parameters of care: 16 17 18 19 20 21 surgical … · 167 a. physical evidence of musculoskeletal,...

1 2 3 4 5 6 7 8 9 10 11

Parameters of Care: 12

Clinical Practice Guidelines 13

for Oral and Maxillofacial Surgery 14

(AAOMS ParCare 2017) 15 16 17 18 19 20 21

SURGICAL CORRECTION OF MAXILLOFACIAL 22

SKELETAL DEFORMITIES 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

©Copyright 2017 by the American Association of Oral and Maxillofacial Surgeons. 38 This document may not be copied or reproduced 39

without the express written permission of the 40 American Association of Oral and Maxillofacial Surgeons. 41

All rights reserved. 42 J Oral Maxillofac Surg 43

44 45 46

THIS SECTION IS 1 OF 11 CLINICAL SECTIONS INCLUDED IN AAOMS 47 PARCARE 2017, WHICH IS VIEWED AS A LIVING DOCUMENT APPLICABLE 48

TO THE PRACTICE OF ORAL AND MAXILLOFACIAL SURGERY. IT WILL BE UPDATED 49 AT DESIGNATED INTERVALS TO REFLECT NEW INFORMATION CONCERNING THE 50

PRACTICE OF ORAL AND MAXILLOFACIAL SURGERY. 51 52 53

AAOMS ParCare 2017 Surgical Correction of Maxillofacial Skeletal Deformities

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54

INTRODUCTION 55 56 The surgical correction of maxillofacial skeletal deformities includes the reconstructive procedures that correct 57 deformities of the maxilla, mandible, facial skeleton, and associated soft tissue structures. The etiology of 58 maxillofacial skeletal deformities may be congenital, developmental, or acquired. Deformities may be evident at 59 birth or may manifest during subsequent growth and development, creating functional, degenerative, cosmetic, 60 and/or psychosocial problems. The timing of corrective surgery can be critical and may occur during or after 61 completion of growth. Radiographic evaluation prior to and following treatment is critical but should be used 62 judiciously as clinically indicated. With advancing technology, integrated computer and radiographic techniques 63 can be an integral part of planning and treatment. Orthodontic consultation and treatment in conjunction with 64 surgical correction are frequently necessary and highly favorable in most cases. Treatment planning can involve 65 single or multiple separate, staged surgical and nonsurgical treatments. The temporal order for orthodontic and 66 surgical intervention may take place at any time during treatment. Earlier surgical intervention with a “surgery 67 first” approach can be considered when it will benefit the patient and may have specific advantages over a more 68 traditional “orthodontics first” treatment sequence. Other nonsurgical specialties (eg, speech therapy, sleep 69 medicine, psychology, prosthodontics) may also be helpful or necessary for completion of treatment in more 70 complicated cases. The principal goal for surgical correction of the maxillofacial skeletal deformity is to create or 71 restore normal form, function, and health, while minimizing potential negative short-term and long-term sequelae. 72

Procedures used for the correction of maxillofacial skeletal deformities may also be necessary to correct 73 obstructive sleep apnea (OSA). It is recognized that obstructive sleep apnea due to upper airway obstruction can 74 effectively be corrected with maxillomandibular advancement procedures, whether or not traditional 75 cephalometric landmarks and analysis diagnose a specific maxillofacial skeletal abnormality. 76

Cosmetic alterations may result after the treatment of maxillofacial surgical deformities. Treatment planning for 77 the correction of maxillofacial skeletal deformities normally entails basic cosmetic tenets and guidelines to 78 maximize patient outcomes both functionally and esthetically. The parameters for the correction of cosmetic 79 deformities are included in the Facial Cosmetic Surgery chapter. 80

Congenital, developmental, and acquired abnormalities of the temporomandibular joint can result in functional 81 alterations, distortion, and/or disfigurement of the mandible, maxilla, and related structures. Distortion and 82 disfigurement of the maxillofacial skeleton can also cause temporomandibular joint problems. Surgical correction 83 of the maxillofacial skeletal structures may include surgical and nonsurgical treatment of the temporomandibular 84 joint. Parameters for management of temporomandibular joint pathology are included in the Temporomandibular 85 Joint Surgery chapter. 86

Cleft lip and palate and/or craniofacial deformities often occur in conjunction with other maxillofacial skeletal 87 deformities and are not independent of each other. Recognition and treatment of these associated cleft and 88 craniofacial deformities may influence or change treatment guidelines for maxillofacial skeleton deformities. 89 Parameters for management of cleft lip/palate and craniofacial deformities are included in the Cleft and 90 Craniofacial Surgery chapter. 91

These parameters were prepared with the recognition that there is more than one approach to treating specific 92 deformities of the maxillofacial skeleton. Each patient may require an individualized treatment based on a number 93 of contributing factors. Consequently, flexibility has been incorporated into this document to allow the 94 practitioner to select the most appropriate treatment option in each case. Newer diagnostic and surgical adjuvants, 95 including computed tomography (CT), 3-dimensional modeling, computer aided surgical simulation (CASS), 96 virtual surgical planning (VSP) and CT-generated surgical guides may be indicated to reduce surgical risk and 97 improve outcomes. This is particularly true in more severe deformities and/or developmental anomalies with 98 abnormal anatomical variants requiring complicated surgical maneuvers. In addition, navigational and endoscopic 99 surgical techniques are rapidly evolving and may offer an advantage over traditional surgical techniques in 100 selected instances. The future application of robotic surgery may even develop into a useful surgical tool for the 101 treatment of maxillofacial skeletal deformities and adjunctive procedures. Surgically assisted osteogenic 102 orthodontics (SAOO) is also a promising treatment modality comprised of techniques such as selective alveolar 103 corticotomies, grafting, and temporary anchorage devices (TAD). These combined procedures, when clinically 104 indicated, are potential outpatient treatment options in the preparation and correction of maxillomandibular 105 skeletal deformities. Advantages may include lower morbidity, early recovery, decreased duration of orthodontic 106 therapy and presurgical orthodontic decompensation via a temporary phase of accelerated tooth movement known 107 as regional acceleratory phenomenon (RAP). Future changes in the treatment of maxillofacial skeletal 108

AAOMS ParCare 2017 Surgical Correction of Maxillofacial Skeletal Deformities ____________________________________________________________________________________________________ deformities, resulting from new research findings and evolving technologic developments, will undoubtedly 109 extend the capabilities for treatment and enable an even higher quality of patient care. 110

The surgical correction of maxillofacial skeletal deformities requires clear mutual understanding, by both 111 surgeon and patient, of stated treatment objectives and expectations regarding the proposed treatment and 112 expected outcome, recognizing that different treatment modalities for the same deformity may not only be 113 acceptable but may also present different risks, benefits, and outcomes. 114

115

116

GENERAL CRITERIA, PARAMETERS, AND CONSIDERATIONS FOR 117

SURGICAL CORRECTION OF MAXILLOFACIAL SKELETAL 118

DEFORMITIES 119 120 INFORMED CONSENT: All surgery must be preceded by the patient's or legal guardian’s consent, unless an 121 emergent situation dictates otherwise. Emergent circumstances should be documented in the patient’s record. 122 Informed consent is obtained after the patient or the legal guardian has been informed of the indications for the 123 procedure(s), the goals of treatment, the known benefits and risks of the procedure(s), the factors that may affect 124 the risk, the treatment options, and the favorable outcomes. 125 126 PERIOPERATIVE ANTIBIOTIC THERAPY: In certain circumstances, the use of antimicrobial rinses and 127 systemic antibiotics may be indicated to prevent infections related to surgery. The decision to employ 128 prophylactic perioperative antibiotics is at the discretion of the treating surgeon and should be based on the 129 patient’s clinical condition as well as other comorbidities which may be present. 130 131 DEALING WITH NEUROLOGIC DEFECITS: Injuries to the terminal branches of the trigeminal nerve (eg, 132 lingual, inferior alveolar, long buccal nerves), as well as the facial nerve, are known risks of oral and maxillofacial 133 surgery. It should be noted that the presence of a pathologic craniomaxillofacial condition, dentoskeletal or 134 craniofacial abnormality, or traumatic craniomaxillofacial injury may result in nerve injury prior to surgical 135 management. In addition, the use of local anesthesia (eg, mandibular block) may increase the risk of nerve injury. 136 Most nerve injuries resolve spontaneously, but some do not, and these may require consideration for non-surgical 137 and/or surgical intervention. Microneurosurgical repair should be considered when the disability is of concern to 138 the patient, and there is clinical evidence of moderate, severe, or complete neurosensory impairment of various 139 areas of the orofacial region (eg, lips, chin, tongue); paresis or paralysis of facial muscles; loss, decreased, or 140 abnormal taste sensation; or neuropathic pain of peripheral origin. Surgical repair should incorporate specialized 141 microsurgical techniques (eg, operating magnification, nerve grafting), when indicated. Also see the 142 Reconstructive Surgery chapter. 143 144 USE OF IMAGING MODALITIES: Imaging modalities may include panoramic radiograph, periapical and/or 145 occlusal radiographs, maxillary and/or mandibular radiographs, computed tomography, cone beam computed 146 tomography, positron emission tomography, positron emission tomography/computed tomography, and magnetic 147 resonance imaging. In determining studies to be performed for imaging purposes, principles of ALARA (as low 148 as reasonably achievable) should be followed. 149 150 DOCUMENTATION: The AAOMS ParCare 2017 includes documentation of objective findings, diagnoses, and 151 patient management interventions. The ultimate judgment regarding the appropriateness of any specific 152 procedure must be made by the individual surgeon in light of the circumstances presented by each patient. 153 Understandably, there may be good clinical reasons to deviate from these parameters. When a surgeon chooses 154 to deviate from an applicable parameter based on the circumstances of a particular patient, he/she is well advised 155 to note the reason for the procedure followed in the patient’s record. Moreover, it should be understood that 156 adherence to the parameters does not guarantee a favorable outcome. 157 158 COMPREHENSIVE CARE: Comprehensive care in the surgical correction of maxillofacial skeletal deformities 159 usually includes orthodontic therapy. In cases where orthodontics is not included, adequate documentation is 160 recommended. Other comprehensive care may include any necessary evaluations or interventions for medical, 161 dental, psychological, speech, or airway concerns before surgery. 162


____________________________________________________________________________________________________ 163 GENERAL INDICATIONS FOR THERAPY FOR SURGICAL CORRECTION OF MAXILLOFACIAL 164 SKELETAL DEFORMITIES: 165 166

A. Physical evidence of musculoskeletal, dento-osseous, and/or soft tissue deformity 167 B. Imaging evidence of musculoskeletal, dento-osseous, and/or soft tissue deformity 168

1. Deviation from cephalometric norms 169 2. Other imaging disclosure of abnormality 170

C. Malocclusion that cannot be reasonably corrected by a nonsurgical means (eg, unstable or traumatic 171 occlusion, compromised aesthetics, protracted treatment time) 172

D. Speech pathology 173 E. Masticatory and swallowing abnormalities 174 F. Incomplete correction or unstable result of previous treatment 175 G. Dental and/or periodontal pathology 176 H. Social and psychological impairment 177 I. Associated temporomandibular joint disorders 178 J. Associated muscular disorder (surgical correction may be useful when reversible occlusal alteration 179

demonstrates relief of symptoms) 180 K. Sleep disordered breathing 181

182 183 GENERAL THERAPEUTIC GOALS FOR SURGICAL CORRECTION OF MAXILLOFACIAL 184 SKELETAL DEFORMITIES: 185 186

A. Improved musculoskeletal, dento-osseous, and/or soft tissue relationships 187 B. Improved masticatory and swallowing 188 C. Improved occlusion 189 D. Improved quality of speech 190 E. Enhanced stability of orthodontic result 191 F. Improved dental and periodontal health 192 G. Improved social and psychological well-being 193 H. Improved associated temporomandibular joint and/or muscular disorders 194 I. Limited period of disability 195 J. Improved airway, including improvement of signs and symptoms of sleep disordered breathing 196

197 GENERAL FACTORS AFFECTING RISK DURING SURGICAL CORRECTION OF 198 MAXILLOFACIAL SKELETAL DEFORMITIES: 199 200

A. Degree of patient and/or family understanding of the origin and natural course of the condition or disorder 201 and therapeutic goals and acceptance of proposed treatment 202

B. Presence of coexisting major systemic disease (eg, disease that increases a patient's American Society of 203 Anesthesiologists classification to II, III, or IV), as detailed in the Patient Assessment chapter 204

C. Age of patient 205 D. Active and/or disproportionate maxillofacial growth 206 E. Presence and severity of temporomandibular joint and/or muscular disorders 207 F. Severity of maxillofacial skeletal deformity (eg, severe hemifacial microsomia syndromes, distorted or 208

unusual anatomy, malocclusions with large occlusal discrepancies (generally >1 cm)) 209 G. Presence and severity of acquired maxillary and/or mandibular skeletal, dento-osseous, or soft tissue 210

deformities (eg, secondary to facial trauma, compromised dentoalveolar health, previous surgical 211 treatment) 212

H. Presence of parafunctional habits (eg, bruxism, clenching, tongue thrusting, finger sucking) 213 I. Presence of local or systemic conditions that may interfere with the normal healing process and 214

subsequent tissue homeostasis (eg, previously irradiated tissue, diabetes mellitus, chronic renal disease, 215 liver disease, blood disorder, steroid therapy, contraceptive medication, immunosuppression, 216 malnutrition) 217

AAOMS ParCare 2017 Surgical Correction of Maxillofacial Skeletal Deformities ____________________________________________________________________________________________________

J. Presence of behavioral, psychological, neurologic, and/or psychiatric disorders, including habits (eg, 218 substance abuse, including tobacco and alcohol), seizure disorders, self-mutilation that may affect 219 surgery, healing, and/or response to therapy 220

K. Degree of patient’s and/or family’s cooperation and/or compliance 221 L. Regulatory and/or third-party decisions concerning access to care, indicated therapy, drugs, devices, 222

and/or materials 223 M. Presence of sleep disordered breathing, including obstructive sleep apnea, upper airway resistance 224

syndrome, and the potential for obstructive sleep apnea (recognizing that patients with borderline airway 225 issues can be pushed into frank obstructive sleep apnea with an imprudent treatment plan) 226

N. Subsequent operative surgery to correct suboptimal results from prior maxillofacial skeletal surgery 227 O. Subsequent operative surgery due to prior planned/staged maxillofacial skeletal surgery 228 P. Maxillofacial skeletal surgery after prior adjunctive hard and soft tissue surgery (eg, pharyngeal flap, cleft 229

repair, distraction osteogenesis) 230 Q. Correction of traumatic deformities 231 R. Preoperative deformity, condition, and/or temporomandibular joint disease complicating the 232

establishment of a secure airway for surgery (eg, significant retrognathia, temporomandibular joint 233 hypomobility/ankylosis, macroglossia, scleroderma) 234

235 236 GENERAL FAVORABLE THERAPEUTIC OUTCOMES FOR SURGICAL CORRECTION OF 237 MAXILLOFACIAL SKELETAL DEFORMITIES: 238 239

A. Long-term improvement in the musculoskeletal, dento-osseous, and/or soft tissue relationships 240 B. Improved masticatory and swallowing function 241 C. Improved speech 242 D. Stable functional occlusion 243 E. Satisfactory temporomandibular function 244 F. Satisfactory range of motion 245 G. Stable orthodontic result 246 H. Improved dental and periodontal health 247 I. Improved social and psychological well-being 248 J. Uncompromised facial aesthetics 249 K. Stable surgical result 250 L. Satisfactory surgical wound healing 251 M. Limited period of disability 252 N. Patient (family) acceptance of procedure and understanding of options and outcomes 253 O. Improvement or elimination of OSA 254

255 GENERAL KNOWN RISKS AND COMPLICATIONS FOR SURGICAL CORRECTION OF 256 MAXILLOFACIAL SKELETAL DEFORMITIES: 257 258

A. Unplanned admission to intensive care unit after elective surgery 259 B. Unplanned intubation for longer than 12 hours after surgery 260 C. Reintubation or tracheostomy after surgery 261 D. Use of parenteral drugs and/or fluids for longer than 72 hours after elective surgery 262 E. Failure to ambulate within 48 hours of elective surgery 263 F. Failure to begin or maintain adequate nutritional intake following surgery 264 G. Facial and/or trigeminal nerve dysfunction after surgery 265 H. Facial fracture during or after surgery 266 I. Unplanned Caldwell-Luc, bronchoscopy, or other exploratory procedures associated with surgery 267 J. Dental injury during surgery 268 K. Soft tissue and/or osseous periodontal injury 269 L. Ocular and orbital injury during surgery 270 M. Repeat oral and/or maxillofacial surgery 271 N. Core temperature of greater than 101 ºF 72 hours after elective surgery 272


____________________________________________________________________________________________________ O. Postsurgical radiograph indicating presence of foreign body 273 P. Surgical anesthesia risks and complications 274 Q. Unplanned transfusion(s) of blood or blood components during or after surgery 275 R. Readmission for complications or incomplete management of problems during previous hospitalization 276 S. Respiratory and/or cardiac arrest 277 T. Impaired dental occlusion 278 U. Impaired airway or worsening of sleep disordered breathing 279 V. Impaired social and psychological well-being 280 W. Deterioration of facial appearance 281 X. Onset or exacerbation of temporomandibular disorders 282 Y. Clinically significant neurologic deficit 283 Z. Failure of bone to heal (eg, delayed or nonunion) 284 AA. Damage or loss of teeth, bone, and/or soft tissue 285 BB. Dental pathology requiring treatment 286 CC. Infection (eg, acute or chronic) 287 DD. Unplanned need for removal of fixation devices 288 EE. Hemorrhage (may include unplanned blood transfusion) 289 FF. Pain 290 GG. Restricted mandibular range of motion 291 HH. Skeletal relapse and/or unstable surgical result 292 II. Onset of parafunctional habits 293 JJ. Prolonged period of disability 294 KK. Delayed wound healing 295 LL. Scar 296 MM. Excess or deficiency of anticipate growth after surgery 297 NN. Growth disturbance 298 OO. Death 299

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SPECIAL CONSIDERATIONS FOR THE SURGICAL CORRECTION OF 302

PEDIATRIC MAXILLOFACIAL SKELETAL DEFORMITIES 303 304 The Oral and Maxillofacial Surgeon performing orthognathic surgery in children must make a special effort to 305 ensure that the parent/guardian and the child (depending on age) understand the indications, risks and benefits, 306 and the change in appearance that will accompany the correction of maxillofacial skeletal deformities. The 307 relationship between the child patient and the parents may complicate the patient-physician relationship. It is 308 important for the surgeon to develop a relationship with the child and the family to understand their concerns and 309 expectations. Psychological consultation may be required. 310

The principles of management of maxillofacial skeletal deformities in children are similar to those for adults. 311 The major difference is related to determining the proper timing for surgery. The patient’s age, stage of 312 development, growth history, and the nature of the deformity and its consequences to the child must be considered 313 when establishing the timing and sequencing of treatment. For example, the rate of growth in height, in the years 314 immediately preceding an evaluation, is helpful in judging where a child is on the growth curve. Information on 315 the height of siblings and parents may be helpful. For females, the time of onset of menses is very informative. 316 Most females stop growing approximately 2.5 to 3 years after beginning menstruation. The hand-wrist radiograph 317 may be helpful because skeletal maturity in normal jaw growth correlates with closure of the radial and ulnar 318 epiphyses. Correlative indices based on cervical vertebral maturation have been developed. Bone scanning and 319 serial cephalometric radiographs, along with clinical examinations, photographs, and models, can provide 320 additional information concerning growth, particularly with abnormal or disproportionate growth and cases of 321 delayed pubertal onset. Facial growth, whether normal or abnormal, is not entirely predictable even with the best 322 technology. Newer approaches to surgical orthodontic sequencing include the advent of a “surgery first” protocol 323 that has been shown to significantly shorten total treatment time (orthodontics and surgery) for those patients 324 determined to benefit from this approach. Other desirable advantages of the surgery first protocol for the pediatric 325 or young adult patient may include early improvement in facial esthetics, dental function, speech and swallowing 326

AAOMS ParCare 2017 Surgical Correction of Maxillofacial Skeletal Deformities ____________________________________________________________________________________________________ along with more rapid postsurgical orthodontic movements, increased patient cooperation, and a stable result 327 comparable to other approaches. 328

The nature of the deformity and an understanding of the growth pattern of the maxillofacial skeleton also help 329 the Oral and Maxillofacial Surgeon make a decision on timing of surgery. For example, surgery for mandibular 330 prognathism generally is delayed until the patient reaches skeletal maturity and mandibular growth has ceased. 331 Similarly, surgery for class III malocclusion secondary to maxillary hypoplasia may be delayed to avoid relapse 332 secondary to subsequent mandibular growth. Examples of reasons for exceptions include the management of sleep 333 disordered breathing, psychological issues secondary to severe facial deformities, associated condylar procedures 334 to halt excessive abnormal mandibular growth, or a staged treatment plan, such as one that might involve 335 distraction osteogenesis at the LeFort III level to correct upper third facial deficiencies exclusive of the occlusion. 336 If a malocclusion remains stable in the context of proportionate maxillomandibular growth, surgical correction 337 may be appropriate before the completion of active growth. In the case of vertical maxillary excess, surgery can 338 be undertaken after the permanent canines and second molars have erupted because there is little vertical growth 339 of the maxilla after these developmental milestones. In the case of mandibular retrognathism, correction can often 340 be performed during growth. If the jaw grows after correction, it will be in a direction that counters the tendency 341 for relapse. It is clear that active facial growth has a sufficient degree of variability necessitating that decisions 342 concerning surgical timing be based on the individual patient’s findings, using the known norms as general 343 guidelines. 344

The consequences of hypoplasia can be mitigated in the growing skeleton with either classic osteotomies or 345 distraction osteogenesis techniques. Mandibular retrusion and maxillary protraction utilizing temporary anchorage 346 devices (TAD) such as screw retained plating systems and miniscrews may be considered as a more conservative, 347 cost efficient, and less morbid treatment alternative for developing skeletal class III malocclusion in pre-and early 348 adolescents. Examples would include the development of obstructive sleep apnea due to severe mandibular or 349 midface hypoplasia. Speech abnormalities, especially obligate articulation errors, may occasionally be treated in 350 this developing population. Severe lip incompetence, sialorrhea, and significant masticatory problems resulting 351 from a skeletal deformity may also indicate a need for surgery before the completion of growth (also see the Cleft 352 and Craniofacial Surgery chapter). Because there are many valid reasons for a particular treatment that falls 353 outside accepted norms, treatment planning that significantly deviates from standard accepted guidelines should 354 be clearly documented and should include documentation of appropriate multidisciplinary consultation. 355

The presence of developing teeth, the relative positions of anatomical landmarks, and the character of young 356 bone requires the modification of adult orthognathic surgical techniques for use in the pediatric patient. For 357 example, internal fixation methods will also have to be modified to account for these differences, and the 358 postoperative management may also require alteration. 359

Distraction osteogenesis is a useful technique in the pediatric population and may overcome many anatomical 360 challenges encountered with classic osteotomies and fixation techniques. Distraction techniques, however, impose 361 a significant additional burden on a child and family beyond that encountered with classic osteotomies. 362 Distraction osteogenesis is a more expensive technique due to the additional cost of the distraction devices and the 363 second operation required for their removal. Additional patient visits are also required compared with classic 364 techniques. Furthermore, distraction cannot predictably achieve the same precise 3-dimensional anatomical 365 correction of classic osteotomies. Surgeons should consider these limitations and must have a clear rationale for 366 the use of distraction osteogenesis in place of immediate surgical repositioning for correction of a given 367 deformity. Due to the added advantages of lower costs and morbidity, fast recovery, and decreased duration of 368 orthodontic therapy and decompensation, surgically assisted osteogenic orthodontics (SAOO) may be considered 369 as a treatment option when clinically indicated. 370

Computer aided surgical simulation (CASS) can greatly enhance the efficiency and accuracy of dentofacial 371 deformity correction particularly in the pediatric patient. Virtual surgical planning (VSP) can illustrate the 372 multidimensional correction required at both the skeletal and dental level, provide preoperative insight into the 373 surgical intervention (segment orientation, fixation requirements, grafting needs, etc) and has proven to be 374 accurate in the transfer of the virtual plan to the operating room. VSP can be utilized to fabricate anatomic 375 templates, jigs, and cutting guides to aid in the transfer of the virtual plan to the operating room to elevate 376 efficiency, accuracy, and patient outcomes. 377

Advances in computer-assisted surgery, including computed tomography (CT) scans, laser surface scans, 3-378 dimensional photography, 3-dimensional diagnostics, and 3-dimensional treatment planning, along with surgical 379 simulation, rapid prototyping for surgical guide fabrication, and intraoperative navigational techniques, are 380 rapidly evolving and may offer an advantage over traditional surgical techniques in selected cases. 381


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SPECIAL CONSIDERATIONS FOR THE GERIATRIC PATIENT 384 385 With advances in the diagnosis and treatment of medical and dental disease, the geriatric population requires more 386 advanced oral and maxillofacial surgical care. Increased lifespans have resulted in a larger geriatric population 387 with multifaceted dental and oral needs. Surgical care is safer, more predictable and continues to evolve, although 388 the consequences of aging may dictate modifications of traditional protocols for treatment. As a result of 389 improved health and longer lifespans, the goals of dental rehabilitation are evolving with more focus on 390 maintenance of an active lifestyle with an emphasis on function and esthetics. 391

Traditional removable dental prosthetics are no longer the only or best option available to the geriatric patient 392 with advanced dental disease. Patients with moderate to severe bone loss can create or exacerbate skeletal 393 discrepancies making dental and oral rehabilitation challenging without surgical correction. Orthodontics, even in 394 a compromised periodontium is often indicated, and may require adjunctive surgery or more traditional 395 dentofacial skeletal correction. Intricate implant supported fixed and removable prosthetics can provide the 396 geriatric patient with improved mastication, esthetics, speech, and oral function, but advanced dental restoration 397 of the geriatric patient without correction of dentofacial deformities can result in compromised outcomes, poor 398 function or early failure of dental reconstruction. 399

Esthetic surgery in the geriatric patient often requires correction of dentofacial deformities with traditional or 400 adjunctive procedures to restore facial proportions and volume. Obstructive sleep apnea is more common in the 401 geriatric population and surgical correction is often indicated to correct anatomical deficiencies of the airway. 402 Temporomandibular joint replacement due to advanced autoimmune or degenerative joint disease may require 403 simultaneous dentofacial skeletal correction. Treatment for head and neck cancer can result in poor dental 404 function requiring correction of congenital or acquired deformities with traditional or adjunctive procedures. 405 Computer aided surgical simulation (CASS), virtual surgical planning (VSP) and a “surgery first” approach have 406 an obvious benefit in the geriatric population and may be the treatment approach of choice for many patients, 407 particularly as technology continues to advance. 408 409

410

MANDIBULAR PROGNATHISM/HYPERPLASIA 411 412 I. Indications for Therapy for Mandibular Prognathism/Hyperplasia 413 414

May include one or more of the following: 415 416

A. One or more indications for therapy, as listed in the section entitled General Criteria, Parameters, and 417 Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 418

B. Bilateral condylar hyperplasia 419 II. Specific Therapeutic Goals for Mandibular Prognathism/Hyperplasia 420 421

The goal of therapy is to restore form and/or function. However, risk factors and potential complications may 422 preclude complete restoration of form and/or function. 423

424 A. One or more therapeutic goals, as listed in the section entitled General Criteria, Parameters, and 425

Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 426 III. Specific Factors Affecting Risk for Mandibular Prognathism/Hyperplasia 427 428

Factors that increase risk and the potential for known complications: 429 430

A. Presence of one or more general factors affecting risk, as listed in the section entitled General Criteria, 431 Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 432

B. Existing or recently removed impacted mandibular third molars 433 C. Presence of sleep disordered breathing preoperatively 434 D. Active pathologic growth process 435

AAOMS ParCare 2017 Surgical Correction of Maxillofacial Skeletal Deformities ____________________________________________________________________________________________________ IV. Indicated Therapeutic Parameters for Mandibular Prognathism/Hyperplasia 436 437

The presurgical evaluation includes, at a minimum, a history and physical examination and diagnostic 438 records, including a panoramic radiograph, cephalometric analysis, photographic documentation, and dental 439 model assessment. CT scanning and computer-assisted surgical techniques, including 3-dimensional 440 modeling, computational planning, and rapid prototyping of surgical guides, may be indicated in select cases. 441 Also see the Patient Assessment chapter. 442

443 Navigational surgical techniques may also be indicated in select cases based on the surgical deformity, 444 proposed procedures, surgeon experience and preference, and potential for an improved outcome. 445

446 The following procedures for the management of mandibular prognathism are not listed in order of 447 preference: 448

449 A. Sagittal split ramus osteotomy 450 B. Vertical oblique ramus osteotomy (eg, intraoral, extraoral, endoscopic) 451 C. Supplemental procedures 452

1. Le Fort I maxillary osteotomy 453 2. Mandibular symphysis vertical osteotomy 454 3. Subapical or body osteotomy/ostectomy 455 4. Grafting procedures (eg, autogenous, allogeneic bone, alloplasts, bone morphogenetic protein) 456 5. Genioplasty 457 6. Contour augmentation and/or reduction 458 7. Coronoidectomy and/or coronoidectomy 459 8. High condylectomy (in severe cases demonstrating continuous abnormal growth) 460 9. Alveolar bone grafting in preparation for orthodontic movement 461 10. Surgically assisted orthodontic movement (includes skeletal anchorage devices, corticotomies) 462 11. Partial glossectomy 463 12. Dental extractions (includes third molar removal) 464 13. Speech and swallowing therapy 465

D. Instructions for posttreatment care and follow-up 466 V. Outcome Assessment Indices for Mandibular Prognathism/Hyperplasia 467 468

Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through 469 clinical evaluation and may include an imaging evaluation. 470

471 A. Favorable therapeutic outcomes 472

1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, 473 and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 474

B. Known risks and complications associated with therapy 475 1. Presence of a general known risk and/or complication, as listed in the section entitled General 476

Criteria, Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal 477 Deformities 478

479

480

MANDIBULAR RETROGNATHISM/HYPOPLASIA 481 482 I. Indications for Therapy for Mandibular Retrognathism/Hypoplasia 483 484


A. Presence of one or more indications for therapy, as listed in the section entitled General Criteria, 487 Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 488

B. Associated developmental, pathologic, or acquired condylar disorders (eg, ankylosis, idiopathic condylar 489


____________________________________________________________________________________________________ resorption) 490

C. Associated airway obstruction (eg, obstructive sleep apnea or upper airway resistance syndrome, when 491 confirmed by appropriate sleep studies as part of a multidisciplinary approach to treatment) 492

II. Specific Therapeutic Goals for Mandibular Retrognathism/Hypoplasia 493 494


497 A. Presence of one or more general therapeutic goals, as listed in the section entitled General Criteria, 498

Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 499 B. Correction of airway obstruction and signs and symptoms of obstructive sleep apnea 500

III. Specific Factors Affecting Risk for Mandibular Retrognathism/Hypoplasia 501 502


B. Presence of or recent removal of impacted mandibular third molar 505 IV. Indicated Therapeutic Parameters for Mandibular Retrognathism/Hypoplasia 506 507

The presurgical evaluation includes, at a minimum, a history and physical examination and diagnostic 508 records, including a panoramic radiograph, cephalometric analysis, photographic documentation, and dental 509 model assessment. CT scanning and computer-assisted surgical techniques, including 3-dimensional 510 modeling, computational planning, and rapid prototyping of surgical guides, may be indicated in selected 511 cases. Also see the Patient Assessment chapter. 512

513 Navigational surgical techniques may also be indicated in select cases based on the surgical deformity, 514 proposed procedures, surgeon experience and preference, and potential for improved outcomes. 515

516 The following procedures for the management of mandibular retrognathism are not listed in order of 517 preference: 518

519 A. Sagittal split ramus osteotomy with rigid fixation 520 B. Inverted "L" osteotomy with bone grafting and rigid fixation 521 C. Supplemental procedures 522

1. Le Fort I maxillary osteotomy 523 2. Mandibular symphysis vertical osteotomy 524 3. Grafting procedures (eg, autogenous, allogeneic bone, alloplasts) 525 4. Subapical or alveolar osteotomies 526 5. Genioplasty 527 6. Contour augmentation and/or reduction (augmentation with prosthesis, bone graft, or osteoplasty) 528 7. Myotomy 529 8. Hyoid suspension 530 9. Genial tubercle advancement 531 10. Reconstruction (condyle/mandible) 532 11. Alveolar bone grafting in preparation for orthodontic movement 533 12. Surgically assisted orthodontic movement (includes skeletal anchorage devices and corticotomies) 534 13. Dental extractions (includes third molar removal) 535 14. Pharmaceutical management to minimize temporomandibular instability 536

D. Distraction osteogenesis both for mandibular widening and lengthening 537 E. Instructions for posttreatment care and follow-up 538

V. Outcome Assessment Indices for Mandibular Retrognathism/Hypoplasia 539 540




1. Presence of general favorable therapeutic outcomes, as listed in the section entitled General Criteria, 545 Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 546

2. Improved airway (OSA patients) 547 B. Known risks and complications associated with therapy 548

1. Presence of general known risks and/or complications, as listed in the section entitled General 549 Criteria, Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal 550 Deformities 551

2. Unimproved airway 552 3. Altered growth 553 4. Degenerative condylar disease (idiopathic condylar resorption, rheumatoid arthritis) 554

555

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MANDIBULAR ASYMMETRY 557 558 Mandibular asymmetry may result from congenital, developmental, or acquired condylar anomalies. It may be 559 manifested as hyperplasia with overgrowth or hypoplasia with deficiency and may also be present without 560 apparent condylar involvement. 561 562 The condition may be isolated to the transverse plane or demonstrate transverse, sagittal, and vertical skeletal 563 deformity. 564 565 I. Indications for Therapy for Mandibular Asymmetry 566 567



B. Associated developmental, pathologic, or acquired condylar disorders affecting mandibular symmetry 572 C. Vertical and/or horizontal asymmetry of the ramus and/or body of the mandible 573

II. Specific Therapeutic Goals for Mandibular Asymmetry 574 575

The goal of therapy is to restore form and/or function. However, risk factors, soft tissue abnormalities, severe 576 skeletal deformities, and potential complications may preclude complete restoration of form and/or function. 577

578 A. Presence of one or more general therapeutic goals, as listed in the section entitled General Criteria, 579

Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 580 III. Specific Factors Affecting Risk for Mandibular Asymmetry 581 582

Severity factors that increase risk and the potential for known complications: 583 584

A. Presence of one or more of the general factors affecting risk, as listed in the section entitled General 585 Criteria, Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 586

B. Severity of mandibular condylar deformity 587 C. Etiology of condylar deformity (eg, tumor, idiopathic condylar resorption, ankylosis) 588 D. Associated soft tissue asymmetry 589 E. Severity of mandibular asymmetry 590 F. Lack of functional condylar articulation 591

IV. Indicated Therapeutic Parameters for Mandibular Asymmetry 592 593



____________________________________________________________________________________________________ 599

Navigational surgical techniques may also be indicated in select cases based on the surgical deformity and 600 proposed procedures, surgeon experience and preference, and potential for improved outcomes. 601

602 The following procedures for the management of mandibular asymmetry are not listed in order of preference: 603

604 A. Sagittal split ramus osteotomy, vertical ramus osteotomy, inverted "L" osteotomy 605 B. Le Fort I osteotomy with or without segmentalization 606 C. Partial or complete condylectomy 607 D. Supplemental procedures 608

1. Mandibular symphysis vertical osteotomy 609 2. Grafting procedures (eg, autogenous, allogeneic bone, alloplasts) 610 3. Genioplasty 611 4. Contour augmentation and/or reduction, including soft tissue augmentation (eg, fat grafting and soft 612

tissue flaps) 613 5. Temporomandibular joint surgery including total joint replacement 614 6. Genial tubercle advancement 615 7. Alveolar bone grafting in preparation for orthodontic movement 616 8. Surgically assisted orthodontic movement (includes skeletal anchorage devices and corticotomies) 617 9. Dental extractions (includes third molar removal) 618 10. Pharmaceutical management to minimize temporomandibular instability 619

E. Distraction osteogenesis 620 F. Soft tissue grafts or flaps (eg, microvascular transfer of adipofascial flap for soft tissue augmentation) 621 G. Instructions for posttreatment care and follow-up 622

V. Outcome Assessment Indices for Mandibular Asymmetry 623 624






2. Soft tissue response to hard/soft tissue augmentation or reduction 635 3. Continued facial asymmetry 636

637

638

MAXILLARY HYPERPLASIA 639 640 Maxillary hyperplasia consists of three component subsets: vertical, horizontal, and transverse. Items listed under 641 this condition are applicable to all subsets of this condition unless otherwise designated. 642 643 I. Indications for Therapy for Maxillary Hyperplasia 644 645



B. Airway obstruction (eg, sleep disordered breathing, nasal airway obstruction) 650 C. Associated soft tissue deformities (eg, lip incompetence) 651

II. Specific Therapeutic Goals for Maxillary Hyperplasia 652

AAOMS ParCare 2017 Surgical Correction of Maxillofacial Skeletal Deformities ____________________________________________________________________________________________________ 653


656 A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and 657

Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 658 III. Specific Factors Affecting Risk for Maxillary Hyperplasia 659 660


A. Presence of a general factor affecting risk as listed in the section entitled General Criteria, Parameters, 663 and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 664

B. Presence of or recent removal of impacted maxillary third molars 665 IV. Indicated Therapeutic Parameters for Maxillary Hyperplasia 666 667


673 Navigational surgical techniques may also be indicated in select cases based on the surgical deformity and 674 proposed procedures, surgeon experience and preference, and potential for improved outcomes. 675

676 The following procedures for the management of maxillary hyperplasia are not listed in order of preference: 677

678 A. Segmental maxillary alveolar osteotomies 679 B. Le Fort I osteotomy with or without segmentalization 680 C. Supplemental procedures 681

1. Grafting procedures (eg, autogenous, allogeneic bone, alloplasts) 682 2. Contour augmentation and/or reduction 683 3. Septorhinoplasty 684 4. Turbinoplasty and/or turbinectomy 685 5. Genioplasty 686 6. Mandibular osteotomy 687 7. Dental extractions (includes third molar removal) 688 8. Soft tissue procedures (eg, V-Y closure, nasal cinch, buccal fat removal) 689 9. Biopsy or debridement and removal of maxillary sinus pathology (eg, mucous retention cyst, 690

mucocele, polyp) 691 10. Palatal or alveolar cleft repair with/without bone grafting 692 11. Surgically assisted orthodontic movement (includes skeletal anchorage devices and corticotomies 693 12. Malar osteotomies/augmentation 694

D. Instructions for posttreatment care and follow-up 695 V. Outcome Assessment Indices for Maxillary Hyperplasia 696 697




2. Improved airway 704 B. Known risks and complications associated with therapy 705

1. Presence of a general known risk and/or complication, as listed in the section entitled General 706 Criteria, Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal 707


____________________________________________________________________________________________________ Deformities 708

2. Impaired nasal and/or sinus function 709 3. Unfavorable nasal changes, including overrotation of nasal tip, alar base widening, nasal septal 710

deviation 711 4. Epiphora 712

713

714

MAXILLARY HYPOPLASIA 715 716 Maxillary hypoplasia consists of three component subsets: vertical, horizontal, and transverse. Items listed under 717 this condition are applicable to all subsets of this condition unless otherwise designated. Also see the Cleft and 718 Craniofacial Surgery chapter. 719 720 I. Indications for Therapy for Maxillary Hypoplasia 721 722



B. Transverse maxillary discrepancies not amenable to orthodontic correction 727 C. Obstructive sleep apnea, upper airway resistance syndrome 728 D. Airway obstruction (eg, nasal airway) 729 E. Exorbitism with risk of exposure keratopathy (LeFort III level) 730 F. Posttraumatic 731

II. Specific Therapeutic Goals for Maxillary Hypoplasia 732 733



Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 738 B. Improved airway 739

III. Specific Factors Affecting Risk for Maxillary Hypoplasia 740 741


A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, 744 and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 745

B. Severity of maxillary deformity 746 C. Presence of or recent removal of impacted maxillary third molars 747 D. Presence of cleft palate or prior palatal surgery (eg, uvulopalatopharyngoplasty) 748

IV. Indicated Therapeutic Parameters for Maxillary Hypoplasia 749 750



759 The following procedures for the management of maxillary hypoplasia are not listed in order of preference: 760

761


A. Segmental maxillary alveolar osteotomies 762 B. Le Fort I, II, or III osteotomy with or without segmentalization (quadrangular and Kufner modifications) 763 C. Distraction osteogenesis 764 D. Supplemental procedures 765

1. Grafting procedures (eg, autogenous, allogeneic bone, alloplasts) 766 2. Contour augmentation and/or reduction 767 3. Malar osteotomies/augmentation 768 4. Septorhinoplasty 769 5. Turbinoplasty and/or turbinectomy 770 6. Genioplasty 771 7. Mandibular osteotomy 772 8. Dental extractions (includes third molar removal) 773 9. Soft tissue procedures (eg, V-Y closure, nasal cinch, buccal fat removal) 774 10. Biopsy or debridement and removal of maxillary sinus pathology (eg, mucous retention cyst, 775

mucocele, polyp) 776 11. Palatal or alveolar cleft repair with/without bone grafting 777 12. Surgically assisted orthodontic movement (includes skeletal anchorage devices and corticotomies) 778 13. Instructions for posttreatment care and follow-up 779

V. Outcome Assessment Indices for Maxillary Hypoplasia 780 781




2. Improved airway 788 B. Known risks and complications associated with therapy 789

1. Presence of a general known risk and/or complication, as listed in the section entitled General 790 Criteria, Parameters, and Considerations for Surgical Correction of Maxillofacial Skeletal 791 Deformities 792

2. Impaired nasal and/or sinus function 793 3. Unfavorable nasal changes, including nasal tip overrotation, alar base widening, septal deviation 794 4. Epiphora 795

796

797

SKELETAL OPEN BITE (APERTOGNATHIA) 798 799 Skeletal open bite can be developmental or acquired, as well as secondary to local factors influencing tooth 800 eruption and dentoalveolar growth. The condition may be isolated to the vertical dimension in one or both jaws, 801 may be seen in conjunction with sagittal and transverse problems, and may occur anteriorly or posteriorly, both 802 unilaterally or bilaterally. 803 804 I. Indications for Therapy for Skeletal Open Bite (Apertognathia) 805 806



B. Associated developmental, pathologic, or acquired condylar disorders resulting in open bite (eg, 811 ankylosis, idiopathic condylar resorption, osteochondroma, rheumatoid arthritis) 812

C. Associated soft tissue deformities (eg, lip incompetence) 813 D. Dry mouth 814 E. Mouth breathing gingivitis 815


____________________________________________________________________________________________________ II. Specific Therapeutic Goals for Skeletal Open Bite (Apertognathia) 816 817



Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 822 B. Improvement in lip incompetence 823

III. Specific Factors Affecting Risk for Skeletal Open Bite (Apertognathia) 824 825


A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, 828 and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 829

B. Severity of open bite 830 C. Presence and severity of localized conditions (eg, tongue posture, tongue size, mode of respiration as it 831

influences jaw posture) 832 D. Active condylar disease (eg, rheumatoid arthritis, idiopathic condylar resorption) 833

IV. Indicated Therapeutic Parameters for Skeletal Open Bite (Apertognathia) 834 835



844 The following procedures for the management of skeletal open bite are not listed in order of preference: 845

846 A. Le Fort I osteotomy with or without segmentalization 847 B. Segmental maxillary alveolar osteotomies 848 C. Sagittal split ramus osteotomy with rigid fixation 849 D. Inverted "L" osteotomy with bone grafting and rigid fixation 850 E. Vertical ramus osteotomies in conjunction with mandibular setback procedures 851 F. Supplemental procedures 852

1. Grafting procedures (eg, autogenous, allogeneic bone, alloplasts) 853 2. Septorhinoplasty 854 3. Partial glossectomy 855 4. Distraction osteogenesis 856 5. Speech therapy 857 6. Turbinoplasty and /or turbinectomy 858 7. Reconstruction (condyle/mandible)), including autogenous or alloplastic total joint reconstruction 859 8. Dental extractions (includes third molar removal) 860 9. Soft tissue procedures (eg, V-Y closure, nasal cinch, buccal fat removal) 861 10. Biopsy or debridement and removal of maxillary sinus pathology (eg, mucous retention cyst, 862

mucocele, polyp) 863 11. Palatal or alveolar cleft repair with/without bone grafting 864 12. Surgically assisted orthodontic movement (includes skeletal anchorage devices and corticotomies) 865 13. Pharmaceutical management to minimize temporomandibular instability 866

V. Outcome Assessment Indices for Skeletal Open Bite (Apertognathia) 867 868



A. Favorable therapeutic outcomes 872 1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, 873

and Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 874 2. Improved airway 875



880

881

SPECIAL CONSIDERATIONS FOR SLEEP DISORDERED BREATHING 882 883 Surgical correction of maxillofacial skeletal deformities is often indicated for the treatment of sleep-disordered 884 breathing, which includes most commonly obstructive sleep apnea (OSA) and upper airway resistance syndrome. 885 Untreated, the disorder can increase the risk of cardiovascular disease, cerebrovascular disease, diabetes, and 886 other metabolic and endocrine dysfunctions. It may also increase the risk for work-related injuries and motor 887 vehicle collisions and may exacerbate psychiatric conditions. In the pediatric population, sleep disordered 888 breathing can have a profound impact on a child’s achievement of developmental milestones and quality of life. 889 Neuropsychological manifestations predominate with behavioral and attention deficit issues, and learning 890 disabilities being frequent complaints. In severe cases, sleep apnea may result in failure to thrive. A thorough 891 history with screening questionnaires and diagnostic evaluation including polysomnography, radiography, and 892 clinical evaluation, can be essential for diagnosing obstructive sleep apnea and subtler forms of sleep-disordered 893 breathing so that an appropriate treatment plan be developed. 894

Maxillomandibular advancement procedures demonstrate well-documented success in the treatment of 895 obstructive sleep apnea. Consideration for a surgery first approach in the patient with OSA may be appropriate, 896 especially in those individuals intolerant to CPAP and other forms of non-surgical therapeutic mechanisms. 897 Ancillary/adjunctive procedures, such as hyoid suspension, genioglossus advancement, tonsillectomy and/or 898 adenoidectomy, uvulopalatopharyngoplasty, radiofrequency tongue base reduction, tracheostomy, and 899 turbinectomy, can also provide relief and may be indicated for the treatment of obstructive sleep apnea in both 900 children and adult patients. As with the surgical correction of maxillofacial skeletal deformities, proper patient 901 assessment and informed consent is critical to maximizing results. It is important to note that for some patients 902 with a history of OSA undergoing surgery for maxillofacial skeletal deformities, inpatient overnight observation 903 with consideration given to intensive care monitoring, may be indicated. 904

905

906

OBSTRUCTIVE SLEEP APNEA (OSA) 907 908 I. Indications for Therapy for Obstructive Sleep Apnea 909 910


A. One or more indications for therapy, as listed in the section entitled General Criteria, Parameters, and 913 Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 914

B. An elevated Respiratory Disturbance Index (RDI) or Apnea Hypopnea Index (AHI), as measured 915 objectively by polysomnography (PSG) 916

C. Nocturnal hypoxia 917 D. Excessive daytime sleepiness (as measured by Epworth Sleepiness Scale) 918 E. Positive STOP-BANG sleep apnea questionnaire 919 F. Reduced quality of life 920 G. Cardio-pulmonary disease 921 H. Upper airway obstruction or collapse as documented by imaging of the upper airway 922 I. Maxillary or mandibular retrognathism (ie, hypoplasia) 923


____________________________________________________________________________________________________ J. Cleft and craniofacial syndromes 924 K. Nocturnal enuresis 925 L. Cognitive delays, behavioral problems and attentional deficits in pediatric population 926 M. Failure to thrive 927

II. Specific Therapeutic Goals for Obstructive Sleep Apnea 928 929


932 A. One or more therapeutic goals as listed in the section entitled General Criteria, Parameters, and 933

Considerations for Surgical Correction of Maxillofacial Skeletal Deformities 934 B. Reduce RDI and/or AHI 935 C. Reduce nocturnal hypoxia 936 D. Improve nocturnal esophageal pressure (Pes) 937 E. Improve esophageal pH 938 F. Reduce daytime sleepiness 939 G. Improve quality of life 940 H. Improve cardiovascular health 941 I. Reduce upper airway obstruction or collapse 942 J. Improve form and function of the upper airway by increasing upper airway space 943 K. Reduce snoring 944 L. Reduce or eliminate need for continuous positive pressure airway (CPAP) and/or tracheostomy 945 M. Improve cognitive and behavioral function and development 946

III. Specific Factors Affecting Risk for Obstructive Sleep Apnea 947 948

Factors that increase risk and the potential for known complications: 949 950


B. Associated comorbid conditions including: obesity, cardio-pulmonary disease, hypertension, history of 953 stroke, history of myocardial infarction, diabetes, neuromuscular disorders, metabolic disease 954

C. Drug and alcohol dependence 955 D. Presence and severity of localized conditions (eg, tongue posture, tongue size, periodontal disease, 956

impacted teeth) 957 E. Temporomandibular joint (TMJ) and jaw deformities, (eg, ankylosis, Pierre Robin sequence, hemifacial 958

microsomia) 959 F. TMJ pain and dysfunction 960 G. Cleft and craniofacial disorders 961 H. Family history of OSA 962

IV. Indicated Therapeutic Parameters for Obstructive Sleep Apnea 963 964

The presurgical evaluation includes, at a minimum, a history and physical examination. Lifestyle changes, 965 such as losing weight, alcohol cessation before bed, and CPAP can result in clinical improvement. When 966 specific anatomical conditions may exist, diagnostic records should be obtained and can include a panoramic 967 radiograph, cephalometric analysis, photographic documentation, dental model assessment, 968 polysomnography sleep study (with or without Pes), upper airway endoscopy, esophageal pH monitoring, or 969 other studies. Computed tomography (CT) scanning and computer-assisted surgical techniques, including 3-970 dimensional modeling, computational planning, and rapid prototyping of surgical guides, may be indicated in 971 select cases. Specialty consultations may be indicated to optimize treatment of comorbid conditions prior to 972 surgical correction of OSA. Also see the Patient Assessment chapter. 973

974 Navigational surgical techniques may also be indicated in select cases based on the surgical deformity, 975 proposed procedures, surgeon experience and preference, and potential for an improved outcome. 976

977 The following procedures for the management of obstructive sleep apnea are not listed in order of preference: 978


A. Maxillomandibular advancement (MMA) to improve form and function of the upper airway 980 B. Consideration of specific adjunctive surgical techniques to maximize stability of MMA, minimize 981

neurosensory deficits and promote normal wound healing including: 982 1. Mandibular advancement 983 2. Maxillary and/or mandibular expansion 984 3. Chin advancement 985 4. Genial advancement 986 5. Hyoid (suprahyoid muscle complex) advancement 987 6. Uvulopalatophargoplasty (or variant) 988 7. Tracheostomy 989 8. Nasal septoplasty/polypectomy/turbinectomy 990 9. Tonsillectomy and adenoidectomy 991 10. Partial glossectomy (or variant) 992 11. Tongue suspension 993 12. Orthodontics 994 13. Prosthetics 995 14. Oral appliances 996 15. Diaphragmatic Stimulator 997

C. Consideration of specific postoperative management strategies to minimize wound healing problems, 998 establish normal TMJ function, functional occlusion and promote recovery of mandibular mobility 999

D. Instructions for posttreatment care and follow-up 1000 V. Outcome Assessment Indices for Obstructive Sleep Apnea 1001 1002




2. Reduction in OSA with reduction in AHI, RDI, as measured objectively by PSG 1009 3. Routine postoperative course including uneventful wound healing 1010 4. Imaging documentation of positive upper airway change, adequate bone healing and stability of 1011

MMA or adjunctive procedures 1012 5. Establish and maintain functional occlusion and normal TMJ function 1013 6. Minimal neurosensory dysfunction 1014



2. Perioperative hypertension, cardiovascular events, respiratory and venous thromboembolic events 1019 3. Persistent OSA requiring additional treatment such as CPAP or tracheostomy 1020 4. Need for further upper airway surgery 1021 5. Revision surgery 1022

1023

1024

SELECTED REFERENCES – SURGICAL CORRECTION OF 1025

MAXILLOFACIAL SKELETAL DEFORMITIES 1026 1027 This list of selected references is intended only to acknowledge some of the sources of information drawn on in 1028 the preparation of this document. Citation of the reference material is not meant to imply endorsement of any 1029 statement contained in the reference material. The list is not an exhaustive compilation of information on the 1030 topic. Readers should consult other sources to obtain a complete bibliography. 1031 1032


____________________________________________________________________________________________________ 1033

SPECIAL CONSIDERATIONS FOR THE SURGICAL CORRECTION OF PEDIATRIC 1034 MAXILLOFACIAL SKELETAL DEFORMITIES 1035

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by orthodontic and orthognathic treatment. Int J Oral Maxillofac Surg 42:752, 2013 1038 2. Al-Nawas B, Kammerer PW, Hoffmann C, et al: Influence of osteotomy procedure and surgical experience 1039

on early complications after orthognathic surgery in the mandible. J Craniomaxillofac Surg 42:3284, 2014 1040 3. Altug-Atac AT, Grayson BH, McCarthy JG: Comparison of skeletal and soft-tissue changes following 1041

unilateral mandibular distraction osteogenesis. Plast Reconstr Surg 121:1751, 2008 1042 4. Arslan SG, Kama JD, Baran S: Correction of a severe Class III malocclusion. Am J Orthod Dentofacial 1043

Orthop 126:237, 2004 1044 5. Baker SB, Reid RR, Burkey B, et al: Rapid maxillary distraction protocol utilizing the halo distraction 1045

system and rigid internal fixation. Cleft Palate Craniofac J 44:476, 2007 1046 6. Bays R, Bouloux G: Complications of orthognathic surgery. Oral Maxillofac Surg Clin North Am 15:229, 1047

2003 1048 7. Bechtold TE, Briegleb HK: Periodontal and gingival incisor findings in patients with anterior open bite in 1049

the mixed dentition. J Orofac Orthop 71:199, 2010 1050 8. Bengi AO, Gurton AO, Okcu KM, et al: Premaxillary distraction osteogenesis with an individual tooth-borne 1051

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segmental distraction: a preliminary report. J Craniomaxillofac Surg 35:302, 2007 1054 10. Bobek S, Farrell B, Choi C, et al: Virtual surgical planning for orthognathic surgery using digital data 1055

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Craniofac Surg 21:555, 2010 1088 27. Iannetti G, Fadda TM, Riccardi E, et al: Our experience in complications of orthognathic surgery: a 1089

retrospective study on 3236 patients. Eur Rev Med Pharmacol Sci 17:379, 2013 1090 28. Iatrou I, Theologie-Lygidakis N, Schoinohoriti O: Mandibular distraction osteogenesis for severe airway 1091

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treatment of Crouzon syndrome and critical obstructive sleep apnea: a case report. J Oral Maxillofac Surg 1094 67:2004, 2009 1095

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33. Ko EW, Hung KF, Huang CS, et al: Correction of facial asymmetry with multiplanar mandible distraction: a 1104 one-year follow-up study. Cleft Palate Craniofac J 41:5, 2004 1105

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35. Meazzini MC, Mazzoleni F, Gabriele C, et al: Mandibular distraction osteogenesis in hemifacial 1109 microsomia: long-term follow-up. J Craniomaxillofac Surg 33:370, 2005 1110

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38. Mojdehi M, Buschang PH, English JD, et al: Postsurgical growth changes in the mandible of adolescents 1115 with vertical maxillary excess growth pattern. Am J Orthod Dentofacial Orthop 119:106, 2001 1116

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41. Nagy K, Kuijpers-Jagtman AM, Mommaerts MY: No evidence for long-term effectiveness of early 1121 osteodistraction in hemifacial microsomia. Plast Reconstr Surg 124:2061, 2009 1122

42. Paeng JY, Lee JH, Lee JH, et al: Condyle as the point of rotation for 3-D planning of distraction osteogenesis 1123 for hemifacial microsomia. J Craniomaxillofac Surg 35:91, 2007 1124

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45. Robiony M, Salvo I, Costa F, et al: Virtual reality surgical planning for maxillofacial distraction 1129 osteogenesis: the role of reverse engineering rapid prototyping and cooperative work. J Oral Maxillofac Surg 1130 65:1198, 2007 1131

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49. Sinn DP, Cillo JE Jr, Miles BA: Stereolithography for craniofacial surgery. J Craniofac Surg 17:869, 2006 1138 50. Skolnick J, Iranpour B, Westesson PL, et al: Prepubertal trauma and mandibular asymmetry in orthognathic 1139

surgery and orthodontic patients. Am J Orthod Dentofac Orthop 105:73, 1994 1140 51. Steel BJ, Cope MR: Unusual and rare complications of orthognathic surgery: a literature review. J Oral 1141

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____________________________________________________________________________________________________ 52. Turvey TA, Simmons K: Orthognathic surgery before completion of growth. Oral Maxillofac Surg Clin 1143

North Am 6:121, 1994 1144 53. Ward JL, Garri JI, Wolfe SA: Posterior movements of the maxilla. J Craniofac Surg 18:882, 2007 1145 54. Weisner SM: Treatment of a skeletal Class III malocclusion with mandibular asymmetry using a single 1146

miniscrew. J Clin Orthod 43:335, 2009 1147 55. Wolford LM, Karras SC, Mehra P: Considerations for orthognathic surgery during growth, part 1: 1148

mandibular deformities. Am J Orthod Dentofacial Orthop 119: 95, 2001 1149 56. Wolford LM, Karras, SC, Mehra, P: Considerations for orthognathic surgery during growth, part 2: 1150

maxillary deformities. Am J Orthod Dentofacial Orthop 119:102, 2001 1151 57. Wolford LM, Movahed R, Perez DE: A classification system for conditions causing condylar hyperplasia. J 1152

Oral Maxillofac Surg 72:567, 2014 1153 58. Wootten CT, Shott SR: Evolving therapies to treat retroglossal and base-of-tongue obstruction in pediatric 1154

obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 136:983, 2010 1155 1156 1157

MANDIBULAR PROGNATHISM/HYPERPLASIA 1158 1159 59. Agbaje JO, Sun Y, De Munter S, et al: CBCT-based predictability of attachment of the neurovascular bundle 1160

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