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Changes in scleral exposure after modified LeFort III osteotomy
ORAL AND MAXILLOFACIAL SURGERY e142 Abstracts Results: The patient was taken to the operating room and underwent a subtotal maxillectomy with placement of an obturator. Pathology found well-differentiated squamous cell carcinoma involving approximately 6 cm (in greatest dimension) of the palate and right maxillary sinus. An additional finding of rhabdomyosarcoma was discovered involving the right pterygoid muscle, most likely secondary to radiation therapy. During surgical resection, the pterygoid musculature, clinically, showed no evidence of tumor, however, positive margins for rhabdomyosarcoma were appreciated upon histologic examination. Conclusions: Radiation-induced sarcomas of the head and neck are rare and tend to occur decades after treatment. Our case involves a rapid-onset postirradiation rhabdomyosarcoma, with a latency period of only 4 months, which ultimately proved to be fatal.
LONG-TERM STABILITY OF MANDIBULAR RAMUS ELONGATION IN SEVERE FACIAL ASYMMETRY H. Martinez, B. Beltran-Salinas, A. Flores Residency program: Universidad Autónoma de Nuevo León Posgrado de Especialización en Cirugía Oral y Maxilofacial, Hospital Metropolitano, Monterrey, Nuevo Leon, Mexico Program director: Belinda Beltran Salinas Purpose: The purpose of this report is to present adjunctive use of botulinum toxin A (Botox) in lengthening the pterygomasseteric sling when correcting hemimandibular hyperplasia. We present the surgical management of a case of severe facial asymmetry with orthognathic surgery using 3-dimensional models in treatment planning and Botox as adjunct therapy. Methods: A 33-year-old woman sought care because of an asymmetrical facial appearance. She presented with enlargement of the left side of the mandible, chin, and angle deviation to the opposite side, Class II molar relationship on the left side, and severely canted maxillary occlusal plane. Imaging showed a 3dimensional increase of the left hemimandible and an increased distance between the root apexes and the mandibular alveolar nerve. Surgical first approach was performed without a preoperative orthodontic preparation. Left mandibular advancement was achieved with a left sagittal split osteotomy followed by the transposition of the alveolar nerve allowing an ostectomy of the left inferior border of the mandible from the chin to the angle. Elongation and advancement of the right side of the mandible was performed with a “C” ramus osteotomy fixed with preformed plates followed by coronoidectomy and osteoplasty of the right lateral surface. LeFort I maxillary osteotomy downgraft with interpositional bone graft was made. The bone graft was harvested from the anterior iliac crest inner table and placed on the right side to level the occlusal plane. Botox (50 units) was applied to the right masseteric sling and the right medial pterygoid to prevent induced muscle relapse. Results: The results were immediately noticeable. Cant and yaw correction were perceptible on the occlusal plane. Mandibular reduction in height of the left side and elongation of the right side provided a satisfactory appearance and facial balance. Stability was markedly noted at 6, 12, and 18 months. Conclusions: An integrative approach for assessing and treating severe facial asymmetries can significantly improve outcome. The challenging surgery in this case significantly balanced asymmetry and corrected skeletal disharmony and malocclusion, with good aesthetics and patient satisfaction. Botox can be useful to provide stability and enhance long-term prognosis.
OOOO November 2014 CHANGES IN SCLERAL EXPOSURE AFTER MODIFIED LEFORT III OSTEOTOMY Caitlin B.L. Magraw, DDS, Rachel N. Garaas, DMD, MD, Ceib Phillips, MPH, PhD, Timothy A. Turvey, DDS Residency program: University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Program director: George Blakey, DDS Purpose: Excessive scleral exposure commonly accompanies midface deficiency, especially when the deformity extends to the orbit. A modified LeFort III osteotomy (Kufner), which leaves the nose in place and advances the orbits, cheeks, and midface, can be used to address this deformity. The purpose of this project is to analyze the changes in medial, lateral, and inferior scleral exposure after a modified LeFort III osteotomy. Methods: A total of 12 patients (24 eyes) with midface hypoplasia treated with modified LeFort III osteotomies as described by Kufner were enrolled in an institutional review boardeapproved study. Photographs were obtained in natural head position pre- and postoperatively (average, 12.5 months). Photographs were sized and analyzed using Adobe Photoshop software, and scleral exposure area (SSA) in each eye was determined by pixel count. The distance from the inferior eyelid margin to the center of the pupil (midpupil-eyelid distance, MED) was measured in each eye both pre- and postoperatively. All measurements were converted into ratios for standardization purposes and were obtained on 3 different occasions, with 1-week intervals between the measurements. The average percent change in SSA and MED from baseline values was calculated for each eye. A decrease in percent change 5% was considered clinically important. Intraclass correlation coefficients (ICCs) and repeatedmeasures analysis of variance (ANOVA) P values were computed for the SSA measurements on 10 randomly selected eyes. A value of P < .05 was considered to be statistically significant. Results: Pre- and postoperative ICC values were both 0.99. Repeated-measures ANOVA P values were 0.71 and 0.18 for preoperative and postoperative measurements, respectively. The 25% to 75% interquartile range for average percent change in total SSA ranged from 13.38% to 5.6% (median, 8.51%), with 18 eyes demonstrating clinically important percent changes in scleral exposure. The 25% to 75% interquartile range for percent change in MED ranged from 12.76% to 6.11% (median, 9.33%), with 22 eyes demonstrating clinically important percent changes in scleral exposure. Conclusions: ICC values and repeated-measures ANOVA P values indicate that SSA can be reliably determined using the aforementioned method. Analysis of preoperative and postoperative SSA and MED measurements found that the modified LeFort III osteotomy decreases medial, lateral, and inferior scleral exposure. The reduction in sclera appears to be more substantial inferiorly and in individuals with a greater degree of exorbitism preoperatively.
REHABILITATION OF PATIENTS WITH BIG RESIDUAL JAW DEFECTS BY DENTAL IMPLANTS A. Albustanji, BDS, MSc(OMFS), MOMS RCPS Glagow, A. Al-Jawadi, BDS, Iraqi Board(OMFS), M. Rababah, BDS, PhD (Prosthodontics) Residency program: Doctors Without Borders at Jordan Red Crescent Hospital, Amman, Jordan Purpose: To report our experience in rehabilitation with dental implants of patients with big upper and lower jaw defects caused by war injuries.
LONG-TERM STABILITY OF MANDIBULAR RAMUS ELONGATION IN SEVERE FACIAL ASYMMETRY H. Martinez, B. Beltran-Salinas, A. Flores Residency program: Universidad Autónoma de Nuevo León Posgrado de Especialización en Cirugía Oral y Maxilofacial, Hospital Metropolitano, Monterrey, Nuevo Leon, Mexico Program director: Belinda Beltran Salinas Purpose: The purpose of this report is to present adjunctive use of botulinum toxin A (Botox) in lengthening the pterygomasseteric sling when correcting hemimandibular hyperplasia. We present the surgical management of a case of severe facial asymmetry with orthognathic surgery using 3-dimensional models in treatment planning and Botox as adjunct therapy. Methods: A 33-year-old woman sought care because of an asymmetrical facial appearance. She presented with enlargement of the left side of the mandible, chin, and angle deviation to the opposite side, Class II molar relationship on the left side, and severely canted maxillary occlusal plane. Imaging showed a 3dimensional increase of the left hemimandible and an increased distance between the root apexes and the mandibular alveolar nerve. Surgical first approach was performed without a preoperative orthodontic preparation. Left mandibular advancement was achieved with a left sagittal split osteotomy followed by the transposition of the alveolar nerve allowing an ostectomy of the left inferior border of the mandible from the chin to the angle. Elongation and advancement of the right side of the mandible was performed with a “C” ramus osteotomy fixed with preformed plates followed by coronoidectomy and osteoplasty of the right lateral surface. LeFort I maxillary osteotomy downgraft with interpositional bone graft was made. The bone graft was harvested from the anterior iliac crest inner table and placed on the right side to level the occlusal plane. Botox (50 units) was applied to the right masseteric sling and the right medial pterygoid to prevent induced muscle relapse. Results: The results were immediately noticeable. Cant and yaw correction were perceptible on the occlusal plane. Mandibular reduction in height of the left side and elongation of the right side provided a satisfactory appearance and facial balance. Stability was markedly noted at 6, 12, and 18 months. Conclusions: An integrative approach for assessing and treating severe facial asymmetries can significantly improve outcome. The challenging surgery in this case significantly balanced asymmetry and corrected skeletal disharmony and malocclusion, with good aesthetics and patient satisfaction. Botox can be useful to provide stability and enhance long-term prognosis.
OOOO November 2014 CHANGES IN SCLERAL EXPOSURE AFTER MODIFIED LEFORT III OSTEOTOMY Caitlin B.L. Magraw, DDS, Rachel N. Garaas, DMD, MD, Ceib Phillips, MPH, PhD, Timothy A. Turvey, DDS Residency program: University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Program director: George Blakey, DDS Purpose: Excessive scleral exposure commonly accompanies midface deficiency, especially when the deformity extends to the orbit. A modified LeFort III osteotomy (Kufner), which leaves the nose in place and advances the orbits, cheeks, and midface, can be used to address this deformity. The purpose of this project is to analyze the changes in medial, lateral, and inferior scleral exposure after a modified LeFort III osteotomy. Methods: A total of 12 patients (24 eyes) with midface hypoplasia treated with modified LeFort III osteotomies as described by Kufner were enrolled in an institutional review boardeapproved study. Photographs were obtained in natural head position pre- and postoperatively (average, 12.5 months). Photographs were sized and analyzed using Adobe Photoshop software, and scleral exposure area (SSA) in each eye was determined by pixel count. The distance from the inferior eyelid margin to the center of the pupil (midpupil-eyelid distance, MED) was measured in each eye both pre- and postoperatively. All measurements were converted into ratios for standardization purposes and were obtained on 3 different occasions, with 1-week intervals between the measurements. The average percent change in SSA and MED from baseline values was calculated for each eye. A decrease in percent change 5% was considered clinically important. Intraclass correlation coefficients (ICCs) and repeatedmeasures analysis of variance (ANOVA) P values were computed for the SSA measurements on 10 randomly selected eyes. A value of P < .05 was considered to be statistically significant. Results: Pre- and postoperative ICC values were both 0.99. Repeated-measures ANOVA P values were 0.71 and 0.18 for preoperative and postoperative measurements, respectively. The 25% to 75% interquartile range for average percent change in total SSA ranged from 13.38% to 5.6% (median, 8.51%), with 18 eyes demonstrating clinically important percent changes in scleral exposure. The 25% to 75% interquartile range for percent change in MED ranged from 12.76% to 6.11% (median, 9.33%), with 22 eyes demonstrating clinically important percent changes in scleral exposure. Conclusions: ICC values and repeated-measures ANOVA P values indicate that SSA can be reliably determined using the aforementioned method. Analysis of preoperative and postoperative SSA and MED measurements found that the modified LeFort III osteotomy decreases medial, lateral, and inferior scleral exposure. The reduction in sclera appears to be more substantial inferiorly and in individuals with a greater degree of exorbitism preoperatively.
REHABILITATION OF PATIENTS WITH BIG RESIDUAL JAW DEFECTS BY DENTAL IMPLANTS A. Albustanji, BDS, MSc(OMFS), MOMS RCPS Glagow, A. Al-Jawadi, BDS, Iraqi Board(OMFS), M. Rababah, BDS, PhD (Prosthodontics) Residency program: Doctors Without Borders at Jordan Red Crescent Hospital, Amman, Jordan Purpose: To report our experience in rehabilitation with dental implants of patients with big upper and lower jaw defects caused by war injuries.