomy.

Magnitude of Horizontal Advancement is Associated With Apnea Hypopnea Index Improvement and Counter-Clockwise Maxillary Rotation After Subcranial Distraction for Syndromic Synostosis.

PURPOSE: Subcranial midface distraction is used to treat central midface deficiency in syndromic synostosis. Our aim was to determine which maxillary movements were associated with improvement in measures of obstructive sleep apnea. METHODS: This was a retrospective cohort study that reviewed patients with syndromic midface retrusion and documented sleep apnea who underwent subcranial midface distraction via either Le Fort 3 osteotomy or Le Fort 2 osteotomy with zygomatic repositioning. The predictor variables measured on cephalograms were the magnitude and direction of midface and mandibular movements. The primary outcome was the change in the apnea hypopnea index (AHI) from polysomnography before and after surgery. The secondary outcomes were volumes of upper airway containing bone spaces calculated from computed tomography scans. Data analysis included linear regression to estimate the effect of distraction vectors on bone space volumes and AHI changes. RESULTS: We included 18 patients primarily with Crouzon or Apert syndrome. The magnitude of distraction in a horizontal direction was the most significant factor for AHI improvement and primarily expanded the nasopharyngeal space, but with a smaller impact on the oral cavity space. Clockwise palate rotation was most influenced by a downward direction of distraction, with 24° below horizontal creating a neutral advancement. The greater the magnitude of advancement, the more likely a counterclockwise rotation was observed. CONCLUSIONS: Horizontal magnitude of advancement had the greatest impact on AHI improvement. Vertical lengthening and closure of anterior open bite deformities can be done without compromising airway results as long as total advancement is not compromised. Palate rotation is best controlled by a downward distraction vector, but counterclockwise rotation increases with greater advancement.

Is It Necessary to Free the Inferior Alveolar Nerve From the Proximal Segment in the Sagittal Split Osteotomy?

PURPOSE: When the inferior alveolar nerve (IAN) is contained within the proximal segment after a mandibular sagittal split osteotomy (SSO), conventional teaching is to release the nerve so that it freely enters the distal segment. However, manipulation of the IAN may cause further injury. The purpose of this study was to measure IAN neurosensory recovery in SSOs when the nerve was not freed from the proximal segment. MATERIALS AND METHODS: This was a prospective split-mouth study of patients undergoing bilateral sagittal split osteotomy (BSSO). The sample was composed of patients who underwent a BSSO in which the IAN was intact bilaterally but freely entering the distal segment on one side (IANDI) and contained within the proximal segment on the other (IANPR). The outcome of interest was time to functional sensory recovery (FSR) of the IAN, measured in days. Descriptive, bivariate, and Kaplan-Meier statistics were computed. P ≤ .05 was considered statistically significant. RESULTS: Twenty patients undergoing 40 SSOs were included as study patients. The sample's mean age was 19.0 ± 2.4 years (range, 15 to 26 years); there were 13 female patients. Of these patients, 15 underwent BSSO whereas 5 underwent BSSO plus genioplasty. The planned mean composite 3-dimensional mandibular movements for IANDI and IANPR were 6.3 ± 2.8 mm (range, 2.5 to 12.3 mm) and 6.3 ± 2.3 mm (range, 2.7 to 10.8 mm), respectively (P = .96). All patients achieved FSR in the bilateral IAN distributions within 1 year of surgery (range, 34 to 284 days). The median times to FSR were 100 days for IANDI and 101 days for IANPR (P = .64). CONCLUSIONS: In patients undergoing SSOs, maintaining the IAN within the proximal segment of the mandible may not affect neurosensory recovery.

The Low Medial Horizontal Osteotomy in Patients With Atypical Ramus Morphology Undergoing Sagittal Split Osteotomy.

PURPOSE: Sagittal split osteotomy (SSO) of rami with fused cortices or minimal marrow space above the lingula can increase the risk of an unfavorable osteotomy split of the proximal ramus. To reduce the risk of a proximal segment fracture, a recent modification of the SSO places the medial horizontal osteotomy below the lingula. The purpose of the present study was to evaluate the outcomes of SSOs utilizing a low medial horizontal osteotomy in patients with atypical ramus morphologies. PATIENTS AND METHODS: The present study was a prospective series composed of patients with atypical proximal ramus anatomy undergoing SSOs. All patients had undergone bilateral SSO for correction of mandibular deformities. The horizontal ramus osteotomy had been placed at or slightly above the mandibular occlusal plane because of atypical ramus morphology (thin ramus with no appreciable marrow space at or above the lingula and/or narrow retromolar ramus width). The outcome variables were an unfavorable split of the proximal or distal segments, nerve location after SSO (proximal or distal segment), and neurosensory recovery of the inferior alveolar nerve (IAN). RESULTS: The sample included 25 patients who had undergone 50 SSOs using a low medial horizontal osteotomy. Their mean age was 19.6 ± 3.2 years; 14 patients were female. Of the 25 patients, 22 had a primary diagnosis of craniofacial anomaly; 23 had undergone bimaxillary surgery and 6 had received concomitant genioplasty. No unfavorable fractures of the proximal segment occurred. No intraoperative IAN injuries occurred. The IAN was contained within the proximal segment in 52% of the cases. All the patients achieved functional sensory recovery of the IAN bilaterally by 1 year postoperatively. The mean interval to functional sensory recovery was 116 days. CONCLUSIONS: The low medial horizontal osteotomy is an effective technique for reliable execution of SSOs in morphologically atypical mandibles.

Do Academic Oral and Maxillofacial Surgeons Comply With Best Practices for Reporting the Results of Randomized Clinical Trials?

PURPOSE: To address the shortcoming of reporting P values, several leading medical journals have revised their guidelines for reporting results, specifically mandating the use of confidence intervals (CIs). The purpose of the present study was to evaluate the frequency of reporting CIs in randomized clinical trials (RCTs) by academic oral and maxillofacial surgeons. MATERIALS AND METHODS: We implemented a retrospective cohort study and enrolled a sample composed of RCTs reported in 3 oral and maxillofacial surgery (OMS) journals in 2009, 2012, 2015, and 2018. We identified RCTs using a Medical Subject Headings (MeSH) search in Medline. Studies were included in the sample if they were randomized and reported a measure of association. Predictor variables included the year of publication, journal, OMS focus area (eg, dentoalveolar surgery, anesthesia/facial pain, craniomaxillofacial trauma), reported confounding factors, funding sources, conflict of interest, study region, number of institutions involved, number of authors, and academic rank of the authors. The primary outcome of interest was reporting of the CI. Descriptive and bivariate statistics were computed. A P value of ≤ .05 was considered significant. RESULTS: The sample included 102 reports. The P value was uniformly reported (100%) in all 102 publications. CIs were reported in 29 reports (28.4%; 95% CI, 19.9 to 38.2). The OMS focus area was associated with reporting CIs (P = .02). Anesthesia/facial pain studies were significantly less likely to report the CIs (12.0%) compared with studies of craniomaxillofacial deformities (100%; Bonferroni P = .02). No other significant associations were found between the predictors and CI reporting (P ≥ .08). CONCLUSIONS: CIs have been reported in a small proportion of RCTs within OMS. Given the shortcomings of reporting only the P values, a significant need exists for improving the statistical reporting standards among OMS journals.

Are Oral and Maxillofacial Surgeons Prescribing Fewer Opioids and More Non-Narcotic Analgesics for Postoperative Pain After Third Molar Removal?

PURPOSE: In response to the national opioid epidemic crisis, the purpose of this study was to measure changes in opioid and non-narcotic analgesia (NNA) prescribing practices over time after third molar (M3) removal. MATERIALS AND METHODS: A retrospective double cohort study was utilized enrolling 2 samples of patients who had M3s removed during 2 different 3-month intervals. The primary predictor variable was prescribing practice, divided into cohorts: 1) previous prescribing practice (PPP) occurring early during the evolving opioid epidemic (2014); and 2) current prescribing practice (CPP) (2018). The outcome measures were morphine milligram equivalents (MMEs), NNA prescriptions, and refill MMEs for inadequate pain control (IPC). Other variables were age, gender, payor, provider, anesthesia, procedure, and number of M3s removed. Descriptive, bivariate, and multiple linear and logistic regression models were computed. RESULTS: The sample included 330 subjects with a mean age of 23.1 ± 8.1 years; 42.4% were male. Of the 330 subjects, 147 were in the PPP cohort (44.5%) and 183 in CPP cohort (55.5%). Mean MMEs were 130.1 ± 42.4 and 68.5 ± 32.0 in the PPP and CPP cohorts, respectively (P ≤ .001). An adjusted linear regression model showed differences in MMEs prescribed persisted (P ≤ .001). The frequency of postoperative NNA prescriptions written increased from 2.7 to 71.6% (P ≤ .001). An adjusted logistic regression model also revealed that NNA prescriptions had significantly increased (odds ratio, 242.00; P ≤ .001). No difference was found in the frequency of refills for IPC (P = .13) or mean refill MME prescriptions between the cohorts (P = .48). CONCLUSIONS: Within our academic practice, fewer opioids and more NNAs are being prescribed for postoperative pain after M3 removal without an increase in IPC. Increased awareness through prescribing regulations, non-narcotic research findings, and organizational guidelines could have contributed to these changes.

Global Interest in Oral and Maxillofacial Surgery: Analysis of Google Trends Data.

PURPOSE: Oral and maxillofacial surgery (OMS) has an expansive scope, with myriad diagnoses treated by practicing surgeons. Patients and referring providers are increasingly turning to Web-based sources to find information about clinical conditions before consultations or in conjunction with ongoing care. The purpose of this study was to examine the current trends of public interest of OMS procedures as assessed by online search trends. MATERIALS AND METHODS: A cross-sectional study of Internet search data obtained via Google Trends (GT; Alphabet, Mountain View, CA) was conducted. Data were collected using GT for OMS-related search terms between January 2004 and May 2019. The search terms used in the analysis were "wisdom teeth," "TMJ," "dental implants," "jaw surgery," "jaw fracture," "facial trauma," and "facial cosmetic surgery," defined to be the core surgical aspects of OMS based on public awareness campaigns sponsored by the American Association of Oral and Maxillofacial Surgeons. Relative search volumes, trends over time, geographic trends, and seasonal trends were analyzed. For all analyses, P ≤ .05 was considered significant. RESULTS: Overall search volume trends for OMS procedures showed an increase over time, with seasonal and geographic trends. "Wisdom teeth" was the most searched term and had the greatest increase in search volume over time. "Facial trauma" was the least searched term, with no appreciable trend over time. Geographic search volume was greatest in the United States. Seasonal changes were most apparent with searches for "wisdom teeth" and "jaw surgery." CONCLUSIONS: Analysis of GT data shows substantial interest in core OMS procedures, with seasonal variations noted for certain areas of practice (third molars and jaw surgery) and consistent interest in other areas (facial cosmetic surgery, dental implant reconstruction, and temporomandibular disorders). The use of GT data may be a powerful tool for predicting demand for OMS services and for public education campaigns.

Technical Modifications Specific to the Cleft Le Fort I Osteotomy.

PURPOSE: To discuss technical modifications specific to the cleft Le Fort I osteotomy that improve mobilization and demonstrate the stability of the maxilla at the Le Fort I level in a cohort of patients with cleft palate (with or without cleft lip) who underwent traditional maxillary advancement. METHODS: This was a retrospective evaluation of patients with cleft palate (+/- cleft lip) who underwent orthognathic surgery for management of skeletal malocclusions. All study subjects had a Le Fort I osteotomy +/- bilateral mandibular sagittal split osteotomies. The cleft Le Fort I osteotomy technique is modified to extensively release fibrous tissue and scar from the posterior maxilla, including around the tuberosity, along the posterior maxillary sinus wall, and circumferentially around the descending palatine canal. Maxillary position was assessed using angular and linear measurements pre-operatively (T0), immediately post-operatively (T1), and at 1-year post-operatively (T2). Descriptive and bivariate statistics were computed; a P < 0.05 was considered significant. RESULTS: Twenty-eight patients with cleft palate (with or without cleft lip) were included. The sample's mean age was 18.9 ±â€Š1.4 years and included 11 females. The majority of subjects (64.3%) underwent bimaxillary surgery; eight subjects (28.6%) had segmental maxillary surgery and 14 subjects (50%) had simultaneous maxillary interpositional bone grafting. The mean maxillary sagittal advancement was 6.1 mm (range: 0-10 mm). At 1-year post-operatively, the absolute change in SNA was 0.7 ±â€Š0.9 degrees; the absolute change in maxillary sagittal position was 0.8 ±â€Š0.6 mm. There was no association between the magnitude of advancement and the magnitude of position change (P = 0.86). Stability was not influenced by segmental surgery, bone grafting, or bimaxillary surgery (P > 0.33). CONCLUSION: Using a modified technique with extensive release of posterior scar and graduated intra-operative traction, maxillary advancement of up to 10 mm can be performed in patients with cleft palate (± cleft lip) with sagittal relapse of < 1 mm at 1-year post-operatively.

Microsurgical Resection of a Primary Intraosseous Meningioma Encasing the Superior Sagittal Sinus.

Primary intraosseous meningiomas (PIMs) are an infrequent variant of meningiomas characterized by hyperostosis and brain compression. En bloc surgical resection of giant PIMs involving critical structures such as venous sinuses or cranial nerves could be associated with significant morbidity. The objective of this report is to demonstrate the safety and feasibility of piecemeal resection of PIMs involving the superior sagittal sinus and frontal sinus. A 54-year-old female with a large 5 cm thick bifrontal primary intra-osseous meningioma encasing the anterior segment of the superior sagittal sinus and frontal sinus underwent a bifrontal craniotomy with piecemeal microsurgical resection of the lesion, complete frontal sinus exoneration, and a synthetic cranioplasty. Clinical outcome was measured by extent of resection, preservation of cortical draining veins and postoperative course. A Simpson grade I resection of the lesion was achieved following piecemeal resection of the giant PIM without clinical or radiographic evidence of venous infarct or injury. The postoperative course was uncomplicated, and the patient was discharged home 3 days after cranioplasty. A complete resection of a giant bifrontal PIM with superior sagittal sinus encasement and frontal sinus involvement can be achieved safely via a piecemeal approach without significant intra-operative morbidity.

Is Gender Associated With Success in Academic Oral and Maxillofacial Surgery?

PURPOSE: Several studies of surgical specialties have shown disparities in measures of research productivity and academic rank between female and male surgeons. The purpose of this work was to measure the role of surgeon gender in academic success in oral and maxillofacial surgery. MATERIALS AND METHODS: We performed a cross-sectional study of full-time academic oral and maxillofacial surgeons (OMSs) in the United States as of June 2017. The primary study variable was surgeon gender (male or female). The primary outcome variable was research productivity assessed using 2 different parameters: 1) h index (number of publications h with at least h citations each) and 2) academic rank. The other study variables were demographic characteristics potentially related to the outcome measures. Descriptive, bivariate, and regression statistics were computed. RESULTS: The study sample comprised 306 full-time academic OMSs, 53 (17.3%) of whom were women. On average, female OMSs had shorter academic careers (mean time since completion of training, 11.0 ± 8.2 years for female OMSs vs 22.0 ± 14.1 years for male OMSs; P < .001). There were no other significant differences between male and female OMSs regarding the secondary measures (P ≥ .23). Male OMSs had a higher mean h index than female OMSs (7.1 ± 8.6 vs 5.1 ± 7.9, P = .01). Academic rank was statistically significantly different between female and male OMSs, with a greater proportion of higher ranks seen in male OMSs (P = .001). After adjustment for career length and other confounders or effect modifiers, gender was not an independent predictor of the h index or academic rank (P ≥ .22). CONCLUSIONS: Although female surgeons represent a minority of full-time academic OMSs, academic success measured using research productivity and academic rank was not associated with gender.

Le Fort II Distraction With Zygomatic Repositioning: A Technique for Differential Correction of Midface Hypoplasia.

Severe midface hypoplasia is frequently addressed with subcranial midface advancement at the Le Fort II or Le Fort III level. Le Fort II advancement has a predominant affect on the vertical and sagittal positioning of the nasomaxillary complex; in contrast, the Le Fort III advancement allows for correction of zygomatic position and exorbitism. In this report, the authors described a technique for correction of exorbitism which concomitantly addresses central midface vertical and sagittal deficiency. The technique involves a combination of a Le Fort III osteotomy with a Le Fort II distraction. The Le Fort III osteotomy allows repositioning and fixation of the zygomas to correct lateral hypoplasia and exorbitism, maintaining the globes in a more functional position. The Le Fort II distraction allows for movement of the central midface independent of the lateral orbits and zygomas, correcting the sagittal and vertical position without orbital distortion. With the medial canthal apparatus attached to the Le Fort II segment and the lateral canthus attached to the stabilized lateral orbits, the differential movement achieved can also have a favorable effect on palpebral fissure orientation.

Is Formal Research Training Associated With Academic Success in Oral and Maxillofacial Surgery?

PURPOSE: Pursuing promotion in academic rank and seeking funded research opportunities are core elements of academic practice. Our purpose was to assess whether formal research training influences academic rank or National Institutes of Health (NIH) funding among full-time academic oral and maxillofacial surgeons (OMSs). MATERIALS AND METHODS: We performed a cross-sectional study of full-time academic OMSs in the United States. The primary predictor variable was completion of formal research training, defined as a research fellowship or advanced non-clinical doctoral research degree (PhD, DMSc, DPH, DPhil, ScD). The outcomes measures were current academic rank and successful acquisition of NIH funding (yes vs no). Other study variables included MD degree, clinical fellowship training, years since training completion, and Hirsch index (H-index), a measure of academic productivity. We computed the descriptive, bivariate, and multiple regression models and set P ≤ .05 as significant. RESULTS: A total of 299 full-time academic OMSs were included in the study sample. Of the 299 OMSs, 41 (13.7%) had had formal research training. Surgeons with formal research training had a greater mean interval since completion of training (P = 0.01) and had a greater mean H-index (P = 0.02). Formal research training was not associated with academic rank (P = .10) but was associated with an increased likelihood of receiving NIH funding (P < .001). In a multiple logistic regression model, after adjusting for years since completing training and H-index, formal research training was associated with an increased likelihood of obtaining NIH funding (odds ratio, 3.22; 95% confidence interval, 1.15 to 9.00; P = .03). CONCLUSIONS: Among academic OMSs, those with formal research training had greater success with obtaining NIH funding. However, formal research training did not appear to influence an OMS's current academic rank.