Maxillary Surgery Research Articles

Soft Tissue Profile Changes After Bilateral Sagittal Split Osteotomy for Mandibular Setback: A Systematic Review

To evaluate the ratio of soft tissue to hard tissue in bilateral sagittal split setback osteotomy with rigid internal fixation or wire fixation. A literature search was performed using PubMed, Medline, CINAHL, Web of Science, the Cochrane Library, and Google Scholar Beta. From the original 766 articles identified, 8 articles were included. Two articles were prospective and 6 retrospective. The follow-up period ranged from 1 year to 12.7 years for rigid internal fixation. Two articles on wire fixation were found to be appropriate for inclusion. The differences between short- and long-term ratios of the lower lip to lower incisors for bilateral sagittal split setback osteotomy with rigid internal fixation or wire fixation were quite small. The ratio was 1:1 in the long term and by trend slightly lower in the short term. No distinction was seen between the short- and long-term ratios for mentolabial fold. The ratio was found to be 1:1 for the mentolabial fold to point B. In the short term, the ratio of the soft tissue pogonion to the pogonion showed a 1:1 ratio, with a trend to be lower in the long term. The upper lip showed mainly protrusion, but the amount was highly variable. This systematic review shows that evidence-based conclusions on soft tissue changes are difficult to draw. This is mostly because of inherent problems of retrospective studies, inferior study designs, and the lack of standardized outcome measurements. Well-designed prospective studies with sufficient samples and excluding additional surgery, ie, genioplasty or maxillary surgery, are needed.

Nucleic Acid Extraction Efficiency and Bacterial Recovery from Maxillary Sinus Mucosal Samples Obtained by Brushing or Biopsy

Chronic rhinosinusitis (CRS) is a common disease with a complex pathophysiology involving a microbial component. Culture-independent molecular analysis represents a promising new approach to clarify the microbiology of CRS, but standardized, optimized sampling methods still have not been defined. This study was designed to compare nucleic acid extraction rates and recovery of bacteria for two methods of sampling the maxillary sinus, mucosal biopsy, and brushing. Samples were obtained from 20 patients undergoing maxillary sinus surgery. Total extracted nucleic acid concentration and bacterial burden were compared between sample types. Total nucleic acid concentration varied across patients. No statistically significant difference in mean total DNA concentration from mucosal biopsy specimens or brushings was observed. However, compared with biopsy specimens, brush samples possessed a significant (p < 0.035) increase in bacterial copy number. Endoscopically directed mucosal brushings of the maxillary sinus provide equivalent concentrations of total DNA to mucosal biopsy specimens but possess greater concentrations of bacterial DNA, likely because of the greater surface area sampled by this method. Given the additional advantage of lower risk associated with obtaining brush samples, we suggest they represent the preferred sampling method for future genomic sinus studies.

Melanotic neuroectodermal tumour of infancy (progonoma) treated by radical maxillary surgery

Two cases of melanotic neuroectodermal tumour of infancy (MNTI), otherwise known as melanotic progonoma, both arising from the maxilla are presented here. The two infants both presented within three months of each other and though clinically Burkitt's lymphoma was stated as a possible diagnosis, the correct diagnosis was made on biopsy specimens. Radical surgery consisting of wide resection of the tumour with margins of healthy tissue via hemi-maxillectomy was performed in each case as an initial method of treatment. At follow up four months later, both infants appeared clinically well. One infant was then lost to follow up thereafter but the other was reviewed three years later, and apart from slight facial asymmetry, there was no evidence of tumour recurrence.

Orthodontic-surgical treatment of Class III malocclusion with extraction of an impacted canine and multi-segmented maxillary surgery

Establishment of a treatment plan is based on efficacy and easy application by the clinician, and acceptance by the patient. Treatment of adult patients with Class III malocclusion might require orthognathic surgery, especially when the deformity is severe, with a significant impact on facial esthetics. Impacted teeth can remarkably influence treatment planning, which should be precise and concise to allow a reasonably short treatment time with low biologic cost. We report here the case of a 20-year-old man who had a skeletal Class III malocclusion and impaction of the maxillary right canine, leading to remarkable deviation of the maxillary midline; this was his chief complaint. Because of the severely deviated position of the impacted canine, treatment included extraction of the maxillary right canine and left first premolar for midline correction followed by leveling, alignment, correction of compensatory tooth positioning, and orthognathic surgery to correct the skeletal Class III malocclusion because of the severe maxillary deficiency. This treatment approach allowed correction of the maxillary dental midline discrepancy to the midsagittal plane and establishment of good occlusion and optimal esthetics.

37 Patient-centred evaluation of satisfaction levels following orthognathic surgery

Overall complication rate is 20%. 3.5% (n = 3) of our patients had devitalisation of teeth. 2.4% (n = 2) of patients developed minor localised periodontal defects which were clinically significant, 1.2% (n = 1) had tooth loss secondary to mobility. Maxillary osteosynthesis removal was carried out in 8.2% (7) of patients. 4.7% (n = 4) patients developed post-operative palatal fistula: 3 were managed conservatively, one healed spontaneously and two persisted; one persisted despite surgical repair. There was no segmental loss of bone or teeth. Conclusion: Our results show complication rates in this cohort is relatively low. It shows that segmental maxillary surgery is safe as an adjunct in carefully selected cases.

Soft Tissue Profile Changes After Bilateral Sagittal Split Osteotomy for Mandibular Advancement: A Systematic Review

The purpose of the present systematic review was to evaluate the soft tissue/hard tissue ratio in bilateral sagittal split advancement osteotomy (BSSO) with rigid internal fixation (RIF) or wire fixation (WF). The databases PubMed, Medline, CINAHL, Web of Science, Cochrane Library, and Google Scholar Beta were searched. From the original 711 articles identified, 12 were finally included. Only 3 studies were prospective and 9 were retrospective. The postoperative follow-up ranged from 3 months to 12.7 years for RIF and 6 months to 5 years for WF. The short- and long-term ratios for the lower lip to lower incisor for BSSO with RIF or WF were 50%. No difference between the short- and long-term ratios for the mentolabial-fold to point B and soft tissue pogonion to pogonion could be observed. It was a 1:1 ratio. One exception was seen for the long-term results of the soft tissue pogonion to pogonion in BSSO with RIF; they tended to be greater than a 1:1 ratio. The upper lip mainly showed retrusion but with high variability. Despite a large number of studies on the short- and long-term effects of mandibular advancement by BSSO, the results of the present systematic review have shown that evidence-based conclusions on soft tissue changes are still unknown. This is mostly because of the inherent problems of retrospective studies, inferior study designs, and the lack of standardized outcome measures. Well-designed prospective studies with sufficient sample sizes that have excluded patients undergoing additional surgery (ie, genioplasty or maxillary surgery) are needed.

Long-term stability of adolescent versus adult surgery for treatment of mandibular deficiency

In mandibular deficient patients, mandibular growth is not expected after the adolescent growth spurt, so mandibular advancement surgery is often carried out at 13 years. To test if the long-term stability for younger patients is similar to that for adult patients, the authors compared cephalometric changes from 1-year postsurgery (when changes due to the surgery should be completed) to 5-year follow up. 32 patients who had early mandibular advancement with or without simultaneous maxillary surgery (aged up to 16 for girls and 18 for boys), and 52 patients with similar surgery at older ages were studied. Beyond 1-year postsurgery, the younger patients showed significantly greater change in the horizontal and vertical position of points B and pogonion, the horizontal (but not vertical) position of gonion, and mandibular plane angle. 50% of younger patients had 2-4mm backward movement of Pg and another 25% had >4mm. 15% of older patients had 2-4mm change and none had >4mm. Long-term changes in younger patients who had two-jaw surgery were greater than for mandibular advancement only. Changes in younger groups were greater than for adult groups. Satisfaction with treatment and perception of problems were similar for both groups.

Interim Endodontic Therapy for Alveolar Socket Bone Regeneration of Infected Hopeless Teeth Prior to Implant Therapy

The immediate placement of implants in the fresh extraction sockets of infected teeth with periradicular and periapical lesions is contraindicated because of both the infection and the loss of architecture required for proper implant placement. There are 4 approaches for implant replacement of a hopeless tooth with lesions: (1) extraction and delayed implant placement; (2) extraction, debridement, guided bone regeneration (GBR), guided tissue regeneration (GTR), and delayed implant placement; (3) extraction, intrasocket debridement, and immediate implant placement; or (4) extraction, debridement, GBR, GTR, and simultaneous implant placement. The extraction of such hopeless teeth often results in large bone and soft tissue defects that are difficult to repair. This article introduces an alternative approach: interim endodontic implant site preparation, defined as a transitional, surgical, or nonsurgical endodontic treatment to regenerate the hopeless tooth bone defects and prepare the site for proper implant placement. This article describes 3 distinct interim endodontic protocols used to manage 5 patients, all of whom had severely infected hopeless teeth with large lesions and were treatment planned for implant replacement: the first, interim nonsurgical endodontic treatment to restore the normal anatomy of the infected hopeless tooth; the second, interim surgical endodontics on the hopeless tooth with preexisting endodontic treatment to regenerate apical bone for primary implant stability, thus avoiding the involvement of the maxillary sinus and other critical anatomic structures; and the third, interim surgical endodontics on the hopeless tooth with preexisting endodontic treatment to confine the size of the osseous defect and simplify the GBR and GTR procedures. The outcome of interim endodontic treatment on these 5 patients demonstrated that tooth extraction would have been a less predictable approach. The interim treatment changed the overall direction of the patients' dental care. When treated, these hopeless teeth served many preventive, biologic, and esthetic functions. The infections of the alveolar sockets were eliminated, the alveolar bone defects were repaired through normal bone regeneration, and sockets anatomies were maintained or restored. Furthermore, the patients were spared maxillary sinus surgery and the possible complications resulting from major GBR and GTR procedures. In summary, the interim treatment facilitated tooth extraction and immediate implant placement.

Relapse following bilateral sagittal split osteotomy with rigid internal fixation

PubMed, Ovid (including OLDMedline), Google Scholar Beta, the Cochrane Library and references of identified articles were used to identify data sources. Studies were included if they involved more than 10 adults, a followup of greater than 6 months, and mandibular advancement by bilateral sagittal split osteotomy (BSSO) with rigid internal fixation. Studies that included another surgical intervention (eg, Le Fort I osteotomy), syndromic or medically compromised patients, case reports, case series, descriptive studies, review and opinion articles or abstracts were excluded. The following data items were extracted: year of publication, study design, followup, number and mean age of patients, ethnic background of patients, number of surgeons operating, type of rigid internal fixation, use of MMF (maxillomandibular fixation), use of genioplasty, mean advancement, mean relapse, correlations between relapse and different variables, proportion of patients with more than 2 mm of sagittal relapse, and authors' conclusions. A quality assessment of the included studies was undertaken following selection. Studies were categorised as medium or low quality based on study design, sample size, selection descriptions, withdrawals, valid methods, confounding factors, method error analysis, blinding in measurements and adequate statistics. None of the included studies met the criteria of the high-quality category. Twenty-four articles were finally included, comprising six prospective and 18 retrospective studies. The range of postoperative study records was 6 months to 12.7 years. The short-term relapse for bicortical screws was between 1.5 and 32.7%, for miniplates between 1.5 and 18.0%, and for bioresorbable bicortical screws between 10.4 and 17.4%, at point B (the deepest concavity on the anterior profile of the maxilla). The long-term relapse for bicortical screws was between 2.0 and 50.3%, and for miniplates between 1.5 and 8.9%, at point B. To obtain reliable scientific evidence, further short-term and long-term research into BSSO advancement with rigid internal fixation should exclude additional surgery, ie, genioplasty or maxillary surgery, and include a prospective study or randomised controlled clinical trial (RCT) design with correlation statistics.

Factors related to root resorption in edgewise practice.

In a series of 200 consecutively debanded patients receiving comprehensive orthodontic treatment with the edgewise appliance, six (3%) showed severe resorption (greater than one-quarter of the root length) of both maxillary central incisors. For other teeth, resorption of this extent occurred in less than 1% of the patients. Using a case-control design, the characteristics of 21 patients with severe resorption were compared to randomly selected controls from the case series. There were significantly more Class III patients among the severe resorption cases than would have been expected. Risk indicators for resorption that were related to treatment procedures included approximation of the maxillary incisor roots against the lingual cortical plate (odds ratio 20), maxillary surgery (odds ratio 8), and root torque (odds ratio 4.5).

Mandibular distraction osteogenesis and maxillary osteotomy in a class II division 1 patient with chronic juvenile arthritis.

A patient with juvenile chronic arthritis presented with a malocclusion characterized by mandibular hypoplasia, symphysial deficiency, and an increased mandibular occlusal plane angle. Correction of the mandibular defect required both the horizontal advancement of the mandible and a counterclockwise rotation of the proximal segment to reduce the mandibular occlusal plane angle. This was achieved by a combination of distraction osteogenesis to horizontally advance the mandible (14 mm), followed by manipulation of the postdistraction regenerate to reduce the mandibular occlusal plane and increase the symphysial projection. The counterclockwise rotation of the mandibular body resulted in the creation of a posterior open bite. After a three-month period to allow consolidation of the mandibular distraction osteogenesis, secondary maxillary surgery at the Le Fort 1 level was performed to reestablish maxillary occlusal contact at the new mandibular occlusal plane. A genioplasty was also performed to improve chin projection.

Endoscopic nasal lateral wall dissection approach for benign lesions of maxillary sinus

Objective:To report our experience on endoscopic nasal lateral wall dissection approach for treatment of refractory benign maxillary sinus diseases.Methods:The data of 8 patients,who had relapsing maxillary diseases 2 to 4 times after maxillary sinus or ethmoid sinus surgery,were retrospectively analyzed.The patients included 6 males and 2 females,with an average age of(55±14) years(41-69 years).Under general anesthesia the operation started from an incision in front of the inferior turbinate(IT),then the lacrimal duct(LD) was dissected to form a IT-LD flap.The flap was placed inwardly and the maxillary sinus lesion was removed under endoscope.The inferior antrostomy was performed when necessary.The possibility of maxillary sinus malignant lesions was ruled out by postoperative pathology.Results:Postoperative pathological findings confirmed that the lesions were all benign.The follow-up period ranged from 6-14 months.Five patients were cured and 3 were improved 6 months after operation.There were no complications such as cheek numbness,epiphora,orbital hemorrhage,visual disorder or cerebrospinal fluid rhinorrhea during follow-up.Conclusion:The endoscopic nasal lateral wall dissection approach provides a wider vision field and allows for a thorough removal of maxillary sinus lesions,while reserving the LD and IT.

Transseptal Approach for Extended Endoscopic Resections of the Maxilla and Infratemporal Fossa

Larger and more extensive lesions of the maxilla and infratemporal fossa are being successfully managed by entirely endoscopic approaches. There are still limitations in access, especially the anterolateral maxilla. The suitability of various surgical approaches was assessed in relation to surgical access achieved. Surgical access was compared in 10 cadaver heads. Five zones were defined: zone 1, nasal cavity; zone 2, medial to infraorbital nerve (ION); zone 3, lateral to ION; zone 4, anterior maxilla; and zone 5, premaxillary tissue. Endoscopic maxillary surgery consisted of standard antrostomy, modified medial maxillectomy, or complete medial maxillectomy with lacrimal duct resection. Transseptal and ipsilateral approaches were compared in each surgical state. The degree of angulations and resection zone accessed were recorded from image-guided surgery. The limits of both straight and curved instrumentation were also compared. Transseptal access improved surgical access by 14.7 +/- 2.5 degrees when compared with ipsilateral approaches (p < 0.001) across all situations. The access to zone 3 across all specimens was significantly improved by 63.3-97.6% (chi2 = 20.83; p < 0.001) after all three surgical states. After complete medial maxillectomy, access to zone 4 increased from 25.0 to 85.0% (chi2 = 14.54; p < 0.001) with a transseptal approach. Extended endoscopic maxillary surgery combined with a transseptal option enables additional access to previously considered challenging locations. Preoperative assessment of skull base tumor, papilloma and angiofibroma extent, and resection margin will dictate surgical approach.

Sensory retraining following orthognathic surgery: effect on threshold measures of sensory function

The purpose of this analysis was to examine the effect of sensory retraining on sensory function after bilateral sagittal split osteotomy (BSSO). A total of 186 subjects were enrolled in a multi-centre double-blind two parallel group stratified block randomized clinical trial. Subjects were randomized to group immediately after surgery. Threshold measures for contact detection, two-point discrimination and two-point perception were obtained on the chin before and 1, 3 and 6 months and 1 and 2 years after surgery. The ratio of each threshold measure (post-surgery value/pre-surgery value) was calculated to characterize subjects' impairment. A general linear mixed model was fit for the impairment to examine the effect of the sensory retraining before and after adjusting for demographic, surgical and psychological factors. On average, two-point perception was less impaired in subjects who were retrained than in those who were not retrained (P = 0.04). Significant recovery continued up to 6 months after surgery for contact detection and two-point perception and up to 24 months for two-point discrimination. Older subjects experienced more impairment in two-point discrimination than younger subjects (P = 0.009). Subjects who received maxillary surgery in addition to mandibular surgery experienced more impairment on the chin in both two-point discrimination (P = 0.0003) and perception (P = 0.0013) than subjects who received mandibular surgery only. Psychological factors did not explain additional variability in subjects' impairment post-surgery. These finding indicate that a simple non-invasive exercise programme initiated shortly after orthognathic surgery can alter the way patients experience or respond to tactile stimulation long after the exercise regimen has stopped.

The Relation Between Pogonion Advancement and Posterior Maxillary Impaction

Controversy exists about the relation between the amount of posterior maxillary impaction and pogonion (P) advancement. The aims of the current study were to (1) propose a formula to predict the amount of P advancement due to posterior maxillary impaction surgery, (2) predict the amount of posterior maxillary impaction by means of a formula to achieve the best facial harmony, and (3) identify the compatibility between proposed formulas and the actual resultant mandibular position after posterior maxillary impaction surgery. For obtaining the formulas, 2 cephalograms were taken from 1 patient in centric occlusion and rest position. Afterward, mandibular rotational center was obtained by superimposing the cephalograms; by the help of which the 2 formulas were obtained. To check the reliability of the formulas, 10 patients with the mean age of 21 +/- 1.5 years who had undergone posterior maxillary impaction were selected. The presurgical and postsurgical cephalograms of patients were obtained. These cephalograms were superimposed to find the center of mandibular rotation. Pearson correlation coefficient test was used to evaluate the relation between the suggested formulas and the clinical data. This test showed that there were significant correlations between maxillary impaction and P advancement in both the formulas and clinical evaluation. This correlation (r) was 0.993 (P < 0.001) based on formulas and r = 0.806 (P < 0.005) based on tracing. This study showed that the amounts of anterior facial height reduction and P advancement were almost the same, and the anterior facial height was reduced 1.5 times more than the amount of maxillary impaction.

Stability After Bilateral Sagittal Split Osteotomy Advancement Surgery With Rigid Internal Fixation: A Systematic Review

The purpose of this systematic review was to evaluate horizontal relapse and its causes in bilateral sagittal split advancement osteotomy (BSSO) with rigid internal fixation of different types. A search of the literature was performed in the databases PubMed, Ovid, Cochrane Library, and Google Scholar Beta. From 488 articles identified, 24 articles were finally included. Six studies were prospective, and 18 were retrospective. The range of postoperative study records was 6 months to 12.7 years. The short-term relapse for bicortical screws was between 1.5% and 32.7%, for miniplates between 1.5% and 18.0%, and for bioresorbable bicortical screws between 10.4% and 17.4%, at point B. The long-term relapse for bicortical screws was between 2.0% and 50.3%, and for miniplates between 1.5% and 8.9%, at point B. BSSO for mandibular advancement is a good treatment option for skeletal Class II, but seems less stable than BSSO setback in the short and long terms. Bicortical screws of titanium, stainless steel, or bioresorbable material show little difference regarding skeletal stability compared with miniplates in the short term. A greater number of studies with larger skeletal long-term relapse rates were evident in patients treated with bicortical screws instead of miniplates. The etiology of relapse is multifactorial, involving the proper seating of the condyles, the amount of advancement, the soft tissue and muscles, the mandibular plane angle, the remaining growth and remodeling, the skill of the surgeon, and preoperative age. Patients with a low mandibular plane angle have increased vertical relapse, whereas patients with a high mandibular plane angle have more horizontal relapse. Advancements in the range of 6 to 7 mm or more predispose to horizontal relapse. To obtain reliable scientific evidence, further short-term and long-term research into BSSO advancement with rigid internal fixation should exclude additional surgery, ie, genioplasty or maxillary surgery, and include a prospective study or randomized clinical trial design with correlation statistics.

テルダーミスを用いた骨形成性上顎洞手術

Osteoplastic maxillary antrostomy is performed to restore the normal anatomy and physiology of the maxillary sinus. Although endoscopic sinus surgery has been employed since the 1980s, antrostomy through the canine fossa is still required in cases such as an inverted papilloma originating from the maxillary sinus or a blow-out fracture of the inferior orbital floor. Herein, we demonstrate a new procedure using a collagen sponge (Terudermis®, Olympus Terumo Biomaterials Co., Ltd., Tokyo, Japan) to support the free bone flap of the anterior wall of the maxillary sinus. The collagen sponge also promotes epithelialization of the maxillary sinus. We employed this procedure in 11 cases, including five cases involving repair of a blow-out fracture of the inferior orbital floor, two to remove fungal growth from the maxillary sinus, three to remove an inverted papilloma of the maxillary sinus, and one for removal of an odontogenic maxillary cyst. In all cases, the maxillary sinus was epithelialized without infection, except for one recurrent case of papilloma. In seven of the 11 cases, postoperative CT was performed, showing that the bony flap was maintained in the original position. This new method simplifies osteoplastic maxillary surgery and reduces the surgical time.

The Effect of Tranexamic Acid on Blood Loss During Orthognathic Surgery: A Randomized Controlled Trial

Tranexamic acid has been used to reduce blood loss and the subsequent need for transfusion in orthopedic, spinal, and cardiac surgery. Orthognathic surgery can be associated with significant bleeding yet its efficacy in this setting is not clear. The purpose of this study was to investigate the effect of tranexamic acid on blood loss during bimaxillary osteotomy. Seventy-three consecutive patients, scheduled for elective bimaxillary osteotomy, were included in this double blind, randomized, controlled trial. They received either a bolus of tranexamic acid (20 mg/kg) or placebo (normal saline) intravenously just before surgery. All patients received induced mild hypotension and had surgery according to a standard protocol. Intraoperative blood loss, operation time, transfusion of blood products, perioperative hemoglobin, and hematocrit were recorded. The total blood loss and blood loss during maxillary surgery was reduced significantly in the tranexamic acid group compared with the control group (878.6 +/- 577.7 mL vs 1,257.2 +/- 817.8 mL and 428.0 +/- 233.3 mL vs 643.8 +/- 430.0 mL, respectively; P < .05). Considering the duration of operation and the treatment groups only, the mean total blood loss in the control group was 422 mL more than that in the tranexamic acid group (P < .001). There was no significant difference in blood transfusion or the length of hospital stay between the 2 groups. Preoperative intravenous bolus administration of tranexamic acid at 20 mg/kg reduces blood loss compared with placebo during bimaxillary osteotomy.

O.389 Nasal morphology and function following maxillary surgery

O.389 Nasal morphology and function following maxillary surgery

Surgery-First-Orthognathic-Approach (SFOA) to Prognathism: Indications and Limitations

Surgery-First-Orthognathic-Approach (SFOA), defined as orthognathic surgery without preoperative orthodontic treatment, is a new paradigm in the combined orthodontic-orthognathic approach to jaw deformities. Refinement in maxillary surgery, especially posterior impaction of the maxilla and rotation of the occlusal plane markedly diminished the necessity for extraction of upper premolars to get sufficient reverse overjet in mandibular set-back surgery for Class III patients. Patients with mild to moderate crowding and acceptable arch coordination can receive orthognathic surgery without preoperative orthodontic treatment. With considerable preoperative planning and precise surgery, the postoperative orthodontic procedure is direct and rapid; patients can get the desired facial profile and occlusion in much less period of time.