Spatial Analysis of the Temporomandibular Joint and Condyle Following Mandibular Distraction in Robin Sequence.

ABSTRACT: To comprehensively assess changes in temporomandibular joint and mandibular condyle morphology in Robin sequence (RS) patients undergoing mandibular distraction osteogenesis (MDO). A retrospective analysis of pediatric patients with RS and functional temporomandibular joints who underwent MDO by a single surgeon was performed. Preoperative and postoperative computed tomography (CT) scans were morphometrically analyzed three-dimensional in 3-matic and Mimics (Materialise). Comparative analysis was performed using Wilcoxon signed-rank tests. Fourteen RS patients were included (28 condyles, 56 CT scans), 78% male and 22% females. The mean age at surgery was 9.4 weeks (range 1.6-46.7 weeks). The average age at initial CT was 5.3 days (range 0-11 days). The mean time interval for CT scan before MDO and after hardware removal were 8.8 ±â€Š6.4 days and 11.2 ±â€Š25.8 days, respectively. Rotatory changes of the condyle revealed a significantly decreased horizontal angle following MDO (-7.55°, 95% confidence interval -11.13° to -3.41°; P < 0.001). Anteroposteriorly, the angle between condylar process and ramus (incline) increased significantly (14.14°, 95% confidence interval 10.71°-19.59°; P < 0.001). Intragroup analysis revealed no difference between left versus right condylar position measurements. The condyle itself increased in size and length and the intercondylion distance increased post-MDO. There were no complications and all patients achieved relief of airway obstruction without tracheostomy. Morphologic and positional changes of the mandibular condyle following MDO in RS patients parallel changes that occur during normal development in non-RS patients. As a result, MDO may facilitate normal condylar morphology and function in RS patients.

Osseous Convexity at the Anterior Fontanelle: A Presentation of Metopic Fusion?

BACKGROUND: Craniosynostosis, or a premature fusion of 1 or more cranial vault sutures, results in characteristic head shape deformities. In previous reports, an osseous prominence at the anterior fontanelle has been suggestive of adjacent suture fusion and local elevation in intracranial pressure (ICP). This prominence has been termed the "volcano" sign, and has been described in the anterior fusion of the sagittal suture and serves as an indication for surgery. METHODS: Two patients presented for head shape evaluation with mild metopic ridging and anterior fontanellar osseous convexities consistent with the volcano sign. Low-dose computed tomography imaging was performed in both patients due to concern for underlying craniosynostosis with elevated locoregional ICP. RESULTS: In both patients, imaging was significant for a localized, superior forehead metopic fusion, as well as a bony, convex prominence at the site of the ossified anterior fontanelle. There were no other clinical or radiologic signs or symptoms to suggest elevated ICP. Surgery was not indicated in either patient. CONCLUSIONS: Here the authors present 2 patients with osseous convexities at the site of the closed anterior fontanelle without signs or symptoms of elevated ICP, or classic signs of metopic synostosis. The authors hypothesize that this pattern may be due to a form of mechanically induced premature fusion of a normal metopic suture that is focused superiorly at the bregma, with minimal resultant restriction of overall skull growth. This is in contrast to metopic synostosis, which primarily has a sutural pathology and leads to characteristic findings of hypotelorism and trigonocephaly.

A Thirty-Year Experience With Head and Neck Flap Reconstruction.

BACKGROUND: Head and neck (HN) defects after tumor extirpation can be challenging to repair. Historically, pedicled flaps were the mainstay for reconstruction, but recently, free tissue transfer has been preferred. This study compares patient characteristics and flap outcomes for HN defects over a 30-year period at the authors' institution. METHODS: Head and neck cancer patients receiving flap reconstruction from 1983 to 2013 were included. Records were reviewed for demographic and perioperative data. Flap complications were compared and statistical tests were 2-tailed with a significance level of 0.05. RESULTS: Eight hundred sixty-one patients fulfilled inclusion and exclusion criteria. Pedicled reconstruction predominated during early time-points (96.3% pedicled), compared with later years (69.5% free-tissue). Free flaps were associated with significantly longer operative times (643.5 versus 429.7 minutes, P<0.0001) and postoperative stays (16.89 versus 14.01 nights, P = 0.0005) and had higher rates of emergent reoperation, total flap loss, hematoma, and donor site morbidity. Previous irradiation did not affect major complication rate for either flap type. CONCLUSIONS: A shift from pedicled to free flaps for HN reconstruction occurred over the last 30 years. Free flaps had a higher complication profile in this cohort, which was largely accounted for by a higher return rate to the operating room compared with pedicled flaps (17.31% versus 5.46%, P<0.0001). Additionally, this complication profile may reflect the increasingly common use of free tissue flaps for more complex reconstructions. Several of these differences in complication rates between flap types were no longer significant in the last 5 years of this study.