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Correction of Dentofacial Deformities with Orthognathic Surgery. Outcome

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Correction of Dentofacial Deformities with Orthognathic Surgery. Outcome CORRECTION OF KARI DENTOFACIAL DEFORMITIES PANULA WITH ORTHOGNATHIC Department of Oral and Maxillofacial Surgery, SURGERY Institute of Dentistry, Outcome of treatment with special reference to University of Oulu costs, benefits and risks OULU 2003 KARI PANULA CORRECTION OF DENTOFACIAL DEFORMITIES WITH ORTHOGNATHIC SURGERY Outcome of treatment with special reference to costs, benefits and risks Academic Dissertation to be presented with the assent of the Faculty of Medicine, University of Oulu, for public discussion in the Auditorium 1 of the Institute of Dentistry, on May 9th, 2003, at 12 noon. OULUN YLIOPISTO, OULU 2003 Copyright © 2003 University of Oulu, 2003 Reviewed by Docent Knut Tornes Docent Pekka Ylipaavalniemi ISBN 951-42-6993-4 (URL: http://herkules.oulu.fi/isbn9514269934/) ALSO AVAILABLE IN PRINTED FORMAT Acta Univ. Oul. D 718, 2003 ISBN 951-42-6992-6 ISSN 0355-3221 (URL: http://herkules.oulu.fi/issn03553221/) OULU UNIVERSITY PRESS OULU 2003 Panula, Kari, Correction of dentofacial deformities with orthognathic surgery. Outcome of treatment with special reference to costs, benefits and risks Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Oulu, P.O.Box 5281, FIN-90014 University of Oulu, Finland Oulu, Finland 2003 Abstract Considerable amounts of research have been done on various aspects of orthognathic surgery during its short history. Nevertheless, there are no comprehensive publications on the cost-risk-benefit analysis of the entire process of orthognathic surgery. The purpose of the present study was to evaluate the psychosocial and biophysiological outcomes of orthognathic surgery with special reference to complications and financial costs. The study series consisted of patients referred for consultations and treatment of dentofacial deformities and involved a total of 953 patients and 20 controls. Both prospective clinical follow-up examinations with measurements of various clinical parameters and retrospective assessments of radiographs and patient records were included. Functional and pain-related reasons were found to motivate patients to seek orthognathic surgery, and this impression was confirmed by the clinical findings. The great majority of the subjects examined had signs and symptoms of temporomandibular disorders (TMD). The significance of facial appearance for the motivation to seek treatments seemed to play a lesser role compared to most earlier studies. Most of the patients felt that their expectations had been fulfilled by the treatment, and despite the potential risks involved, the overall complication rate in orthognathic surgery was very low. The most usual problem was neurosensory deficit of the inferior alveolar nerve. TMD patients with skeletal Class II non-open bite dentofacial deformity seem to have the greatest probability to benefit from orthognathic surgery, especially if their TMD is mostly of muscular origin. Pain in the face and headache improved significantly. The outcomes were more variable when the TMD mainly originated from internal derangements. In these cases, the individual outcome of treatment is more difficult to predict, and conservative treatment methods should probably be tried first. The orthognathic surgery of patients with non-open bite skeletal Class II dentofacial deformity is also cost-effective due to the low complication rate and the low cost, since sagittal ramus osteotomy is often sufficient treatment. However, there must be weighty grounds for orthognathic surgery of skeletal open-bite deformities due to their greater risk for relapse and condylar resorption. The high expenses of their treatment also result in a poor cost-effectiveness ratio. Keywords: benefit, cost, orthognathic surgery, risk Acknowledgements This research was basically carried out at the Department of Oral and Maxillofacial Surgery, Vaasa Central Hospital, and at the Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Oulu, during the years 1994–2003. I owe my gratitude to several persons for support during these years, and I would especially like to mention some of them. I wish to express my greatest gratitude to my supervisor Professor Kyösti Oikarinen, DDS, PhD, who took me under his wings after I had presented my ideas for doctoral research. With his straightforward, sincere manner he has guided through the pitfalls and mysteries of scientific research. Professor Aune Raustia, DDS, PhD, was also one of the first persons to push me forward in this study. I wish to thank the official referees, Docent Pekka Ylipaavalniemi, D.D.S, Ph.D, and Docent Knut Tornes, D.D.S, Ph.D, for their careful revision and constructive criticism of the manuscript. I am deeply grateful to my colleague and co-author, Kaj Finne, DDS, Head of the Department of Oral and Maxillofacial Surgery, Vaasa Central Hospital. From him I have learned the techniques and philosophy of orthognathic surgery, and his open mind and everlasting enthusiasm for everything new have encouraged me during my whole surgical career. My co-authors Katri Keski-Nisula, DDS, Leo Keski-Nisula, MD, PhD, Sanna Keski- Nisula, MSc, Matti Somppi, DDS, and Docent Heli Forssell, DDS, PhD, deserve my warmest appreciation for their co-work and many interesting discussions. Ms Eija Takkula, Mrs Ann-Charlotte Nickull and Mrs Lilly Hästö have never hesitated to help me in secreterial work. Mrs Sirkka-Liisa Leinonen has kindly and efficiently helped me to express my thought in correct English language. I warmly thank my father and my late mother, who have always encouraged and supported me in my efforts and decisions. Finally, I express my deepest gratitude to my beloved wife Sari and to our children Katariina, Sakari and Johanna for their support and patience during this long process and for reminding me that there is life outside work and scientific research. This work was financially supported by the Finnish Dental Society, Vaasa Central Hospital and Oulu University. Abbreviations BSSO bilateral sagittal split osteotomy TMJ temporomandibular joint TMD temporomandibular disorder 2-PD 2-point discrimination (sensitivity test) MR magnetic resonance IMF intermaxillary fixation EMG electromyography IAN inferior alveolar nerve LN lingual nerve PIC Patient Insurance Center List of original papers The thesis is based on the following original articles, which are referred to in the text by numerals I to V: I Forssell H, Finne K, Forssell K, Panula K, Blinnikka L-M (1998) Expectations and perceptions regarding treatment: A prospective study of patients undergoing orthognathic surgery. Int J Adult Orthognath Orthod Surg 13: 107–113. II Panula K, Somppi M, Finne K, Oikarinen K (2000) Effects of orthognathic surgery on temporomandibular joint dysfunction . A controlled prospective 4-year follow-up study. Int J Oral Maxillofac Surg 29: 183–187. III Panula K, Finne K, Oikarinen K (2001) Incidence of complications and problems related to orthognathic surgery: a review of 655 patients. J Oral Maxillofac Surg 59: 1128–1136. IV Panula K, Finne K, Oikarinen K (xxxx) Neurosensory deficits after bilateral sagittal split ramus osteotomy of the mandible – the influence of medial side soft tissue handling of the ascending ramus. Int J Oral Maxillofac Surg (submitted). V Panula K, Keski-Nisula L, Keski-Nisula K, Keski-Nisula S, Oikarinen K (2002) Costs of surgical-orthodontic treatment in community hospital care: An analysis of the different phases of treatment. Int J Adult Orthognath Orthod Surg 17: 297–306. Reprints were made with the permission of the journals. Contents Abstract Acknowledgements Abbreviations List of original papers 1 Introduction ...................................................................................................................13 2 Review of the literature .................................................................................................15 2.1 Prevalence of dentofacial deformities.....................................................................15 2.2 Historical development of orthognathic surgery.....................................................16 2.2.1 Mandibular osteotomies ..................................................................................16 2.2.2 Maxillary osteotomies .....................................................................................17 2.2.3 The role of orthodontics in orthognathic surgery.............................................18 2.3 Psychological considerations in orthognathic surgery............................................18 2.3.1 Psychosocial profiles of patients and their expectations regarding orthognathic surgery........................................................................................18 2.3.2 Psychological risks and adverse outcomes ......................................................20 2.4 Effects of occlusal factors on temporomandibular disorders and masticatory function...................................................................................................................22 2.4.1 Temporomandibular disorders (TMD): general view ......................................22 2.4.2 TMD and malocclusion ...................................................................................23 2.4.3 TMD and orthognathic surgery........................................................................25 2.4.4 Masticatory performance and malocclusion ....................................................28 2.5 Complications and adverse effects of orthognathic surgery ...................................29
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