Costochondral graft in growing patients with hemifacial microsomia case series: Long-term results compared with non-treated patients.

OBJECTIVE(S): The aim of this study was to evaluate the long-term effectiveness of costochondral graft in hemifacial microsomia (HFM) type III patients. SETTINGS AND SAMPLE POPULATION: A sample of 10 patients affected by HFM type III treated during growth in the same Centre with costochondral graft (CCG patients group) is compared with a control group (CG) sample of 10 non-treated patients affected by the same malformation in order to understand whether surgery during growth provides advantages in terms of bony and facial symmetry after an 8-year follow-up. MATERIALS AND METHODS: The growth of the CCG was assessed on panoramic X-rays. To assess facial symmetry, a photometric evaluation on the frontal view was carried out. RESULTS: In CCG patients group the graft grown in mean less than the healthy ramus, a good facial symmetry was achieved after surgery, but was lost in the majority of the cases at the most recent control. In CG, occlusal canting slightly increased and facial asymmetry was relatively stable during the years. CONCLUSION: In patients with a congenital deformity, restoring the height of the ramus leads to an immediate restitution of facial symmetry, but in the long term, there is a return to the asymmetrical pattern. In CG, the asymmetry is stable during years with no increase of the facial deformity.

Evaluation of a Sample of Patients With Unilateral Cleft Lip and Palate Treated With a Two-Stage Protocol.

The aim of this paper was to assess growth, speech, and aesthetic results at the completion of growth in patients with unilateral cleft lip and palate treated with the 2 stages Milan surgical protocol.Craniofacial growth was evaluated with cephalometric analysis and a theoretical need for orthognathic surgery.Nasolabial appearance was qualitatively assessed using the Asher McDade Aesthetic Index.Speech was assessed using the Gos.Sp.Ass '98 modified for Italian language scoring system.Burden of care was recorded in terms of number of secondary surgical procedures. All of the patients were treated and evaluated at San Paolo Hospital, Smile House, Milan.Fifty-two consecutive patients treated by the same surgeon were recalled, 12 patients did not come for assessment.The first surgical step (average age of 6 months) was cheilorhinoplasty (Millard modified Delaire technique) and soft palate rapair (Pigott). The second step (average age of 35 months) was hard palate and alveolar repair performed simultaneously with an early secondary gengivo alveolo plasty. Fifty-six percent of the patients did not need further surgery after the 2-stage surgery protocol.The 2-stage surgical protocol of Milano, Smile House, seems to be effective for treatment of unilateral cleft lip and palate, with good results in terms of speech, labial appearance, and alveolar cleft management. Nevertheless, maxillary growth was moderately impaired by the protocol.

Photometric Evaluation in Adolescence of Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening.

OBJECTIVE: Nasal stigma in patients with bilateral cleft lip and palate (BCLP) are a short columella and a flattened nasal tip. DESIGN: The aim of this study was to evaluate the aesthetics of adolescents with BCLP, operated with a modified Cutting primary columella lengthening technique, associated to a modified Grayson orthopedic nasoalveolar molding (NAM). SETTING AND PATIENTS: 72 BCLP patients were operated with this approach. Standardized photographic records were taken every 2 years. A group of 23 patients between 12 and 13 years of age was compared through normalized photogrammetry to a matched control of 23 noncleft adolescents. RESULTS: Nasal protrusion and length of the columella were very close to normal. On the other hand, nasolabial angle and interalar width were still excessively wide compared to the noncleft sample. CONCLUSIONS: NAM and primary columella lengthening in BCLP has allowed to avoid traditional secondary columella lengthening at 5 to 6 years of age and given the patients a more pleasing, near-normal nasolabial appearance until adolescence. Some of the patients will require correction of the nasal width at a later stage.

Long-Term Follow-Up of UCLP Patients: Surgical and Orthodontic Burden of Care During Growth and Final Orthognathic Surgery Need.

OBJECTIVE: The goal of this study was to evaluate the craniofacial morphology at 5 and 10 years of age and at the completion of growth, the need for final orthognathic surgery, and the orthodontic burden in a sample of patients with unilateral cleft lip and palate consecutively treated by the same surgeon with the same two-step protocol. DESIGN: A sample of 62 adult patients with unilateral cleft lip and palate was retrospectively collected (mean age, 17.5 years). Lateral cephalograms at three time points were traced. The need for orthognathic surgery was assessed, subdividing the sample into an orthognathic surgery group and nonorthognathic surgery group. Time and modality of orthodontic treatment were recorded. RESULTS: Cephalometric values related to maxillary growth (SNA, SNAns) and maxillomandibular relation (ANB, NAPg) were significantly different between the two groups already at 5 and 10 years of age. All patients presenting an ANB smaller than 2° at 5 years needed a Le Fort I osteotomy. Mandibular protrusion (SNB, SNPg) was not different at 5 and 10 years, but was different at the completion of growth. Patients with the same initial maxillomandibular relation did not show better growth when subjected to earlier or longer orthodontic treatment. CONCLUSION: Patients needing final jaw surgery had a more severe skeletal discrepancy during early childhood. The ANB angle at 5 years allowed doctors to identify 45% of the need for orthognathic surgery. The final craniofacial pattern does not seem to change significantly with early or prolonged orthodontic treatment.

The role of maxillary osteotomy in the treatment of arhinia.

PURPOSE: Arhinia is a very rare malformation, and only 41 cases are described in the literature. Given its rarity, there is no standardized surgical protocol. This article describes our preferred treatment, which underlines the importance of maxillary osteotomy for obtaining satisfactory results. METHODS: We observed 3 girls with arhinia, 2 of whom were treated by a 2-step surgical protocol. During the first phase, the patients underwent maxillary osteotomy with the creation of a new epithelium-lined nasal cavity. A skin expander was also placed in the forehead. During the second step, an external nose was created in both patients from the expanded forehead flap with local perinasal flaps and costochondral grafts. RESULTS: Both reconstructions were viable and esthetically acceptable. No internal nose restenosis was observed. CONCLUSIONS: On the basis of our experience, maxillary osteotomy should be considered part of an integrated approach in treating arhinia.

Long-term outcome of dental implants placed in revascularized fibula free flaps used for the reconstruction of maxillo-mandibular defects due to extreme atrophy.

PURPOSE: the objectives of this study were to evaluate (a) the clinical outcome of revascularized fibula flaps used for the reconstruction of extremely atrophic jaws and (b) the survival rates of dental implants placed in the reconstructed areas. MATERIALS AND METHODS: between 1999 and 2004, 12 patients presenting with extreme atrophy of the edentulous jaws were reconstructed with fibula free flaps. Five to 12 months after the reconstructive procedure, 75 titanium dental implants were placed in the reconstructed areas, while prosthetic rehabilitation was started 4-6 months afterward. The mean follow-up of patients after the start of prosthetic loading was 77 months (range: 48-116). RESULTS: an uneventful healing of the bone transplants occurred in all patients. One out of the 75 dental implants placed was not loaded due to prosthetic reasons. No dental implants failed to integrate before prosthetic loading, while three were removed during the follow-up period. Despite the high survival rate of dental implants (95.8%), a relevant number of them presented relevant peri-implant bone-level loss, ranging from 1 to 7 mm for maxillary dental implants and from 1 to 4.5 mm for mandibular dental implants. CONCLUSION: although no failures of the bone transplants occurred and a high long-term survival rate of dental implants were observed, this study showed that fibula free flaps do not guarantee dimensional stability of peri-implant bone, despite the immediate blood supply delivered by the vascular pedicle. The peri-implant bone resorption was higher when compared with the one related to dental implants placed in native bone.

True hemifacial microsomia and hemimandibular hypoplasia with condylar-coronoid collapse: diagnostic and prognostic differences.

INTRODUCTION: Long-term results after orthopedic or surgical treatment of hemifacial microsomia (HFM) have shown a tendency toward recurrence of the facial asymmetry. However, the literature contains a number of successful case reports that show surprising changes in the morphology of the condyles. In addition, patients with similar mandibular asymmetries, treated early with surgery, have excellent long-term follow-ups, especially those who have little or no soft-tissue involvement, but only severe mandibular ramal deformities. The phenotypes of these cases are unexpectedly similar, with a consistent collapse of the condyle against the coronoid and a deep sigmoid notch. The objectives of this article were to help distinguish true HFM from this peculiar type of hemimandibular asymmetry morphologically and to quantify their differences before treatement and in the long term. METHODS: Panoramic radiographs taken at pretreatment and the long-term follow-up of 9 patients with hemimandibular hypoplasia, characterized by the collapse of the condyle against the coronoid, were compared with those of 8 patients with severe type I and type II HFM; these records were collected before and at least 10 years after distraction osteogenesis. RESULTS: Ratios and angular measurements before and after treatment differed significantly between the 2 groups. CONCLUSIONS: Perhaps these patients were misdiagnosed and actually had secondary injuries of the condyle, which have a normal functional matrix. Therefore, with growth and functional stimulation, they would tend to grow toward the original symmetry. To make a differential diagnosis between true HFM and this peculiar type of hemimandibular hypoplasia, the collaboration between not only orthodontists and surgeons, but also geneticists and dysmorphologists, is of great importance because of the different prognoses.

Vertical excess of the premaxilla in bilateral cleft lip and palate patients: a protocol for treatment.

Bilateral cleft lip and palate patients may present a vertical excess of the premaxilla, which is a severe aesthetic and functional problem. Early surgical correction may lead to secondary growth impairment. We present a suggested protocol based on the severity of the vertical excess and on the age of the patient, which includes orthopedic, orthodontic, and surgical corrections. Patients are presented to elucidate each different approach.

Photometric evaluation of bilateral cleft lip and palate patients after primary columella lengthening.

OBJECTIVE: To evaluate the results in terms of nasal esthetics of children with bilateral cleft lip and palate, operated with the Cutting primary columella lengthening technique, associated with Grayson orthopedic nasoalveolar molding, and to compare them with the nasal aspects of children with bilateral cleft lip and palate operated with a traditional approach and to an age-matched sample of normal Caucasian children. DESIGN: Normalized photogrammetry. SETTING: Regional Center for CLP, Department of Maxillo-Facial Surgery, San Paolo Hospital, Milan. PATIENTS: Three groups of patients 5 years of age. Cutting group: 18 patients treated with the Grayson-Cutting technique. Delaire group: 18 patients treated with the traditional Delaire technique. Normal children: 40 normal preschool children. RESULTS: With the Cutting-Grayson technique, the columella length, nasal tip angle, and protrusion are greatly improved compared with the previous protocol and are close to normal. On the other hand, the nasolabial angle and interalar distances are still excessively wide in both samples. CONCLUSIONS: Although this is not a long-term study, at this time none of the patients operated with this technique have needed secondary columella lengthening. On the other hand, although certainly improved, the nasal anatomy obtained is far from normal.

A cephalometric intercentre comparison of patients with unilateral cleft lip and palate at 5 and 10 years of age.

The aim of this study was to evaluate any differences between the craniofacial growth of unilateral cleft lip and palate (UCLP) patients who underwent surgery in the Milan CLP centre with those from the Oslo CLP centre at 5 and 10 years of age. The Milan sample comprised 88 UCLP patients (60 males, 28 females) at 5 years of age and 26 patients (17 males, 9 females) at 10 years of age all operated on by the same surgeon. The Oslo sample consisted of 48 UCLP patients (26 males, 22 females) aged 5 years and 29 patients (20 males, 9 females) aged 10 years treated by four different surgeons. Lateral cephalometric radiographs obtained for both samples were analysed and angular measurements and ratios were calculated both for the hard and soft tissues. Statistical analysis was undertaken with an unpaired t-test. At 5 years of age, there were neither sagittal nor vertical hard tissue differences between the two groups. With regard to the soft tissues, only the naso-labial angle showed a statistically significant difference (Milan greater than Oslo by 5 degrees, P < 0.01). At 10 years of age, both SNA and ANB differences were larger in the Oslo group than in the Milan group, >2.6 degrees, P < 0.01 and >2.9 degrees, P < 0.001, respectively. At 5 years of age, the Milan UCLP sample had the same maxillary protrusion as the Oslo group, while at 10 years of age, the Milan sample were slightly less protruded than the Oslo group.

Long-term results of mandibular reconstruction with autogenous bone grafts and oral implants after tumor resection.

OBJECTIVES: (a) To evaluate retrospectively the clinical outcome of non-vascularized bone grafts used for the reconstruction of mandibular defects following tumor resection; (b) to evaluate the clinical outcome of implants and implant-supported prostheses placed in the reconstructed areas; and (c) to evaluate patients' satisfaction regarding function and esthetics after oral rehabilitation. MATERIAL AND METHODS: In a 9-year period (1995-2003), 29 patients affected by mandibular tumors involving to tooth bearing areas were treated by means of tumor resection and immediate or delayed reconstruction with autogenous non-revascularized calvarial or iliac bone grafts. Among these patients, 16 patients were selected for dental rehabilitation of the lost dentition with implant-supported 3fixed prosthese333s. For to 7 months later, the patients received 60 oral implants for the prosthetic rehabilitation of the reconstructed edentulous areas. RESULTS: No total failure of the graft was observed, while partial loss of the graft was observed in one patient. The mean follow-up of patients after the start of prosthetic loading of implants treated was 94 months (range: 36-132 months). Two patients dropped out of the follow-up after 3 and 4 years of observation, respectively. Two implants were removed due to loss of osseointegration, while two implants, although still integrated, presented peri-implant bone resorption values higher than those proposed by Albrektsson et al. for successful implants. Cumulative survival and success rates of implants were 96.7% and 93.3%, respectively. CONCLUSION: Results from this study demonstrated that bone defects following resection of mandibular tumors can be predictably reconstructed with autogenous bone grafts taken from the calvarium or the anterior iliac crest. It has also been shown that the long-term survival and success rates of implants placed in the reconstructed areas (96.7% and 93.3%, respectively) may guarantee an excellent prognosis of implant-supported prostheses.

Does functional appliance treatment truly improve stability of mandibular vertical distraction osteogenesis in hemifacial microsomia?

AIM: After mandibular unilateral distraction osteogenesis (DO) a gradual reappearance of the vertical asymmetry during growth is observed. A pre- and post-surgical functional-orthodontic treatment was added to our distraction protocol in the attempt to increase long-term stability. In order to evaluate the actual efficacy of such a combined treatment, two samples of children affected by hemifacial microsomia were compared long-term. MATERIAL: Ten children were treated by a combined orthodontic-distraction treatment, seven by distraction only. METHOD: Only the vertical changes in the mandible and maxilla in the panoramic and postero-anterior cephalometric X-rays were measured. RESULTS: All of the patients showed a gradual return of the asymmetry with growth. Occlusal plane correction and, to a much lesser extent, mandibular vertical ramus height correction were better maintained over 5 years post-DO in the orthopaedic group. CONCLUSION: Although orthopaedic treatment allows for a more stable occlusal plane and for a slower return of the mandibular vertical asymmetry, it has mainly a dento-alveolar effect. Therefore, the decision of applying an orthopaedic treatment associated with distraction, should be taken by surgeon and orthodontist together, considering both the advantages and the disadvantages of this treatment.

Maxillary growth impairment in cleft lip and palate patients: a simplified approach in the search for a cause.

No true consensus exists regarding the causes of maxillary growth restriction in cleft lip and palate patients. The aim of this study was to evaluate a simplified method to identify the causes of this growth impairment. We analyzed a sample of 82 consecutively treated 5-year-old patients with unilateral complete cleft lip and palate, operated on by the same surgeon (R.B.). Multiple cephalometric measurements of the sample revealed a wide distribution of maxillary growth values. We selected Sella-Nasion A point angle (SNA) as a value describing maxillary position, and we arbitrarily isolated 2 "extreme" groups of patients: the 20 patients with the highest SNA were called "good growers" (group A), and the 20 patients with the lowest SNA were called "poor growers" (group B). Parameters investigated to search for different influencing factors within the groups were initial cast measurements, timing of lip and of gingivoalveoloplasty/palatal surgery, presence of lateral incisors, and family history of maxillary hypoplasia. Statistical differences were investigated with an independent-samples t-test. The 2 extreme groups had a significant difference (P < 0.01) in SNA and in lip protrusion relative to true vertical line. Cranial base angle was larger in group A. Timing of lip surgery in group B was earlier than in group A, but only close to significance. Timing of gingivoalveoloplasty did not differ. In group A, the permanent lateral incisor was missing in 20% of the patients; whereas in group B, it was missing in 82% of the patients (P < 0.01). Selecting cleft lip and palate population with different growth pattern might help in isolating the factors responsible for maxillary growth impairment. Congenitally missing laterals that could indicate inherent tissue hypoplasia seems to be the most important factor.

Comparison of growth results in patients with unilateral cleft lip and palate after early secondary gingivoalveoloplasty and secondary bone grafting: 20 years follow up.

The Milan surgical protocol from 1988 has included repair of lip, nose, and soft palate at 6-9 months of age, and closure of the hard palate and alveolus with an early secondary gingivoalveoloplasty at 18-36 months. The goal of this study was to evaluate the long-term maxillary growth in patients with unilateral cleft lip and palate (UCLP) who had had the early secondary gingivoalveoloplasty, compared with the growth in a sample treated before 1988, by the same surgeon, with a surgical protocol that differed only by the method and the timing of alveolar closure. In the second group they were repaired by secondary bone grafting. The samples consisted of lateral cephalograms of the UCLP early secondary gingivoalveoloplasty sample (15 patients with a mean age of 18 (1.2) years) and of the UCLP bone graft sample (10 patients with a mean age of 19 (1.1) years). The early secondary gingivoalveoloplasty patients showed that maxillary growth was inhibited compared with the secondary bone graft group. Although the early secondary gingivoalveoloplasty allowed for early repair of the alveolus together with palatal repair, eliminating the need for secondary bone grafting, it seemed to have an inhibiting influence on maxillary growth that increased the need for Le Fort I osteotomies. Even with a Le Fort I osteotomy, the early secondary gingivoalveoloplasty allows the total number of operations to be kept down to three, as in most European protocols.

Evolution of my philosophy in the treatment of unilateral cleft lip and palate.

At the end of 50-year-long clinical activity, the evolution of my approach to the treatment of unilateral cleft of the lip and palate is discussed. I had several teachers in this field (Rusconi, Reherman, Perko, Delaire, Talmant, Sommerlad and others) and I introduced in my approach what I considered to be improvements from all of them. My current protocol is related to the anatomy of the cleft: for wide clefts a two-stage protocol is applied (1° step: soft palate and lip and nose repair; 2° step: hard palate repair with gingivoalveoloplasty); for narrow cleft (less than 1 cm at the posterior border of hard palate) an "all in one" protocol is performed with or without gingivoalveoloplasty (in accordance to the presence or absence of contact between the stumps at alveolar level). The most important details regarding surgery of the lip and palate are discussed. Robust data collection on speech and skeletal growth is still needed to determine whether the "all in one" approach can be validated as the treatment of choice for unilateral complete lip and palate cleft in selected cases.

Long-Term Computed Tomographic Evaluation of Alveolar Bone Formation in Patients with Unilateral Cleft Lip and Palate after Early Secondary Gingivoalveoloplasty.

BACKGROUND: The goal of this study was to evaluate with a three-dimensional method the long-term quality of alveolar ossification in unilateral cleft lip and palate patients who underwent early secondary gingivoalveoloplasty according to the Milan surgical protocol. METHODS: The sample consisted of 63 computed tomographic scans of unilateral cleft lip and palate patients in permanent dentition. The average age at the time of assessment was 15.7 years. Alveolar thickness, nasoalveolar height, nasal floor ossification, and hard palate morphology were evaluated using dental, axial, and coronal cuts on computed tomographic scans and three-dimensional models. All measurements were normalized and ratios of the affected side versus the nonaffected side were provided. Volume measurements and ratios of each hemimaxilla were added. The presence or absence of the permanent lateral incisor on the cleft side was also recorded. RESULTS: Alveolar thickness and height were ideal or good, respectively, in 89.5 and 91.4 percent of the sample. Insufficient ossification (<25 percent) was found in three patients (5.2 percent), and only one of them (1.7 percent) presented no bone bridging. A statistically significant association was detected between the degree of alveolar ossification, the type of nasal floor ossification, and volume ratio. CONCLUSIONS: Early secondary gingivoalveoloplasty seemed to allow an adequate ossification of both the alveolar and nasal region. Three-dimensional evaluation of the alveolar cleft ossification provided further information on alveolar bridging and allowed evaluation of the bone availability for implant placement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Long-term follow-up of large maxillary advancements with distraction osteogenesis in growing and non-growing cleft lip and palate patients.

BACKGROUND: Maxillary distraction osteogenesis (DO) in cleft lip and palate patients has been described by several authors, but most studies have a relatively short follow-up and do not clearly separate growing patients from non-growing patients. METHOD: The records of 22 consecutive patients affected by cleft lip and palate, who underwent Le Fort I osteotomy and maxillary distraction with a rigid external distractor (RED), were reviewed. The sample was subdivided into a growing and a non-growing group. All patients had pre-DO cephalometric records, immediately post DO, 12 months post DO and long-term records with a long-term follow-up of >5 years (range 5-13 years). As a control sample for the growing group, cleft children with a negative overjet not subjected to distraction or any protraction treatment during growth were followed up until the completion of growth. RESULTS: The average maxillary advancement in the growing group was 22.2 ± 5.5 mm (range: 15-32 mm); in the non-growing group, it was 17.7 ± 6.6 mm (range: 6-25 mm). Excellent post-surgical stability was recorded in the adult sample. On the other hand, growing children had an average 16% relapse in the first year post DO and an additional 26% relapse in the long-term follow-up. CONCLUSIONS: This study seems to point out that early Le Fort I DO allows for the correction of very severe deformities. It is followed by a relatively high amount of true skeletal relapse in children with cleft lip and palate. Prognosis should be discussed in depth with the family and true aesthetic and psychological needs assessed.

Function of the great auricular nerve following surgery for benign parotid disorders.

INTRODUCTION: The main concern in benign parotid surgery is complete removal of the lesion whilst avoiding any harm to the facial nerve. Some time ago, surgeons also began to spare other structures including the great auricular nerve. The purpose of this paper was to study these procedures prospectively and to evaluate the sensory recovery of this nerve. MATERIAL: Fourteen patients undergoing parotid surgery with preservation of the great auricular nerve (group A) have been studied and compared with 10 patients whose operations involved sacrificing the nerve (group B). METHODS: The function of the great auricular nerve has been tested (qualitatively and quantitatively) before the operation, and postoperatively during the first few days and at 3, 6, 9 and 12 months. RESULTS: Twelve months postoperatively, no area of anaesthesia was found in group A, whilst all patients in group B had some degree of sensory loss. In group A, the qualitative and quantitative tests documented complete recovery of various types of surface sensitivity in 80% of cases, with the remaining 20% showing only a moderate reduction in comparison with the unoperated side. CONCLUSION: From this study, it seems reasonable to spare the great auricular nerve during parotid surgery for benign disease because the procedure takes very little time, but guarantees a major improvement of postoperative sensitivity of the region innervated by the great auricular nerve.

Neurosensory alterations of the inferior alveolar and mental nerve after genioplasty alone or associated with sagittal osteotomy of the mandibular ramus.

AIMS: The purpose of our protocol is to study neurosensory disturbances following genioplasty, sagittal split mandibular osteotomy, or both procedures in combination. Many authors assessed the incidence and degree of neurosensory disturbances of the inferior alveolar nerve following orthognathic surgery but often results are difficult to interpret and compare due to a lack of standardization of methods. PATIENTS: Fifty patients (24 males and 26 females) were tested with qualitative (touch sensation, sharp/blunt test, cold sensation and hot sensation) and quantitative methods (localization test, two point static and dynamic test) at least 1 year after orthognathic surgery. The patients were divided into the following groups: 10 patients in group 1 (controls); 12 patients in group 2 (genioplasty alone or in association with maxillary osteotomy or vertical mandibular ramus osteotomy); 10 patients in group 3 (sagittal split osteotomy alone); 18 patients in group 4 (sagittal split osteotomy with concomitant genioplasty). METHOD: On both sides four areas were tested: centre of chin and lip (cutaneous and mucosal sides), 2 cm lateral to the chin centre (cutaneous and mucosal sides), 3 cm lateral to the chin centre i.e. approximately at the mental foramen (cutaneous and mucosal sides) and vermilion. Tests were always performed by the same person. All patients were also asked to indicate whether the altered sensation was considered subjectively as being disabling. RESULTS: None of the patients showed persistent anaesthesia in the tested areas according to the qualitative tests. In group 2 the quantitative sensory tests revealed normal or slight hypoaesthesia (17%) in all areas tested; in 30% of the patients of group 3, minimal quantitative sensory disturbances were noted, while the incidence of objective sensory deficits increased in patients who had undergone a concomitant genioplasty (40% among group 4). Among the tested areas the vermilion and oral commissure were affected most often in all groups. Statistical analysis (using STATA 6.0) revealed that these differences were significant (p<0.05). There were also significant differences between group 1 and groups 3 and 4 for tactile sensitivity, location tests and sharp-blunt discrimination, while two point discrimination (quantitative test) showed statistically significant differences between group 1 and all other groups (2-4). No statistically significant differences among the four groups were found for thermal sensation (hot and cold). CONCLUSIONS: The combination of genioplasty and sagittal split osteotomy seems to be more detrimental for the lip sensibility than genioplasty or sagittal split alone. Thermal sensation is less affected than tactile sensation, location and two point discrimination tests (static and dynamic). Despite that, sensory deficit was never considered as disabling by the patients subjectively.

Comparison of mandibular vertical growth in hemifacial microsomia patients treated with early distraction or not treated: follow up till the completion of growth.

AIM: Comparison of the long-term follow-up until the completion of growth of two homogeneous samples of children affected by hemifacial microsomia (HFM), one treated by mandibular distraction osteogenesis (DO) in the deciduous or early mixed dentition, the other not subjected to any treatment until adulthood. MATERIAL: Fourteen patients affected by vertically severe type I or II HFM were operated at an average age of 5.9 years with an average follow-up of 11.2 years. They were compared to a sample of eight patients who were never treated until the completion of growth. METHODS: Mandibular vertical changes were measured on panoramic radiographs taken at different time points. Ratios between affected and non affected ramal heights were calculated and compared. RESULTS: In the DO sample, after correction, mandibular vertical changes showed a gradual return of the asymmetry with growth in all patients. The ratio in the non treated sample was unchanged between the initial and the long term panoramic x-rays. CONCLUSION: The facial proportions of HFM patients are maintained, when not treated, throughout growth. The same proportions return to their original asymmetry after DO. Even though short term aesthetic and psychological advantages of distraction osteogenesis are well accepted, early surgery should only be applied after careful patient selection and honest clarification of the long term recurrence by genetically guided craniofacial growth pattern.