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A case of subcutaneous parotid secretion after extraoral vertical mandibular osteotomy for prognathism has been described. The possible causes have been discussed and a rationale for conservative management has been suggested.
A 23-year-old female patient had a sagittal split mandibular osteotomy performed to correct prognathism. Two years after surgery she developed pain in the distribution of the right inferior dental and mental nerves. The area was investigated surgically and a traumatic neuroma was excised.
A retrospective recall study of forty patients was made to examine mandibular function after orthognathic surgery. Maximum maxillomandibular opening, protrusion, and lateral excursions were measured and compared with similar mandibular movements in a control group of patients of comparable age. Six months to 42 months after maxillary and mandibular osteotomies, the majority of patients demonstrated decreased maxillomandibular opening compared to the control group 54.8 mm (SD 4.7). The decrease was most dramatic in patients previously treated with sagittal split ramus osteotomies. The mean maxillomandibular opening after Le Fort I osteotomy to reposition the maxilla superiorly was 48.7 mm (SD 5.7); after bilateral intraoral vertical ramus osteotomies to retract the mandible it was 48.6 mm (SD 5.7); and after bilateral sagittal split ramus osteotomies to advance the mandible it was 35.1 mm (SD 6.7). The presence of mandibular hypomobility after orthognathic surgery and maxillomandibular immobilization may be due to pre-existing or surgically induced muscle or temporomandibular joint dysfunction. Our findings indicate the need for routine clinical assessment of mandibular function preoperatively and for a systematic regimen of muscular and occlusal rehabilitation postsurgically to normalize muscle function, condylar movement, and range of mandibular motion.
The aim of the present study was to compare the effect on swelling after bilateral osteotomies of the mandible of treatment with organo-heparinoid (Hirudoid) cream and that of a placebo cream. 12 patients (7 female, 5 male), median age of 29.5 years, were included in the study. 5 patients received bilateral sagittal-split procedures for symmetrical mandibular advancement, and 7 patients received bilateral mandibular osteotomies for symmetrical mandibular set-back. Each of the 2 operated sides were randomized for treatment with active medication or placebo; 1.5 g of the active- or placebo cream were carefully rubbed into the skin above the masseteric muscle 4 times a day for 4 days. Periodic identical CT-scans were performed to evaluate swelling; patients were CT-scanned preoperatively and once or twice postoperatively. 3 variables were used to assess the swelling: (1) thickness of the subcutis; (2) maximum thickness of the masseteric muscle; (3) cross-sectional area of the soft tissues facial to the ramus of the mandible. No significant differences in postoperative swelling could be demonstrated between the 2 treatments. There were no detectable systemic effects of the treatment with organo-heparinoid.
In 1984, Attia et al described the double mandibular osteotomy as a more direct approach for tumors of the ptergomaxillary and parapharyngeal space. The procedure incorporates the traditional parasymphyseal osteotomy of the mandible with a horizontal osteotomy of the ascending ramus. Several modifications of this technique are described that increase the surgical exposure, while requiring less surgical dissection. The incorporation of rigid fixation with miniplates has improved postoperative recovery by avoiding maxillomandibular fixation and improving oral nutrition.
Although the oncologic validity and perioperative complications of midline mandibular osteotomy are well described, little attention has been directed toward the long-term functional problems that may be associated with its use. Thirty-one patients who had undergone this procedure were examined to assess postoperative sensation, temporomandibular joint (TMJ) function, occlusion, and cosmesis. The majority (27 of 31) patients had some sequelae but these were minor in nature. Twenty of 31 patients had abnormal sensation, 24 of 31 noted a changed occlusion, and 15 of 31 had signs or symptoms of TMJ myofascial pain. Although patients should be advised of the potential for functional problems with this procedure, they can be reassured that these are likely to be relatively minor in significance. If technically feasible and if an exact restoration of occlusion is a priority, a prefabricated lingual splint should be used.
In some cases, the inferior alveolar nerve runs through a lower course than usual. In such cases, osteotomy of the mandible can injure the inferior alveolar nerves. In other instances, the course of the mandibular osteotomy can meet that of the inferior alveolar nerve. In these cases, a useful method may be excavating the canal and drawing the nerve out through it. With this technique, we can make the osteotomy as initially planned with minimal damage to the inferior alveolar nerve.
INTRODUCTION: Injury of the inferior alveolar nerve (IAN) is one of the most common complications of mandibular osteotomy. The wide differences in results published to date led us to evaluate the incidence of sensorial disorders persisting for one year in a series of 40 patients. MATERIAL AND METHOD: This study included 40 patients aged 14-58 years. We studied subjective expression of sensorial disorders using a questionnaire with items for the different orofacial functions related to the IAN. We studied the clinical expression of these sensorial disorders by testing the three modes of exteroceptive sensitivity (tact, temperature, pain) in 25 patients. Four clinical tests appropriate for the area of the mental nerve. Somesthesic evoked potentials were recorded in 8 patients. RESULTS: 77% of the patients complained of altered skin sensitivity but a sensorial deficit was revealed by clinical tests in only 60%. Somesthesic evoked potentials were perturbed for 64% of the nerves with a clinical deficit and in 100% without a clinical deficit. DISCUSSION: There was a greater incidence of subjective complaints than objective nerve injury. Recoring somesthesic evoked potentials provides interesting information for the electrophysiological diagnosis of nerve injury. Indications could be widened for traumatic injury of the IAN, particularly to obtain medicolegal documentation.
Skeletal stability was examined in 16 patients following combined maxillary and mandibular osteotomies using rigid internal fixation. Postoperative changes (T2 to T3) were generally less than 1.0 mm for linear measurements and less than 2.0 degrees for angular measurements. The removal of maxillomandibular fixation (MMF) splints accounted for 85% to 95% of the counterclockwise rotation in the proximal and distal mandibular segments from T2 to T3. Maxillary inferior repositioning and large mandibular advancements exhibited the greatest tendency for relapse; however, the changes were less than with comparable procedures using nonrigid methods for stabilization. Except for large mandibular advancements, relapse was essentially unrelated to the magnitude of the surgical repositioning. Although the use of skeletal, maxillomandibular, and transosseous wire fixation have traditionally provided satisfactory clinical results, the use of rigid internal fixation in combined osteotomy procedures provides better stabilization of dentosseous segments when compared with these nonrigid methods, and may be particularly indicated in complex surgical procedures.
Activity of transforming growth factors (TGFs) in urine from the patients with surgical bone wound involved in mandibular osteotomy, was examined by the use of NRK-49F indicator cells. The urine was extracted by an acid-ethanol method, fractionated on a Bio-Gel P-100 column or reverse-phase high performance liquid chromatography (HPLC), and analysed for TGF activity. TGF-alpha activity in the Mr 30-27 or 12-10 kDa ranges, which was determined in the HPLC fractions containing TGF activity by dot-blot analysis using antisera to human TGF-alpha (hTGF-alpha) and hEGF, was detected in urine from the patients but not from normal controls. From an analysis of urine samples collected prior to operation and after operation in individual patients, we have shown that there is an intimate relationship between repair of surgical bone wound and the TGF-alpha activity.
Two women, 43 and 46 years old, weighing respectively 51 kg and 49 kg, underwent mandibular osteotomy with retrusion, after which they began to snore heavily at night. The initial events were central; obstructive apneic and hypopneic events, documented by polysomnography, developed over time. When patient 2 was on her back, she frequently had central apneas (identified by esophageal pressure monitoring) preceded by increasing swings in pressure, indicative of increased airway resistance without oxygen desaturation.
The improved stability that results from the combination of K-wire transfixion of a mandibular osteotomy with direct wiring has made it possible to use a straight, as opposed to a stepped, bone cut and to avoid the invariable need for dental extractions. It has also made possible an alternative osteotomy site, immediately anterior to the mental foramen. The use of this site allows mandibular swing to take place after division only of mucous membrane and mylohyoid. It is best combined with a modified lip-splitting incision which has been found to improve ultimate cosmesis.
In a prospective randomized study on treatment of obstructive sleep apnea syndrome, anterior-inferior mandibular osteotomy with the purpose of stretching the suprahyoidal muscle was performed as one of the treatment methods. Ten men aged 20 to 65 years, without cardiovascular or neurologic disease, with normal maxillomandibular relation, and having an apnea index between 5 and 25 were included in the study. After a specially designed osteotomy of the chin, the anterior suprahyoidal muscles were detached, stretched approximately 10 to 12 mm, and sutured. The chin was then placed in its original position and post-operative evaluation was performed. Although there were initial reports of decreased daytime sleepiness and less snoring after surgery, the results after 12 months were discouraging. Somnographic registration (apnea index, apnea/hypopnea index, and oxygen desaturation index) as well as cephalometric analysis failed to show positive results. Hence, suspension of the suprahyoidal muscles as a method of treatment for obstructive sleep apnea syndrome cannot be recommended.
Fifty-five patients with obstructive sleep apnea syndrome (OSAS) were evaluated following inferior mandibular osteotomy with hyoid myotomy and suspension. Patients were objectively examined by polysomnography before and 6 months following the surgical procedure. Thirty-seven patients (67%) had a good response from surgery, and 18 patients (33%) were considered nonresponders. Lung disease, mandibular deficiency, and obesity were factors found to affect the success of surgical treatment.
OBJECTIVE: The purpose of this study was to examine both condylar displacement of the temporomandibular joint after sagittal split ramus osteotomy with rigid osteosynthesis and intraoral vertical ramus osteotomy without osteosynthesis in patients with mandibular prognathism by means of three-dimensional computed tomography. STUDY DESIGN: In this pilot study, five patients treated with sagittal split ramus osteotomy and 5 patients treated with intraoral vertical ramus osteotomy were evaluated. A technique to superimpose a postoperative three-dimensional computed tomography image on its corresponding preoperative image was designed. Postoperative condylar displacement, rotation, and tilting were measured in three-dimensional computed tomography images. RESULTS: Within 3 to 6 months after surgery, changes in the inclination of the condylar axes were distinctly seen, although changes in the position of the condyles within the joints were minimal. In particular, outward rotation of the condylar long axes after intraoral vertical ramus osteotomy was a frequent finding. CONCLUSIONS: The three-dimensional computed tomography superimposition technique was a practical method of evaluating postsurgical condylar displacement after mandibular osteotomy.
A 33-yr-old woman with marked maxillo-facial deformities as a result of underlying beta-thalassaemia major was to undergo corrective maxillary and mandibular osteotomies. The placement of an endotracheal tube posed a problem in this patient because of anatomical deformities in her nasal passage, surgical constraints on using the oral route, and reluctance of the patient to have a tracheostomy. This case report describes the use of a submental tracheal intubation technique, and the associated anaesthetic difficulties encountered in patients with this pathology.
Transoral approaches are used to expose the craniovertebral junction anteriorly. In patients in whom there is limited mandibular excursion, the placement of retractors and/or surgical instruments is difficult, and midline "stairstep split mandibulotomy" has been advocated as an adjunctive procedure. Although effective, this approach requires external splitting of the lip as well as median glossotomy or a lateral mucosal incision. The purpose of this study was to show that bilateral sagittal split mandibular osteotomies (BSSMOs), which are used in orthognathic surgery, represent a safer and more effective alternative to the stairstep split mandibulotomy when performed as an adjunct to the transoral approach because all incisions are intraoral and the plane of retraction is rostrocaudal instead of lateral. Hospital records and radiographic files of four patients who underwent BSSMO/transoral approach for odontoidectomy between 1994 and 1997 were reviewed retrospectively. There were three women and one boy (mean age 37.8 years, range 11-68 years). Predisposing conditions included rheumatoid arthritis (two patients), Klippel-Feil syndrome (one patient), and congenital occipitocervical instability (one patient). Jaw mobility was limited in all patients. In addition, one patient had macroglossia, another micrognathia, and another retrognathia. The BSSMO provided excellent exposure for resection of the odontoid process, as verified on follow-up magnetic resonance imaging or computerized tomography studies obtained in all patients. All mandibles were rigidly fixed by placing anterior mandibular border titanium plates and unicortical screws, and there was no incidence of nonunion or of lingual or inferior alveolar nerve injuries. The mean follow-up period was 26 months. The BSSMO is an excellent, less invasive adjunct to the transoral approach in patients with limited jaw mobility.
BACKGROUND: Infection is a rare complication after orthognathic surgery. A rate of 1% to 15% has been reported in the literature. We reviewed our experience. MATERIAL AND METHODS: We reviewed retrospectively 60 mandibular osteotomies performed between 1998 and 1999. There were 41 women and 19 men, mean age 24 years. All were given antibiotic therapy using cefamandol 1500 mg preoperatively then 750 mg every 6 hours peroperatively and cefixime 400 mg/d postoperatively for 7 days. Patients were followed for at least 6 months after surgery. RESULTS: There were 10 infections (16% of the cases) involving a hematoma in 2 cases, adenitis in 1, osteitis on a cortical fragment in 2 and osteitis on implanted material in 5. DISCUSSION: We defined infection following orthognathic surgery as a collection or purulent fistula with either a high polynuclear count in the discharge fluid or a positive culture. Both soft tissue (for example infection of a perimandibular hematoma) or bone infections were equally considered. We found two types of risk factors: patient-related or procedure-related. Patient-related factors included smoking, paradontal status, and dental hygiene. The main procedure-related factor was duration of surgery. Measures of prevention include extraction of the wisdom teeth, interruption of smoking, preoperative scaling and careful dental care, rigorous operative technique, antibiotic therapy.