David A. Cottrell

Diagnosis of macroglossia and indications for reduction glossectomy

Macroglossia can create dentomusculoskeletal deformities, instability of orthodontic and orthognathic surgical procedures, and masticatory, speech, and airway problems. The cause of macroglossia must be clearly defined, and true macroglossia separated from pseudomacroglossia (displacement of the tongue created by anatomic factors other than tongue size alone). This article discusses the signs and symptoms of macroglossia, including the clinical and radiographic features, treatment techniques, as well as previously reported results. Cases are shown to illustrate the applicability of this technique.

Long-term evaluation of the use of coralline hydroxyapatite in orthognathic surgery.

PURPOSE This prospective study was designed to evaluate the long-term clinical and radiographic results of porous block hydroxyapatite (PBHA) used as a synthetic bone graft in orthognathic surgery and craniofacial augmentation. PATIENTS AND MATERIALS A total of 245 consecutive patients were treated initially. Inclusion criteria for this study included a minimum clinical and radiographic follow-up of 5 years. In addition, all patients with known implant failures were included regardless of whether they met the study criteria. There were 111 patients that met the criteria for inclusion in this study. All patients had undergone orthognathic surgery with rigid fixation and had had inlay or onlay PBHA implants placed. Ninety-six percent of the implants were placed through an intraoral approach. Long-term postoperative radiographs were visually compared with immediate postoperative radiographs for implant position, stability, resorption, and other significant radiographic changes. The clinical examination evaluated for signs and symptoms of infection, wound dehiscence, implant exposure, implant displacement, changes in the overlying mucosa, and development of oronasal or oroantral fistulae. RESULTS Four hundred seventy-one implants were placed: 403 in the maxilla, 44 in the mandible, and 24 in the periorbital region. There were 289 implants placed in direct communication with the maxillary sinus. The average follow-up time was 7.2 years (range, 5.0 to 10.3 years). Twenty-three implants (4.9%) were removed during the evaluation period. Lateral maxillary wall grafting had 95.7% success, with nine implants being lost in three patients. One chin implant was removed because of dissatisfaction with the aesthetics. Seven (14%) midpalatal implants used for maxillary expansion were lost, primarily because of exposure of the implant to the oral or nasal cavity at the time of surgery. When PBHA was used for alveolar cleft grafting, there was a 100% failure rate. CONCLUSION The use of PBHA as a bone graft substitute in orthognathic surgery and for facial augmentation showed a high percentage of success and efficacy. However, adequate soft tissue coverage in the nasal floor and on the palate are paramount for success of midpalatal implants. PBHA should not be used for alveolar cleft grafting. Rigid fixation for inlay implants in the maxilla is important to provide stress shielding of the material and minimize micromovement during the initial healing phase.

Altered orthognathic surgical sequencing and a modified approach to model surgery

Advances in orthognathic surgical treatment planning and in techniques for complex, simultaneous maxillary and mandibular repositioning have resulted in improved surgical accuracy. In traditional surgical sequencing, maxillary surgery is performed first; the maxilla is set, with or without an intermediate splint, using external reference points to verify and/or determine appropriate movement. However, errors in model surgery and intermediate splint fabrication can lead to surgical inaccuracy despite good surgical technique. In repositioning the maxilla first, when thin bony walls are present, and/or in conjunction with large mandibular advancements, maxillary shifting may occur when maxillomandibular fixation is applied. Soft tissue tension and surgical manipulation in this sequencing technique may result in a less desirable functional and esthetic outcome. This article presents an alternative to surgical sequencing and a modification of model surgery techniques to improve surgical accuracy, and thus predictability and stability of the results.

Management of heparin therapy in the high-risk, chronically anticoagulated, oral surgery patient: A review and a proposed nomogram

PURPOSE This study analyzes the use of a standard nomogram that can help reduce the level of anticoagulation preoperatively to effectively manage perioperative heparin therapy in chronically anticoagulated oral surgery patients who are at high risk for thromboembolism. PATIENTS AND METHODS Twenty patients with significant cardiovascular disease, ranging in age from 56 to 79 years and requiring oral surgery, were randomly divided into 2 groups. All patients were on chronic warfarin therapy, and perioperative heparinization was recommended by their cardiologist. Group A (n = 10) had their anticoagulation therapy managed with the use of a standard nomogram. The heparin therapy for group B (n = 10) was managed without the use of the nomogram. The records of all patients were analyzed for therapeutic efficacy of heparinization, number of laboratory tests required, duration of hospitalization, and complications related to heparinization. RESULTS Patients in group A did significantly better in all parameters when compared with group B patients. There were no complications in group A, whereas there was a 20% incidence of complications related to anticoagulation therapy in group B. CONCLUSIONS The use of a standard nomogram to manage anticoagulation therapy in the oral surgery patient requiring heparinization is strongly recommended. This provides optimal therapeutic benefit, decreases the incidence of complications, and makes the hospitalization less costly and more comfortable for the patient.

Life-threatening, delayed epistaxis after surgically assisted rapid palatal expansion: A case report

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Orthognathic Surgery in the Young Cleft Patient: Preliminary Study on Subsequent Facial Growth

PURPOSE This study evaluated the long-term effects of orthognathic surgery on subsequent growth of the maxillomandibular complex in the young cleft patient. PATIENTS AND METHODS We evaluated 12 young cleft patients (9 male and 3 female patients), with a mean age of 12 years 6 months (range, 9 years 8 months to 15 years 4 months), who underwent Le Fort I osteotomies, with maxillary advancement, expansion, and/or downgrafting, by use of autogenous bone or hydroxyapatite grafts, when indicated, for maxillary stabilization. Five patients had concomitant osteotomies of the mandibular ramus. All patients had presurgical and postsurgical orthodontic treatment to control the occlusion. Radiographs taken at initial evaluation (T1) and presurgery (T2) were compared to establish the facial growth vector before surgery, whereas radiographs taken immediately postsurgery (T3) and at longest follow-up (T4) were used to determine postsurgical growth. Each patients lateral cephalograms were traced, and 16 landmarks were identified and used to compute 11 measurements describing presurgical and postsurgical growth. RESULTS Before surgery, all patients had relatively normal growth. After surgery, cephalograms showed statistically significant growth changes from T3 to T4, with the maxillary depth decreasing by -3.3 degrees +/- 1.8 degrees , Sella-nasion-point A by -3.3 degrees +/- 1.8 degrees, and point A-nasion-point B by -3.6 degrees +/- 2.8 degrees. The angulation of the maxillary incisors increased by 9.2 degrees +/- 11.7 degrees. Of 12 patients, 11 showed disproportionate postsurgical jaw growth. Maxillary growth occurred predominantly in a vertical vector with no anteroposterior growth, even though most patients had shown anteroposterior growth before surgery. The distance increased in the linear measurement from nasion to gnathion by 10.3 +/- 7.9 mm. Four of 5 patients operated on during the mixed dentition phase had teeth that erupted through the cleft area. A variable impairment of postoperative growth was seen with the 2 types of grafting material used. No significant difference was noted in the effect on growth in patients with unilateral clefts versus those with bilateral clefts. The presence of a pharyngeal flap was noted to adversely affect growth, whereas simultaneous mandibular surgery did not. After surgery, 11 of 12 patients tended toward a Class III end-on occlusal relation. CONCLUSIONS Orthognathic surgery may be performed on growing cleft patients when mandated by psychological and/or functional concerns. The surgeon must be cognizant of the adverse postsurgical growth outcomes when performing orthognathic surgery on growing cleft patients with the possibility for further surgery requirements. Performing maxillary osteotomies on cleft patients would be more predictable after completion of facial growth.

Condylar change after upward and forward rotation of the maxillomandibular complex

Tomographic radiographs of 44 healthy temporomandibular joints in 22 patients undergoing large upward and forward rotations of the maxillomandibular complex were evaluated. Immediate postsurgery results showed decreases in all areas of the joint space. Long-term results showed a decrease in the superior and posterior regions, 14.8% and 19.7%, with no significant change anteriorly. Simple and multiple regression analysis did not show any relationship with age, gender, or degree of change in the decrease of the occlusal plane angle, to the temporomandibular joint changes described. Some condylar remodeling was noted.

Efficacy of anti-inflammatory drugs in third molar surgery: a randomized clinical trial.

This was a double-blind randomized clinical trial to assess the effect of different pharmacological regimens on the level of prostaglandin E2 (PGE2) in urine and saliva, and to correlate the findings to the clinical course after removal of impacted lower third molars. Eighty patients were randomly divided into four groups: group 1 received placebo; group 2 received preoperative ibuprofen, which was continued for a week; group 3 received intraoperative dexamethasone; and group 4 received preoperative ibuprofen, which was continued for a week, in addition to intraoperative dexamethasone. Saliva and urine samples were taken at scheduled intervals. Patients receiving ibuprofen fared significantly better in most parameters. A single dose of dexamethasone alone had a potent but transient beneficial effect when compared to the results with ibuprofen, which showed significant improvement in both subjective and objective parameters. Use of a single dose of intravenous steroids perioperatively helped reduce untoward sequelae, although to a lesser degree and for a shorter duration than continuous ibuprofen. Combining ibuprofen with perioperative dexamethasone added some benefit in some of the measured parameters, but without a statistically significant advantage over using ibuprofen only.

Painless Mass in the Parotid Region

A 12-year-old Hispanic girl presented to the oral and maxillofacial surgery clinic at Woodhull Medical Center with a chief complaint of a nontender right facial swelling. The history was obtained from both the father and the patient through a translator. This revealed that the patient first became aware of the swelling about 4 months previously and that it had continued to increase in size. On further questioning about the origin of the swelling, the father gave a history of a mild to moderate upper respiratory infection at about the same time that the swelling first appeared. The medical history indicated that the child had not received the usual childhood vaccines. She was never hospitalized, was not on any medications, and did receive routine pediatric care. Overall, her general health had been good. The social history disclosed that the patient moved from Mexico approximately 1 year ago and was living with her father, aunt, uncle, and 2 siblings, ages 5 and 18 years, in a 3-bedroom apartment in Brooklyn, New York. The mother was still living in Mexico with her remaining 2 children, ages 14 and 15 years. The patient had achieved the fourth grade while in Mexico, but had never attended school in the United States. She denied having a boyfriend; nor had she had any close personal or sexual contact with anyone in the United States. There was no history of tobacco, alcohol, or illicit drug usage. The review of systems revealed that she had had 3 or 4 upper respiratory infections since coming to the United States; there was no history of chronic cough or hemoptosis. She had not yet reached menarche. Examination showed a 5.0 3.5-cm swelling located over the center of the right parotid gland (Fig 1). The skin was erythematous, and there was a sinus tract located at the inferior aspect from which a serosanguinous exudate was draining. On palpation, the swelling was noted to be fixed, fluctuant, and was not warm to touch. The submandibular and cervical lymph nodes were palpable and nontender. Cranial nerves II to XII were grossly intact. The rest of the head and neck examination was within normal limits. The intraoral examination showed a mixed dentition in good repair. The oral mucosa, tongue, floor of mouth, and throat appeared normal. Stenson’s duct was patent and produced clear saliva on milking. Results of the rest of the physical examination were normal. The patient did not have an elevated temperature. The panoramic radiograph of the jaws showed a pattern that was normal for a 12-year-old child.

Infraorbital nerve sharing to restore sensibility to the lower lip: Case report

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