Craniofacial Surgery

Evaluation of Vestibular Bone Thickness in Class I Malocclusion Treatment With Corticotomy-Assisted Rapid Orthodontics Background: Corticotomy-assisted rapid orthodontics is a widely used method for speeding up conventional orthodontics. This study evaluates the effects of corticotomy alone, corticotomy combined with bone graft, and corticotomy with platelet-rich fibrin (PRF) on vestibular alveolar bone thickness in patients with class I malocclusion;compares the treatment time with a conventional orthodontic therapy group, andinvestigates the periodontal health of patients who have undergone corticotomy-assisted rapid orthodontics. Methods: The patients were divided into 3 groups: Group 1 (n = 10) underwent corticotomy alone; Group 2 (n = 10) underwent corticotomy combined with bone graft, and Group 3 (n = 10) underwent corticotomy combined with PRF. In the following stage, vestibular alveolar bone thicknesses were evaluated using 3-dimensional cone-beam computed tomography images. Results: The findings showed that Group 2 achieved a more significant augmentation of the vestibular alveolar bone than Groups 1 and 3 (P = 0.001, P = 0.003), while corticotomy-assisted rapid orthodontics decreased treatment times. Sufficient alveolar bone thickness and preservation of the periodontal health were achieved when the corticotomy procedure was either combined with a bone graft or with PRF in the Class-I malocclusion patients. Conclusion: Bone grafts provided better bone thickness at the buccal surface of the anterior teeth of the mandible and maxilla, whereas the thickness of the keratinized gingiva was better with PRF. Address correspondence and reprint requests to Zeynep Burcin Gonen, DDS, PhD, Oral and Maxillofacial Surgery, Genome and Stem Cell Center, Erciyes University, 38039 Kayseri, Turkey; E-mail: zburcin@gmail.com Received 17 July, 2018 Accepted 8 May, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Computer-Assisted Design and Manufacturing Assists Less Experienced Surgeons in Achieving Equivalent Outcomes in Cranial Vault Reconstruction Purpose: The purpose of this study was to assess whether long-term outcomes were equivalent between computer-assisted design and manufacturing (CAD/CAM) -assisted cranial vault reconstruction performed by an inexperienced surgeon, with fewer years of surgical experience, and traditional reconstruction performed by senior surgeons with many decades of experience. Methods: An Institutional Review Board-approved retrospective cohort study was performed for all patients with nonsyndromic craniosynostosis between the ages of 1 month to 18 years who received primary, open calvarial vault reconstruction at the Johns Hopkins Hospital between 1990 and 2017. The primary outcome variable was the Whitaker category (I-IV) for level of required revision at the 2-year follow-up visit. Secondary outcomes included estimated blood loss, length of stay, operative time, and postoperative complications. CAD/CAM-assisted surgery was considered noninferior if the proportion of cases requiring any revision (Whitaker II, III, or IV) was no more than 10% greater than the proportion in the traditional surgery group with multivariate logistic regression analysis. t tests and fisher exact tests were used for secondary outcomes. Results: A total of 335 patients were included, with 35 CAD/CAM-assisted reconstructions. CAD/CAM-assisted reconstruction was noninferior to traditional after accounting for patient demographics, type of surgery, and experience level of the plastic surgeon. The traditional group required revision more frequently at 29.0% compared to CAD/CAM at 14.3%. Secondary outcomes were not significantly different between groups, but CAD/CAM had significantly longer average operative times (5.7 hours for CAD/CAM, 4.3 hours for traditional, P < 0.01). Conclusion: CAD/CAM technology may lower the learning curve and assist less experienced plastic surgeons in achieving equivalent long-term outcomes in craniofacial reconstruction. Address correspondence and reprint requests to Amir H. Dorafshar, MBChB, FACS, Division of Plastic and Reconstructive Surgery, Rush University Medical Center, 1725 E. Harrison St, Suite 425, Chicago, IL 60612; E-mail: amir_dorafshar@rush.edu Received 10 October, 2018 Accepted 27 May, 2019 Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). AD receives indirect research support and is entitled to royalties from KLS Martin. He also receives research support from DePuy Synthes. RSC has received research support from the Johns Hopkins Institute for Clinical and Translational Research (ICTR) which is funded in part by Grant Number TL1 TR001078 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), as well as the NIH Roadmap for Medical Research. All other authors have no disclosures to report. RSC and JL contributed equally to this work. © 2019 by Mutaz B. Habal, MD.

A Novel Stitching Technique: Adjustable Closed-Loop Sewing Machine Lock Stitching Technique to Bend or Unbend Cartilages This study aimed to evaluate the effect of a novel adjustable, closed-loop sewing machine lock stitching technique on cartilage shape. This study was performed on 18 rabbits that were divided into 3 groups to evaluate the short- (Group I), medium- (Group II), and long-term (Group III) effects of the technique on cartilage shape. Three cartilage grafts were obtained from the right and left ears of the rabbits and measured angularly. For the cartilage grafts obtained from the right ears, contours were corrected using the stitching technique proposed herein. The cartilage grafts obtained from the left ears were not stitched; these were maintained as the control group. Angular measurements were performed for the stitched cartilage grafts, and all the cartilages grafts obtained were finally embedded into the rabbits’ backs. The rabbits in Groups I, II, and III were euthanized at week 2, 6, and 12, respectively, after which the cartilages were reevaluated for angular measurement and submitted for histopathological examination. A significant improvement from baseline was detected in the angular measurements of the stitched cartilage grafts obtained from the rabbits in each group. For the stitched cartilage grafts obtained from Group II and III rabbits, the angular measurements obtained immediately after stitching were found to be better than those obtained after euthanasia. In histopathological evaluation elevated collagen, perichondrium, and connective tissue levels were detected in grafts obtained from Group III rabbits. The novel stitching technique proposed herein appears to have beneficial long-term effects on the maintenance of cartilage contour. Address correspondence and reprint requests to Serhat Sibar, MD, Muratdede Mah., Karci Yolu No: 57, 20010, Merkezefendi, Denizli, Turkey; E-mail: serhatsibar@hotmail.com Received 17 November, 2018 Accepted 8 May, 2019 This article presented at “Scientific Competition of Specialists-Experimental Studies” at the 39th Congress of the Turkish Society of Plastic Reconstructive and Aesthetic Surgery, October 11 to 14, 2017 Antalya, Turkey. The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Long-term Effects of Augmented Corticotomy-Assisted Orthodontics in Patients With Mandibular Anterior Alveolar Defect Objective: The purpose of this study was to quantitatively investigate the long-term effects of augmented corticotomy-assisted orthodontics in adult patients with alveolar defect in mandibular anterior region. Materials and Methods: Thirty lower incisors with alveolar defect on the labial sides were included in this study from 10 adult patients received augmented corticotomy-assisted orthodontics in mandibular anterior region. Cone-beam computed tomography images were obtained before orthodontic treatment (T0), 3 months after augmented corticotomy (T1) and 2 years after removal of orthodontic appliance (T2). Measurements of variables at different time points were compared using Student–Newman–Keuls test. Results: Each patient completed augmented corticotomy-assisted orthodontics successfully. In the 30 subjects studied, root length and bone thickness on the labial side at 1/2 root length level were maintained from T0 to T2 (P >.05). Bone thickness at 3/4 root length level increased from T0 to T1 (P <.001), then decreased from T1 to T2 (P <.001), and which of T2 is greater than that of T0 (P <.001). Bone thickness at root apex level increased from T0 to T1 (P <.001), and remained steady from T1 to T2 (P >.05). Conclusions: Augmented corticotomy-assisted orthodontics is a promising approach for the treatment of adult patients with alveolar defect, which showed stable long-term effect of bone augmentation and minimal periodontal iatrogenic sequelae during treatment. Address correspondence and reprint requests to Bing Fang, DDS, PhD, Department of Orthodontics, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, 500 Qu Xi Road, Huangpu District, Shanghai 200011, People's Republic of China; E-mail address: doctorfangbing@hotmail.com; Hongbo Yu, DDS, PhD, Department of Oral and Craniomaxillofacial Science, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, 500 Qu Xi Road, Huangpu District, Shanghai 200011, People's Republic of China; E-mail: yhb3508@163.com Received 6 January, 2019 Accepted 9 May, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Effect of Alveolar Bone Grafting on Health Quality in Patients With Cleft Lip and Palate Introduction: This study aimed to explore the effect of alveolar bone grafting on the clinical outcomes, health quality, and satisfaction in patients with cleft lip and palate. Materials and Methods: Questionnaire review study was done to patients who underwent secondary alveolar bone grafting retrospectively. This study included 28 patients who underwent secondary alveolar bone grafting by harvesting graft from the anterior iliac crest, excluding one, in Oral and Maxillofacial Department, Faculty of Dentistry, Ankara University, Turkey, during the period from January 2012 to March 2016. All patients were operated using the same technique and by the same surgical team. Patients were interviewed to fill Short-Form Health Survey (SF-12) and Postsurgical Patient Satisfaction Questionnaire (PSPSQ) 6 months postoperatively. The questionnaires were used to assess the relationship between health quality and patient satisfaction. Also, grafted sites were evaluated with respect to fistula, presence of cleft palate. Results: The sample consisted of 28 patients (19 females and 9 males), including 13 with bilateral clefts and 15 with unilateral clefts. The mean Physical Component Summary (PCS) and Mental Component Summary (MCS) of SF-12 scores were 54.5718 and 44.6436, respectively. The mean PSPSQ score was 36.7368. PCS scores were found to be significantly correlated with the PSPSQ scores (P ≤0.05). No correlation was found between MCS and PSPSQ scores (P >0.05). A precise and good planned surgery resulted in good satisfaction among patients with cleft lip and palate who underwent alveolar bone grafting. The patient satisfaction was correlated with the success of the operation. Address correspondence and reprint requests to Kevser Sancak, PhD, Ankara Üniversitesi, Diş Hekimliği Fakültesi, Beşevler, Ankara, Turkey; E-mail: kvsrttnclr@gmail.com Received 7 February, 2019 Accepted 12 May, 2019 This study was presented at CAOMS 2016 Annual Conference on Oral Maxillofacial Surgery at Halifax, Nova Scotia, Canada, held between June 2 and 4, 2016. The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Pediatric Cervicofacial Actinomycosis: Lessons From a Craniofacial Unit Actinomycosis is a rare disease that remains difficult to diagnose and manage. Prompted by 2 recent cases the authors sought evidence-based conclusions about best practice. A systematic review was conducted using standard PRISMA methodology. The study was registered prospectively (PROSPERO: CRD42018115064). Thirty-three children from 23 series are described. The mean age was 8 years (range 3–17). Fifty-five percent were female. Twenty cases involved bone (usually mandible); 13 cases involved cervicofacial soft tissue. Poor dental hygiene and oral trauma were implicated. The median diagnostic delay was 12 weeks (range 1–156 weeks). The median duration of definitive antibiotic therapy was 17 weeks (range 1–130 weeks). Although diagnostic delay did not correlate with number of surgeries, bony involvement was associated with more procedures (P  = 0.008, unpaired t test). All (6) cases with residual infection had bony involvement (P  = 0.06, Fisher exact test). Neither diagnostic delay nor number of surgeries significantly influenced infection-free outcome which, instead, relies on aggressive surgical debridement and prolonged antibiotic therapy. Mandibular involvement exhibits a higher surgical burden and chronicity in around a third of cases. As dental caries are implicated in mandibular disease, preventative strategies must focus on improving pediatric oral hygiene. Address correspondence and reprint requests to Graeme E. Glass, PhD, FRCS(Plast), Room C1-120, 1st Floor OPC, Al Luqta Street, Education City North Campus, Qatar Foundation, PO BOX 26999, Doha, Qatar; E-mail: gglass@sidra.org Received 5 March, 2019 Accepted 25 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Pediatric Maxillofacial Trauma Patterns Among Different Types of Road Traffic Accidents Background: Traffic accidents are one of the most leading cause of maxillofacial trauma. Defining the bone fracture patterns in different type of traffic accidents may enable for appropriate surgical approach. Objectives: This study research the pattern of pediatric maxillofacial fractures in terms of different type of traffic road accidents and age groups. Methods: The data on road traffic accidents that caused maxillofacial trauma between May 2014 and January 2019 was gained from the University of Gaziantep hospital data system. Road accident type, age groups, and the type of fractures were the evaluation parameters. Results: A total of 61 patients meet the criteria and 41 of those were boys. The midface bones of orbital, maxillar, and frontal are the most fractured structures with a total number of 48. The least fractured bone was mandibula with a number of 4. The comparisons of these fractures among the different type of road traffic accidents and age groups were found to be statistically significant. Conclusion: Car-pedestrian and car-passengers type of road traffic accident mostly seem to cause midface fractures at the primary and secondary school-aged children. Address correspondence and reprint requests to Alper Yazici, Otorhinolaryngology Department, University of Gaziantep Medical Faculty, Gaziantep, Gaziantep, Turkey; E-mail: alperyazici1@gmail.com Received 8 March, 2019 Accepted 30 May, 2019 Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Radiologic Evaluation of Exiting Points of Supraorbital Region Neurovascular Bundles in Patients With Migraine Purpose: To reveal the presence and nature of exiting points of supraorbital region neurovascular structures and determine the distances of those structures to midline with computed tomography images by taking into account gender and sides in patients with migraine. Methods: The study was conducted retrospectively on computed tomography images of 70 migraine and 70 control patients with a mean age of 39.5 ± 13.8 years (range: 18–80). Presence and nature (foramen or notch) of exiting points of neurovascular structures in terms of side and gender in both groups, and the distances of these structures to the midline of the face were evaluated. Results: In migraine and control groups, the most commonly seen structure was single notch. Coexistence of foramen and notch was statistically significant in migraine and female migraine groups than control and female control groups (P < 0.05). Bilateral presence of supraorbital structure was 51.4% in migraine group and 64.3% in control group patients. In all cases, foramen-midline distance was statistically significant longer than the notch-midline distance (P < 0.05). In migraine patients, no statistically significant difference was detected regarding distances of foramen and notch to midline in terms of side and gender. Conclusion: Consideration of variable presence and location of the supraorbital notch and foramen, analysis of computed tomography scan might be beneficial in preoperative planning of foraminotomy and fascial band release in adult migraine patients to prevent intraoperative complications. Also, coexistence is more frequent on left side in migraine patients that might cause overlooking those structures during surgery. Address correspondence and reprint requests to Özlem Elvan, PhD, School of Health, Mersin University, Çiftlikköy Campus, Yenişehir, 33343 Mersin, Turkey; E-mail: ozlemelvan33@gmail.com Received 13 March, 2019 Accepted 30 May, 2019 Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Virtual Surgical Planning in Craniofacial Surgery Background: Virtual surgical planning (VSP) is increasingly described in craniofacial surgery literature. However, the quality of the literature that has been published is unknown. The objective of this systematic review was to determine the level of evidence of published articles on VSP. Methods: In this systematic review, PubMed, Web of Science, and ScienceDirect databases were queried for key terms in craniofacial VSP. Inclusion and exclusion criteria concentrated on patient-specific surgical outcomes in studies that could be rated for level of evidence. The articles were ranked according to their level of evidence, with level I being the highest level of evidence (randomized-controlled trials) and level V being the lowest (eg, case reports). Results: The initial keyword search yielded 1524 articles, 273 of which were ranked and included in the systematic review. The average level of evidence for an article published was 4.1 (between level IV and level V). Level IV was the most common level of evidence (65.6%), followed by level V (24.9%), level III (7.3%), level II (2.2%), respectively. There were not any level I articles. The most common study type was case series, accounting for 68.1% of the studies, followed by case reports (23.0%), case-control studies (4.7%), cohort studies (3.3%), and randomized controlled trials (1.1%), respectively. Conclusion: Although the quantity of craniofacial VSP studies has proliferated, the quality of the studies has not. In order for VSP literature to feature a higher level of evidence, future studies would require more sophisticated study design, such as prospective cohort or prospective randomized control trials. Address correspondence and reprint requests to Lindsey N. Teal, BS, 4646 Mueller Blvd, Apt. 1063; Austin, TX 78723; E-mail: lindseyteal14@gmail.com Received 29 March, 2019 Accepted 9 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Virtual Surgical Planning and One-Stage Treatment of Active Hemimandibular Hyperplasia Hemimandibular hyperplasia was first described in 1836 by Adams as a disorder that causes condylar hyperplasia, deforming facial asymmetry and has an unknown etiology. The objective of this study was to report a patient with surgical correction through orthognathic surgery and high condilectomy for the treatment of hemimandibular hyperplasia. The patient complained of pain and cracking in the right temporomandibular joint region and was dissatisfied with the aesthetic appearance of the face. Virtual planning was done for bimaxillary orthognathic surgery and preparation of prototyped surgical guides. Stereolithographic models were used for the preparation of the acrylic guides of the osteotomies for the high condilectomy and the contour of the mandibular base. Orthognathic surgery resulted in the maxillary repositioning with correction of the inclination of the occlusal plane, reduction of the height of the ramus and right mandibular body and class I dental attachment. Mandibular contour osteotomy was performed with acrylic guide in the basilar. The condilectomy was performed by endaural access. In 2-year follow-up, there are no signs of recurrence. Address correspondence and reprint requests to Jiordanne Araújo Diniz, MSc, Faculdade de Odontologia, Universidade de Pernambuco, Av Gen Newton Cavalcanti, 1650 Tabatinga, Camaragibe, PE, CEP 54.753-220, Brazil; E-mail: jiordannediniz18@hotmail.com Received 12 April, 2019 Accepted 13 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.