Craniofacial disorders.

The complexity of the craniofacial patient mandates the cooperation of a multidisciplinary team that can systematically evaluate each individual and ensure that a protocol-driven pathway is undertaken for the best patient care. Oral and maxillofacial surgeons contribute to surgical care in this setting with specific knowledge of growth and development of the face. This enables optimum timing for early skeletal correction where appropriate, and definitive surgery following the cessation of growth to maximize function and aesthetics. This chapter will describe the major principles in managing patients with specific craniofacial anomalies and provide examples of the outcomes possible.

Versatile facial osteotomies.

Facial Osteotomy techniques have evolved enormously over the past 20 years providing significant and often life-changing benefits to our dental patients with skeletal malocclusions. Advancements in technology and refined surgical techniques have resulted in improvements in surgical outcomes, a reduction in post-operative complications and a quicker recovery for today's patients undergoing orthognathic surgery. This paper aims to an update on the contemporary approach to the correction of skeletal malocclusions with facial osteotomies.

High-flow paediatric mandibular arteriovenous malformations: case reports and a review of current management.

High-flow vascular malformations in the paediatric population are potentially life-threatening and are challenging to treat. This paper describes the management of three cases of mandibular arteriovenous malformations and reviews the contemporary management options for these serious lesions.

Skeletal stability of maxillary advancement with and without a mandibular reduction in the cleft lip and palate patient.

The stability of surgical maxillary advancement in a consecutive series of patients with cleft lip and palate who underwent Le Fort I osteotomy with and without simultaneous mandibular setback surgery was evaluated. Preoperative, postoperative, and follow-up lateral cephalograms of 21 patients were assessed to compare differences in surgical movement and postoperative relapse between two groups: those who underwent maxillary surgery alone and those who underwent bimaxillary surgery. Differences in the number of patients who experienced relapse of <2mm, 2-4mm, and >4mm between the groups were also compared. Mean advancement of the cleft maxilla was 5.5mm in the maxilla only group and 3.6mm in the bimaxillary group, with a mean horizontal relapse of 0.8mm and 0.2mm, respectively. Mean surgical movement in the vertical dimension was comparable in the two groups and the magnitude of vertical relapse was less than 0.4mm overall. Approximately 80% of patients in both groups experienced horizontal relapse of less than 2mm. There was no significant difference in the degree of postoperative relapse between those who had single-jaw surgery and those who had two-jaw surgery.

Odontogenic myxoma in the paediatric patient: a review of eight cases.

Paediatric odontogenic myxoma (OM) is a rare pathological condition in the oral and maxillofacial region. There has been much debate in the literature regarding the preferred method of treatment; however due to the rare nature of this disease, definitive algorithms of management are yet to be determined. A case series of eight paediatric patients with OM is presented. Six of the lesions were in the maxilla and two were mandibular lesions. The patients were aged between 2 and 18 years. Treatment ranged from excision and the application of Carnoy's solution to segmental resection and reconstruction. From this case series it can be seen that even in situations where treatment was limited to excision and the application of Carnoy's solution, no recurrences occurred. As such the present authors favour an initially more conservative approach to the management of these lesions where possible and reserving conventional resective treatment for recurrences, lesions causing pathological fracture, and those in regions that are difficult to access.

Isolated orbital floor fractures in the paediatric patient: case series and review of management.

Orbital injuries warranting surgical intervention are infrequent in the paediatric population, but 'blowout, trap door' fractures are unique in children and may constitute a relative surgical emergency. A retrospective review of isolated orbital floor fractures at the Royal Children's Hospital of Melbourne over a 10-year period was undertaken to evaluate the outcome of those patients who required surgical exploration. Twenty-two patients with documented isolated orbital floor injuries were studied. Preoperative signs and symptoms including diplopia, ocular motility, paresthesia, enophthalmos, hypoglobus, and the presence of nausea and vomiting were recorded. Thirteen patients underwent non-surgical management and nine patients underwent surgical exploration of the orbital floor via a trans-subconjunctival approach to reduce any entrapped soft tissue. Postoperative follow-up of these patients varied between 1 month and 18 months and none had any visual disturbance or diplopia in central gaze; however, two patients experienced diplopia in upward gaze at follow-up, although this did not impair the quality of life. Due to the risk of permanent soft tissue damage from the entrapment of the periorbita with or without extraocular muscle tissue, it is recommended that exploration be undertaken as soon as possible to minimize the risk of persistent diplopia due to impaired ocular motility.

The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) is a serious condition that can be the cause of a number of systemic symptoms and conditions. The diagnosis of OSA is made by clinical and radiological examination, with polysomnography as the gold standard for recording the severity of the disorder. Among the many therapies offered for OSA, maxillomandibular advancement is recognized as a powerful technique for relieving upper airway obstruction. The upper airway may be further opened by an advancement genioplasty, but this may compromise facial aesthetics by over-projecting the chin prominence. To overcome this difficulty, a modified genioplasty is presented. This is designed to enable a rotational repositioning that allows for advancement of the genioglossus attachments but also avoids an excessive projection of pogonion, which would otherwise result in an unfavourable profile.

Avascular necrosis of the midface secondary to disseminated intravascular coagulation.

To the authors' knowledge, avascular necrosis of the midface secondary to disseminated intravascular coagulation has yet to be described following a hypoxic syncopal episode secondary to 'heat stroke'. A slow, progressive loss of anterior maxillary bone and the collapse of the nasal dorsum in a healthy young man with no other known medical co-morbidities led to the diagnosis. Following debridement, a staged reconstruction of the maxilla-nasal complex was successfully performed.

Tongue reduction for macroglossia in Beckwith Wiedemann syndrome: review and application of new technique.

Beckwith Wiedemann syndrome (BWS) is a rare, congenital overgrowth disorder that is characterized by macroglossia, anterior abdominal wall defects, visceromegaly, gigantism, and neonatal hypoglycaemia. Macroglossia may contribute to anterior open bite malocclusion with prognathism, speech articulation disturbances, drooling and the perception of intellectual disability. It was the purpose of this study to review a series of BWS patients who underwent surgical reduction of the tongue by a modified technique with respect to aesthetic and functional outcomes. Seven BWS patients, age 6 months to 21 months, had a 'stellate/anterior wedge' reduction with an anterior rotation flap and were followed up from 4 months to 9 years postoperatively. Assessment of aesthetics together with tongue morphology and mobility were recorded and a postoperative speech evaluation was performed. Minor contour deformities were present in two patients during function but all parents were satisfied with the results. The speech pathology assessment results indicated positive outcomes for speech, oral structure and function, and feeding for all children assessed. This modified technique allows for an adequate reduction of tongue volume with conservation of motor and sensory function as well as preservation of anatomical contour.

Treatment outcomes for adolescent ectodermal dysplasia patients treated with dental implants.

UNLABELLED: To evaluate dental implant survival in patients with ectodermal dysplasia (ED). To assess patterns of hypodontia in this patient group. METHOD: . A retrospective analysis of the use of dental implants in ED patients treated at the Royal Children's Hospital, Melbourne. RESULTS: Sixty-one implants were placed into 14 patients (nine male and five female). The mean age of patients receiving maxillary implants was 18 years 6 months (range 17 years 9 months-20 years 0 months) and mandibular implants was 17 years 5 months (range 12 years 2 months-21 years 11 months). The mean follow-up period was 3 years 4 months (range 1 year 18 months-5 years 1 month). Forty-three implants were placed in the anterior mandible, three in the posterior mandible and the remaining 15 in the anterior maxilla. Of the 61 implants placed, 54 [88.5%] successfully integrated and were able to be restored. Three of the 15 implants placed into the anterior maxilla [20%] failed, while four of the 46 in the anterior mandible failed [8.7%]. Five of the 14 patients [35.7%] had at least one implant fail prior to abutment connection. At the 12-month review appointments, 41 of the integrated 54 implants [76%] were reviewed and classed as successful, giving an overall success at follow up of 67.2%. Thirteen implants [21.3%] were unable to be reviewed owing to geographical reasons. Teeth most likely to be present in the maxilla were the central incisors [71%], first molars [54%] and canines [43%], whereas in the mandible they were the canines [53%] and the first premolars and first molars [40%]. CONCLUSIONS: Dental implants can be placed, restored and loaded in ED patients. Maxillary teeth most likely to be present are the central incisors, canines and first molars, whereas in the mandible the canines, first premolars and molars are most likely to be present. Prior to cessation of growth, implant placement in the symphyseal region of the anterior mandible may be performed with caution. Despite the limited numbers and with due consideration to jaw development, the results support the continual use of endosseous dental implants in this group of patients for optimal clinical outcomes.

Skeletal stability following maxillary impaction and mandibular advancement.

The purpose of this study was to retrospectively evaluate the stability of combined Le Fort I maxillary impaction and mandibular advancement performed for the correction of skeletal Class II malocclusion. Twenty-nine patients, mean age 22.6 years, underwent bimaxillary surgery with rigid internal fixation. Standardised cephalometric analyses were performed using serial lateral cephalometric radiographs. The post-surgical follow-up was a minimum of 12 months, with a mean of 25.2 months. The maxilla was impacted by a mean of 4.3 +/- 3.3 mm, and horizontally advanced by a mean of 2.6 +/- 2.3 mm. The results demonstrated that the maxilla tended to move anteriorly and inferiorly but this was not significant in either horizontal or vertical planes (P > 0.05). The mean advancement of the mandible, at menton, was 10.7 +/- 5.6 mm, and in 14 cases (48.2%) menton was advanced greater than 10 mm. In 34.7% of the patients the mandible underwent posterior movement between 2 and 4 mm. In the vertical plane, gonion moved superiorly by a mean of 2.7 +/- 3.6 mm which was significant. Significant mandibular relapse was found to have occurred in five female patients, with high mandibular plane angles who had undergone large advancements of greater than 10 mm. In conclusion, the majority of patients undergoing bimaxillary surgery for the correction of skeletal Class II malocclusions maintained a stable result. However, a small number of patients, exhibiting similar characteristics, suffered significant skeletal relapse in the mandible secondary to condylar remodelling and/or resorption.

Juvenile mandibular chronic osteomyelitis: a distinct clinical entity.

Sclerosing osteomyelitis of the mandible is an uncommon disease of unknown aetiology. A series of eight female children (6 to 12 years old) with a distinct mandibular inflammatory disease were studied. Each presented with pain and a recurrent soft tissue swelling overlying a predominantly unilateral mandibular enlargement. On imaging, this deformity demonstrated a mixture of patchy sclerosis and radiolucency. A raised erythrocyte sedimentation rate was the only consistent serological finding. Treatment varied from symptomatic control with non-steroidal anti-inflammatory medication, to surgical management that included decortication and contouring and, in one case, resection with reconstruction. A potential protocol for treatment of this disease is given. The early age of onset of the disease process and the uniformity of the features distinguish this condition from other groups of disorders that, previously, have been collectively designated as chronic diffuse sclerosing osteomyelitis. It is proposed that this inflammatory disease of mandibular bone, in the paediatric patient, should be regarded as a separate clinical entity: 'juvenile mandibular chronic osteomyelitis'.

Allogeneic bone grafting of calvarial defects: an experimental study in the rabbit.

The purpose of this study was to investigate the incorporation of fresh frozen irradiated membranous allogeneic bone grafts into critical size calvarial defects in the rabbit. Fifteen rabbits had calvarial defects prepared. Twelve rabbits received allogeneic grafts and three received autogenous bone grafts. The rabbits were sacrificed at 9 and 12 months postoperatively, and the specimens were examined radiologically, histopathologically and with fluorescence microscopy. Neovascularization, bone marrow regeneration and new bone formation was evident throughout the grafts however revitalization of the entire graft was incomplete at 12 months. This study revealed that the FFI membranous grafts were well incorporated into rabbit calvarial defects.

Use of a resorbable fixation system in orthognathic surgery.

We present our early experience with the use of a resorbable plating system in orthognathic surgery. Thirty-one patients who have finished growing and who had dentofacial deformities that were not part of syndromes were treated by routine orthognathic repositioning procedures: maxillary (n = 8) and mandibular (n = 9) osteotomies, or bimaxillary procedures (n = 14). All skeletal fragments were fixed with resorbable plates and screws. The follow-up period ranged from 2-8 months (mean 5). All the patients recovered normally except for one who developed a localized buccal space infection. In the early postoperative period, six patients had mild mobility of the maxilla, but stability was within normal limits at six weeks postoperatively. We conclude that, though technique has an important influence on success, LactoSorb is a good fixative for maxillo-mandibular repositioning.

Unusual jaw lesions in the paediatric and adolescent patient: a management challenge.

While major maxillofacial pathology in the young patient is relatively uncommon, non-malignant conditions may pose a significant treatment dilemma due to their aggressive or unpredictable behaviour. Several such diseases managed by the Oral and Maxillofacial Surgery Unit at the Royal Children's Hospital of Melbourne have been selected for review. Illustrative case reports to highlight the principles of management are presented.

Anterior open-bite malocclusion: stability of maxillary repositioning using rigid internal fixation.

A retrospective cephalometric study was performed to investigate the stability of 37 non-growing anterior open-bite cases using mini-plate rigid fixation. The sample was divided into two groups: Group A: maxillary repositioning alone (17 cases) and Group B: bimaxillary surgery (20 cases). Tracings were performed pre-operatively (T1), immediately post-operatively (T2) and at a minimum of one year follow-up (T3) (12-90 months). In Group A, the maxilla was advanced (3.8 +/- 2.8 mm, p < 0.01) and superiorly repositioned at PNS (2.8 +/- 2.3 mm, p < 0.001). In Group B, the maxilla was advanced (3.5 +/- 3.0 mm, p < 0.01) and superiorly repositioned at PNS (3.7 +/- 1.8 mm, p < 0.001); and the mandible (11.7 +/- 3.8 mm, p < 0.001), with no significant change in the vertical plane (p > 0.05). Late relapse due to condylar remodelling or resorption was found as a cause of large horizontal relapse (8.0 < x < 14.0 mm) in three cases (15%), the amount being associated with the amount of operative advancement (r = 0.7, r-sq = 40%, p < 0.01). It was concluded that the correction of anterior open bite by posterior repositioning of the maxilla using rigid fixation is a stable procedure during the follow-up period, and that in bimaxillary cases, post-operative stability depends largely on the stability of the mandibular advancement, which in turn relates to the amounts of advancement, the pre-operative anterior open bite and the mandibular plane angle.

Juvenile ossifying fibroma of the midface.

Juvenile ossifying fibroma is an unusual maxillofacial fibro-osseous lesion characterized by cell-rich osteoid strands. A 7-year-old girl presenting with a massive juvenile ossifying fibroma of the maxilla resulting in facial deformity, orbital displacement, and extension into the anterior skull base is discussed. The importance of combining clinical, radiographic, and histopathological findings for the diagnosis and management of the tumor is discussed.

Rhinoplasty in achieving total facial harmony.

Surgical alteration of the nose has challenged surgeons for decades and rhinoplasty is often described as one of the most difficult aesthetic procedures to master. As in the case of planning the orthognathic patient, there is a blend of aesthetic and functional goals. While patients may primarily present for cosmetic reasons, the maintenance of functional nasal airways in the pursuit of an improvement in facial balance is essential. It is the purpose of this paper to present the assessment and management of common nasal deformities, some of which are integrated within simultaneous orthognathic surgery.