The quantitative analysis of facial soft tissues is of overwhelming importance for orthodontic patients. To assess the normal age-related variations in shape, soft tissue facial profiles were studied in 96 healthy male children 3 to 11 years of age and 16 young men (age 18). Standardized left-side photographs were taken of each subject, and facial profiles were traced between trichion and cervical point. The line joining the 2 landmarks was set as the baseline, and each outline was automatically digitized and mathematically reconstructed by a 30-harmonic elliptic Fourier series expansion. The same soft tissue profile was traced and digitized from the Bolton standards of comparable age. All profiles were standardized to the same area, and shape modifications were quantified by calculating the morphologic distance between the Fourier reconstructions of each facial profile and of (1) the 18-year-old Bolton standard (MD-18) and (2) the age-related Bolton standard. Descriptive statistics were computed for each age class. On average, MD-18 was 7.23 at 3 years of age, increased between 6 and 9 years of age, and decreased hereafter, reaching 6.86 at 18 years of age. Within-group variability peaked at 8 years of age, and was minimal at 6 and 18 years of age. The current soft tissue child profiles seemed different from the profile obtained from the Bolton standards.

To prevent relapse after orthodontic treatment, retention is often considered indispensable. Soft tissues are thought to have a significant influence on dental movements. To quantify the influence of masticatory muscles on post-treatment relapse, and in an attempt to avoid unnecessary procedures, 2 male orthodontic patients (13 and 30 years old at debonding) were followed up. The patients completed 2 years of fixed orthodontic treatment and received no post-orthodontic retention. After 1 week and again after 6 months, alginate impressions of dental arches and a surface electromyographic (EMG) assessment of the masseter and temporalis muscles during maximum voluntary clenching were performed. The younger patient received surface EMG monitoring once a month for the first 6 months and at the 1-year follow-up appointment. Arch dimensions and the 3-dimensional inclination of the facial axis of the clinical crown (FACC) were measured using a computerized digitizer. Symmetry in muscular contraction was measured by the percentage overlapping coefficient (POC), and potential lateral displacing components were assessed by the torque coefficient (TC). At the 6-month follow-up, no clinical modifications were observed. Quantitative evaluation assessed that arch dimensions had changed slightly (up to 1 mm). While the adolescent patient had no modifications in FACC inclinations, the 30-year-old patient showed significant alterations (up to 18 degrees). In all examinations of the adolescent patient, POC was higher than 86% and TC was lower than 10%. In the adult, POC was inside the normal range, while all TCs were higher than 10.5%. The larger TC measured in the adult may explain the larger modifications in the 3-dimensional position of his dental crowns. In conclusion, a surface EMG assessment may help in the detection of patients who might need post-orthodontic retention.

The purpose of this retrospective study was to analyze the accuracy of computer predictions by CASSOS (Computer-Assisted Simulation System for Orthognathic Surgery) 2001 software (2000 SoftEnable, Technology). Forty adult patients who had undergone orthognathic surgery were evaluated. Pre- and postsurgical lateral cephalographs were scanned into the computer, and 71 landmarks for each cephalograph were digitized. Digitization error was assessed from repeated digitizations. A customized cephalometric analysis consisting of 14 measurements was used in this study. Predicted and actual postsurgical hard tissue landmarks were compared using the Student t test. Results showed good correlation between repeated digitization for all measurements. There were no statistically significant differences in 10 of the 14 measurements. The differences that were statistically significant were in angular measurements for SNA angle, upper incisor to maxillary plane angle (U1-MxP), interincisal angle (U1-L1), and upper incisor to anterior cranial base angle (U1-SN). The greatest mean difference measured was the interincisal angle (U1-L1) which, although statistically significant, was clinically insignificant. This investigation showed that CASSOS 2001 software provides accurate hard tissue prediction for orthognathic surgical procedures.

The aim of this study was to register and assess the accuracy of the superimposition method of a 3-dimensional (3D) soft tissue stereophotogrammetric image (C3D image) and a 3D image of the underlying skeletal tissue acquired by 3D spiral computerized tomography (CT). The study was conducted on a model head, in which an intact human skull was embedded with an overlying latex mask that reproduced anatomic features of a human face. Ten artificial radiopaque landmarks were secured to the surface of the latex mask. A stereophotogrammetric image of the mask and a 3D spiral CT image of the model head were captured. The C3D image and the CT images were registered for superimposition by 3 different methods: Procrustes superimposition using artificial landmarks, Procrustes analysis using anatomic landmarks, and partial Procrustes analysis using anatomic landmarks and then registration completion by HICP (a modified Iterative Closest Point algorithm) using a specified region of both images. The results showed that Procrustes superimposition using the artificial landmarks produced an error of superimposition on the order of 10 mm. Procrustes analysis using anatomic landmarks produced an error in the order of 2 mm. Partial Procrustes analysis using anatomic landmarks followed by HICP produced a superimposition accuracy of between 1.25 and 1.5 mm. It was concluded that a stereophotogrammetric and a 3D spiral CT scan image can be superimposed with an accuracy of between 1.25 and 1.5 mm using partial Procrustes analysis based on anatomic landmarks and then registration completion by HICP.

Many 3-dimensional (3D) techniques have been utilized to register and analyze the face in 3 dimensions, but each system has its own merits and disadvantages. C3D is a relatively new 3D imaging system that was developed to capture the 3D geometry of the face. Landmark identification on 3D facial models is facilitated by a software-based facial analysis tool developed by the authors. The reproducibility of landmark identification was high for 20 of the chosen points (standard deviations of repeated placements of landmarks around their centroids were 0.5 mm or less). The method is useful in studying facial soft tissue changes following orthognathic surgery and other types of facial surgery, as well as assessing facial soft tissue growth and development of the craniofacial complex.

Excessive blood loss is one of the major complications of orthognathic surgery. Numerous strategies, including hypotensive anesthetic techniques and blood transfusion, have been developed to deal with the blood loss. Blood for transfusions can be obtained from banked blood or from autologous donation. In this study, the authors looked at 2 groups of patients who had bimaxillary orthognathic surgery. One group included patients who had autodonated blood (group 1) and who were operated on between 1991 and 1993, and the other patients did not autodonate and were operated on between 1998 and 2000 (group 2). It was found that fewer than 50% of patients in group 1 were transfused, and none of the group 2 patients were. A protocol to lessen blood loss that should obviate the need for blood transfusion is proposed. It is concluded that blood transfusion should no longer be a consideration during routine bimaxillary orthognathic surgery.

To determine the distribution of costs and various influencing factors in the entire process of surgical-orthodontic treatment in community hospital care, a retrospective study was carried out. The records and radiographs of 99 community hospital patients operated on between 1994 and 2001 were included. Cost analysis data were gathered from 4 phases of treatment: the orthodontics, the surgical outpatient assessments, the surgery/surgeries, and the inpatient period. The results showed that the surgical phases together are responsible for roughly 61% of the costs, 28% of which were attributed to the surgical operation itself. Orthodontics made up approximately 39% of the total costs, with an average of 26 visits. The average total costs of all treatments were US $6,206 +/- 912. Patients that could be operated on with bilateral sagittal split ramus osteotomy of the mandible only had the lowest costs, and those who required bimaxillary osteotomies had the highest costs. Of the several clinical and cephalometric measurements made in this study, only skeletal open bite and orthodontic space closure after tooth extraction were found to affect the costs. It can be concluded that surgical-orthodontic treatment is a rather expensive way to correct dentofacial malocclusions due to the high costs of the surgical phase. Skeletal open bite constituted the most costly entity, while malocclusion resulting from mandibular deformity was the cheapest.

A 17-year-old female patient presented with sequelae to ankylosis of the temporomandibular joint, which included vertical maxillary protrusion, anterior open bite, labial incompetence, micrognathia, undefined neck angle, facial asymmetry, Class II molar relationship, and Class III canine relationship. She presented with the following cephalometric and soft tissue data: SNA angle = 78 degrees, SNB angle = 70 degrees, incisor-nasion-point A = 11 degrees, incisor-nasion-point B = 33 degrees, Frankfort-mandibular plane angle = 43 degrees, occlusal plane = 25 degrees, subnasale-stomion = 20 mm, stomion superius-stomion inferius = 9 mm, stomion inferius-soft tissue menton = 30 mm, neck angle = 144 degrees, and chin projection = 10 mm. Orthognathic surgery and mandibular osteogenic distraction were employed, specifically Le Fort I osteotomy to decrease a vertical excess of 12 mm, augmentation genioplasty of 17 mm, and bilateral extraoral distractors of bidirectional vector for a 14-mm augmentation of the mandible. The result was satisfactory with minimal adverse complications.

The objectives of this retrospective study were to assess the clinical applications of mandibular step osteotomy (MSO) and to evaluate its long-term clinical morbidities. A total of 152 patients with MSO performed between 1990 and 1999 were assessed. Forty-two patients were successfully recalled through questionnaires and clinical parameters for clinical evaluation, which included (1) tooth sensibility; (2) periodontal status; (3) neurosensory deficit in terms of light-touch threshold, 2-point discrimination, and pain threshold; and (4) temporomandibular joint function. The patients were finally asked about their overall satisfaction with the surgical treatment. The result revealed that MSO was commonly indicated for the correction of mandibular hyperplasia. Clinical assessments showed that 2.75% of the teeth assessed had negative pulpal response, 3.9% showed mildly increased probing depth, and another 3.9% showed gingival recession. Neurosensory assessment revealed that 31% of the operating sites had an increased light-touch threshold, 4.8% had heightened 2-point discrimination, and 9% had an elevated pain threshold. Also, 9.7% of the patients showed reduced mouth opening and 17% had mild tenderness of masticatory muscles. Of all the patients assessed, 12% were not satisfied with the orthognathic treatment. The reasons included relapse, residual asymmetry, and persistent paresthesia.

Anterior maxillary osteotomy is frequently applied to skeletal Class II cases with maxillary protrusion. In addition to the anteroposterior problem, these cases are often accompanied with a long midfacial appearance and display of incisors and gingiva during smiling. In the application of anterior maxillary osteotomy to such patients, it is necessary to move the anterior maxillary segments upward as well as backward. Since the upward movement occasionally interferes with the intranasal endotracheal tube, orotracheal intubation is recommended for the operation. Recently, the use of a resin replica of the mandibular dental arch was introduced to place the anterior maxillary segment correctly in the planned position and to obtain the correct occlusion. This article reports on 3 maxillary protrusive skeletal Class II patients with deep overbites and vertical esthetic problems treated by this method. The treatment results show that all 3 patients exhibited large upward and backward movements of the anterior maxillary segments and desirable facial profiles, with a reduction of the deep overbites after the treatment. This case report demonstrates that the anterior maxillary osteotomy under orotracheal intubation with the use of a resin replica is a useful method to treat maxillary protrusive skeletal Class II patients with a large alveolar height.

Today many surgical procedures involving head and neck areas can be performed under local anesthesia and intravenous sedation. The authors add to this list the sagittal osteotomies of the mandibular rami, thereby avoiding the need for general anesthesia and a hospital stay. The authors designed a protocol to be followed in a multicenter study (Milan and Barcelona) and applied it in 35 clinical cases with Class II malocclusion. The surgical procedure was performed with the Monitored Anesthesia Care technique, a combination of regional anesthesia and intravenous sedation. The results were good in all the clinical cases; skeletal correction of Class II was achieved in all patients and there were no intraoperative or postoperative complications. The major advantage of this technique is the functional control of the temporomandibular joint, which avoids displacements caused by gravity and the muscular relaxation commonly seen under general anesthesia. Furthermore, this protocol allows a reduction in costs, duration of surgery, and patient morbidity and convalescence. When this technique is accepted without hesitation, all Class II patients with only mandibular deficiency deformity may be treated in the most suitable way, thus providing the most satisfactory outcomes for the patient, orthodontist, and surgeon.

The purpose of this report is to present a new method for placing orthodontic mini-implants using a stent fabricated on a selectively colored stereolithographic model. A stent was fabricated that incorporated a guide groove drilled in accordance with the planned direction of the mini-implant. Tooth crowns, gingiva, tooth roots, and the maxillary sinuses were clearly identified in the stereolithographic model. As a result, the stent could be fabricated while taking into account the anatomic characteristics of both the bone interior and the dental surface. A stent fabricated on the selectively colored stereolithographic model is suggested to be a promising device for guiding placement of orthodontic mini-implants adjacent to the tooth roots and the maxillary sinuses.

The authors evaluated the surgical area, indications, and procedures for segmental dentoalveolar osteotomy carried out on 16 jaws in 13 patients treated at the Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, between 1990 and 2001. Osteotomy was indicated mainly in cases where tooth repositioning by orthodontic treatment was limited, where social conditions (e.g., age, time, finances) precluded orthodontic treatment, or where revision of orthodontic or surgical treatment was required. In cases of maxillary anterior segmental dentoalveolar osteotomy, the modified Wunderer method was used, where after an incision was made in the palatal mucosa, a mucoperiosteal flap was abraded as much as possible until the area of the osteotomy on the palatal side could be visualized. In maxillary posterior segmental dentoalveolar osteotomy, the operation was carried out in 2 stages because of the risk of necrosis of the bone fragments. In the first stage, an osteotomy was carried out on the vestibular side, since the vestibular gingival pedicle was intact. In the second stage, 3 weeks later, another osteotomy was performed after the palatal mucoperiosteal flap was abraded to visualize the area of the osteotomy as well as that of the maxillary anterior segmental dentoalveolar osteotomy.

The skeletal anchorage system (SAS) consists of titanium anchor plates and monocortical screws that are temporarily implanted in either the maxilla or the mandible as absolute orthodontic anchorage. With SAS, anterior open bite can be improved by the counterclockwise rotation of the mandible, accompanied by the intrusion of molars. The present study was designed to evaluate treatment and posttreatment dentoalveolar changes following the intrusion of mandibular molars. Nine adult open bite patients (7 women and 2 men) successfully treated with SAS were included in the following study. The amount of intrusion, relapse, and dentoalveolar changes were measured on cephalometric radiographs, panoramic radiographs, and dental casts. The results of this study were as follows: (1) the average amount of intrusion of the mandibular first and second molars was 1.7 mm and 2.8 mm, respectively; (2) the average relapse rates were 27.2% at the first molars and 30.3% at the second molars; (3) there were no significant changes in crestal bone heights, clinical crown length, or root length; and (4) counterclockwise rotation of the mandible and decrease of anterior facial height were observed during treatment. Thus, it was concluded that SAS would be a valid modality to intrude mandibular molars for correction of open bite.

Maxillomandibular advancement is an integral part of the surgical treatment of patients suffering from obstructive sleep apnea. A number of publications report its efficacy and have attempted to define predictive success criteria. However, few authors have shown an interest in the surgical specificity of this intervention and in the difficulties that can be encountered, which differ from those seen in conventional orthognathic surgery. In this article, a series of patients treated with maxillomandibular osteotomy to correct obstructive sleep apnea syndrome (n = 17) are compared with patients who underwent surgery for the correction of dentofacial disharmonies (n = 33). Observations emphasized the importance of respecting a strict surgical and postsurgical protocol to avoid any technical traps linked to maxillomandibular advancement, both in preoperative simulations and during and after surgery. Results concerning sleep parameters will be the subject of a future publication.