Salvage or Solution: Alloplastic Reconstruction in Hemifacial Microsomia.

INTRODUCTION: Skeletal reconstruction in severe grades of hemifacial microsomia (HFM) continues to be challenging. Traditional techniques of autografts and osseous distraction for reconstruction of the glenoid fossa, condyle, and ramus can fall short of expectations and can create new problems. This intercontinental study analyzes the role of alloplastic skeletal rehabilitation in severe HFM. METHODS: Ten consecutive patients with Pruzansky grade III HFM were reconstructed between October 2014 and July 2017 at 2 craniofacial centers following the same protocol. Data were gathered retrospectively from the medical records, including photographs and virtual planning records. Pre and postoperative photos were taken to compare occlusal status, interincisal opening, sagittal mandibular projection, and posterior facial height. Alloplastic reconstruction was accomplished using a custom designed titanium implant. RESULTS: Ten consecutive skeletally mature patients with HFM with failed traditional reconstructions were successfully treated with virtually planned alloplastic reconstructions (11 joints) and simultaneous orthognathic surgery. The glenoid fossa, condyle, and ramus on the affected sides were reconstructed with custom designed titanium implants. All patients achieved occlusal stabilization, normalization of posterior facial height and sagittal mandibular projection, and maintenance or improved inter-incisal opening. There were no major complications or repeated surgeries. Follow-up ranges from 6 to 50 months. CONCLUSION: Alloplastic reconstruction allows for precise vertical reconstruction of the ramus and condyle and sagittal repositioning of the mandibular body. The glenoid fossa component is firmly anchored to the skull base assuring a stable centric relation on the reconstructed side. Consistent and acceptable results can be achieved in skeletally mature patients.

Correction of alveolar cleft with calcium-based bone substitutes.

The criterion standard of alveolar cleft repair is iliac crest bone graft before secondary canine eruption. Tooth eruption has never been shown to occur in synthetic bone substitute, and there is no ideal autologous bone graft for primary repair. This prospective study evaluated alveolar cleft grafting with a calcium substitute before primary canine eruption. Ten consecutive patients with complete cleft lip, palate, and unilateral alveolar cleft with reasonably aligned arches were grafted beginning in January 2003 to March 2007. Mean age at surgery was 10.4 months. Follow-up ranged from 3 to 7 years. Radiologic evaluation of alveolar ridge was performed at the age of 4.All 10 patients were operated on by the same surgeon using the same technique, that is, conservative elevation of nasal, oral, and anterior alveolar mucosal flaps around the cleft, closure of nasal and oral flaps, placement of 1 to 3 mL of calcium substitute paste or crystals in the pocket, and closure of the anterior alveolar mucosa. All 10 patients healed without complication. Clinical evaluation revealed a well-healed arch with primary canine growth in the area of the previous cleft. Adequate normal bone formation and often a descending secondary canine were radiologically confirmed. Calcium substitutes offer significant advantages over other biomaterials as well as autologous bone grafts particularly in the primary alveolar cleft reconstruction. Our study has shown for the first time that teeth can erupt through this material, which turns into a normal functioning bone in the alveolar ridge.