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Esthetic changes in the nasolabial complex following maxillary surgery: A panel assessment
Oral Abstract SessionV: Orthognathic Surgery extent of maxillary expansion achieved with dental arch expansion following modified maxillary corticotomy. 30 patients received modified bilateral maxillary corticotomies in which osteotomies were performed under conscious sedation through the lateral wall of the maxilla from the piriform rim extending posteriorly to the tuberosity. The bony cut was then tapered inferiorly to terminate anterior to the pterygoid plate. No midline or palatal cuts were made. Patients began expansion on the second postoperative day using a traditional jack screw appliance which was activated at a rate of 0.5 mm per day. Maxillary expansion ranging from 3 to 15 mm was then achieved and expansion appliances were maintained in the mouth for 3 months after expansion was completed. Posteroanterior head films were exposed preoperatively, within 1 week of cessation of expansion, 6 months after expansion and at debanding wherever possible. Maxillary widths were measured between the points of greatest concavity on basal bone and between the buccal cusps of the first molars. The ratio of initial maxillary to molar expansion was 85%, with 9 patients showing 100%. A mean of 22 months later, 98% of the initial maxillary expansion remained. This means that 84% of the initial molar expansion was maintained long term as maxillary expansion, making the modified corticotomy a stable and effective procedure. Its efficacy and indications will be presented. Results are also analyzed with respect to different facial skeletal patterns as well as jack screw appliances used. References Glassman, AS., Nahigian, S.J., Medway, J.M., et al: Conservative surgical orthodontic adult rapid palatal expansion: Sixteen cases. Am J Orthodont 86:207,1984 Kuo, P.C., Will, L.A.: Surgical-orthodontic treatment of maxillary constriction: State of the art. Oral Maxillofac Surg Clin North Am 2:751-759,199o
EstheticChangesin the Nasohbial Compkx FollowingMirxiuary Surgery:A Panel Assessment David B. Poor, DMD, 501 Ocean Ave., New London, CT 06320 (O’Ryan, F., Schendel, S.A.) The primary goal of orthognathic surgery, from both the patient’s and surgeon’s perspective, is to improve facial esthetics as well as masticatory function. Successful correction is therefore dependent upon an optimal position of the dentofacial structures whereupon the harmonious proportional relationship of all hard and soft tissue co-exist. These changes while. numerically minimal, can be surprisingly unesthetic, causing a relative disruption in the relationships of facial proportions, 94
which ultimately can be of great concern to the patient. The purpose of this study was to subjectively evaluate the perceived esthetic changes of the nasolabial complex following LeFort I level osteotomies as determined by the visual assessment of an eight member panel. Twenty eight patients (6 male, 22 female) with a mean age of 33 who had undergone LeFort I osteotomies were evaluated with the use of standardized photographic records. Frontal and profile views taken immediately preoperatively and a mean of nine months postoperatively were shown to the panel. In order to focus the attention of the panel on the soft tissue morphology of the nasal region the lower third of the face was masked from lower lip stomion inferiorly. Viewing conditions were standardized with the projected image size, viewing distance and duration of the presentation being held constant. Preoperative and postoperative views were randomized to prevent viewer bias. Using a standardized response form the panel members, consisting of two oral and maxillofacial surgeons, two plastic surgeons, two artists and two lay persons were asked to subjectively evaluate nine soft tissue points as esthetically favorable (+) or unfavorable (-). The data were analyzed to determine if the panel perceived an esthetic benefit as a result of the surgical procedure. Correlation was based on the number of positive and negative responses for each area evaluated as well as for the nasal subunit as a whole. As the results of observations are patient specific and as there were nine different points analyzed for each patient, statistical measurements of overall significance can not be applied. Of the twenty eight patients evaluated, fourteen were perceived to have favorable esthetic results postsurgitally, two were unchanged and twelve patients were perceived to have unfavorable esthetic changes. A strong correlation exists between the perceived changes for the nine individual soft tissue points analyzed when compared with the overall subjective evaluation. Careful analysis of those patients who received a strong favorable or unfavorable rating illustrates the nature of the nasolabial changes and why surgical changes in one person may be unfavorable while esthetically pleasing in another. Subjective qualitative, rather than quantitative assessment of the nasolabial complex of the face needs to be given strong consideration prior to maxillary surgery. Attention in the literature has been primarily focused on changes in the soft tissue from a linear perspective only. The fact that 43% of the patients in this study were perceived to have unesthetic nasolabial changes by the panel demonstrates the need for proper preoperative esthetic evaluation and postoperative expectations which may require concomitant secondary surgical procedures. AAOMS
.
1991
OralAbstractSession V: Orthognathic Surgery References Schendel, S.A., Williamson, L.W.: Muscle reorientation following superior repositioning of the maxilla. J Oral Maxillofac Surg 41:235, 1983 Rosen, H.M.: Lip-nasal aesthetics following LeFort I osteotomy. Plast Reconstr Surg 81:173,1988
Evaluationof 126 BedsideTmcheostomies at NorthwesternMedM Center Mark D. Pogue,DDS, NorthwesternUniv. Dental School,Dept. of OMS, 240E. Huron, Chicago,IL 60611(Pecaro,B.C.) Severalstudieshave shown that transportationof a critically ill patient from an ICU setting can be expensive, labor intensive,time consumingand may jeopardize the patient’s health. A retrospectivestudy was performedover a 2 yearperiod to determinethe safety and time efficiency of tracheostomiesperformed at bedside in the ICU. A total of 126 patients with ventilatoryinsufficiencyfollowing severeneurologicalor systemicdiseaseprocessesunderwent bedsidetracheostomiesduring this time period (l/88-1/90).Anesthesia personnelwerepresentto providesedationandmanage airwayand ventilatory support.Continuousmonitoring andrecordingof the patient’svitals wasaccomplishedby the ICU nurse.Standardtracheostomyinstrumentpacks were utilized in all proceduresperformed over previouslyplacedoral/nasalendotrachealtubes. The anestheticand ICU records, operativereports and progressnotes were reviewed and evaluatedfor intraoperative complications of; 1) signi@nt physiologic changesrequiring pharmacologicintervention, 2) aspiration,3) loss of airwayand/or obstructionand, 4) greater than 5Occblood loss. Post-operativecomplications evaluatedfor 48 hours post surgically were; 1) pneumothorax/mediastinum,2) hemorrhagerequiring
AAOMS
.
1991
pharmacologic,replacement,or surgicalintervention,3) decannulationand,4) subcutaneousemphysema. This investigationrevealedan averageanesthetictime of 41minutesandoperativetime of 29minutes.Sevenof the 126 patients had perioperative complications (3 anestheticand4 surgical)for a morbidity of 5.5%.The 3 anesthetic complications include; 1) an incident of bradycardiarequiring sympathomimeticdrug support, 2) immediatepost-operativehypotensionrequiringcontinuous vasopressiveinfusion and, 3) prolongedpostoperativesedationrequiringovernightventilation.The 4 surgical complicationswere, 1) post-operativehemorrhagesecondaryto thrombocytopeniarequiringreplacement therapy, 2) post-operativehemorrhagethat required bedside re-exploration and cauterization, 3) cricoid lacerationrepairedintraoperativelywithout complication and 4) surgery was aborted secondaryto inadequateexposure-requiringthe tracheostomyto be completedin the operatingroom. The conclusionsfor our investigation;1) a complication rate of 5.5%is similar to tracheostomiesperformed in an operatingroom, 2) the length of the procedureis shorterthan thoseperformedin the operatingroom, 3) based upon 1) and 2) we believe that the bedside tracheostomyis a safe and time effective procedure when proper instrumentation, monitors and staff are utilized. Additional advantagesincludedecreaseduseof a busyoperatingroom with better utilization of operating time and decreasein transportationof the severely injured and compromisedpatient to and from the ICU. References Chew, J.Y., Cantrell, R.W.: Tracheostomy: Complications and their management. Arch Otolaryngol96:538,1972 Indeck, M., Peterson, S., Brotman, S.: Risk, cost and benefit of transporting patients from the ICU for special studies. Crit Care Med 15:350,1987
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EstheticChangesin the Nasohbial Compkx FollowingMirxiuary Surgery:A Panel Assessment David B. Poor, DMD, 501 Ocean Ave., New London, CT 06320 (O’Ryan, F., Schendel, S.A.) The primary goal of orthognathic surgery, from both the patient’s and surgeon’s perspective, is to improve facial esthetics as well as masticatory function. Successful correction is therefore dependent upon an optimal position of the dentofacial structures whereupon the harmonious proportional relationship of all hard and soft tissue co-exist. These changes while. numerically minimal, can be surprisingly unesthetic, causing a relative disruption in the relationships of facial proportions, 94
which ultimately can be of great concern to the patient. The purpose of this study was to subjectively evaluate the perceived esthetic changes of the nasolabial complex following LeFort I level osteotomies as determined by the visual assessment of an eight member panel. Twenty eight patients (6 male, 22 female) with a mean age of 33 who had undergone LeFort I osteotomies were evaluated with the use of standardized photographic records. Frontal and profile views taken immediately preoperatively and a mean of nine months postoperatively were shown to the panel. In order to focus the attention of the panel on the soft tissue morphology of the nasal region the lower third of the face was masked from lower lip stomion inferiorly. Viewing conditions were standardized with the projected image size, viewing distance and duration of the presentation being held constant. Preoperative and postoperative views were randomized to prevent viewer bias. Using a standardized response form the panel members, consisting of two oral and maxillofacial surgeons, two plastic surgeons, two artists and two lay persons were asked to subjectively evaluate nine soft tissue points as esthetically favorable (+) or unfavorable (-). The data were analyzed to determine if the panel perceived an esthetic benefit as a result of the surgical procedure. Correlation was based on the number of positive and negative responses for each area evaluated as well as for the nasal subunit as a whole. As the results of observations are patient specific and as there were nine different points analyzed for each patient, statistical measurements of overall significance can not be applied. Of the twenty eight patients evaluated, fourteen were perceived to have favorable esthetic results postsurgitally, two were unchanged and twelve patients were perceived to have unfavorable esthetic changes. A strong correlation exists between the perceived changes for the nine individual soft tissue points analyzed when compared with the overall subjective evaluation. Careful analysis of those patients who received a strong favorable or unfavorable rating illustrates the nature of the nasolabial changes and why surgical changes in one person may be unfavorable while esthetically pleasing in another. Subjective qualitative, rather than quantitative assessment of the nasolabial complex of the face needs to be given strong consideration prior to maxillary surgery. Attention in the literature has been primarily focused on changes in the soft tissue from a linear perspective only. The fact that 43% of the patients in this study were perceived to have unesthetic nasolabial changes by the panel demonstrates the need for proper preoperative esthetic evaluation and postoperative expectations which may require concomitant secondary surgical procedures. AAOMS
.
1991
OralAbstractSession V: Orthognathic Surgery References Schendel, S.A., Williamson, L.W.: Muscle reorientation following superior repositioning of the maxilla. J Oral Maxillofac Surg 41:235, 1983 Rosen, H.M.: Lip-nasal aesthetics following LeFort I osteotomy. Plast Reconstr Surg 81:173,1988
Evaluationof 126 BedsideTmcheostomies at NorthwesternMedM Center Mark D. Pogue,DDS, NorthwesternUniv. Dental School,Dept. of OMS, 240E. Huron, Chicago,IL 60611(Pecaro,B.C.) Severalstudieshave shown that transportationof a critically ill patient from an ICU setting can be expensive, labor intensive,time consumingand may jeopardize the patient’s health. A retrospectivestudy was performedover a 2 yearperiod to determinethe safety and time efficiency of tracheostomiesperformed at bedside in the ICU. A total of 126 patients with ventilatoryinsufficiencyfollowing severeneurologicalor systemicdiseaseprocessesunderwent bedsidetracheostomiesduring this time period (l/88-1/90).Anesthesia personnelwerepresentto providesedationandmanage airwayand ventilatory support.Continuousmonitoring andrecordingof the patient’svitals wasaccomplishedby the ICU nurse.Standardtracheostomyinstrumentpacks were utilized in all proceduresperformed over previouslyplacedoral/nasalendotrachealtubes. The anestheticand ICU records, operativereports and progressnotes were reviewed and evaluatedfor intraoperative complications of; 1) signi@nt physiologic changesrequiring pharmacologicintervention, 2) aspiration,3) loss of airwayand/or obstructionand, 4) greater than 5Occblood loss. Post-operativecomplications evaluatedfor 48 hours post surgically were; 1) pneumothorax/mediastinum,2) hemorrhagerequiring
AAOMS
.
1991
pharmacologic,replacement,or surgicalintervention,3) decannulationand,4) subcutaneousemphysema. This investigationrevealedan averageanesthetictime of 41minutesandoperativetime of 29minutes.Sevenof the 126 patients had perioperative complications (3 anestheticand4 surgical)for a morbidity of 5.5%.The 3 anesthetic complications include; 1) an incident of bradycardiarequiring sympathomimeticdrug support, 2) immediatepost-operativehypotensionrequiringcontinuous vasopressiveinfusion and, 3) prolongedpostoperativesedationrequiringovernightventilation.The 4 surgical complicationswere, 1) post-operativehemorrhagesecondaryto thrombocytopeniarequiringreplacement therapy, 2) post-operativehemorrhagethat required bedside re-exploration and cauterization, 3) cricoid lacerationrepairedintraoperativelywithout complication and 4) surgery was aborted secondaryto inadequateexposure-requiringthe tracheostomyto be completedin the operatingroom. The conclusionsfor our investigation;1) a complication rate of 5.5%is similar to tracheostomiesperformed in an operatingroom, 2) the length of the procedureis shorterthan thoseperformedin the operatingroom, 3) based upon 1) and 2) we believe that the bedside tracheostomyis a safe and time effective procedure when proper instrumentation, monitors and staff are utilized. Additional advantagesincludedecreaseduseof a busyoperatingroom with better utilization of operating time and decreasein transportationof the severely injured and compromisedpatient to and from the ICU. References Chew, J.Y., Cantrell, R.W.: Tracheostomy: Complications and their management. Arch Otolaryngol96:538,1972 Indeck, M., Peterson, S., Brotman, S.: Risk, cost and benefit of transporting patients from the ICU for special studies. Crit Care Med 15:350,1987
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