DO REGIONAL NERVE BLOCKS PRIOR TO BIMAXILLARY SURGERY REDUCE POST-OPERATIVE PAIN? Publication date: Available online 28 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s): Vikram Shetty, Bylapudi BhanuPrakash, Anirudh Yadav, Nanda Kishore P, Akash Menon Abstract Purpose Any elective surgery should be as atraumatic to the patient as possible allowing for comfortable post-operative recovery. This study was carried out to evaluate the efficacy of pre-surgical regional blocks in reducing pain, discomfort and analgesic use in patients scheduled to undergo bimaxillary surgery. Methods A prospective double-blinded randomized controlled trial was conducted to include all patients between 16 to 30 years requiring bimaxillary surgery, excluding patients with syndromes and systemic conditions. The primary predictor variable was the maxillary and mandibular nerve blocks (extraoral lateral pterygoid method) administered pre-surgically in the operating room using 0.25% bupivacaine hydrochloride. Standard anaesthetic and post-operative protocols were followed. Primary outcome variable was post-operative pain and secondary outcome variables were post-operative discomfort, analgesic consumption, duration of surgery and blood loss. Unpaired t-test and Mann-Whitney test were used for statistical analyses with p < 0.05 considered to be statistically significant. Results A total of 110 patients were included in the study (55 - control group; 55 - test group) of which 61 were female and 49 were male. Postoperative pain described using VAS was significantly lower (p < 0.001) in the test group compared to the control group. Secondary outcome variables like post-operative discomfort and analgesic consumption were also significantly lower in the test group. Significant positive correlation was present between the duration of surgery and pain measured at 6, 12, 24 and 48 hours postoperatively in both groups. Conclusion Based on our results, it can be established that administration of pre-surgical regional blocks using 0.25% bupivacaine immediately prior to bimaxillary surgery can effectively minimize the post-operative pain, discomfort and the consumption of analgesics.

The Midfacial Advancement Line - a comparative evaluation of a new measurement method in orthognathic surgery Publication date: Available online 28 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s): K. Willinger, J. Cede, G. Guevara-Rojas, K. Sinko, M. Figl, K. Schicho, S. Nemec, Klug C Abstract Purpose For planning an intraoral quadrangular Le Fort II osteotomy (IQLFIIO), simulation of hard- and soft tissue changes is important at the infraorbital, Le Fort I and incisor level. The aim of this study was to evaluate a new method for visualization and quantification. Material and Methods Three different methods of quantification were compared: The Point-to-Point (PTP) measurement, which can be seen as a gold-standard method, the Part Comparison Analysis (PCA) and a new method: the Midfacial Advancement Line (MFAL) measurement. This study was performed as a measurement comparison study using the Bland-Altman method to measure agreement and enrolled patients suffering from midfacial deficiency and Class III malocclusion, who underwent IQLFIIO. The primary predictor variable was the method of measurement. The primary outcome variable was the midfacial advancement. We also investigated time required, visualization quality and inter-observer agreement. Results The sample included 12 subjects with a mean age of 21.6 years, 7 patients were male. PTP and MFAL showed no significant observer dependence. The advancement measured with PTP and MFAL showed no significant difference, whereas the advancement measured with MFAL and PCA showed a significant difference. The highest rating of visualization was found for MFAL. Time requirements were similar in all three methods. Conclusion The Midfacial Advancement Line is a suitable method for visualization and quantification of soft and hard tissue changes in all three face levels in one image. It may be a valuable tool for virtual planning of midfacial advancement surgery.

News and Announcements Publication date: Available online 28 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s):

Long Term Post-Operative Cone Beam Commuted Tomography Analysis of Secondary Bone Grafting in 79 Patients with Unrepaired Alveolar Clefts Publication date: Available online 25 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s): Tamir Dean Anver, Lida Mirzai, Peng Li, Kathlyn Powell, Peter D. Waite Abstract Purpose Use cone-beam computed tomography (CBCT) analysis to assess the long term radiographic outcomes of early secondary alveolar bone grafting. Patients and Methods The most recent post-operative CBCT of 79 alveolar cleft patients that underwent of anterior iliac crest bone grafting (AICBG) by a single surgeon over 6 years and met all inclusion criteria was analyzed using the modified assessment tool. Clefts were measured vertically, horizontally and superiorly in terms of nasal support, then assigned corresponding scores of 0-4 to help determine radiographic success. The sites were interpreted as poor (0 or 1), acceptable (2 or above), or favorable (3 or above). Similarly, clefts overall (vertical + horizontal) were poor (0-3), acceptable (4 or above) or favorable (5 or above). Statistical analysis was used to characterize patient demographics, subgroup comparisons, and to identify factors specifically predictive of favorable outcomes. Results 79 patients with a total of 105 clefts were included. 60.8% were male, and 32.9% had a bilateral cleft. The average age at time of surgery was 8 years 0 months, and average time to furthest post-op CBCT was 2 years 8 months. The average scores were: vertical – 2.9 (4), horizontal – 3.1 (4), nasal support – 2.7 (4), cleft overall – 6.0 (8). All 79 patients were discharged on post op day #1 and the re-graft rate was 0%. Multivariate analysis demonstrated that younger patients had a significantly higher chance of achieving favorable results in terms of vertical scores (p=0.0081) and cleft overall scores (p=0.0204). The association with younger age and horizontal scores was marginally significant (p=0.0667), but there was no significant association between age and nasal support. Conclusions Younger patients have an improved long-term radiographic success of grafted alveolar clefts. This supports performing AICBG at a younger age on cleft lip patients.

Endoscopic Infraorbital Microdissection for Localized V2 Trigeminal Neuralgia Publication date: Available online 25 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s): Max Ward, Neil Majmundar, Antonios Mammis, Boris Paskhover Abstract Background Trigeminal neuralgia is a chronic and debilitating syndrome characterized by short paroxysms of lancinating facial pain. Patients may be medically managed; however, in cases of medically refractory trigeminal neuralgia surgical management is often required. Objective To present and describe the technique for endoscopic microdissection of the infraorbital nerve, a peripheral method of management for refractory V2 trigeminal neuralgia in patients without evidence of neurovascular compression. The technique is designed to spare sensation in unaffected portions of the V2 distribution. Methods We present 2 patients with medically refractory V2 trigeminal neuralgia localized to the lateral mid-face who underwent infraorbital microdissection. After first confirming that there was no neurovascular compression on imaging, the patients received infraorbital bupivacaine injections to localize the symptomatic nerve. The nerve was then accessed via a 1.5cm gingivobuccal incision and the connective tissue sheath was incised. The nerve fascicles were bluntly separated and the symptomatic branches cauterized with fine-tipped monopolar. Results All patients reported complete resolution of their pain post-operatively and were pain free at last follow up. Patients reported some hypoesthesia in the lateral face; however, they retained some sensation in the medial upper lip, mid-face, and nose. Conclusion Infraorbital microdissection is a safe and effective technique for symptomatic management of V2 trigeminal neuralgia while sparing sensation in asymptomatic portions of dermatome.

Apicoecto-Guide 3D: optimizing access for apicoectomies Publication date: Available online 25 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s): Warley Luciano Fonseca Tavares, Francielen Oliveira Fonseca, Lucas Moreira Maia, Vinícius de Carvalho Machado, Nelson Renato França Alves Silva, Gil Moreira Junior, Antônio Paulino Ribeiro Sobrinho Abstract When conventional endodontic treatment resources are depleted, endodontic surgery becomes an alternative treatment for apical periodontitis to remove unreachable infected areas and seal the root canal. Digital workflows have been used more frequently in many dental applications in recent years. In endodontics, virtual 3D planning and endodontic guidance are new aspects important for the treatment of complex cases. This report aimed to present Apicoecto-Guide 3D (AG3D), a novel method of performing guided ultraconservative endodontic surgery with conventional implant guided drills, and to describe its application in a case with a complex anatomic scenario and intimate contact with the maxillary sinus. Implantology computer software, as well as cone-beam computed tomography (CBCT) images and a digital scanning 3D impression, enabled virtual planning of the surgery. Subsequently, a 3D template was produced to guide the instruments utilized in the osteotomy and root resection. The patient was completely asymptomatic at the 1-week follow-up visit. CBCT scans were performed at 1 and 6 months after surgery and revealed that resection of the apex of the root was performed accurately and that a thin dentin slice remained distally, preventing the rupture of the sinus membrane. The patient remained asymptomatic, and the tissue healed normally. The method employed was demonstrated to be very straightforward and reliable. This method allowed the patient to be treated expeditiously with very precise tissue removal.

Vascular compromise following soft tissue facial fillers: Case report and review of current treatment protocols Publication date: Available online 19 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s): Steven Halepas, Scott M. Peters, Jenna L. Goldsmith, Elie M. Ferneini Abstract The use of facial fillers for soft tissue augmentation is becoming a mainstream treatment modality for patients. Due to the relative ease of administration, as well as the lucrative nature of such procedures, the number of providers offering facial fillers has been expanding. While many of these are minor and localized to the site of injection, one potential serious, albeit uncommon, adverse effect of facial filler treatment is avascular necrosis. Herein, the authors report a review of soft tissue filler complications describing a case of a 52-year-old female who developed vascular compromise following facial filler administration. In addition to a review of complications and best practices for treatment management, the authors discuss anatomical considerations, an overview of the most common filler materials, histological changes with dermal fillers, and litigation consequences with the use of these minimally invasive procedures. Although facial filler treatment is regarded as a minimally invasive and extremely safe procedure, it is not without complications. Avascular necrosis following soft tissue augmentation with facial filler is exceedingly rare with only few cases reported in the literature, but practitioners who offer these procedures need to be well versed with treatment protocols.

Facial Versus Skeletal Landmarks for AP Diagnosis in Orthognathic Surgery and Orthodontics: Are They The Same? Publication date: Available online 19 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s): Chad M. Rasmussen, Paul J. Meyer, John E. Volz, James M. Van Ess, Thomas J. Salinas Purpose The purpose of this investigation was to evaluate the diagnostic agreement in anterior-posterior categorization of the maxilla and mandible between a skeletal landmark analysis versus a facial landmark analysis for treatment planning orthognathic surgery and orthodontics. Methods A retrospective consecutive case series of adult patients who presented to the Mayo Clinic Orthodontic Department compared maxillary and mandibular AP diagnoses. Steiner’s Analysis of SNA and SNB was used as skeletal landmark diagnosis. Element II of Andrews’ Six Elements of Orofacial Harmony was used as a facial landmark diagnosis. Both diagnoses were categorized into deficient, optimal, and excessive for each jaw. Categorization for the skeletal landmark was determined by normative data, while the facial landmark provides a customized categorization unique to each individual. Results Weighted Kappa Statistics were completed to test agreement between the categories determined by the skeletal and facial landmarks. The maxilla demonstrated poor agreement and the mandible had slight agreement. Conclusion No agreement was found for AP categorization of the maxilla and mandible between a skeletal and a facial landmark analysis. The majority of mandibles were diagnosed as retrognathic by a facial landmark while the skeletal landmark diagnosed the majority as optimal. When the two landmarks disagreed the facial landmark defined the optimal position farther anterior. The landmark chosen for diagnosis will impact the optimal jaw position and can affect orthognathic and orthodontic outcomes.

Sinus Imaging of Asymptomatic Patients: Putting the Cart Before the Horse Publication date: Available online 17 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s): Galal Omami

In Reply Publication date: Available online 17 October 2019 Source: Journal of Oral and Maxillofacial Surgery Author(s): Eda Didem Yalcin, Sedef Akyol