Alvaro A. Figueroa

Management of severe cleft maxillary deficiency with distraction osteogenesis: Procedure and results ☆ ☆☆

Distraction osteogenesis has become an important technique to treat craniofacial skeletal dysplasia. In this study, the technique of maxillary distraction with a rigid external distraction device is presented. Cephalometric results in the first 14 consecutive patients are analyzed. The study sample consisted of 14 patients with various cleft types and maxillary hypoplasia treated with the rigid external distraction technique. Analysis of the predistraction and postdistraction cephalometric radiographs revealed significant skeletal maxillary advancement. All patients had correction of the maxillary hypoplasia with positive skeletal convexity and dental overjet after maxillary distraction. The morbidity for the procedure was minimal. Surgical and orthodontic procedures are thoroughly described.

Longitudinal assessment of mental development in infants with nonsyndromic craniosynostosis with and without cranial release and reconstruction.

The effect of cranial release and reconstruction on the mental development of infants with nonsyndromic craniosynostosis was evaluated. Longitudinal assessment of mental development for infants before and after cranial release and reconstruction and for infants not undergoing surgical treatment was obtained by using the mental scale of the Bayley Scales of Infant Development. Severity of anatomic craniofacial deformity, perinatal medical risk factors, and age at time of surgery also were investigated. None of the infants displayed mental retardation [Mental Development Index (MDI) score < 70] before or after cranial release and reconstruction. Scores ranged from borderline retardation to very superior following a normal distribution. Severity of anatomic craniofacial deformity and perinatal risk factors were unrelated to mental development. Cranial release and reconstruction did not affect mental development positively or negatively but did result in improvement of the original craniofacial deformity.

Monobloc craniomaxillofacial distraction osteogenesis in a newborn with severe craniofacial synostosis: A preliminary report

Severe craniofacial synostosis can be a devastating problem for a newborn infant. Reasons for early surgical intervention include cranial stenosis, hydrocephalus, inadequate globe and corneal protection, compromised airway patency, and feeding problems. In this preliminary report, we describe the management of severe craniofacial synostosis in a newborn infant by means of cranial and midfacial distraction osteogenesis.

Long-term follow-up of a mandibular costochondral graft

The long-term follow-up of a patient with unilateral mandibular condylar dysplasia and facial asymmetry, treated with a costochondral graft, is presented. The etiology of the deformity and the surgical treatment are discussed. A detailed review of the literature is included to introduce the reader to the biology and rationale for the use of costochondral grafts in growing patients.

Maxillary distraction for the management of cleft maxillary hypoplasia with a rigid external distraction system

Maxillary hypoplasia is a common finding in patients with repaired orofacial clefts. Management of this condition has been a challenge to the reconstructive team. The introduction of distraction osteogenesis to treat craniofacial skeletal dysplasias has opened alternative approaches to manage these severe conditions. In this article, the authors present their technique to distract the hypoplastic cleft maxilla using a rigid external distraction device. The clinical assessment, indications, orthodontic procedure, surgical technique, and distraction protocol are reviewed. A case report shows the use of the technique. This technique allows the reconstructive team to treat patients in all age groups with predictable and stable results.

Iliac versus cranial bone for secondary grafting of residual alveolar clefts.

Secondary bone grafting of the maxilla in the mixed transitional dentition stage has become a well-accepted procedure in the surgical protocol for rehabilitation of patients with residual alveolar clefts. This retrospective study was undertaken to evaluate and compare the long-term results obtained with iliac or cranial cancellous bone graft material in the area of alveolar clefts and was based on the independent experience of two plastic surgeons from the same center using exclusively cranial or iliac cancellous bone, respectively. The criteria for surgery were similar. The surgical technique, with the exception of the bone-grafting material, also was similar, and all patients were treated by the same group of orthodontists. Fifteen patients from each group, from a total of over 100 patients, were randomly selected and included in the study. All patients were followed up from 18 to 60 months. Operative and perioperative parameters, donor-site morbidity, and long-term results were evaluated, compared, and analyzed. There were no significant differences between the two groups, and equally good results in terms of bone incorporation, tooth eruption, and appearance were obtained with both iliac and cranial bone grafts. We conclude from our study that successful bone grafting is primarily achieved by adherence to meticulous surgical technique, simultaneous closure of coexisting oronasal or palatal fistulae, use of cancellous bone particles only, and coverage of the grafts with well-vascularized flaps. The source of bone graft does not seem to primarily influence the success of the outcome.

Long-term effects of rigid fixation on the growing craniomaxillofacial skeleton.

&NA; Fixation of craniomaxillofacial bones with plates and screws is becoming an increasingly popular method of managing patients with maxillofacial fractures, congenital anomalies, and skeletal defects after tumor extirpation. The effects of rigid fixation on growth, however, are not well defined and remain controversial. This experimental work was designed to evaluate the effects of rigid fixation on the growing craniomaxillofacial skeleton. Eight 2‐month‐old beagle dogs were divided into two groups. Cephalometric analysis and computed tomography were obtained preoperatively to establish a baseline of the craniomaxillofacial skeleton. Rigid fixation using plates and screws was applied across the intact coronal and nasofrontal sutures. The contralateral side served as the control. The periosteum was elevated over the contralateral suture and replaced without any surgical intervention. The animals were killed one year after application of rigid fixation, when they had achieved full and mature skeletal growth. The skulls were evaluated both grossly and cephalometrically. There was bony growth over some of the plates, as well as sclerosis of the plated suture lines. Cephalometric analysis demonstrated consistent asymmetry between the plated and nonplated sides, with deviation of the midline toward the plated side in all of the animals. Although further studies are necessary to clarify this issue fully, we conclude from our study that rigid fixation during skeletal development can potentially alter the growth patterns of the craniomaxillofacial skeleton and should be used with caution.

Craniofacial growth data for cleft lip patients infancy to 6 years of age: Potential applications

The present work was undertaken to provide craniofacial roentgenocephalometric growth data on a group of patients with cleft lip ranging in age from infancy to 6 years. Included are variables related to the neurocranium and orbit. Mensurational data were derived from cephalograms of 72 patients (44 male and 28 female subjects) with cleft lip only (n = 38) or cleft lip with varying degrees of alveolar cleft (n = 34). The data in this mixed longitudinal sample are reported for ten age groups. On the basis of comparison with reported noncleft roentgenocephalometric values, it is suggested that the data may serve as a reference for early craniofacial growth. Measurements from four persons with different types of craniofacial anomalies are also presented to illustrate the application of the reported data in the assessment of craniofacial growth.

Intraoral-Appliance Modification To Retract the Premaxilla in Patients With Bilateral Cleft Lip

Management of the protrusive premaxilla in patients with bilateral cleft lip is challenging for the reconstructive team. Several intra- and extraoral orthopedic techniques to reposition the protrusive premaxilla prior to bilateral cleft lip repair have been presented in the literature. A modification to a previously described tissue-borne palatal plate with a latex strap is presented. In the modified plate, the latex strap is replaced by an orthodontic elastomeric chain, and the chain over the prolabium is covered with soft denture liner. This appliance is effective in retracting the premaxilla, noninvasive, easy to construct and adjust, economic, well tolerated by the patient, and accepted by the parents.

Simultaneous distraction osteogenesis and microsurgical reconstruction for facial asymmetry.

Restoring facial balance in patients with severe facial asymmetry is a challenging problem for the craniofacial team. Attention to bony reconstruction as well as soft-tissue contouring is required for patients with moderate to severe deformities. Traditionally, facial skeletal reconstruction was performed with osteotomies and bone grafting. More recently, distraction osteogenesis has proven to be successful in achieving bone lengthening. For select cases, distraction osteogenesis has lessened the need for major skeletal procedures and has allowed earlier surgical intervention. The reconstruction of the soft tissues in facial asymmetry has generally been performed as a second-stage procedure after skeletal reconstruction. The disadvantage of these traditional approaches is that it requires two separate major operative procedures, with the accompanying increased morbidity, hospital stay, and cost. We present a patient with hemifacial microsomia and a grade III mandibular deformity, in whom both the hard- and soft-tissue deficiencies were corrected in one surgical procedure with mandibular distraction osteogenesis and soft-tissue augmentation with a vascularized parascapular osteocutaneous flap. The technique and results at 1-year follow-up are presented.