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Grillo R, Borba AM, da Silva YS, Brozoski MA, Miloro M, Naclério-Homem MDG. Exploring the relationship between the number of systematic reviews and quality of evidence: an orthognathic surgery-based study. Oral Surg Oral Med Oral Pathol Oral Radiol 2024; 137:101-112. [PMID: 38155010 DOI: 10.1016/j.oooo.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE We analyzed the quality and quantity of systematic reviews (SRs) of orthognathic surgery, the most frequently published topic in maxillofacial surgery. STUDY DESIGN We searched the PubMed database for SRs of orthognathic surgery with no restriction on the language of publication date. We assessed the certainty of evidence presented according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol and the Leiden Manifesto using the Grading of Recommendations Assessment, Development, and Evaluation approach. We analyzed the data using descriptive statistics, Pearson´s correlation test, and linear regression. RESULTS Of the 171 SRs evaluated, approximately one fifth presented evidence with a high level of certainty. The number of orthognathic surgery SRs has been increasing, and many SRs were published after very similar topics had already been published. There is no relationship between the impact factor and the certainty of evidence. CONCLUSIONS An excessive number of SRs of orthognathic surgery are published, and many SRs are superfluous, simply reporting previous findings. Clinicians should not base treatment decisions solely on the evidence presented in SRs, and journal editors and reviewers should evaluate these SRs more critically, particularly when they address topics that have already been covered in the literature.
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Affiliation(s)
- Ricardo Grillo
- Department of Oral and Maxillofacial Surgery, Traumatology and Prosthesis-Faculty of Dentistry of the University of São Paulo, Brazil; Department of Oral and Maxillofacial Surgery, Faculdade Patos de Minas, Brasília, Brazil.
| | - Alexandre Meireles Borba
- Research Program in Integrated Dental Sciences Department, Faculty of Dentistry of the University of Cuiabá, Cuiabá-MT, Brazil
| | | | - Mariana Aparecida Brozoski
- Department of Oral and Maxillofacial Surgery, Traumatology and Prosthesis-Faculty of Dentistry of the University of São Paulo, Brazil
| | - Michael Miloro
- Department of Oral and Maxillofacial Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Maria da Graça Naclério-Homem
- Department of Oral and Maxillofacial Surgery, Traumatology and Prosthesis-Faculty of Dentistry of the University of São Paulo, Brazil
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Atipatyakul P, Chen YF, Yao CF, Chen YA, Chen YH, Liao YF, Chen YR. Three-dimensional evaluation of skeletal stability after surgery-first bimaxillary surgery for class III asymmetry in 70 consecutive patients. J Dent Sci 2024; 19:532-541. [PMID: 38303824 PMCID: PMC10829717 DOI: 10.1016/j.jds.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/21/2023] [Indexed: 02/03/2024] Open
Abstract
Background/purpose Skeletal stability after orthognathic surgery is essential for positive treatment outcome. This study evaluated the stability of osteotomy segments after surgery-first bimaxillary surgery for class III asymmetry. Materials and methods Seventy adults with class III asymmetry consecutively corrected through surgery-first Le Fort I and bilateral sagittal split osteotomies were investigated. Cone-beam computed tomography before treatment (T0), 1-week after surgery (T1), and after all treatment (T2, ≥1-year after surgery) was used to assess surgical movement (T0 to T1) and skeletal stability (T1 to T2) regarding the translation and rotation of the maxillary, mandibular distal, and proximal segments. Results At T1, the maxillary segment had moved forward and upward, turned to the deviated side, and rotated downward (all P < 0.01). The distal segment of mandible had moved forward and upward and rotated upward (all P < 0.001). The deviated proximal segment had moved upward, tilted to the opposite side, and rotated upward (all P < 0.001). The opposite proximal segment had moved upward and tilted to the deviated side (both P < 0.01). At T2, significant relapse occurred in the mandible. The distal segment moved forward and upward and rotated upward (all P < 0.001). The deviated proximal segment moved upward, tilted to the opposite side, and rotated upward (all P < 0.001). The opposite proximal segment moved upward and tilted to the deviated side (both P < 0.01). Conclusion Clinically significant relapse of class III asymmetry was discovered on the mandibular distal and opposite proximal segments.
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Affiliation(s)
- Piengkwan Atipatyakul
- Graduate Institute of Dental and Craniofacial Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yun-Fang Chen
- Graduate Institute of Dental and Craniofacial Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan
- Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chuan-Fong Yao
- Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ying-An Chen
- Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yi-Hsuan Chen
- Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Fang Liao
- Graduate Institute of Dental and Craniofacial Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Ray Chen
- Graduate Institute of Dental and Craniofacial Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
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Du A, Ding N, Zhang J, Zhang J, Zhu J, Zhu L. Impact of Mandibular Angle Osteotomy Using a Geometric Mathematical Design on the Aesthetic Osteotomy Line: A Retrospective Observational Study. Aesthetic Plast Surg 2023; 47:1945-1956. [PMID: 36315263 DOI: 10.1007/s00266-022-03117-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/08/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mandibular angle osteotomy (MAO) is a frequently described technique in Eastern females. The success hinges on the precise positioning of the osteotomy line. The geometric mathematical method is viable. Therefore, we explored the impact of mandibular angle osteotomy using aesthetic standards and printed digital osteotomy templates (DOTs) on the aesthetic osteotomy line. METHODS This retrospective observational study included female patients with prominent mandibular angle (PMA) who underwent MAO at our hospital between January 2020 and March 2021. Thirty-three female patients were included, 22 in the DOTs group using new DOTs, and 11 in the traditional group using traditional free-hand techniques. RESULTS Regarding the width of the excised bone, the postoperative deviation from the preoperative plan was not significant in the DOTs group (0.5 ± 0.3 mm, P > 0.05), while the deviation was significant for the traditional group (2.5 ± 1.2 mm, P<0.05). The preparation time was longer in the DOTs group than in the traditional group (82 ± 11 vs. 53±4 min, P < 0.001). The osteotomy time and the operation time were shorter in the DOTs group than in the traditional group (osteotomy: 54 ± 5 vs. 73 ± 6 min; preparation: 124 ± 10 vs. 169 ± 13 min; both P < 0.001). The Likert (4.0 ± 0.5 vs. 1.0 ± 0.6, P = 0.006) and FACE-Q scores (17.5 ± 1.7 vs. 15.6 ± 1.3, P = 0.029) were higher in the DOTs group. CONCLUSIONS The new method of positioning the new aesthetic osteotomy line based on geometric analysis might provide a possible osteotomy method that strongly suggests effectiveness, safety, individualization, and accuracy, with a shorter operation and higher patient satisfaction. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Antong Du
- Department of Plastic and Reconstructive Surgery, Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital), Ward Building 18th Floor, 415 Fengyang Road, Huangpu, Shanghai, 200003, China
| | - Neng Ding
- Department of Plastic and Reconstructive Surgery, Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital), Ward Building 18th Floor, 415 Fengyang Road, Huangpu, Shanghai, 200003, China
| | - Jian Zhang
- Shanghai Universal Medical Imaging Diagnostic Center, Shanghai University, Shanghai, 200237, China
| | - Jianlin Zhang
- Department of Plastic and Reconstructive Surgery, Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital), Ward Building 18th Floor, 415 Fengyang Road, Huangpu, Shanghai, 200003, China
| | - Jie Zhu
- Department of Plastic and Reconstructive Surgery, Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital), Ward Building 18th Floor, 415 Fengyang Road, Huangpu, Shanghai, 200003, China
| | - Lie Zhu
- Department of Plastic and Reconstructive Surgery, Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital), Ward Building 18th Floor, 415 Fengyang Road, Huangpu, Shanghai, 200003, China.
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Eshghpour M, Samieirad S, Shooshtari Z, Shams A, Ghadirimoghaddam N. Three Different Fixation Modalities following Mandibular Setback Surgery with Sagittal Split Ramus Osteotomy: A Comparative Study using Three-dimensional Finite Elements Analysis. World J Plast Surg 2023; 12:43-57. [PMID: 37220573 PMCID: PMC10200092 DOI: 10.52547/wjps.12.1.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/30/2023] [Indexed: 05/25/2023] Open
Abstract
Background The provision of sufficient stability after maxillofacial surgery is essential for the reduction of complications and disease recurrence. The stabilization of osteotomized pieces results in rapid restoration of normal masticatory function, reduction of skeletal relapse, and uneventful healing at the osteotomy site. We aimed to compare qualitatively stress distribution patterns over a virtual mandible model after bilateral sagittal split osteotomy (BSSO) bridged with three different intraoral fixation techniques. Methods This study was conducted in the Oral and Maxillofacial Surgery Department of Mashhad School of Dentistry, Mashhad, Iran, from March 2021-March 2022. The mandible computed tomography scan of a healthy adult was used to generate a 3D model; thereafter, BSSO with a 3mm setback was simulated. The three following fixation techniques were applied to the model: 1) two bicortical screws, 2) three bicortical screws, and 3) a miniplate. The bilateral second premolars and first molars were placed under mechanical loads of 75, 135, and 600N in order to simulate symmetric occlusal forces. Finite element analysis (FEA) was carried out in Ansys software, and the mechanical strain, stress, and displacement calculations were recorded. Results The FEA contours revealed that stress was mainly concentrated in the fixation units. Although bicortical screws presented better rigidity than miniplates, they were associated with higher stress and displacement readings. Conclusion Miniplate fixation demonstrated the most favorable biomechanical performance, followed by fixation with two and three bicortical screws, respectively. Intraoral fixation with miniplates in combination with monocortical screws can serve as an appropriate fixation arrangement and treatment option for skeletal stabilization after BSSO setback surgery.
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Affiliation(s)
- Majid Eshghpour
- Dental Research Center, Mashhad Univer-sity of Medical Sciences, Mashhad, Iran
| | - Sahand Samieirad
- Oral and Maxillofacial Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Shooshtari
- Dental Research Center, Mashhad Univer-sity of Medical Sciences, Mashhad, Iran
| | - Abdolrahim Shams
- Oral and Maxillofacial Surgery Depar-tment, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nafiseh Ghadirimoghaddam
- Oral and Maxillofacial Surgery Depar-tment, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
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Bendersky J, Uribe M, Bravo M, Vargas JP, Flores E, Aguero I, Villanueva J, Urrutia G, Bonfill X. Systematic mapping review of orthognathic surgery. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e285-e305. [PMID: 35568120 DOI: 10.1016/j.jormas.2022.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/08/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
STUDY DESIGN Systematic mapping review AIM AND SCOPE: The objective of this mapping review was to identify, describe, and organize clinical research currently available from systematic reviews and primary studies regarding co-interventions and different surgical modalities used in orthognathic surgery (OS) and their outcomes. METHODS Systematic reviews (SRs), randomized controlled trials, and observational studies that evaluated perioperative OS co-interventions and surgical modalities were identified in an exhaustive search of MEDLINE, EMBASE, Epistemonikos, Lilacs, Web of Science, and CENTRAL. Grey literature was also screened. RESULTS Included were 35 SRs and 253 primary studies, 103 from SRs, and another 150 identified in our search. Overall, SR quality was rated as critically low, with only two SRs rated as of high quality. 19 questions on population, interventions, comparisons, and outcomes (PICO) extracted from the SRs focused on osteosynthesis methods, surgical cutting devices, and use of antibiotics, corticosteroids, and induced hypotension. Also identified were 15 research gaps. Evidence bubble maps were created to graphically depict the available evidence. CONCLUSION Future high-quality research, both primary and secondary, is needed to address the knowledge gaps identified in this systematic mapping review.
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Affiliation(s)
- Josefina Bendersky
- Iberoamerican Cochrane Center, Institut d'Recerca-Servei d'Epidemiologia Clínica i Salut Pública. Carrer de Sant Quintí, 89, 08041 Barcelona, Spain; School of Dentistry, Faculty of Medicine, Pontifical Catholic University of Chile, Vicuña Mackenna 4860, Santiago, Chile; Universitat autónoma de Barcelona, Campus de la UAB, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.
| | - Macarena Uribe
- School of Dentistry, Faculty of Medicine, Pontifical Catholic University of Chile, Vicuña Mackenna 4860, Santiago, Chile.
| | - Maximiliano Bravo
- Oral and Maxillofacial Surgery Program, Universidad de los Andes, Santiago, Chile.
| | - Juan Pablo Vargas
- School of Dentistry, Faculty of Medicine, Pontifical Catholic University of Chile, Vicuña Mackenna 4860, Santiago, Chile.
| | - Enrique Flores
- Faculty of Dentistry, University of Chile, Olivos 943, Independencia, Santiago, Chile..
| | - Ignacio Aguero
- Faculty of Dentistry, University of Chile, Olivos 943, Independencia, Santiago, Chile..
| | - Julio Villanueva
- Department of Oral & Maxillofacial Surgery and Cochrane Associated Center at Faculty of Dentistry, University of Chile, Olivos 943, Independencia, Santiago, Chile.; Servicio de Cirugía Maxilofacial. Hospital Clínico San Borja-Arriarán. Sta. Rosa 1234, Santiago, Región Metropolitana, Chile.
| | - Gerard Urrutia
- Iberoamerican Cochrane Center, Institut d'Recerca-Servei d'Epidemiologia Clínica i Salut Pública. Carrer de Sant Quintí, 89, 08041 Barcelona, Spain; Iberoamerican Cochrane Center, c (IIB Sant Pau). Carrer de Sant Quintí, 77, 08041 Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP). Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0 28029 Madrid, Spain; Universitat autónoma de Barcelona, Campus de la UAB, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.
| | - Xavier Bonfill
- Iberoamerican Cochrane Center, Institut d'Recerca-Servei d'Epidemiologia Clínica i Salut Pública. Carrer de Sant Quintí, 89, 08041 Barcelona, Spain; Iberoamerican Cochrane Center, c (IIB Sant Pau). Carrer de Sant Quintí, 77, 08041 Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP). Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0 28029 Madrid, Spain; Universitat autónoma de Barcelona, Campus de la UAB, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.
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Is There Any Differences in Dento-Skeletal Stability between One Vs. Three-Screw Fixation of Mandible Following Bilateral Sagittal Split Osteotomy (BSSO)? World J Plast Surg 2022; 11:46-56. [PMID: 36117899 PMCID: PMC9446116 DOI: 10.52547/wjps.11.2.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 04/22/2022] [Indexed: 11/18/2022] Open
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Bahmanyar S, Namin AW, Weiss RO, Vincent AG, Read-Fuller AM, Reddy LV. Orthognathic Surgery of the Mandible. Facial Plast Surg 2021; 37:716-721. [PMID: 34587642 DOI: 10.1055/s-0041-1735309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Orthognathic surgery performed in conjunction with orthodontic treatment is commonly performed to correct skeletal irregularities and realign the maxillomandibular relationship to improve occlusal function and facial esthetics. A thorough understanding of soft tissue esthetics, skeletal and occlusal relationships, and surgical techniques is required to obtain successful results. Surgical techniques have evolved greatly throughout history, as technological advances such as virtual surgical planning have become available and widely used to obtain predictable movements with minimized complications. The aim of this article is to review the orthognathic surgical procedures of the mandible, with particular attention to the indications, contraindications, preoperative assessment, surgical technique, and possible complications encountered.
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Affiliation(s)
- Sara Bahmanyar
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Texas A&M Health Science Center, Dallas, Texas
| | - Arya W Namin
- Department of Otolaryngology, University of Missouri School of Medicine, University of Missouri, Columbia, Missouri
| | - Robert O Weiss
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Texas A&M Health Science Center, Dallas, Texas
| | - Aurora G Vincent
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Andrew M Read-Fuller
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Texas A&M Health Science Center, Dallas, Texas
| | - Likith V Reddy
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Texas A&M Health Science Center, Dallas, Texas
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Zachariah T, Bharathi R, Ramanathan M, Parameswaran A. The Anatomical Basis for Plate Fixation in BSSO to Minimize Condylar Torquing: A Comparative CT Study of Mandibular Advancement and Setback. J Maxillofac Oral Surg 2021; 20:432-438. [PMID: 34408370 DOI: 10.1007/s12663-021-01564-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 04/10/2021] [Indexed: 10/21/2022] Open
Abstract
Introduction Condylar displacement after bilateral sagittal-split osteotomy (BSSO) occur in the sagittal plane as clockwise/counter-clockwise rotation of the ramus, in the coronal plane as medial/lateral inclination, or in the axial plane as medial/lateral condylar torquing. The purpose of this prospective CT study was to evaluate the role of plate fixation in minimizing condylar torquing or rotational changes in the axial plane. Materials and Methods This prospective study was carried out on 26 patients, 13 of whom underwent advancement BSSO and 13 setback BSSO, without maxillary LeFort I osteotomies. All mandibular movements were symmetrical. Fixation of the osteotomized segments was achieved with a single 4-hole plate and monocortical screws. In case of mandibular setbacks, a straight plate was used, whereas an inset-bent plate was used for advancements. Computed tomography scans were obtained preoperatively and postoperatively to measure condylar rotation or torqueing in the axial plane. An increase in condylar angle on axial slices was considered as lateral condylar torquing, whereas a decrease was considered as medial condylar torquing. Results A mean medial condylar torquing of 0.2° was noted postoperatively in case of setbacks (p > 0.05 not significant). This suggested minimal condylar torquing, indicating that the proximal and distal segments maintained contact at the anterior vertical osteotomy fixed with a straight plate. In case of advancements, a mean lateral condylar torquing of 2.2° was noted postoperatively (p < 0.005, highly significant). This suggested that the proximal segment flare at the anterior vertical osteotomy site was maintained by inset-bent plate fixation. Conclusion The gaps between the proximal and distal segments created by mandibular advancement and setback should be maintained. An attempt to close these gaps, especially in mandibular advancement, will result in an unfavourable axial condylar torque. Consequently, the areas of bony contact between the proximal and distal osteotomy sites created by mandibular advancement and setback should be maintained as well.
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Affiliation(s)
- Thomas Zachariah
- Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and General Hospital, Meenakshi Academy of Higher Education and Research (Deemed To Be University), Alapakkam Main Road, Maduravoyal, Chennai, Tamil Nadu 600095 India
| | - Rajkumar Bharathi
- Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and General Hospital, Meenakshi Academy of Higher Education and Research (Deemed To Be University), Alapakkam Main Road, Maduravoyal, Chennai, Tamil Nadu 600095 India
| | - Manikandhan Ramanathan
- Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and General Hospital, Meenakshi Academy of Higher Education and Research (Deemed To Be University), Alapakkam Main Road, Maduravoyal, Chennai, Tamil Nadu 600095 India
| | - Anantanarayanan Parameswaran
- Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and General Hospital, Meenakshi Academy of Higher Education and Research (Deemed To Be University), Alapakkam Main Road, Maduravoyal, Chennai, Tamil Nadu 600095 India
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Sinha SP, Duong TDH, Duy TDT, Ko EWC, Chen YR, Huang CS. Penetration of inferior alveolar nerve canal increased by bicortical fixation after bilateral sagittal split osteotomy in mandibular prognathism. Int J Oral Maxillofac Surg 2021; 51:200-205. [PMID: 33985866 DOI: 10.1016/j.ijom.2021.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 03/10/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
The purpose of this three-dimensional cone beam computed tomography (CBCT) study was to identify the difference between monocortical fixation (MCF) and bicortical fixation (BCF) in mandibular canal penetration after bilateral sagittal split osteotomy (BSSO) to correct mandibular prognathism, where interosseous fixation was done by BCF or MCF. CBCT was performed 1 week postoperatively and Dolphin 3D software was used to assess direct penetration of the mandibular canal by either type of screw. The primary outcome variable was the presence or absence of mandibular canal penetration and was categorized as a binary coded variable. The BCF and MCF groups were compared by χ2 test, and the odds ratio for canal penetration was estimated. Multiple logistic regression was performed to identify factors related to canal penetration. A total of 118 patients were included. The MCF group had only 6% canal penetrations (3/50 patients) and the BCF group had 58.8% canal penetrations (40/68 patients). The regression model showed that BCF was the only factor causing mandibular canal penetration, with an adjusted odds ratio of 52.5. Awareness of the increased risk of canal penetration with BCF and potential nerve injury might influence case selection.
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Affiliation(s)
- S P Sinha
- Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - T D H Duong
- Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan; Department of Maxillofacial Surgery and Odonto-stomatology, National Children's Hospital, Hanoi, Viet Nam
| | - T-D T Duy
- Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan; Department of Orthodontics, Ho Chi Minh City Dental Hospital, Ho Chi Minh City, Viet Nam
| | - E W-C Ko
- Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan; Graduate Institute of Dental and Craniofacial Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y-R Chen
- Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Dental and Craniofacial Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - C S Huang
- Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan; Graduate Institute of Dental and Craniofacial Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Janssens E, Shujaat S, Shaheen E, Politis C, Jacobs R. Long-term stability of isolated advancement genioplasty, and influence of associated risk factors: A systematic review. J Craniomaxillofac Surg 2021; 49:269-276. [PMID: 33583665 DOI: 10.1016/j.jcms.2021.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/11/2020] [Accepted: 01/31/2021] [Indexed: 11/26/2022] Open
Abstract
The aim of this review was to investigate the skeletal and soft tissue stability of isolated advancement genioplasty after more than 1 year, and to observe the influence of associated risk factors. A literature search was performed on PubMed, Web of Science, Embase, ScienceDirect, and Cochrane. Only studies with at least 10 patients who underwent an isolated advancement genioplasty, and with a follow-up period of at least 1 year, were included. Of the 2224 records initially identified, eight articles met the eligibility criteria. The mean age of the total study population was 23 years and ranged from 19.1 to 26.5 years in the individual studies. The average surgical advancement at pogonion was 8.2 mm and ranged from 6.2 to 11.7 mm in the individual studies. After 1 year, the horizontal hard tissue relapse at the level of pogonion varied from 0.1 to 2.1 mm. In two studies, this was reported as statistically significant. Regarding the soft tissue, the horizontal relapse varied from 0.3 to 2.9 mm, which was also considered statistically significant in two studies. Isolated advancement genioplasty was found to be a predictable and stable orthognathic procedure in the sagittal plane at both soft and hard tissue levels. The amount of relapse was not associated with the fixation method or with the amount of surgical advancement.
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Affiliation(s)
- E Janssens
- OMFS IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven & Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - S Shujaat
- OMFS IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven & Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - E Shaheen
- OMFS IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven & Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - C Politis
- OMFS IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven & Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - R Jacobs
- OMFS IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven & Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Li H, Zhou N, Huang X, Zhang T, He S, Guo P. Biomechanical effect of asymmetric mandibular prognathism treated with BSSRO and USSRO on temporomandibular joints: a three-dimensional finite element analysis. Br J Oral Maxillofac Surg 2020; 58:1103-1109. [PMID: 32646786 DOI: 10.1016/j.bjoms.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 06/05/2020] [Indexed: 10/23/2022]
Abstract
Asymmetric mandibular prognathism is a clinically common skeletal dentomaxillofacial deformity. Unilateral sagittal split ramus osteotomy (USSRO) is an effective alternative procedure to bilateral sagittal split ramus osteotomy (BSSRO) for some patients. However, the biomechanical effect of temporomandibular joint (TMJ) of USSRO has not been fully studied. This study aims to evaluate the stress distribution changes in the TMJ of asymmetric mandibular prognathism treated with BSSRO/USSRO, to validate the clinical feasibility of USSRO. Nineteen patients with mandibular prognathism patients who were treated with BSSRO (n=12) and USSRO (n=7) had preoperative and postoperative computed tomographic scanning. Preoperative and postoperative 3-dimensional finite element analysis (FEA) of functional TMJ movements were made on one BSSRO patient and one USSRO patient. In all patients, the ANB angle and mandibular deviation were significantly improved postoperatively. There was no significant difference in the postoperative ANB angle and mandibular deviation between the BSSRO group and the USSRO group. In two preoperative FEA models, the maximum stresses of non-deviation side TMJ structures were greater than the deviation side during functional movements. The unbalanced stress distribution was corrected postoperatively in both BSSRO/USSRO FE models. Both BSSRO/USSRO can improve the ANB angle and mandibular deviation. The bilateral TMJ structure in patients with asymmetric mandibular prognathism had unbalanced stress, which could be significantly improved with the USSRO as effectively as BSSRO.
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Affiliation(s)
- H Li
- College & Hospital of Stomatology, Guangxi Medical University, Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi clinical Research Center for Craniofacial Deformity, Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, 10 Shuangyong Rd, Nanning, Guangxi, 530021 China.
| | - N Zhou
- College & Hospital of Stomatology, Guangxi Medical University, Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi clinical Research Center for Craniofacial Deformity, Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, 10 Shuangyong Rd, Nanning, Guangxi, 530021 China.
| | - X Huang
- College & Hospital of Stomatology, Guangxi Medical University, Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi clinical Research Center for Craniofacial Deformity, Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, 10 Shuangyong Rd, Nanning, Guangxi, 530021 China.
| | - T Zhang
- College & Hospital of Stomatology, Guangxi Medical University, Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi clinical Research Center for Craniofacial Deformity, Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, 10 Shuangyong Rd, Nanning, Guangxi, 530021 China.
| | - S He
- College & Hospital of Stomatology, Guangxi Medical University, Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi clinical Research Center for Craniofacial Deformity, Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, 10 Shuangyong Rd, Nanning, Guangxi, 530021 China.
| | - P Guo
- College & Hospital of Stomatology, Guangxi Medical University, Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi clinical Research Center for Craniofacial Deformity, Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, 10 Shuangyong Rd, Nanning, Guangxi, 530021 China.
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Haas Junior O, Guijarro-Martínez R, de Sousa Gil A, da Silva Meirelles L, Scolari N, Muñoz-Pereira M, Hernández-Alfaro F, de Oliveira R. Hierarchy of surgical stability in orthognathic surgery: overview of systematic reviews. Int J Oral Maxillofac Surg 2019; 48:1415-1433. [DOI: 10.1016/j.ijom.2019.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 03/03/2019] [Accepted: 03/06/2019] [Indexed: 12/26/2022]
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Comparisons of Jaw Line and Face Line after Mandibular Setback: Intraoral Vertical Ramus versus Sagittal Split Ramus Osteotomies. BIOMED RESEARCH INTERNATIONAL 2019; 2018:1375085. [PMID: 30662900 PMCID: PMC6312596 DOI: 10.1155/2018/1375085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 12/03/2018] [Indexed: 11/28/2022]
Abstract
Background This study investigates the differences in the lateral profile and frontal appearance after sagittal split ramus osteotomy (SSRO) and intraoral vertical ramus osteotomy (IVRO) procedures for the correction of mandibular prognathism. Methods Sixty patients (30 SSRO and 30 IVRO) underwent mandibular setback surgery. Serial cephalograms were obtained: (1) T1: approximately 1 month before surgery; (2) T2: at least 6 months after surgery for SSRO and at least 1 year after surgery for IVRO. The landmarks, linear distances, and related angles were measured. The t-test was applied to the intragroup and intergroup comparisons. The null hypothesis was that SSRO and IVRO made no difference in the facial appearance. Results In the IVRO group, the ramus and gonial widths significantly decreased by 3.9 mm and 5.8 mm, respectively. SSRO significantly reduced the gonial angle by 2.6°, and IVRO increased it significantly by 5.3°. The postoperative increases at frontal bone levels 0 and 1 after IVRO were significantly larger than those after SSRO, but, at level 3, the increases after SSRO were larger than those after IVRO. In the frontal muscular and facial planes, SSRO and IVRO presented no difference. The frontal jaw angle and face angle were significantly larger with IVRO than with SSRO. Therefore, the null hypothesis was rejected. Conclusions The ramus width and gonial width were significantly decreased in IVRO compared to SSRO. IVRO increased angles in the lateral profile (gonial angle and mandibular plane angle) and frontal appearance (jaw angle and face angle) more than SSRO did.
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Three-Dimensional Analysis of Perioperative Condylar Displacement After Mandibular Setback Surgery With Intended Manual Condylar Positioning. J Craniofac Surg 2019; 29:e767-e773. [PMID: 30015735 DOI: 10.1097/scs.0000000000004733] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The purpose of this study is to investigate the effect of orthognathic surgery with intended manual condylar positioning on condyle by examining a change in its position. METHOD About 18 patients with mandibular prognathism who underwent orthognathic surgery with intentional manual condyle positioning were included. Condyle displacement was analyzed through 3D cone-beam computed tomography before and after operation. The patients were categorized into 2 experimental groups: group A (1-jaw) and group B (2-jaw). The experimental groups were examined before surgery (T0), 3 days (T1), and 6 months (T2) after surgery. Condylar displacement direction was investigated in terms of bodily shift and rotational movement. RESULTS Downward bodily shift of condyle after surgery was significantly apparent from all of the patients. Condylar bodily shift in other directions was statistically insignificant. Gross bodily shift of condyle right after surgery was anterolateral-inferior direction. In perspective of rotational movement, condyle rotated in infero-medial direction right after operation, but no significant change was presented afterwards. In addition, no significant difference in the amounts of condylar shift and pattern existed between groups A and B. CONCLUSION Intended manual condylar positioning may minimize postoperative displacement of condyle while accomplishing skeletal stability.
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The Changes of Cheek Line (Lateral) and Face Line (Frontal) after Correction of Mandibular Prognathism. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4926528. [PMID: 29992146 PMCID: PMC6016152 DOI: 10.1155/2018/4926528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 05/06/2018] [Indexed: 11/18/2022]
Abstract
Objective The purpose of the present study was to investigate the improvements of facial profile and postoperative stability by single mandibular setback surgery. Materials and Methods The study included twenty-seven patients who underwent mandibular prognathism correction by sagittal split ramus osteotomy (SSRO). Cephalometric radiograms (lateral and frontal) were collected and analyzed at three intervals: preoperatively (T1), immediately postoperatively (T2), and final follow-up postoperatively (T3). The lateral and frontal cephalometric parameters were measured. The immediate postoperative change (T21), postoperative stability (T32), and final surgical change (T31) were calculated and analyzed. The null hypothesis is that postoperative stability (T32) was not significantly correlated to amount of mandibular setback (T21). Results The immediate postoperative change (T21) of menton (Me) was significantly backward 8.7 mm. In the final postoperative change (T31), average chin points anterior movements were approximately 0.32 mm. Investigating frontal appearance, inter ramus posterior (InterRp) and intergonion (InterGo) widths were significantly increased with 1.8 and 2.2 mm, respectively. Bilateral ramus angles were not significantly increased, about 1°. The horizontal Me (T32) had significant correlation (p = 0.028) with amount of setback (T21). Therefore, null hypothesis is rejected. Conclusion Postoperative relapse was significantly correlated to the amount of setback. The frontal transverse changes (InterRp and InterGo) were significantly increased.
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Tabrizi R, Pourdanesh F, Sadeghi HM, Shahidi S, Poorian B. Does Fixation Method Affect Stability of Sagittal Split Osteotomy and Condylar Position? J Oral Maxillofac Surg 2017; 75:2668.e1-2668.e6. [DOI: 10.1016/j.joms.2017.08.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/21/2017] [Accepted: 08/16/2017] [Indexed: 11/24/2022]
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Chen CM, Chen MYC, Cheng JH, Chen KJ, Tseng YC. Facial profile and frontal changes after bimaxillary surgery in patients with mandibular prognathism. J Formos Med Assoc 2017; 117:632-639. [PMID: 28911792 DOI: 10.1016/j.jfma.2017.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 08/05/2017] [Accepted: 08/24/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND/PURPOSE Patients are always concerned about their postoperative appearance before surgery for facial deformity correction. The present study investigated the facial profile and frontal changes following two-jaw surgery. METHODS Forty patients who underwent two-jaw surgery were divided by the amount of mandibular setback (group I: ≤8 mm and group II: >8 mm). Cephalometric radiograms (lateral and frontal) were collected and analyzed at three intervals: preoperatively (T1), immediately postoperatively (T2), and final follow-up (T3). The following points were identified: cheek points (C1-C5), pronasale (Prn, tip of the nose), anterior nasal spine (ANS), subnasal (Sn), point A, labrale superius (Ls), incision superius (Is), labrale inferius (Li), incision inferius (Ii), point B, labiomental sulcus (Si), pogonion (Pog), soft tissue pogonion (PogS), ramus point (RP), and gonion (Go). The immediate postoperative changes (T21), final postoperative changes (T32), and final stability (T31) were calculated and analyzed. RESULTS In T31, the cheek line showed significant advancements of 2.3 mm (group I) and 1.6 mm (group II). The soft:hard tissue ratios were significantly correlated: Prn:ANS (0.37:1), Prn:A (0.39:1), Sn:A (0.85:1), C3:A (0.82:1), Ls:Is (0.92:1), Li:Ii (0.91:1), Si:B (0.88:1), and PogS:Pog (group I, 0.78:1 and group II, 0.93:1). The intercondylion and intergonial widths of group II (T31) significantly increased 1.8 and 4 mm, respectively. Regarding the postoperative skeletal stability (T32), group I showed significant correlations between amounts of mandibular setback, but group II did not. CONCLUSION In the facial profile, the cheek line showed significant advancement postoperatively. The frontal mandibular transverse dimensions were significantly increased.
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Affiliation(s)
- Chun-Ming Chen
- Department of Oral and Maxillofacial Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Michael Yuan-Chien Chen
- Department of Dentistry, China Medical University Hospital, China Medical University, Taichung, Taiwan; School of Dentistry, College of Medicine, China Medical University, Taichung, Taiwan
| | - Jung-Hsuan Cheng
- School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthodontics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Kwei-Jing Chen
- Department of Dentistry, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Yu-Chuan Tseng
- School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthodontics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
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Elledge R, Chandegra R, Stockton P. Use of buccal cortex as interpositional graft in mandibular setbacks. Br J Oral Maxillofac Surg 2017; 55:853-854. [PMID: 28818503 DOI: 10.1016/j.bjoms.2017.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 07/14/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Ross Elledge
- University Hospitals Birmingham NHS Foundation Trust.
| | | | - Peter Stockton
- University Hospitals Coventry and Warwickshire NHS Trust.
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Karsy M, Moores N, Siddiqi F, Brockmeyer DL, Bollo RJ. Bilateral sagittal split mandibular osteotomies for enhanced exposure of the anterior cervical spine in children: technical note. J Neurosurg Pediatr 2017; 19:464-471. [PMID: 28186477 DOI: 10.3171/2016.11.peds16530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The bilateral sagittal split mandibular osteotomy (BSSMO), a common maxillofacial technique for expanding the oropharynx during treatment of micrognathia, is a rarely employed but useful adjunct to improve surgical access to the ventral cervical spine in children. Specifically, it provides enhanced exposure of the craniocervical junction in the context of midface hypoplasia, and of the subaxial cervical spine in children with severe kyphosis. The authors describe their technique for BSSMO and evaluate long-term outcomes in patients. The pediatric neurosurgical database at a single center was queried to identify children who underwent BSSMO as an adjunct to cervical spine surgery over a 22-year study period (1993-2015). The authors retrospectively reviewed clinical and radiographic data in all patients. The authors identified 5 children (mean age 5.3 ± 3.1 years, range 2.1-10.0 years) who underwent BSSMO during cervical spine surgery. The mean clinical follow-up was 3.0 ± 1.9 years. In 4 children, BSSMO was used to increase the size of the oropharynx and facilitate transoral resection of the odontoid and anterior decompression of the craniocervical junction. In 1 patient with subaxial kyphosis and chin-on-chest deformity, BSSMO was used to elevate the chin, improve anterior exposure of the subaxial cervical spine, and facilitate cervical corpectomy. Careful attention to neurovascular structures, including the inferior alveolar nerve, lingual nerve, and mental branch of the inferior alveolar artery, as well as minimizing tongue manipulation and compression, are critical to complication avoidance. The BSSMO is a rarely used but extremely versatile technique that significantly enhances anterior exposure of the craniocervical junction and subaxial cervical spine in children in whom adequate visualization of critical structures is not otherwise possible.
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Affiliation(s)
- Michael Karsy
- Department of Neurosurgery, Division of Pediatric Neurosurgery, and
| | - Neal Moores
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Faizi Siddiqi
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | | | - Robert J. Bollo
- Department of Neurosurgery, Division of Pediatric Neurosurgery, and
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