Barry H. Grayson

Lengthening the Human Mandible by Gradual Distraction

Lengthening of the mandible by gradual distraction was performed on four young patients (average age 78 months). The amount of mandibular bone lengthening ranged from 18 to 24 mm; one patient with Nagers syndrome underwent bilateral mandibular expansion. Following the period of expansion, the patients were maintained in external fixation for an average of 9 weeks to allow ossification. The patients were followed for a minimum of 11 months to a maximum of 20 months with clinical and dental examinations as well as photographic and radiographic documentation. The technique holds promise for early reconstruction of craniofacial skeletal defects without the need for bone grafts, blood transfusion, or intermaxillary fixation.

Three-dimensional computer-assisted design of craniofacial surgical procedures : optimization and interaction with cephalometric and CT-based models

A computer program is described which aids the clinician in planning craniofacial surgical procedures. It operates on a three-dimensional landmark data base derived by combining posteroanterior and lateral cephalograins from the patient and from the Bolton normative standards. A three-dimensional surgical simulation program based on computerized tomographic (CT) data is also described which can be linked to the cephalometrically based program. After the clinician has selected the number and type of osteotomies to be performed on the patient, an automated optimization program computes the postoperative positions of these fragments which best fit the appropriate normal cephalometric form. The clinician then interactively modifies the design to account for such variables as bone-graft resorption, relapse tendency, occlusal disparities, and the condition of the overlying soft-tissue matrix. Osteotomy movement specifications are easily transferred between the CT-based and the cephalometrically based surgical simulation programs. This allows the automated positioning step to be performed on the cephalometrically based model while the interactive step is performed using the superior image provided by the CT-based model.

Twenty-year experience with early surgery for craniosynostosis. I: Isolated craniofacial synostosis : results and unsolved problems

Early surgery for isolated craniosynostosis is designed to improve morphology, to prevent functional disturbances, and equally important, to enhance the psychosocial development of the child. As the first of a two-part series, 104 patients with isolated craniofacial synostosis were retrospectively analyzed. Diagnoses included bilateral coronal (10), unilateral coronal (57), metopic (29), and sagittal synostosis (8). All patients underwent primary fronto-orbital advancement-calvarial vault remodeling procedures at less than 18 months of age (mean 8.1 months). Thirteen percent of patients (14) required a secondary cranial vault operation (mean age 22.6 months) to address residual deficits in craniofacial form. Perioperative complications were minimal (5.0 percent), and there was no mortality. Average length of postoperative follow-up was 46.0 months. By the classification of Whitaker et al., which assesses surgical results, 87.5 percent of patients were considered to have at least satisfactory craniofacial form (category I–II) at latest evaluation. Overall rates of hydrocephalus, shunt placement, and seizures (3.8, 1.0, and 2.9 percent, respectively) were low. Among the isolated craniosynostoses, unilateral coronal synostosis/plagiocephaly poses the most complex problems, including vertical orbital dystopia, nasal tip deviation, and residual craniofacial asymmetry; there is also a wide spectrum of findings and growth patterns in this subgroup.

Three-Dimensional Computer-Aided Design of Craniofacial Surgical Procedures

Computer graphics promises to provide a tool for the precise planning of craniofacial procedures and the rigorous evaluation of results. There are three essential ingredients: three-dimensional imaging, simulation of surgical osteotomies, and quantitation of the residual deformity.

Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair

&NA; We present a new combined approach to primary bilateral cleft lip, nose, and alveolus repair using presurgical nasoalveolar molding combined with a one‐stage lip, nose, and alveolus repair. Presurgical alveolar molding is used to bring the protruding premaxilla back into proper alignment with the lateral segments in the maxillary arch. Presurgical nasal molding produces tissue expansion of the short columella and nasal lining. A coordinated surgical approach involves a one‐stage repair of the lip, nose, and alveolus. The nasal repair uses a retrograde approach in which the prolabial flap and columella are reflected over the nasal dorsum by continuing the dissection behind the prolabium up the membranous septum and over the septal angle. Tissues are dissected out from between the tip cartilages, and the domes are sutured together in the midline. This method joins a new class of bilateral cleft repairs that place the primary emphasis on correction of the deformity of the nasal tip cartilages.

Long-Term Effects of Nasoalveolar Molding on Three-Dimensional Nasal Shape in Unilateral Clefts

OBJECTIVE This objective of this study was to determine the effect of presurgical nasoalveolar molding on long-term nasal shape in complete unilateral clefts. DESIGN The study was retrospective, and the subjects were chosen at random. Nasal casts of the subjects were scanned in three dimensions. Each nose was best fit to its mirror image, and a numerical asymmetry score was determined. SETTING All patients were treated at the Institute of Reconstructive Plastic Surgery, NYU Medical Center, New York, New York. PATIENTS The study subjects (n = 10) were selected from a group that had undergone presurgical nasal molding in conjunction with alveolar molding. The control subjects (n = 10) were selected from a group that had undergone presurgical alveolar molding alone. INTERVENTIONS All subjects underwent presurgical orthopedic treatment until the age of approximately 4 months at which time the primary surgery was performed. MAIN OUTCOME MEASURE The nasal shape following nasal molding should be more symmetrical than if molding had not been done. RESULTS The mean asymmetry index for the nasoalveolar molding group was 0.74, and the control group was 1.21. This difference was statistically significant (p < .05). CONCLUSIONS Presurgical nasoalveolar molding significantly increases the symmetry of the nose. The increase in symmetry is maintained long term into early childhood. The limitations of this study include (1) asymmetry alone is not an adequate shape result in most situations, (2) the children evaluated in this study were not fully grown, and (3) the control group was not age matched.

Twenty-year experience with early surgery for craniosynostosis : II. The craniofacial synostosis syndromes and pansynostosis-Results and Unsolved Problems

As the second of a two-part series, 76 patients with pansynostosis and craniofacial synostosis syndromes were retrospectively analyzed. Diagnoses included pansynostosis (7), craniofrontonasal dysplasia (8), and Apert (24), Crouzon (15), and Pfeiffer (15) syndromes. All patients underwent primary fronto-orbital advancement-calvarial vault remodeling procedures at less than 18 months of age (mean 6.1 months). Twenty-eight patients (36.8 percent) required a secondary cranial vault operation (mean age 28.4 months). Additionally, a major tertiary procedure was necessary in 5 patients to deal with persistent unacceptable craniofacial form. To address the associated finding of midface hypoplasia, 64.8 percent (n = 35) of patients underwent Le Fort III midface advancement or had that procedure recommended for them. The remainder were awaiting appropriate age for this reconstruction. The more extensive pathologic involvement of the pansynostosis and craniofacial syndrome group is illustrated. As compared with the isolated craniofacial synostosis group previously reported, the incidence of major secondary procedures (36.8 versus 13.5 percent), perioperative complications (11.3 versus 5.0 percent), follow-up complications (44.7 versus 7.7 percent), hydrocephalus (42.1 versus 3.9 percent), shunt placement (22.4 versus 1.0 percent), and seizures (11.8 versus 2.9 percent) was significantly increased. Complex problems including those of increased intracranial pressure, airway obstruction, and recurrent turricephaly or cranial vault maldevelopment are repeatedly encountered. In addition, that early fronto-orbital advancement-cranial vault remodeling failed to promote midface development and hypoplasia of this region is almost a consistent finding in the craniofacial syndromic group. The average length of postoperative follow-up was 6 years. According to the classification of Whitaker et al., which assesses surgical results, 73.7 percent of patients were considered to have at least satisfactory craniofacial form (category I–II) at latest evaluation. An algorithmic approach to the treatment of all patients with craniosynostosis is presented utilizing early surgical intervention as the key element.

Mandibular growth after distraction in patients under 48 months of age

Distraction osteogenesis is an effective technique for reconstruction of the congenitally deficient mandible. However, the age at which it is best performed remains under discussion. Distraction performed at an early age, while possibly allowing the face to develop with a more normal functional matrix, may entail a higher rate of complications. Additionally, it is possible that subsequent asymmetric growth of the mandible may necessitate serial distraction. To address this issue, the clinical records and cephalometric radiographs of all patients less than 48 months of age undergoing mandibular distraction at New York University Medical Center between August of 1989 and August of 1997 were examined. There was a total of 14 patients ranging in age from 19 months to 43 months. Nine patients had a diagnosis of unilateral craniofacial microsomia, three had Treacher Collins syndrome, one had Nager syndrome, and one had bilateral developmental micrognathia. The average amount of distraction was 27 mm (range, 23 to 39 mm) in unilateral cases and 24 mm in bilateral cases (range, 15 to 31 mm). The period of clinical follow-up averaged 32.6 months (range, 12 to 92 months). All patients showed significant improvement in craniofacial appearance, and in four patients, long-term tracheostomy tubes were removed. There were two major complications. In one patient with craniofacial microsomia, there was a relapse in the early postretention phase related to the presence of a dentigerous cyst. This required removal of the cyst and repeat distraction. In the patient with Nager syndrome, a coronoid ankylosis developed requiring surgical release. There were no other major complications. The scars required revision in only two of the patients. Cephalometric analysis of the patients in the study revealed a differential in the rate of growth between the affected and the unaffected side in all cases of craniofacial microsomia. The affected side always grew at a slower rate than the contralateral side after the distraction process was complete. This led to a progressive asymmetry of the rami, clinically expressed by some degree of facial asymmetry and an occlusal cant. For this reason, secondary distraction was required in one patient and is planned in a second. Initial overcorrection of the patient would seem to minimize the likelihood that secondary distraction will be necessary. Distraction osteogenesis for reconstruction of the mandible in this subset of young patients was a safe and effective technique for improving the craniofacial skeletal form and appearance, with minimal associated morbidity. Longer follow-up is necessary to assess the full impact of growth in these cases.

Effect of Mandibular Distraction on the Temporomandibular Joint: Part 2, Clinical Study

Mandibular lengthening by gradual distraction has been gaining popularity. However, the effect of osteodistraction on the temporomandibular joint has been evaluated in patients with craniofacial anomalies who underwent mandibular distraction. Five patients had unilateral expansion and five had bilateral expansion. The mandibles were expanded 1 mm per day until the pogonion was in the midline. Preoper-ative, immediate, 6-month, and 12-month panoramic and cephalometric radiographs were evaluated. In unilaterally expanded mandibles, the ipsilateral condyle increased in size and volume, became more upright, and was oriented in a more normal vertical axis. The contralateral unexpanded condyle did not show deformational changes. In those mandibles that were bilaterally expanded, both condyles increased in size and volume and became more symmetrical and upright. Osteodistraction appears to affect bone in both local and distant sites. The expanded condyles were stimulated to ensure a more nearly normal shape, size, and configuration.

Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus and Palate

The principle objective of presurgical nasoalveolar molding (NAM) is to reduce the severity of the initial cleft deformity. This enables the surgeon and the patient to enjoy the benefits associated with a repair of a cleft deformity that is of minimal severity. Retraction of the premaxilla, presurgical elongation of the columella, correction of the nasal cartilage deformity, alignment of the cleft alveolar segments, increase in the surface area of the nasal mucosal lining, up-righting of the columella, and achieving close approximation of the cleft lip segments at rest result from gentle application of forces through the NAM appliance. Preservation of these presurgical changes is achieved through the coordinated and modified surgical technique of the primary cleft repair.