Orthognathic Intervention Research Articles

Outcomes and Stability of Anterior Open Bite Treatment with Skeletal Anchorage in Non-Growing Patients and Adults Compared to the Results of Orthognathic Surgery Procedures: A Systematic Review.

The objective of this review is to evaluate, on the basis of the available literature, if anterior open bite (AOB) can be successfully treated with the intrusion of molar teeth using skeletal anchorage in non-growing patients and adults and if this treatment modality provides comparable results to those obtained by orthognathic surgery procedures. Methods: A systematic review of published data in major databases from 2000 to 2021 was performed. Results: In total, 92 articles were included in title and abstract screening, and only 16 articles (11 concerning AOB correction by molar intrusion with skeletal anchorage, and five considering AOB treatment by orthognathic surgical intervention) qualified for thorough data extraction and analysis. Conclusions: On the basis of this review, it seems to be possible to obtain successful results for AOB treatment in non-growing patients and adults by means of the intrusion of molar teeth with skeletal anchorage. However, due to the different methods of assessing treatment outcomes used by different authors, it is not possible to state conclusively whether the treatment of AOB by means of molar intrusion with skeletal anchorage provides long-term results that are comparable to orthognathic surgery procedures.

Classification for mandibular deviation and facial asymmetry and its clinical significance

Judged from the clinical manifestations, etiological mechanisms and jaw morphological structures, malocclusions with mandibular deviation and facial asymmetry are classified into three main categories, i.e., those with mandibular positioning factors, those with mandibular condyle defects, and those with jaw congenital deformities. In the first category, three subtypes, including mandibular rotation caused by dentitional irregularities, by dental compensation and by habitual posturing, are further defined. In the second category, mandibular deviation caused by condylar asymmetrical resorption or hyperplasia are defined as the two subtypes. The third category is further divided into two subtypes, i.e., jaw and facial asymmetry resulting from maxillary or mandibular structural deformities. The prime goal of orthodontic therapy is to displace and restore the deviated mandible to its right position, followed by correction of occlusal intercuspation. As an important procedure of the whole treatment protocol, It is critical to detect and localize the correct mandibular position by manipulation and then register it by wax pattern and articulator transferring. For the cases with mandibular functional elements and condylar asymmetrical length, the treatment modalities include orthopedic repositioning of the mandible by using occlusal and bite plane, SGTB and SGHB therapies; for cases with growth and developmental anomalies, orthognathic intervention should be an optimal solution.

The Likelihood of Orthognathic Surgery After Orofacial Cleft Repair.

Midface hypoplasia is one of the most significant sequelae of cleft lip and/or palate surgery. A complete understanding of the rate of orthognathic surgery across varying cleft phenotypes is a powerful tool for educating patients and families as to the treatment course that the patient will incur during their lifetime. Understanding the average rates of orthognathic intervention also can act to develop metrics for outcome evaluation with different treatment protocols. Attempting to identify the average rates of orthognathic intervention, the authors conducted a systematic review and meta-analysis by combining studies from 1987 to 2016 describing the frequency of orthognathic intervention on the different cleft phenotypes as the primary outcome. Secondary outcomes included identification of surgical protocol, age of patient at orthognathic intervention, and the method by which patients were evaluated for orthognathic intervention. The rate of orthognathic surgery was 38.1% for bilateral cleft lip and palate (BCLP), 30.2% for unilateral cleft lip and palate (UCLP), 4.4% for isolated cleft palate (ICP), and 1.8% for patients with isolated cleft lip (ICL). 71% (n = 10) reported using lateral cephalograms for orthognathic surgery evaluation and only one of those studies reported specific objective cephalometric measurements for orthognathic intervention. Our findings demonstrated that BCLP possessed the highest rate of orthognathic intervention followed by UCLP, ICP, and ICL. ICP and ICL both possessed low rates of orthognathic intervention. By sharing our findings, the authors hope to provide a useful tool for informing patients' families as to their risk of needing orthognathic intervention.

Institutional Orthognathic Intervention after Orofacial Cleft Repair: A Systematic Review and Meta-Analysis

Orofacial cleft deformities are prevalent congenital defects which can affect approximately 7.75 neonates out of every 10 000 live births.1 As these patients age, they receive surgical correction of their orofacial clefts, and subsequent midface hypoplasia is a commonly reported problem. Between institutions, the reported incidence of the surgical correction for midface hypoplasia varies drastically. The relationship between the need for orthognathic corrective surgery, the institution’s preferred surgical protocol, and threshold for orthognathic surgery remains unclear. Some institutions report orthognathic surgery rates as high as 70%.2 An improved understanding of the overall incidence of orthognathic surgery and treatment patterns is important to determine optimal treatment and standard of care for these patients.

The Impact of Bilateral Suprazygomatic Maxillary Nerve Blocks on Postoperative Pain Control in Patients Undergoing Orthognathic Surgery

Aims: The mainstay of analgesia in orthognathic interventions for maxillary hypoplasia is perioperative opioids, however, the side effect profile is broad with the potential for well-described deleterious effects. The suprazygomatic maxillary nerve block has been previously shown to be effective in decreasing pain associated with palatal surgery. To date, there have been no studies detailing the use of maxillary nerve blocks as an adjunctive pain control measure during correction of maxillary hypoplasia. Consequently, we sought to evaluate the efficacy of intra-operative, ultrasound-guided bilateral suprazygomatic maxillary nerve blockade in decreasing postoperative narcotic consumption in patients undergoing Le Fort I level surgical orthognathic correction of cleft-related maxillary hypoplasia. Methods: Between January and December 2019, patients underdoing suprazygomatic maxillary nerve blockade for orthognathic correction of maxillary hypoplasia via either Le Fort I advancement or distraction were prospectively collected and compared to controls. Patient demographics, narcotic use (represented as morphine milligram equivalents per kg; MME/kg), self-reported pain scales, operative times, length of stay (LOS), and complication rates were compared. Results: Over the 12-month interval, 40 patients met inclusion criteria (n = 19 Block; n = 21 Control). Mean ages were 15.6 and 15.9 years, respectively. The block group demonstrated a significant reduction in postoperative narcotic requirements on POD1 and POD2 when compared to controls (POD1: 0.020 mg/kg vs 0.066 mg/kg, P < .005; POD2: 0.030 mg/kg vs 0.080 mg/kg, P < .016), with a trend toward significance thereafter. Corroboratively, self-reported pain scores in the first 24 hours were significantly decreased in the block compared to control groups with a trend toward significance thereafter (POD1: 1.13 vs 2.72, P < .001; POD2: 1.72 vs 2.56, P < .08; POD3: 1.21 vs 2.07, P < .06). LOS was decreased by an average of 1 day in the block group, operative times were unchanged, and neither group evidenced perioperative complication or return to service within 30 days. Conclusion: Administration of bilateral suprazygomatic maxillary nerve blocks in patients undergoing Le Fort I maxillary osteotomy for correction of cleft-related maxillary deficiency demonstrated a significant reduction in post-operative narcotic requirements, self-reported pain scales, and LOS without increased complications, suggesting its utility as a safe and effective analgesic adjunct in this patient population.

Assessing the midface in Muenke syndrome: A cephalometric analysis and review of the literature

Max Muenke included midface hypoplasia as part of the clinical syndrome caused by the Pro250Arg FGFR3 mutation that now bears his name. Murine models have demonstrated midface hypoplasia in homozygous recessive mice only, with heterozygotes having normal midfaces; as the majority of humans with the syndrome are heterozygotes, we investigated the incidence of midface hypoplasia in our institution's clinical cohort. We retrospectively reviewed all patients with a genetic and clinical diagnosis of Muenke syndrome from 1990 to 2014. Review of clinical records and photographs included skeletal Angle Class, dental occlusion, and incidence of orthognathic intervention. Cephalometric evaluation of our patients was compared to the Eastman Standard Values. 18 patients met inclusion criteria - 7 females and 11 males, with average follow-up of 11.2 years (1.0-23.1). Cephalometric analysis revealed an average sella-nasion-A point angle (SNA) of 82.5 (67.8-88.8) and an average sella-nasion-B point angle (SNB) of 77.9 (59.6-84.1). The SNA of our cohort was found to be significantly different from the Eastman Standards (p=0.017); subgroup analysis revealed that this was due to the mixed dentition group which had a higher than average SNA. 12 patients were noted to be in Class I occlusion, 4 in Class II malocclusion, and 2 in Class III malocclusion. Only one patient (6%) underwent orthognathic surgery for Class III malocclusion. While a part of the original description of Muenke syndrome, clinically significant midface hypoplasia is not a common feature. This data is important, as it allows more accurate counseling of patients and families. III.

Progressive facial asymmetry resulting from condylar osteochondroma – A case report detailing the resection, subsequent orthognathic intervention and custom joint replacement

We discuss a 37 year old male – who presented with marked facial asymmetry and signs/symptoms suggestive of condylar hyperplasia. Imaging confirmed a large exophytic growth arising from the right mandibular condylar head. Treatment included tumour resection, orthognathic intervention and total joint replacement. The clinical presentation, pathology and treatment, along with a brief discussion are described in this report.

Editor's Summary and Q&A

Introduction Orthognathic treatment is undertaken to correct jaw discrepancies and involves a combination of orthodontics and surgery. The effects of orthodontic treatment on temporomandibular disorders (TMD) have been widely debated in the literature, but fewer studies focus on the effects of orthognathic treatment on TMD. Methods A systematic review was conducted to (1) determine the percentage of orthognathic patients with signs or symptoms of TMD, (2) establish the range of signs or symptoms, and (3) examine studies that followed patients longitudinally through treatment to determine the effect of orthognathic intervention on TMD symptoms. Results Of 480 identified articles, 53 were eligible for inclusion in this review. Part 1 of this 2-part article describes the methodology of conducting this review, the difficulties encountered (including the quality-assessment issues), and a narrative analysis of study characteristics and classification methods. Part 2 reports the remaining results, evidence tables, and meta-analyses. Conclusions The diversity of diagnostic criteria and classification methods used in the included studies makes interstudy comparisons difficult. There is a definitive need for well-designed studies with standardized diagnostic criteria and classification methods for TMD. Orthognathic treatment is undertaken to correct jaw discrepancies and involves a combination of orthodontics and surgery. The effects of orthodontic treatment on temporomandibular disorders (TMD) have been widely debated in the literature, but fewer studies focus on the effects of orthognathic treatment on TMD. A systematic review was conducted to (1) determine the percentage of orthognathic patients with signs or symptoms of TMD, (2) establish the range of signs or symptoms, and (3) examine studies that followed patients longitudinally through treatment to determine the effect of orthognathic intervention on TMD symptoms. Of 480 identified articles, 53 were eligible for inclusion in this review. Part 1 of this 2-part article describes the methodology of conducting this review, the difficulties encountered (including the quality-assessment issues), and a narrative analysis of study characteristics and classification methods. Part 2 reports the remaining results, evidence tables, and meta-analyses. The diversity of diagnostic criteria and classification methods used in the included studies makes interstudy comparisons difficult. There is a definitive need for well-designed studies with standardized diagnostic criteria and classification methods for TMD.

Orthognathic treatment and temporomandibular disorders: A systematic review. Part 1. A new quality-assessment technique and analysis of study characteristics and classifications

Orthognathic treatment is undertaken to correct jaw discrepancies and involves a combination of orthodontics and surgery. The effects of orthodontic treatment on temporomandibular disorders (TMD) have been widely debated in the literature, but fewer studies focus on the effects of orthognathic treatment on TMD. A systematic review was conducted to (1) determine the percentage of orthognathic patients with signs or symptoms of TMD, (2) establish the range of signs or symptoms, and (3) examine studies that followed patients longitudinally through treatment to determine the effect of orthognathic intervention on TMD symptoms. Of 480 identified articles, 53 were eligible for inclusion in this review. Part 1 of this 2-part article describes the methodology of conducting this review, the difficulties encountered (including the quality-assessment issues), and a narrative analysis of study characteristics and classification methods. Part 2 reports the remaining results, evidence tables, and meta-analyses. The diversity of diagnostic criteria and classification methods used in the included studies makes interstudy comparisons difficult. There is a definitive need for well-designed studies with standardized diagnostic criteria and classification methods for TMD.

Lingual Orthodontics with Orthognathic Surgery in a Severe Class II, Division 2 Case

To what extent are incisor protrusion, intrusion and torque feasible with orthodontic therapy in an adult? Does a lingually-fixed appliance lend itself to the controlled execution of such extensive tooth movements, and can such an appliance be used in an orthognathic surgical approach with mandibular repositioning? The treatment of a 47-year-old male patient presenting a severe Angle Class II, Division 2 with traumatic deep overbite is demonstrated in all phases of an orthodontic-surgical therapeutic approach. The preoperative harmonization of the upper and lower dental arches preceded the surgical correction via a bilateral sagittal split osteotomy in the gonial angle according to Hunsuck-Epker. Postoperative therapy included compensation for the surgical overcorrection, and the final setting of the occlusion. Extensive tooth movements of the incisors in particular were realized with a lingually-fixed appliance. The appliance did not hamper the surgical correction in any way. Key changes in several cephalometric values were observed: the U1:NL(ANS-PNS) angle (70 degrees) changed from 106 degrees to 70 degrees, the U1:N-S (77 degrees) from 110 degrees to 76 degrees, the distance U1: NA (4 mm) from -8 mm to +3 mm, and the interincisal angle (135 degrees) from 183 degrees to 134 degrees (average values in parentheses). Standard clinical values were obtained for the upper and lower incisors, and complete leveling of the arches was achieved. The orthognathic surgical intervention changed the Wits value from +7 to 0 mm. The intended result (as laid out in the set-up) was realized. This case report demonstrates that extensive and difficult orthodontic treatment requiring orthognathic surgery to correct a skeletal malocclusion is feasible with a fixed lingual appliance.

A cost–utility analysis of patients undergoing orthognathic treatment for the management of dentofacial disharmony

Introduction: Management of dentofacial discrepancies using orthognathic treatment is now a common procedure in the United Kingdom. Although the benefits of orthognathic intervention are often considered, the cost implications have not been investigated to our knowledge. This study is a cost–utility analysis of orthognathic treatment. Patients and methods: Twenty-one patients were interviewed five times during treatment using the time trade-off (TTO) method to establish utility values. Quality adjusted life years (QALYs) gained as a result of treatment were calculated and discounted. The resource use was calculated for each of the 21 patients individually and the costs subjected to both a sensitivity analysis and discounting. The incremental mean cost per additional QALY was calculated (as compared with a ‘no treatment’ approach). Results: The incremental cost for each additional QALY was £561 for the groups combined, based on mean additional costs and QALYs (£546 for the bimaxillary group and £617 for the single jaw group). Discussion: Orthognathic treatment seems to provide good outcomes at relatively low cost. Even allowing for the uncertainty in mean costs and QALYs, there is a high probability of treatment being cost-effective. Cost–utility analysis is still a relatively new technique in dentistry and further studies should be encouraged.

Estudo de cinco dimensões esqueléticas lineares, em indivíduos da raça negra, através de análise cefalométrica computadorizada

O presente estudo estabelece valores através de exames radiográficos em teleperfil, entre os pontos de maior convexidade da maxila (ponto A) e o plano facial, do comprimento anterior do crânio, da altura facial posterior, da posição do pório e do comprimento mandibular entre indivíduos da raça negra de ambos os gêneros. Tais dimensões, após comparadas ao padrão de normalidade utilizado pelo programa Sistema de Medição e Traçado Cefalométrico (SMTC) e submetidas a estudo estatístico, determinam valores específicos que servem de parâmetro nas intervenções ortognáticas para correções de deformidades faciais. Após ter-se procedido à análise estatística constatou-se que a única dimensão cefalométrica linear, em norma lateral, a não apresentar diferença estatisticamente significativa foi aquela referente à convexidade do ponto A, quando comparadas as amostras dos gêneros masculino e feminino. Ao compararmos, entretanto, a média das dimensões cefalométricas lineares, em norma lateral, no que concerne à amostragem da raça negra trabalhada com a raça branca, verificou-se que o comprimento anterior do crânio foi a única dimensão linear a não apresentar significância para a raça branca.