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Segmental Maxillary Osteotomies in Conjunction With Bimaxillary Orthognathic and Intranasal Surgery: Indications - Safety - Outcome
Oral Abstract Track 2 laboratory. The purpose of this study is to compare the time required for preoperative planning and model surgery by the standard technique versus VTP. We hypothesize that there is a significant reduction in laboratory time with VTP. This was a prospective study of orthognathic surgery planning done at Massachusetts General Hospital (MGH) from January 2014 through January 31, 2015. Inclusion criteria included bimaxillary cases where both standard and VTP planning were used. Workflow data was collected, dividing it into 3 parts. Part 1 included time required for history and clinical examination, impressions, obtaining facebow mounting, pouring and trimming models, surveying models and preparation for model surgery. Part 2 involved steps performed by the surgeon to execute the plan in the operating room: occlusal grinding and bite analysis, model surgery and traditional splint fabrication (2 splints per case, final and intermediate). The sum of times spent in Parts 1 and 2 corresponds to traditional treatment planning. Part 3 included time for an online VTP session with Materialise (Plymouth, MI) engineers. The sum of times spent on Parts 1 and 3 corresponds to VTP. The time required for a CT scan, occlusal model scan, mapping of orthognathic reference points, 3-D model preparation and 3-D printing of the splints performed by Materialise technicians was not included in the surgeons’ time for VTP. Average times were collected and analyzed for each step in the workflow. Comparison of the accuracy of fabricated splints was not analyzed in this study. There were 42 bimaxillary cases that met the inclusion criteria for this study: 21 asymmetry, 18 symmetric and 7 segmental Le Fort I osteotomy cases. Average total time spent on the process for Part 1 was 4.43 hrs and for Part 2, 3.08 hrs. Average VTP session time (Part 3) was 0.67 hours. Average surgeons’ time required for traditional treatment planning, Part 1 plus Part 2 was 7.48 hours versus average time required for VTP (Part 1 plus Part 3) of 4.27 hrs, a 47.6% (p<.001) time reduction. VTP fabricated splints were noted to fit well and were used in all cases except for one final splint. The results of this prospective study indicate that VTP reduces total time for treatment planning of bimaxillary and asymmetry cases by 47% when compared to standard surgical planning. Since part 1 data gathering is the same for both methods, the time saved occurs in the elimination of (part 2) the preparation and execution of model surgery and construction of splints by hand rather than by 3-D printing. References: 1. Stokbro K, Aagaard E, Torkov P, Bell RB, Thygesen T. Virtual planning in orthognathic surgery. Int J Oral Maxillofac Surg. 2014 Aug;43(8): 957-65. 2. Farrell BB, Franco PB, Tucker MR. Virtual surgical planning in orthognathic surgery. Oral Maxillofac Surg Clin North Am. 2014 Nov;26(4):459-73.
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Segmental Maxillary Osteotomies in Conjunction With Bimaxillary Orthognathic and Intranasal Surgery: Indications - Safety - Outcome A. O. Adachie: Posnick Center for Facial Plastic Surgery, E. Choi, J. C. Posnick The purpose of this study was to assess the indications, safety, and results of maxillary segmental osteotomies used to manage arch form anomalies as part of the patient’s orthognathic correction. The authors executed a retrospective case series derived from patients treated by a single surgeon between 2004 and 2013. A consecutive series of subjects with both chronic obstructed nasal breathing and a dentofacial deformity (DFD) scheduled for simultaneous Le Fort I, sagittal ramus osteotomies, septoplasty; inferior turbinate reduction; and osseous genioplasty procedures were identified. Demographic variables included age and gender. Other variables included the pattern of presenting DFD and the orthodontist providing care. The outcome variables studied were: presence of arch form anomalies; occurrence of maxillary complications; and need for re-operation. Assessment of treatment outcome as judged by each subjects’ treating orthodontist was documented through a questionnaire completed at > one year after surgery. The data was entered in a database using Microsoft Access. This included information from standardized pre- and postoperative photographs and radiographs. Descriptive statistics were computed for all variables. During the study period, 262 subjects met the inclusion criteria. Their age at operation averaged 25 years and included 134 females (51%). The pattern of presenting DFD includes: long face (27.8%); maxillary deficiency (27.9%); asymmetric mandibular excess (18.7%); mandibular deficiency (12.6%); short face (11.5%); and bimaxillary dental protrusion (1.5%). Thirty percent of subjects presented with an arch width skeletal anomaly benefiting from a 2-segment Le Fort I. Thirty-four percent presented with both arch width and curve of Spee skeletal anomalies requiring a 3-segment Le Fort I. In no case (segmental or non-segmental) was there direct surgical injury to a dental root or perforation through the lamina dura. Analysis of periodontal status after maxillary segmental osteotomies included 1,002 sites. The findings include 14/1,002 sites with reduced gingival levels (1.4%); We also analyzed the periodontal status after non-segmental Le Fort I as a comparison group. The findings include 10/564 (2%) sites with reduced gingival levels. In 1,572 teeth at risk, 3 sustained a pulpal injury (segmental- nonsegmental). In each case, root canal therapy was successfully accomplished. There were no cases of wound infection, fibrous union or aseptic necrosis in the maxillary region. Two of the segmental osteotomy AAOMS 2015
Oral Abstract Track 2 subjects sustained a persistent oronasal fistula. Each were successfully closed with palatal flaps. Only 2 of the 262 subjects required hardware removal. The treating orthodontist’s assessment of occlusal outcome after segmental Le Fort I rated 92% of subjects as favorable; 5.6% as having a less than ideal occlusion; and 2.4% with an unfavorable occlusion. Assessment of facial esthetics confirmed a favorable result in 98% of study subjects. The orthodontist found improved efficiency of care provided segmental Le Fort I in 98% of subjects. Only one of the subjects was considered by their orthodontist to have sustained a dental injury and only 3 were believed to have a degree of periodontal deterioration as a result of the maxillary surgery. A majority of DFD patients presenting for bimaxillary orthognathic correction will have skeletal arch form anomalies. Segmentation of the Le Fort I is a safe method of addressing skeletal arch form anomalies. Orthodontists report a high level of satisfaction with the occlusion and facial esthetic results after orthognathic surgery that includes maxillary segmental osteotomies. Orthodontists also report improved efficiency of care delivered with few dental injuries or periodontal sequelae. References: 1. Ho MW, Boyle MA, Cooper JC, Dodd MD, Richardson D: Surgical complications of segmental Le Fort I osteotomy. British J. Oral Maxillofac Surg. 49:562, 2011. 2. Mordenfeld A, Andersson L: Periodontal and pulpal condition of the central incisors after midline osteotomy of the maxilla. J. Oral Maxillofac. Surg: 57:523, 1999.
Surgically Assisted Rapid PalatoMaxillary Expansion With/Without Pterygomaxillary Disjunction: A Systematic Review and Meta-Analysis P. Sadr Eshkevari: Professional Program for International Dentists, UCLA School of Dentistry, A. Hamedi Sangsari, A. Rashad, R. E. Friedrich, E. G. Freymiller A consensus in the literature has not been reached on the necessity and stability of Pterygo-Maxillary Dysjunction (PMD) in Surgically Assisted Rapid Palatal Expansion (SARPE). Some surgeons prefer not to separate the pterygoid processes due to the risk of injury to the pterygoid plexus. The purpose of this review was, therefore, to evaluate the outcome measures of anterior expansion, posterior expansion, and complications following with or without PMD. A computerized database search was performed using PubMed, CINAHL, Cochrane, Scopus and Web of Science and was supplemented with Google Scholar and ProQuest searches to overcome publication bias as much as possible. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines were observed. PICO was defined as:
AAOMS 2015
The patient population (P) included individuals indicated to undergo SARPE. The intervention (I) included SARPE with PMD with a comparator (C) of SARPE without PMD. The evaluated outcomes (O), based on the retrieved studies, comprised of (i) anterior expansion, (ii) posterior expansion, and (iii) complications. Finally, the study design (S) included any controlled intervention. Included were human trials where patient population did not have significant anomalies, the indications for SARPE were clearly stated, specific emphasis was placed on PMD, comparator population was clearly mentioned and grouped. Kappa statistics was used to measure the author agreement on the inclusion of the studies. The Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies (QATQS) was used to assess the quality of the available evidence. The two first authors independently assessed the quality of the included studies and any discrepancies were resolved by discussion and consensus. Kappa statistics were used to assess inter-rater agreement on the quality assessment results. It was decided to perform meta-analyses of the included articles whenever commonality of variables, proper statistical analyses, and homogeneity of the studies allowed. From the original 125 combined results, 3 met the inclusion criteria (Kappa = 0.806; ‘‘very good’’ inter-rater agreement) which based on EPHPP were assessed as 2 weak reports and 1 moderate report (Kappa = 1.000; ‘‘perfect’’ inter-rater agreement). Included were 48 patients, 11 males and 37 females. Transverse discrepancy was > 4 mm in 28 patients. 23 SARPE were done without PMD. A tooth-borne fixed hyrax-type palatal expansion screw appliance was used for all cases, activated 1 to 2 mm intraoperatively and after a latency period of 3 to 7 days, activated 0.5-0.6 mm per day for 38 patients and 0.25 mm for the other 10 until adequate expansion. Post-expansion retention was done using ligature wired Hyrax in 18 patients for 4 months. The comparisons were made based on CBCT projections, study models only, or a combination of study models, anteroposterior cephalometric radiograms, and occlusal radiographs. The time to measure the changes ranged from before fixed orthodontic retention to 6 months after the completion of the active expansion. The main outcome variables in the included studies could be categorized into four groups based on a modification of the Sygouros et al classification according to skeletal, dentoalveolar, dental, and periodontal measurements of either linear or angular nature. Linear dental measurements for inter-canine (anterior dental expansion), inter-premolar, and inter-molar (posterior dental expansion) were possible. A meta-analysis was only possible for anterior (p = 0.965) and posterior (p = 0.476) dental expansions. There were no ‘‘statistically significant’’differences between the SARPE-induced skeletal, dentoalveolar, dental, and periodontal changes with or without PMD.
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Segmental Maxillary Osteotomies in Conjunction With Bimaxillary Orthognathic and Intranasal Surgery: Indications - Safety - Outcome A. O. Adachie: Posnick Center for Facial Plastic Surgery, E. Choi, J. C. Posnick The purpose of this study was to assess the indications, safety, and results of maxillary segmental osteotomies used to manage arch form anomalies as part of the patient’s orthognathic correction. The authors executed a retrospective case series derived from patients treated by a single surgeon between 2004 and 2013. A consecutive series of subjects with both chronic obstructed nasal breathing and a dentofacial deformity (DFD) scheduled for simultaneous Le Fort I, sagittal ramus osteotomies, septoplasty; inferior turbinate reduction; and osseous genioplasty procedures were identified. Demographic variables included age and gender. Other variables included the pattern of presenting DFD and the orthodontist providing care. The outcome variables studied were: presence of arch form anomalies; occurrence of maxillary complications; and need for re-operation. Assessment of treatment outcome as judged by each subjects’ treating orthodontist was documented through a questionnaire completed at > one year after surgery. The data was entered in a database using Microsoft Access. This included information from standardized pre- and postoperative photographs and radiographs. Descriptive statistics were computed for all variables. During the study period, 262 subjects met the inclusion criteria. Their age at operation averaged 25 years and included 134 females (51%). The pattern of presenting DFD includes: long face (27.8%); maxillary deficiency (27.9%); asymmetric mandibular excess (18.7%); mandibular deficiency (12.6%); short face (11.5%); and bimaxillary dental protrusion (1.5%). Thirty percent of subjects presented with an arch width skeletal anomaly benefiting from a 2-segment Le Fort I. Thirty-four percent presented with both arch width and curve of Spee skeletal anomalies requiring a 3-segment Le Fort I. In no case (segmental or non-segmental) was there direct surgical injury to a dental root or perforation through the lamina dura. Analysis of periodontal status after maxillary segmental osteotomies included 1,002 sites. The findings include 14/1,002 sites with reduced gingival levels (1.4%); We also analyzed the periodontal status after non-segmental Le Fort I as a comparison group. The findings include 10/564 (2%) sites with reduced gingival levels. In 1,572 teeth at risk, 3 sustained a pulpal injury (segmental- nonsegmental). In each case, root canal therapy was successfully accomplished. There were no cases of wound infection, fibrous union or aseptic necrosis in the maxillary region. Two of the segmental osteotomy AAOMS 2015
Oral Abstract Track 2 subjects sustained a persistent oronasal fistula. Each were successfully closed with palatal flaps. Only 2 of the 262 subjects required hardware removal. The treating orthodontist’s assessment of occlusal outcome after segmental Le Fort I rated 92% of subjects as favorable; 5.6% as having a less than ideal occlusion; and 2.4% with an unfavorable occlusion. Assessment of facial esthetics confirmed a favorable result in 98% of study subjects. The orthodontist found improved efficiency of care provided segmental Le Fort I in 98% of subjects. Only one of the subjects was considered by their orthodontist to have sustained a dental injury and only 3 were believed to have a degree of periodontal deterioration as a result of the maxillary surgery. A majority of DFD patients presenting for bimaxillary orthognathic correction will have skeletal arch form anomalies. Segmentation of the Le Fort I is a safe method of addressing skeletal arch form anomalies. Orthodontists report a high level of satisfaction with the occlusion and facial esthetic results after orthognathic surgery that includes maxillary segmental osteotomies. Orthodontists also report improved efficiency of care delivered with few dental injuries or periodontal sequelae. References: 1. Ho MW, Boyle MA, Cooper JC, Dodd MD, Richardson D: Surgical complications of segmental Le Fort I osteotomy. British J. Oral Maxillofac Surg. 49:562, 2011. 2. Mordenfeld A, Andersson L: Periodontal and pulpal condition of the central incisors after midline osteotomy of the maxilla. J. Oral Maxillofac. Surg: 57:523, 1999.
Surgically Assisted Rapid PalatoMaxillary Expansion With/Without Pterygomaxillary Disjunction: A Systematic Review and Meta-Analysis P. Sadr Eshkevari: Professional Program for International Dentists, UCLA School of Dentistry, A. Hamedi Sangsari, A. Rashad, R. E. Friedrich, E. G. Freymiller A consensus in the literature has not been reached on the necessity and stability of Pterygo-Maxillary Dysjunction (PMD) in Surgically Assisted Rapid Palatal Expansion (SARPE). Some surgeons prefer not to separate the pterygoid processes due to the risk of injury to the pterygoid plexus. The purpose of this review was, therefore, to evaluate the outcome measures of anterior expansion, posterior expansion, and complications following with or without PMD. A computerized database search was performed using PubMed, CINAHL, Cochrane, Scopus and Web of Science and was supplemented with Google Scholar and ProQuest searches to overcome publication bias as much as possible. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines were observed. PICO was defined as:
AAOMS 2015
The patient population (P) included individuals indicated to undergo SARPE. The intervention (I) included SARPE with PMD with a comparator (C) of SARPE without PMD. The evaluated outcomes (O), based on the retrieved studies, comprised of (i) anterior expansion, (ii) posterior expansion, and (iii) complications. Finally, the study design (S) included any controlled intervention. Included were human trials where patient population did not have significant anomalies, the indications for SARPE were clearly stated, specific emphasis was placed on PMD, comparator population was clearly mentioned and grouped. Kappa statistics was used to measure the author agreement on the inclusion of the studies. The Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies (QATQS) was used to assess the quality of the available evidence. The two first authors independently assessed the quality of the included studies and any discrepancies were resolved by discussion and consensus. Kappa statistics were used to assess inter-rater agreement on the quality assessment results. It was decided to perform meta-analyses of the included articles whenever commonality of variables, proper statistical analyses, and homogeneity of the studies allowed. From the original 125 combined results, 3 met the inclusion criteria (Kappa = 0.806; ‘‘very good’’ inter-rater agreement) which based on EPHPP were assessed as 2 weak reports and 1 moderate report (Kappa = 1.000; ‘‘perfect’’ inter-rater agreement). Included were 48 patients, 11 males and 37 females. Transverse discrepancy was > 4 mm in 28 patients. 23 SARPE were done without PMD. A tooth-borne fixed hyrax-type palatal expansion screw appliance was used for all cases, activated 1 to 2 mm intraoperatively and after a latency period of 3 to 7 days, activated 0.5-0.6 mm per day for 38 patients and 0.25 mm for the other 10 until adequate expansion. Post-expansion retention was done using ligature wired Hyrax in 18 patients for 4 months. The comparisons were made based on CBCT projections, study models only, or a combination of study models, anteroposterior cephalometric radiograms, and occlusal radiographs. The time to measure the changes ranged from before fixed orthodontic retention to 6 months after the completion of the active expansion. The main outcome variables in the included studies could be categorized into four groups based on a modification of the Sygouros et al classification according to skeletal, dentoalveolar, dental, and periodontal measurements of either linear or angular nature. Linear dental measurements for inter-canine (anterior dental expansion), inter-premolar, and inter-molar (posterior dental expansion) were possible. A meta-analysis was only possible for anterior (p = 0.965) and posterior (p = 0.476) dental expansions. There were no ‘‘statistically significant’’differences between the SARPE-induced skeletal, dentoalveolar, dental, and periodontal changes with or without PMD.
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