Interpositional arthroplasty using autogenous costal cartilage graft for temporomandibular joint ankylosis in adults

This retrospective study evaluated 11 adult patients with TMJ ankylosis treated by interpositional arthroplasty using autogenous costal cartilage grafts between 1985 and 2003. Minimum follow-up was 2 years. Basic personal data, function of TMJ and complications of operation were recorded. Mouth opening increased during operation by a mean of 25.5mm and postoperatively by a mean of 26.2mm. The procedure failed in one case with recurrent ankylosis. The remaining 10 cases had final opening ranges in excess of 30mm. Complications included one numb lower lip. There were no instances of a facial nerve or internal maxillary artery injury. Consideration is given to the width and level of gap arthroplasty, fixation of the grafts, complications at both donor and recipient sites, postoperative physical therapy, occlusal change, and the need for coronoidectomy. This study demonstrated that autogenous costal cartilage is a suitable material for interpositional arthroplasty in adults. Complications were low. The intraoral approach and the role of postoperative physical therapy appear key elements in the success of this procedure.     

Effects of wire and miniplate fixation on mandibular stability and TMJ symptoms following orthognathic surgery

The effects of wire and miniplate fixations on mandibular stability and temporomandibular joint (TMJ) symptoms were analyzed in 145 patients in whom mandibular prognathism had been corrected by the bilateral sagittal split osteotomy (BSSO). The subjects were divided into two groups based on the method of fixation. Group I consisted of 105 patients treated with intraosseous wiring and group II consisted of 40 patients treated with titanium miniplates. The mean maxillomandibular fixation periods for groups I and II were 48 days and 23 days, respectively. Lateral cephalograms were taken immediately before surgery, within a week after surgery, and at least a year after surgery. Changes in the positions of the incisal edge of the lower central incisors, point B, pogonion, and menton were examined. TMJs were examined clinically for pain, sounds, movements, and limitations before treatment and at least a year after surgery. In both groups, the mean of the horizontal relapses was correlated to the magnitude of their surgical movements. In group II, the mean horizontal relapse was smaller, but not significantly more than that of group I. There was no statistical difference in the pre‐ and postoperative incidence of TMJ signs and symptoms between the two groups. It can be concluded that miniplate fixation for the BSSO procedure has the advantages of shortening the maxillomandibular fixation period and maintaining the postoperative stability of the mandible without causing adverse effects on the TMJ.     

Surgical orthodontic correction of mandibular deficiency by sagittal osteotomy: Clinical and cephalometric analysis of 1-year data

A homogeneous sample of 76 mandibular retrognathic patients (mean age, 28 years) were examined for postoperative alterations after surgical treatment by bilateral sagittal split osteotomy and mandibular advancement with wire fixation. Skeletal and dental measures were obtained from preoperative, immediate postoperative, fixation-release, and 1-year cephalograms. Spearman correlation was used as a preliminary analysis to assess the relationship between postsurgical change and age, genioplasty, amount of mandibular advancement, and preoperative mandibular plane angle. Genioplasty and amount of mandibular advancement were included as independent factors in the subsequent repeated-measures analysis of variance, since these were the only two factors that showed a consistent trend of correlations with postoperative change. Genioplasty was a significant factor in the X and Y coordinate changes in pogonion, while the amount of mandibular advancement was a significant factor in the X coordinate movements of all mandibular landmarks except gonion and condylion. The mean amount of horizontal advancement was 5.2 mm, and anterior face height increased 5.1 mm. During fixation, B point moved posteriorly (x = -1.6 mm, p less than 0.01) and inferiorly (y = 1.0 mm, p less than 0.01). After fixation release, these trends were reversed, resulting in a nonsignificant net horizontal change (x = -0.5 mm, p = 0.10) and a significant net superior movement (y = -1.3 mm, p = 0.01) by 1 year. Pogonion, menton, and mandibular incisor tip showed similar patterns.(ABSTRACT TRUNCATED AT 250 WORDS)     

Outcome of early rigid fixation and removal of rigid external distraction system after distraction osteogenesis of the midface

After distraction osteogenesis of the midface using a rigid external distraction (RED) system, there is a high possibility that a relapse might occur due to an incomplete fixation during the consolidation period, and it is uncomfortable for the patients to wear a head frame for 2 to 3 months. There are also risks of trauma that are developing. To overcome these problems, we suggest the protocol of early rigid fixation, with excellent treatment outcomes and a review of literatures. Of 9 patients, Le Fort III osteotomy was completed in 2 patients with Crouzon disease, and a Le Fort I osteotomy was completed in 7 patients with a cleft lip and palate. Immediately after the distraction with RED was completed, the fixation was done using a miniplate. This was followed by the early removal of the RED system. In patients who underwent the current procedure, an analysis was performed for the degree and the duration of distraction and the period of use of the RED system. Then, the presence of relapse was examined. The mean degree of bone distraction was found to be 18.05 mm (range, 9-31.5 mm). The mean period of wearing RED system was 29.78 days (range, 21-43 days). Thereafter, the mean follow-up period was 13 months (range, 6 months to 3 years). The degree of accumulated relapse was found to be 1.7 mm (10%) on postoperative year 1, 2.4 mm (13.3%) on postoperative year 2, and 2.3 mm (14.6%) on postoperative year 3. With the concept of early rigid fixation, we were able to eliminate the disadvantages of distraction osteogenesis such as the long period of wearing a head frame, the delay of returning to society, and the inconvenience of patients. Moreover, early rigid fixation could decrease the need of overcorrection and the amount of relapses.     

Lag screw versus wire osteosynthesis in mandibular advancement.

The records of two homogeneous groups of mandibular advancement patients were selected from the 1961 to 1985 files of the Department of Maxillofacial Surgery, University of Zurich. The groups were differentiated by the osteosynthesis technique: lag screw or wire. The preoperative, short-term postoperative, and 1-year postoperative lateral cephalograms of both groups were subjected to the same digitizing procedure and statistical analysis. The mean sagittal relapse of 11% in the rigid osteosynthesis group was not statistically significant, whereas the wire fixation group experienced mean regression of 45% at pogonion after 1 year.     

Intraoral maxillary quadrangular Le Fort II osteotomy: a long-term follow-up study.

PURPOSE: This study evaluated the clinical outcome and skeletal stability of the intraoral maxillary quadrangular Le Fort II osteotomy (IQLO) with wire or rigid internal fixation following horizontal maxillary advancement. PATIENTS AND METHODS: All 21 patients who had undergone the IQLO were analyzed for operation time, blood loss, length of hospitalization, intraoperative and postoperative complications, and radiographic abnormalities. Lateral cephalometric radiographs were taken preoperatively (T1), postoperatively (T2) and late postoperatively (T3) to analyze skeletal movement. Two maxillary landmarks (posterior nasal spine [PNS] and A point) and 2 dental landmarks (the distobuccal cusp tip of the maxillary left second molar [2M] and the maxillary incisal tip [CI]) were used to determine horizontal and vertical changes for each time period. Student t test was used to evaluate early postoperative changes and late postoperative stability. In addition, 21 patients completed a questionnaire at the most recent follow-up visit regarding personal intentions, perceived outcome, and overall satisfaction. RESULTS: Twenty-one patients (9 females, 12 males) with an average age of 20.3 years diagnosed with horizontal maxillary-zygomatic deficiency underwent IQLO by 1 surgeon with an average follow-up of 6.3 years. Nine patients received mini-plate osseous segment fixation and 12 patients received wire osseous segment fixation. The mean time from surgery to the first postoperative radiograph (T2) was 4.4 weeks (range 1.0 to 6.7 weeks) and the mean time from surgery to the late postoperative radiograph (T3) was 6.2 years (range, 7.9 to 176.3 months). Statistical analysis of cephalometric landmarks revealed the following significant late postsurgical movements (T3-T2) for wire fixation: PNS moved 1.0 mm inferiorly (SD, 1.2), and 2M moved 1.5 mm inferiorly (SD, 2.2). The remaining cephalometric landmarks for rigid and wire fixation showed no statistically significant late postsurgical movement. Clinical outcome analysis revealed few complications, low surgical and postsurgical morbidity, and excellent patient satisfaction. CONCLUSION: The IQLO is a predictable procedure that exhibits long-term skeletal stability. Long-term retrospective review revealed low postsurgical morbidity and high patient satisfaction.     

Bioabsorbable plates and screws in pediatric craniofacial surgery: a review of 22 cases.

The purpose of this study was to evaluate the application of bioabsorbable fixation devices in reconstructive craniofacial procedures in the pediatric population. We reviewed 22 cases in which bioabsorbable plates and screws were used in craniofacial surgery for reconstruction. The procedures were performed in a 7-month period. The patients ranged in age from 5 to 228 months at the time of surgery (mean, 76.7 months). The postoperative clinical follow-up ranged from 2 to 16 weeks. The fixation devices were evaluated with regards to satisfactory fixation at the time of procedure. The postoperative follow-up evaluated clinical wound healing, signs of infection or local inflammation, and visibility or palpability of plates through the skin. All patients except one showed satisfactory wound healing with no sign of infection or local inflammation. The plates provided satisfactory fixation and were not visible through the skin. Two patients had plates that were palpable at the 4-month follow-up period. One patient with repair of a blow-out fracture of the orbit with resorbable mesh had redness and swelling over the wound site 2 weeks postoperatively with resolution 4 weeks postoperatively. Our early experience suggests reabsorbable fixation is an attractive option in pediatric plastic and craniofacial surgery. With further experience, this technology may represent the standard of care in reconstruction of the infant calvarium.     

The stability of facial osteotomies. 4. Maxillary and mandibular (with or without chin) advancement with rigid internal fixation

The short-term (6 weeks postoperative) and long-term (12 months postoperative) horizontal skeletal stability of combined maxillary and mandibular advancement was evaluated by cephalometric analysis of 15 patients.
The mean horizontal advancement of the maxilla was 5.84 mm. Six weeks later a mean horizontal relapse of 0.03 mm (0.05%) was identified. The mean horizontal relapse at long-term follow-up was 0.59 mm (10.1%).
The mean horizontal advancement of the mandible was 12.35 mm at menton and 12.65 mm at pogonion. At 6 weeks, mean horizontal relapse, respectively at the above landmarks, was 0.11 mm and 0.21 mm (1.3%). The mean horizontal relapse at long-term follow-up was 2.19 mm and 1.98 mm (16.6%) respectively for the same landmarks.
Subjectively and objectively, improvements were seen in facial aesthetics and dental occlusion. The results indicate that rigid fixation of osteotomies undertaken to correct 'horizontal facial deficiency' is a surgically predictable and relatively stable procedure when reviewed up to 12 months after surgery.     

Correction of condylar displacement following intraoral vertical ramus osteotomy

Fifteen patients who demonstrated condylar sag after intraoral vertical ramus osteotomy for the correction of mandibular prognathism were treated nonsurgically to establish the desired postoperative occlusion. A mean inferior displacement of 3.33 mm and anterior displacement of 2.18 mm were observed tomographically after surgery. Postoperatively, a geometric splint was constructed to compensate for the magnitude of condylar displacement and was used to replace the original splint to hold the distal segment in an overcorrected position. Skeletal fixation was maintained for 5 to 6 weeks. Tomographic evaluation of the temporomandibular joint (TMJ) during maxillomandibular fixation showed a slight superior (1.03 mm) and posterior (0.51 mm) movement of the condyle in the fossa. After release of fixation and removal of splint, a further superior (2.05 mm) and posterior (1.01 mm) repositioning of the condyle was observed. This later movement correlated with the placement of light class III elastic traction to seat the condyles into the glenoid fossae and establish a class I occlusion. Temporomandibular joint tomograms confirmed complete seating of the condyles in the fossa and lateral cephalograms demonstrated a corresponding change in the position of the mandible to the desired postoperative position. This technique has been effective in preventing postoperative malocclusion resulting from condylar sag.     

Condylar displacement and temporomandibular joint dysfunction following bilateral sagittal split osteotomy and rigid fixation

In this study changes in intercondylar width (ICW) and intercondylar angle (ICA) that occurred with rigid fixation after bilateral sagittal split osteotomy and mandibular advancement are documented and correlated with temporomandibular (TM) symptoms, magnitude of advancement, and mandibular shape. Even though individual changes occurred, there was no significant difference between the mean preoperative and postoperative ICA and ICW measurements. There was also no significant difference between the preoperative and postoperative incidence of TM pain or clicking. No correlation was found between the magnitude of advancement and the percent change in ICA or ICW, and the mandibular shape did not correlate to changes in ICW. This study suggests that screw osteosynthesis does not significantly change ICA or ICW. The fact that no significant increase in TM symptoms occurred indicates that the changes in condylar position that did occur were within the range of clinical adaptability of the patients.     

Postsurgical maxillary movement: a comparison study of bone plate and screw versus wire osseous fixation

This study was designed to examine amounts of postoperative maxillary movement in patients who received Lefort I osteotomies, comparing bone plate and screw fixation with conventional transosseous wire fixation. Cephalograms of 17 patients whose maxillae were fixated with wire osseous fixation and 13 patients whose maxillae were fixed with bone plates and screws were compared at four different time periods throughout the first postoperative year. Millimeters of movement of five maxillary assessment points were assessed in the horizontal and vertical planes of space by use of a line constructed 7 degrees to sella-nasion at nasion as the horizontal reference. Results indicate that the amount of maxillary movement was similar for the two groups during the two time periods subsequent to the surgical procedure. However, it appears that the maxillae fixated with bone plates and screws were more stable than those with wire osteosynthesis during the last postoperative period (6 months to 1 year) and during the overall postoperative time interval (2 days to 1 year).     

经腮腺入路复位固定下颌骨骨折

目的：探讨经腮腺入路行髁突低位骨折和下颌支骨折切开复位内固定的可行性。方法：对22例低位髁突骨折和4例下颌支骨折采用经腮腺入路行切开复位内固定术。结果：26例（100％）均使用2块接骨板固定,26（100％）例咬合关系基本恢复到伤前情况,术后开口度26～48mm（平均38．3mm）。2例（8％）出现面神经颊支损伤症状,3个月内均恢复正常,未出现面神经永久损伤病例及涎漏等并发症。结论：经腮腺人路行髁突低位骨折和下颌支骨折解剖复位坚强内固定,视野暴露好,复位固定可靠,面神经损伤较少。     

The skeletal stability of one-piece Le Fort 1 osteotomy to advance the maxilla; Part 1. Stability resulting from non-bone grafted rigid fixation

During the past decade, we have increasingly preferred to do a one-piece Le Fort 1 osteotomy to advance the maxilla, sometimes in isolation to treat patients with maxillary retrusive skeletal Class III patients or combined with mandibular advancement to treat bimaxillary retrusive skeletal Class II. Clinical impressions of rigid fixation techniques have indicated that there is improved stability when compared with wire fixation. There are few studies in the literature that have addressed relapse following one-piece Le Fort 1 osteotomy to advance the maxilla. Such surgery involves one single spatial movement and thereby eliminates other possible surgical variables, which may impact on the degree of stability achievable postoperatively. We studied 45 patients who had undergone a uniform one-piece maxillary advancement with elimination of controllable variables, apart from 15 patients who had simultaneous mandibular advancement. Rigid fixation was adopted throughout the study. The mean surgical change documented was 7.42 mm. The mean stability calculated at 12 months revealed a relapse of 0.72 mm (10%). This was not significant (P = 0.3). We conclude that the Le Fort 1 advancement osteotomy is a stable and surgically predictable procedure that gives only slight relapse at 12 months.     

Stability after rigid fixation of simultaneous maxillary impaction and mandibular advancement osteotomies

The purpose of this study was to investigate the short- and long-term stability of bimaxillary surgery following LeFort I (LF-1) impaction with simultaneous bilateral sagittal split ramus osteotomy (BSSO) and mandibular advancement using the technique of rigid internal fixation (RIF). In order to assess the postoperative maxillary and mandibular movement pattern in 26 patients with vertical maxillary excess and mandibular deficiency, cephalograms were taken immediately preoperatively, and 1 week, 2 months, and 1 year after surgery. With paired t-test showing no statistically significant postoperative change for the point A of the maxilla from immediate postsurgery to longest follow-up (P> 0.05), the used technique of "RIF LF-I impaction and RIF BSSO advancement" tended to render excellent postsurgical stability in the horizontal (0.1+/-0.8mm mean posterior movement) and vertical (0.1+/-0.5mm mean inferior movement) direction. There was no instance of maxillary relapse of >2mm. Regarding mandibular BSSO advancement, the point B showed a significant vertical upward movement (1.6+/-1.2mm) (P< 0.001) and a slight horizontal forward movement (0.3+/-2.0mm) (P> 0.05) at 1-year follow-up. The incidence of posterior relapse of >2mm accounted for 11.5%. The data confirm the concept that the bimaxillary approach of "LF-I impaction and BSSO advancement" using the described technique of RIF is a stable procedure in the treatment of open bite patients classified as vertical maxillary excess in combination with mandibular deficiency.     

Retromandibular approach for reduction and fixation of mandibular condylar fractures: A clinical experience

This study evaluated the efficiency and safety of a retromandibular approach to reduce and fix displaced condylar fractures. The study group included 31 patients who had undergone surgery for 35 condylar fractures (8 bilateral, 23 unilateral). Consultants and residents had performed the procedure. Inclusion criteria were: patient's choice for open reduction and fixation; displaced unilateral condylar fractures with occlusal derangement; bilateral condylar fractures with anterior open bite. Restriction of lateral movement towards the unaffected side was observed preoperatively in all cases taken up. There was a difference in the lateral movements towards the fractured side (mean 7.2) and unaffected side (mean 4.2) during the first postoperative review. Functional occlusion identical to the preoperative occlusion and good reduction of the condyles was noted in all cases. Facial nerve was encountered in 6 cases (17%) intraoperatively. There was one case (3%) of temporary facial nerve weakness, which resolved within 2 weeks. There was no permanent facial nerve damage in any patient. The retromandibular-transparotid approach seems to be a safe and efficient method for reduction and internal fixation of condylar fractures with little or no risk to the branches of facial nerve.     

The retromandibular transparotid approach to mandibular subcondylar fractures

The aim of this study was to evaluate the safety, utility and morbidity associated with the treatment of mandibular subcondylar fractures using the retromandibular transparotid approach and to evaluate the stability of a single 2mm miniplate fixation system for such fractures. Forty-two cases with 48 mandibular subcondylar fractures were analysed prospectively for 12 months and evaluated for functional results, scar, postoperative complications and stability of fixation. There were three cases of suboptimal occlusal status, two cases of haematoma that were drained and resolved, eight patients with facial nerve weakness which resolved in a few weeks, and three cases of salivary fistulae that resolved after treatment. All cases showed stable osteosyntheses. Maximal postoperative interincisal distance was 32-61 mm (mean 44 mm). Four patients had deflection on opening, while clicking on opening or chewing was observed in five patients. The postoperative scars were well accepted by all patients. The results of this study suggest that a retromandibular approach will facilitate accurate reduction and fixation of subcondylar fragments with a good cosmetic result and minimal complications. A single 2 mm miniplate fixation provides stable results.     

唇腭裂正颌手术中应用微型钢板固定后上颌骨稳定性研究

２１例唇腭裂继发畸形患者接受ＬｅＦｏｒｔⅠ型手术并采用微型钢板固定，术后平均随访时间１４个月．采用标准头影侧位片测量比较．标志点Ａ在单侧唇腭裂组中，术后平均仅后移１．２ｍｍ，上移０．８ｍｍ，ＳＮＡ角减少１．３°．双侧唇腭裂组中，前移０．１ｍｍ，上移０．３ｍｍ．ＳＮＡ角增加０．３°．两组之间移动情况无显著性差异．微型钢板固定技术显著地改善了唇腭裂患者正颌手术后截骨段的稳定，但不能完全消除移动，原因主要是唇腭裂整复术遗留下的疤痕组织．     

A comparison of the stability of single-piece and segmental Le Fort I maxillary advancements

This study retrospectively evaluated the stability of Le Fort I maxillary advancements and compared segmental and one-piece maxillary osteotomy procedures. A cephalometric analysis was performed on 26 cases of maxillary advancement. The sample comprised 11 cases of one-piece and 15 cases of segmental maxillary procedures. The tracings were superimposed and digitized by computer software, and the skeletal changes were analyzed before surgery, immediately after surgery, and at a minimum of 1 year of follow-up. Different values were compared by the paired and nonpaired t tests and were correlated by the Pearson correlation test. The significant value was set at a 95% confidence interval. The maxilla was advanced by a mean of 5.0 +/- 1.6 mm (P < 0.001), and the anterior maxilla was repositioned inferiorly by a mean of 1.5 +/- 3.3 mm (P < 0.05). The maxilla relapsed posteriorly by a mean of 0.6 +/- 1.2 mm (P < 0.05) and superiorly at the anterior maxilla by a mean of 0.8 +/- 1.1 mm (P < 0.001). Overjet and overbite did not significantly change (P > 0.05). It was concluded that maxillary advancement using rigid fixation and interpositional bone grafting in both groups was a stable procedure, particularly in the horizontal plane. In the one-piece group, there was a significantly higher relapse in the vertical plane than in the segmental group (P < 0.05), however. Minor skeletal relapse was compensated for by postoperative tooth movement, and segmental procedures are recommended when required to enhance occlusal results.     

Two-point nasomaxillary fixation of the Le Fort I osteotomy: assessment of stability at one year postoperative

The purpose was to assess maxillary position among patients undergoing Le Fort I maxillary advancement with internal fixation placed only at the nasomaxillary buttresses. This was a retrospective study of patients undergoing a Le Fort I osteotomy for maxillary advancement, with internal fixation placed only at the nasomaxillary buttresses. Demographic and cephalometric measures were recorded. The outcome of interest was the change in maxillary position between immediately postoperative (T1), 6 weeks postoperative (T2), and 1 year postoperative (T3). Fifty-eight patients were included as study subjects (32 male, 26 female; mean age 18.4 ± 1.8 years). Twenty-five subjects (43.1%) had a diagnosis of cleft lip and palate. Forty-three subjects (74.1%) had bimaxillary surgery, 16 (27.6%) had bone grafts, and 18 (31.0%) had segmental maxillary osteotomies. At T3, there were no subjects with non-union, malunion, malocclusion, or relapse requiring repeat surgery. Mean linear changes between T1 and T3 were ≤1 mm. Mean angular changes between T1 and T3 were <1°. There was no significant difference in stability in multi-segment maxillary osteotomies (P =  0.22) or with bone grafting (P =  0.31). In conclusion, anterior fixation alone in the Le Fort I osteotomy results in a stable maxillary position at 1 year postoperative.     

Long-term hard and soft tissue relapse rate after genioplasty

PURPOSE: The purpose of this study was to assess hard and soft tissue stability 12 months after advancement genioplasty. MATERIAL AND METHODS: This is a retrospective study of 20 patients who underwent either advancement genioplasty alone (n = 11) or in combination with bilateral sagittal split osteotomy for mandibular advancement (n = 9). Lateral cephalometric radiographs were traced and immediate postoperative changes and 12-month postoperative changes were defined. The relapse rate for the pogonion, the soft tissue pogonion, and the soft tissue B point (Bs) were evaluated. The results were compared for combined mandibular advancement plus genioplasty versus genioplasty alone. Relapse rates were also correlated with the amount of advancement. All patients were treated with rigid internal fixation. RESULTS: After 12 months, the pogonion, the soft tissue pogonion, and the soft tissue B point had a mean relapse rate of -0.38 mm, -1.2 mm, and -1.5 mm (negative value indicates a relapse, and a positive value indicates prolapse), respectively, which was not significant at probability values of.45,.069, and.054, respectively. Relapse was not statistically related to the amount of advancement. There was no significant difference between the relapse rate for genioplasty alone versus combined bilateral sagittal split osteotomy and genioplasty, even with different amounts of advancement. CONCLUSIONS: Advancement genioplasty is an important and reliable technique for the esthetic treatment of the lower facial skeleton. The results indicate that there is no significant relapse after genioplasty and bilateral sagittal split osteotomy or genioplasty alone after 12 months when rigid internal fixation is used. The changes were minimal and hard to detect clinically. Genioplasty, with or without mandibular advancement, is a stable surgical procedure when used in conjunction with rigid internal fixation.