A osteogenesis distraction device enabling control of vertical direction for syndromic craniosynostosis

Le fort II distraction osteogenesis with a hybrid system for an Apert syndrome patient: A case report

Background

Le Fort II advancement is considered for normalizing the facial appearance in Apert syndrome. When these procedures are performed during growth, overcorrection of midface advancement is required. We developed a system that can control the distance and vector of movement for the central midface to create more normal facial proportions. This case report shows Le Fort II distraction osteogenesis with this hybrid system for an Apert syndrome patient.

Case

The patient was a girl with Apert syndrome with midfacial-nose hypoplasia and skeletal class III malocclusion. She was healthy without respiratory problems and had no learning disabilities. She underwent our Le Fort II distraction osteogenesis with the hybrid system at 10 years and 6 months of age. Her midface was elongated 22 mm at point Or forward and moved 5° downward to the Frankfort horizontal plane compared to the standard position of average Japanese adult women on the cephalogram. Examining the facial image, the midfacial depression was improved 4 years after the operation.

Discussion

Overcorrection of midface advancement is required for patients to reduce the number of procedures during growth. The system that we developed could control the distance and vector of movement steadily when the central midface was overcorrected to try to create normal adult facial proportions.

Overcorrected Midface Advancement to Improve Airway Problems in Severe Pfeiffer Syndrome Types II and III

INTRODUCTION

Treatment of patients with severe Pfeiffer syndrome types II and III is difficult. The purpose of this article is to present our method of overcorrecting midface advancement to improve airway problems in such patients.

MATERIALS AND METHODS

One boy and two girls with types II and III Pfeiffer syndrome and who underwent Le Fort III midface advancement using our previously described corrected cephalometric analysis and distraction system were included in the study.

RESULTS

The authors overcorrected by advancing the midface to make it look as similar as possible to an adult face. While the overcorrected midface advancement widened the upper airway spaces in the 3 patients, the tracheostomy that had already been placed during infancy could not be closed, probably because of an underlying tracheal abnormality or tracheomalacia.

DISCUSSION

Overcorrected midface advancement cannot enable tracheostomy closure, probably because of severe tracheal anomalies, such as tracheomalacia, below the tracheostomy. However, with the possibility of gradual improvement of the tracheomalacia with age, closure of the tracheostomy can eventually be expected. Therefore, efforts to close a tracheostomy should be pursued even if the probability of its removal is low.

CONCLUSION

Overcorrected midface advancement did not enable tracheostomy closure, probably because of severe tracheal anomalies such as tracheomalacia. However, the severe exophthalmos and angle III malocclusion were improved, and with the possibility of gradual improvement of the tracheomalacia with age, closure of the tracheostomy can eventually be expected. Therefore, efforts to close a tracheostomy should be pursued even if the probability of its removal is low.

Corrected Cephalometric Analysis to Determine the Distance and Vector of Distraction Osteogenesis for Syndromic Craniosynostosis

Background:

The purpose of this study was to confirm the utility of a corrected cephalometric analysis to facilitate the planning of distraction osteogenesis with Le Fort III osteotomy for syndromic craniosynostosis.

Methods:

This prospective study involved 4 male and 2 female patients (mean patient age, 8 years 9 months; age range, 4 years 6 months to 13 years 2 months) with Crouzon syndrome who were treated with Le Fort III maxillary distraction using our previously described system of analysis of a corrected cephalogram and who underwent clinical follow-up. Lateral cephalograms were obtained immediately after device removal.

Results:

Distraction of orbitale moved the vector downward to the adult profile, but there was slightly less elongation than the adult profile for the distraction distance. The desired and real mean angles after distraction of point A were 29.2 ± 7.9° and 6.1 ± 8.5°, respectively, and the desired and the real mean distances after distraction of point A were 30.6 ± 12.7 mm and 29.4 ± 4.1 mm, respectively.

Conclusions:

Using the corrected cephalometric analysis, the distance and vector of distraction osteogenesis with Le Fort III osteotomy could be determined in patients with syndromic craniosynostosis. The distraction system brought the patients' facial bones to the planned position using controlling devices.

Transmaxillary Sinus Approach for Le Fort II Osteotomy

The Le Fort II osteotomy is a relatively rare operation. The posterior wall osteotomy of the maxillary sinus (MS) is often difficult for Le Fort III. We developed the transmaxillary sinus approach (TSA) for the Le Fort II osteotomy that cuts the posterior wall of the MS directly. This report illustrates this easy-to-use procedure for the Le Fort II osteotomy in syndromic craniosynostosis. This procedure was performed in an 18-year-old patient with Apert syndrome and a 15-year-old patient with Pfeiffer syndrome. The thin anterior walls of the MS were removed through an intraoral approach to look inside the MS. Then, the posterior walls were cut by chisel under direct vision using light. The other osteotomy was performed as usual. Distraction osteogenesis with internal and external devices was used in combination. The advantages of TSA are the direct posterior wall osteotomy of the MS with no down fracture and minimal invasiveness to the mucosa of the MS under direct vision. However, the disadvantage is that TSA becomes a blind procedure in a case with no MS or hypoplasia. We developed the TSA for the Le Fort II osteotomy, which could provide direct observation and perform the posterior wall osteotomy of the MS without down fracture. We believe that TSA is an effective surgical procedure for the Le Fort II osteotomy.