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Prevention and management of undesirable soft tissue changes in orthognathic surgery
Symposia infection. Although hyperbaric oxygen may not prevent necrosis it may limit the extent of the necrosis. It may also hasten delineation of the necrotic tissue and assist debridement. Reconstruction may require closure of the defects with soft tissue flaps and bone grafts, while lost teeth may be replaced with a prosthesis or dental implants. References Bell WH, Fonseca RJ, Kennedy JW, et al: Bone healing and revascularization after total maxillary osteotomy. J Oral Surg 33:253, 1975 Meyer MW, Cavanagh GD: Blood flow changes after orthognathic surgery: Maxillary and mandibular subapical osteotomy. J Oral Surg 34:495, 1976 Lanigan DT, Hey JH, West RA: Aseptic necrosis following maxillary osteotomies: Report of 36 cases. J Oral Maxillofac Surg 48:142, 1990
Prevention and Management of Undesirable Soft Tissue Changes in Orthognathic Surgery Joseph E. Van Sickels, DDS, Lexington, KY Undesirable soft tissue changes can occur with orthognathic surgery in the midface, nose, nasolabial angle, upper and lower lips, the chin, and the angles of the mandible depending on preexisting anatomy and the surgical move accomplished. Prevention and management of these undesirable soft tissue changes start with the initial evaluation of the patient. Patients may have abnormal soft/hard tissue anatomy in several planes in space. In the evaluation phase, it should be determined whether the overlying soft tissue drape parallels the underlying bony anatomy. Fortunately, in most patients the soft tissue contour follows the underlying bony anatomy. However, hard and soft tissue abnormalities may not complement one another. In addition, the patient may not be aware of some/all of their discrepancies until after the surgery is completed. Correcting a bony discrepancy may worsen a soft tissue discrepancy. For example, patients with hemifacial microsomia frequently have deficient hard and soft tissue on one side that will be accentuated with lengthening of the ramus. In the assessment of a patient, a judgment must be made as to whether the skeletal movement will have a positive or a negative effect on the soft tissue. How predictable are the soft tissue changes that will occur? Particularly with surgery that involves movement of the upper and lower lip, the results are quite variable. Should additional soft or hard tissue procedures be done in concert with the primary bony movement, to enhance the result or minimize adverse results? Should additional procedures be done after the results of the primary are assessed? Finally, does the patient have realistic expectations as to what will be accomplished with the surgery? There are a number of intraoperative maneuvers that can improve or hurt the final result. These include the management of the nasal septum with maxillary AAOMS • 2004
impactions and advancements. Management of soft tissue around the upper lip and nose with an alar cinch and a V-to-Y closure are well-recognized techniques to enhance the soft tissue results after a maxillary osteotomy. Management of the proximal segment of the mandible can have profound effects on the soft tissue, especially when both jaws are moved. The geometry and movement of a bony genioplasty cut and the reattachment of the facial musculature can result in less than ideal results. Postoperative management of an undesirable soft tissue result will be predicated on the cause and the outcome of the primary surgery. For example, if the patient has an acceptable occlusal result, a masking procedure may be in order. In contrast, if the occlusal result is poor, the patient may need to have the bony surgery redone. References Hackney FL, Nishioka GJ, Van Sickels JE: Frontal soft tissue morphology with double V-Y closure following Le Fort I osteotomy. J Oral Maxillofac Surg 46:850, 1988 Stella JP, Streater MR, Epker BN, et al: Predictability of upper lip soft tissue changes with maxillary advancement. J Oral Maxillofac Surg 47:697, 1989 Rosenberg A, Muradin MS, van der Bilt A: Nasolabila esthetics after Le Fort I osteotomy and V-Y closure: Statistical evaluation. Int J Adult Orthod Orthog Surg 17:29, 2002
Prevention and Management of Positioning Errors in Le Fort I Osteotomies Edward Ellis III, DDS, MS, Dallas, TX Positioning errors during maxillary surgery can produce unfavorable outcomes, including malocclusion and esthetic deformities. Positioning errors occur for a number of reasons, including during the work-up and during the surgical phases of treatment. If the records obtained are inaccurate, the position of the maxilla will also be inaccurate. The mounting of the models on the articulator is often a source of inaccuracy. For instance, if the interocclusal registration is not accurate, the relationship of one model to the other will be improper. Model surgery on these models will therefore lead to inaccurate information. Splints made on them will produce inaccurate positioning of the maxilla during surgery. Another source of inaccuracy is in the positioning of the maxillary model during model surgery for a bimaxillary surgery. If this step is not done accurately, one will produce an unfavorable position of the maxilla during surgery. The inaccuracy will be compounded in a bimaxillary case because the mandible will also be inaccurately positioned. Another source of inaccuracy in positioning the maxilla comes during the surgical procedure. If the mandibular condyles are not properly seated during repositioning, a malocclusion will result once the patient awakens 15
Prevention and Management of Undesirable Soft Tissue Changes in Orthognathic Surgery Joseph E. Van Sickels, DDS, Lexington, KY Undesirable soft tissue changes can occur with orthognathic surgery in the midface, nose, nasolabial angle, upper and lower lips, the chin, and the angles of the mandible depending on preexisting anatomy and the surgical move accomplished. Prevention and management of these undesirable soft tissue changes start with the initial evaluation of the patient. Patients may have abnormal soft/hard tissue anatomy in several planes in space. In the evaluation phase, it should be determined whether the overlying soft tissue drape parallels the underlying bony anatomy. Fortunately, in most patients the soft tissue contour follows the underlying bony anatomy. However, hard and soft tissue abnormalities may not complement one another. In addition, the patient may not be aware of some/all of their discrepancies until after the surgery is completed. Correcting a bony discrepancy may worsen a soft tissue discrepancy. For example, patients with hemifacial microsomia frequently have deficient hard and soft tissue on one side that will be accentuated with lengthening of the ramus. In the assessment of a patient, a judgment must be made as to whether the skeletal movement will have a positive or a negative effect on the soft tissue. How predictable are the soft tissue changes that will occur? Particularly with surgery that involves movement of the upper and lower lip, the results are quite variable. Should additional soft or hard tissue procedures be done in concert with the primary bony movement, to enhance the result or minimize adverse results? Should additional procedures be done after the results of the primary are assessed? Finally, does the patient have realistic expectations as to what will be accomplished with the surgery? There are a number of intraoperative maneuvers that can improve or hurt the final result. These include the management of the nasal septum with maxillary AAOMS • 2004
impactions and advancements. Management of soft tissue around the upper lip and nose with an alar cinch and a V-to-Y closure are well-recognized techniques to enhance the soft tissue results after a maxillary osteotomy. Management of the proximal segment of the mandible can have profound effects on the soft tissue, especially when both jaws are moved. The geometry and movement of a bony genioplasty cut and the reattachment of the facial musculature can result in less than ideal results. Postoperative management of an undesirable soft tissue result will be predicated on the cause and the outcome of the primary surgery. For example, if the patient has an acceptable occlusal result, a masking procedure may be in order. In contrast, if the occlusal result is poor, the patient may need to have the bony surgery redone. References Hackney FL, Nishioka GJ, Van Sickels JE: Frontal soft tissue morphology with double V-Y closure following Le Fort I osteotomy. J Oral Maxillofac Surg 46:850, 1988 Stella JP, Streater MR, Epker BN, et al: Predictability of upper lip soft tissue changes with maxillary advancement. J Oral Maxillofac Surg 47:697, 1989 Rosenberg A, Muradin MS, van der Bilt A: Nasolabila esthetics after Le Fort I osteotomy and V-Y closure: Statistical evaluation. Int J Adult Orthod Orthog Surg 17:29, 2002
Prevention and Management of Positioning Errors in Le Fort I Osteotomies Edward Ellis III, DDS, MS, Dallas, TX Positioning errors during maxillary surgery can produce unfavorable outcomes, including malocclusion and esthetic deformities. Positioning errors occur for a number of reasons, including during the work-up and during the surgical phases of treatment. If the records obtained are inaccurate, the position of the maxilla will also be inaccurate. The mounting of the models on the articulator is often a source of inaccuracy. For instance, if the interocclusal registration is not accurate, the relationship of one model to the other will be improper. Model surgery on these models will therefore lead to inaccurate information. Splints made on them will produce inaccurate positioning of the maxilla during surgery. Another source of inaccuracy is in the positioning of the maxillary model during model surgery for a bimaxillary surgery. If this step is not done accurately, one will produce an unfavorable position of the maxilla during surgery. The inaccuracy will be compounded in a bimaxillary case because the mandible will also be inaccurately positioned. Another source of inaccuracy in positioning the maxilla comes during the surgical procedure. If the mandibular condyles are not properly seated during repositioning, a malocclusion will result once the patient awakens 15