Virtual planning for corrections of hemifacial microsomia.

Objectives: This article describes the many anomalies within and outside the head and neck of hemifacial microsomia (HFM). Methods: The OMENS+ classification system is described with particular reference to the mandibular features classified by Pruzansky and modified by Kaban. The application of virtual surgical planning (VSP) to HFM, largely in children, is described and taken through to aspects indicated in maturity. Results: VSP is demonstrated with clinical cases examples in HFM patients for (1) grafts and flaps replacing missing parts of the zygomatic bone, temporo-mandibular joint and mandible, (2) distraction osteogenesis for lengthening of the mandibular ramus, advancement of the mandibular body, widening of the face and simultaneous mid-face and mandibular rotation, (3) implants and correction of microtia for bone anchored ear prostheses, (4) correction of microtia by autogenous ear construction, and (5) end stage rotational bimaxillary osteotomies. Conclusions: 3D virtual and physical planning is a valuable adjunct to the treatment of this complex condition.

Le Fort I advancement osteotomies of 1 cm or more. How safe or stable?

We studied the results and stability of Le Fort I maxillary osteotomies with advancement of at least 1cm. We analysed prospective data from 32 consecutive patients who were operated on by a single surgeon between 1985 and 2007, and who had mean advancement of the maxilla of 14 mm (range 10-22 mm). Mean relapse for all cases antero-posteriorly was 1mm, 10% (range 0-4mm). Relapse was marginally greater in the 24 patients with a repaired cleft palate (11%) compared with those without a cleft (8%). The results were essentially stable at least one year after surgery and without significant complications. This study indicates that Le Fort I osteotomies of 1cm or more carried out in the way described are safe and stable.

The minimum time for cranioplasty insertion from craniectomy is six months to reduce risk of infection--a case series of 82 patients.

OBJECTIVE: Cranioplasty is carried out for cosmesis, protection and also for neurological improvement following cranial defect. Infection post cranioplasty is problematic. We look at the outcome from 10 years of cranioplasty patients, and aim to see if there is a correlation between infection and time to insertion of cranial plate. METHODS: A retrospective case series identifying all cranioplasty patients between 1998-2008 using the maxillofacial laboratory data log of all plates that were made during this time. Data was yielded from the clinical case notes and the microbiology database. The outcome measure was infection defined as removal of cranioplasty plate. RESULTS: Total cranioplasties performed = 82. Infected cranioplasties = 9 (7 titanium 2 acrylic). An 11% infection rate of cranioplasties. Craniectomy due to trauma, with cranioplasty occurring between 0 to 6 months had the greatest number of infective cases, with 8 out of 9 occuring in this period (p value = 0.0076). CONCLUSION: Cranioplasty carried out at a minimum of 6 months post craniectomy limits the risk of infection.

Retrieval of the displaced condylar fragment with a screw: simple method of reduction and stabilisation of high and intracapsular condylar fractures.

We acknowledge the difficulties that arise when attempting to reduce and stabilise some condylar fractures, particularly those that are high or intracapsular. This paper highlights retrieval of the proximal fragment with a screw, and its benefit for reduction and stabilisation of the fractured condylar head before fixation. Eight patients with condylar fractures were treated at two centres, Morriston Hospital, Swansea, South Wales, and the General Hospital St. Jan, Brugge, Belgium between 1998 and 2007. The proximal fragment was retrieved by insertion of a screw in all cases. Three patients had unilateral, and five had bilateral high or intracapsular fractures. In all cases postoperative scans showed excellent anatomical repositioning and fixation of the condylar fragments. Postoperative follow-up showed good, stable occlusion, excellent mouth opening, and no facial nerve weakness even for a temporary period. Once the screw is in position the operator can gain precise control of the reduction, and the ease of manipulation reduces operating time considerably. The technique provides an excellent solution to the difficult task of reduction and stabilisation of the displaced fragment in condylar fractures, particularly in high fractures, and can be extended to other areas of maxillofacial trauma and corrective bone surgery.

The use of detachable flanges on customized titanium orbital implants: a technical note.

The combined use of three-dimensional reformatted images, stereolithographic models, and rapid prototyping allows the construction of an accurate, individually made titanium implant for the reconstruction of orbital floor defects. Despite the perfect fit of the custom-made plate to the model, there might be several locations on the bone where the plate may reside intraoperatively. Most titanium orbital plates therefore contain extensions over the inferior orbital rim to help locate and stabilize the plate in its position on the bone. Such over-the-rim extensions may be palpable and can cause discomfort postoperatively. We describe the use of two small detachable flanges that help to accurately locate the orbital plate in place and allow its fixation. The locating flanges are then detached and discarded, leaving a smooth implant surface within the confines of the bony orbit.

Current practice of distraction osteogenesis for craniofacial anomalies in Europe: a web based survey.

Aim of the study was to get more insight into the opinion of European surgeons and orthodontists on the use of distraction osteogenesis (DO) for patients with different diagnoses and treatment protocols. A web based survey was set up, showing records of four patients with different conditions: hemifacial microsomia (case 1), bilateral mandibular deficiency (case 2), cleft lip and palate (case 3) and Crouzon syndrome (case 4). Respondents from 181 Eurocleft centres were asked to fill out a questionnaire for each patient. Most of the respondents considered case 1 (80%), case 3 (81%) and case 4 (86%) suitable for DO, while only 31% were considering case 2 for DO. There was lack of consensus among the respondents about many aspects of DO. Out of six different treatment parameters, an acceptable degree of agreement was only seen in two: a latency period of 3-7 days and a distraction rate of 1mm per day. Furthermore, there was noticeable disagreement on the ideal age for treatment, surgical technique, distraction device, and retention period. Our results showed that there is a wide variety in treatment approaches for craniofacial anomalies in Europe. There is disagreement on essential steps in the distraction procedures.

The 3-dimensional construction of the average 11-year-old child face: a clinical evaluation and application.

PURPOSE: This article describes construction of the average face and its application in the clinical environment. SUBJECTS AND METHODS: A total of 72 children, mean age 11.8 years, were selected for the study. Laser-scanned images of the subjects were obtained under a reproducible and controlled environment with 2 Minolta Vivid 900 (Minolta, Osaka, Japan) optical laser-scanning devices assembled as a stereo pair. A set of left and right scanned images was taken for each subject and each scan took an average of 2.5 seconds. These scanned images were processed and merged to form a composite 3-dimensional soft tissue reproduction of the subjects using commercially-available reverse modeling software. The differences in facial morphology were measured using shell deviation color maps. The average face was used to compare differences between male and female groups and 3 subjects with craniofacial anomalies. RESULTS: The difference between the average male and female face was 0.460 +/- 0.353 mm. The areas of greatest deviation were at the zygomatic area and lower jaw line, with the males being more prominent. The results of the surface deviation between the subjects with craniofacial anomalies were significant. CONCLUSIONS: The construction of the average face provides an interesting perspective into measuring changes in groups of patients and also acts as a useful template for the comparison of craniofacial anomalies.

The development of a collaborative medical modelling service: organisational and technical considerations.

We describe the steps, problems, pitfalls and modifications in the development of a collaborative medical modelling service for a general hospital in the United Kingdom. We emphasise the value of having as much control as possible in the hands of clinicians so that the maximum relevant information can be obtained at minimum cost. Three-dimensional imaging, modelling and planning are now essential parts of any reconstructive surgery unit and must be adapted to make them as user friendly as possible for clinicians.