Vertical Lengthening Research Articles

Single-Stage Comprehensive Surgical Treatment of the Rheumatoid Arthritis Temporomandibular Joint Patient

To prospectively evaluate the outcomes of single-stage reconstruction of patients with rheumatoid arthritis (RA) with temporomandibular joint (TMJ) pathologic features and an associated dentofacial deformity. Fifteen patients (12 females, 3 males) with RA underwent TMJ reconstruction, with or without a Le Fort I osteotomy in a single operation. Clinical and radiographic examinations were performed before surgery, immediately after surgery, and at the longest follow-up intervals. Numeric analog scales were used for subjective evaluation of TMJ pain, jaw function, diet, and disability. The maximal interincisal opening, lateral excursions, and TMJ crepitus were recorded at each visit. Standardized cephalometric acetate tracings were superimposed to assess for surgical (immediately after surgery compared with before surgery) and postoperative (longest follow-up interval compared with immediately after surgery) changes. The average patient age was 27.4 years (range 15 to 61), and the follow-up was 34.3 months (range 10 to 77). At the longest follow-up interval, all 15 patients had had a statistically significant reduction in the incidence and severity of TMJ pain and headaches. The average maximal interincisal opening increased after surgery, but the difference was not statistically significant. Lateral excursions decreased significantly after surgery. Dietary restrictions and disability were significantly improved, and TMJ crepitus had reduced significantly. The average advancement at point B was 21.7 mm (range 14 to 28), and the postoperative change at the longest follow-up interval was 0.1 mm (range 0 to 1). The average pogonion advancement was 29.2 mm (range 19.5 to 38), with a postoperative change of 0.2 mm (range 0 to 1). The average gonion vertical lengthening was 20.7 mm (range 10.5 to 29) with a postoperative change of 1.4 mm (range 0 to 4.5). The average occlusal plane angle change was a decrease of 20.7 degrees (range 16 degrees to 26 degrees), with a postoperative change of 0.4 degrees (range 0 degrees to 2 degrees). Of the 15 patients, 10 had undergone maxillary orthognathic surgery performed at the same operation. The average advancement of these 10 patients at point A was 3 mm (range 2 to 7), and the postoperative change was 0.5 mm (range 0 to 1). Surgical correction of rheumatoid-associated TMJ disease and the resulting dentofacial deformity can successfully be performed in a single operation using custom-made TMJ total joint prostheses to reconstruct the TMJs and advance the mandible, with maxillary orthognathic surgery and genioplasty performed at the same operation when indicated. The significant reduction in TMJ dysfunction symptoms and the long-term stability of the orthognathic surgery movements show the benefits and predictability of treating these complex patients with this treatment protocol.

Stress Distribution in Mandible and Temporomandibular Joint by Mandibular Distraction: A 3-Dimensional Finite-element Analysis

The effects of mandibular distraction on the mandible and its surrounding tissue remain to be clarified. Here, we used a 3-dimensional finite-element method to investigate the effects of unilateral horizontal lengthening of the mandibular body and vertical lengthening of the mandibular ramus on the mandible and temporomandibular joint (TMJ). With horizontal loading that assumed mandibular body lengthening, tensile and compressive stresses were great near the anterior region of the mandibular angle (the loading area). With vertical loading that assumed mandibular ramus lengthening, tensile and compressive stresses were great at the center of the mandibular ramus (the loading area). Under both loading conditions, stress distribution in the TMJ was greater on the loading side than on the non-loading side. With mandibular body lengthening, the center of the mandible deviated in the direction of the non-lengthened side to widen the mandible in the lateral direction. With mandibular ramus lengthening, the occlusal plane tilted in the inferior direction on the lengthened side. In the TMJ, stress was greatest on the affected side during mandibular ramus lengthening, suggesting the need to consider the mandibular condyle on the affected side during this procedure.

A quantitative and descriptive approach to morphological variation of the endocranial base in modern humans

The cranial base is one of the major foci of interest in functional craniology. The evolution and morphogenesis of this structure are still poorly known and rather controversial because of multifactorial influences and polyphasic stages. Endocranial dynamics are associated anteriorly with the upper facial structures, laterally with the mandibular system and midsagittally with brain development. In the present study, we investigated the endocranial morphology of modern humans using 3D landmark-based approaches, i.e. geometric morphometrics and Euclidean distance matrix analysis. The structure of endocranial variation is poorly integrated, with only weak reciprocal influences among the three fossae. Some major variations are associated with changes in the posterior fossa, with possible consequences on the anterior areas. These main patterns of integration are hypothesized to be influenced by the connective tensors of the dura layers. Static allometry and sex differences are largely related to the ontogenetic sequences, characterized by early maturation of the anterior fossa with respect to the middle and posterior regions (i.e., relatively shorter posterior part of the planum sphenoideum and vertical lengthening of the clivus in males). The relative independence between the endocranial fossae, as well as their structural connection through the meningeal tensors, must be carefully considered in studies on the evolutionary dynamics, since they lead to mosaic changes through phylogeny.

Mandibular Ramus Response to Vertical Lengthening With Distraction Osteogenesis

Statement of the Problem: Vertical lengthening of the mandibular ramus is considered as one of the unstable surgical procedures in the management of maxillofacial deformities. The aim of this study is to evaluate the response of mandibular ramus following vertical lengthening by means of distraction osteogenesis.

Surgical Repair of Lateral Canthal Web

To present a complication of combined upper and lower eyelid blepharoplasty and its surgical correction. Observational case report. A lateral canthal web that resulted from upper and lower blepharoplasty was treated using the del Campo tissue transposition technique, previously described for repair of epicanthal folds. The transposition flap corrected the lateral canthal web, improving the patient's symptoms and the appearance of the eyelids. A lateral canthal web may form as a consequence of vertical tissue insufficiency after blepharoplasty. A vertical lengthening procedure can correct the lateral canthal web.

Changes in alveolar morphology during open bite treatment and prediction of treatment result.

It has been postulated that dentoalveolar height is enlarged by a compensation mechanism in long face subjects. In this study, dentoalveolar composition was studied in 83 open bite patients. It was found that increases in overbite during treatment coincided with vertical lengthening of the symphysis, which exceeded increments in lower face height. This vertical growth coincided mainly with an increase in the area of the symphysis. Furthermore, a retrusion of the maxillary incisors enhanced bite deepening. Stability of the overbite during the retention period was studied in a subset of 22 patients. It was found that retrusion of the maxillary incisors during treatment led to a more stable overbite during the retention period. Vertical lengthening of the symphysis relative to the increase in lower face height seemed to enhance bite opening during retention. Prediction of the overbite may be reliable, if a re-evaluation of the patients takes place during active treatment. The angle NTGoGn had a substantial predictive value (multiple R = 0.46) for post-treatment overbite. It is concluded that in open bite patients, a dentoalveolar compensation mechanism results in a stable overbite at the end of treatment by enlarging symphysial height through a moderate increase in symphysial volume. In addition, retrusion of the maxillary incisors contributes to overbite reduction. However, an excessive increase in vertical height of the symphysis relative to lower face height may relapse after active treatment. For prediction of the post-treatment overbite, the angle NTGoGn may be used, although a re-evaluation during treatment is recommended.

Skeletal stability of Le Fort I osteotomy in patients with isolated cleft palate and bilateral cleft lip and palate

Abstract.The skeletal stability of Le Fort I osteotomy was evaluated retrospectively in 14 patients with isolated cleft palate (CP, mean age 27.2 years) and 11 patients with bilateral cleft lip and palate (BCLP, mean age 23.7 years). The osteotomy was fixed with titanium plates and the osteotomy gap was grafted with autologous bone. Neither intermaxillary fixation nor occlusal splints were used postoperatively. Skeletal stability was analysed both horizontally and vertically by cephalograms taken shortly before operation, immediately afterwards, and at six months and at one year postoperatively.In the CP group the mean maxillary horizontal advancement (point A) was 4.7mm (range 0.3–7.8) and the mean vertical lengthening 3.6mm (range 0.7–6.1). One year postoperatively the mean relapse was 8.5% (0.4mm) horizontally and 16.7% (0.6mm) vertically. In the BCLP group the mean horizontal advancement was 5.3mm (range 0.2–10.7) and the mean vertical lengthening 7.3mm (range 0.6–11.8). The mean postoperative relapse was 9.4% (0.5mm) horizontally and 17.8% (1.3mm) vertically. The skeletal stability and relapse were similar in both cleft types although BCLP patients had more residual cleft problems and their mean surgical advancement was greater. There was great individual variation.

Cephalometric pharyngeal changes after Le Fort I osteotomy in patients with unilateral cleft lip and palate

Pharyngeal changes after Le Fort I osteotomy were evaluated cephalometrically in 37 patients (27 M, 10 F; mean age 23.8 years) with unilateral cleft lip and palate (UCLP). Seven patients had previously undergone velopharyngeal (VPP) flap surgery to improve speech. One year postoperatively the patients without previous VPP showed a significant change (55%-85% of the surgical change) in the upper and lower sagittal depth of the nasopharyngeal airway, but not in the depth of oropharyngeal airway, length of soft palate, or position of hyoid bone. No significant changes were observed between 6 months and 1 year postoperatively. Mean surgical horizontal advancement was 4.7 mm and the mean vertical lengthening 4.7 mm anteriorly and 1 mm posteriorly. There was a correlation between the amount of horizontal advancement and the amount of change in the nasopharyngeal airway. The patients with previous VPP showed significant postoperative change (85% of the surgical change) only in the lower nasopharyngeal airway, although their surgical advancement was similar to that without previous VPP. Patients with previous VPP showed significantly smaller depths of upper nasopharyngeal airway postoperatively than the patients without previous VPP. Five patients (13%) needed VPP after the osteotomy. There was no difference in the nasopharyngeal airway in the patients with VPP after the osteotomy when compared to those without, but they seemed to have shortest maxillary lengths and largest mean surgical changes vertically both anteriorly (5.5 mm) and posteriorly (2.3 mm). Moderate maxillary advancement in UCLP patients results in significant changes in the nasopharyngeal airway.

Skeletal stability of Le Fort I osteotomy in patients with unilateral cleft lip and palate.

The skeletal stability of Le Fort I osteotomy was evaluated cephalometrically in 40 consecutive patients with unilateral cleft lip and palate (UCLP) (27 male and 13 female) who were operated on between 1987-1995. Their mean age at the time of operation was 23.7 years (range 16.3-40.4). The one-piece Le Fort I osteotomy was fixed with titanium plates and the osteotomy line was bone-grafted. Neither intermaxillary fixation nor occlusal splints were used postoperatively. Skeletal stability was analysed both horizontally and vertically on cephalograms taken shortly before operation, immediately afterwards, and at six months and at one year postoperatively. The mean maxillary advancement (point A) during the Le Fort I was 3.9 mm (range 0-8.9) and mean vertical lengthening 4.5 mm (range -0.6-10.5). One year postoperatively the mean maxillary horizontal relapse was 20.5% (0.8 mm, range 0-3.7) whereas the mean vertical relapse was 22.2% (1 mm, range 0-5.7). The vertical relapse reduced from 38% to 8.3% between 1987 and 1995, and there was a positive correlation between the amount of maxillary advancement and relapse both horizontally and vertically.

Minimal-incision endoscopic face-lift.

Ptosis of the midfacial tissues with resultant deepening of the melolabial folds, vertical lengthening of the lower eyelid, and depression of the oral commissure are generally only slightly improved with traditional superficial musculoaponeurotic system (SMAS) suspension or rhytidectomy techniques. Subperiosteal, deep plane, and composite rhytidectomies have evolved in an attempt to rejuvenate these areas. This article reviews a series of patients who underwent an endoscopic subperiosteal face-lift either as an isolated procedure or in conjunction with an SMAS rhytidectomy. Although all patients showed good initial improvement, patients with thin faces and well-defined facial bone structure maintained the best long-term result. Complications were minimal, with no permanent facial nerve injuries observed. The endoscopic subperiosteal face-lift is a useful technique as an isolated procedure or in conjunction with facial liposuction or SMAS suspension rhytidectomy. Arch Facial Plast Surg. 2000;2:274-278

Two-year follow-up of distraction osteogenesis: Its effect on mandibular ramus height in hemifacial microsomia

Distraction osteogenesis has been used to lengthen the mandible in patients with hemifacial microsomia. Questions regarding soft tissue and skeletal growth after distraction osteogenesis have not been clearly elucidated in the literature. In this case report, a 2-year follow-up of distraction osteogenesis in a 7 year old boy is documented with lateral and posterior/anterior cephalometric analysis. The analysis was performed preoperatively and at specific postsurgical periods to evaluate the facial soft tissue and skeletal growth patterns. Objective analysis of this growing patient after distraction osteogenesis clearly demonstrates that the anteroposterior elongation of the mandible is relatively stable, whereas the vertical lengthening and soft tissue effects are minimal. Critical evaluation of other patients who have undergone distraction osteogenesis is needed to determine if this was an isolated incident or the expected result in similar patients. (Am J Orthod Dentofacial Orthop 2000;117:130-9)

Soft tissue profile changes after Le Fort I osteotomy in UCLP patients

The changes in soft tissue profile after Le Fort I osteotomy were evaluated cephalometrically in 38 consecutive UCLP patients (25 males, 13 females) operated on between 1987 and 1995. Mean age at operation was 23.5 years. The one-piece Le Fort I osteotomy was fixed with titanium plates and the osteotomy site was bone grafted. Neither intermaxillary fixation nor occlusal splints were used postoperatively. Soft tissue changes were analyzed both horizontally and vertically by cephalograms taken shortly before surgery, 6 months and 1 year postoperatively. The mean maxillary skeletal advancement (point A) during surgery was 3.8 mm and mean vertical lengthening 4.4 mm. One year postoperatively the horizontal change in the upper lip profile (point a) was 80% of the skeletal change. Vertically, the soft tissue change in the upper lip was smaller 40%, but increased significantly (to 58%) if V-Y plasty was used. The V-Y plasty also increased the anteroposterior thickness of the upper lip. No significant soft tissue changes were observed between 6 months and 1 year postoperatively.

The generation, segregation, ascent and emplacement of granite magma: the migmatite-to-crustally-derived granite connection in thickened orogens

The generation, segregation, ascent and emplacement of granite magma: the migmatite-to-crustally-derived granite connection in thickened orogens

Vertical lengthening of the unilateral cleft lip after a triangular flap repair

Vertical lengthening of the unilateral cleft lip after a triangular flap repair

The Pieniny Klippen Belt in the Western Carpathians of northeastern Slovakia: Structural evidence for transpression

The Pieniny Klippen Belt represents a 600-km-long but only a few kilometers wide suture zone in the Carpathian orogenic belt. Based on a quantitative analysis along a part of its NW-trending segment in northeastern Slovakia, we present structural data supporting transpression, the continuous interaction of strike-slip shearing, horizontal shortening, and vertical lengthening, as a major deformation style in its polyphase deformation history. Dextral transpression is expressed in the map scale and outcrop fault pattern, the oblique orientation of fold axes to the faults bounding the Klippen Belt, and extension parallel to the fold axes. The transpression-related strain field is described and quantified by the analysis of: (1) orientation of rotated fold axes (displaying an acute angle to the margins of the Klippen Belt); (2) orientation and geometry of paleostress derived from mesoscale fault-striae analysis (E-trend of σ 3-trajectories and flattening geometry); and (3) the deformation history indicated by extension veins (non-coaxial regime). Different techniques using fault-striae data quantify paleostress and subdivide heterogeneous data sets mathematically into homogeneous subsets. The observed deformation history is modelled as a homogeneous transpression deformation. The best-fitting model requires a NW-trending (present-day orientation) external contraction direction (e.g., plate-slip vector), and predicts 16% fold axes parallel extension and 23% axial plane normal shortening.

Vertical lengthening of the unilateral cleft lip after a triangular flap repair

A triangular flap repair for unilateral cleft lip is stated to have the potential problem of creating a lip that is too long. Although preoperative measurements were performed with calipers, the gap created in the medial segment was directly measured during the procedure, in order to determine the size of the flap more precisely. Ninety patients with complete unilateral cleft lips underwent a triangular flap repair using this method. The symmetry of the Cupid's bow was evaluated at a follow-up period averaging between six years and three months. Sixty-two lips obtained “symmetry” and the remaining 28 cases showed a lip which was “too long”; none of the lips were “too short”. The comparison between 27 primary palate clefts (UCLA) and 63 primary and secondary palate clefts (UCLP) showed no significant difference in the surgical result. The preoperative shortness of the lip on the cleft side was significantly greater in the “too long” group (5.01 ± 0.95 mm) than in the “symmetry” group (4.40 ± 0.87 mm). The width of the flap used was significantly larger in the “too long” group (3.76 ± 0.79 mm) than in the “symmetry” group (3.42 ± 0.69 mm). The triangular flap repair with intraoperative measurements is considered to be beneficial, although preoperative measurements provide an optimal design in most cases. It is suggested that the use of a wider triangular flap results in a lip which tends to be too long in spite of the preoperative shortness on the cleft side.

Mandibular contouring surgery for purely aesthetic reasons

The mandible's contour determines the shape of the lower part of the face and thus influences the appearance of the face and neck. There are two types of operative procedures that can be used on mandibular contour and they do not require orthodontic treatment: mandible angle reduction and genioplasty. We divided the mandible angle reduction group into Types A, B, and C according to the grade of angle protrusion. Type A needs just an angle resection, Type B needs an angle resection and resection of part of the body, and Type C needs resection of the angle, the body, and part of the symphysis. We have performed 258 mandibular contouring procedures. In genioplasty, shaving, advancement, shortening, and lengthening generally can be employed. Furthermore, when vertical lengthening is used, ostectomized mandible angle bone is carved and then grafted between the horizontal osteotomy site. Of the mandible angle reduction cases, 21 were Type A, 186 were Type B, and 28 were Type C. The curved ostectomy is most important in mandible angle reduction cases in order to achieve a more natural curve of the mandible's lower border. A total of 71 patients were very pleased with the results of the combined procedures of genioplasty and angle reduction.

Experience with the Functional Cleft Lip Repair

The first 12 functional cleft lip repairs performed on unselected consecutive patients immediately following the completion of training by the author are presented. Previous reports on this cleft lip repair have shown excellent results but have always been based on patients operated on by the originator of the procedure. This report gives credence to the ease with which a cleft lip repair that gives reproducible good results can be taught and learned even by plastic surgeons with limited experience. It reviews the technical steps of the procedure, which emphasizes wide undermining and release of the orbicularis oris muscle on the lateral side of the cleft to allow redraping and lengthening of the lip skin, step-by-step layered closure of the mucosa, muscle, and skin, and further vertical lengthening of the lip with a Z-plasty skin closure. Three elements that are difficult to achieve or restore with cleft lip revision are evaluated: (1) achievement of a good skin scar, (2) maintenance of the alar-facial groove, and (3) achievement of adequate lip height without sacrificing horizontal lip length. Ten of the 12 patients had a satisfactory scar, 9 patients had a good alar-facial groove, and all patients had a normal-appearing horizontal lip length. Nine patients required secondary surgery; however, in six patients, this included correction of the nasal deformity that was not corrected at the time of cleft lip repair.

Surgical correction of the vertically deficient chin.

Surgical correction of the vertically deficient chin has received relatively little attention. This paucity of information is most likely related to the failure to diagnose vertical microgenia and the questionable stability of its surgical correction utilizing autogenous bone grafts. This paper reports on eight patients who have undergone vertical augmentation genioplasty utilizing a transverse symphyseal osteotomy and interpositional implantation of porous, block hydroxyapatite. All patients had preoperative measured decreases in lower face height. Mean vertical lengthening of the chin was 5.3 mm. Seven of the eight patients had class II occlusions and underwent simultaneous sagittal advancement of the chin. Follow-up at a mean time of 11.1 months revealed complete stability of the vertically repositioned symphyseal segment. Mean ratio of the vertical soft to hard tissue augmentation was 0.89:1. There were no instances of operative complications. Vertical facial aesthetics and their application in the evaluation and treatment of patients with vertically deficient lower faces and chins are reviewed.

Use of preformed hydroxylapatite blocks for grafting in genioplasty procedures

Dense hydroxylapatite is a synthetic, biocompatible, immunologically inert material that can establish a chemical union with bone when placed in intimate contact in histologic studies. The following is a preliminary report of the use of preformed dense, non-resorbable hydroxylapatite blocks as a grafting material for use in advancement and vertical lengthening of the bony chin associated with orthognathic surgical procedures. In rare instances where an autogenous bone graft would be required for vertical lengthening without any advancement of bony pogonion, the need is obviated by utilization of the hydroxylapatite solid block.