Orthodontic treatment in combination with Le Fort II bone distraction in patient with Apert syndrome

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, oral, and cervical morphological characteristics in Japanese patients with Apert syndrome or Crouzon syndrome

BACKGROUND AND OBJECTIVES

Mutations in the fibroblast growth factor receptor 2 (FGFR2) gene are responsible for both Apert syndrome (AS) and Crouzon syndrome (CS). These diseases share phenotypic characteristics, including midfacial hypoplasia and premature fusion of the calvarial suture(s). Given the extensive range of craniofacial growth and developmental abnormalities, management of these patients requires a multidisciplinary approach. This study aimed to compare craniofacial, oral, and cervical morphological characteristics in Japanese orthodontic patients with AS or CS.

SUBJECTS AND METHODS

Lateral cephalograms, orthopantomograms, dental casts, medical interview records, facial photographs, and intraoral photographs of 7 AS patients and 12 CS patients on initial visits were used in this study. Cephalometric analyses were performed, and standard scores were calculated based on age- and sex-matched Japanese standard values.

RESULTS

Cephalometric analysis revealed that AS patients had significantly more severe maxillary hypoplasia in two dimensions and increased clockwise mandibular rotation. Additionally, cleft of the soft palate, anterior open bite, severe crowding in the maxillary dental arch, and congenitally missing teeth occurred more frequently among AS patients. Multiple fusions between cervical vertebrae C2, C3, C5, and C6 were observed in the AS patients.

LIMITATIONS

Small sample size.

CONCLUSIONS/IMPLICATIONS

Our study shows that AS patients have more severe craniofacial and maxillofacial deformities than CS patients.

Cleft Lip and Palate Midfacial Hypoplasia: Criteria to Choose the Treatment

ABSTRACT

A series of skeletal and dentoalveolar/occlusal criteria were proposed for choosing the treatment modality for the management of midface hypoplasia in cleft lip/palate patients, focusing on functional improvement, aesthetics, and minimizing the risk of recurrence and secondary alterations. For which, 42 patients with nonsyndromic cleft lip/palate, all with previous primary lip/palate surgeries and without previous osteotomies, were analyzed. Orthognathic surgery (OS) (n = 24) and maxillary distraction osteogenesis (n = 18) with anterior segmental osteotomies (segmental distraction osteogenesis [SD]), alveolar transport disc (TD), and midface total distraction osteogenesis (TDO) by modified Le Fort III osteotomy was done.The average of maxillary advancement for OS was 5.58 ± 0.83 mm, for SD 9.4 ± 0.89 mm, for TD 8.00 ± 1.00 mm, and for TDO was 8.13 ± 1.55 mm.In the presence of infraorbital and/or zygomatic hypoplasia, TDO was performed using skeletal anchorage, with the requirement of occlusal stability in dental cast in occlusion. In short maxillary arch without dental cast feasibility in occlusion, hypodontia/agenesis or absence of premaxilla, TD and SD was performed. There was only 1 mm of recurrence in 1 patient of each group. Changes in speech were detected in 2 patients in the OS group (8.3%). Orthognathic surgery can be indicated for advancements ≤7 mm not requiring orbito-zygomatic advancement, whereas distraction osteogenesis can be indicated for advances >8 mm with or without the need for orbito-zygomatic advancement, in addition with other dentoalveolar factors and velopharyngeal function.

Retrospective study on midfacial advancement in syndromic craniosynostosis: case series

AIMS

The aim of this study was to evaluate elastic distraction surgical procedures performed on patients with syndromic craniosynostosis using cephalometric analyses.

METHODS

Eleven patients who underwent surgical midfacial advancement were divided into three groups: G1 - monobloc frontofacial; G2 - Le Fort III; and G3 - high-level Le Fort I. The cephalometric analyses were manually created through cephalometric radiographs of each patient: T1 - preoperative; T2 - 6 months postoperatively; and T3 - 12 months postoperatively. The cephalometric landmark points were A and O. The distances between preoperative and postoperative tracings were measured.

RESULTS

Point A advanced with no significant relapse 12 months after surgery. Point O advanced with a significant relapse rate of 28.5% postoperatively (p = 0.019). The vertical movement of points A and O increased by 40.6% (p = 0.033) and 38.8% (p = 0.032), respectively. There were no significant statistical differences between the assessed surgical techniques and syndromes with regard to midfacial advancement.

CONCLUSION

Point O has presented statistically significant relapse only in horizontal movement after 12 months. The cephalometric analysis performed in the present study only suggested no differences between the studied surgical techniques and syndromes with regard to midfacial advancement in syndromic craniosynostosis.

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.