Preoperative autologous blood donation in orthognathic surgery]

AIM: To minimize the perioperative risk of transfusion-associated complications, preoperative autologous blood donation is routinely performed in orthognathic surgery. This study critically analyzed the necessity of this procedure with respect to clinical, economic, and juridical issues. MATERIAL AND METHODS: In the Department of Oral and Maxillofacial Surgery, Bonn Medical School, 178 orthognathic surgical procedures were performed from 1994 to 2002. All patients (women, n=101; men, n=77) were informed about the possibility of autologous blood donation. This procedure was carried out in 83%, for single jaw surgery two and for bimaxillary osteotomies three to four units of packed red blood cells were predeposited. Of the patients, 99 underwent monognathic surgery in the lower jaw, 27 patients in the upper jaw, and bimaxillary osteotomy was performed in 52 patients. RESULTS: The average blood loss for the monognathic procedure in the lower jaw was 756 ml, in the upper jaw 858 ml, and in double jaw surgery 1391 ml. In 13 patients the hemoglobin concentration fell below 7.5 g/dl and 12 patients received their predeposited autologous blood units. A total of 57.7% of all donated autologous blood units were discarded. CONCLUSION: Autologous blood donation should be performed from the medical point of view for double jaw surgery and considered in single cases with special risks in monomaxillary osteotomies.     

Decision strategy in orthognathic surgery. Part 2: The esthetic choice in orthognathic surgery--practical applications]

Even if the functional factors are the most important in the decision, we have always to remember the need of our patient concerning aesthetic improvement. At this moment, the traditional approach based upon morphologic cephalometric analysis (which are frequently discordant) must be substituted by an aesthetic approach. The goal is to obtain a realistic 3D-imaging of the face as it will be after surgery. But it cannot really be achieved yet and we are obliged to work on lateral X-ray cephalograms. The most important at this stage of the decision is not to make a static aesthetic evaluation. It is on the contrary to perform a prospective simulation of the new profile line, as accurate as possible, based upon statistical correlations between soft- and hard-tissues changes. Even if there are some technical problems, even if the results are not currently good enough, the aesthetic prospective analysis allows validation or modulation of the initial functional surgical indication. We can compare for instance the aesthetic results of different amounts of displacements in bimaxillary surgery. Meanwhile, it is sure that the result depends also on the precision of the surgical procedure and on the good functional re-equilibration which is essential for the stability.     

Cryopreserved allografts in orthognathic surgery

After more than two years' use of cryo-preserved allografts in orthognathic surgery, the authors show the value of the use in a General Hospital of material from a cryo-preserved bone bank supplied with femoral heads by the Orthopedic Traumatology Dept.     

Initial and general orthodontic and surgical studies. Prerequisites of orthognathic surgery]

On the basis of 3 cases, we try to demonstrate the dominating role of model surgery in the patient's motivation, the surgical indication and the cooperation with orthodontists. This is achieved with a perfectly reproducible and didactic surgery. The use of color wax and of the TARG are the two deciding elements of this work.     

Allografts of cryo-preserved and radio-sterilized spongy bone tissue. Their use in orthognathic surgery]

In some circumstances, the orthognathic surgery creates inter-fragmentary spaces which have to be filled to ensure that the osteotomized segments are wedged and consolidated, and to avoid the appearance of unsightly subcutaneous contours. The authors report the results obtained through the use of cryo-preserved radio-sterilized cancellous bone allografts, coming from femoral heads, used as fillers, in diverse types of osteotomy. Thus, 19 centers of osteotomy have been filled. Follow-up periods ranged from 5 to 20 months. In 8 cases, evidence was made through radiology of the blending of the grafts. The stability of the correction was constantly noticed as well as the perfectly harmonious facial contours, which testifies the osteogenic qualities of this material. No sepsis was observed. It is a quantitatively available material, of easy shaping, the use of which does not lead to a lengthening of the operation, nor to the creation of cutaneous scars. The risk of viral transmission through allografts, specially H.I.V. and hepatitis non A - non B - non C virus is nil due to the radiosterilization.     

Evaluation of the nasal shape after orthognathic surgery

IntroductionPatients with dentofacial deformities may benefit from orthognathic surgery in the maxilla. Maxillary osteotomy may include procedures in the bone, cartilaginous, and soft tissues of the nose, leading to shape alterations.ObjectiveTo evaluate the anatomic alterations of the nasal region in patients undergoing a Le Fort I osteotomy for advancement or superior impaction.MethodsThis is a clinical prospective study. Twenty-one patients were evaluated during the pre- and postoperative periods. The positioning of the nasal tip and the modification of the nasal base were evaluated.ResultsThe results showed that the nasal tip was superiorly positioned in 85% of the cases, advanced in 80%, rotated in 80%, and there was a wide nasal base in 95%, resulting in esthetic improvement.ConclusionsSurgeries of maxillary advancement and superior reposition tend to cause elevation and advancement of the nasal tip, as well as enlargement of the nasal base.     

Results of the application of the Goettingen concept for three-dimensional repositioning of the maxilla in orthognathic surgery]

During orthodontic-surgical treatment, a three-dimensional repositioning of the maxilla is needed after Le Fort I osteotomy. The preoperatively planned and desired position of the maxilla could often not be implemented satisfactorily in the surgical procedure. Several authors described deviations of up to 15 mm in the vertical dimension and 5 mm in the sagittal dimension between the planned and the achieved position. In order to avoid this error, the "model-repositioning instrument" for three-dimensionally controlled cast surgery and the "three-dimensional doublesplint method" in combination with a surgical facebow for actual surgery were developed. A group of 20 adult patients with severe dentofacial deformities were treated according to the Goettingen concept for combined orthodontic-surgical treatment with condylar position control with a surgical facebow. For each patient the position of three marked reference points on the maxillary dental arch under pre- and postoperative conditions was evaluated using superimposed tracings of lateral radiographs. These values were compared with the performed movements of the dental maxillary arch during cast surgery. It can be shown that with the new developments the planned position of the maxillary dental arch could be transferred from cast surgery to actual surgery with an accuracy of +/- 1 mm vertically and sagittally.     

Differed autotransfusion in orthognathic surgery. Impact on the economics of blood products. Our experience of 40 cases

Delayed autotransfusion has been recommended for orthognathic surgery. The authors review and discuss the advantages of this technique. Emphasis is placed on the preventive aspect as it relates to transfusion-associated viral contamination, as well as on the positive implications on health expenditures in the long run. This technique requires excellent intercollaboration on the part of the blood transfusion centers and should definitely be recommended in certain cases of planned surgery. Furthermore, combined with hemodilution methods, it constitutes a very effective means of struggle against edema.     

Maxillary sequels in labial-alveolar-velopalatine clefts. The role of orthognathic surgery

Maxillary hypoplasia is a common sequel in cleft lip and palate deformities. After primary surgery to close lip and palate, patients routinely need extensive treatment particularly orthodontic management. With this type of approach, maxillary hypoplasia is less frequent and severe and subsequent orthognathic surgery is efficient in most cases. Without the proper management maxillary hypoplasia may be severe and patients will need a modified management and specific revision. At the end of maxillar growth, the first aim of treatment is to achieve continuity of the maxillary arch with gingivoperiosteoplasty. The transversal insufficiency can then be treated by distraction osteogenesis. Orthodontic treatment should leave place for missing teeth.     

Orthodontic implications in the correction of the transverse dimension in orthognathic surgery

Transverse skeletal discrepancies are treated in skeletally mature patients with an association of orthodontics and surgical procedures. The orthodontics procedures used depend on the type of surgical maxillary expansion performed. Orthodontics procedures performed before surgery are designed around the analysis of frontal asymmetry. Indications and proper treatment strategy for surgically-assisted maxillary expansion, or for Lefort I osteotomy depend on the magnitude of the transverse deficiency. The orthodontics implications of facial asymmetry remains one of the specific points requiring special care before and after surgery. Long length orthodontics stabilization is required after surgically-assisted rapid maxillary expansion to limit transversal relapse by use of a rigid fixation or another auxiliary stabilizing arch wire.     

Limitations of orthognathic model surgery: theoretical and practical implications

Orthognathic model surgery is a classical technique used to simulate orthognathic surgical cases. However, a detailed analysis of this technique demonstrates that theoretical errors and inaccuracies can occur in routine practice. 2D and 3D cephalometric analysis is the first source of inaccuracies. Then, during the occlusal plane transfer from the patient to the semi-adjustable dental articulator, errors can occur by inaccurate manipulation of the facial bow. Simulating the operation on the plaster cast is difficult due to the lack of a real link between the cephalometric analysis and the model surgery. Rotation and translation movements of the plaster casts are insufficiently controlled during the model surgery stage. Finally, the splint, which transfers the final relative position of maxilla to the mandible, summates all of the errors of the previous stages.     

Focus on the effect of orthognathic surgery on condylar remodeling

Condylar remodeling is a physiologic process that aims to adapt the structure of the temporo-mandibular joint (TMJ) to meet the functional demands. It is based on an interaction between the mechanical forces sustained by the TMJ and the adaptative capacities of the condyle. Orthognathic surgery can sometimes be responsible for an excessive physical stress to the articular surfaces. In these cases, normal functional condylar remodelling shifts to the process of progressive condylar resorption. Effect of orthognathic surgery on condylar remodeling is a poorly understood and controversial issue. It is however considered as an etiology of postoperative skeletal relapse following orthognathic surgery. Based on two case reports, etiopathogenic hypotheses of this process are discussed as well as predisposing factors to condylar resorption following orthognathic surgery.     

Results of an evaluation of clinical practice in orthognathic surgery in France in 2002

BACKGROUND: Over the years, orthognathic surgery has become a mainstay of maxillofacial surgery and is the object of many publications and oral communications. However, in spite of well-established methodology, disparities still exist in France basically concerning the way orthognathic surgery is performed. MATERIALS AND METHODS: In relation with the XXXIXth congress of Stomatology and Maxillofacial surgery, a questionnaire was mailed to 100 French maxillofacial surgeons. Questions dealing with some practical points of orthognathic surgery (condylar positioning, osteosynthesis technique, rate of condylar resorption.) were asked. RESULTS: Overall reply rate was 37%. Condylar positioning was performed empirically in 73% of the cases. Mandibular osteosynthesis was achieved by titanium miniplates alone in 70%. Post-operative condylar resorption rate was about 2%. This survey produced numerous astute comments. DISCUSSION: This survey highlighted the interest of maxillofacial surgeons for practical aspects of orthognathic surgery including the questions of condylar positioning or osteosynthesis technique. These points are instrumental in achieving high-quality surgical result.     

Hybrid osteosynthesis in orthognathic surgery: 28 cases of Le Fort I osteotomy

INTRODUCTION: The use of resorbable materials in orthognathic surgery is presently the object of numerous clinical and experimental studies. Their main drawbacks are their lack of rigidity and induced chronic inflammatory reactions. The purpose of this study was to propose and to test an original system of hybrid osteosynthesis associating a single titanium plate with three resorbable plates in Le Fort I osteotomies in the absence of maxillary expansion, or two titanium plates with two resorbable plates in case of maxillary expansion. METHODS: Our retrospective study concerned 28 patients operated between 2002 and 2005. A clinical follow-up of over one year detected the specific complications of the hybrid system and a cephalometric study analyzed the secondary relapse 5 months after surgery. These results were compared to the literature. RESULTS: One case of mobility and a case of instability of the jaw were observed, along with 5 cases of local chronic inflammatory reaction. The radiological results found a secondary sub-clinical relapse. The removal of the titanium material under local anesthesia was performed without difficulties in ambulatory care, which avoided a new hospitalization for the patient and a new general anesthesia. DISCUSSION: The hybrid system allowed obtaining a postoperative stability of the jaw comparable to that obtained by the exclusive use of titanium plates with an acceptable morbidity. This method of osteosynthesis combined the advantages of the resorbable material (removal of titanium plates under local anesthesia) and of titanium material (stability of the procedure). However this method requires a good experience of working with resorbable material, a good follow-up, and cooperative patients. These encouraging results urge us to extend the indications to mandibular sagittal osteotomy and to bi-maxillary osteotomies.     

Complications of orthognathic surgery. Apropos of a series of 84 patients

BACKGROUND: Patients demand satisfactory functional and esthetic results from orthognatic surgery. The aim of this study as to assess adverse outcomes after orthognatic surgery. PATIENTS AND METHODS: We retrospectively reviewed 84 patients who underwent maxillary (22.6%), mandibular (29.8%) or bimaxillary (38.1%) osteotomy in 1997. We re-examined 76 of these patients at a mean 21 months follow-up. Data were recorded for the preoperative, early postoperative, secondary postoperative and late postoperative periods. RESULTS: Infectious complications occurred in 2% of the cases of maxillary surgery. For mandibular surgery there were 10.5% infectious complications including 83% that resolved spontaneously, 3.5% neurological complications and 1.7% temporomandibular joint complications. DISCUSSION: Maxillary osteotomy has proven reliable. Major adverse outcome is infrequent but serious. Adverse outcomes in mandibular surgery are more common but less problematic.     

Effect of greater palatine canal injection on estimated blood loss during endoscopic sinus surgery

Purpose

We compare estimated blood loss (EBL) during endoscopic sinus surgery (ESS) between patients receiving transoral greater palatine canal (GPC) and transnasal infiltration (combined group) to patients receiving only transnasal infiltration (control group). CT stage, endoscopic stage, revision surgery, presence of polyps, degree of resident involvement, and operative time (OT) are also evaluated.

Methods

Injection with 1% lidocaine with 1:100,000 epinephrine was performed through the GPC and transnasally in the “combined” study group (20 patients) and only transnasally in the control group (22 patients). Charts, operative reports, and CT scans were reviewed and demographic data as well as pertinent information collected. Data analysis was performed using SPSS Version 16 (SPSS Inc., Chicago, Illinois).

Results

Twelve females and 8 males underwent combined injections and 16 males and 6 females received transnasal injections only. Average ratio of EBL to OT was 2.9 mL/min for the combined group and 4.1 mL/min for the control group (p = 0.05). Presence of polyps and revision surgery lead to a statistically significantly higher EBL (p < 0.05). Increased EBL and OT were noted with higher endoscopic and CT stages. No complications were reported.

Conclusions

Increased endoscopic and CT stages, presence of polyps, and revision surgery may all lead to greater EBL in ESS. Although there was a trend towards decreased EBL in the combined group, this however did not reach statistical significance. Combined injection through the GPC and nasal cavity appears to be a safe method to decrease EBL during ESS.     

Limitations of blood supply to the skin flap in face lift surgery]

BACKGROUND: Besides nerve injuries or hematomas, one of the main risks of face lift surgery is the development of skin necrosis. We therefore investigated which arteries contribute to the blood supply of the face lift skin flap and how extensively mobilization can be performed before arterial cutaneous circulation is endangered. MATERIAL AND METHOD: In six cadavers, selective dye injections into the branches of the carotid external artery were performed to determine the location of their vascular territories in relation to the face lift region. In another 12 cadavers, face lift flaps were raised with different extension of the undermined skin area before dye injections were performed. RESULTS: It was shown that the facial artery provides blood supply to the area of the face lift flap by perforating vessels in the paranasal, perioral and submental regions and the transverse facial artery by a perforating vessel below the malar bone prominence. Although the perforating vessel of the transverse facial artery was transected by standard mobilization, the face lift flaps were sufficiently perfused via the paranasal and perioral perforating vessels of the facial artery alone. CONCLUSION: We conclude that undermining of the face lift flap should not exceed the nasolabial fold to preserve the perforating vessels of the facial artery in the centrofacial region.