In the field of nursing, we have been performing a presurgical verbal orientation using an explanation sheet for patients. However, many patients complained after surgery, “It was more stressful than I expected” and “It was hard to breathe.” These complaints indicate that patients suffered considerable stress by intermaxillary wire fixation. We thought that a presurgical orientation including a simulated experience would help them understand the postsurgical condition and relieve the postsurgical stress. Thus, we decided to perform a presurgical verbal orientation using either an explanation sheet （explanation group） or a simulated experience of using intermaxillary elastics （simulated-experience group） randomly assigned to patients, and compared the effect of the two methods. The results showed that both methods could provide enough information on intermaxillary wire fixation before surgery. Among the explanation group, there were many who replied that the surgery was the same as the image they had imagined before the surgery. In contrast, among the simulated-experience group, there were some who replied that the surgery was more stressful than expected. This was because the simulated experience using intermaxillary elastics, which could allow mouth opening, might have provided an incorrect image that intermaxillary wire fixation was not so stressful. Patients in the simulated-experience group felt that intermaxillary wire fixation was much more stressful than they had expected, and the orientation did not help relieve their stress. However, there were some who said the simulated experience was worthwhile and effective for orthognathic surgery. The present study highlighted the problems in performing our simulated experience, and enabled us to improve the method for pain relief.
A clinical analysis was performed on 208 patients who underwent orthognathic surgery at the Department of Oral and Maxillofacial Surgery, Gifu Prefectural Tajimi Hospital, during the 10 years from 2010 to 2019.
The results were as follows:
1. The number of orthognathic surgery operations increased yearly.
2. There were 57 male and 151 female patients （ratio 1：2.6）. The mean age at surgery was 23.7 （15-56） years old. Patients in their teens accounted for 45.2％ of the subjects.
3. The most common clinical diagnosis was mandibular retrognathism with and without other conditions, accounting for 46.2％, followed by mandibular prognathism with and without other conditions, accounting for 44.7％.
4. The most frequently performed operation was sagittal split ramus osteotomy （SSRO）, accounting for 67.3％, followed by the combination of Le Fort Ⅰ osteotomy and SSRO （LF1＋SSRO） at 16.3％.
5. The average operating time and average amount of bleeding for SSRO were 131 minutes and 54g, and those for LF1＋SSRO were 246 min and 128.3g, respectively.
Most patients with cleft lip and palate receive proper and consistent treatment; however, in some cases, patients are not satisfied with the treatment outcomes regardless of improvements in jaw function and morphology after orthognathic surgery, which is considered as one of the final phases of the treatment. Therefore, to improve patients’ satisfaction with the treatment, their psychological conditions were surveyed before and after orthognathic surgery.
Thirty-four patients with cleft lip and palate completed a psychological test （MINI-124） before orthognathic surgery, and the findings revealed that the majority showed high scores in each scale designed for measuring lie, hysteria, and association problem. Furthermore, the scores of hypochondriasis, hysteria, and bodily symptoms were significantly higher in patients with cleft lip and palate than in 70 jaw deformity patients without any congenital anomalies measured before surgery. In addition, a questionnaire survey on the orthognathic surgery performed at more than 6 months after the surgery, showed that patients with cleft lip and palate were mostly satisfied with their surgeries. However, some of them showed a slightly lower degree of satisfaction and a strong obsession with their lip scars and nasal deformities.
Panfacial fracture is often accompanied by soft tissue injuries and loss of bony structures. Because of the lack of normative anatomical structure, it is difficult to reduce and fix to the former state. Moreover, it could lead to post-traumatic deformities and dysfunctions. If appropriate primary treatment is not performed, it can cause abnormal bone healing and scarring of soft tissue. Therefore, orthognathic surgery is frequently performed for jaw deformity due to malunited panfacial fracture.
The present case was a 24-year-old man who suffered panfacial fracture in a traffic accident. The maxilla and mandible were openly reduced and internally fixed at another hospital; other fractures in this region were conservatively managed. However, malocclusion and facial deformity caused by malunion were seen and nine months later he was referred to our hospital with a chief complaint of concave profile and occlusal reconstruction. We aimed to improve his concave profile and decided to perform orthognathic surgery. Intraoral findings showed Angle Class Ⅰ and Class Ⅲ molar relations on the right and left, respectively. Cephalometric analysis revealed SNA 72.0°, SNB 77.7°, ANB−5.7° and A-B plane 7.4°. He was diagnosed as maxillary retrusion associated with malunited panfacial fracture. In order to achieve functional occlusion, two surgical plans were proposed: 5mm advance by Le Fort Ⅰ osteotomy or 5mm setback by bilateral sagittal split ramus osteotomy. We performed 3D virtual planning using software, which showed that Le Fort Ⅰ osteotomy was appropriate compared with bilateral sagittal split ramus osteotomy. We informed him of this surgical plan with 3D simulation data, and he agreed to it. It was expected to be difficult to perform normal osteotomy because of bone defect and malunion, so we constructed a 3D stereolithographic model and carried out surgery on the model. Finally, we performed orthognathic surgery as planned and safely. The postoperative course has been uneventful since then.
It is thought that these surgical procedures may be effective for patients with malunited panfacial fracture, and that preoperative management led to good results.