Anterior Nasal Spine Research Articles

Persistent pediatric obstructive sleep apnea treated with skeletally anchored transpalatal distraction

The aim of this study was to evaluate the impact of nasomaxillary expansion using skeletally anchored transpalatal distraction (TPD) in children without transverse maxillary deficiency that were previously treated by rapid palatal expansion (RPE). Twenty-nine consecutive children were treated by TPD. Twenty-five children, aged 10-16 years completed pre- and post-operative clinical evaluations, questionnaires (OSA-18), cone beam computed tomography (CBCT), and polysomnography (PSG). The pre- and post-operative CBCT data were used to reconstruct the 3-dimensional shape of the upper airway. Two measures of airflow function (pressure and velocity) were simulated by using computational fluid dynamics (CFD) at four different airway segments (nasal, nasopharyngeal, oropharyngeal and hypopharyngeal). Twenty-three patients (92%) experienced improvement based on PSG. The apnea hypopnea index (AHI) improved from 6.72 ± 4.34 to 3.59 ± 5.11 (p<0.001) events per hour. Clinical symptoms based on OSA-18 scores were improved in all patients. Twenty-five patients (100%) had successful expansion defined as separation of the midpalatal suture at least 1mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal sidewall widening was 2.59 ± 1,54 mm at canine, 2.91 ± 1,23 mm at first molar and 2.30 ± 1,29 mm at PNS. The ratio of dental expansion to nasal expansion was 1.12:1 (2.90mm:2.59mm) at canine and 1.37:1 (3.98mm:2.91mm) at first molar. The nasal airflow pressure reduced by 76% (-275.73 to -67.28 Pa) and the nasal airflow velocity reduced by over 50% (18.60 to 8.56 m/s). Nasomaxillary expansion by skeletally anchored TPD improves OSA in children without transverse maxillary deficiency that were previously treated by RPE. A nearly parallel anterior-posterior opening of the mid-palatal suture achieves enlargement of the entire nasal passage with improvement of the airflow characteristics in the nasal and pharyngeal airway. The improved airflow characteristic is significantly correlated with the improved polysomnographic findings, thus demonstrating that nasomaxillary expansion in previously expanded patients is a viable treatment option.

Anatomical Patterns of the Nasopalatine Canal and Incisive Foramen in an African Setting: A Cross-Sectional Study.

Study Design: Descriptive cross-sectional. Objective: To determine the morphology and morphometry of the nasopalatine canal (NPC) and incisive foramen (IF) in an African population. Methods: Measurements of the NPC and the IF were carried out on 150 Cone-Beam computed tomography (CBCT) scans. The maxillary bone thickness anterior to the NPC was measured at 3 levels. Independent t-test and Chi-square test were performed to determine the presence of sexual dimorphism. Results: The presence of one Stenson's foramen was most prevalent. The mean length of NPC was 13.21 ± 3.25mm with significantly longer canals in males. The most prevalent shape of NPC was cylindrical in sagittal view and a single canal in coronal view. The mean angulation of NPC was 118.42° to the horizontal plane. The average dimensions of the IF were 3.53mm and 3.07mm in the anteroposterior and mediolateral diameter, respectively, while the most common shape was round. The anterior maxillary bone was thicker in males and generally reduced in thickness from the anterior nasal spine superiorly towards the alveolar crest inferiorly. Conclusion: This study highlights the anatomical characteristics of the NPC and IF, with significant sexual dimorphism observed regarding the number of Stenson's foramina, length of NPC, shapes of the NPC and IF, as well as alveolar bone thickness anterior to NPC.

A Safe Nonsurgical Rhinoplasty Procedure.

Nonsurgical rhinoplasty procedures are not without risks: although rare, intravascular injections of hyaluronic acid can lead to serious complications. Very few authors have reported using cannulas for filler injection in the nose. The purpose of this article is to describe how the authors perform nonsurgical rhinoplasty using a single entry point and cannulas, significantly reducing vascular and infection risks. The procedure described in this article can be applied to all indications of nonsurgical rhinoplasty. The key point of the authors' procedure is the definition of a single, medial entry point. Using a 5-cm, 25-gauge, dome-shaped cannula, all nasal regions can be reached, from the anterior nasal spine to the nasion. The authors' nonsurgical rhinoplasty procedure using cannulas reduces complications and provides results similar to those achieved with needles.

Localization of The Infraorbital Foramen with Reference to Facial Bony Landmarks: The Predictive Method And Its Accuracy

The infraorbital nerve (ION) provides sensation around mid‐face and the ION block is used for regional anesthesia in many procedures. Therefore, the location of infraorbital foramen (IOF) and accessory infraorbital foramen (AIOF) where the ION and its branches exit through is important. Although, many studies tried to identify the location of the foramen using facial landmarks, the results varied and some of them were not applicable in practice. This study aims to find the relationship between IOF and AIOF, predict the location of IOF with reference to anterior nasal spine (ANS) and the lowest point of the zygomaticomaxillary junction (Z) which are palpable both in bone and soft tissue surface and assess an accuracy of the proposed predictive method.A total of 216 dry skulls were examined. Specimens with facial distortion were excluded. Live images of skull were analyzed by Leica Application Suite Core V4.12. The anatomical position of IOF and AIOF was observed. The line between ANS and Z (A) was the main reference line. For localization of IOF, the vertical distance from IOF to line A (B) and ratio of the distance from ANS to the intersecting point of line B with line A (D) to distance A (D:A) were measured. Statistical analysis was conducted to analyze the statistical difference between sex and sides with a significance level of 0.05. Accuracy assessment was determined in 15 cadavers. To find the predicted IOF in cadaver, measured from ANS for the length of predicted distance D which was calculated by multiplying the average distance A of cadaver with the average D:A of skulls and then measured above that point for the length of average distance B of skulls. Distance between the predicted IOF to the exact IOF was measured.There were 86 AIOFs in skulls. Most of them located superomedial to IOF except for 3 AIOFs which located in the inferolateral position. The mean distance between IOF and AIOF was 7.47 ± 2.70 mm. The location of IOF was predicted by the mean distance B and the mean ratio D:A which were 15.14 ± 1.99 mm and 63.35 ± 3.9%. No statistically significant difference was found between sex and sides (p&gt;0.05). In cadavers, mean distance error of the predicted IOF was 1.10 ± 1.44 mm lateral and 0.59 ± 1.39 mm inferior to the exact IOF. There were 50% of predicted IOFs which accurately located within the exact IOF. From the results, clinicians can apply this predictive method in performing the ION block by palpating bony prominence of ANS at the uppermost part of philtrum at the level of nostrils and Z at the lowest bony prominence of cheek, then measure about medial two‐thirds of the line between ANS and Z and measure above the line for 15 mm where IOF is suspected to be.The predictive method for localization of IOF by using ANS and Z as reference points has the mean distance error of 1‐2 mm which is small and might not be discriminated by palpation. Moreover, there were 50% of the predicted IOFs locating within the exact IOF.Therefore, this study provides an alternative method for localization of IOF which could be useful in performing more effective and safer ION block. For further consideration, assessing the accuracy of this method in real patients and comparing with the standard method should be considered.

Investigation the angulation of maxillary impacted canines by using cone-beam computed tomography

Aim: This study aimed to evaluate the angulation and localization of unilaterally impacted canines by using CBCT. Methodology: Seventy-two images were included in the study based on the inclusion criteria. Demographic information (age and gender), localization and angulation of the impacted canine teeth were recorded. Canine angulation was measured between the two lines drawn on the coronal section of CBCT, with the first line drawn from the crista galli to the anterior nasal spine and the second line drawn along the long axes of the impacted canine teeth. Results: The mean age was 35.42±12.29 years in men and 31.10±11.09 years in women. In women, 16 of the impacted canines were on the right and 23 were on the left side, while in men, 21 of them were on the right and 12 were on the left side. Mean angulation was 34.6° (range, 17.6°-64.4°) for women and 36.2° (range, 21.4°-56.3°) for men. A weak negative correlation was found between patient age and angulation (p=0.49, rho = - 0.233). Conclusion: Angulation of maxillary impacted canines is an important predictive factor in orthodontic treatment. In the present study, no significant difference was found between angulation and canine localization and gender. How to cite this article: Laçin N, Yalçın M. Investigation the angulation of maxillary impacted canines by using cone-beam computed tomography. Int Dent Res 2022;12(1):9-13. https://doi.org/10.5577/intdentres.2022.vol11.no1.2 Linguistic Revision: The English in this manuscript has been checked by at least two professional editors, both native speakers of English.

Effectiveness of miniscrew assisted rapid palatal expansion using cone beam computed tomography: A systematic review and meta-analysis.

ObjectiveThis study aims to examine the effectiveness of miniscrew assisted rapid palatal expansion (MARPE) treatment in late adolescents and adult patients using cone-beam computed tomography (CBCT).MethodsLiterature search was conducted in five electronic databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) based on the PICOS keyword design focusing on MARPE. Out of the 18 CBCT screened outcomes, only nine parameters were sufficient for the quantitative meta-analysis. The parameters were classified into three main groups 1) skeletal changes, 2) alveolar change, and 3) dental changes. Heterogeneity test, estimation of pooled means, publication bias, sensitivity analysis and risk of bias assessment were also performed.ResultsUpon database searching, only 14 full-text articles were qualified from the 364 obtained results. Heterogeneity test indicated the use of the random-effects model. The pooled mean estimate were as follows 1) Skeletal expansion zygomatic width, 2.39 mm; nasal width, 2.68 mm; jugular width, 3.12 mm; and midpalatal suture at the posterior nasal spine and anterior nasal spine, 3.34 mm and 4.56 mm, respectively; 2) Alveolar molar width expansion, 4.80 mm; and 3) Dental expansion inter-canine width, 3.96 mm; inter-premolar width, 4.99 mm and inter-molar width, 5.99 mm. The percentage of expansion demonstrated a skeletal expansion (PNS) of 55.76%, alveolar molar width expansion of 24.37% and dental expansion of 19.87%.ConclusionsIn the coronal view, the skeletal and dental expansion created by MARPE was of the pyramidal pattern. MARPE could successfully expand the constricted maxilla in late adolescents and adult patients.

Evaluation of maxillary and mandibular growth patterns with cephalometric analysis based on cervical vertebral maturation: A Japanese cross-sectional study.

BackgroundAppropriate maxillofacial growth and development evaluation is important for effective orthodontic treatment. Growth evaluation is based on physiological age determined by individual development, but not chronological age. One strategy for determining physiological age is using the cervical vertebral bone age.ObjectivesThis study aimed to clarify the standard size of the upper and lower jawbones in Japanese patients using the cervical vertebral maturation stages (CVMS) as an index and clarify the growth pattern. And to use the cervical spine age as a diagnostic aid in orthodontic treatment.Material and methodsRandom sampling was performed from the outpatients who visited the Orthodontics department, Tokyo Medical and Dental University Dental Hospital, and 400 patients were enrolled before treatment. Lateral cephalometric radiographs were obtained to measure the height and length of the mandible and the maxilla length with cephalometric analysis. Standard values were calculated for each cervical-spine-age group to analyze changes during mandibular and maxillary growth. Furthermore, we compared the differences between males and females. The Kruskal–Wallis test was used to compare cervical-spine-age groups, and the Steel–Dwass test was used for multiple comparisons. The reliability of CVMS was confirmed by calculating the weighted kappa coefficient (κ).Resultsκ for the degree of intra-evaluator agreement and the degree of the inter-evaluator agreement were calculated, and both indicated almost perfect agreement. We found that the distance between the anterior nasal spine (ANS) and posterior nasal spine (PNS) (i.e., ANS–PNS) increased significantly between CVMS II and CVMS III in males. The distance between Articulare (Ar) and Gonion (Go) (i.e., Ar–Go) and the distance between Go and Pogonion (Pog) (i.e., Go–Pog) increased significantly between CVMS III and CVMS IV in males.ConclusionThe findings suggested that CVMS is a reliable indicator of the growth stage of the maxilla and mandible.

Localization of infraorbital foramen and accessory infraorbital foramen with reference to facial bony landmarks: predictive method and its accuracy.

The infraorbital nerve block is used for mid-facial anesthesia. We aim to determine the location of infraorbital foramen (IOF) and accessory infraorbital foramen (AIOF) with reference to anterior nasal spine (ANS) and the lowest point of zygomaticomaxillary junction (Z) and assess the accuracy of the predictive method. Two hundred and sixteen dry skulls were examined. A reference line was drawn from ANS to Z (line A) and its length was measured (distance A). The location of IOF was predicted by using the mean vertical distance from IOF to line A (line B) which was 15.14±1.99 mm and the mean ratio of the distance between ANS and the intersecting point of line B and line A (distance D) to distance A (D:A) which was 63.35%±3.90%. Eighty-six AIOFs were found. Most of them located superomedial to IOF, except for 3 AIOFs which located in the inferolateral position. For localization the AIOF, the mean vertical distance was 19.34±3.36 mm and the mean ratio was 51.8%±5.90%. No statistically significant difference of the predicted distances for both foramens was found between sex and sides. The accuracy of the predictive method was assessed in 15 embalmed cadavers. Predicted IOFs were 50% accurate and the mean distance error of the predicted IOF was 1.10±1.44 mm lateral and 0.59±1.39 mm inferior to the exact IOF. Therefore, this study provides an alternative method for localization of IOF and AIOF which could be useful in clinical settings.

Changes in Facial Profile after Modified Anterior Maxillary Subapical Osteotomy.

(1) Background: This study explored the effects of modified anterior maxillary subapical osteotomy (AMSO) on facial profile changes in patients with bimaxillary protrusion. (2) Methods: Cephalograms of patients were collected preoperatively and over 2 months postoperatively. The following landmarks were recorded: pronasale (Prn), subnasale (Sn), labrale superius (Ls), anterior nasal spine (ANS), and incisor superius (Is). The following distances and angles were measured: ANS–Prn, ANS–Sn, ANS–Ls, Is–Sn, Is–Ls, SNA angle, and nasolabial (NLA) angle. (3) Results: Is and ANS were significantly retracted by 7.3 and 2.3 mm, respectively. Soft tissue landmarks (Prn, Sn, and Ls) were significantly retracted (1.2, 1.6, 4.4 mm, respectively). Postoperative changes in soft/hard tissue ratios were 0.54, 0.72, 0.31, and 0.60 for Prn/ANS, Sn/ANS, ANS/Is, and Ls/Is, respectively. The NLA angle was increased significantly by 7.1°. (4) Conclusions: The horizontal soft/hard tissue ratios of Sn/Is, ANS/Is, and Ls/Is were 0.22, 0.31, and 0.60, respectively. The NLA angle was increased significantly by 7.1°. The modified AMSO provides an increased blood supply, allows for direct vision, and results in fewer complications than other AMSO methods.

Morphometric analysis of infraorbital foramen in human dry skull of south Indian population and its clinical implications

Infraorbital foramen,an important anatomical landmark in anaesthetic and surgical interventions of the maxillary region, transmits the infra orbital vessels and nerve. Infraorbital nerve block is commonly used in regional anaesthesia for the midface and paranasal surgeries. The purpose of our study to obtain detailed knowledge of the anatomical location and variations of IOF which is imminent for successful regional anaesthesia and endoscopic surgeries of the maxillary region. The study was conducted on 50 Human skull bones of unknown gender from the Department of Anatomy, Mysore Medical College and Research Institute, Mysore. Both side of skulls were visually observed for shape, direction of the infraorbital foramen and presence of accessory infraorbital foramina. 1. Sagittal Distance between the infraorbital margin to upper margin of infraorbital foramen were measured. 2. Transverse diameter from lateral margin of pyriform aperture to medial margin of IOF were measured. 3. Oblique distance from anterior nasal spine to inferior margin of IOF, were measured. 4. Vertical and transverse diameter of the IOF were measured. 50 skulls (100 sides – both right and left) were studied.Most commonly observed shape of IOF is semilunar 36% on right side, 40% on left side, transversely oval 20% on right side, 28% on left side, vertically oval 18% on right side, 12% on left side, circular 18% on right side, 8% on left side, triangular 8% on right side 12% on left side. Direction of IOF is 88% medially downwards, 12% downwards.The mean distance between IOM and IOF is 6.58±0.28 mm on the right side, 6.78 +0.233 mm on the left side. The mean distance between pyriform aperture to of IOF 16.88+3.7mm on the right side 16.46 +2.7 on the left side. The mean distance between ANS to inferior margin IOF on the 34.77+0.55 mm on right side 34.22+0.3 mm on the left side.Mean vertical diameter of IOF 3.76 mm on right side &amp; 3.94 mm on left side. Mean transverse diameter of IOF 4.18 mm on right side &amp; 4.32+15 mm on left side.Accessory IOF were present in 6% of skulls bilaterally. Our study results will be of immense help to the surgeons and anaesthetists, handling this region for operative procedures.

Influence of Nonsyndromic Bicoronal Synostosis and Syndromic Influences on Orbit and Periorbital Malformation.

Oculoorbital disproportion in patients with craniosynostosis has similarities and dissimilarities between syndromic and nonsyndromic cases. The authors hypothesized that these two conditions have specific individual influences as they relate to development of the orbital and periorbital skeletons. A total of 133 preoperative computed tomography scans (nonsyndromic bicoronal synostosis, n = 38; Apert syndrome bicoronal synostosis subtype, n = 33; Crouzon syndrome bicoronal synostosis subtype, n = 10; controls, n = 52) were included. Craniometric and volumetric analyses related to the orbit and periorbital anatomy were performed. Orbital cavity volume was mildly restricted in nonsyndromic bicoronal synostosis (7 percent, p = 0.147), but more so in Apert and Crouzon syndromes [17 percent (p = 0.002) and 21 percent (p = 0.005), respectively]. The sphenoid side angle in Apert syndrome was wider than when compared to Crouzon syndrome (p = 0.043). The ethmoid side angle in Apert patients, however, was narrower (p = 0.066) than that in Crouzon patients. Maxilla anteroposterior length was more restricted in Apert syndrome than Crouzon syndrome (21 percent, p = 0.003) and nonsyndromic cases (26 percent, p < 0.001). The posterior nasal spine position was retruded in Crouzon syndrome (39 percent, p < 0.001), yet the anterior nasal spine position was similar in Apert and Crouzon syndromes. Orbit and periorbital malformation in syndromic craniosynostosis is likely the combined influence of syndromic influences and premature suture fusion. Apert syndrome expanded the anteriorly contoured lateral orbital wall associated with bicoronal synostosis, whereas Crouzon syndrome had more infraorbital rim retrusion, resulting in more severe exorbitism. Apert syndrome developed maxillary hypoplasia, in addition to the maxillary retrusion, observed in Crouzon syndrome and nonsyndromic bicoronal synostosis patients. Risk, II.

Reliability of Anterior Nasal Spine as a Reference Point After LeFort I Surgery Using Three-Dimensional Analysis.

To evaluate the stability of maxilla following orthognathic surgery, it is necessary to consider the positional change of various landmarks according to bone remodeling of the maxilla. This study aimed to evaluate the stability of the anterior nasal spine (ANS) as a reliable landmark after orthognathic surgery. Forty-seven patients with skeletal class III malocclusion who underwent bimaxillary orthognathic surgery were included. Skeletal changes were measured using cone-beam computerized tomography at 3 time points: preoperative (T0), 1-month postoperative (T1), and 12-month postoperative (T2). Linear changes of the 6 landmark points of the maxilla were measured in 3 directions: anteroposterior, vertical, and transverse. The data were analyzed with paired t tests, independent t tests, and multiple regression analysis. At 12-month postoperatively, the ANS showed mean (standard deviation) 1.23 (1.07) mm posterior movement ( P = 0.00), while other landmarks did not show positional changes, implying bony resorption of ANS. Multiple regression test showed surgical forward movements of ANS (T1-0) affect the postoperative backward changes (β = -0.05, P < 0.05). There was a negative correlation between the surgical movement and postoperative change of ANS by Pearson correlation test ( r = -0.38, P < 0.05). The ANS is not a reliable measurement point in three-dimensional superimposition after orthognathic surgery. Therefore, in studying the stability and positional change pattern after LeFort I surgery, it is not recommended to use ANS as a reference point, as changes can occur in the measurement point itself.

Maxillomandibular Advancement for OSA: A 25-year perspective

The focus of this report is to analyze the pattern of maxillary expansion and complications in patients following surgical and non-surgical maxillary expansion presented for evaluation and second opinion. During a 30-months period, 28 patients presented for second opinion following maxillary expansion performed elsewhere. The indication for treatment was obstructive sleep apnea (OSA). All patients reported a lack of symptomatic improvements and problems associated with the treatment. Clinical examination with pre- and post-expansion cone beam computed tomography (CBCT), and treatment photographs were analyzed. Complete clinical records and CBCT were available in 22 patients for analysis. Six patients had undergone surgical expansion with distraction osteogenesis maxillary expansion (DOME), and 16 patients had undergone a variety of non-surgical expansion with different appliances. All the DOME patients had anterior nasal spine (ANS) separation without posterior nasal spine (PNS) separation. Diastema ranging between 10-16 mm was noted in the DOME patients, and the ratio of anterior diastema to ANS separation was between 2:1 to 3:1. Bone defects existed between the central incisors at 18 months or beyond following DOME in all the patients despite bone grafting attempts in four patients. Anterior gingival recession occurred in two patients and four incisor teeth required endodontic therapy with long-term guarded prognosis. Sixteen patients underwent non-surgical maxillary expansion with four different appliances, including anterior growth guidance appliance (AGGA), daytime-nighttime appliance (DNA), advanced lightwire functionals appliance (ALF), and mini-screw assisted rapid palatal expansion (MARPE). The midpalatal suture did not separate in any of the 16 patients, and the expansion pattern was purely dental and dentoalveolar in nature. Lateral dental tipping, thinning of the labial/buccal alveolar bone with gingival recession were noted in 10 patients. Significant mobility of the maxillary anterior teeth due to vertical and horizontal bone loss was noted in the five patients that underwent AGGA treatment. Different maxillary expansion methods are currently being performed with varying outcomes. Critical analyses of these methods are needed to determine their impact and whether the desired outcomes are achieved.

Is the Mirroring Technology Reliable in the Use of Computer-Aided Design for Orbital Reconstruction? Three-Dimensional Analysis of Asymmetry in the Orbits.

Reconstruction of the orbital area remains a challenge in many cases. The recently introduced mirroring technology provides surgeons with patient-specific information for accurate orbital reconstruction; its premise is that the three-dimensional anatomy of craniofacial bone is symmetric. The purpose of this study was to verify this premise of the mirroring technology by assessing three-dimensional asymmetry. Facial computed tomographic data of 104 patients were imported into iPlan software. Four reference points (i.e., zygomaticofrontal suture, frontomaxillary suture, infraorbital foramen, and optic canal) were set, and the three-dimensional distances from these points to the anterior nasal spine on the mirroring plane were calculated. In addition, the orbital cavity volume and the three-dimensional distances from point optic canal to the other reference points were calculated for the assessment of the orbit anatomy. Three plastic surgeons performed these processes independently. No statistically significant difference was found in the three-dimensional distances between anterior nasal spine and the four reference points bilaterally. Also, no statistically significant difference in the three-dimensional distances between the point representing the optic canal and other reference points was detected bilaterally. Orbital cavity volume showed a mild asymmetry, but the discrepancy was acceptable for computer-aided design applications. For all reference points, the maximum value of the 95 percent CI was less than 1.4 mm. The three-dimensional location of the orbits and the three-dimensional anatomy of the orbit were symmetric. Thus, the mirroring technology could be a reliable first step in computer-aided design, computer-assisted surgery, and navigation-assisted surgery. Therapeutic, V.

Nose Tip Elongation and Elevation: A Novel Filler Injection Technique.

Filler injection for nose tip improvement remains a difficult treatment due to efficacy and safety issues. The authors sought to better the techniques and safety for nose tip improvement with a filler. Patients seeking nose tip improvement were recruited regardless of their pretreatment conditions. A hyaluronic acid filler was injected through the skin behind the nose tip into the potential septal space. To achieve tip elevation, the filler was retro-injected from the anterior nasal spine, stopping at the mid-level of medial crura. To elongate the nose, the filler was deposited just in front of the caudal septal cartilage. The tip extended in the sagittal plane, causing the nose tip to move either caudally (tip elongation) or anteriorly (tip elevation), or both, as directed by the surgeon. Depending on the patients, the nose could be elongated by 2 to 6 mm, and the tip could be elevated by 2 to 8 mm. Additionally, stronger columellar support, finer tip structures, and improved nasolabial angle were observed. Interestingly, the upper lip appeared shorter. The nostril shapes and the alar widths were also improved. A total of 1288 cases are reported. Only 2 patients expressed dissatisfaction. This technique is easy and safe to perform, and the results are natural and comparable with those from rhinoplasty surgeries. Further, this report of filler nose lengthening may be the first large series in the world. Finally, this technique works well in all populations.

Assessment of insertion force for the placement of cortical implants in various anatomic sites in dried human skulls.

Dental implant treatment is an excellent option for prosthetic restoration that is associated with high success rates. Implant stability is essential for a good outcome. The basal bone implants are usually placed in poorly atrophied basal bone areas. To determine the stability during insertion in bones by measuring the torque using a wrench. To obtain the number of cortical engagements via stimulating concerned anatomical location in jaws. The study was designed as an ex vivo study. In case of basal implants, the integration of the implants is in stable cortex. Such a stable engagement is achieved by stimulation of certain areas in anterior maxilla such as anterior nasal spine, nasal floor, canine fossa, while posteriorly, maxillary tuberosity and pterygoid. In mandible the symphysis, parasymphysis, lingual cortex and retromolar pad areas were engaged. In this study, the above-mentioned areas were stimulated for the engagement of cortical bones using cortical implantology. Cortical implants of various sizes and tapers were inserted and analyzed for its bone quality and quantity. The stability of such implants was tested during insertion by measuring the torque with the use of a torque wrench instrument. Comparative observational study using standards of deviation. Within the limitations of this study, it may be concluded that there was a significant correlation between insertion force and diameter of implants when placed in jaws in a dried human skull model. The present study needs to be further conducted to establish the observational results completely and hence correlate the results with human studies.

S Alar Cinch Suture Effective in Controlling Alar Base Widening in Le Fort 1 Osteotomy?

Le Fort I osteotomy causes nasolabial alterations that may be unattractive, such as expansion of the alae and alar bases and thinning of the upper lip. After maxillary impaction, there is a propensity for the tip to elevate, and in some circumstances, this may even become excessive. The nasolabial angle closes and similar alterations are observed with maxillary advancement. When Le Fort I impaction or maxilla advancement occurs, the alar base cinch suture is frequently utilised to reduce the unfavourable rise in nasal width. There are significant changes in the nasolabial morphology associated with Le Fort 1 osteotomy. Numerous changes occur after the surgical intervention in the maxilla namely- widening of the alar base of the nose, upturning of the nasal tip, flattening and thinning of the upper lip and down turning of the commissures. Widening of the alar bases of the nose appears to be the most common undesirable outcome. Some people may benefit aesthetically from nasal widening. For instance, the long face syndrome is frequently characterised by a narrow nose with a large dorsum. In these situations, superior maxillary relocation typically improves the look of the nose by enlarging the bases of the arches. However, excessive alar base broadening and superior retraction would cause the alar-facial groove to aesthetically deepen, giving the patient an older appearance, and may cause asymmetry in the alas. It is crucial for the surgeon to comprehend the preoperative aesthetic facial linkages and anticipate any potential impact the surgical operation may have on the nasolabial region before performing maxillary surgery. To control the width of the alar base after maxillary osteotomy clinicians have advocated the placement of cinch sutures, reduction of the anterior nasal spine and use of V-Y closure technique. There are inconstant opinions on the effect of the cinch suture.

Three-dimensional evaluation of skeletal and dental effects of treatment with maxillary skeletal expansion

The objective was to determine the skeletal and dental changes with microimplant assisted rapid palatal expansion (MARPE) appliances in growing (GR) and nongrowing (NG) patients using cone-beam computed tomography and 3-dimensional imaging analysis. The sample consisted of 25 patients with transverse maxillary discrepancy treated with a maxillary skeletal expander, a type of MARPE appliance. Cone-beam computed tomography scans were taken before and after maxillary expansion; the interval was 6.0 ± 4.3 months. The sample was divided into GR and NG groups using cervical vertebral and midpalatal suture maturation. Linear and angular 3-dimensional dentoskeletal changes were assessed after cranial base superimposition. Groups were compared with independent-samples t test (P<0.05). Both groups displayed marked transverse changes with a similar ratio of skeletal to dental transverse changes and parallel sutural opening from the posterior nasal spine-anterior nasal spine; a similar amount of expansion occurred in the anterior and the posterior regions of the maxilla. The maxilla expanded skeletally without rotational displacements in both groups. The small downward-forward displacements were similar in both groups, except that the GR group had a significantly greater vertical displacement of the canines (GR, 1.7 ±1.0 mm; NG, 0.6 ± 0.8 mm; P= 0.02) and anterior nasal spine (GR, 1.1 ± 0.6 mm; NG, 0.5 ± 0.5 mm; P= 0.004). Treatment of patients with MARPE appliance is effective in GR and NG patients. Although greater skeletal and dental changes were observed in GR patients, a similar ratio of skeletal to dental transverse changes was observed in both groups.

Septocolumellar Suture Technique for Correction of Septal Caudal Dislocation

Objective: To describe this technique for treatment of caudal septal dislocation and to evaluate the effectiveness of this technique in terms of correction of cosmetic deformity and relief of nasal obstruction.Methods: This was a descriptive case series study performed at ENT department of Services Institute of Medical Sciences (SIMS), Services Hospital, Jail Road, Lahore. 30 Cases of mild to moderate degree of septal caudal dislocation were selected and operated. The septum was fixed by sutures to the anterior nasal spine. Columellar pocket was made and septum was sutured in the pocket by two sutures at upper and lower levels to increase the stability of corrected septum.Results: We performed this suturing technique on 30 septoplasty cases during 3 years from Jan-2016 to Jan-2019. Among them 12 (40%) were male and 18 (60%) were female. Total follow up period ranged between 3 to 6 months. Anterior rhinoscopy showed no persistence of deviation or dislocation in 25 patients. 5 cases had mild deviation of septum on non-operated side.Conclusion: Two level septocolomellar suture technique is very effective, easy to learn &amp; perform and shows long term reliability in correction of caudal septal dislocation. This is effective in improving cosmesis and nasal air flow.

Open Rhinoplasty: A Personal Evolution of Technique.

Rhinoplasty remains one of the most commonly performed aesthetic surgical procedures, and the open approach has gained more popularity.1,2 Closed rhinoplasty can address dorsal hump deformities, with minimal tip modification.1 Meanwhile, the open approach provides undistorted exposure of the nasal anatomy, allowing for greater accuracy in the diagnosis and approach to nasal obstruction or deformity.1–3 Many trainees and young plastic surgeons become accustomed to the way they were taught rhinoplasty. As an otolaryngology resident, I was taught to commence a rhinoplasty with marginal incisions. Once through the vestibular skin, the lower lateral cartilages are revealed and the nasal dorsum and sidewalls are undermined blindly with a Littler scissor. This was imprecise, often leading to out-of-plane dissections and subsequent bleeding. One reform I have made in fellowship under the direction of my program director (P.B.) is to first make the transcolumellar incision. Once the skin–soft tissue envelope is elevated, the medial crura are dissected and followed superolaterally to then dissect the lateral crura. Staying on cartilage with this technique helps the surgeon to stay in the right plane and maintain hemostasis. Next in the sequence of performing a proper rhinoplasty, the anterior septal angle needs to be identified to allow for proper mucoperichondrial dissection and cartilage release.4 It is especially important to start a septoplasty and dorsal work. The anterior septal angle represents the anteriormost projecting point of the septum, contributing to nasal tip support, projection, length, and airway function. In secondary rhinoplasty, its identification is paramount because it is usually one of the landmarks that is preserved, serving as a guide when anatomical planes have been scarred or are even missing.4 In residency, we retracted the domes laterally with single skin hooks to identify the anterior septal angle. This commonly traumatized the nasal cartilages, rendering them prone to damage or avulsion. In addition, the tactile feedback was not optimized. In fellowship, I have learned to handle cartilage delicately with Adson-Brown forceps (Fig. 1). This change has allowed me to preserve the integrity of the cartilages while maintaining proper control and feedback. Adson-Brown forceps are precise because they allow one grasp at a time from a single point.5 Another modification I have made is the process by which I identity the anterior septal angle. In residency, I would turn my Iris scissors parallel between the medial crura to find the caudal septum low as it takes off from the anterior nasal spine. In fellowship, I have transitioned to beginning my dissection superiorly under the direction of the senior author (P.B.) (Fig. 2). The septum has more stability at this position, thus making it less prone to fracture. In addition, we find this location easier to begin the mucoperichondrial dissection.Fig. 1.: Lower lateral cartilages being handled delicately with Adson-Brown forceps while maintaining tactile feedback.Fig. 2.: Dissection of the anterior nasal spine superiorly, allowing for easier identification and mucoperichondrial dissection.Although these nuances may seem subtle, they can impact the final result. Throughout one’s training and subsequent career, surgeons should be encouraged to reform their surgical technique and the use of surgical instruments accordingly. PATIENT CONSENT The patient provided written consent for use of the patient’s images. DISCLOSURE The authors report no financial disclosures or conflicts of interest. Jason E. Cohn, D.O.Sunrise Facial PlasticsLindenhurst, N.Y. Katherine Chemakin, B.S.Albert Einstein College of MedicineBronx, N.Y. Paige Bundrick, M.D.Department of Otolaryngology–Head and Neck SurgeryDivision of Facial Plastic Reconstructive SurgeryOchsner Louisiana State University of HealthShreveport, La.