New Approach for the Surgico-Orthodontic Treatment of Hemifacial Microsomia

Distribution and Phenotype of Goldenhar Syndrome and Its Association With Other Anomalies

The purpose of this study was to investigate the distribution and phenotype of Goldenhar syndrome (GS) and its association with other anomalies. The samples consisted of 18 GS patients (6 males and 12 females; mean age at investigation, 7.4 ± 4.8 y) who were treated or followed up at the Department of Orthodontics, Seoul National University Dental Hospital between 1999 and 2021. The prevalence of side involvement and degree of mandibular deformity (MD), midface anomalies, and association with other anomalies were evaluated using statistical analysis. The prevalence of unilateral and bilateral MD did not differ (55.6% versus 44.4%). In unilateral MD cases, there was a tendency for higher prevalence of more severe Pruzansky-Kaban types than mild ones (type I, 10%; type IIa, 10%; type IIb, 50%; type III, 30%). Despite hypoplasia of the condyle/ramus complex, compensatory mandibular body growth occurred in 33.3% of GS patients (more severe side in bilateral MD cases, 37.5%, and ipsilateral side in unilateral MD cases, 30%). Class II molar relation was more prevalent than class I and class III molar relations (72.2% versus 11.1% versus 16.7%, P <0.01). Al total of 38.9% of patients had congenitally missing tooth. #7 facial cleft was found in 44.4% of patients. In midface anomalies, ear problem was the most common anomaly, followed by hypoplasia/absence of zygomatic arch and eye problem (88.9% versus 64.3% versus 61.1%, P <0.01). Association with the midface, spine, cardiovascular, and limb anomalies did not differ between unilateral and bilateral MD cases. These results might provide a basic guideline for diagnosis and treatment planning for GS patients.

Three-dimensional surgical management of a patient with Pruzansky I hemifacial microsomia and severe facial asymmetry: A 4-year follow-up

Treatment of hemifacial microsomia is challenging and often requires multiple interventions to restore function and facial esthetics. In this article, the combined orthodontic-surgical treatment of a young patient exhibiting Pruzansky I hemifacial microsomia is reported. The patient was aged 15 years, but his bone age was determined to be 18 years. His facial asymmetry was severe, with the nose and a retrusive chin deviated to the left side and a canted smile. The presurgical phase was aimed at centering the mandibular midline to the center of the chin through the distal movement of the mandibular left buccal dentition. The surgery was planned with 3-dimensional computer-aided surgical simulation and included a LeFort I and unilateral sagittal split osteotomies combined with a genioplasty. This report illustrates the therapeutic stages and a 4-year follow-up of a unique and complex orthognathic surgical approach, chosen among other alternatives and leading to improved function and appearance and stable results.

Using orthodontic elastic traction during the active period of distraction osteogenesis to increase the effective vertical extension of hemifacial microsomia patients: A multi-center randomized clinical trial

In this study, the aim was to assess whether using elastic traction during the active period of distraction osteogenesis could effectively increase the vertical extension. Patients with Pruzansky-Kaban Type II mandibular deformity were recruited and randomly assigned into Elastic traction + Distraction Osteogenesis group or Distraction Osteogenesis group, respectively. During the active period, the experimental group received orthodontic elastic traction 3 days after distraction osteogenesis implantation, while the control group received no treatment. All the participants underwent computed tomography (CT) examination before surgery, at the end of the active period, 6 months and 2 years after distraction osteogenesis tractor implantation. The primary outcome was the effective vertical extension rate of the mandible from the baseline to the end of the active period after operations, and there were 7 secondary outcomes used. 70 patients were included. The effective vertical extension rates were 85.021% ± 7.432% (mean ± SD) and 68.811% ± 9.510% (mean ± SD) in the experimental and control groups, respectively (P = 0.001). The average distances between the lower middle incisor point to the sagittal plane at the end of the active period were 2.485 ± 1.411 mm and 3.938 ± 2.293 mm in the experimental and control groups, respectively (P = 0.026). At the end of the active period of distraction osteogenesis, the average values of the mandibular occlusal plane canting were -4.887 ± 3.126 mm and -0.177 ± 4.029 mm in the experimental and control groups, respectively (P = 0.026). Elastic traction-assisted distraction osteogenesis could improve traction efficiency and facial symmetry.

Treatment modalities for Korean patients with unilateral hemifacial microsomia according to Pruzansky-Kaban types and growth stages

Objective

To investigate the treatment modalities (Tx-Mods) for patients with unilateral hemifacial microsomia (UHFM) according to Pruzansky–Kaban types and growth stages.

Methods

The samples consisted of 82 Korean UHFM patients. Tx-Mods were defined as follows Tx-Mod-1, growth observation due to mild facial asymmetry; Tx-Mod-2, unilateral functional appliance; Tx- Mod-3, fixed orthodontic treatment; Tx-Mod-4, growth observation due to a definite need for surgical intervention; Tx-Mod-5, unilateral mandibular or bimaxillary distraction osteogenesis (DO); Tx-Mod-6, maxillary fixation using LeFort I osteotomy and mandibular DO/sagittal split ramus osteotomy; Tx- Mod-7, orthognathic surgery; and Tx-Mod-8, costochondral grafting. The type and frequency of Tx-Mod, the number of patients who underwent surgical procedures, and the number of surgeries that each patient underwent, were investigated.

Results

The degree of invasiveness and complexity of Tx-Mod increased, with an increase in treatment stage and Pruzansky–Kaban type (initial < final; [I, IIa] < [IIb, III], all p < 0.001). The percentage of patients who underwent surgical procedures increased up to 4.2 times, with an increase in the Pruzansky–Kaban type (I, 24.1%; IIa, 47.1%; IIb, 84.4%; III, 100%; p < 0.001). However, the mean number of surgical procedures that each patient underwent showed a tendency of increase according to the Pruzansky–Kaban types (I, n = 1.1; IIa, n = 1.5; IIb, n = 1.6; III, n = 2.3; p > 0.05).

Conclusions

These findings might be used as basic guidelines for successful treatment planning and prognosis prediction in UHFM patients.

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.

Distribution and phenotypes of hemifacial microsomia and its association with other anomalies

Objective

To investigate the distribution and phenotypes of hemifacial microsomia (HFM) and its association with other anomalies.

Methods

This study included 249 Korean patients with HFM, whose charts, photographs, radiographs, and/or computed tomography scans acquired during 1998–2018 were available from Seoul National University Hospital and Dental Hospital. Prevalence according to sex, side involvement, degree of mandibular deformity, compensatory growth of the mandibular body, and Angle's classification, and its association with other anomalies were statistically analyzed.

Results

Prevalence was not different between male and female patients (55.0% vs. 45.0%, p > 0.05). Unilateral HFM (UHFM) was more prevalent than bilateral HFM (BHFM) (86.3% vs. 13.7%, p < 0.001). Although distribution of the Pruzansky–Kaban types differed significantly in patients with UHFM (I, 53.0%; IIa, 18.6%; IIb, 24.7%; III, 3.7%; p < 0.001), no difference was observed in occurrence between the right and left sides (52.6% vs. 47.4%, p > 0.05). Among patients with BHFM, prevalence of different Pruzansky–Kaban types on the right and left sides was greater than that of the same type on both sides (67.6% vs. 32.4%, p < 0.05). Despite hypoplasia of the condyle/ramus complex, compensatory growth of the mandibular body on the ipsilateral side occurred in 35 patients (14.1%). Class I and II molar relationships were more prevalent than Class III molar relationships (93.2% vs. 6.8%, p < 0.001). Forty-eight patients (19.3%) had other anomalies, with 50.0% and 14.4% in the BHFM and UHFM groups (p < 0.001).

Conclusions

Patients with HFM require individualized diagnosis and treatment planning because of diverse phenotypes and associations with other anomalies.

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.

Distraction osteogenesis

James Sidman, MD, and Sherard A. Tatum, MD, address the following questions for discussion and debate. Is neonatal distraction osteogenesis (DO) better than lip-tongue adhesion or tracheotomy for micrognathic airway compromise? What role does DO have in adult orthognathic surgery situations? In monobloc and Le Fort III procedures, are internal or external devices preferable? What role does DO play in craniofacial microsomia? Is endoscopic DO better than open procedures for synostosis management? How has your technique changed or evolved over the past 5 years and what has doing this technique taught you?