Adult patient with hemifacial microsomia treated with combined orthodontics and distraction osteogenesis

Distraction Osteotomy Combined With Orthodontics: An Effective Way to Decrease Short-term Recurrence in Treating Child Craniofacial Microsomia

BACKGROUND

This study aims to investigate strategies for reducing early relapse following mandibular distraction osteotomy (MDO) in craniofacial microsomia (CFM) patients.

METHODS

Forty CFM patients were divided into 2 groups: 20 underwent MDO alone, while 20 received MDO combined with orthodontic treatment (MDO-O). Preoperative, prefixation, and postfixation CT data in DICOM format were collected and reconstructed using Proplan software. Spatial geometric analysis was conducted to assess the inclination angle of the occlusal plane (OP), and OP deviation was directly measured using the software.

RESULTS

Patients in the MDO-O group demonstrated a statistically significant improvement in OP inclination at the end of the fixation period compared with those who underwent MDO alone ( P =0.003).

CONCLUSIONS

Combining MDO with a bite plate and bite glue sticks in CFM patients during the mixed dentition period enhances OP outcomes, effectively reducing short-term recurrence.

Condylar resorption post mandibular distraction osteogenesis in craniofacial microsomia: A retrospective study

The aim of this study was to investigate the characteristics of condylar resorption in craniofacial microsomia (CFM) patients following mandibular distraction osteogenesis (MDO). Patients with unilateral type-IIa and type-IIb CFM, who had completed MDO and mandibular distractor extraction (MDE), were recruited. The height and volume of the condyle were measured on three-dimension models created by the analysis of computed tomography (CT) data. Normality analysis was performed using the Shapiro-Wilk test. Data for the affected and unaffected sides were compared using the paired t-test or Wilcoxon signed-rank test. Data for both type-IIa and type-IIb CFM were compared using the independent-samples t-test or Mann-Whitney U test. The Pearson or Spearman correlation was used to determine the correlations of condylar resorption rate with related measurements. In total, 48 type-IIa and 48 type-IIb CFM patients were included. The condylar resorption rate in type-IIa CFM (0.35 ± 0.32) was significantly associated with the height of the condyle (r = 0.776, p < 0.001) and distraction distance (r = 0.447, p = 0.001), while the condylar resorption rate in type-IIb CFM (0.49 ± 0.46) was significantly associated with the height of the condyle (r = 0.924, p < 0.001). However, there was no significant difference in condylar resorption rate between type-IIa and type-IIb CFM (p = 0.075). In addition to occlusal changes, no other negative symptoms of the TMJ were observed with condylar resorption. Condylar resorption was evident in CFM patients following mandibular distraction osteogenesis, and the condylar resorption rate showed a relationship with distraction distance and condylar height.

Three-Dimensional Measurement of the Temporomandibular Joint in Pruzansky-Kaban Type IIa Hemifacial Microsomia

OBJECTIVE

This observational retrospective cross-sectional study aimed to investigate the morphological characteristics of the temporomandibular joint (TMJ) in type IIa hemifacial microsomia (HFM).

METHODS

We recruited 88 patients with unilateral type IIa HFM. Data relating to the length, distance, and angle of the TMJ, were measured on 3-dimensional models created by the analysis of computed tomography data. Normality analysis was performed by using the Shapiro-Wilk test. Data were compared with the paired t test and Wilcoxon signed-rank test.

RESULTS

The height, long axis, and short axis of the affected condyle were significantly shorter than the unaffected side ( P <0.001); the ratios were 0.41±0.15, 0.75±0.20, and 0.95±0.24, respectively. The spaces between the condyle and the glenoid fossa were significantly larger in affected TMJs ( P <0.001). The ratio between the ipsilateral and contralateral anterior space in the sagittal plane was 4.62±2.59; this was significantly different than the ratio of inner space (1.50±1.70), superior space (1.70±0.97), and lateral space (1.28±0.62) in the coronal plane ( P <0.001) and the ratio of superior space (1.43±1.05) and posterior space (1.47±0.98) in the sagittal plane ( P <0.001); there were no statistical differences between the 5 spaces ( P >0.05). The breadth and depth of the glenoid fossa were significantly shorter in affected TMJs ( P <0.001), the ratio of the breadth in the affected and unaffected glenoid fossa was between 0.5 and 1 and the depth of the affected glenoid fossa was almost half of that on the unaffected side. The ratio between the ipsilateral and contralateral height of the condyle was significantly different when compared with the length of the mandibular ramus ( P <0.001). The ratio between the ipsilateral height of the condyle and the length of the mandibular ramus was significantly different when compared with that of the contralateral side ( P <0.001). The height of the affected condyle were significantly different ( P =0.005) among different ages.

CONCLUSIONS

We found that hypoplasia was more severe in terms of the height of the condyle than the long axis and short axis of the condyle. The degree of condyle deformity was more severe than the mandible. And the affected condyle still had growth potential in the vertical direction with age.

Morphologic Changes of the Temporomandibular Joint in Pruzansky-Kaban Type IIa Hemifacial Microsomia Postmandibular Distraction Osteogenesis

OBJECTIVE

Mandibular distraction osteogenesis (MDO) is a powerful tool for the correction of hemifacial microsomia (HFM). The temporomandibular joint (TMJ) is the focus of attention in the diagnosis and treatment of HFM. This observational retrospective cross-sectional study aimed to investigate morphologic changes in TMJ post-MDO in type IIa HFM.

METHODS

We recruited 48 patients with unilateral type IIa HFM who had completed MDO and mandibular distractor extraction (MDE). Data relating to the length, distance, angle, and volume of the TMJ were measured on 3-dimension models created by the analysis of computed tomography data. Normality analysis was performed by using the Shapiro-Wilk test. Data were compared with the paired t test and Wilcoxon signed-ranks test.

RESULTS

The spaces between the affected condyle and the affected glenoid fossa before MDO were all significantly larger than before MDE (P<0.05). The breadth of the affected glenoid fossa before MDO was significantly longer than before MDE (P<0.001). The height of the affected condyle before MDO was significantly longer than before MDE (P<0.001). The volume of the affected condyle before MDO was significantly larger than before MDE (P<0.001). The ratio between the volume of the affected condyle and unaffected condyle before MDO was 0.20±0.13. The ratio between the volume of the affected condyle before MDE and MDO was 0.65±0.32. The resorption rate of the affected condyle post-MDO was 0.35±0.32.

CONCLUSION

Herein, we characterized anatomic changes of the TMJ in type- IIa HFM post-MDO. Condylar resorption and the compression of space between the condyle and the glenoid fossa on the affected side were 2 typical manifestations. Our findings enhanced the understanding of the application of MDO on HFM.

The Use of Computer-Guided Half Propeller Genioplasty for the Correction of Mandibular Asymmetry (A Mandibular Orthognathic Surgery Without a Condylar Intervention Technical Strategy)

INTRODUCTION

Mandibular asymmetry is a facial deformity that results from multiple causes; among these are growth deficiency like hemifacial microsomia and growth excess as in condylar hyperplasia. The facial asymmetry caused by condylar hyperplasia has been treated over the years with different surgical and nonsurgical modalities dependent on the age of the patient and the severity of the condition. The authors in this article introduce a modified version of the propeller genioplasty technique.

MATERIALS AND METHODS

A new surgical technique "modified propeller genioplasty" is introduced for the management of facial asymmetry. Virtual surgical planning of the osteotomies and segment repositioning was done virtually. A cutting guide, positioning guides and 3D model of the corrected chin were 3D printed, to facilitate replication of the virtually planned osteotomies, prebending of plates, and segment repositioning.

RESULTS

The esthetically accepted result was achieved using this technique with minimal postoperative complications.

CONCLUSIONS

The technique appeared to be accurate, simple, and more cost efficient when compared to patient-specific plates.

Effect of mesenchymal stem cells with platelet-rich plasma carriers on bone formation after rapid maxillary expansion: An Animal Study

OBJECTIVE

To evaluate the effect of bone mesenchymal stem cells (BMSCs) with or without platelet-rich plasma (PRP) carriers on sutural new bone formation after rapid palatal expansion (RPE).

SETTINGS AND SAMPLE POPULATION

Sixty male Wistar rats were used in this study.

MATERIAL AND METHODS

All samples were subjected to 50cN of palatal expansion force for 7 days followed by 3 weeks of the retention period. The experimental groups received a single-dose injection of the specified solution at the time of retainer placement (BMSCs, PRP, BMSCs+PRP, normal saline). BMSCs used in this study were marked with the green fluorescent protein (GFP). New bone formation (NBF) in the sutural area was evaluated by µCT and occlusal radiography. In addition, semi-quantitative analyses were performed on histology images to analyse the quality of sutural bone, connective tissue and vascularization. Immunohistochemistry analyses were conducted for osteocalcin and collagen type I proteins.

RESULTS

After the 21-day retention period, limited GFP marked cells were detected around the sutural area. Samples treated with BMSCs + PRP had the highest NBF and showed higher expression of collagen type I and osteocalcin.

CONCLUSION

Injecting BMSCs + PRP may increase sutural bone density significantly. However, injecting BMSCs or PRP carriers alone did not affect sutural bone density.

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.

Maxillary Distraction Osteogenesis in Unilateral Cleft Lip and Palate Patients with Rigid External Distraction System

Aim:

Distraction osteogenesis (DO) is a treatment option for patients with maxillary hypoplasia secondary to cleft lip and palate (CLP).

Purpose:

The aim of this study is to present a technique for maxillary DO using Le Fort I osteotomy with rigid external distraction (RED) system.

Subjects and Methods:

The patient presented in this paper was an Asian female with CLP aged 13 years and 6 months. She presented with severe midfacial deficiency with a Class III dental malocclusion with a negative overjet and concave facial profile. Cone-beam computed tomography images were recorded preoperatively and the operation performed involved a high Le Fort I osteotomy. The appliance fabricated was banded to upper first molars used for anchorage of the RED system. Distraction of the maxilla was initiated after 7-day latency period.

Results:

Postoperative cephalometric analysis showed maxillary advancement anteriorly and superiorly, the total distraction treatment period was 10 days. The maxillary advancement was 10.5 mm and the SNA angle increased from 67.5° to 77.9°. Furthermore, the ANB angle changed from −9.8° to 1.6° and the occlusion changed from Class III to Class I. The profile of the face changed from concave to convex and a much better esthetic result was achieved.

Conclusion:

The study suggests RED system to be a reliable alternative procedure for the treatment of midfacial hypoplasia with or without cleft. Furthermore, it minimizes the risk of the surgical procedure and shortens the operating time.

Simultaneous maxillomandibular distraction osteogenesis in hemifacial microsomia: Report of 7 cases

INTRODUCTION

The goal in treating Hemifacial microsomia (HFM) is to improve facial symmetry, allow functional jaw movement, obtain stable occlusion, and achieve patient satisfaction. This study was planned with an aim to assess the outcome of simultaneous maxillomandibular distraction osteogenesis in hemifacial microsomia.

MATERIAL & METHODS

Seven patients with hemifacial microsomia were included in this study and demographic data was obtained. Simultaneous maxillo-mandibular distraction was planned for correction of maxillary cant, vertical ramal lengthening and midline, by performing unilateral mandibular osteotomy in ramus and distractor fixation, a Le Fort I osteotomy, with fixation at contralateral zygomatic buttress and intermaxillary elastics. Derriford Appearance Scale was used to measure individual responses to address problems of appearance.

RESULTS

6 males and 1 female, with age range 18-26 years, mean 22.14 were included in the study. Maxillary occlusal cant varied from 4-16°, mean 9.85° and distraction achieved ranged from 12-19 mm, mean 15.57. Preoperatively DAS score ranged from 42-61, mean 51.7 and improved to 10-27, mean 18.4. 100% success was achieved in 5 cases, while other two showed 96% and 99% success.

CONCLUSION

Simultaneous maxillomandibular distraction osteogenesis improves facial esthetics and obviates the need for postoperative orthodontics, minimizing the treatment period.

Orthodontic and surgical management of a patient with severe skeletal Class II deformity and facial asymmetry: A case report with a 5-year follow-up

In this case report, we present the orthodontic and surgical management of an 18-year-old girl who had a severe craniofacial deformity, including maxillary prognathism, vertical maxillary excess (gummy smile), mandibular retrognathism, receding chin, and facial asymmetry caused by unilateral temporomandibular joint ankylosis. For correction of the facial asymmetry, the patient's right mandibular ramus and body were lengthened via distraction osteogenesis after 5 months of preoperative orthodontic therapy. Subsequently, extraction of 4 first premolars, bimaxillary anterior segmental osteotomy, and genioplasty were simultaneously performed in the second-stage operation to correct the skeletal deformities in the sagittal and vertical planes. Postoperative orthodontic treatment completed the final occlusal adjustment. The total active treatment period lasted approximately 30 months. The clinical results show that the patient's facial esthetics were significantly improved with minimal surgical invasion and distress, and a desirable occlusion was achieved. These pleasing results were maintained during the 5-year follow-up.

Installing an original sleeve for rod unaccessible pain from a distraction device in a hemifacial microsomia patient

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Lengthening of the mandible by distraction osteogenesis using an internal device is the preferred method for the treatment of hemifacial microsomia. Despite its advantages, this technique can lead to various complications after the surgery.

•

We describe a case in which rod unaccessible pain developed after the initial mandibular distraction activation, and the pain was resolved by installing an original sleeve.

Introduction

Lengthening of the mandible by distraction osteogenesis using an internal device is the preferred method for the treatment of hemifacial microsomia. Despite its advantages, this technique can lead to various complications after the surgery.

Presentation of case

We report the case of an 8-yr-old Japanese girl whose case presented practical difficulties in device activation because of rod unaccessible pain after the initial mandibular distraction with an internal device, and this complication was addressed with the installation of an original sleeve.

Discussion

In the present patient, the region of the bend rod was located at the inferior border of the right mandible, causing rod unaccessible pain by contacting the surrounding tissue including a sensory nerve. Careful vertical ramus distractor position planning and tools to resolve complications are the key factors for accomplishing the scheduled elongation.

Conclusion

Alternative techniques using a sleeve for safer and gentle distraction for rod unaccessible pain on activation should be considered.

Costochondral grafting in craniofacial microsomia

BACKGROUND

Craniofacial microsomia encompasses a spectrum of diagnoses associated with variable degrees of mandibular hypoplasia, facial asymmetry, chin deviation, occlusal abnormalities, and potential airway compromise. This study presents one surgeon's experience with costochondral rib grafting for mandibular reconstruction in children with Pruzansky/Kaban type 2B and type 3 mandibular hypoplasia.

METHODS

An institutional review board-approved retrospective chart review was performed of all patients with craniofacial microsomia who underwent costochondral rib grafting for mandibular reconstruction performed by the senior author (S.P.B.) at The Children's Hospital of Philadelphia from January of 1998 to September of 2013. Demographic information, surgical history, operative details, postoperative complications, and outcomes were recorded. Plain radiographs and preoperative and postoperative three-dimensional computed tomographic scans were reviewed.

RESULTS

Two hundred fifty-five patients were diagnosed with craniofacial microsomia, and 22 patients met inclusion criteria. Twelve boys and 10 girls underwent grafting at an average age of 7.2 years. Thirty-three costochondral rib grafts were performed, 11 unilateral reconstructions and 11 bilateral reconstructions. Twelve hemimandibles were type 2B and 21 were type 3. No intraoperative complications were reported, and no incidence of graft resorption was noted. No additional procedures were required in 27 reconstructed hemimandibles (81.8 percent), whereas six (18.2 percent) required secondary distraction osteogenesis. Only one patient developed postoperative ankylosis. No malunion or nonunion was noted.

CONCLUSION

The approach described in this article allowed the authors to obtain reliably good results with costochondral rib grafting for type 2B and type 3 mandibular hypoplasia associated with craniofacial microsomia.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Effects of laser vs ultrasound on bone healing after distraction osteogenesis: A histomorphometric analysis

Objective: 

To assess the effects of low-level laser irradiation vs ultrasound irradiation on bone healing after distraction osteogenesis.

Materials and Methods: 

Distraction osteogenesis was performed with rapid maxillary expansion devices (Hyrax-Morelli, Sorocaba, São Paulo Brazil) in 24 rabbits (Oryctolagus cuniculus). After a 2-day latency period, the distraction devices were activated for 10 days at a rate of 1 mm/d. Four groups of six animals were treated as follows: (1) control, (2) laser irradiation on the right side, (3) ultrasound irradiation on the right side, and (4) laser irradiation on the right side and ultrasound on the left side. Histomorphometric analysis was used to assess the bone healing area. Analysis of variance was used to perform the statistical analyses.

Results: 

The influence of low-intensity laser associated with ultrasound irradiation on bone healing was statistically significant. The analyses showed the greatest amount of bone healing in the jaws of animals in group 4, which received treatment with both ultrasound and laser.

Conclusion: 

This study concluded that bone healing is accelerated with the application of laser irradiation. The greatest effects were observed with combined ultrasound and laser treatment.