What are the Effects of Internal Fixation on Trigeminal Neurosensory Function and the Temporomandibular Joints Following Intraoral Vertical Ramus Osteotomy?

PURPOSE: Intraoral vertical ramus osteotomy (IVRO) has, traditionally, been accomplished without internal fixation, necessitating a period of maxillomandibular fixation (MMF). With advances in instrumentation, internal fixation of IVRO is feasible, obviating the need for MMF. The purpose is to investigate the effects of transoral internal fixation on the prevalence of third division trigeminal nerve (CNV3) injury, temporomandibular joint (TMJ) arthralgia, and surgical site bleeding following IVRO. MATERIALS AND METHODS: A retrospective study was conducted on patients who underwent IVRO at Vanderbilt University Medical Center between January 2017 and December 2020. The primary predictor variable was fixation status-internal fixation versus MMF. The primary outcome variable was postoperative CNV3 neurosensory disturbance. The secondary outcome variables were TMJ arthralgia and surgical site bleeding. Statistical analysis included Fisher's exact test and McNemar's Chi-squared test. RESULTS: Seventy two subjects (59 IVROs without internal fixation and 65 IVROs with internal fixation) were studied. The frequency of CNV3 neurosensory deficit was 0% in the IVRO without internal fixation group and 3.1% in the IVRO with internal fixation group (P = .49). Within group analysis showed a decreased frequency of postoperative TMJ arthralgia compared to preoperative records in both groups (IVRO without internal fixation group, P = .04 and IVRO with internal fixation group, P = .004). The frequency of active surgical site bleeding controlled with local measures was 1.7% in the IVRO without internal fixation group and 3.1% in the IVRO with internal fixation group (P = 1). CONCLUSION: Internal fixation of IVRO is associated with low incidence of neurosensory deficit, TMJ arthralgia, and active surgical site bleeding.

What are the Effects of Age and Presence of Third Molars on the Occurrence of Unfavorable Splits During Sagittal Split Osteotomy?

PURPOSE: Several studies have investigated risk factors of unfavorable splits associated with sagittal split osteotomies but yielded conflicting information. The purpose of this study is to estimate the frequency of and identify factors associated with unfavorable splits during sagittal split osteotomies (SSOs). MATERIAL AND METHODS: A retrospective cohort study was conducted on patients who underwent orthognathic surgery, including SSOs at our institution from January 2010 to October 2016. The independent variables were mandibular third molar (M3) status, age, gender, and preoperative dentofacial diagnosis. The outcome variable was the effectiveness of the sagittal split resulting in either favorable or an unfavorable split. Data analyses were performed using logistic regression models except in the case of small sample sizes of preoperative dentofacial diagnoses for which the Fisher's exact test was used. RESULTS: A total of 888 patients with an average age of 24.97 ± 5.09 years underwent 1,776 SSOs. Sixteen (0.90%) unilateral unfavorable splits occurred. Unfavorable splits were less common in patients with an M3 present than in patients with the M3 absent. Having an M3 present reduced the chance of an unfavorable split by 69%, adjusted for age and gender; OR (95% CI) = 0.308 (0.103, 0.919); P = .035. The odds of having an unfavorable split were increased by 8.8% for every year of age increase; adjusted OR (95% CI) = 1.088 (1.004, 1.178); P = .038. Based on this estimation, a 45-year-old is 2.3 times more likely to have an unfavorable split compared to a 35-year-old (95% CI:1.041, 5.146), and is 5.4 times more likely to have an unfavorable split compared to a 25-year-old (95% CI:1.083, 26.48). CONCLUSIONS: The presence of a mandibular third molar (M3) was associated with a decreased risk of an unfavorable split, independent of age and gender. There was a significant association between increased age and the incidence of an unfavorable split.

Simultaneous Surgical Correction of Skeletal Class III Dentofacial Deformity During Acute Management of Facial Fractures: Patient Selection and Surgical Technique.

BACKGROUND: Mandibular prognathism is a common dentofacial deformity in Asia. Treatment of such condition may vary from orthodontic camouflage to surgical orthodontics with orthognathic surgery depending on the severity of the condition. Because of the prominent position of the mandible, fractures involving different locations of the mandible commonly occur in maxillofacial trauma. Anatomical reduction of maxillofacial fractures and restoration of the pretraumatic occlusion are the primary goals of acute management of facial fractures. In patients with dentofacial deformity, simultaneous surgical correction of their malocclusion and improvement of their facial aesthetics while providing open treatment to the maxillofacial fractures are rarely reported in the literature. PATIENTS AND METHODS: We reported 3 cases with combined open reduction and internal fixation and surgery-first orthognathic surgery principles to correct class III malocclusion with mandibular prognathism during acute management of maxillofacial fractures. Computer-assisted surgical simulation was used in surgical planning and fabrication of surgical splint. RESULTS: Two patients underwent mandibular osteotomies in addition to open reduction and internal fixation of maxillofacial fractures. One patient had both maxillary and mandibular osteotomies during facial fracture repair. Class I occlusion with satisfactory facial profile was achieved in all 3 cases. CONCLUSIONS: Careful patient selection with presurgical planning using computer-assisted surgical simulation is essential in achieving successful outcomes in correcting dentofacial deformities while managing maxillofacial fractures. This combined technique is a viable option in the surgical management of facial fractures in patients with dentofacial deformities.

Masseter Muscle Volume Changes Evaluated by 3-Dimensional Computed Tomography After Repeated Botulinum Toxin A Injections in Patients With Square Facial Morphology.

INTRODUCTION: Botulinum neurotoxin A (BoNT-A) is a minimally invasive and technically straightforward treatment of masseter muscle (MM) volume reduction and facial contouring, but the literature on its long-term effect on MM volume remains unclear. OBJECTIVE: This study aimed to assess quantitatively for progressive volume changes of lower facial contour after 3 BoNT-A injections in patients with bilateral MM hypertrophy causing square facial morphology using 3-dimensional computed tomographic scans. MATERIALS AND METHODS: Ten female patients with square facial morphology due to bilateral MM hypertrophy were recruited to, and 6 completed, this clinical study. Each received 24 U of BoNT-A into the inferior portion of each MM on both sides, repeated 6 monthly to complete 3 treatments. Masseter muscle volume changes were assessed using 3-dimensional computed tomography at pretreatment (before injections) and posttreatment (1 year after the third injection). RESULTS: Mean MM volume significantly reduced from 26.39 ± 4.18 cm before treatment to 23.26 ± 4.31 cm 1 year after treatment (P = 0.002). CONCLUSION: Three consecutive 6-monthly BoNT-A injections into the MMs reduced their volume by 12% when assessed 1 year after completion of treatment.

Effects of Hypotensive Anesthesia on Reducing Intraoperative Blood Loss, Duration of Operation, and Quality of Surgical Field During Orthognathic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: The objective of this study was to evaluate the efficacy of hypotensive anesthesia in reducing intraoperative blood loss, decreasing operation time, and improving the quality of the surgical field during orthognathic surgery. A systematic review and meta-analysis of randomized controlled trials addressing these issues were carried out. MATERIALS AND METHODS: An electronic database search was performed. The risk of bias was evaluated with the Jadad Scale and Delphi List. The inverse variance statistical method and a random-effects model were used. RESULTS: Ten randomized controlled trials were included for analysis. Our meta-analysis indicated that hypotensive anesthesia reduced intraoperative blood loss by a mean of about 169 mL. Hypotensive anesthesia was not shown to reduce the operation time for orthognathic surgery, but it did improve the quality of the surgical field. Subgroup analysis indicated that for blood loss in double-jaw surgery, the weighted mean difference favored the hypotensive group, with a reduction in blood loss of 175 mL, but no statistically significant reduction in blood loss was found for anterior maxillary osteotomy. If local anesthesia with epinephrine was used in conjunction with hypotensive anesthesia, the reduction in intraoperative blood loss was increased to 254.93 mL. CONCLUSIONS: Hypotensive anesthesia was effective in reducing blood loss and improving the quality of the surgical field, but it did not reduce the operation time for orthognathic surgery. The use of local anesthesia in conjunction with hypotensive general anesthesia further reduced the amount of intraoperative blood loss for orthognathic surgery.

Minimal Invasive Rhinoplasty: Fat Injection for Nasal Dorsum Contouring.

PURPOSE: To determine the graft retention rate of fat injection rhinoplasty in the nasal dorsum region using 3dMD System. MATERIALS AND METHODS: Thirteen consecutive patients (12 women and 1 man) treated by the corresponding author (F.C.S.C.) between April of 2014 and December of 2015 for autologous fat injection rhinoplasty at the nasal dorsum region to improve facial esthetics were included in this study. Preoperative and postoperative 3-dimensional (3-D) photography images taken 3 months after fat injection rhinoplasty were superimposed at the level of forehead to measure the volume changes at the nasal dorsum region. The same evaluator repeated the measurements 1 week after the initial measurements. Pearson correlation test was used to determine the intraobserver correlation. RESULTS: Twenty-six scans from 13 patients were analyzed. The amount of fat injected for nasal dorsum augmentation was 1.67 ± 0.95 mL (range, 0.6-3.3 mL). The volume changes calculated using the 3dMD system was 0.74 ± 0.42 mL for the first measurements and 0.74 ± 0.43 mL for the second measurements. The Intraobserver consistency was high with Cronbach α = 0.96 (P < 0.001). The mean volume change according to 3-D photography was 0.74 ± 0.42 mL (range, 0.21-1.53 mL). The mean retention rate was 44.54% (range, 21-74%). CONCLUSIONS: In this pilot study, we reported the fat graft retention rate for nasal dorsum augmentation using 3-D photography. Future studies with a larger sample size, longer-term follow-up, and different anatomical regions will be beneficial to better understand the long-term fat graft retention rate.

Comparative assessment of orthodontic and aesthetic outcomes after orthognathic surgery with clear aligner or fixed appliance therapy.

BACKGROUND: Clear aligner therapy has an aesthetic advantage over fixed appliance therapy. However, to our knowledge, no study has objectively compared patient orthodontic and aesthetic outcomes between clear aligner and fixed appliance therapies administered after orthognathic surgery (OGS). METHODS: This study included patients with no history of congenital craniofacial deformities who underwent surgery-first OGS and received clear aligner or fixed appliance therapy. The patients' grades on the Dental Health Component (DHC) and Aesthetic Component (AC) of the Index of Orthodontic Treatment Need and scores on the Peer Assessment Rating (PAR) index were calculated before OGS (T0), after OGS (T1), and after orthodontic therapy (T2). RESULTS: This study included 33 patients (clear aligner therapy, 19; fixed appliance therapy, 14). No considerable between-group differences were noted in the DHC and AC grades at T0, T1, or T2. Furthermore, %reduction in the PAR index score was more significant in the clear aligner group (74.4%) than in the fixed appliance group (63.2%) from T0 to T1 (p = .035); however, no between-group differences were noted from T1 to T2 or from T0 to T2. Both groups exhibited substantially improved DHC grades, AC grades, and PAR index scores at T1 and T2. CONCLUSIONS: Patient outcomes were similar between the clear aligner and fixed appliance groups after orthodontic therapy. However, the former group exhibited more favorable immediate results after OGS than did the latter group. Thus, as an adjunct therapy for patients with malocclusion, clear aligner therapy may be more effective than fixed appliance therapy.

Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty.

BACKGROUND: Since 2006, the authors have explored the option of using septal cartilage as an alar rim graft on the cleft side during primary rhinoplasty to improve nasal symmetry. The aim of this study was to compare the nasal shape with or without rim graft. METHODS: A total of 98 patients with unilateral complete cleft lip and palate were included; 39 patients had septal cartilage as the rim graft, and 59 patients did not. Measurements of the nostril height, nostril width, one-fourth medial part of nostril height, nostril area, nasal dome height, and nostril axis were obtained on the cleft and noncleft sides. Ratios of these measurements were calculated. These ratios were then compared between the graft and nongraft groups. The levels of asymmetry were categorized into four levels-less than 5 percent, 5 to 10 percent, 10 to 15 percent, and greater than 15 percent-based on the percentages deviated from perfect symmetry (100 percent). Panel assessment was also performed. Nasolabial angle and tip projection ratio were measured for the comparison of nasal growth. RESULTS: The nostril height, height-to-width ratio, and nasal dome height were higher in the graft group (p = 0.003, p < 0.001, and p < 0.001, respectively). The graft group showed more consistency regarding the nostril shape and axis, and the differences were statistically significant (p < 0.05). The nasolabial angle and tip projection ratio showed no significant difference between the two groups. CONCLUSION: This preliminary study suggests that the use of a primary septal cartilage graft may offer better support at the alar rim and improve the long-term outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Diced Cartilage Graft for Revision Rhinoplasty in a 64-year-old Cleft Patient: A Case Report.

Pure diced cartilage graft has been the technique of choice for revision rhinoplasty in cleft patients since 2003 at our center. This technique has several advantages over the traditional en bloc cartilage onlay graft including minimal risk of warping, its technical simplicity, and the ability to adjust the shape of the graft with manual massage for up to 3 weeks postoperatively. Calcification of the costal cartilage, however, poses a real concern for surgeons. In this case report, we are presenting a 64-year-old woman with a right unilateral complete cleft lip and palate deformity who presented to our clinic for secondary revision. Central-pattern rib calcification was encountered during the operation. Outcomes, details of the operation, and potential limitations of this technique are discussed in this case report.

Histology and Long-term Stability of Diced Cartilage Graft for Revision Rhinoplasty in a Cleft Patient.

Diced cartilage graft wrapped in Surgicel or fascia has been widely reported in the literature. Pure diced cartilage graft without the use of a "sleeve," on the contrary, is not as commonly reported. This could be due to concerns of graft dispersion, palpability, or visibility. In this case report, histologic findings of a pure diced cartilage graft placed 4½ years ago are reported. In addition, advantages and disadvantages of this technique are discussed in detail. Two pieces of the diced cartilage graft placed 4½ years prior were excised and sent for histologic analysis during a revision procedure. The microscopic examination reveals several small blocks of mature hyaline cartilage embedded in dense fibrous connective tissue with widely scattered small vascular channels. The cartilage is vital with scattered chondrocytes within their lacunae. Histology of the diced cartilage graft demonstrated viability and stability of the graft 4½ years after insertion. This case report also suggests that pure diced cartilage graft can provide reliable volume augmentation of nasal dorsum in cleft rhinoplasty.