Ten-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis and orthodontics: an implant analysis

An Interdisciplinary Management of Severe Facial Asymmetry Due to Hemifacial Microsomia

This case report outlines the importance of an interdisciplinary approach and a patient centric outcome for the treatment of facial asymmetry resulting from hemifacial microsomia. Different treatment modalities are available to treat asymmetries. However, the best treatment outcome can be achieved only when the treatment plan is individualized for every patient. This report portrays an adult patient with hemifacial microsomia, who had facial asymmetry from the level of supraorbital region with a Class II skeletal base. Orthodontic treatment, along with surgical management, was required to transform the patient into a symmetrical profile, which is esthetically pleasing. A sound knowledge of the various technologies and resources that are available to us and making the best use of it to bring out a drastic change in the patient's life. Combined effort of the orthodontists and oral surgeons are required to manage patient's with hemifacial microsomia that has caused the severe facial asymmetry. Moreover, special attention has to be given to a patient-centric outcome.

Early hemi-mandibular lengthening by distraction osteogenesis contributes to compensatory maxillary growth

Mandibular distraction osteogenesis at an early age is the standard hemifacial microsomia treatment. Nevertheless, the recurrence rate remains high and the definition of early age is controversial. We explored the optimal timing for mandibular distraction, when the surrounding skeleton, such as maxilla, can grow compensatory, to reduce recurrence. Hemifacial microsomia patients were prospectively divided into Groups A (1-3 years old) and B (4-6 years old), according to maxillary and mandibular growth curves. Computed tomography scans were obtained before distractor implantation and after removal surgery. Maxillary volume increase percentage was the main outcome indicator; other indicators (maxillary symmetry and complications) were secondary outcomes. Fifty-eight patients were enrolled and all but one patient in Group A (failed distraction) completed the study. Two patients had facial nerve injury and another two had mouth-opening limitation, which was relieved after coracoid resection. The difference in percentage increase in maxillary volume between the affected and unaffected sides was 5.06 ± 2.73% and 3.18 ± 1.99% in Groups A and B, respectively, suggesting better compensatory growth in younger patients (P = 0.004). Maxillary symmetry was apparently elevated after mandibular distraction. Mandibular distraction osteogenesis was confirmed to be feasible and safe at age <4 years.

Mandibular Gonial Angle Measurement as a Predictor of Gender-A Digital Panoramic Study

Objective:

The present study is intended for properly assessing, comparing, and evaluating the contemporary measurements of gonial angle using digital panoramic radiography. In addition, this research evaluates the importance of mandibular gonial angle in gender determination.

Materials and Methods:

Technically, this is a retrospective cross-sectional study, where the study sample was composed of 590 (295 males and 295 females) patients undergoing digital panoramic radiography in the College of Dentistry in University of Science & Technology of Fujairah, Fujairah, UAE . These patients had been prescribed panoramic radiographs based on different factors. As a generally adopted procedure, bilateral gonial angle measurements were carried out, results were recorded, and their predictability as a determinant of gender was assessed. ANOVA and t-test procedures were utilized for statistical analysis of the collected data.

Results:

The analysis of the present study confirmed a statistically significant difference between the right and left sides of the gonial angle in both genders. Further, the mean comparison exposed a variation between males and females, based on gonial angle values; females have a statistically significant higher mean angle values than males. Based on the analysis, the present study concludes that this difference between males and females from both sides suggests that the gonial angle helps in sex identification.

Conclusion:

It has been concluded that gender significantly influences the gonial region and has great potential to be used as a forensic tool in gender determination. Digital panoramic radiography is a good study tool and it can be used to determine the morphology of the mandible.

A case of cleft lip and palate with severe maxillary retrognathism treated by distraction osteogenesis and custom made intraoral rapid maxillary expansion appliance: A 2-year follow-up of retention

Herewith, a case is reported of an adolescent female patient with maxillary retrognathism due to restricted growth arising out of the previous cheiloplasty and palatoplasty surgeries treated for cleft lip and palate. She also presented an oroantral fistula in the scarred tissues of the palatal region. There was anterior crossbite and distorted occlusion in the anterior segment with crowding and open bite. There is maxillomandibular discrepancy of 6 degrees°. The distraction osteogenesis was performed so as treat the maxillary hypoplasia. This allows undermanding adaptation of the soft-tissue structures to the modification in the skeletal structures as a result of surgical procedures and ensures long-term stability. A custom made intraoral rapid maxillary expansion device was prepared utilizing the hyrax screw for the distraction of the bony segments. At the end of the treatment and a retention period of 24 months, the patient exhibited improved facial profile and hence esthetics.

One-Year Relapse of Mandibular Distraction for Hemifacial Microsomia Using Masseteric Botulinum Toxin Type A Injections

BACKGROUND

The relapse of hemifacial microsomia was thought to be highly related to the soft tissue envelope around the mandible angle mainly composed by masseter and medial pterygoid. According to the reason, we tried to apply masseter injection of type A botulinum toxin to weaken the soft envelope tension on the early stage post mandible distraction in adult HFM patients.

METHODS

Eight patients diagnosed with HFM were studied and randomly assigned to an experimental or control group. Patients in the experimental group were treated with DO, orthognathic surgeries, autologous fat grafting, and bilateral masseter muscle injection with type A botulinum toxin. The patients in control group were treated with the same procedures as the patients in experimental group except for masseter muscle injection with type A botulinum toxin. The recurrence rates of both groups were evaluated and analyzed after nearly 1 year of follow-up.

RESULTS

The mean recurrence rate was 26.30% ± 11.84% (range 7.62%-37.27%) in the 8 patients after 1-year follow-up. The relapse rate was 16.32% ± 7.78% (7.62%-26.22%) in the experimental group and 36.28% ± 1.03% (34.84%-37.27%) in the control group. There was a significant difference (P = 0.002) between the experimental group and the control group.

CONCLUSIONS

The combination of DO, orthognathic surgeries, autologous fat particle transplantation, and masseter muscle type A botulinum toxin injection technique could be a comprehensive treatment plan for adult patients of HFM. Furthermore, masseter injection of type A botulinum toxin might be an alternative method to reduce the early recurrence rate of postoperative adult patients of HFM.

Changes in width of lower face after unilateral mandibular distraction osteogenesis

Distraction osteogenesis (DO) has been popular to improve hypoplastic mandible in patients with hemifacial microsomia in craniofacial surgery. However, changes in width of the lower face after DO still lack in literatures. The aim of this pilot study was to evaluate cephalometric changes in width of the lower face at different time points after DO and to give an insight into the influence on facial contour. A total of 10 patients (8 males and 2 females) with hemifacial microsomia received DO of the mandibular body measured by posteroanterior cephalograms. Five landmarks (crista galli, latero-orbitale, gonion of the unaffected side, incisor point superior of the unaffected maxilla, incisor point inferior of the unaffected side of the mandible) were chosen for cephalometric analysis. Six distances from the soft tissue contour perpendicularly to the vertical reference line (through crista galli) were calculated through the incisor point superior of the unaffected maxilla, gonion of the unaffected side, incisor point inferior of the unaffected side of the mandible. Measurements were taken preoperatively and postoperatively on the day distraction started (time 1), at the end of distraction (time 2), and at the end of the consolidation period (time 3). Calculations for statistical significance were done for all patients. Mean differences between 3 periods were measured by repeated-measures analysis with significance determined at the 0.05 level of confidence. The results suggested that the values of 6 distances at times 2 and 3 had no significant differences when compared with the values at time 1 (P>0.05). In conclusion, DO of the unilateral mandibular body in patients with hemifacial microsomia should not be beneficial to improve the width of the lower face at a short-term follow-up.

Mandibular hypoplasia with curvilinear distraction

Mandibular distraction with intraoral curvilinear distractor is an effective procedure for lengthening the mandibular corpus and ramus dimensions. Mandibular distractor is valuable for the treatment of hypoplastic mandible. The aim of this article was to describe the treatment of a patient with hypoplastic and severely retrognathic mandible resulting from isolated Pierre Robin sequence, by means of curvilinear distraction osteogenesis followed by fixed orthodontic treatment. As a result, the curvilinear path of distraction can form a new mandibular angle and bring the mandible significantly forward. Attention should be given for the stability of the treatment results.