Early Mandibular Distraction in Craniofacial Microsomia and Need for Orthognathic Correction at Skeletal Maturity: A Comparative Long-Term Follow-Up Study

Exploring Progression and Differences in Facial Asymmetry for Hemifacial Microsomia and Isolated Microtia: Insights from Extensive 3D Analysis

BACKGROUND

Aiming to measure and compare asymmetry of facial hard and soft tissues in patients with HFM and isolated microtia, examining how it evolves.

METHODS

This cross-sectional study assessed facial asymmetry in male East Asian patients aged 5-12 diagnosed with unilateral hemifacial microsomia (Pruzansky-Kaban types I and IIA) or isolated microtia. Using 3D imaging of computed tomography scans, it measured root-mean-square (RMS) values for surface deviations across facial regions. Statistical analyses explored differences between conditions and the relationship of age with facial asymmetry.

RESULTS

A total of 120 patients were categorized into four groups by condition (HFM or isolated microtia) and age (5-7 and 8-12 years). Patients with HFM exhibited the greatest asymmetry in the lower cheek, while those with isolated microtia showed primarily upper face asymmetry. Significant differences, except in the forehead and nasal soft tissue, were noted between the groups across age categories. Notable distinctions in hard tissue were found between age groups in the nasal and mid-cheek areas for patients with HFM (median RMS (mm) 0.9 vs. 1.1, P = 0.02; 1.5 vs. 1.7, P = 0.03) and in the nasal and upper lip areas for patients with isolated microtia (median RMS (mm) 0.8 vs. 0.9, P = 0.002; 0.8 vs. 1.0, P = 0.002). Besides these areas for HFM, no significant age-asymmetry correlation was detected.

CONCLUSIONS

Significant differences in facial asymmetry were observed between HFM and isolated microtia, with the asymmetry in specific area evolving over time.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of post-activation mandibular remodelling in children with craniofacial microsomia treated with distraction osteogenesis

OBJECTIVE

Patients with type IIA craniofacial microsomia (CFM) may benefit from mandibular distraction osteogenesis (MDO) treatment during childhood; however, remodelling of the mandible during the consolidation phase, which may affect the short-term outcomes of MDO, has not yet been quantitatively analysed using computed tomography. Therefore, we aimed to investigate bone remodelling of the mandible in children with type IIA CFM treated with MDO before distractor removal and the factors that influence ramus vertical elongation efficiency.

MATERIALS AND METHODS

Twenty-three children with unilateral CFM were studied between 2020 and 2024. Longitudinal computed tomography data (preoperative, end of active phase and at pre-distractor removal) were analysed. Condyle positions and the mandibular cant were analysed using a paired-sample t test. The relapse rates of vertical lengthening and mandibular cant were calculated. The correlation between distraction efficiency and preoperative craniofacial morphology was analysed.

RESULTS

The condyle on the affected side moved upwards and backwards by 28.84 ± 4.08 and 2.85 ± 4.33 mm, respectively during the active phase but lost 7.66 ± 2.64 mm of vertical extension during the consolidation phase. The relapse rates for vertical extension of the condyle and occlusal plane were 27% and 35%, respectively. The ratio of mandibular ramus height was positively related to EV.

CONCLUSIONS

In children with CFM, attention should be paid to vertical elongation instability and relapse of mandibular inclination during consolidation. Severe mandibular ramus hypoplasia is a preoperative risk factor for vertical skeletal relapse during consolidation. Further efforts are required to reduce the stress that leads to relapse.

Goldenhar Syndrome: Quality-of-Life Analysis of 43 Consecutive Patients

Goldenhar syndrome is a rare congenital disease, characterized by the malformation of craniofacial features, spine, and other organs. Its pathogenesis and impact on patients' quality of life (QoL) have not been fully elucidated as yet. Therefore, data of all patients with Goldenhar syndrome, who were treated at Hannover Medical School between 1997 and 2020, were analyzed. Forty-three patients were identified. Their medical records were carefully reviewed for data regarding their age, sex, demographics, Pruzansky classification, surgical history, and affected side. Goldenhar syndrome-associated medical conditions, therapeutic procedures, and the impact of disease on QoL were assessed. Their QoL was assessed using the Oral Health Impact Profile (OHIP)-14 questionnaire. The χ 2 test and Pearson correlation were performed for statistical evaluation. Female sex was positively correlated with OHIP outcomes, whereas male sex had a negative correlation with OHIP outcomes. Therefore, females had significantly worse QoL than males. No significant correlation was observed between the Pruzansky classification and QoL or between surgical history and QoL. Goldenhar syndrome is a rare disease that presents with varying severity. Hence, prospective studies are required to further investigate the impact of Goldenhar syndrome on the QoL.

Average Three-Dimensional Skeletofacial Model as a Template for Bone Repositioning during Virtual Orthognathic Surgery

BACKGROUND

Virtual planning has revolutionized orthognathic surgery. This study presents a computer-assisted method for constructing average three-dimensional skeletofacial models that can be applied as templates for surgical planning for maxillomandibular repositioning.

METHODS

The authors used the images of 60 individuals (30 women and 30 men) who had never undergone orthognathic surgery to construct an average three-dimensional skeletofacial model for male participants and one for female participants. The authors validated the accuracy of the newly developed skeletofacial models by comparing their images with 30 surgical simulation images (ie, skulls) that had been created using three-dimensional cephalometric normative data. The comparison was conducted by superimposing surgical simulation images created using the authors' models with the previously created images to analyze their differences, particularly differences in the jawbone position.

RESULTS

For all participants, the authors compared the jaw position in the surgical simulation images created using the authors' average three-dimensional skeletofacial models with that in the images created using three-dimensional cephalometric normative data. The results revealed that the planned maxillary and mandibular positions were similar in both images and that the differences between all facial landmarks were less than 1 mm, except for one dental position. Most studies have reported less than 2 mm to be the success criterion for the distance difference between planned and outcome images; thus, the authors' data indicate high consistency between the images in terms of jawbone position.

CONCLUSION

The authors' average three-dimensional skeletofacial models provide an innovative template-assisted orthognathic surgery planning modality that can enhance the fully digital workflow for virtual orthognathic surgical planning.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Utilization of extended temporomandibular joint replacements in patients with hemifacial microsomia

Hemifacial microsomia (HFM) patients may benefit from extended temporomandibular joint replacements (eTMJR) to improve function and quality of life. A cross-sectional survey was sent to surgeons who place alloplastic temporomandibular joints regarding their experience with and complications encountered when placing eTMJR in patients with HFM. Fifty-nine responded to the survey. Thirty-six (61.0%) reported treating patients with HFM and 30 (50.8%) of those reported placing an alloplastic temporomandibular joint (TMJ) prosthesis for patients with HFM. Twenty-three of the 30 surgeons (76.7%) placing alloplastic TMJ prostheses reported using an eTMJR in patients with HFM. The average maximum inter-incisal opening (MIO) after an eTMJR in HFM patients was repor ted as> 25 mm by 82.6% of the participants, and between 16 mm and 25 mm by 17.4%. No participants reported MIO < 15 mm. To avoid condylar sag and open bite changes postoperatively, over 70% reported using some form of modification to stabilize the occlusion. Respondents reported good functional outcomes for eTMJR in patients with HFM with relatively few complications. Therefore, eTMJR could be considered a viable option in the management of this patient population.

Orthognathic surgery with iliac bone grafting for an interpositional gap in a patient with type III hemifacial microsomia: A case report

Hemifacial microsomia (HFM) is characterized by uni- or bilateral microtia and hypoplasia of the mandible, orbits, facial nerve, and adjacent soft tissues. Patients with Pruzansky-Kaban type III HFM show the most severe facial deformities and often encounter difficulty obtaining treatment. In recent years, orthognathic surgery for HFM-related deformities has often been performed after the patient has stopped growing. However, few detailed reports have described the difficulties of orthognathic surgery for patients with type III HFM. This report describes the case of a patient with type III HFM who underwent three unilateral mandibular reconstructions while still growing, including autogenous reconstructions and secondary distraction osteogenesis, followed by orthognathic surgery with iliac bone grafting for an interpositional gap between the proximal and distal segments after she had stopped growing to improve facial asymmetry and malocclusion.

Longitudinal Skeletal Growth Analysis of Mandibular Asymmetry in Unoperated Patients With Unilateral Craniofacial Microsomia (UCFM)

PURPOSE

To examine the growth rate discrepancy of the affected and unaffected ramus heights in Pruzansky Type I and Type II mandibles.

METHODS

This is a serial retrospective longitudinal growth study of 30 untreated patients (21 males and 9 females) with UCMF (age range from 5 years to 14 years). The mean age of patients was 8.5 years, and the mean follow-up records were 3.7 years. There were 13 patients in group I with a Pruzansky Type I mandible and 17 patients in group II with a Pruzansky Type II. The unaffected side of the mandible served as a control. Eighteen cephalometric parameters were examined at each of the two-time intervals.

RESULTS

In patients with Pruzansky Type I mandible, the affected ramus grew on average 1.41 mm per year; the unaffected ramus grew 1.66 mm per year during the same period. In patients with Pruzansky Type II mandible, the affected ramus grew on average 0.84 mm per year; during the same period, unaffected ramus grew 1.79 per year. When the growth rate of the ramus height on the affected side was compared to the unaffected side, there was no statistically significant difference in Pruzansky Type I mandibles (p > .05); however, there was a statistically significant difference in the Pruzansky Type II mandibles (p < .05).

CONCLUSION

The growth rate discrepancy of the affected and unaffected ramus heights was more severe in Pruzansky Type II mandibles than Pruzansky Type I mandibles explaining the progressive nature of facial asymmetry in Pruzansky II mandibles.

Quantitative structural analysis of hemifacial microsomia mandibles in different age groups

Introduction

This study aims to quantitively analyze mandibular ramus and body deformities, assessing the asymmetry and progression in different components.

Methods

This is a retrospective study on hemifacial microsomia children. They were divided into mild/severe groups by Pruzansky-Kaban classification and into three age groups (<1 year,1-5 years, 6-12 years old). Linear and volumetric measurements of the ramus and the body were collected via their preoperative imaging data to compare between the different sides and severities, using independent and paired tests, respectively. The progression of asymmetry was assessed by changes in affected/contralateral ratios with age using multi-group comparisons.

Results

Two hundred and ten unilateral cases were studied. Generally, the affected ramus and body were significantly smaller than those on the contralateral side. Linear measurements on the affected side were shorter in the severe group. Regarding affected/contralateral ratios, the body was less affected than the ramus. Progressively decreased affected/contralateral ratios of body length, dentate segment volume, and hemimandible volume were found.

Discussion

There were asymmetries in mandibular ramus and body regions, which involved the ramus more. A significant contribution to progressive asymmetry from the body suggests treatment focus in this region.

A decade of clinical research on clinical characteristics, medical treatments, and surgical treatments for individuals with craniofacial microsomia: What have we learned?

AIM

This article provides a review of a decade of clinical research studies on clinical features, medical interventions, and surgical interventions for individuals with craniofacial microsomia (CFM). We also provide recommendations for future clinical research.

METHOD

A systematic search of literature was conducted in Embase and PubMed/MEDLINE Ovid. All publications from 2010 to 2020 that included at least 10 individuals with CFM were considered relevant for this study.

RESULTS

A total of 91 articles were included. In the past decade, many new studies on CFM have been published providing more insight on the diagnosis and management of patients with CFM. This review encompasses findings on the clinical difficulties patients with CFM encounter, including the craniofacial and extracraniofacial characteristics of patients with CFM and its related clinical consequences on breathing, feeding, speech, and hearing.

CONCLUSIONS

A considerable number of large multicenter studies have been published in recent years, providing new insights in the clinical consequences of CFM. The phenotypic variety between patients with CFM makes patient-specific treatment tailored to individual needs essential. The research and development of clinical care standards might be challenging because of the heterogeneity of CFM. Future research on clinical and patient-reported outcomes can help identify optimal treatment strategies. Cooperation between craniofacial centers, using uniform registration and outcome measurement tools, could enhance research and future care for these patients.

LEVEL OF EVIDENCE

Level IV.

Modern Mandibular Distraction Applications in Hemifacial Microsomia

Phenotypic severity dictates the timing and type of surgical intervention required. Mandibular distraction in children without respiratory and feeding difficulties remains controversial with regard to long-term mandibular growth outcomes and reducing surgical burden. Early mandibular distraction does not obviate secondary orthognathic surgery at skeletal maturity; it provides improved functional, aesthetic, and psychosocial outcomes, at least in the short term. Costochondral rib grafting for Pruzansky type IIB and III mandibles can produce reliable results, especially when combined with subsequent mandibular distraction. Secondary 2-jaw orthognathic surgery plus genioplasty at skeletal maturity benefits from improved bone volume from prior mandibular distraction.

Treatment of hemifacial microsomia using conventional orthodontic techniques: Report of a case with long-term follow-up

BACKGROUND AND OVERVIEW

The authors successfully treat a case of hemifacial microsomia involving unilateral condylar hypoplasia using conventional orthodontic techniques followed by long-term retention.

CASE DESCRIPTION

A girl aged 10 years and 2 months received a diagnosis of hemifacial microsomia resulting from unilateral condylar hypoplasia. During a growth period, premature incisal contact was abolished. After her growth was complete, she received conventional orthodontic treatment with preadjusted edgewise appliances. After 27 months of multibracket treatment, acceptable occlusion with a class I canine and molar relationship was achieved. The occlusion remained stable throughout the 15-year retention period, although there was a slight facial change.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Early orthodontic management only can have some limitations but could be one of the treatment options for hemifacial microsomia.

Three-Dimensional Computer-Assisted Orthognathic Surgery: Traditional Hybrid Versus Full Digital Planning Models

PURPOSE

Three-dimensional (3D) computer-aided planning has truly revolutionized orthognathic surgery (OGS) treatment, but no study has compared the traditional hybrid and full 3D digital planning models. This study compared these virtual planning models in the treatment of asymmetric maxillomandibular disharmony.

METHODS

Young adult patients with an asymmetric skeletal class III deformity who underwent 3D computer-aided 2-jaw OGS using hybrid (alginate dental impression, 2D cephalometric tracings, manual-guided stone model surgery, occlusion setup, and splint fabrication; n = 30) or full digital (laser-scanned dentition, 3D cephalometric tracings, virtual-based occlusion setup and surgery, and computer-generated surgical splint; n = 30) planning models were consecutively recruited. Preoperative and postoperative 3D cephalometric analyses (dental relation, skeletal assessments based on sagittal and frontal views, and soft tissue evaluations) were adopted for intragroup and intergroup comparisons. Postoperative patient-perceived satisfaction with facial appearance was also recorded.

RESULTS

Both hybrid and full digital planning groups had significant (all P < 0.05) improvements after surgery with respect to facial convexity, incisor overjet, and frontal symmetry parameters. The full 3D digital planning-based OGS treatment had similar (all P > 0.05) 3D cephalometric-derived outcomes (preoperative, postoperative, and treatment-induced change data) and patient-perceived outcomes compared with the traditional hybrid 3D planning method.

CONCLUSIONS

For the decision-making process in selecting the planning model, multidisciplinary teams could consider additional parameters such as patient comfort, storage needs, convenience for data reuse, overall planning time, availability, and costs.

Application of Virtual Planning for Three-Dimensional Guided Maxillofacial Reconstruction of Pruzansky-Kaban III Hemifacial Microsomia Using Custom Made Fixation Plate

PURPOSE

Pruzansky-Kaban III hemifacial microsomia (HFM) is a rare congenital facial deformity, and it is challenging to reconstruct the facial appearance. The aim of the present study was to describe a technique of application of virtual planning for three-dimensional (3D) guided maxillofacial reconstruction of Pruzansky-Kaban III HFM using custom made fixation plate.

METHODS

With the help of 3D models, a preoperative virtual planning and surgical simulation were performed. Computer-aided design/computer-aided manufacture (CAD/CAM) patient customized guides and custom fixation plates were designed to reconstruct the maxillofacial skull intraoperatively. Assessment was achieved through evaluation of the postoperative effects, such as imaging, facial appearance recovery and operation time.

RESULTS

Five patients with Pruzansky-Kaban III HFM were enrolled into this study. The results showed an exceptional accuracy between the preoperative virtual planning and the outcomes actually achieved postoperatively. Intraoperative measurements were no longer needed and the different surgical steps became more simple and easier. The total time was distributed as: 160 minutes for the surgical time, 40 minutes for preoperative virtual plan, and 80 minutes for designing the patient specific cutting guides and custom fixation plates. The operating time and tissue damage were reduced. All cases underwent uneventful healing without any complications.

CONCLUSION

The technique of patient specific guides and custom fixation plates is a reliable method of conveying the virtual plan to the operative field with higher efficiency in patients with Pruzansky-Kaban III HFM.

Pseudo Hemifacial Microsomia With Condylar-Coronoid Collapse: New Therapeutic Approach in Growing Patients

The purpose of this study is to describe the management of 2 dimorphic patients affected by Hemimandibular Hypoplasia with Condylar-Coronoid Collapse (HH-CCC), also called Pseudo Hemifacial Microsomia, where the orthopedic treatment gave an excellent long-term follow-up. The patients were a 7-year-old female and a 6-year-old male with a HH-CCC on the left side, an asymmetrical face with chin deviation, class II dental malocclusion and canting of the occlusal plane. An X-ray evaluation and clinical observation confirmed the unilateral mandibular deficiency and the collapse of the condyle on the coronoid process on the affected side. The treatment plan consisted of the use of an asymmetrical functional appliance with a vertical screw. The appliance was gradually activated on the vertical plane on one side by a screw incorporated on an acrylic plate. It was used for 22 hours/day, including sleep time but not during meals. This treatment improved the patient' s facial appearance. HH-CCC showed a positive response to functional therapy.

Isolated Fat Grafting for Reconstruction of Lower Face Volumetric Asymmetry in Skeletally Immature Patients: A Clinical Outcome Study

BACKGROUND

The purpose of this study was to assess the objective and subjective outcomes of lower face volumetric (contour) asymmetry correction with isolated fat grafting in skeletally immature patients.

METHODS

A prospective analysis was conducted of skeletally immature patients (n = 73) with craniofacial microsomia and Parry-Romberg syndrome who underwent isolated fat grafting (with no previous or concomitant bone surgery) using anatomical surgical principles (facial subunits and fat compartments) for the reconstruction of lower face volumetric asymmetry. Objective ultrasound and photogrammetric lower face symmetry analyses were blindly performed preoperatively and at 3 and 12 months postoperatively. A panel assessment of blinded surgical professionals and laypersons was also obtained to grade the subjective lower face symmetry.

RESULTS

There were significant (all P < 0.05) postoperative objective and subjective lower face symmetry enhancements (preoperative < postoperative) after isolated fat grafting, with no differences (all P > 0.05) between 3 versus 12 months' postoperative comparisons.

CONCLUSIONS

Growing patients with unilateral lower face volumetric asymmetries presented with improvement of objective and subjective symmetry after a single isolated fat grafting procedure.

Do patient-specific cutting guides and plates improve the accuracy of maxillary repositioning in hemifacial microsomia?

The aim of this retrospective study was to use computer-aided design and manufacturing (CAD/CAM) patient-specific plates and cutting guides for the waferless positioning and fixation of the maxilla after bimaxillary osteotomies in cases of hemifacial microsomia with condylar dysplasia or absence of the temporomandibular joint (TMJ), and to compare the results with the CAD/CAM fabricated surgical wafer by 3-dimensional analysis. Eighteen patients were selected from the hospital database, preoperative surgical planning and simulation were done on 3-dimensional computed tomographic models for all patients, and they were divided into Group I - in which CAD/CAM patient-specific cutting guides and plates were used; and Group II - in which CAD/CAM fabricated surgical wafers were used. Finally, the outcome was evaluated by comparing planned with postoperative outcomes. The largest discrepancies of the Le Fort I segment were 0.50 (0.18) mm in the anteroposterior direction and 0.82 (0.60)° in the yaw orientation with Group I. The largest discrepancies of the Le Fort I segment were 1.32 (1.40) mm in superioinferior direction and 8.48 (7.73)° in the yaw orientation with Group II. The CAD/CAM patient-specific cutting guides and plates proved to be reliable and have great value in improving the accuracy in repositioning the Le Fort I segment and in the efficacy of orthognathic treatment of hemifacial microsomia with condylar dysplasia or no TMJ. The CAD/CAM patient-specific cutting guides and plates are therefore a useful alternative to the wafer technique.