The effect of botulinum toxin-A injection into the masseter muscles on prevention of plate fracture and post-operative relapse in patients receiving orthognathic surgery

Comparison between 2- and 4-plate fixation in Le Fort I osteotomy: a mixed methods systematic review

OBJECTIVE

Achieving postsurgical skeletal stability is crucial for successful outcomes and patient satisfaction. Precision maxillofacial surgery, which integrates precision techniques with minimally invasive approaches, is increasingly recognized for its potential to enhance long-term stability and reduce surgical risks and complications. This study aimed to comprehensively evaluate the impact of fixation techniques (2 vs 4 plates) during Le Fort I osteotomy in orthognathic surgery on skeletal stability. The main focus was to compare the stability achieved and potential risks of relapse between these two fixation methods.

MATERIAL AND METHODS

A mixed-methods approach was employed, combining a systematic review, in silico analysis, and in vitro studies. The systematic review adhered to Joanna Briggs Institute methodology and Good Reporting of A Mixed Methods Study guidelines, focusing on comparative studies that evaluated skeletal stability as the primary outcome measure. In silico and in vitro analyses were conducted to assess the biomechanical principles and relapse risks associated with maxillary advancement using different fixation techniques.

RESULTS

The systematic review included three clinical trials, four finite element analysis studies, and two in vitro analyses. The meta-analysis revealed no significant difference in skeletal stability between the 2- and 4-plate fixation methods. However, biomechanical analysis showed an atypical increase in relapse risk with 2-plate fixation at 3 mm maxillary advancement, compared to a 10 mm advancement for 4-plate fixation.

CONCLUSIONS

While both 2- and 4-plate fixation methods are viable, the findings suggest that 4-plate fixation offers superior stability, particularly in cases of significant maxillary advancement, where 2-plate fixation showed an increased risk of relapse. Future research with larger sample sizes and addressing the biases identified in this study is needed to validate these findings and effectively guide clinical practice.

Application of botulinum toxin A in tissue repair and regeneration

Tissue repair and regeneration present significant clinical challenges. Despite the array of treatments currently available in this domain, the urgent demand for innovative therapies persists, with the goal of enhancing patient quality of life. Recently, the application of botulinum neurotoxin type A (BoNT/A) has expanded within the realm of tissue repair and regeneration. This review critically examines the utilization of BoNT/A, specifically focusing on its vascular effects, potential in nerve regeneration, and contributions to bone healing. This analysis not only offers fresh insights into the diverse mechanisms of action of BoNT/A but also explores additional therapeutic possibilities for patients.

Systematic review of the histological and functional effects of botulinum toxin A on masticatory muscles: Consideration in dentofacial orthopedics and orthognathic surgery

INTRODUCTION

Botulinum toxin type A causes muscle paralysis and is widely used in the masticatory muscle for stomatognathic diseases, such as temporomandibular disorder, bruxism, or masseteric hypertrophy. Nonetheless, its muscular effect remains unclear. Better understanding could aid improved use and perhaps new indications, particularly in dentofacial orthopaedics and orthognathic surgery.

METHODS

This systematic review explored the histologic and functional effects of botulinum toxin in animal and human masticatory muscles and was conducted in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The MEDLINE, Web of Science, and Cochrane Library electronic databases were searched for relevant articles. The inclusion criteria were human or animal masticatory muscle analysis after botulinum toxin injection(s) AND histological structural/ultrastructural analysis by optical or electronic microscopy OR functional effect analysis by bite force evaluation (occlusal force analyzer) and muscle activity (electromyography).

RESULTS

Of an initial 1578 articles, 44 studies were eventually included. Botulinum toxin injection in the masticatory muscle altered its histological structure and functional properties. The human and animal studies revealed ultrastructural change, atrophy, and fiber type modifications of the masticatory muscles after one injection. Botulinum toxin decreased bite force and muscle activity, but recovery was uncertain.

CONCLUSIONS

Muscle forces applied on the skeleton is a key feature of facial growth. Masticatory muscle paralysis changes mechanical stress on bones, which rebalances the force applied on facial bones. This new balance could benefit dental deformity or surgical relapse. Therefore, botulinum toxin could limit the orthognathic effect of the masticatory muscles in such patients. Given the uncertain recovery, multiple injections should be avoided, and usage should not deviate from established consensus.

Optimizing drug regimens and supplementation in orthognathic surgery: A comprehensive and practical guide

OBJECTIVE

This study aimed to comprehensively review the literature and provide a practical guide for optimizing drug regimens and supplementation related to orthognathic surgery.

METHODS

The authors conducted a thorough review of the existing literature, following the PRISMA-ScR guidelines. Various types of studies except case reports and reviews were included. The study applied specific inclusion criteria, focusing on perioperative and/or postoperative drugs, medications, or supplementation related to orthognathic surgery.

RESULTS

This guide included 78 studies on various medications in orthognathic surgery. It encompasses clinical trials, cohort studies, cross-sectional studies, prospective and retrospective studies. The topics covered include antibiotics, analgesics, corticosteroids, antiemetics, hemostatic agents, local anesthetics, herbal medicine, and botulinum toxin. Pain and edema control involved specific medications, while local anesthesia utilized ropivacaine and bupivacaine. The guide also discusses mineral and vitamin supplementation. The effectiveness of hemostatic agents and antiemetics was highlighted.

CONCLUSION

Pain management, reduced swelling, enhanced wound healing, and faster recovery are among the advantages. In addition to the standard drugs and medications, the inclusion of vitamin and mineral supplements, tranexamic acid, postoperative anesthetic blocks, and preemptive antiemetics is anticipated to offer various benefits in orthognathic surgery, despite the limited available evidence.

Botulinum Toxin Injection into the Digastric Muscle: Current Clinical Use and a Report of Five Cases

The present research aimed to review the clinical applications of botulinum toxin-A (BTX-A) injection into the anterior belly of the digastric muscle (ABDM) and to highlight the potential role of the BTX-A injection into ABDM in preventing postsurgical relapse. Five Class II malocclusion patients who underwent orthognathic surgery received BTX-A injections into both ABDM for the prevention of postoperative relapse. The relapse was evaluated using lateral cephalometric radiographs by comparing the postoperative cephalometric analyses at two different time points, postoperatively at 2 weeks (T1), and long-term, at 9 months after the surgical intervention (T2). The results demonstrated no significant differences between T2 and T1 for the Selle-Nasion-point A (SNA) angle, Selle-Nasion-point B (SNB) angle, point A-Nasion-point B (ANB) angle, mandibular length, and sagittal mandibular position. The patients exhibited stable occlusion without any signs of relapse after the surgery. A single BTX-A injection into the ABDM can effectively prevent postoperative relapse in Class II malocclusion patients, following orthognathic surgery. From a clinical perspective, in case of optimal dosage and procedure, BTX-A injection could be considered as the primary option for the prevention of postsurgical relapse for Class II malocclusion patients.

Nonunion in Orthognathic Surgery: A Case-Series of 15 Patients

BACKGROUND

Bone nonunion is extensively studied in the orthopedic literature, but the knowledge in oral and maxillofacial surgery, specifically orthognathic surgery, is scarce. Since this complication has a significant negative impact on postoperative management of patients, more studies are needed.

PURPOSE

To report the characteristics of patients presenting with bone nonunion after orthognathic surgery.

STUDY DESIGN, SETTING, SAMPLE

This is a retrospective case-series study on subjects who underwent orthognathic surgery between 2011 and 2021 and developed nonunion. Inclusion criteria were mobility at the site of the osteotomy and the need for a second surgical intervention. Exclusion criteria were an incomplete medical chart; the absence of nonunion upon surgical exploration, or radiological evidence of nonunion; cleft lip/palate; or syndromic patients.

MAIN OUTCOME VARIABLE

The outcome variable was bone healing after nonunion care.

COVARIATES

Demographics (age, sex), medical/dental comorbidities, type of surgery (type of fixation, bone grafts, Botox injection), amplitude of movements, nonunion treatment.

ANALYSES

Descriptive statistics were computed for each study variable.

RESULTS

The sample was composed of 15 patients (11 females, mean age 40.4 years old) with nonunion (maxilla: 8 cases, mandible: 7 cases) out of 2036 patients who underwent orthognathic surgery during the period studied (incidence 0.74%). Nine (60%) were bruxers, three were smokers (20%) and one had diabetes. Mean forward movement of the maxilla was 6.55 mm (4-9 mm) and 7.71 mm (4.8-12 mm) for the mandible. All patients but one (who refused surgery) were treated by curettage of fibrous tissue and new hardware placement. In addition, 11 received a bone graft, and 4 had Botox injections. All osteotomies healed after the second surgical intervention.

CONCLUSION

Curettage with or without grafting appears to be a good strategy for the cure of nonunion. Bruxism may be a risk factor (60% of patients were bruxers in this study).

Botulinum toxin as adjunct therapy in surgical management of a periprosthetic scapular spine fracture: a case report

Six months after undergoing reverse shoulder arthroplasty (RSA) a 73-year-old woman sustained a periprosthetic scapular spine fracture following a fall. She was treated with open reduction and internal fixation (ORIF), followed by botulinum toxin injection into the deltoid muscle to temporarily minimize strain at the fracture. Fracture union was achieved by 3 months, with excellent clinical function more than 1 year following fracture fixation and full resolution of deltoid function. Scapular spine fracture following RSA can be treated with ORIF and temporary deltoid paralysis using botulinum toxin in the immediate postoperative period to safely support fracture healing.

Systematic mapping review of orthognathic surgery

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.

Botulinum toxin A in dentistry and orofacial surgery: an evidence-based review - part 1: therapeutic applications

Objective An evidence-based review on the safety and efficacy of botulinum toxin type-A (BoNTA) in orofacial conditions, focusing on the therapeutic applications and role of BoNTA as an adjuvant treatment.Data source and selection Data was collected using PubMed (Medline), Cochrane Library of Systematic Reviews and Cochrane Central Register of Controlled Trials electronic databases. Having satisfied the search parameters, 32 studies for therapeutic applications and 26 for BoNTA as an adjunctive treatment were included. The quality of relevant studies was assessed using the Best Evidence Topics (BETs) Critical Appraisal Tool.Data extraction The highest level of evidence (LOE) behind BoNTA safety and efficacy was for wound healing and scar management in the orofacial surgery context, where BoNTA was presented as an adjunctive modality. Level-I evidence was controversial for temporomandibular disorders and bruxism. However, it showed promising results for painful temporomandibular disorders of myogenic origin refractory to conservative therapies, and to decrease muscle contraction intensity in sleeping bruxism. There was only one level-II study for persistent recurrent aphthous stomatitis. Data showed limited level-III evidence for orofacial pain conditions (temporomandibular joint recurrent dislocation and pain, burning mouth syndrome or atypical odontalgia), oral cancer complications, or as an adjuvant to maxillofacial and orthognathic surgeries. Benefits of BoNTA in prosthodontics had weak level-IV evidence. No evidence was found among the periodontology field.Conclusion There is growing evidence to support the safety and efficacy of BoNTA in the investigated orofacial pathological conditions, with high levels of satisfaction from the patient and clinician perspective. However, there are some inconsistencies and limited high-quality evidence available. Well-designed controlled clinical trials are necessary to evaluate long-term safety, efficacy and cost-effectiveness before BoNTA is widely adopted with irrefutable evidence-based clinical guidelines.

Use of non-surgical aesthetic refinement after orthognathic surgery: Case studies

Orthognathic surgery has an undeniable functional effect, but the aesthetic result must not be disregarded, especially since many patients visit the surgeon precisely because of an aesthetic complaint and ignore the practical benefits. The aim of this paper is to discuss about an ideal treatment that combines this functional improvement with facial aesthetics and improves it after the operation. In order to predict which aesthetic deficits may occur, a facial analysis is essential. As precise as the virtual planning may be, there is still no exact predictability of soft tissue behavior. Some non-surgical procedures can help the surgeon achieve a result that better meets the patients' expectations. Imaging exams, photographs, facial analyzes, and patient complaints are essential to assess the possibility of any postoperative refinement. The entire surgical planning is discussed with the patient; the possibility of refinement must be part of the treatment plan. The surgeon's focus is on the functional correction of the dentofacial deformity, but the aesthetic outcome is essential for the patient. The results of this study suggest that refinement should be part of the treatment plan.

Ultrasound dimensional changes of the anterior belly of the digastric muscle induced by orthognathic surgery and botulinum toxin A injection in Class II malocclusion

OBJECTIVES

The aim of the study is to evaluate the ultrasonographic dimensional changes of the anterior belly of the digastric muscle (ABDM), occurring after intramuscular botulinum toxin A (BTX-A) injection during orthognathic surgery, in a series of five Class II malocclusion patients.

METHODS

All the patients received 20 units of BTX-A, into both ABDM, intraoperatively. The length, width and cross-sectional area (CSA) of the ABDM were ultrasonographically measured at three different time points: T₀ (preoperatively), T₁ (postoperatively at 2 weeks after the surgical intervention), and T₂ (postoperatively at 6-9 months).

RESULTS

A statistically significant higher length of the ABDM was noted postoperatively, at T₁ and T₂ compared to T₀. The patients showed an increased length by 12.2% at 2 weeks postoperatively and continued to increase, reaching 24.6% at 6 months. A decreased width of ABDM by 6.5% at T₁ compared with T₀ was also found.

CONCLUSIONS

Postoperative ultrasound (US) follow-up measurements in patients with Class II malocclusion, orthognathic surgery and intraoperative BTX-A injection in the ABDM, showed dimensional changes of the muscle, with elongation and thinning. The muscular modifications were more pronounced at 6 months postoperatively, indicating consistency and potential benefit of using BTX-A in reducing the risk of surgical relapse. Further data on longer-term follow-up and larger number of cases are necessary.

Classification of the journal category "oral surgery" in the Scopus and the Science Citation Index Expanded: flaws and suggestions

Objectives

The aim of this study was to evaluate the journal category “oral surgery” in Scopus and in the Science Citation Index Expanded (SCIE).

Materials and Methods

The Journal of Oral and Maxillofacial Surgery (JOMS), The Journal of the Korean Association of Oral and Maxillofacial Surgeons (JKAOMS), and The Journal of Prosthodontic Research (JPR) were selected from the Scopus list of journals as oral surgery journals. Maxillofacial Plastic and Reconstructive Surgery (MPRS) was selected from PubMed as a Scopus oral surgery title. From these titles, 10 recently published articles were collected and used for reference analysis.

Results

The percentage of citations from oral surgery journals was 26.7%, 24.5%, and 40.1% for JKAOMS, MPRS, and JOMS, respectively. In total, 1.1% of JPR's citations were from oral surgery journals and significantly fewer from other journals (P<0.001). The percentage of citations from dentistry journals excluding oral surgery journals was 11.9%, 34.4%, and 15.8% for JKAOMS, MPRS, and JOMS, respectively. For JPR, 80.6% of citations were from dentistry journals and significantly more were from other journals (P<0.001).

Conclusion

Selected samples revealed that JPR is incorrectly classified as an oral surgery journal in Scopus. In addition, the scientific interaction among JKAOMS, MPRS, and JOMS was different to JPR in the reference analysis.

[Secondary surgeries for facial osteotomies: 10 cases]

Orthognathic surgery, now well known to the general public, is becoming increasingly successful. It is the most predictable approach to the treatment of dento-maxillo-facial deformities. As with plastic surgery the number of indications increasing the number of difficult cases follows as well as the searching for perfection. The aim of these treatments must be triple and take into account the functional elements of the face, the dental occlusion and the aesthetic objectives of the patient and therapists. Orthognathic surgery procedures having become quite bearable patients who feel that the result is not up to their requirement easily require a reoperation to achieve their objective. PATIENTS AND METHODS: We studied 10 cases of facial redone osteotomies from 4 different surgeons. We looked at the initial indication, the type of surgery, the initial orofacial functions, the delay of the reoperation, the technique of redo and the result. RESULTS AND DISCUSSION: Like other authors, we found that there are surgeries and at-risk patients. The patients who were re-operated all had at least one of the three negative factors: OSAS, lingual dysfunction, oral ventilation. We have not been able to highlight an overall frequency of surgical resumption in the studied literature which is poor about reoperations after osteotomies of the face.

Botulinum toxin A injection into the anterior belly of the digastric muscle increased the posterior width of the maxillary arch in developing rats

Background

The purpose of this study was to evaluate the effects of botulinum toxin A (BTX) injection into the anterior belly of the digastric muscle on a growing rat.

Methods

Ten Sprague Dawley rats were used in this study. When the rats were 13 days old, 0.5 units of BTX was injected into the anterior belly of the digastric muscle for the experimental group (n = 5). For the control, the same volume of normal saline was injected (n = 5). The rats were sacrificed at 60 days old, and the skulls were harvested for micro-computed tomography (μCT) analysis.

Results

In anthropometric analysis, the zygomatic arch and mandibular bi-condylar width were significantly lower in the experimental group than those in the control group (P = 0.025 and 0.027, respectively). The maxillary point width was significantly higher in the experimental group than that in the control group (P = 0.020).

Conclusion

BTX injection into the anterior belly of the digastric muscle had effects on the maxillofacial bony width in growing rats.