Brent A. Golden

Orbital Anatomy for the Surgeon

An anatomic description of the orbit and its contents and the eyelids directed toward surgeons is the focus of this article. The bone and soft tissue anatomic nuances for surgery are highlighted, including a section on osteology, muscles, and the orbital suspensory system. Innervation and vascular anatomy are also addressed.

Systematic review of preoperative mandibular canal position as it relates to postoperative neurosensory disturbance following the sagittal split ramus osteotomy

The purpose of this study was to review the current literature for the relationship between the preoperative position of the mandibular canal on three-dimensional (3D) radiographic imaging and postoperative neurosensory disturbance (NSD) following a sagittal split ramus osteotomy (SSRO). A literature search was conducted using PubMed, EMBASE, and the Cochrane Database for articles published from 1 January 2000 through 31 December 2013. Studies that included preoperative 3D imaging and assessment of NSD after surgery were reviewed. Study sample characteristics and results were extracted. Of the 69 articles identified, seven met the inclusion and exclusion criteria. There was no standardization for measuring the canal position or for evaluating NSD. General consensus was that the less space between the mandibular canal and the outer border of the buccal cortex the more frequent the occurrence of NSD. Increased bone density also appeared to contribute to a higher incidence of NSD. Utilization of 3D images to locate and measure the position of the mandibular canal is not standardized. Advances in 3D imaging and evaluation tools allow for new methodologies to be developed. Early attempts are informative, but additional studies are needed to verify the relationship between the location of the nerve and NSD following surgery.

Changes Over Time in the Periodontal Status of Young Adults With No Third Molar Periodontal Pathology at Enrollment

PURPOSE To assess changes in periodontal status over time in subjects with all third molar region periodontal probing depths (PDs) of less than 4 mm at enrollment. PATIENTS AND METHODS Subjects were a subsample of young adults enrolled with 4 asymptomatic third molars in an institutional review board-approved longitudinal study. Full-mouth periodontal PD data, 6 sites per tooth, were measures of periodontal status. Data were aggregated to subject and jaw levels. A PD of 4 mm or greater was considered an indicator variable for periodontal pathology. Subjects were classified according to PD at follow-up: all PDs of less than 4 mm or at least 1 PD of 4 mm or greater. The demographic differences and the third molar anatomic position at baseline were compared to assess whether enrollment factors were related to the changes in periodontal pathology. The level of significance was set at .05. RESULTS One hundred six subjects had all third molar region PDs of less than 4 mm at enrollment and were aged 25 years on average. Of these, 38% had a change in third molar region periodontal status, with at least 1 third molar region PD of 4 mm or greater detected at a median follow-up of 4.1 years (interquartile range, 2.4-5.9 years). A PD of at least 4 mm was detected significantly more often in the mandibular third molar region than in the maxillary third molar region (P < .01). No significant differences in age, gender, education, or length of follow-up were detected between the 40 subjects with a change in periodontal status in the third molar region and the 66 subjects who remained periodontally healthy (P > .05). At follow-up, 50% of subjects with at least 1 PD of 4 mm or greater in the third molar region had at least 1 PD of 4 mm or greater in non-third molar regions as compared with 15% of subjects with all third molar region PDs of less than 4 mm (P < .01). CONCLUSIONS Periodontal pathology developing over time in healthy young adults was significantly more likely in the mandibular third molar region and mandibular non-third molars.

Multimodal Protocol Reduces Postoperative Nausea and Vomiting in Patients Undergoing Le Fort I Osteotomy

PURPOSE To assess the impact of a multimodal antiemetic protocol on postoperative nausea and vomiting (PONV) after Le Fort I osteotomy. MATERIALS AND METHODS Consecutive patients undergoing Le Fort I osteotomy with or without additional procedures at a single academic institution were recruited as the intervention cohort for an institutional review board-approved prospective clinical trial with a retrospective comparison group. The intervention cohort was managed with a multimodal antiemetic protocol, including total intravenous anesthesia; prophylactic ondansetron, steroids, scopolamine, and droperidol; gastric decompression at surgery end; opioid-sparing analgesia; avoidance of morphine and codeine; prokinetic erythromycin; and fluids at a minimum of 25 mL/kg. The comparison group consisted of consecutive patients from a larger study who underwent similar surgical procedures before protocol implementation. Data, including occurrence of PONV, were extracted from medical records. Data were analyzed in bivariate fashion with the Fisher exact and Wilcoxon rank-sum tests. Logistic regression was used to compare the likelihood of nausea and vomiting in the 2 cohorts after controlling for demographic and surgical characteristics. A P value less than .05 was considered significant. RESULTS The intervention (n = 93) and comparison (n = 137) groups were similar in gender (58% and 65% female patients; P = .29), race (72% and 71% Caucasian; P = .85), age (median, 19 and 20 years old; P = .75), proportion of patients with known risk factors for PONV (P = .34), percentage undergoing bimaxillary surgery (60% for the 2 groups), and percentage for whom surgery time was longer than 180 minutes (63% and 59%; P = .51). Prevalence of postoperative nausea was significantly lower in the intervention group than in the comparison group (24% vs 70%; P < .0001). Prevalence of postoperative vomiting was likewise significantly lower in the intervention group (11% vs 28%; P = .0013). The likelihood that patients in the comparison group would develop nausea was 8.9 and that for vomiting was 3.7 times higher than in the intervention group. CONCLUSION This multimodal protocol was associated with substantially decreased prevalence of PONV in patients undergoing Le Fort I osteotomy.

Difference in maxillary sinus volumes of patients with cleft lip and palate

BACKGROUND AND OBJECTIVE Sinus disease is noted to be common in patients with cleft lip and palate. Many have wondered if anatomic differences are a cause or at least a contributor of this. In this sense, comparisons of sinus volumes of patients with different craniofacial clefts may be helpful to determine possible differences from normal. Thus, the present study aimed to evaluate and compare the maxillary sinus volume of patients with unilateral (UCLP) and bilateral (BCLP) cleft lip and palate to control, i.e. non-cleft patients, using cone beam computed tomography (CBCT) images. METHODS The sample consisted of 30 subjects with UCLP, 15 with BCLP and 15 control individuals (non-cleft). Each maxillary sinus was assessed three-dimensionally, segmented and its volume was calculated. The comparison between right and left sinus was performed by Student t-test, and the differences between the control and cleft groups were calculated using ANOVA. RESULTS No statistical differences were found when the sides were compared (p>0.05). In relation to the assessment among groups, all comparisons had statistically significant differences (p<0.05), with the UCLP group presenting the lowest sinus volume. CONCLUSION UCLP individuals present maxillary sinuses with smaller volumes, without differences found between the cleft and non-cleft side. BCLP subjects also present a reduction in the volume when compared to a control sample, but the average sinus volume is larger than in UCLP patients.

Orbital apex disorders: A case series

Orbital apex syndrome is an uncommon disorder characterized by ophthalmoplegia, proptosis, ptosis, hypoesthesia of the forehead, and vision loss. It may be classified as part of a group of orbital apex disorders that includes superior orbital fissure syndrome and cavernous sinus syndrome. Superior orbital fissure syndrome presents similarly to orbital apex syndrome without optic nerve impairment. Cavernous sinus syndrome includes hypoesthesia of the cheek and lower eyelid in addition to the signs seen in orbital apex syndrome. While historically described separately, these three disorders share similar causes, diagnostic course, and management strategies. The purpose of this study was to report three cases of orbital apex disorders treated recently and to review the literature related to these conditions. Inflammatory and vascular disorders, neoplasm, infection, and trauma are potential causes of orbital apex disorders. Management is directed at the causative process. The cases described represent a rare but important group of conditions seen by the maxillofacial surgeon. A review of the clinical presentation, etiology, and management of these conditions may prompt timely recognition and treatment.

Craniofacial and Orbital Dermoids in Children

Dermoid cysts are congenital lesions that commonly arise from nondisjunction of surface ectoderm from deeper neuroectodermal structures. They tend to be found along planes of embryonic closure. Classification by site is helpful for diagnostic planning and surgical treatment. A distinction can be made between frontotemporal, orbital, frontoethmoidal, and calvarial lesions. The risk of extension into deeper tissues must be determined before surgical intervention. Simple lesions are amenable to direct excision. Deeper lesions often require a coordinated surgical approach between a neurosurgeon and craniofacial surgeon after thorough radiographic imaging. Follow-up through the developmental years is recommended for complex dermoid lesions.

Ultrasound-Guided Navigation System for Orthognathic Surgery

Around 1–2 % of the US population has craniofacial deformities severe enough to be disabling and stigmatizing, and could benefit from orthognathic surgery. This surgery involves repositioning the jaws, due to the unique features of each patient’s teeth, jaws, and joint. Approximately 20 % of patients who had mandibular advancement surgery experience moderate relapse 1–5 years after surgery. We believe ultrasound is a promising imaging technology for orthognathic surgery guidance that can assist surgeons to visualize the condyle/ramus segment in order to guide it into its pre-surgical, biologically stable position. This paper explores the role of 3D ultrasound imaging as a real-time surgical guidance to improve treatment outcomes for orthognathic surgery. This paper shows our work designing a 3D ultrasound volume reconstruction system and our results demonstrating its ability to capture the bony structures of the mandible, compared with those structures reconstructed from pre-surgical Cone Beam Computed Tomography (CBCT).