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A 32-year-old white man presented for orthodontic treatment with the chief complaint of mandibular prognathism; he was later found to have acromegaly. General information about pituitary adenomas, specifically growth hormone adenomas, is given, and treatment options are discussed.
This paper is concerned with a three-dimensional (3D) analysis on soft and hard tissue changes after mandibular setback surgery. For comparing with previous two-dimensional (2D) cephalometric data, we proposed a three-dimensional registration and analysis method based on the cephalometric knowledge. The 3D changes of bone, soft tissue and the ratio of soft tissue to bony movement were investigated in eight skeletal class III mandibular prognathism patients. CT scans of each patient were taken at pre- and post-operative states. Each scan was registered to a universal 3D coordinate system defined by cephalometric landmarks. A grid, parallel to the coronal plane, was also designed for the comparison of the changes. The bone and soft tissue was intersected by the projected line from each point on the grid. The coordinate values of intersected point were measured and compared between the pre- and post-operative models. In addition, the reproducibility of the universal coordinate system and the grid was evaluated. The facial surface changes after setback surgery occurred not only in the mandible but also in the mouth corner region. The soft tissue changes of the mandible were measured relatively by the proportional ratios to the bone changes. The ratios at the mid-sagittal plane were 77-102% (p<0.05). The ratios at all other sagittal planes had similar patterns to the mid-sagittal plane with decreased values. All the results conformed to the previous 2D based clinical knowledge and instinct of orthodontists. It is expected that the proposed approach would be applicable to other oral and maxillofacial surgeries as well as plastic surgeries.
The aim of this study was to investigate the position and course of the mandibular canal through the mandibular ramus using computed tomographic (CT) imaging and to relate the findings to performing sagittal split ramus osteotomies. The mandibles of 35 patients with skeletal Class III prognathism with symmetry (12 males and 23 females) were observed on transaxial computed tomograms acquired with a slice thickness of 2 mm. The position and course of the mandibular canal from the mandibular foramen to the mandibular body at the level of the second molar were measured at four specific locations in the same plane. Among the 70 rami examined, lack of a bone marrow space on the buccal side, including a fusion type anatomy with no buccal side cortical bone of the mandibular canal, were observed at the CT location between the mandibular foramen and mandibular angle. Our results suggest that special care must be taken when sagittal splitting is performed, and the safest location for the buccal corticotomy is anterior to the mandibular angle.
This study was designed to assess skeletal stability after bilateral sagittal split ramus osteotomy (BSSO) and fixation with a poly-l-lactic acid (PLLA) plate, as compared to that after BSSO and fixation with a titanium plate, and to analyze the change in the condylar long axis after these procedures. The study group comprised 40 patients who had mandibular prognathism (20, titanium group; 20, PLLA group). The groups were randomized to show similar distributions of preoperative SNB. All patients underwent BSSO setback by the Obwegeser method. Fixation was done with bent titanium plates or bent PLLA plates, applied in a similar manner. Lateral, frontal, and submental-vertical cephalograms were analyzed preoperatively and postoperatively. The maximum mouth opening range and the incidence of temporomandibular disorders were also evaluated. There was no significant difference in the right condylar angle or width between the two groups, but the left condylar angle and width, gonial angle, and ramus inclination differed significantly between them (P<0.05). SNA, SNB, and ANB were similar in both groups. There was no significant difference between the groups in maximum mouth opening range or temporomandibular disorders. We conclude that the change in condylar angle after BSSO and fixation with a titanium plate is greater than that after BSSO and fixation with a PLLA plate, but skeletal stability related to the occlusion is similar for the two procedures.
The purpose of this study was to evaluate hypoesthesia of the lower lip using trigeminal somatosensory-evoked potential following 2 types of sagittal split ramus osteotomy (SSRO) and intraoral vertical ramus osteotomy (IVRO). There were 30 patients with mandibular prognathism, with and without asymmetry, who were divided into three groups: the Obwegeser method (Ob) group, the Obwegeser-Dal Pont method (ODP) group and the intraoral vertical ramus osteotomy (IVRO) group. The trigeminal somatosensory-evoked potential was recorded in the region of the lower lip and evaluated preoperatively and postoperatively. The average recovery periods from lower lip hypoesthesia in the IVRO and the Ob group were significantly shorter than in the ODP group (P<0.05). In conclusion, IVRO showed the earliest recovery from hypoesthesia or an absence of hypoesthesia, and lower lip hypoesthesia was less with the Ob method than the ODP method.
PURPOSE: The purpose of this study was to evaluate the advantageous use of an ultrasonic bone curette and to assess the mobilization of the pterygoid process after a Le Fort I osteotomy. MATERIAL AND METHODS: 14 Japanese adults (ranging in age from 17 to 30 years, mean 22.4) with jaw deformities diagnosed as mandibular prognathism or bimaxillary asymmetry underwent Le Fort I osteotomy with bilateral sagittal split ramus osteotomy or intraoral vertical ramus osteotomy. During the Le Fort I osteotomy, the Sonopet UST-2000 ultrasonic bone curette was used to fracture the pterygoid process slightly above the level of the maxillary osteotomy without damaging the descending palatine artery or other blood vessels and nerves. After surgery, the pterygoid process osteotomy and its mobility were evaluated from three-dimensional computed tomographic images. RESULTS: In all cases, the mobility of the pterygoid process could be achieved by using the device safely with minimal bleeding and no notable complications. The maxillary segment could be fixed in an ideal position and in all 14 cases, an ideal profile was achieved. CONCLUSION: Ultrasonic bone curette offers a safe procedure for performing pterygoid process fractures without damaging the surrounding tissue such as the descending palatine artery.
PURPOSE: The benefits of minimally invasive surgery have been well documented. The purpose of this report was to present early results in a series of patients who had endoscopic mandibular orthognathic surgery. Patients and methods This is a retrospective evaluation of 14 patients who underwent endoscopic vertical ramus osteotomy and rigid fixation for the treatment of mandibular prognathism (n = 9), malocclusion secondary to trauma (n = 3), or other pathology (n = 2). A 1.5-cm incision was made directly below the mandibular angle. The dissection was continued bluntly to the masseter muscle, which was incised using a needlepoint electrocautery. Then, with endoscopic elevators, an optical cavity was created for insertion of a Hopkins endoscope and visualization of the ramus/condyle unit. Anatomic landmarks were identified and the operation carried out with specially designed endoscopic equipment. Preoperative (T0), postoperative (T1), and follow-up (T2) clinical examinations; lateral cephalograms; and panoramic radiographs were used to evaluate the outcomes. RESULTS: The procedures performed included: vertical ramus osteotomy (n = 13 patients, 23 sides) and condylectomy plus vertical ramus osteotomy (n = 1 patient, 1 side). Mean operating time was 37 minutes per side. One patient had temporary marginal mandibular nerve weakness. The occlusal result was as planned in all cases. Panoramic radiographs documented postoperative ramus/condyle unit position and lateral cephalograms documented mandibular position. CONCLUSIONS: The results of this case series indicate that endoscopic vertical ramus osteotomy with rigid fixation is feasible for correction of a variety of mandibular deformities.
PURPOSE: It is difficult to predict the need for blood transfusion during orthognathic surgery. The purpose of this study was to evaluate differences between patients who underwent different orthognathic procedures, and to assess the need for transfusion in orthognathic surgery. SUBJECTS AND METHODS: We examined 62 prognathic patients who underwent orthognathic surgery in our hospital. The subjects were divided into 4 groups according to procedure. Pre- and postoperative values of blood parameters were evaluated statistically. RESULTS: A greater amount of blood was lost in the double-jaw surgeries than in the single-jaw surgeries. There was a significant difference between sagittal split ramus osteotomy (SSRO) combined with Le Fort I osteotomy and intraoral vertical ramus osteotomy (IVRO) ( P < .05). However, none of the patients required transfusion intraoperatively. In all groups except the IVRO group, there were significant differences in red blood cell count, hemoglobin, and hematocrit between preoperative values and 1 week postoperative values ( P < .05). Although the values of red blood cell, hemoglobin, and hematocrit tended to decrease until 2 weeks postoperative, no complications occurred. Simple regression analysis showed significant positive correlation between duration of operation and blood loss ( P < .05). CONCLUSION: The present results indicate that there is little risk of marked bleeding in routine procedures, and that IVRO causes minimal bleeding. Transfusion was not necessary in IVRO or SSRO with or without Le Fort I osteotomy.
A patient suffering from classical hemophilia had previous surgery for ankylosis of the right temporomandibular joint. This was replaced by a costochondral graft and an overlay of temporalis muscle. A bilateral sagittal split was performed for a micrognathic mandible and a sleep apnea problem. That procedure solved the sleep apnea; however, it resulted in a prognathic mandible and an anterior open bite. The lower anterior teeth were periodontally involved with impaired alveolar support. The restricted opening of the oral cavity of 18 mm between maxillary and mandibular centrals and the potential danger of bleeding complicated the surgical and restorative procedures. The patient was prepared medically on each of 4 occasions with factor VIII replacement concentrate, and oral antifibrinolytic therapy (tranexamic acid). The treatment of choice was the extraction of the remaining lower incisors and their replacement with an implant-supported temporarily cemented retrievable fixed prosthesis. Serial extractions and chairside temporization provided the surgeon with precise guides for implant placement, and enabled the patient to enjoy unimpaired function through periods of healing and osseointegration.
BACKGROUND: It was previously reported that both pro- and anti-inflammatory cytokines are elevated in systemic inflammatory response syndrome (SIRS). Cytokine-mediated systemic neutrophil activation is a direct consequence of SIRS, and can lead to multiple organ dysfunction syndrome (MODS). This prospective study assessed the risk of SIRS and MODS after orthognathic surgery by measuring the circulating levels of inflammatory cytokines such as IL-6 and IL-10 as well as the neutrophil functions as a marker of organ failure. MATERIALS AND METHODS: Blood samples for the measurement of IL-6, IL-10, CRP, neutrophil counts, and neutrophil function were drawn from 21 patients with mandibular prognathism at 2 days before, and at 1 and 3 days after orthognathic surgery. The neutrophil function was estimated by superoxide production and elastase release under the stimulation of FMLP. RESULTS: Eight of the 21 patients were applicable to SIRS criteria 1 day postoperatively, and all of the subjects were excluded from SIRS criteria 3 days postoperatively. Although IL-6 and IL-10 levels were raised 1 day postoperatively, increased cytokine concentrations were decreased in most patients at 3 days postoperatively. The IL-6 concentration and the ratio of IL-6 to IL-10 were higher in the SIRS-matched group compared with the non-SIRS-matched group. Neutrophil priming for superoxide production and elastase release was discovered 1 day after orthognathic surgery, and differences in those values could not be distinguished between the groups. CONCLUSIONS: These results suggest that a few patients in whom high levels of circulating inflammatory cytokine and neutrophil-derived toxic factor continue may have a possibility of contracting severe diseases such as SIRS and MODS after orthognathic surgery. We conclude that the ratio of IL-6 to IL-10 may be a predictive factor in SIRS.
OBJECTIVE: This study was performed to compare the condylar position and angulation on 3-dimensional (3D) views between greater setback side (GSS) and lesser setback side (LSS) after asymmetric mandibular setback (AMS) using computed tomography. STUDY DESIGN: The sample consisted of 12 Korean skeletal class III malocclusion patients with mandibular prognathism and facial asymmetry, who underwent sagittal split ramus osteotomy (SSRO) with rigid fixation. Tomographs were taken 1 month before (T1) and 6 months after surgery (T2). Position and angulation of the condyles were measured. RESULTS: At T1 stage, the condylar head in GSS showed more forward inclination on the sagittal view (P < .05) than that of LSS. Although there were significant inward and backward rotations of the condylar head in GSS (P < .01) and significant backward rotation in LSS at T2 stage (P < .05), 3D positions of the condyle in GSS and LSS were not changed after AMS. CONCLUSION: SSRO might be effective to stabilize the condylar position for AMS.
This study determines deformations that contribute to a Class III mandibular morphology, employing thin-plate spline (TPS) analysis. A total of 133 lateral cephalographs of prepubertal children of European-American descent with either a Class I molar occlusion or a Class III malocclusion were compared. The cephalographs were traced and checked, and eight homologous landmarks on the mandible were identified and digitized. The datasets were scaled to an equivalent size and subjected to statistical analyses. These tests indicated significant differences between average Class I and Class III mandibular morphologies. When the sample was subdivided into seven age and sex-matched groups statistical differences were maintained for each group. TPS analysis indicated that both affine (uniform) and non-affine transformations contribute towards the total spline, and towards the average mandibular morphology at each age group. For non-affine transformations, partial warp 5 had the highest magnitude, indicating large-scale deformations of the mandibular configuration between articulare and pogonion. In contrast, partial warp 1 indicated localized shape changes in the mandibular symphyseal region. It is concluded that large spatial-scale deformations affect the body of the mandible, in combination with localized distortions further anteriorly. These deformations may represent a developmental elongation of the mandibular corpus antero-posteriorly that, allied with symphyseal changes, leads to the appearance of a Class III prognathic mandibular profile.
Twenty-three families with X-linked mental retardation were examined for the presence of a fragil site on the long arm of the X chromosome (Xq27 fra). Specific culture media were necessary to demonstrate this site. In only seven of the families was the Xq fragile site observed; in these, all of the affected males had both the fragile X and macro-orchidism. Macro-orchidism was not observed in the remaining 16 families. In the families with Xq27 fra segregating the fraes. This correlated with the age of the carrier. The 25 affected males with macro-orchidism and Xq27 fra had some minor clinical features in common: there was an increase in birth weight, high forehead, prognathism, pale irides, big ears, and an increased head circumference in infancy and childhood which did not persist into adult life. The majority of the affected individuals were moderately retarded.
PURPOSE: This investigation studied the changes in temporomandibular joint function and condylar position after mandibular setback using different ramus osteotomies. PATIENTS AND METHODS: The sample consisted of 50 Chinese adults with mandibular prognathism. Twenty-eight of the patients underwent intraoral oblique ramus osteotomy (IORO), and 22 received sagittal split ramus osteotomy (SSRO) with rigid internal fixation (RIF). TMJ symptoms and radiographic findings were evaluated preoperatively and postoperatively. RESULTS: After surgery in the IORO group, the TMJ radiographs showed a significant anterior-inferior displacement of the condyle. Seventy-five percent of the preoperatively symptomatic patients reported fewer or no TMJ symptoms and no preoperatively asymptomatic patients developed new TMJ symptoms. In the SSRO group, the TMJ radiographs showed a posterior displacement of the condyle. Sixty percent of the preoperatively symptomatic patients had no improved TMJ function and 8% of asymptomatic patients developed TMJ symptoms after surgery. CONCLUSION: The results of this study show that IORO with MMF appears to be more favorable to the TMJ than the SSRO with RIF; IORO is particularly good in orthognathic surgery patients with preoperative TMJ symptoms.
PURPOSE: We sought to assess the relationship of the inferior alveolar nerve to the osteotomy site after bilateral sagittal split osteotomy (BSSO) and to correlate the nerve osteotomy relationship as the cause of long-term postoperative hypesthesia. PATIENTS AND METHODS: The subjects consisted of 28 patients with mandibular prognathism who underwent BSSO setback surgery. The distance between the ostectomized surface of the mandibular ramus and mandibular canal was measured and scored on a computed tomograph (CT). The relationship between this distance and the presence and degree or absence of trigeminal nerve hypesthesia was objectively evaluated by latency delay of the trigeminal somatosensory evoked potential (TSEP) records. RESULTS: Five of the 56 sides (8.9%) showed latency delays more than 1 year after the operations. Scored CT points between the canal and the split surface strongly correlated with TSEP latency recovery (Y = 1.716X + 41.2). CONCLUSIONS: This relationship between the canal and the osteotomy site is related to long-term hypesthesia in BSSO postoperatively.
The results of a national survey pertaining to the IVSO are presented and the findings are contrasted with the literature on the procedure. It was found that the IVSO is a popular procedure for mandibular setback, that the value of determining the mandibular divergence angle is equivocal, that the Stryker oscillating saw is the most popular instrument for performing the osteotomy, that most operators leave the segments unfixed, and that the intraoral approach to the correction of mandibular prognathism is preferred. There were no geographic trends noted.
In endeavoring to find a comprehensive method providing good treatment results in cases of mandibular prognathism, retrognathism and laterognathism, the sagittal splitting technique has been on trial in the Department of Oral Surgery in Boden since 1972. Experience gained from the first 12 operated cases is discussed from a clinical viewpoint. After a control period of 24-36 months, it was found that this method is to be preferred to that previously used in the Department, horizontal ramus osteotomy.
In order to quantify the blood flow conditions of the mobilized anterior maxillary fragment after an operation to correct severe maxillary prognathism, maxillary blood flow measurements were carried out using the washout of the inert, radioactive tracer. Xenon-133. It shows that post-operative blood flow is not decreased.