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Is Malar Augmentation Required to Correct Malar Deficiency With Le Fort Advancement?
Poster Session
ORTHOGNATHIC SURGERY POSTER 26 Comparison of Medial Aspect of Ramus for Sagittal Split Ramus Osteotomy in Patients With Different Skeletal Pattern M. N. Kadioglu: Tulay Akkol Special Dental Clinic, O. Karaahmetoglu, A. Kortmaz, N. Yetimoglu Ozdil, C. Arslan, K. Kamburoglu, A. T. Altug, A. M. Tuzuner Oncul The sagittal split ramus osteotomy (SSRO) is the most common surgical technique for the correction of cases of mandibular deformity. Advantage of SSRO is that the surgical access to the mandible is intraorally, which does not produce scars on the face and lowers risk of the injury to the facial nerve. SSRO starts with a horizontal cut on the medial aspect of the mandible just above the lingula, deepening half-way through the thickness of the ramus. ‘ Rai triangle’, a new anatomic landmark on the medial surface of the ramus of the mandible which when identified and taken into consideration, may have a definite advantage. Our hypothesis is the mandibular ramus of patients with prognathic mandible are thinner than the retrognathic mandible. The aim of this retrospective clinical study is to evaluate and compare the RAI triangle area of the mandibular ramus with skeletal class I, II and III patients who undergo orthognathic surgery. The mandibular ramus of 35 patients were evaluated by high-resolution computed tomography (CT) scans and 3D-Doctor software. Those patients were divided into three groups. Group 1: skeletal class II (n:11); group 2: skeletal class III (n:11) and group 3: skeletal class I (n:13) patients. Group 3 patients has been served as control group for comparing the results of groups 1 and 2. Group 1 and 2 patients’ had orthognathic surgery (Le Fort I osteotomy and SSRO) in Ankara University Faculty of Dentistry Oral and Maxillofacial Surgery Department. The medial cuts were made 1 mm above the level of the mandibular lingula. All the images were high-resolution scans, that were carried out in the radiology department of our hospital by the same doctor. Group 1 and 2 include 17 female and 18 male patients. All patients in study groups had mandibular osteotomy and some patients had bimaxillary osteotomy. The mediolateral width of the RAI triangle area and the distance between the fusion point of the external and internal cortical plates above and posterior to the mandibular lingual were measured in all patients. Each mandibular ramus were measured separately. The measures were analyzed by two way anova test. In cephalometric analysis, the mean ANB angle values of group 1, 2, 3 were 5.17 o, -2.57o, 1.03 o respectively. The mean thicknesses of RAI triangle area in group 1, 2,3 AAOMS 2016
were 114,7795 mm2, 109,3350 mm2 , 123,3558mm,2 respectively. The mean volumes of RAI triangle were 16,3015, 15,7595 and 13,8486 mm in groups 1,2,3. There is not a statistically significant difference in the thickness and volumes of the ramus between 3 groups. Our clinical observations showed that the lindemann cut area is smaller and thinner in class III patients than in class II patients. However the radiological examination showed that there is no statically significant difference in RAI triangle area and volume of the patients with different skeletal relationship. References: 1. Kirthi Kumar RAI, Gururaj Araker, et al: A bony landmark ‘ RAI Triangle’ to prevent ’Misplaced’ and ’Misdirected’ medial cut in SSRO. J Oral Maxillofac Surg 10(1):90-92, 2011 2. Muto T, Shigeo K, et al : Computed tomography morphology of the mandibular ramus in prognatism: Effect on the medial osteotomy of the sagittal split ramus osteotomy. J Oral Maxillofac Surg 61:89, 2003 3. Kim HJ, Lee HY, Chung IH, et al: Mandibular anathomy related to sagittal split ramus osteotomy in Koreans. Yonsei Med J 38:19, 1997
POSTER 27 Is Malar Augmentation Required to Correct Malar Deficiency With Le Fort Advancement? C. W. Petersen: University of Illinois at Chicago, M. Miloro Statement of Problem: Many patients with anteroposterior maxillary hypoplasia may also have significant malar deficiency. As a result, preoperative planning for maxillary advancement surgery often includes consideration for simultaneous malar augmentation, but patients who have Le Fort advancement without malarplasty do not usually complain of malar deficiency postsurgically, and rarely undergo subsequent malarplasty. The aim of this study is to compare pre- and postoperative profiles of subjects who underwent orthognathic surgery that included Le Fort I advancement, with and without malarplasty, to assess the subjective perception of malar eminence projection alterations. Materials and Methods: Subjects who underwent maxillary advancement, with and without malarplasty, at a single center by one surgeon (MM) from January 2013 to October 2015 were assessed. The non-malarplasty cohort served as the control group. Pre- and postoperative photos with questionnaires were created and assessed by two groups: oral surgery faculty and residents (professional group), dental assistants and ancillary staff (layperson group). The photos were arranged randomly and participants were asked to score each photo using a visual analogue scale (VAS) to assess the malar region (range: 1 = deficient to 5= excessive). In a second questionnaire, pre- and postoperative photos were shown side by side and participants were asked to indicate which subjects they perceived to have undergone malarplasty. e-65
Poster Session Methods of Data Analysis: Data from the surveys were recorded and averaged. Changes in perception of malar eminence projection were analyzed and correlated with the presence or absence of malar implants, the amount of maxillary advancement, and patient demographic data to determine significance (p<0.05). Results: Of 43 patients that underwent maxillary advancement surgery, a total of 23 met the inclusion criteria. Seven of the 23 subjects received malarplasty at the time of maxillary advancement. The average age of all patients was 18.2 years (range 14-28) and 52% were female. Pre-operative photos were taken within one month of surgery and post-operative photos were obtained between four and eight months post-operatively. There were 27 survey participants including 15 professionals and 12 laypersons. On average, 100% of subjects were perceived as having an increase in malar eminence projection postoperatively. In the non-malarplasty cohort, laypersons noted an average increase in projection (based upon the 1 (deficient) – 5 (excessive) VAS scale) from 1.90 to 2.50 and professionals noted an increase from 2.14 to 2.59 (p<0.05). In the malarplasty cohort, laypersons noted an average increase in projection from 1.86 to 2.69 and among professionals an increase from 1.96 to 2.73 (p<0.05). In the second questionnaire, laypersons tended to overestimate the number of malarplasty subjects. Alternatively, professionals were better able to accurately assess when malarplasty had not been done. Outcomes Data: The perceived change of the malar area following Le Fort I advancement, with and without simultaneous malarplasty, was the primary outcome variable according to the VAS scale used. Additionally, the amount of maxillary advancement was correlated with perceived subjective changes in the malar region. Conclusions: The decision for malar augmentation at the time of maxillary advancement should be considered on an individual basis since this study indicates there will be subjective improvement of the malar region with Le Fort advancement alone without malarplasty. References: 1. O’Ryan, F, Lassetter J: Optimizing facial esthetics in the orthognathic patient. J. Oral Maxillofac. Surg, 69:702-715, 2011 2. Robiony, M, et al: Simultaneous malaroplasty with porous polyethylene implants and orthognathic surgery for correction of malar deficiency. J. Oral Maxillofac. Surg, 56:734-741, 1998
POSTER 28 Orthognathic Surgery Risk Factors and Complications in Patients with Increasing Age A. Irby: Tufts University School of Dental Medicine Background: The average patient receiving orthognathic surgery is usually in their second or third decade e-66
of life. Over the past decade there has been a significant increase in the number of patients seeking orthognathic surgery including those over the age of 40. With this increase in the older population (>40 yr. old) this retrospective study sought to identify perioperative and postoperative difficulties that are significantly different for patients with increasing age; evaluating age as a continuum. Surgeons benefit from an increased knowledge for this cohort of patients and furthermore will have more information to better manage patient care pre-, intra- and postoperatively. Methods: This retrospective cohort study of patients was conducted in the Department of Oral Surgery at Tufts University School of Dental Medicine. Following IRB approval, we reviewed medical records of all patients who underwent orthognathic surgery in the past 10 years (4/1/2005-4/1/2015). The dependent variables were amount of blood loss, the necessity for blood transfusions, length of hospital stay and intraoperative complications and the independent variables were age, gender, race, BMI, medical history, type of orthognathic surgery, and duration of the surgery. Descriptive statistics were computed for all variables. Associations between variables were assessed via the Spearman correlation. Pvalues less than 0.05 were considered statistically significant. SPSS version 22 was used in the analysis. Results: This retrospective chart review included 230 patient charts. The average length of hospital stay for patients >40 yr. old was higher than <40 yr. old (64.55 hours vs 51.67 hours, respectively). Patients >40 yr. old lost more blood, in liters, compared to <40 yr. old (.212 vs .175, respectively). Greater complications were experienced by <40 yr. old group due to various mandibular fracture while those >40 yr. old experienced more complications related to excessive bleeding. Association between blood loss and age: n = 108. Spearman correlation = 0.264. p = 0.006. Association between length of stay and age: n = 93. Spearman correlation = 0.214. p = 0.039. Conclusion: The findings from this retrospective chart review of patients undergoing orthognathic surgery indicate that: 1. There is a significant increase in intraoperative complications and the necessity for post-surgical supportive care following surgery for patients over the age of 40. 2. There was an increased incidence of intraoperative mandibular fracture in patients under the age of 25. 3. Comorbidities including increased BMI and increased incidence of disease states contribute to intraoperative complications irrespective of age. Retrospective chart review is an essential methodology which has the potential to provide oral surgery with valuable research opportunities. It is imperative that further studies with larger core groups be conducted to expand upon this foundation and provide better supportive care for patients as they increase in age. AAOMS 2016
ORTHOGNATHIC SURGERY POSTER 26 Comparison of Medial Aspect of Ramus for Sagittal Split Ramus Osteotomy in Patients With Different Skeletal Pattern M. N. Kadioglu: Tulay Akkol Special Dental Clinic, O. Karaahmetoglu, A. Kortmaz, N. Yetimoglu Ozdil, C. Arslan, K. Kamburoglu, A. T. Altug, A. M. Tuzuner Oncul The sagittal split ramus osteotomy (SSRO) is the most common surgical technique for the correction of cases of mandibular deformity. Advantage of SSRO is that the surgical access to the mandible is intraorally, which does not produce scars on the face and lowers risk of the injury to the facial nerve. SSRO starts with a horizontal cut on the medial aspect of the mandible just above the lingula, deepening half-way through the thickness of the ramus. ‘ Rai triangle’, a new anatomic landmark on the medial surface of the ramus of the mandible which when identified and taken into consideration, may have a definite advantage. Our hypothesis is the mandibular ramus of patients with prognathic mandible are thinner than the retrognathic mandible. The aim of this retrospective clinical study is to evaluate and compare the RAI triangle area of the mandibular ramus with skeletal class I, II and III patients who undergo orthognathic surgery. The mandibular ramus of 35 patients were evaluated by high-resolution computed tomography (CT) scans and 3D-Doctor software. Those patients were divided into three groups. Group 1: skeletal class II (n:11); group 2: skeletal class III (n:11) and group 3: skeletal class I (n:13) patients. Group 3 patients has been served as control group for comparing the results of groups 1 and 2. Group 1 and 2 patients’ had orthognathic surgery (Le Fort I osteotomy and SSRO) in Ankara University Faculty of Dentistry Oral and Maxillofacial Surgery Department. The medial cuts were made 1 mm above the level of the mandibular lingula. All the images were high-resolution scans, that were carried out in the radiology department of our hospital by the same doctor. Group 1 and 2 include 17 female and 18 male patients. All patients in study groups had mandibular osteotomy and some patients had bimaxillary osteotomy. The mediolateral width of the RAI triangle area and the distance between the fusion point of the external and internal cortical plates above and posterior to the mandibular lingual were measured in all patients. Each mandibular ramus were measured separately. The measures were analyzed by two way anova test. In cephalometric analysis, the mean ANB angle values of group 1, 2, 3 were 5.17 o, -2.57o, 1.03 o respectively. The mean thicknesses of RAI triangle area in group 1, 2,3 AAOMS 2016
were 114,7795 mm2, 109,3350 mm2 , 123,3558mm,2 respectively. The mean volumes of RAI triangle were 16,3015, 15,7595 and 13,8486 mm in groups 1,2,3. There is not a statistically significant difference in the thickness and volumes of the ramus between 3 groups. Our clinical observations showed that the lindemann cut area is smaller and thinner in class III patients than in class II patients. However the radiological examination showed that there is no statically significant difference in RAI triangle area and volume of the patients with different skeletal relationship. References: 1. Kirthi Kumar RAI, Gururaj Araker, et al: A bony landmark ‘ RAI Triangle’ to prevent ’Misplaced’ and ’Misdirected’ medial cut in SSRO. J Oral Maxillofac Surg 10(1):90-92, 2011 2. Muto T, Shigeo K, et al : Computed tomography morphology of the mandibular ramus in prognatism: Effect on the medial osteotomy of the sagittal split ramus osteotomy. J Oral Maxillofac Surg 61:89, 2003 3. Kim HJ, Lee HY, Chung IH, et al: Mandibular anathomy related to sagittal split ramus osteotomy in Koreans. Yonsei Med J 38:19, 1997
POSTER 27 Is Malar Augmentation Required to Correct Malar Deficiency With Le Fort Advancement? C. W. Petersen: University of Illinois at Chicago, M. Miloro Statement of Problem: Many patients with anteroposterior maxillary hypoplasia may also have significant malar deficiency. As a result, preoperative planning for maxillary advancement surgery often includes consideration for simultaneous malar augmentation, but patients who have Le Fort advancement without malarplasty do not usually complain of malar deficiency postsurgically, and rarely undergo subsequent malarplasty. The aim of this study is to compare pre- and postoperative profiles of subjects who underwent orthognathic surgery that included Le Fort I advancement, with and without malarplasty, to assess the subjective perception of malar eminence projection alterations. Materials and Methods: Subjects who underwent maxillary advancement, with and without malarplasty, at a single center by one surgeon (MM) from January 2013 to October 2015 were assessed. The non-malarplasty cohort served as the control group. Pre- and postoperative photos with questionnaires were created and assessed by two groups: oral surgery faculty and residents (professional group), dental assistants and ancillary staff (layperson group). The photos were arranged randomly and participants were asked to score each photo using a visual analogue scale (VAS) to assess the malar region (range: 1 = deficient to 5= excessive). In a second questionnaire, pre- and postoperative photos were shown side by side and participants were asked to indicate which subjects they perceived to have undergone malarplasty. e-65
Poster Session Methods of Data Analysis: Data from the surveys were recorded and averaged. Changes in perception of malar eminence projection were analyzed and correlated with the presence or absence of malar implants, the amount of maxillary advancement, and patient demographic data to determine significance (p<0.05). Results: Of 43 patients that underwent maxillary advancement surgery, a total of 23 met the inclusion criteria. Seven of the 23 subjects received malarplasty at the time of maxillary advancement. The average age of all patients was 18.2 years (range 14-28) and 52% were female. Pre-operative photos were taken within one month of surgery and post-operative photos were obtained between four and eight months post-operatively. There were 27 survey participants including 15 professionals and 12 laypersons. On average, 100% of subjects were perceived as having an increase in malar eminence projection postoperatively. In the non-malarplasty cohort, laypersons noted an average increase in projection (based upon the 1 (deficient) – 5 (excessive) VAS scale) from 1.90 to 2.50 and professionals noted an increase from 2.14 to 2.59 (p<0.05). In the malarplasty cohort, laypersons noted an average increase in projection from 1.86 to 2.69 and among professionals an increase from 1.96 to 2.73 (p<0.05). In the second questionnaire, laypersons tended to overestimate the number of malarplasty subjects. Alternatively, professionals were better able to accurately assess when malarplasty had not been done. Outcomes Data: The perceived change of the malar area following Le Fort I advancement, with and without simultaneous malarplasty, was the primary outcome variable according to the VAS scale used. Additionally, the amount of maxillary advancement was correlated with perceived subjective changes in the malar region. Conclusions: The decision for malar augmentation at the time of maxillary advancement should be considered on an individual basis since this study indicates there will be subjective improvement of the malar region with Le Fort advancement alone without malarplasty. References: 1. O’Ryan, F, Lassetter J: Optimizing facial esthetics in the orthognathic patient. J. Oral Maxillofac. Surg, 69:702-715, 2011 2. Robiony, M, et al: Simultaneous malaroplasty with porous polyethylene implants and orthognathic surgery for correction of malar deficiency. J. Oral Maxillofac. Surg, 56:734-741, 1998
POSTER 28 Orthognathic Surgery Risk Factors and Complications in Patients with Increasing Age A. Irby: Tufts University School of Dental Medicine Background: The average patient receiving orthognathic surgery is usually in their second or third decade e-66
of life. Over the past decade there has been a significant increase in the number of patients seeking orthognathic surgery including those over the age of 40. With this increase in the older population (>40 yr. old) this retrospective study sought to identify perioperative and postoperative difficulties that are significantly different for patients with increasing age; evaluating age as a continuum. Surgeons benefit from an increased knowledge for this cohort of patients and furthermore will have more information to better manage patient care pre-, intra- and postoperatively. Methods: This retrospective cohort study of patients was conducted in the Department of Oral Surgery at Tufts University School of Dental Medicine. Following IRB approval, we reviewed medical records of all patients who underwent orthognathic surgery in the past 10 years (4/1/2005-4/1/2015). The dependent variables were amount of blood loss, the necessity for blood transfusions, length of hospital stay and intraoperative complications and the independent variables were age, gender, race, BMI, medical history, type of orthognathic surgery, and duration of the surgery. Descriptive statistics were computed for all variables. Associations between variables were assessed via the Spearman correlation. Pvalues less than 0.05 were considered statistically significant. SPSS version 22 was used in the analysis. Results: This retrospective chart review included 230 patient charts. The average length of hospital stay for patients >40 yr. old was higher than <40 yr. old (64.55 hours vs 51.67 hours, respectively). Patients >40 yr. old lost more blood, in liters, compared to <40 yr. old (.212 vs .175, respectively). Greater complications were experienced by <40 yr. old group due to various mandibular fracture while those >40 yr. old experienced more complications related to excessive bleeding. Association between blood loss and age: n = 108. Spearman correlation = 0.264. p = 0.006. Association between length of stay and age: n = 93. Spearman correlation = 0.214. p = 0.039. Conclusion: The findings from this retrospective chart review of patients undergoing orthognathic surgery indicate that: 1. There is a significant increase in intraoperative complications and the necessity for post-surgical supportive care following surgery for patients over the age of 40. 2. There was an increased incidence of intraoperative mandibular fracture in patients under the age of 25. 3. Comorbidities including increased BMI and increased incidence of disease states contribute to intraoperative complications irrespective of age. Retrospective chart review is an essential methodology which has the potential to provide oral surgery with valuable research opportunities. It is imperative that further studies with larger core groups be conducted to expand upon this foundation and provide better supportive care for patients as they increase in age. AAOMS 2016