Cotton on to the problems: a visual aid for mimicking maxillary advancement surgery chairside

There are a variety of different facial assessments (clinical and cephalometric, hard and soft tissue) that can be conducted to help plan orthognathic surgery. However, in mild skeletal Class III cases, it can be challenging for patients and clinicians to assess whether the patient would benefit from maxillary advancement only, compared to a bimaxillary procedure. An additional challenge lies in our ability, or lack thereof, to forecast the soft tissue changes in a way that is meaningful to patients.

The procedure presented is a quick and easy chairside aid which can help patients and clinicians to visualise the facial changes with maxillary advancement surgery. It involves placing two damp cotton wool rolls under the upper lip to mimic anterior repositioning of the maxilla.

Clear clinical photographs should be taken before and after placement of the cotton wool rolls so the patient can see the difference between the images. This can help in shared decision-making, whereby patients are given the opportunity to reflect on this altered facial appearance.

Procedure

• Take pre-operative extraoral photographs of the patient's front and profile in natural head position
• Dampen the cotton wool rolls. Gently squeeze the rolls to remove excess liquid and flatten gently between the forefinger and thumb
• Lift and gently manipulate the upper lip to place two cotton wool rolls either side of the labial frenum. They should rest comfortably in the sulcus
• With the cotton wool rolls in situ, take a second series of clinical photographs of the patient's frontal and profile extraoral views in the natural head position
• Remove cotton wool rolls and show the patient both images side by side.

Impression rather than prediction

This technique should be used to allow an impression of the facial changes with maxillary advancement rather than as a direct prediction of the changes. For instance, it will not mimic the soft tissue changes in and around the nose.

Dermal fillers

Dermal fillers, including lip fillers, are becoming more common, especially in young adults. A poll by Save Face, a national register of accredited practitioners providing non-surgical cosmetic treatment, showed that 68% of the 47,000 people surveyed knew at least one person with dermal fillers.⁷

Fillers are mostly temporary, with their longevity ranging from 6–24 months depending on the type of filler used and where it is administered.⁶ Over time, lips treated with fillers may appear less full as the body metabolises the active component, leading to a change in soft tissue profile. Table 1 summarises the most common types of lip filler and their longevity.

Although there is a lack of literature evaluating the qualitative impact dermal fillers have on facial assessment, it is likely that an artificially augmented tissue profile will have an impact on facial assessment, clinical decisions and surgical planning.

The pre-operative orthodontic phase of treatment is often between 18 and 24 months long. Some patients, as they are decompensated and their apparent malocclusion worsens, may turn to dermal fillers to help camouflage the discrepancy. This is often seen in patients who have upper lip fillers to help mask a Class III skeletal relationship or vertical maxillary excess.

At the start of the orthognathic surgery pathway, the use of dermal facial fillers should be a mandatory part of the information gathering and consent process. Patients should be made aware that cosmetic procedures like dermal fillers are likely to influence interdisciplinary assessment and planning. The authors suggest an approach whereby patients are encouraged not to use any dermal fillers at any point along the active orthognathic pathway, or to delay facial assessment on any multidisciplinary clinic until any dermal fillers have dissolved.