Controversies in the Management of Craniofacial Malformations

Volumetric Analyses of Dysmorphic Maxillofacial Structures Using 3D Surface-Based Approaches: A Scoping Review

Background/Objectives: Three-dimensional (3D) analysis of maxillofacial structures in dysmorphic patients offers clinical advantages over 2D analysis due to its high accuracy and precision in measuring many morphological parameters. Currently, no reliable gold standard exists for calculating 3D volumetric measurements of maxillofacial structures when captured by 3D surface imaging techniques. The aim of this scoping review is to provide an overview of the scientific literature related to 3D surface imaging methods used for volumetric analysis of the dysmorphic maxillofacial structures of patients affected by CL/P or other syndromes and to provide an update on the existing protocols, methods, and, when available, reference data. Methods: A total of 17 papers selected according to strict inclusion and exclusion criteria were reviewed for the qualitative analysis out of more than 4500 articles published between 2002 and 2024 that were retrieved from the main electronic scientific databases according to the PRISMA-ScR guidelines. A qualitative synthesis of the protocols used for the selection of the anatomical areas of interest and details on the methods used for the calculation of their volume was completed. Results: The results suggest a great degree of heterogeneity between the reviewed studies in all the aspects analysed (patient population, anatomical structure, area selection, and volume calculation), which prevents any chance of direct comparison between the reported volumetric data. Conclusions: Our qualitative analysis revealed dissimilarities in the procedures specified in the studies, highlighting the need to develop uniform methods and protocols and the need for comparative studies to verify the validity of methods in order to achieve high levels of scientific evidence, homogeneity of volumetric data, and clinical consensus on the methods to use for 3D volumetric surface-based analysis.

Síndrome de Apert: alternativas de tratamiento ortodóntico - quirúrgico y tiempos de ejecución. Una revisión de la literatura

Objetivo: realizar una revisión de la literatura acerca de los tratamientos ortodónticos y quirúrgicos del síndrome de Apert durante las diferentes etapas de crecimiento y desarrollo. Métodos: se llevó a cabo una búsqueda en las bases de datos MedLine (PubMed), Science Direct, Scopus y Wiley Online Library con la combinación de los siguientes términos: Syndromic craniosynostosis, Dental treatment, orthodontic treatment, Apert Syndrome, surgical treatment, dental care. Se incluyeron revisiones sistemáticas y de literatura, estudios retrospectivos, longitudinales y de cohorte, series y revisiones de caso publicados entre 1990 y 2020 en español o inglés; se excluyeron artículos relacionados con otros síndromes, así como estudios en animales. Los artículos fueron seleccionados según su pertinencia y disponibilidad de texto completo; hallazgos repetidos fueron eliminados; adicionalmente, se utilizó el sistema bola de nieve en los artículos seleccionados; la calidad de la evidencia fue evaluada mediante el sistema GRADE. Resultados: 34 artículos fueron incluidos (calidad alta: 2, moderada: 1, baja: 19 y muy baja: 12). Entre estos, se identificaron discusiones relacionadas con la etapa de crecimiento a la que se recomienda realizar los procedimientos quirúrgicos requeridos para minimizar sus impactos negativos. La mayoría de los artículos apoyan el manejo terapéutico ejecutado por equipos multidisciplinarios. Conclusiones: un plan de tratamiento combinado de ortodoncia y cirugía ortognática se presentó como la mejor opción para obtener los mejores resultados funcionales y estéticos para la población en cuestión. El momento adecuado durante el crecimiento y desarrollo de los individuos para implementar cada fase de tratamiento fue decidido por cada equipo multidisciplinario.

Craniofacial morphology and growth in Muenke syndrome, Saethre-Chotzen syndrome, and TCF12-related craniosynostosis

Objectives

To determine whether the midface of patients with Muenke syndrome, Saethre-Chotzen syndrome, or TCF12-related craniosynostosis is hypoplastic compared to skeletal facial proportions of a Dutch control group.

Material and methods

We included seventy-four patients (43 patients with Muenke syndrome, 22 patients with Saethre-Chotzen syndrome, and 9 patients with TCF12-related craniosynostosis) who were referred between 1990 and 2020 (age range 4.84 to 16.83 years) and were treated at the Department of Oral Maxillofacial Surgery, Special Dental Care and Orthodontics, Children’s Hospital Erasmus University Medical Center, Sophia, Rotterdam, the Netherlands. The control group consisted of 208 healthy children.

Results

Cephalometric values comprising the midface were decreased in Muenke syndrome (ANB: β = –1.87, p = 0.001; and PC1: p < 0,001), Saethre-Chotzen syndrome (ANB: β = –1.76, p = 0.001; and PC1: p < 0.001), and TCF12-related craniosynostosis (ANB: β = –1.70, p = 0.015; and PC1: p < 0.033).

Conclusions

In this study, we showed that the midface is hypoplastic in Muenke syndrome, Saethre-Chotzen syndrome, and TCF12-related craniosynostosis compared to the Dutch control group. Furthermore, the rotation of the maxilla and the typical craniofacial buildup is significantly different in these three craniosynostosis syndromes compared to the controls.

Clinical relevance

The maxillary growth in patients with Muenke syndrome, Saethre-Chotzen syndrome, or TCF12-related craniosynostosis is impaired, leading to a deviant dental development. Therefore, timely orthodontic follow-up is recommended. In order to increase expertise and support treatment planning by medical and dental specialists for these patients, and also because of the specific differences between the syndromes, we recommend the management of patients with Muenke syndrome, Saethre-Chotzen syndrome, or TCF12-related craniosynostosis in specialized multidisciplinary teams.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-04275-y.

Craniofacial Stability in Patients with Crouzon or Apert Syndrome after Le Fort III Distraction Osteogenesis

Objective

Le Fort III osteotomy with distraction osteogenesis (DO) is used to improve the retruded midface in patients with Crouzon or Apert syndrome. This study aimed to evaluate sagittal and vertical preoperative and postoperative cephalometric changes of DO of the midface in patients with Crouzon or Apert syndrome.

Design

Population-based case-control study.

Patients and Methods

Records of patients with the syndrome of Crouzon (N = 6) or Apert (N = 7) were compared, before and after Le Fort III DO, with a nonsyndromic untreated control group (N = 486).

Main Outcome Measures

Sagittal and vertical cephalometric maxillary landmarks and measurements were used to predict and measure midface advancement and rotation after Le Fort III DO. Cephalograms were taken before surgery (T0), 4 months after surgery at removal of the distraction device (T1), and 1 year after removal of the distraction device (T2).

Analysis

Z scores were performed to compare cephalometric measures of syndromic patients with control subjects.

Results

Cephalograms of 13 patients with Crouzon syndrome (N = 6) or Apert (N = 7) (age range 8.2 to 19.8 years) were evaluated. Treatment changes (T1-T2) showed statistically significant maxillary advancement, with no significant differences between the patients with the Crouzon or Apert syndrome.

Conclusions

DO of the midface in patients with Crouzon or Apert syndrome seems to be stable in the sagittal direction after follow-up. Although Crouzon and Apert differ after DO, anteroposterior craniofacial dimensions were significantly improved and were closer to patterns of normal subjects.

Facial growth in patients with apert and crouzon syndromes compared to normal children

OBJECTIVE

To evaluate vertical and sagittal facial growth in children with Apert and Crouzon syndromes and compare it to the growth patterns of a nonsyndromic control group.

DESIGN

Case-control study.

SETTING

Department of Orthodontics, Children's Hospital Erasmus Medical Centre, Sophia, Rotterdam, The Netherlands.

PATIENTS, PARTICIPANTS

Sixty-two patients (37 patients with Crouzon syndrome and 25 patients with Apert syndrome) born between 1971 and 2001 (age range 3.9 to 32 years) and 482 nonsyndromic children as a control group.

INTERVENTIONS

Lateral cephalograms performed prior to any midfacial surgery of 62 patients and 482 nonsyndromic children were traced and horizontal and vertical measurements were digitized.

MAIN OUTCOME MEASURES

Cephalometric measurements of SNA, SNB, ANB, NSMe, and SN/palatal plane angles and lower facial height ratio.

RESULTS

Horizontal measurements for the syndromic groups showed no change in SNA angle during growth. SNA angles were lower in patients with Apert syndrome compared to patients with Crouzon syndrome. The syndromic groups showed smaller values for ANB angles compared to the nonsyndromic group. Vertical measurements showed increased lower facial height ratios for the syndromic groups compared to control subjects. There was an increasing counterclockwise rotation of the palatal plane in relation to the anterior cranial base in syndromic patients. NSMe angles among the three groups were not significantly different.

CONCLUSIONS

Based on the growth differences identified, the sagittal and vertical jaw relationships differ in patients with Crouzon syndrome, patients with Apert syndrome, and control subjects. Syndromic patients show aggravation of midfacial underdevelopment and anterior rotation of the mandible.

Correction of hemifacial microsomia with the help of mirror imaging and a rapid prototyping technique: case report

A 23-year-old man presented with an 8-year history of unilateral hemifacial microsomia. A three-dimensional model of the maxillofacial bones was generated after acquisition of helical computed tomographic data. A customised implant model was designed by projecting a mirror image of the healthy mandible on to the three-dimensional model. A resin model of the implant was then made using a rapid prototyping machine. A polymeric biomaterial was sculpted according to the model and implanted into the affected side of the mandible to restore his facial symmetry. The hemifacial microsomia was corrected and a symmetrical facial contour obtained. No complications developed during the 6-year follow-up.