[Show abstract][Hide abstract] ABSTRACT: : Bilateral mandibular condylar fractures accounts for 24% to 33% of condylar fractures but the indications of open reduction of bilateral condylar fracture are still controversial. It is generally accepted that displaced subcondylar fractures are indicated for open reduction, but the proper treatment of condylar head fractures are still variable. This retrospective study compares the radiographical and functional outcomes of bilateral condylar head fractures between open and closed reduction groups.
From February 1994 to June 2012, a total of 85 patients with bilateral condylar head fractures were retrospectively reviewed. Among this group, 41 cases underwent open reductions while the other 44 cases had closed reductions. Only adult patients with adequate follow-up and complete radiographic study were included in this study: consisting of 20 patients in the open group and 18 patients in the closed group.The subjective symptoms including temporomandibular joints (TMJ) symptoms, complications or adverse sequelae, and functional results, such as maximal mouth opening, were recorded. The outcome of patient's satisfaction was individually assessed by an independent reviewer. The computed tomographic results after treatment were evaluated between both groups.
The mean follow-up period was 25.5 ± 13.3 months. The open reduction group had better postoperative chewing functions, less malocclusion rates, less degree of TMJ pain (p = 0.046), better radiographic outcome ("p = 0.036), and an overall satisfaction rate (p = 0.039).There were 4 cases of failure in the closed reduction group. Subsequent open reduction (n = 2) and redo closed reduction with intermaxillary fixation (n = 2) were performed. Eleven patients in the close reduction group presented persistent malocclusion through objective evaluation. The subsequent treatment included further orthognathic surgery (n = 1) and orthodontic treatment (n = 7). Three of the patients refused further treatment.
Open reduction for bilateral condylar head fractures presented an overall better functional and radiographic outcome, with higher patient satisfaction if condylar fracture segments were still feasible for rigid fixation.
Annals of Plastic Surgery 02/2015; 74. DOI:10.1097/SAP.0000000000000457 · 1.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Upper airway narrowing has been a concern of mandibular setback. The aims of this study were (1) to evaluate the effect of bimaxillary rotational setback surgery on upper airway structure in patients with skeletal class III deformities, and (2) to compare the preoperative and postoperative upper airways of class III patients with age- and sex-matched class I control subjects.
The upper airways of 36 adults who consecutively underwent bimaxillary rotational setback surgery for skeletal class III deformities were assessed by means of cone-beam computed tomography before and at least 6 months after surgery. Results were compared with those of age- and sex-matched control subjects with skeletal class I structure.
Before surgery, the class III patients had significantly larger velopharyngeal, oropharyngeal, and hypopharyngeal volumes than did the control subjects (all p < 0.01). The velopharyngeal, oropharyngeal, and hypopharynx volumes decreased significantly after surgery (all p < 0.01). The postoperative airways of class III patients were similar with regard to velopharyngeal, oropharyngeal, and hypopharyngeal volume (all p > 0.01) compared to control subjects. The postoperative velopharyngeal and oropharyngeal airway volumes were associated with the baseline airway volume (p < 0.001) and horizontal movement of the soft palate (p < 0.01).
These results suggest that upper airway volume is decreased after bimaxillary rotational setback surgery for skeletal class III deformities, but is not smaller than in normal controls, and the postoperative upper airway volume is related to airway volume at baseline and changes in the surrounding structures.
[Show abstract][Hide abstract] ABSTRACT: The study was conducted to evaluate the effect of early physical rehabilitation by comparing the differences of surface electromyographic (sEMG) activity in the masseter and anterior temporalis muscles after surgical correction of skeletal class III malocclusion. The prospective study included 63 patients; the experimental groups contained 31 patients who received early systematic physical rehabilitation; the control group (32 patients) did not receive physiotherapy. The amplitude of sEMG in the masticatory muscles reached 72.6–121.3% and 37.5–64.6% of presurgical values in the experimental and control groups respectively at 6 weeks after orthognathic surgery (OGS). At 6 months after OGS, the sEMG reached 135.1–233.4% and 89.6–122.5% of presurgical values in the experimental and control groups respectively. Most variables in the sEMG examination indicated that recovery of the masticatory muscles in the experimental group was better than the control group as estimated in the early phase (T1 to T2) and the total phase (T1 to T3); there were no significant differences between the mean recovery percentages in the later phase (T2 to T3). Early physical rehabilitative therapy is helpful for early recovery of muscle activity in masticatory muscles after OGS. After termination of physical therapy, no significant difference in recovery was indicated in patients with or without early physiotherapy.
Journal of Cranio-Maxillofacial Surgery 11/2014; 43(1). DOI:10.1016/j.jcms.2014.10.028 · 2.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this prospective study was to compare the mandibular range of motion in Class III patients with and without early physiotherapy after orthognathic surgery (OGS). This study consisted of 63 Class III patients who underwent 2-jaw OGS. The experimental group comprised 31 patients who received early systematic physical rehabilitation. The control group consisted of 32 patients who did not have physical rehabilitation. Twelve variables of 3-dimensional (3D) jaw-motion analysis (JMA) were recorded before surgery (T1) and 6 weeks (T2) and 6 months (T3) after surgery. A 2-sample t test was conducted to compare the JMA results between the two groups at different time points. At T2, the JMA data were measured to be 77.5%–145.7% of presurgical values in the experimental group, and 60.3%–90.6% in the control group. At T3, the measurements were 112.2%–179.2% of presurgical values in the experimental group, and 77.6%–157.2% in the control group. The patients in the experimental group exhibited more favorable recovery than did those in the control group, from T1 to T2 and T1 to T3. However, after termination of physiotherapy, no significant difference in the extent of recovery was observed between groups up to 6 months after OGS.
Journal of Cranio-Maxillofacial Surgery 11/2014; 43(1). DOI:10.1016/j.jcms.2014.10.025 · 2.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The surgery-first approach in orthognathic surgery has recently created a broader interest in completely eliminating time-consuming preoperative orthodontic treatment. Available evidence on the surgery-first approach should be appraised to support its use in orthognathic surgery. A MEDLINE search using the keywords "surgery first" and "orthognathic surgery" was conducted to select studies using the surgery-first approach. We also manually searched the reference list of the selected keywords to include articles not selected by the MEDLINE search. The search identified 18 articles related to the surgery-first approach. There was no randomized controlled clinical trial. Four papers were excluded as the content was only personal opinion or basic scientific research. Three studies were retrospective cohort studies in nature. The other 11 studies were case reports. For skeletal Class III surgical correction, the final long-term outcomes for maxillofacial and dental relationship were not significantly different between the surgery-first approach and the orthodontics-first approach in transverse (e.g., intercanine or intermolar width) dimension, vertical (e.g., anterior open bite, lower anterior facial height) dimension, and sagittal (e.g., anterior-posterior position of pogonion and lower incisors) dimension. Total treatment duration was substantially shorter in cases of surgery-first approach use. In conclusion, most published studies related to the surgery-first approach were mainly on orthognathic correction of skeletal Class III malocclusion. Both the surgery-first approach and orthodontics-first approach had similar long-term outcomes in dentofacial relationship. However, the surgery-first approach had shorter treatment time.
[Show abstract][Hide abstract] ABSTRACT: Maxillomandibular advancement (MMA) is effective in the treatment of obstructive sleep apnoea. We aimed to assess changes in the calibre of the upper airway, facial skeleton, and surrounding structural position after MMA and their association with improvement in symptoms. Sixteen consecutive adults with moderate-to-severe apnoea were treated by primary MMA. Polysomnography and computed tomography (CT) of the head and neck were done before and at least 6 months after MMA. The calibre of the upper airway, the facial skeleton, and the surrounding structures were measured with image analysis software. After MMA, patients had a significant reduction in their apnoea-hypopnoea index (31.2 (18.8) number of events (n)/hour (h)). The mean (SD) volume of the airway increased significantly in the velopharynx (p < 0.01), oropharynx (p = 0.001), and hypopharynx (p < 0.001) (by 2.3 (2.4), 2.1 (2.6), and 1.7 (1.1) cm3, respectively) and the length of the airway was significantly decreased (by 3.1 (3.5) mm p < 0.01). The soft palate (p < 0.001), tongue (p < 0.001), and hyoid (p = 0.001) moved significantly anteriorly (by 4.4 (2.0), 7.5 (2.8), and 5.7 (5.0) mm, respectively), and these movements were related to the MMA (r = 0.6–0.8). The improvement in the apnoea-hypopnoea index was associated with both maxillary advancement and anterior movements of the soft palate and hyoid (r = 0.6–0.7). The results of this study suggest that MMA increases the volume in the upper airway and reduces its length. Improvement in obstructive sleep apnoea is associated with the extent of the anterior movements of the maxilla, soft palate, and hyoid.
British Journal of Oral and Maxillofacial Surgery 05/2014; 52(5). DOI:10.1016/j.bjoms.2014.02.006 · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Although the appropriate management of condylar process fractures after miniplate or microplate fixation has been described, there has been no comparative analysis of these plating systems.
A retrospective review of patients who underwent open reduction and internal fixation (ORIF) of condylar head or neck fractures at our institution from January 2000 through August 2010 identified 70 patients. Of these, 38 were treated with microplates and 32 with miniplates. The primary functional and radiographic results were the maximal mouth opening and condylar bone resorption, respectively. The rates of complications, including malocclusion, chin deviation, temporomandibular joint complaints, and facial nerve palsy, were recorded.
The maximal mouth opening was larger in the microplate group than in the miniplate group throughout the follow-up period; this difference was statistically significant 12 (P = 0.020), 18 (P = 0.026), and 24 (P = 0.032) months after ORIF. Similarly, the radiographic scores for bone resorption and condyle morphology were significantly better in the microplate group than in the miniplate group throughout the follow-up period [6 (P = 0.011), 12 (P = 0.035), 24 (P = 0.026), and 48 (P = 0.040) months after ORIF]. Moreover, patients who underwent miniplate fixation experienced a significantly higher incidence of temporomandibular joint click than those who underwent microplate fixation (P = 0.014).
Microplates limit dissection, providing excellent fixation for intracapsular condylar head fractures, and also provide adequate rigidity for fixation of condylar neck fractures. Microplate fixation of condylar head and neck fractures yielded excellent functional and radiographic results. The rates of complications after microplate fixation were equal to or less than those in the miniplate group. Prospective studies are needed to confirm these findings.
Annals of Plastic Surgery 12/2013; 71(supplement):s61. DOI:10.1097/SAP.0000000000000040 · 1.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction:
Most condylar process fractures can be managed conservatively with satisfactory outcome. However, unsuccessful treatment can result in malocclusion and facial asymmetry. We report our experience in surgical management of malunited condylar process fractures.
This is a retrospective review of clinical records, photographs, imaging, and dental models of 12 consecutive patients who presented with malocclusion and facial asymmetry after nonoperative or failed treatment of condylar process fractures. Eight patients who presented relatively early (<6 months) after the initial trauma were treated with subcondylar osteotomy (SCO), whereas 4 patients who presented relatively late (>18 months) were treated with sagittal split osteotomy (SSO). These 2 groups were compared in terms of 3 parameters, namely, maximum mouth opening, aesthetic improvement, and patient satisfaction.
The 2 groups were statistically similar in all 3 parameters, with the SCO group trending toward higher scores in all 3 parameters. The mean increase in maximal mouth opening in the SCO group was 21 versus 2.5 mm in the SSO group.
Subcondylar osteotomy, performed at a relatively early time point, is at least as effective, if not more effective, than traditional SSO in the treatment of subcondylar malunions. Given this finding, a lower threshold should be adopted for the primary treatment of acute subcondylar fractures with open reduction and internal fixation, especially those with moderate displacement that may be at high risk for malunion.
Annals of Plastic Surgery 12/2013; 2013(71):S8-S12. DOI:10.1097/SAP.0000000000000039 · 1.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Craniofacial Neurofibromatosis is a benign but devastating disease. While the most common location of facial involvement is the orbito-temporal region, patients often present with significant mid-face deformities. We reviewed our experience with Craniofacial Neurofibromatosis from June 1981 to June 2011 and included patients with midface soft tissue deformities defined as gross alteration of nasal or upper lip symmetry. Data reviewed included the medical records and photobank. Over 30 years, 52 patients presented to and underwent surgical management for Craniofacial Neurofibromatosis at the Chang Gung Craniofacial Center. 23 patients (43%) demonstrated gross mid-facial deformities at initial evaluation. 55% of patients with lip deformities and 28% of patients with nasal deformities demonstrated no direct tumour involvement. The respective deformity was solely due to secondary gravitational effects from neurofibromas of the cheek subunit. Primary tumour infiltration of the nasal and/or labial subunits was treated with excision followed by various methods of reconstruction including lower lateral cartilage repositioning, forehead flaps, free flaps, and/or oral commissure suspension. Soft tissue deformities of the midface are very common in patients with Craniofacial Neurofibromatosis and profoundly affect overall aesthetic outcomes. Distinguishing primary from secondary involvement of the midface assists in surgical decision making.
Journal of cranio-maxillo-facial surgery: official publication of the European Association for Cranio-Maxillo-Facial Surgery 10/2013; 42(5). DOI:10.1016/j.jcms.2013.07.032 · 2.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Vomer flap repair is assumed to improve maxillary growth because of reduced scarring in growth-sensitive areas of the palate. Our aim was to evaluate whether facial growth in patients with unilateral cleft lip and palate was significantly affected by the technique of hard palate repair (vomer flap versus two-flap).
For this retrospective longitudinal study, we analyzed 334 cephalometric radiographs from 95 patients with nonsyndromic complete unilateral cleft lip and palate who underwent hard palate repair by two different techniques (vomer flap versus two-flap). Clinical notes were reviewed to record treatment histories. Cephalometry was used to determine facial morphology and growth rate. The associations among facial morphology at age 20, facial growth rate, and technique of hard palate repair were assessed using generalized estimating equation analysis.
The hard palate repair technique significantly influenced protrusion of the maxilla (SNA: β = -3.5°, 95 % CI = -5.2-1.7; p = 0.001) and the anteroposterior jaw relation (ANB: β = -4.2°, 95 % CI = -6.4-1.9; p = 0.001; Wits: β = -5.7 mm, 95 % CI = -9.6-1.2; p = 0.01) at age 20, and their growth rates (SNA p = 0.001, ANB p < 0.01, and Wits p = 0.02).
The results suggest that in patients with unilateral cleft lip and palate, vomer flap repair has a smaller adverse effect than two-flap on growth of the maxilla. This effect on maxillary growth is on the anteroposterior development of the alveolar maxilla and is progressive with age. We now perform hard palate closure with vomer flap followed by soft palate closure using Furlow palatoplasty.
These findings may improve treatment outcome by modifying the treatment protocol for patients with unilateral cleft lip and palate.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: The purposes of this study were to 1) investigate longitudinal changes in electromyographic masticatory activity subsequent to orthognathic surgery (OGS) in patients with skeletal Class III malocclusion, and 2) compare masticatory muscle activity and skeletal factors in patients with stable versus relapsed mandibular positions after OGS. MATERIALS AND METHODS: A consecutive series of patients with skeletal Class III malocclusion who underwent 2-jaw OGS (35 patients, 17 men and 18 women; age, 24.5 ± 5.0 yr) were included. Lateral cephalometric films were obtained preoperatively (T1), 1 month after OGS (T2), and at completion of orthodontic treatment (T3). Serial cephalometric tracings and analyses were obtained. Surface electromyograms of the anterior temporalis and masseter muscles were recorded at T1, T2, and T3 (6 mo after OGS). Resting tonus, maximum voluntary clench with habitual intercuspation and on cotton pads, and maximum muscle firing were evaluated. Percentage of overlapping coefficient and torque coefficient were calculated. Patients were categorized further into stable and relapse groups according to the sagittal relapse rate of mandibular setback. These surface electromyographic variables were compared between the 2 groups. RESULTS: On average, the mandible showed a significant setback of 10.19 mm and a relapse of 1.12 mm (10.99%). Surgical relapse did not correlate with gender or genioplasty. Serial surface electromyographic data indicated a significant decrease from T1 to T2 that then recovered from T2 to T3. No significant difference between T1 and T3 was noted. Percentage of overlapping coefficient was significantly decreased after OGS. The torque coefficient did not differ significantly from T1 to T3. The relapse group (relapse, >11%; n = 15) had a greater resting tonus of the anterior temporalis muscle at T3, a larger percentage of overlapping coefficient at T1, and a greater maximum voluntary clench of the masseter muscles at all times than in the stable group (n = 20). The relapse group exhibited a greater decrease in facial height (2.18 mm) from T2 to T3 than did the stable group (0.5 mm). CONCLUSION: A larger sagittal relapse of mandibular setback occurred in patients with greater masticatory muscle activity. Modifications in surgical design and overcorrection should be considered in patients with greater masticatory muscle activity before OGS.
Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons 04/2013; 71(7). DOI:10.1016/j.joms.2013.01.002 · 1.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Interferon Regulatory Factor 6 (IRF6) is a member of the IRF family of transcription factors. It has been suggested to be an important contributor to orofacial development since mutations of the IRF6 gene has been found in Van der Woude (VWS) and popliteal pterygium syndromes (PPS), two disorders that can present with isolated cleft lip and palate. The association between IRF6 gene and cleft lip and palate has also been independently replicated in many populations.
We screened a total of 155 Taiwanese patients with cleft lip with or without cleft palate (CL/P); 31 syndromic (including 19 VWS families), 44 non-syndromic families with at least two affected members, and 80 non-syndromic patients through a combined targeted, polymerase chain reaction (PCR)-based mutation analysis for the entire coding regions of IRF6 gene.
We found 11 mutations in 57.89% (11/19) of the VWS patients and no IRF6 mutation in 44 of the non-syndromic multiplex families and 80 non-syndromic oral cleft patients. In this IRF6 gene screening, five of these mutations (c.290 A>G, p.Tyr97Cys; c.360-375 16 bp deletion, p.Gln120HisfsX24; c.411_412 insA, p.Glu136fsX3; c.871 A>C, p.Thr291Pro; c.969 G>A, and p.Trp323X) have not been reported in the literature previously. Exon deletion was not detected in this series of IRF6 gene screening.
Our results confirm the crucial role of IRF6 in the VWS patients and further work is needed to explore for its function in the non-syndromic oral cleft with vary clinical features.
BMC Medical Genetics 03/2013; 14(1):37. DOI:10.1186/1471-2350-14-37 · 2.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to provide an overview of a single-institution, 30-year surgical experience with the soft tissue management of orbitotemporal neurofibromatosis. Lessons learned are highlighted in case presentations.
From 1981 to 2011, all patients who presented to the Chang Gung Memorial Hospital Craniofacial Center with craniofacial neurofibromatosis and orbitotemporal involvement were retrospectively reviewed. The medical records of those patients who underwent surgical correction were reviewed for age, extent of involvement, procedures performed, histologic confirmation, and acute complications. All patients were grouped according to the Jackson Classification. The electronic photobank was queried to evaluate results.
Thirty-five patients presented to our center with orbitotemporal neurofibromatosis during the study period. Thirty-one patients underwent surgical management of their disease. The average age was 25 years (range 4 to 57 years). Over half of our patients (n = 18) presented with concomitant disease of the cheek. The 2 most common procedures performed were lateral canthopexy (n = 24) and upper eyelid excision (n = 24). The only acute complication recorded was a postoperative hematoma on the fourth postoperative day following simultaneous lateral canthopexy and upper eyelid excision which required operative evacuation.
In orbitotemporal neurofibromatosis, tissue hyperextensibility and tumor weight adversely affect outcomes. Treatment of concomitant disease of the cheek should be prioritized in order to provide periorbital support prior to addressing the delicate structures of the eyelids. Preservation of the lateral canthal unit and levator muscle, despite neurofibroma infiltration, is critical to maximize outcomes following debulking procedures of the eyelid and orbit.
The Journal of craniofacial surgery 01/2013; 24(1):269-72. DOI:10.1097/SCS.0b013e318270fadd · 0.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:
There is prominent lip asymmetry in patients with unilateral complete cleft lip and palate. Measurement of the lip on cleft and non-cleft sides provides appraisal of the lip deformity and information for planning of surgical correction. The purpose of this retrospective study is to evaluate the degree of lip deformity and to compare it with normative data.
Materials and methods:
From 1983 to 1997, data from a total of 168 patients with unilateral complete cleft lip and palate were collected. There were no other associated craniofacial anomalies in this patient group. The measurement was performed under general anaesthesia by a senior surgeon using a calliper prior to the first lip repair. Corresponding normative data were collected from 2002 to 2003 on 50 patients who had normal facial appearance prior to hernia repair. The measurements included lip height, lip width, philtrum length and vermilion thickness. Comparisons were made between the cleft side and the non-cleft side, as well as between cleft patients and norms.
Comparisons between the cleft and the non-cleft sides revealed significantly longer lip on the non-cleft side, including lip height from alar base to Cupid's bow, lip width from Cupid's bow to commissure and the vermilion thickness. The lip measurements on the norms were longer than those on the cleft side of the lip, but were similar to the non-cleft side.
A wide variety of tissue growth asymmetry is observed between the non-cleft and the cleft sides, indicating a deficiency of tissue development associated with the cleft deformity. These data can provide a fundamental basis for presurgical orthopaedic treatment, surgical planning, execution of surgery, postoperative assessment and may help to predict treatment outcome.
Journal of Plastic Reconstructive & Aesthetic Surgery 12/2012; 66(4). DOI:10.1016/j.bjps.2012.12.002 · 1.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Retrobulbar haematoma formation is a known complication following facial trauma involving the orbits. This is an important clinical entity as it can lead to permanent vision loss if not appropriately managed in the acute setting.
From 1999 to 2009, 2586 patients presented to the Chang Gung Memorial Hospital with orbital fractures. Eight patients presented with nine retrobulbar haematomas. A retrospective review of the patient's medical records was performed. Analysis of visual outcomes was performed based on the improvement degree (ID) formula.
The average age of our patients is 24.5 years with the most common cause of trauma being motor vehicle (motorcycle) collisions. Visual acuity and the light reflex were abnormal in all patients. Five patients (case #1-5) demonstrated an absent relative afferent pupillary defect (RAPD). Computed tomography imaging confirmed the presence of a retrobulbar haematoma in all patients. The average follow-up was 14.5 months (range: 6-20 months). Management was divided into three cohorts: observation alone, medical therapy alone or a combined surgical and medical therapy. The best visual outcomes (ID = 82%) were achieved in the combined treatment group. The worst outcomes (ID = 42%) were in the medical therapy alone group.
In review of our experience, we have found that the presence or absence of an RAPD is the most sensitive indicator of optic nerve compromise and necessity for intervention. An algorithm was also developed based on this study. Once a decision is made to intervene on a retrobulbar haematoma, both medical and surgical therapies should be instituted with a priority given to timely decompression of the orbit.
Journal of Plastic Reconstructive & Aesthetic Surgery 06/2012; 65(10):1325-30. DOI:10.1016/j.bjps.2012.04.037 · 1.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: . The aim of this study was to evaluate the position and dimensions of the genial tubercle in a Taiwanese sample.
Cone-beam computerized tomography (CT) records of 90 adult patients with class I or class II skeletal type were used to evaluate the position and dimensions of the genial tubercle and dimensions of the anterior mandible. Subjects were grouped by sex and skeletal type.
In all groups, the genial tubercle height was close to the genial tubercle width. The distance from the inferior border of the genial tubercle to the inferior border of the mandible was greater in class II male patients than in class I female patients (P < .05). The anterior mandible in class I male patients was thicker than in class II female patients (P < .05).
The variable position and dimensions of this structure among patients suggest the need for cone-beam CT before attempting genioglossus advancement to treat obstructive sleep apnea.