Multi-disciplinary treatment of maxillofacial skeletal deformities by orthognathic surgery combined with periodontal phenotype modification:A case report

BACKGROUND Maxillofacial deformities are skeletal discrepancies that cause occlusal,functional,and esthetic problems,and are managed by multi-disciplinary treatment,including careful orthodontic,surgical,and periodontal evaluations.However,thin periodontal phenotype is often overlooked although it affects the therapeutic outcome.Gingival augmentation and periodontal accelerated osteogenic orthodontics(PAOO)can effectively modify the periodontal phenotype and improve treatment outcome.We describe the multi-disciplinary approaches used to manage a case of skeletal ClassⅢmalocclusion and facial asymmetry,with thin periodontal phenotype limiting the correction of deformity.CASE SUMMARY A patient with facial asymmetry and weakness in chewing had been treated with orthodontic camouflage,but the treatment outcome was not satisfactory.After examination,gingiva augmentation and PAOO were performed to increase the volume of both the gingiva and the alveolar bone to allow further tooth movement.After orthodontic decompensation,double-jaw surgery was performed to reposition the maxilla-mandibular complex.Finally,implant placement and chin molding were performed to restore the dentition and to improve the skeletal profile.The appearance and function were significantly improved,and the periodontal tissue remained healthy and stable.CONCLUSION In patients with dentofacial deformities and a thin periodontal phenotype,multi-disciplinary treatment that includes PAOO could be effective,and could improve both the quality and safety of orthodontic-orthognathic therapy.

Orthodontic camouflage versus orthognathic surgery: A comparative analysis of long-term stability and satisfaction in moderate skeletal Class III

Objective: The purpose of this study was to compare long-term stability and satisfaction between orthodontic camouflage and orthognathic surgery in treatment of moderate skeletal Class III adults. Materials and Methods: A total of 25 adults females who had been treated with orthodontic camouflage for Class III malocclusions were recalled at least 3 years post-treatment to evaluate stability and satisfaction with treatment outcomes. The data were compared with similar data for long-term outcomes in 21 patients with the same Class III problems who had bimaxillary surgical correction. Results: In the camouflage patients, small mean changes in skeletal landmark positions occurred over the long term, although the changes were generally much smaller than in the surgery patients. Dental changes in the surgery group were more severe than those in the camouflage group. The camouflage patients reported fewer functional or temporomandibular joint problems than did the surgery patients. Both groups reported similar levels of overall satisfaction with treatment. Conclusion: The results suggest that both camouflage and surgical treatment in moderate skeletal Class III adults can achieve satisfactory outcomes and provide long-term stability. If patients do not readily accept surgery because of potential surgical complications or financial difficulties, camouflage treatment may be an effective alternative treatment.

Comparison of skeletal, dental and soft tissue changes in young adults with Class II malocclusion, treated either by camouflage, fixed functional appliance or orthognathic surgery—A prospective study on Indian subjects

Introduction: Borderline Class II malocclusion due to deficient mandible can be treated either by orthodontic camouflage, fixed functional appliances or by orthodontics followed by surgical mandibular advancement. Methodology: A prospective study was designed on young adults with Class II malocclusion on account of a deficient mandible. A total of 45 subjects were divided into three groups of 15 individuals each. The patients were treated either by camouflage, fixed functional appliances or by orthognathic surgery. Pre and post treatment cephalograms were used to assess the skeletal, dental and soft tissue changes. Pre and post treatment profile photographs were assessed on a Visual Analogue Scale (VAS) by orthodontists, oral surgeons and laypersons. Results: Each group achieved a reduction in facial convexity, but the results obtained from the surgical group were more pronounced than the camouflage and the fixed functional group. Conclusion: The reduction in convexity in the camouflage group was by retracting the upper anteriors, which increases the nasolabial angle. In the fixed functional appliance a combination of skeletal and dentoalveolar changes can be observed. However the most appropriate reduction in profile convexity can be obtained by combined orthodontic and surgical treatment of malocclusion.

Orthognathic Surgery Combined with Partial Lipectomy of the Buccal Fat Pad： Case Report on Optimization of Esthetic Outcome

Orthognathic surgery involves correction of functional and often esthetic disharmonies. The purpose of this case report is topresent the case of a 22 years-old female with class III dentofacial deformity that required orthognathic surgery to treat hermalocclusion and buccal fat pad excision for optimizing soft-tissue facial contour. Treatment planning involved a counterclockwiserotation of the maxilomandibular complex with genioplasty based on digital 3D surgical planning using the Dolphin Imaging 11.7 3DPremium software. Prototyping splints allowed surgical procedures （bilateral sagital mandibular osteotomy associated to a Le fort Iosteotomy） that corrected position of the gnathic bones. In the same surgical procedure, the buccal fat pad was partially removed for asharp cheek contour giving a slimmer appearance to her face. After 5 months, the patient was reassessed and reported no complaintsregarding esthetics or function. This case illustrates that a combination oforthognathic surgery and an esthetic procedure can result in astable and harmonious facial as well as occlusal outcomes.

A Retrospective Study on Wire Fixation andRigid Internal Fixation in Orthognathic Surgery

Histories of 100 patients undergoing orthognathic surgery either with firation (WF) or rigid internal fixation (RIF)were reviewed in respect to complications and incidences of unforeseen events during and after operation. No obvious difference in complication was found between these two kinds of fixations. However, marked differences occurred 6 monthes later in (1) rates of loss of body weight (more than 10kg) and (2) persistent restriction of mandibular opening (incisal opening less than 35 mm). The two rates in WF group are 30% and 24% and in RIF group. 8%and 4% respectively The results demonstrate that early post-operative mobility of is helpful in rehabilitation of masticatory and movement of temporal mandibular joints(TMJ). Therefore RIF is recommended.

Major Approaches on the Piezoelectric Device, Drills and Saws to Orthognathic Surgery: A Systematic Review

Introduction: The incidence of lesions of sensory and motor nerves associated with oral and maxillofacial surgery is often underestimated, representing around 32.0% of all lesions, and orthognathic surgery contributes 12.3% to these lesions. Thus, the use of piezosurgery (PiZCi) has been indicated in several procedures within oral and maxillofacial surgery due to a number of advantages over conventional drill and saw techniques. Objective: to analyze the main literature on the use of the piezoelectric device in relation to the use of drills and to orthognathic surgery in dentistry. Methods: A total of 41 articles were found involving Orthognathic Surgery, Piezoelectric Device, Drills Device, Saws Device, and Efficiency. Initially, it was held the exclusion existing title and duplications following the interest described this work. After this process, the summaries were evaluated, and a new exclusion was held. 29 articles were included and discussed in this study. Initially, the keywords were determined by searching the DeCS tool (Descriptors in Health Sciences, BIREME base) and later verified and validated by MeSh system (Medical Subject Headings, the US National Library of Medicine). Results and conclusion: It was concluded that the piezoelectric device has excelled with an effective surgical technique, being able to be indicated in the most diverse areas of the oral surgery, providing accurate, clean and minimally traumatic osteotomies for the soft tissues, intraoperative bleeding, when compared to conventional surgery using drills and/or saws.

ELECTROMYOGRAPHIC CHANGES BEFORE AND AFTER ORTHOGNATHIC SURGERY

Objective To improve the lunctional occiusion afer orthognathic operation, the contractiiities of masseter, temporalis and digastric muscles were studied before and after surgery. Methods By means of integrated electromyogram (EMG), bioelectric potentials and EMG activities of these 3 muscles were recorded. ResuIts Signilicant decreases in bioelectric potentials and EMG activities belore and after surgery were observed in working muscles. No doflerence was noted in resting muscles. ConcIusion Postoperative malocclusion necessitates postoperative orthodontic treatment.

Parathyroid Hormone: Is It Really the Cause for Increased Tooth Mobility after Orthognathic Surgery?

Introduction: Following orthognathic surgery, increased tooth mobility is observed clinically and is utilized for postsurgical orthodontic tooth movement. It was suggested that the increase may result from a surgery-associated alteration of parathyroid hormone (PTH) and calcium metabolism. Materials and Methods: 30 young adult patients were divided into a mandibular osteotomy group (Group A, n = 20) and an untreated control group (Group B, n = 10). Tooth mobility was evaluated using the Periotest device. Tooth mobility, serum PTH and calcium levels were determined repeatedly for both groups. Results: The tooth mobility was increased significantly in the Group A patients in the first 10 days post-surgery. All serum PTH and calcium mean levels were within normal ranges. No significant differences were found between the measurements of both groups. The serum calcium levels recorded at the 1st post-surgery day were slightly lower in the operated patients compared to the control group. Conclusion: It can be concluded that the increased facility of orthodontic tooth movement immediately post-surgery was confirmed by Periotest measurements, while no association was found with surgery-related altered levels of PTH and calcium. Since dietary effects can be ruled out, the increase of clinical tooth mobility may rather result from preoperative orthodontic forces and/or the post-surgical elimination of masticatory muscular influences.

Orthognathic Surgery for Achieving Facial Balance and Harmony in Cleft Patients

Cleft surgery requires an expert team performing ongoing treatment in order to achieve optimal outcomes. The senior author's(KES) experiences of more than 2000 patients with cleft lip and palate treated by a surgical-orthodontic protocol were introduced. The paper here will concentrate on not only correcting the occlusion as others have described,but also on what one surgeon can do to achieve optimal aesthetic balance, harmony and beauty. The results of orthognathic surgery in respect to function, stability, cosmesis, and complications are also audited.

Pneumomediastinum after Orthognathic Surgery: Case Report and Review of the Literature

Orthognathic surgery in general addresses young patients and aims to improve their bite function and to harmonize their facial aesthetics. Secure surgical standards and a defined post-surgical protocol of after-care are indispensable to reduce surgical as well as anaesthesiological risks in this area of complex elective surgery. The development of pneumomediastinum is a rare incident but threatens the patients’ physical integrity. The case of a young healthy male who underwent Le Fort I osteotomy in combination with bilateral mandibular sagittal split osteotomy and postoperatively developed pneumomediastinum is presented, together with a discussion of the possible reasons for this rare complication of orthognathic surgery. The avoidance of life-threatening coincidences must be one main focus in the preparation and aftercare in elective orthognathic surgery.

Orthodontic-surgical treatment for severe skeletal class Ⅱ malocclusion with vertical maxillary excess and four premolars extraction: A case report

BACKGROUND Patient satisfaction with facial appearance at the end of orthodontic camouflage treatment is very important, especially for skeletal malocclusion. This case report highlights the importance of the treatment plan for a patient initially treated with four-premolar-extraction camouflage, despite indications for orthognathic surgery.CASE SUMMARY A 23-year-old male sought treatment complaining about his unsatisfactory facial appearance. His maxillary first premolars and mandibular second premolars had been extracted, and a fixed appliance had been used to retract his anterior teeth for two years without improvement. He had a convex profile, a gummy smile, lip incompetence, inadequate maxillary incisor inclination, and almost a class I molar relationship. Cephalometric analysis showed severe skeletal class Ⅱ malocclusion(A point-nasion-B point = 11.5°) with a retrognathic mandible(sella-nasion-B point = 75.9°), a protruded maxilla(sella-nasion-A point = 87.4°), and vertical maxillary excess(upper incisor to palatal plane = 33.2 mm). The excessive lingual inclination of the maxillary incisors(upper incisor to nasion-A point line =-5.5°)was due to previous treatment attempts to compensate for the skeletal class Ⅱ malocclusion. The patient was successfully retreated with decompensating orthodontic treatment combined with orthognathic surgery. The maxillary incisors were repositioned and proclined in the alveolar bone, the overjet was increased, and a space was created for orthognathic surgery, including maxillary impaction, anterior maxillary back-setting, and bilateral sagittal split ramus osteotomy to correct his skeletal anteroposterior discrepancy. Gingival display was reduced, and lip competence was restored. In addition, the results remained stable after 2 years. The patient was satisfied with his new profile as well as with the functional malocclusion at the end of treatment.CONCLUSION This case report provides orthodontists a good example of how to treat an adult with severe skeletal class Ⅱ malocclusion with vertical maxillary excess after an unsatisfactory orthodontic camouflage treatment. Orthodontic and orthognathic treatment can significantly correct a patient’s facial appearance.

Applications of stem cells in orthodontics and dentofacial orthopedics:Current trends and future perspectives

A simple overview of daily orthodontic practice involves use of brackets, wires and elastomeric modules. However, investigating the underlying effect of orthodontic forces shows various molecular and cellular changes. Also, orthodontics is in close relation with dentofacial orthopedics which involves bone regeneration. In this review current and future applications of stem cells(SCs) in orthodontics and dentofacial orthopedics have been discussed. For craniofacial anomalies, SCs have been applied to regenerate hard tissue(such as treatment of alveolar cleft) and soft tissue(such as treatment of hemifacial macrosomia). Several attempts have been done to reconstruct impaired temporomandibular joint. Also, SCs with or without bone scaffolds and growth factors have been used to regenerate bone following distraction osteogenesis of mandibular bone or maxillary expansion. Current evidence shows that SCs also have potential to be used to regenerate infrabony alveolar defects and move the teeth into regenerated areas. Future application of SCs in orthodontics could involve accelerating tooth movement, regenerating resorbed roots and expanding tooth movement limitations. However, evidence supporting these roles is weak and further studies are required to evaluate the possibility of these ideas.

Surgery-first for a patient with mild hemifacial microsomia: A case report and review of literature

BACKGROUND Hemifacial microsomia(HFM)is the second most common craniofacial congenital anomaly following cleft lip and palate.Because of the various phenotypic spectra and the severity of the deformity,a wide range of treatment approaches have been proposed.Recently,the surgery-first approach(SFA)was introduced to treat mild to moderate HFM,and it yielded a balanced facial appearance.The SFA not only promotes rapid improvement in facial aesthetics but also considerably reduces the overall treatment time.CASE SUMMARY A female patient,aged 25 years old,sought orthodontic treatment with the chief complaint of dental and facial asymmetry.After a comprehensive physical examination and imaging analysis were performed,the patient was diagnosed with mild HFM that was primarily attributed to unilateral abnormal development of the maxilla-mandibular.The SFA was carried out to correct the skeletal deformity.The palatal suture was used as the midline of the maxilla in the surgical plan to center the maxilla,and the chin was also properly positioned to obtain a relatively symmetrical facial appearance.Four weeks after the surgery,the patient was referred for postsurgical orthodontics to decompensate the dentition and stabilize the occlusion.After 20 mo of treatment,all orthodontic appliances were removed.The posttreatment photographs of the patient and her smile confirmed good aesthetic and occlusal results.CONCLUSION Mild HFM can be corrected by SFA,which not only promotes rapid improvement in facial aesthetics but also considerably reduces the overall treatment time.

Surgical Manipulation of the Occlusal Plane in Class III Deformities: 5 Features to Help Planning

Class III malocclusion is one of the most common deformities that requires correction through orthodontic-surgical treatment. These patients present different facial patterns depending on the occlusal plane angulation. These patients may benefit from surgical manipulation of the occlusal plane, because only bite correction does not always lead to the improvement of the facial deformity. The purpose of this paper is to show the surgical manipulation of the occlusal plane in Class III patients based on five features: 1) facial type, 2) upper incisor display at rest, 3) dental exposure during smile, 4) soft tissue support, and 5) chin projection. The surgical manipulation of the occlusal plane can improve the esthetic outcome in the treatment of class III deformities, and careful evaluation of the five features described could be a helpful planning method.

A Finite Element Analysis Study Comparing 3 Internal Fixation Techniques in Mandibular Sagittal Split Osteotomy

Purpose: To analyse, and compare using finite element analysis, the biomechanical properties of the 1.7 mm miniplate fixation against 2 conventional fixation techniques (2.0 mm bi-cortical screws and 2.0 mm miniplate) used in the mandibular sagittal split osteotomy. Methods: A 3-D virtual mandible model was constructed using images from CT scan. Sagittal split osteotomy was carried out virtually, and the fixation techniques were applied onto the model. 9 virtual models consisted of the 3 fixation techniques with mandibular movements of 3 mm setback, 3 mm advancement and 7 mm advancement were developed. Bite forces of 50, 75 and 100 N were applied for incisor bite simulation and 100, 200 and 300 N for molar biting force. Finite element analysis was carried out in Solidworks, and readings of stresses and displacement were recorded. Wilcoxon rank sum test was applied and P-value of 0.05 was set for statistical analysis. Results: In this manuscript the authors have compared 3 internal fixation techniques in mandibular sagittal split osteotomy. There was a statistically significant difference for both stress and displacement readings between the 1.7 mm miniplate, the 2.0 mm bi-cortical screws and the 2.0 mm miniplate for all mandibular movements. For the 1.7 mm miniplate vs 2.0 mm bi-cortical screws, the stress reading was (P = 3.063e-08, W = 314), and for displacement was (P = 5.811e-05, W = 282). For the 1.7 mm miniplate vs 2.0 mm miniplate, the stress reading was (P = 9.862e-4, W = 263) and for displacement was (2.05e-2, W = 235). Conclusion: The 1.7 mm miniplate has adequate strength to be used in mandibular sagittal split osteotomy, although statistically less rigid when compared to the conventional 2.0 mm miniplate and 2.0 mm bi-cortical screws, especially in larger movements.