[Application of tunable guide device in prominent mandibular angle osteotomy].

OBJECTIVE: To discuss the application and therapeutic effect of tunable guide device in correction of prominent mandibular angle. METHODS: Since 2007, 50 cases with prominent mandible angle underwent mandible angle osteotomy with the tunable guide device. The patients were followed up for 3-6 months. RESULTS: No severe complication happened. Local seroma occurred in one case. Improved esthetic results were achieved at both frontal and oblique view. CONCLUSIONS: The mandibular angle osteotomy with the tunable guide device makes the procedure safe and easily performed.

[Transcranial surgical correction of cranio-orbital fibrous dysplasia with lateral orbital approach].

OBJECTIVE: To explore the transcranial surgical method with lateral orbital approach for the treatment of cranio-orbital fibrous dysplasia. METHODS: Lateral orbital transcranial extradural approach was adopted to correct complicated fibrous dysplasia in which the frontal, orbital, sphenoid, temporal bones were involved. Partial lesion removal and optic nerve decompression were performed through the transcranial extradural route by fronto-temporal cranial bone flap exposure. The fronto-orbital skeleton was shaped after bone flap deactivation. RESULTS: 8 cases were treated successfully with no complication. The period of follow-up ranged from 9 months to 3 years. The appearance and the vision improved greatly. Cranial CT showed good bony union with no relapse. CONCLUSIONS: Lateral orbital transcranial surgical approach is an optimal technique to correct cranio-orbital fibrous dysplasia.

[Experience of midfacial distraction osteogenesis in upper airway stenosis].

OBJECTIVE: To investigate the therapeutic effects of upper airway stenosis after Le Fort III osteotomy and midfacial distraction osteogenesis (DO). METHODS: Eleven cases (age, 5-16 yrs) with severe midface dysostosis complicated with exophthalmos, anterior crossbite and upper airway stenosis were treated by using Le Fort III osteotomy and midfacial DO from August 2000 to February 2007. The 3D reconstruction of the upper-airway from CT data was used to evaluate the upper airway volume before and after the operation. And meanwhile polysomnography was carried out to demonstrate the upper airway functional changes. RESULTS: There was a 64.3% mean increase [mean, (9.13 +/- 6.94) ml, P < 0.05] in upper airway volume in the 11 cases after the operations. It showed that there was significant improvements in the indexes of polysomnography after the operations, such as apnea and hypopnea index, average SaO2, minimum oxygen saturation and snore index. CONCLUSIONS: The Le Fort III osteotomy and midfacial distraction osteogenesis can efficiently relieve the symptoms of upper-airway stenosis in severe midfacial dysostosis.

[Changes of different section area at different parts of upper-airway after Le Fort III osteotomy].

OBJECTIVE: To observe the therapeutic effects of Le Fort III osteotomy and midface distraction osteogenesis (DO) on the upper-airway narrow. METHODS: Since 2000, 11 cases (10 cases of Crouzon syndrome and 1 case of Apert syndrome) with severe midface deficiency were treated with Le Fort III osteotomy and midface DO. The section area of different parts of upper-airway were tested by computer assistants image measurement preoperatively and postoperatively. Some patients received sleep function monitoring. RESULTS: The face appearance and the function of upper-airway improved significantly after Le Fort III osteotomy and Midface DO. The section area at the level of posterior nasal spine and uvula increased obviously after treatment (P < 0.05), however the section area at the level of epiglottis and separation between airway and esophagus were not obviously enlarged (P > 0.05). CONCLUSIONS: Midface DO after Le Fort III osteotomy can effectively improve the upper-airway narrow, especially the upper part from uvula.

[Establishment of diagnostic criteria for cranio-orbito-zygomatic hypoplasia with computer-assisted measurement].

OBJECTIVE: To establish the quantitative diagnostic criteria for cranio-orbito-zygomatic deformity (COZD). METHODS: Computer-assisted three-dimensional (3-D) CT measurement was performed in 30 cases with unilateral COZD. The differences of the measurement data between the affected and unaffected sides were analyzed. Then the patients were diagnosed and classified according to the affected bone, soft tissue and conjunctival sac. Based on the quantitative diagnosis, 8 patients underwent surgery to test the clinical practicability of the diagnostic criteria. RESULTS: The quantitative diagnostic criteria for COZD could reflect the affected area and the corresponding severity of deformity. It helped to preoperative design and to predict movement of osteotomy segment and. the soft tissue volume needed for augmentation. Good postoperative results were achieved. CONCLUSIONS: The quantitative diagnostic criteria for COZD can describe the affect area and severity of deformity in detail. It is very practical in the guidance of clinical treatment.

[Construction and functional identification of eukaryotic expression vector carrying Sprague-Dawley rat MSX-2 gene].

OBJECTIVE: To construct a high effective eukaryotic expressing plasmid PcDNA 3.1-MSX-2 encoding Sprague-Dawley rat MSX-2 gene for the further study of MSX-2 gene function. METHODS: The full length SD rat MSX-2 gene was amplified by PCR, and the full length DNA was inserted in the PMD1 8-T vector. It was isolated by restriction enzyme digest with BamHI and Xhol, then ligated into the cloning site of the PcDNA3.1 expression plasmid. The positive recombinant was identified by PCR analysis, restriction endonudease analysis and sequence analysis. Expression of RNA and protein was detected by RT-PCR and Western blot analysis in PcDNA3.1-MSX-2 transfected HEK293 cells. RESULTS: Sequence analysis and restriction endonudease analysis of PcDNA3.1-MSX-2 demonstrated that the position and size of MSX-2 cDNA insertion were consistent with the design. RT-PCR and Western blot analysis showed specific expression of mRNA and protein of MSX-2 in the transfected HEK293 cells. CONCLUSIONS: The high effective eukaryotic expression plasmid PcDNA3.1-MSX-2 encoding Sprague-Dawley Rat MSX-2 gene which is related to craniofacial development can be successfully reconstructed. It may serve as the basis for the further study of MSX-2 gene function.

[Reconstruction of the acquired orbital deformities].

OBJECTIVE: To investigate the reconstruction of acquired orbital deformities. METHODS: Through coronal incisions, subciliary incisions and buccal sulcus incisions, or periorbital wound, the displaced orbital walls were repositioned after osteotomy. And the mandibular outer cortex was used to repair the bone defect, so as to restore the orital integrity. RESULTS: From Sept. 2002 to Jun. 2006, 64 patients with acquired orbital deformities were treated. The integrity of orbit and eyeball location recovered very well. CONCLUSIONS: Restoration of the orbital integrity is the key to the treatment of acquired orbital deformities. The periorbital deformities should be corrected after osteotomy with mandibular outer cortex for bone defect.

[3-dimensional position changes of periorbital structures after midface distraction osteogenesis].

OBJECTIVE: To evaluate the 3-D position changes of periorbital structures after midface distraction osteogenesis in patients with Crouzon syndrome. METHODS: The CT data of 8 cases who had accepted the midface distraction osteogenesis following Le Fort III osteotomy were retrospectively analyzed. The patients were averagely 11.9 years old, and the CT was performed before and one year after operation. After 3-D image reconstruction, a right-hand coordinate system based on the preoperational Frankfurt Plane was then established. The pre- and post-operative positions of the superior orbit point (SOr), inferior orbit point (IOr), median orbit point (MOr), lateral orbit point (LOr), anterior ocularis point (AO), ocularis eyeball point (PO) and the four insertion ocularis rectus were documented and compared. The positions of these marked points in normal controls were also documented and compared with those in patients. RESULTS: After midface distraction osteogenesis, the position of AO was not changed significantly on the y-axis and z-axis, but the distance between two AO points on x-axis was reduced by 3.40 mm; IOr moved averagely 12.24 mm on y-axis and 4.25 mm on z-axis, MOr moved averagely 10.11 mm on y-axis and 2.80 mm on z-axis, LOr moved averagely 9.86 mm on y-axis and 2.31 mm on z-axis. The Inferior Rectus attachment moved averagely 3.63 mm on y-axis and 2.98 mm on z-axis. No other significant change was observed on other marked points. CONCLUSIONS: Midface distraction osteogenesis following Le Fort III osteotomy can significantly move the medial, lateral and inferior peri-orbital bone structure anteriorly and inferiorly. The eyeballs have no markedly sagittal position changes after distraction except slight medial, downwards movements and anterior-upwards rotations.

[Research and clinical application of computer-aided design of craniofacial prosthesis using mirror technique].

OBJECTIVE: To explore the feasibility of creating a 3D-CAD model of craniofacial prostheses through mirror technique to repair the unilateral craniofacial defects and restore craniofacial symmetry. METHODS: Patients with unilateral craniofacial defects underwent spiral CT scanning. CAD3-D image was reconstructed ad 3-D CAD model of craniofacial prosthesis was created with mirror technique, Boolean operation and rapid prototyping technique. Then the prosthesis made of bioactive artificial bone was made through plaster cavity block. RESULTS: 15 cases were treated with no complications. Good symmetry was achieved after operation. CONCLUSIONS: Designing the craniofacial prosthesis with mirror technique guarantees excellent functional and cosmetic results for repairing the unilateral craniofacial defects.

[Surgical correction of craniofacial dysostosis with midface distraction osteogenesis].

OBJECTIVE: To investigate the effect of distraction osteogenesis on correction of craniofacial dysostosis. METHODS: Le Fort III osteotomy was applied through coronal route on patients with craniofacial dysostosis such as Crouzon and Apert syndrome. The procedures included disconnecting the skeletal midface from base of cranium, setting up a RED II distraction device, and directing the device bars. The distraction was started 5 days after the surgery, with a rate of 1 mm forward per day. When midface approaching the right position, i.e. a slightly over correction of occlusion was reached, stopped distraction and kept the device for 2 - 4 months. RESULTS: Eight cases completed all the therapy. The average blood lose was 300 ml and the average operation time was 3.5 hours. The midface had been moved averagely 9 mm forwardly and 1.5 mm downwards. The features had been improved obviously and the occlusion reached nearly normal. No serious complications occurred except for 1 case of seroma and 1 case of infection around pin on scalp. No recurrence was found in the 5 months of follow-up. CONCLUSIONS: Midface distraction osteogenesis is propitious to teenage or severe cases of craniofacial dysostosis.

[Surgical correction of craniofacial dysostosis with midface distraction osteotogenesis].

OBJECTIVE: Correction of craniofacial dysostosis with midface distraction osteotogenesis. METHODS: Le Fort III osteotomy has been employed through coronal route on patients with midface craniofacial dysostosis such as Crouzon and Apert syndrome. Then a REDII distraction device was set up, and the device bars directed. The distraction begins 6.4 days after the surgery, with a rate of 1 mm per day. When midface approaching the right position, i.e. an slightly over correction of occlusion is reached, the distraction stops and the device is held for the next 2-4 months. RESULTS: There are 8 cases completed all the therapy with an average age of 11.9 years old. The midface had been moved averagely 9.7 mm forwards and 1.6 mm downwards. The features had been improved obviously and the occlusions reach nearly normal. The exophthalmos reduced from 20.3 mm to 11.9 mm. In cephalometry, SNA was averagely enlarged 9 degrees, and ANB enlarged 8.8 degrees. The snore during sleeping was also improved in 87.5% cases. No serious complication had occurred except minor one such as 1 case of seroma and 1 case of infection around pin on scalp. According to 5 months averagely follow-up, there is no recurrence in our list. CONCLUSIONS: Midface distraction osteotogenesis is propitious to teenage or severe cases of craniofacial dysostosis.

[Reconstruction of orbital deformity after radiotherapy with transcranial orbitotomy advancement combining free flap].

OBJECTIVE: To study clinic therapeutic effect about reconstruction of severe orbital and cul-de-sac deformity after the radiotherapy with transcranial orbitotomy advancement combining cascade free flap both dorsum pedis flap and anterior tibial fascial flap. METHODS: Five cases was subjected to orbital and cut-de-sac severe deformities after both operation and radiotherapy because of retinoblastoma. The technique included transcranial orbital advancement by anterior orbital osteotomy and rigid fixed with titanic plate by coronal incision, and meanwhile incising the cul-de-sac which would be extended circumference around the central incision separation, and then designing extent of cascade flap consisted of dorsum pedis flap and anterior tibial fascial flap according to the size of cul-de-sac defect and extent of temporal depression. Then, the aforementioned two parts of cascade flap were transplanted into cul-de-sac and temple respectively. There is either the superficial temporal artery and vein or facial artery and jugular vein to chose vascular anastomosis. RESULTS: All flaps survived. After 3 to 6 months following up, the results showed satisfactory orbital contour and temporal depression improved significantly in all cases. After the conjunctival sac were fixiformed with prefabricated eye prosthesis mode about 3 months. 3 cases have good appearance with wearing eye prosthesis and the other 2 cases' appearance is poor. One of the poor appearance cases, with depressed eye socket, have orbital implant underlying conjunctival sac in secondary operation. The other one, with swallowed inferior fornix, is transplanted autogenous hard palatal mucosa into inferior fornix in secondary operation. In addition, delayed healing in donor site of dorsum pedis occurred in one of the 4 cases. CONCLUSIONS: It is a reliable procedure about reconstruction of severe orbital and cul-de-sac deformity after both the operation and radiotherapy with transcranial orbitotomy advancement combining cascade free flap both dorsum pedis flap and anterior tibial fascial flap. All deformity was corrected by one staged procedure which lessen patient's suffering and shorten patient's hospital stay and spare patient's costs.

[Surgical treatment of hemifacial microsomia].

OBJECTIVE: To summarize the methods and experiences in surgical treatment of hemifacial microsomia. METHODS: Fifty-eight cases of hemifacial microsomia that have been treated by plastic and reconstructive surgery and followed-up in our department during last 20 years have been reviewed. Every patient's characteristic was assessed by physical examination, photography, craniofacial cephalometry before planned the method of surgery. Different surgical treatments were chosen according to the side and the structures involved in the abnormalities and the severity of hemifacial microsomia, and the cases were followed up since 3 months after the treatments. The follow-up lean of midline of the lower 1/3 face with that before treatment is compared. The degrees of patients' and surgeons' satisfactions with the treatments were evaluated respectively. RESULTS: The average angle of lean of midline of skeletal and soft tissue of the lower 1/3 face decreased 4.2 degrees and 2.9 degrees respectively after treatment. Fifty (82.6%) cases satisfied with the outcome of the surgical treatment and surgeons satisfied with 84.5% of the outcome of all the cases. CONCLUSIONS: Individual surgical treatment based on the side and the structures involved in the abnormalities can effectively correct facial asymmetry of hemifacial microsomia.

[Individual 3-D image prototyping models for orbital reconstruction].

OBJECTIVE: To fabricate a rapid prototyping (RP) 3-D image models for individual reconstruction of orbital bony loss. METHODS: The skull was placed on a helical CT scanner table and the Frankfort plane was perpendicular to the table. The CT data was obtained by a Aquilion (TOSHIBA, Japan) with 1 mm thickness section in spiral mode. By adjusting of CT threshold value and pixels in order to stack the segmental defects, we obtained an approximate 3-dimension visual model of the scanned skull using MedGraphics software. An orbital RP model based on the dataset of the 3-dimension visual model was fabricated by RP machine. Both 3-dimension visual model and RP model were measured against the skull with several anatomic landmarks to examine the accuracy of the models, and the errors were analysed. RESULTS: Integrity precision rapid RP models of the orbital region were reconstructed. The anterior orbital rim, middle orbital section and posterior orbital section were all fabricated. Optic foramen, superior orbital fissure, infraorbital foramen, inferior orbital fissure, lacrimal sac socket and naso-lacrimal duct were shown clearly. But some fine hole and slot, such as the anterior ethmoidal foramen, posterior ethmoidal foramen and zygomaticofrontal suture were not obviously seen. The mean difference between the 3-dimension visual model and the skull was 0.10 +/- 1.02mm. For the RP and dry skull, the mean difference was 0.22 +/- 1.04mm. There were no statistical differences between them. CONCLUSIONS: Integrity precision orbital RP models were fabricated which fulfilled the requirements of the individual reconstruction with bony orbital pathologic changes. The keys to fabricate the precision orbital RP models included a closer cooperation between the surgeon and engineer, thin CT slice in 1mm thick and an appropriated threshold value. Better results for the orbital deformities should be achieved for the contour of orbital region or eye function.

[Lamella osteotomy with separated segments movement in secondary orbito-zygoma deformities after traumatic malar fracture].

OBJECTIVE: For reconstruction of secondary orbit-zygomatic deformities after severe malar fracture. METHODS: We made shaped segments in orbito-zygoma region using lamella osteotomy, rearranged inferior and lateral orbital segment with inner and upper movement, and fixed the zygomatic fragment in new place with lateral and upward movement. Pre and post operative measurements including Hetel measurement and the angle between orbital horizontal level with bilateral tragus linkage(A-OT) have been done. RESULTS: In our 22 cases list, lateral and inferior orbital segment was moved to upper and inner direction with 8.1 mm in average, while zygomatic fragent was lift 9.2 mm and pushed 1.5 mm in average. In average 6.5 months follow-up, good facial contour were maintained in most of our list and no obvious relapse was occurred. CONCLUSIONS: Lamella osteotomy with separated segments movement was benefit to most of secondary deformities in orbito-zygoma displace.

Diagnosis and classification of congenital craniofacial cleft deformities.

Classification and diagnosis of congenital craniofacial cleft deformities are helpful in discerning the severity of the deformity and providing guidance for surgical repair. Eighty-one cases of congenital craniofacial cleft deformity were analyzed using the Tessier classification. Depending on the location, status of the deformity, and results of examinations such as computed tomography, according to the range affected, the location and status of the deformity were designated by the STO classification, with S for skin, T for soft tissue, and O for os (craniofacial bone). The severity of the deformity is delineated by Arabic numerals. The analysis of 81 cases by the STO classification method showed that suborbital deformities mainly were Tessier 3 and 4 clefts (24.70%) and supraorbital deformities mainly were Tessier 9 and 10 clefts (38.27%). There was no definite regular pattern for the affected extent of tissues. STO classification can be a supplement to Tessier classification and can provide references for the surgical repair of craniofacial cleft deformity.

[The diagnoses and classifying of congenital craniofacial cleft].

OBJECTIVE: To diagnose and classify the congenital craniofacial cleft with a uniform scale is helpful to evaluate the abnormality and select the repairing methods. METHODS: We analyzed 81 cases of congenital craniofacial cleft basically using Tessier craniofacial cleft classification. Furthermore, according to the position of soft tissue or bone, the character and degree of clefts or dysplasia and the results of CT scanning, we subdivided the congenital deformities based on S (skin), T (tissue), and O (OS). Arabic numerals were used to express the degree of the abnormality. RESULTS: Of all the cases analyzed with the STO classification, No. III and IV clefts are often seen in the infraorbital region (24.70%). No. IX and X clefts are mostly seen in the supraorbital region (38.27%). The relationship between the cleft types and involved tissue has not been found. CONCLUSIONS: The STO classification reinforces Tessier classification. It offers the basis for craniofacial cleft repair.

[Correction of hypoplastic orbit after eradiation therapy with the technique of ostectomy and flap transplantation].

OBJECTIVE: To introduce an effective method for reconstruction of hypoplastic orbit caused by eradiation therapy. METHODS: The orbital reestablishment was carried out by using the orbital ostectomy to enlarge the orbital cavity and a flap transferring for the socket reconstruction and the repair of the concave deformity around the orbit. RESULTS: Twelve treated patients demonstrated the satisfactory improvement. CONCLUSIONS: The ostectomy combined with the flap transplantation may be available for reconstruction of the hypoplastic orbit.

[Malar reconstruction in the patients with Treacher-Collin's syndrome].

OBJECTIVE: The key feature of Treacher-Collin's syndrome is malar dysostosis. The article focused on malar reconstruction for Treacher-Collin's syndrome and compared the implant materials. METHODS: From 1994 to 2002, a total of 55 patients with Treacher-Collin's syndrome were treated with malar reconstruction. In the operation, the lateral orbital rim and the mala were exposed by the bicoronal incision or the subciliary incision. The mala was augmented and reconstructed with implants of different materials, including autologous bone (rib, ilia or cranium). Medpor biomaterial or bone cement. RESULTS: The operations of the 55 patients were all successful without infection. The satisfactory rate in facial contour was 90%. Implant exclusion occurred in 2 cases using hone cement. CONCLUSION: Malar reconstruction is the most important treatment for Treacher-Collin's syndrome. Every implant material has advantages and shortcomings. Autologous hone is the best material for malar reconstruction. Medpor is the best artificial material, with good histocompatibility, without exclusion, absorption and donor injury.

[Surgical correction of exophthalmos in craniofacial synostosis].

OBJECTIVE: To analyze the efficacy and complications of the surgical correction of exophthalmos in craniofacial synostosis. METHODS: Three different procedures were used in exophthalmos patients with different ages. In patients aged 1 - 3 years old, the fronto-orbital advancing osteotomy to deepen the upper part of orbital cavity was employed. In patients aged 4 - 15 years old, Le Fort III osteotomy and distraction osteogenesis were selected. In patients aged 16 years old or more, Le Fort III osteotomy or monobloc craniofacial osteotomy with immediately advancement of the midface segments were selected. RESULTS: Good results were achieved for all 18 patients. The proptosis reduced 7.8 mm postoperatively. The depth of the skull base increased 8.2 mm and inferior orbit margin was advanced 7.8 mm as compared with the preoperative measurements. The angle between the maxilla and skull base (SNA) increased 9 degree. All of these measurements indicated that the proptosis and craniofacial contouring were approached to the normal situation after surgical intervention. CONCLUSION: Both immediate advancement and gradual distraction after frontal, orbital, and maxillar osteotomy to enlarge the orbital cavities are the best approaches for the treatment of exophthalmos in craniofacial synostosis.