Orthognathic surgery is performed for congenital anomalies, growth of jaw abnormalities, and tumor and trauma after jaw treatment. The sagittal splitting method of the mandibular ramus is performed most commonly in the world, but resulting complications are increasing. The sagittal procedure and perioperative care have been established, however, complications of orthognathic surgery have been reported in many hospitals. Therefore, we should perform the surgery safely, with careful consideration, and eventually we need to improve the surgery.
Our treatment goal is to improve the facial form and to attain appropriate occlusion. Accordingly, we need to understand the patient’s background as a useful reference for drawing up the treatment plan. This paper reports on a safe sagittal splitting method of the mandibular ramus performed by our team.

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Objectives: Intermaxillary fixation (IMF) is used to rest the jaws of patients who have undergone orthognathic surgeries for jaw deformities, until the position of the jaws is stabilized. For the duration of the IMF, the patients are unable to consume solid food. Upon the release of the IMF, recovery until ingestion of solid food as a normal diet is gradual in accordance with the ability of mastication. The objective of the present study was to identify the nutritional issues associated with IMF and their influence on the occlusal force after the release of the IMF.
Methods: Fifteen patients who underwent orthognathic surgery (sagittal split ramus osteotomy ［SSRO］ or SSRO combined with Le Fort I osteotomy) and postoperative IMF were measured for the occlusal force and body weight prior to orthognathic surgery, after the release of the IMF, and during their outpatient visits for up to 6 months after discharge. In addition, the date when the participants ate each of the listed food items for the first time after the release of the IMF was gathered from the patient reports during the 6-month post-orthognathic surgery follow-up. The nutrient intake over a month pre-admission and during the post-discharge period was also investigated by the food frequency method.
Results: The occlusal force and body weight of the patients were reduced after orthognathic surgery and IMF, which required approximately 3 and 6 months for recovery, respectively. Similarly, the restoration to the regular diet required 3 months. Due to the decrease in the overall quantity of food consumption, the patients’ diet after discharge contained less energy than that during the pre-admission period. Furthermore, their intake of the nutrients related to wound healing was less than the estimated nutritional requirement of a physically unimpaired person.
Conclusions: The patients’ food intake was reduced after orthognathic surgery and IMF, and it was associated with the reduction of occlusal force. Therefore, nutritional support, including advice on food choices and cooking methods, for approximately 3 months until the recovery of occlusal force, might be effective in improving the nutritional conditions and promoting wound healing in patients after orthognathic surgery and IMF.

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In the analysis of facial soft tissue, two-dimensional analysis used to be the mainstream. Recently, three-dimensional analysis methods have emerged, and some studies related with a non-contact optical laser scanner have been reported. It is known that the facial soft tissue changes with posture. The posture during surgical operation is different from usual.
The purpose of this study was to analyze the morphological changes of facial soft tissue depending on posture, especially in moving to the supine position from the upright position.
The samples were 20 adults (10 males and 10 female). Fifteen measurement points were set in reference to Martin’s anthropological landmarks, and the face was scanned with some postures. Two images were superimposed and each coordinate level was measured from the same three reference planes.
As a result, at the midline measurement points of the face, there was approximately no meaningful movement, but the measurement points that were located far from the midline moved to the outside, the upper part, and backward. In addition, the distance between two measured points on each scanner image was different from the normal direction distance for all measurement points, especially around the cheek and mandibular angle.
Regarding the evaluation of morphological changes, the measurement of normal direction distance may be enough, but it is suggested that the skin of the face extends and causes a major visual change.

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Acromegaly is caused by growth hormone excess owing to a pituitary adenoma after completion of growth and tends to lead to mandibular prognathism. In this paper, two patients with mandibular prognathism caused by acromegaly and treated by surgical-orthodontic treatment are reported. The first case was a 36-year-old male who was referred to our hospital to correct mandibular prognathism and malocclusion after resection of the tumor in the pituitary gland. The second case was a 26-year-old male who was referred from an orthodontic clinic for orthognathic surgery. He had not been diagnosed as acromegaly but a typical double-floor of the Turkish saddle was found in the lateral cephalogram. Blood tests revealed acromegaly. Surgical-orthodontic treatments were performed after resection of the pituitary adenoma and confirmation of normal level of blood growth hormone (GH) and somatomedin C. In both cases, multi-bracket appliances were worn and bimaxillary osteotomy (Le Fort I osteotomy for maxillary advancement and bilateral sagittal splitting ramus osteotomies for mandibular setback) was carried out to secure the intraoral space for the enlarged tongue. After post-surgical orthodontic treatment, the treatment results were good and stable in both cases.
These cases showed that surgical-orthodontic treatment for patients with acromegaly after pituitary adenoma resection is reliable. The importance of careful examination of the craniofacial shape in patients with mandibular prognathism to detect acromegaly is emphasized.

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We report a case of Apert syndrome improved by surgical orthodontic treatment combined with Le Fort II maxillary distraction, and its long-term management. A 14-year 2-month-old male patient with the chief complaint of anterior crossbite and crowding was referred from the plastic surgery department. He had a concave lateral profile due to hypoplastic midface and protruded lower jaw. The upper dental arch width was narrow with deep palate. Overjet and overbite were －6.0mm and ＋3.0mm, respectively. Cephalometric analysis showed SNA of 77.3°, SNB of 85.0° and ANB of －7.7°, indicating maxillary growth deficiency and forward overgrowth of the mandible. The patient was diagnosed a skeletal Class III case with crowding and hypoplastic midface. After extraction of the upper second premolars, presurgical orthodontic treatment including maxillary expansion was performed for 18 months. Then, at the age of 15 years and 8 months, a bone distraction device was placed immediately after Le Fort II osteotomy. Due to little changes in dimension and less horizontal growth, the characteristic of the cranial base in this syndrome was determined using a profilogram with minor corrections. After 15mm of distraction, the device was placed for 6 months for retention and then removed. Subsequently, at 21 months postoperation (17 years 5 months old), retention was begun. The treatment results showed that the mid-facial deficiency was improved and good occlusion was achieved. During the retention period, occlusion was stable and no relapse of tooth alignment was observed. The occlusal conditions obtained have been maintained even 14 years after treatment.

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Unilateral condylar hyperplasia often causes severe facial asymmetry, malocclusion and temporomandibular joint pain. We present two cases of unilateral condylar hyperplasia with significant facial asymmetry and severe malocclusion. The first case was a 46-year-old female whose complaint was temporomandibular joint pain, facial asymmetry and trismus. The clinical diagnosis was left condylar tumor because these symptoms were recognized in post-adolescence and continued to progress. Low condylectomy with extraction of condylar disk was performed. The pathological diagnosis was condylar hyperplasia. Orthodontic treatment was continued for 5 months after condylectomy, and orthognathic surgery were performed. The second case was a 34-year-old female whose complaint was facial asymmetry and temporomandibular joint pain. These symptoms were recognized in adolescence and progressed slowly. The clinical diagnosis was left condylar hyperplasia. During pre-operative orthodontic treatment, 99mTc scintigram revealed proliferative activity in the left condylar lesion, and resection of the lesion was performed. The residual condyle was trimmed and contoured. Orthodontic treatment was continued for 10 months after the condylar operation, followed by orthognathic surgery. Four years and one year have passed since the orthognathic surgery, and esthetic and functional improvements and patient satisfaction have been obtained in both cases. In cases of facial asymmetry with condylar hyperplasia, it is often difficult to predict the occlusal and esthetic status without the improvement of condylar shape and function. The two-stage approach was a valid procedure to predict and obtain post-operative stability for the jaw and temporomandibular joint deformity.

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