Three-Dimensional Digital Technology: A Powerful Assistant for the Reconstruction of Complex Craniofacial Deformities.

Three-dimensional digital technology has been widely applied in craniofacial surgeries, particularly in conventional procedures such as facial contouring and orthognathic surgery. To some extent, the process has already been standardized. As to reconstruction surgeries of complex craniofacial deformity, however, surgical plans need to be patient-specific. Traditionally, individualized surgical treatment largely relies on the surgeon's clinical experience. The application of digital technology mainly focuses on preoperative planning and postoperative evaluation of surgical outcomes rather than intraoperative patient-specific implants or osteotomy guides. For patients with complex craniofacial deformities, requirements for accurate 3-dimensional digital technology can be much higher. This study presents a favorable surgical reconstruction of the severe craniofacial deformity using 3-dimensional digital technology, providing references for craniofacial surgeons, which could be beneficial to clinical practice and treatment efficacy.

Tessier's Cleft Number 6 Revisited: A Series of 26 new Cases and Literature Review of 44.

OBJECTIVE: To fix a gray zone left in Tessier's classification of rare clefts with cleft 6 and to give a more comprehensive description of cleft 6 anatomy. DESIGN: The material used for the research was a series of 26 clinical cases of patients with assessed cleft 6 and 44 cases found out of a literature review with enough data to be useful. The 70 cases were cross-examined by the authors. STUDY SETTING: The authors are senior craniofacial surgeons working in high-case load department from university centers where the patients are documented and receive primary as well as secondary treatment and follow-up. PATIENTS: The patients were selected out of the series of craniofacial deformities taken care of by the authors' department as rare clefts. MAIN OUTCOME: We describe the full spectrum of cleft 6 as an autonomous entity that could present itself in three subtypes: 6a is the most proximal and could be associated with cleft 8. The subtype 6b is medial toward the zygomatic arch and frequently associated with a bone and teeth appendage (frequently described as a "maxillary duplication"). The subtype 6C goes toward the external ear between the helix crus and the auditory meatus. CONCLUSIONS: The Tessier's opinion is that Treacher Collins syndrome was the association of clefts 6, 7, and 8 and is no longer sustainable in the light of modern genetics. Most of the cleft 6 are misdiagnosed in the literature.

Psychosocial changes in patients submitted to orthodontic surgery treatment: a systematic review and meta-analysis.

OBJECTIVE: This systematic review aims to answer the following question: What is the psychological impact of orthognathic surgery on patients with dentofacial deformities undergoing orthodontic-surgical treatment? MATERIAL AND METHODS: The search was adapted for each of the following databases: American and Caribbean Center on Health Sciences (LILACS), Cochrane Library, Embase, Psychinfo, PubMed/Medline, Scopus and Web of Science, and gray literature using Google Scholar, OpenGrey, and ProQuest. The risk of bias was assessed using the Joanna Briggs Institute Critical Assessment Checklist. This study performed estimates of interest, random-effects meta-analyses, and calculated heterogeneity using Higgins inconsistency index (I2). RESULTS: A total of 6751 references were found in all searches. After applying the eligibility criteria after full-text reading, 37 studies comprised the final qualitative synthesis. Thirteen studies were included in quantitative synthesis, and it was possible to meta-analyze data from the following questionnaires: GHQ-28, MMPI, RSES, and SCL-90-R. There was an improvement in psychological aspects related to depression, hysteria, self-esteem, anxiety, obsessive-compulsiveness, interpersonal sensitivity, paranoid ideas, and psychoticism (p < 0.05). CONCLUSIONS: Correction of dentofacial deformity through orthodontic-surgical treatment is associated with improvements observed in several psychological domains, especially in relation to depressive states. CLINICAL RELEVANCE: This result highlights the importance of surgeons and orthodontists in promoting adequate control of patients' expectations and treatment goals taking into account the individual's psychological aspects.

Transnasal Medial Canthopexy Supported with Autogenous Bone Graft: A New Method for Repair of Traumatic Telecanthus.

INTRODUCTION: The medial canthus is an important structure to maintain the shape of the eye and assist in drainage of the lacrimal sac. Traumatic telecanthus is a difficult deformity to treat which involves both esthetic and functional aspects. Transnasal wiring remains the gold standard for repair of the medial canthal tendon (MCT) avulsion; however, it is often complicated by canthal drift, extrusion of wires, and in-fracture of the contralateral orbital bones from pressure by tied wires. In order to overcome traditional transnasal wiring technique pitfalls, this study proposes a transnasal wiring fixation method supported with a bone graft to treat patients presenting with telecanthus following complex nasoorbitoethmoid fractures. PATIENTS AND METHODS: From December 2018 to October 2020, 12 patients with traumatic telecanthus underwent transnasal wiring fixation of the MCT supported with bone graft. The wire holding the MCT was delivered through a single hole to the contralateral side and secured to a small bone graft by passing the wire through 2 holes in the graft in a button-like fashion. Then the wire end is pulled again to the affected side through the same hole and the 2 wires ends are tightly twisted after setting the MCT posterior to the lacrimal crest. RESULTS: Restoration of the MCT to its normal position was achieved in all patients. There were no observed major complications. Only 2 cases of wound infection and 1 case of dacrocystitis were encountered, which settled with conservative management. The preoperative palpebral fissure width (mean: 28.33mm ± 2.188mm) was significantly lower than the postoperative palpebral fissure width (mean: 34.17mm ± 1.03mm) ( P< 0.05). CONCLUSIONS: This study introduces a modified technique of transnasal wiring fixation to restore palpebral shape and intercanthal distance. The proposed technique could eliminate most of the frequently observed complications of the traditional methods.

Tracking of Oral and Craniofacial Stem Cells in Tissue Development, Regeneration, and Diseases.

PURPOSE OF REVIEW: The craniofacial region hosts a variety of stem cells, all isolated from different sources of bone and cartilage. However, despite scientific advancements, their role in tissue development and regeneration is not entirely understood. The goal of this review is to discuss recent advances in stem cell tracking methods and how these can be advantageously used to understand oro-facial tissue development and regeneration. RECENT FINDINGS: Stem cell tracking methods have gained importance in recent times, mainly with the introduction of several molecular imaging techniques, like optical imaging, computed tomography, magnetic resonance imaging, and ultrasound. Labelling of stem cells, assisted by these imaging techniques, has proven to be useful in establishing stem cell lineage for regenerative therapy of the oro-facial tissue complex. Novel labelling methods complementing imaging techniques have been pivotal in understanding craniofacial tissue development and regeneration. These stem cell tracking methods have the potential to facilitate the development of innovative cell-based therapies.

Effect of Different Bone Grafting Materials and Mesenchymal Stem Cells on Bone Regeneration: A Micro-Computed Tomography and Histomorphometric Study in a Rabbit Calvarial Defect Model.

This study evaluated the new bone formation potential of micro-macro biphasic calcium phosphate (MBCP) and Bio-Oss grafting materials with and without dental pulp-derived mesenchymal stem cells (DPSCs) and bone marrow-derived mesenchymal stem cells (BMSCs) in a rabbit calvarial bone defect model. The surface structure of the grafting materials was evaluated using a scanning electron microscope (SEM). The multipotent differentiation characteristics of the DPSCs and BMSCs were assessed. Four circular bone defects were created in the calvarium of 24 rabbits and randomly allocated to eight experimental groups: empty control, MBCP, MBCP+DPSCs, MBCP+BMSCs, Bio-Oss+DPSCs, Bio-Oss+BMSCs, and autogenous bone. A three-dimensional analysis of the new bone formation was performed using micro-computed tomography (micro-CT) and a histological study after 2, 4, and 8 weeks of healing. Homogenously porous structures were observed in both grafting materials. The BMSCs revealed higher osteogenic differentiation capacities, whereas the DPSCs exhibited higher colony-forming units. The micro-CT and histological analysis findings for the new bone formation were consistent. In general, the empty control showed the lowest bone regeneration capacity throughout the experimental period. By contrast, the percentage of new bone formation was the highest in the autogenous bone group after 2 (39.4% ± 4.7%) and 4 weeks (49.7% ± 1.5%) of healing (p < 0.05). MBCP and Bio-Oss could provide osteoconductive support and prevent the collapse of the defect space for new bone formation. In addition, more osteoblastic cells lining the surface of the newly formed bone and bone grafting materials were observed after incorporating the DPSCs and BMSCs. After 8 weeks of healing, the autogenous bone group (54.9% ± 6.1%) showed a higher percentage of new bone formation than the empty control (35.3% ± 0.5%), MBCP (38.3% ± 6.0%), MBCP+DPSC (39.8% ± 5.7%), Bio-Oss (41.3% ± 3.5%), and Bio-Oss+DPSC (42.1% ± 2.7%) groups. Nevertheless, the percentage of new bone formation did not significantly differ between the MBCP+BMSC (47.2% ± 8.3%) and Bio-Oss+BMSC (51.2% ± 9.9%) groups and the autogenous bone group. Our study results demonstrated that autogenous bone is the gold standard. Both the DPSCs and BMSCs enhanced the osteoconductive capacities of MBCP and Bio-Oss. In addition, the efficiency of the BMSCs combined with MBCP and Bio-Oss was comparable to that of the autogenous bone after 8 weeks of healing. These findings provide effective strategies for the improvement of biomaterials and MSC-based bone tissue regeneration.

Simultaneous LeFort III and LeFort I Osteotomies in Craniometaphyseal Dysplasia.

Craniometaphyseal dysplasia (CMD) is a rare genetic disease affecting bone metabolism with sclerosis of craniofacial bones. Orthognathic surgery has rarely been described in this patient population due to the bony thickness, making osteotomies challenging. We present a 19-year-old male with CMD with malocclusion, severe midface hypoplasia, and obstructive sleep apnea. With the aid virtual planning, we safely performed a combined LeFort III/I midface advancement to correct a negative overjet to improve occlusal balance, decrease scleral show, and diminish daytime sleepiness.

Ascher Syndrome: Acquired Double Lower Lip Combined With Epulis Fissuratum.

Ascher syndrome is characterized by double lip, blepharochalasis, and non-toxic goiter triad. This condition of unknown etiology usually occurs in patients younger than 20 years of age. In this case report, the authors present the diagnostic process of Ascher syndrome and surgical procedure of double lower lip in a female patient who applied to our clinic for prosthetic reasons. A 70-year old female patient was referred to our clinic with the chief complaint of incompatible dentures. The patient had been using the same complete dentures for 40 years. Extraoral clinical examination revealed protruded, bulged lower lip at rest and bilateral blepharochalasis, defined as atrophy of the upper eyelid skin. The upper lip and lower eyelids were not affected. Intraoral examination revealed complete edentation of both jaws and a double lower lip, an accessory fold of excess mucosae inside the vermillion border. Furthermore, epulis fissuratum was observed in the lower jaw. There was no family history of double lip. The patient stated that she had noticed another lip inside her lip for several years. As Ascher syndrome was suspected, the patient was referred to the endocrinology department for thyroid examination, and the non-toxic goiter diagnosis was confirmed. Surgical removal of the redundant tissues was necessary because of deficiencies in speech, chewing, and aesthetics. The excess tissues were excised by transverse ellipse incision technique. Dentists should be familiar with Ascher syndrome, as they may be the first physicians to encounter patients with double lip.

Anatomical Classification of Tessier Craniofacial Clefts Numbers 3 and 4.

BACKGROUND: Craniofacial clefts are rare occurrences with an incidence of about 1.43 to 4.85 per 100,000 live births. Understanding the skeletal deformity in these clefts is basic to any reconstructive surgery of the face. This study documented the skeletal defects present in Tessier numbers 3 and 4 using anthropometric measurements to generate a subclassification which will aim to improve the means of communication between surgeons managing this anomaly. METHODS: Seven computed tomography scans of patients who had been treated for Tessier 3 and 4 clefts between 2003 and 2017 were analyzed. Measurements of the expected defects in each cleft was taken and compared with unaffected side as the reference. Emerging patterns of their analysis was then used to generate a subclassification for these clefts. The reliability and validity of the measurements were ensured by allowing the data to be examined by both an intra- and interobserver. RESULTS: The presence or absence of an alveolar cleft, the emerging patterns of comparison of the measurements of the maxilla and the orbits of the cleft side and the noncleft side as well as absence of the bone were used to arrive at a subclassification system using (a), (b), (c), (M+ O+), (M- O-), and (0). CONCLUSION: The study recommends a subclassification for Tessier clefts numbers 3 and 4 that will allow physicians anticipate the extent and the form of skeletal defects present before even seeing the patient. This can improve the communication among surgeons and team members regarding Tessier craniofacial clefts.

Surgical Approach in a Patient With Agnathia-Otocephaly Complex: Three-Stage Mandibular Distraction Protocol.

Agnathia-otocephaly complex (AOC) is a rare malformation complex of the first pharyngeal arch that is characterized by agnathia/dysgnathia, microstomia, aglossia/hypoglossia and variable displacement of the ears. Only 11 post-infancy patients with severe AOC have been described in the literature, and the incidence of this malformation complex is estimated to be 1 per 70,000 births. In this brief clinical study, the authors describe the case of an 18-year-old female diagnosed with AOC who underwent a 3-step mandibular distraction protocol with an external distraction device. The surgical protocol the authors used was unique in that we first placed a tissue expander in the submental area to enlarge the skin envelope in an effort to mitigate skeletal relapse from soft tissue forces. Furthermore, the way in which the authors slowed the activation of the distraction device to allow for soft tissue healing behind the pins was a novel component of the patient's treatment. The 3-step mandibular distraction protocol the authors present in this study increased the length of the mandible by 20 mm, and nearly doubled the size of the patient's mandible from an initial volume of 3.62 cm to a post-operative volume of 6.89 cm. Future surgeries will aim to improve the function of our patient's expanded mandible. Most important of all, the surgical treatment authors are presenting led to a significant improvement in our patient's physical appearance and 3d quality of life.

Wiring or Screwing at the Craniovertebral Junction in Childhood: Past and Present Personal Experience.

BACKGROUND: Craniovertebral junction (CVJ) instrumentation and fusion in childhood are frequently performed with either sublaminar wires or screws in lateral masses, and both are considered quite safe procedures. METHODS: Our experience deals with 12 children: six (mean age 9.5 years) harbouring a congenital instability associated with Down's or Morquio's syndromes and primary os odontoideum; and six (mean age 11.5 years) with acquired iatrogenic instability due to transoral anterior decompression for different reasons (inferior clivectomy, anterior arch removal and odontoidectomy). All patients in the 'congenital group', except for one, had preoperative dynamic x-rays and underwent surgical correction by means of posterior wiring, fusion and an external orthosis. All patients in the 'iatrogenic group' had no preoperative dynamic x-rays and underwent a screwing technique with fusion and an external orthosis. RESULTS: The postoperative clinical picture had improved in all patients at the latest follow-up (observation range 63-202 months [mean 118.5 months]), with neuroradiological confirmation of satisfactory bony fusion and with neural decompression in all patients. CONCLUSION: Although it requires a more accurate preoperative neuroradiological setting, the screwing technique takes less time and is characterized by less blood loss and less postoperative discomfort than the wiring technique. The latter features confirm the simplicity, safety (continuous fluoroscopic assistance is not necessary, and there is no risk of neurovascular injuries) and lower expense (neither complex hardware devices nor neuronavigation systems are required) of the screwing technique.

Trimming of Absorbable Plates and Screws through Smoothing by Multiple Sonic Activation Procedures Can Increase Local Tissue Reactions in Children with Cranial Fixations.

OBJECTIVE: The aim of this paper was to investigate the local reactions due to the melting of absorbable plates and screws after trimming through smoothing by multiple sonic activation procedures (MSAP). BACKGROUND: Drilling or smoothing by MSAP is performed for the trimming of the absorbable plates and screws for cranial fixation in children. Compared to drilling, smoothing by MSAP is suspected to more commonly cause local tissue reactions; thus, the issue was examined herein. METHODS: For 90 children with smoothing by MSAP and 83 children with drilling procedures who underwent cranial fixation using absorbable plates and screws, the type, time of onset, and incidence of the local reactions were investigated. RESULTS: Swelling was the most common reaction, followed by inflammatory reactions with itching, heating, skin-penetrating drainage, and pus formation. The mean time of onset of the local reaction was 10.0 ± 2.3 months after surgery. Local reactions occurred in 30% of the children in the group with smoothing by MSAP, and in 7.2% of the children in the group with drilling, showing a statistically significant difference between the two groups (p < 0.001). CONCLUSION: It was concluded that drilling rather than smoothing by MSAP to change the shapes of the absorbable plates and screws in cranial fixation can reduce the local reactions.

Scattering of therapeutic radiation in the presence of craniofacial bone reconstruction materials.

PURPOSE: Radiation scattering from bone reconstruction materials can cause problems from prolonged healing to osteoradionecrosis. Glass fiber reinforced composite (FRC) has been introduced for bone reconstruction in craniofacial surgery but the effects during radiotherapy have not been previously studied. The purpose of this study was to compare the attenuation and back scatter caused by different reconstruction materials during radiotherapy, especially FRC with bioactive glass (BG) and titanium. METHODS: The effect of five different bone reconstruction materials on the surrounding tissue during radiotherapy was measured. The materials tested were titanium, glass FRC with and without BG, polyether ether ketone (PEEK) and bone. The samples were irradiated with 6 MV and 10 MV photon beams. Measurements of backscattering and dose changes behind the sample were made with radiochromic film and diamond detector dosimetry. RESULTS: An 18% dose enhancement was measured with a radiochromic film on the entrance side of irradiation for titanium with 6 MV energy while PEEK and FRC caused an enhancement of 10% and 4%, respectively. FRC-BG did not cause any measurable enhancement. The change in dose immediately behind the sample was also greatest with titanium (15% reduction) compared with the other materials (0-1% enhancement). The trend is similar with diamond detector measurements, titanium caused a dose enhancement of up to 4% with a 1 mm sample and a reduction of 8.5% with 6 MV energy whereas FRC, FRC-BG, PEEK or bone only caused a maximum dose reduction of 2.2%. CONCLUSIONS: Glass fiber reinforced composite causes less interaction with radiation than titanium during radiotherapy and could provide a better healing environment after bone reconstruction.

Assessing the Compliance of Randomized Controlled Trials Published in Craniofacial Surgery Journals With the CONSORT Statement.

BACKGROUND: Randomized controlled trials (RCTs) are gold standard assessments for healthcare interventions. The Consolidated Standards of Reporting Trials (CONSORT) statement was published to maximize RCT reporting transparency. The authors conducted a systematic review to assess current compliance of RCTs published within craniofacial surgery with the CONSORT statement. METHODS: The Thomson Reuters Impact Factor Report 2016 was consulted to identify craniofacial surgery journals. PubMed was used to search for recent RCTs published within the 5 journals identified. Two independent researchers assessed each study for inclusion and performed data extraction. The primary outcome was compliance of each RCT with the CONSORT statement. Secondary outcomes were the pathology and interventions examined, impact factor, multi-versus-single center, number of authors, and publication date. RESULTS: Eighty-six studies met the inclusion criteria, across which a median of 56% (range 33%-94%) applicable CONSORT items were reported. The 5 least reported items were: trial design (3a); registration number and name of trial registry (23); who generated random allocation sequences, enrolled participants, and assigned participants to interventions (10); sample size determination (7a); mentioning "randomized trial" in the title (1a). CONCLUSION: The compliance of craniofacial surgery RCTs with the CONSORT statement requires improvement. Areas in need are identified, and methods to improve reporting transparency, are discussed.

Le Fort II Distraction With Zygomatic Repositioning: A Technique for Differential Correction of Midface Hypoplasia.

Severe midface hypoplasia is frequently addressed with subcranial midface advancement at the Le Fort II or Le Fort III level. Le Fort II advancement has a predominant affect on the vertical and sagittal positioning of the nasomaxillary complex; in contrast, the Le Fort III advancement allows for correction of zygomatic position and exorbitism. In this report, the authors described a technique for correction of exorbitism which concomitantly addresses central midface vertical and sagittal deficiency. The technique involves a combination of a Le Fort III osteotomy with a Le Fort II distraction. The Le Fort III osteotomy allows repositioning and fixation of the zygomas to correct lateral hypoplasia and exorbitism, maintaining the globes in a more functional position. The Le Fort II distraction allows for movement of the central midface independent of the lateral orbits and zygomas, correcting the sagittal and vertical position without orbital distortion. With the medial canthal apparatus attached to the Le Fort II segment and the lateral canthus attached to the stabilized lateral orbits, the differential movement achieved can also have a favorable effect on palpebral fissure orientation.

Orthognathic Surgical Outcomes in Patients With and Without Craniofacial Anomalies.

PURPOSE: The objective of this study is to examine hospitalization outcomes after orthognathic surgery. This study tests the hypothesis that patients with craniofacial anomalies have higher billed hospital charges, longer lengths of stay, and increased odds of development of infectious complications when compared with patients without craniofacial anomalies. MATERIALS AND METHODS: The Nationwide Inpatient Sample for the years 2012 and 2013 was used. All patients who underwent an orthognathic surgical procedure were selected. The primary independent variable of interest was presence of a congenital cleft and/or craniofacial anomaly. The outcome variables were the occurrence of complications, billed hospital charges, and length of stay. Multivariable logistic and linear regression models were used to examine the effect of the presence of craniofacial anomalies on outcomes. RESULTS: During the study period, a total of 16,515 patients underwent an orthognathic surgical procedure in the United States. Of these patients, 2,760 had a cleft and/or craniofacial anomaly. An infectious complication occurred in 7.4% of those with a craniofacial anomaly (compared with 0.6% of those without a craniofacial anomaly). The mean billed hospital charges in those with a craniofacial anomaly was $139,317 (compared with $56,189 in those without a craniofacial anomaly). The mean length of stay in the hospital in patients with a craniofacial anomaly was 8.8 days (compared with 1.8 days in those without a craniofacial anomaly). These differences in outcomes between patients with and patients without craniofacial anomalies were significant after we adjusted for patient- and hospital-level confounders. CONCLUSIONS: Patients with a craniofacial anomaly are at higher risk of development of infectious complications, have higher hospital charges, and stay in the hospital for a longer duration after orthognathic surgery when compared with those without a craniofacial anomaly.

Computer-Assisted Surgery in Facial Bipartition Surgery.

PURPOSE: Frontonasal dysplasia or median cleft syndrome is a rare condition often associated with transverse maxillary deficiency for which facial bipartition is the proper surgical treatment. This technical note describes the use and efficacy of 3-dimensional virtual surgical planning and patient-specific cutting guides in facial bipartition. MATERIALS AND METHODS: An 11-year-old boy presented with frontonasal dysplasia and a midline facial cleft. RESULTS: Computed tomographic (CT) scan visualized an intercanthal distance of 40 mm and a maxillary width at the second molar level of 46.2 mm. The osteotomies, amount of bone removal, and movement of the osteotomized bone were planned virtually based on CT findings: the intended postoperative intercanthal distance and maxillary width were 25.5 and 49.6 mm, respectively. Customized cutting guides and titanium miniplates were manufactured. Postoperative CT scan showed an intercanthal distance of 25.5 mm and a maxillary width of 49.7 mm. CONCLUSION: The intercanthal distances and maxillary widths were similar between the simulation and postoperative CT images, confirming the accuracy and utility of computer-assisted surgery in facial bipartition.

Perioperative outcomes and management in midface advancement surgery: a multicenter observational descriptive study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND/AIMS: The evolution of Le Fort III and Monobloc procedures with utilization of distraction devices has resulted in shortened surgical times, greater facial advancements, and decreased transfusion requirements. The aim of this observational study was to utilize data from the multicenter Pediatric Craniofacial Surgery Perioperative Registry to present and compare patient characteristics and outcomes in children undergoing midface advancement with distraction osteogenesis. METHODS: We queried the Pediatric Craniofacial Surgery Perioperative Registry for children undergoing midface advancement involving distractor application from June 2012 to September 2016. Data extracted included demographics, perioperative management, complications, fluid and transfusion volumes, and length of stay. The extracted patient characteristics and perioperative variables were summarized and compared. RESULTS: The query yielded 72 cases from 11 institutions: 49 children undergoing Le Fort III and 23 undergoing Monobloc procedures. Monobloc patients were younger, weighed less, and more likely to have tracheostomies along with elevated intracranial pressure. Greater transfusion was observed in the Monobloc group for nearly all of the transfusion outcomes evaluated. Median ICU and hospital length of stay were 2 and 3 days longer, respectively, in the Monobloc group. Perioperative complications were not uncommon, occurring in 18% of patients in the Le Fort III group and 30% in the Monobloc group. CONCLUSION: Monobloc procedures were associated with greater transfusion and longer ICU and hospital length of stay. Perioperative complications were more prevalent in the Monobloc group.

Rigid External Distractor-Aided Advancement After Simultaneously Performed LeFort-III Osteotomy and Fronto-Orbital Advancement.

Due to the complex development of the craniofacial skull, corrective surgery is a major challenge for patients with severe craniofaciostenosis. Although fronto-orbital advancement and simultaneous LeFort-III osteotomy in combination with distraction osteogenesis have been reported as a safe and successful method to obtain good esthetic and functional results, there is a lack of studies evaluating this method.Our retrospective study included 12 patients with syndromic craniofaciostenosis, who were primarily treated at our department in accordance with a standardized treatment protocol, consisting of a simultaneous fronto-orbital advancement with LeFort-III osteotomy in combination with a rigid external distractor (RED-II). Distraction distance, duration of operation, postoperative complications, perioperative hemoglobin concentration, esthetic outcome, and the subjective Whitaker Scale were used to evaluate the success of our surgical method.The esthetic outcome of all of our patients was assessed as good. Furthermore, the surgical outcome was assigned I for 11 patients and II for 1 patient, who suffered from wound healing disturbance at the left temporal site, which required revision 2 weeks postoperatively. The mean skeletal advancement of the midface was 16.4 mm, ranging from 12 to 20 mm.Our standardized treatment protocol, consisting of fronto-orbital advancement in combination with LeFort-III osteotomy and application of a rigid external distractor device (RED-III) for patients with severe syndromic craniofaciostenosis, goes along with low infection rates and more predictable and precise esthetic and functional outcomes than the conventional surgical technique without distraction osteogenesis.

Evaluation of Fronto-Orbital Advancement Using Titanium-Based Internal Fixation for Corrective Pediatric Craniofacial Surgery.

BACKGROUND: For successful reshaping of the cranial vault in terms of corrective fronto-orbital advancement (FOA) efficient and reliable internal fixation systems for stabilization of bone fragments are indispensable. The rate of complications and feasibility of corrective FOA with the usage of titanium-based rigid fixation systems is rarely analyzed and discussed. METHODS: The authors retrospectively reviewed the medical records of 42 patients who received corrective FOA with the implementation of titanium internal rigid fixation and consecutive secondary surgery for removal. The reliability of the fixation system was judged by the outcome of the FOA as evaluated by the Whitaker score, esthetic outcome as well as by the complication rate of the secondary intervention, necessary for removal of the fixation system. RESULTS: All patients were categorized as Whitaker I (no further treatment desirable). Esthetic outcome was excellent in all patients as judged by surgeon and parents. Mean age at the time of FOA was 9.3 months. Time to removal, duration of the second hospital stay for removal of the fixation system, and duration of surgical drains were on average 5 months, 2 days, and 1.7 days, respectively. Mean duration of the secondary surgery was 63 min. No complications occurred. CONCLUSION: Our investigation supports the usage of titanium internal rigid fixation systems in pediatric craniofacial surgery, thereby providing a reliable alternative to avoid the well-documented problems of bio-absorbable plate fixation systems.