Woo Shik Jeong

Customized Orbital Wall Reconstruction Using Three-Dimensionally Printed Rapid Prototype Model in Patients With Orbital Wall Fracture

Background:It is difficult to restore original orbital contours because of their complex 3-dimensional structure. Moreover, slight implant malpositioning can result in enophthalmos or other complications. The authors describe our experience of using individualized prebent titanium-Medpor mesh implants and stereolithographic modeling in a series of patients who underwent orbital wall reconstruction. Methods:A consecutive series of 104 patients with orbital fractures received computer simulation-designed prebent titanium-Medpor mesh implants insertion. Preoperative computed tomography (CT) data were processed for each patient, and a rapid prototyping (RP) model was produced. The uninjured side was concurrently mirrored and superimposed onto the traumatized side to create a mirror image of the RP model. The authors fabricated the titanium-Medpor implants to intraoperatively reconstruct the 3-dimensional orbital structure. The prefabricated titanium-Medpor implants were inserted into the defective orbital wall and fixed. Postoperative CT images were immediately taken to evaluate the reconstructed contours and compare the preoperative and postoperative intraorbital volumes. Results:All reconstructions were successful without postoperative complications. The implants were correctly positioned in the sagittal, axial, and coronal planes relative to the original orbital contours. The mean preoperative intraorbital volumes of the uninjured and traumatized sides were 21.39 ± 1.93 and 23.17 ± 2.00 cm3, respectively, and the postoperative mean intraorbital volume was 20.74 ± 2.07 cm3. Conclusions:Orbital reconstruction can be optimized using individually manufactured rapid prototype skull model and premolded synthetic scaffold by computer-aid of mirroring-reconstruction of 3-dimensional images and 3-dimensional printing techniques.

Computer Simulation Surgery for Mandibular Reconstruction Using a Fibular Osteotomy Guide

In the present study, a fibular osteotomy guide based on a computer simulation was applied to a patient who had undergone mandibular segmental ostectomy due to oncological complications. This patient was a 68-year-old woman who presented to our department with a biopsy-proven squamous cell carcinoma on her left gingival area. This lesion had destroyed the cortical bony structure, and the patient showed attenuation of her soft tissue along the inferior alveolar nerve, indicating perineural spread of the tumor. Prior to surgery, a three-dimensional computed tomography scan of the facial and fibular bones was performed. We then created a virtual computer simulation of the mandibular segmental defect through which we segmented the fibular to reconstruct the proper angulation in the original mandible. Approximately 2-cm segments were created on the basis of this simulation and applied to the virtually simulated mandibular segmental defect. Thus, we obtained a virtual model of the ideal mandibular reconstruction for this patient with a fibular free flap. We could then use this computer simulation for the subsequent surgery and minimize the bony gaps between the multiple fibular bony segments.

Appropriate and Effective Dosage of Bmp-2 for the Ideal Regeneration of Calvarial Bone Defects in Beagles.

BACKGROUND Although bone morphogenetic protein-2 (BMP-2) is a potent growth factor, the appropriate and effective dosages for ideal bone formation according to defect size and type remain to be established. This study was designed to measure the effects of BMP-2 on calvarial defects in the beagle dog, by means of three-dimensional computed tomographic imaging. METHODS Eight beagles of equal age and weight were divided into one control and three experimental groups. After creating four circular 20-mm diameter defects, a BMP-2/tricalcium phosphate scaffolding mixture with concentrations of BMP-2 was introduced. The defect filling response was assessed until 16 weeks by three-dimensional computed tomograpy for the thickness, area, and density of the regenerating bone. RESULTS Statistically significant responses to BMP-2 were observed. The mean thicknesses of the regenerated bone were 1.6 mm for the control group and 1.6, 2.1, and 2.8 mm for 10, 50, and 200 µg/ml, respectively. As the original mean thickness of the calvarial bone in the beagles was 2.0 mm, a 50-µg quantity of BMP-2 proved to be ideal for 2-cm calvarial defects. The original surface area of the defect created was 314 mm. The mean surface areas of the regenerated bone were 181.94 mm for the control group, and 237, 276, and 288 mm for 10, 50, and 200 µg/ml. CONCLUSIONS BMP-2 promotes anatomically significant bone regeneration in critical-size cranial defects in this model, with an optimal dose-response at 50 µg/ml and without hyperosteogenesis or hypo-osteogenesis.

Premaxillary Repositioning in the Severe Form of Bilateral Cleft Lip and Palate.

AbstractSevere forms of bilateral cleft lip and palate remain a challenging issue. Although nasoalveolar molding dramatically improves overall treatment success, the position of the premaxilla often remains dislocated. The authors attempted to relocate the malpositioned premaxilla into the correct position to obtain the correct three-dimensional (3D) maxillary arch structure and growth. Eight patients with severe bilateral cleft lip and palate were treated with premaxillary osteotomy for premaxilla repositioning. The position of the premaxilla was measured directly using cephalometry. Two raters including orthodontists evaluated the 3D (anteroposterior, transverse, and sagittal) outcomes. Regarding the long-term effects of premaxillary repositioning on midfacial growth, 3D computed tomography scan data were used, including the measurement of the SNA, SNB, and ANB angles according to the time period (T0: preoperative; T1: immediate postoperative; T2: long-term postoperative). All bilateral cleft lips and palates were satisfactorily repaired without any complications, including any premaxillary vascular compromise, nonunion, and occlusal instability. The average visual analog scale scores (0–5) of the anteroposterior, vertical, and transverse dimensions were 3.9, 3.7, and 3.2, respectively. Regarding the effect of premaxillary repositioning on midfacial hypoplasia, the change in the ANB between T1 and T2 was not significant, implying that premaxillary repositioning did not affect the long-term harmony between the maxilla and mandible (ANB of T2–T1: P = 0.1016) based on interim growth data at the time of follow-up and study completion. Premaxillary repositioning effectively corrected the malpositioned premaxilla and repaired the accompanying wide alveolar cleft, achieving successful restoration of maxillary arch coordination. In addition, premaxillary osteotomy after 8 years of age does not seem to cause significant maxillary retrusion.

Effect of Preoperative Nasal Retainer on Nasal Growth in Patients with Bilateral Incomplete Cleft Lip: A 3-Year Follow-Up Study

Background The purpose of this study was to evaluate changes in nasal growth after the implementation of a preoperative nasal retainer in patients with bilateral incomplete cleft lip. Methods Twenty-six infants with bilateral incomplete cleft lip and cleft palate were included in the study. A preoperative nasal retainer was applied in 5 patients from the time of birth to 2.6–3.5 months before primary cheiloplasty. Twenty-one patients who were treated without a preoperative nasal retainer were placed in the control group. Standard frontal, basal, and lateral view photographs were taken 3 weeks before cheiloplasty, immediately after cheiloplasty, and at the 1- and 3-year postoperative follow-up visits. The columella and nasal growth ratio and nasolabial angle were indirectly measured using photographic anthropometry. Results The ratio of columella length to nasal tip protrusion significantly increased after the implementation of a preoperative nasal retainer compared to the control group for up to 3 years postoperatively (P<0.01 for all time points). The ratios of nasal width to facial width, nasal width to intercanthal distance, columellar width to nasal width, and the nasolabial angle, for the two groups were not significantly different at any time point. Conclusions Implementation of a preoperative nasal retainer provided significant advantages for achieving columellar elongation for up to 3 years postoperatively. It is a simple, reasonable option for correcting nostril shape, preventing deformities, and guiding development of facial structures.

Long-Term Outcomes of One-Piece Frontoorbital Advancement with Distraction but without Bandeau for Coronal Craniosynostosis.

INTRODUCTION: Traditional frontoorbital advancement with a supraorbital bar is the standard technique for correcting coronal craniosynostosis. However, several reports indicate that cranioplasty using distraction osteogenesis can be an alternative. To maximize the advantages of distraction, preservation of the dura attachment to the frontal bone appears to be important. Therefore, we designed a novel procedure for coronal craniosynostosis involving a one-piece frontoorbital advancement with distraction but without a supraorbital bar using only a small temporal burr hole.

Comparison of Facial Proportions Between Beauty Pageant Contestants and Ordinary Young Women of Korean Ethnicity: A Three-Dimensional Photogrammetric Analysis

BackgroundAlthough the harmony of facial proportions is traditionally perceived as an important element of facial attractiveness, there have been few objective studies that have investigated this esthetic balance using three-dimensional photogrammetric analysis.ObjectivesTo better understand why some women appear more beautiful, we investigated differences in facial proportions between beauty pageant contestants and ordinary young women of Korean ethnicity using three-dimensional (3D) photogrammetric analyses.MethodsA total of 43 prize-winning beauty pageant contestants (group I) and 48 ordinary young women (group II) of Korean ethnicity were photographed using 3D photography. Numerous soft tissue landmarks were identified, and 3D photogrammetric analyses were performed to evaluate 13 absolute lengths, 5 angles, 3 volumetric proportions, and 12 length proportions between soft tissue landmarks.ResultsGroup I had a greater absolute length of the middle face, nose height, and eye height and width; a smaller absolute length of the lower face, intercanthal width, and nasal width; a larger nasolabial angle; a greater proportion of the upper and middle facial volume, nasal height, and eye height and width; and a lower proportion of the lower facial volume, lower face height, intercanthal width, nasal width, and mouth width. All these differences were statistically significant.ConclusionsThese results indicate that there are significant differences between the faces of beauty pageant contestants and ordinary young women, and help elucidate which factors contribute to facial beauty. The group I mean values could be used as reference values for attractive facial profiles.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Patient-specific puzzle implant preformed with 3D-printed rapid prototype model for combined orbital floor and medial wall fracture

BACKGROUND The management of combined orbital floor and medial wall fractures involving the inferomedial strut is challenging due to absence of stable cornerstone. In this article, we proposed surgical strategies using customized 3D puzzle implant preformed with Rapid Prototype (RP) skull model. METHODS Retrospective review was done in 28 patients diagnosed with combined orbital floor and medial wall fracture. Using preoperative CT scans, original and mirror-imaged RP skull models for each patient were prepared and sterilized. In all patients, porous polyethylene-coated titanium mesh was premolded onto RP skull model in two ways; Customized 3D jigsaw puzzle technique was used in 15 patients with comminuted inferomedial strut, whereas individual 3D implant technique was used in each fracture for 13 patients with intact inferomedial strut. Outcomes including enophthalmos, visual acuity, and presence of diplopia were assessed and orbital volume was measured using OsiriX software preoperatively and postoperatively. RESULTS Satisfactory results were achieved in both groups in terms of clinical improvements. Of 10 patients with preoperative diplopia, 9 improved in 6 months, except one with persistent symptom who underwent extraocular muscle rupture. 18 patients who had moderate to severe enophthalmos preoperatively improved, and one remained with mild degree. Orbital volume ratio, defined as volumetric ratio between affected and control orbit, decreased from 127.6% to 99.79% (p < 0.05) in comminuted group, and that in intact group decreased from 117.03% to 101.3% (p < 0.05). CONCLUSION Our surgical strategies using the jigsaw puzzle and individual reconstruction technique provide accurate restoration of combined orbital floor and medial wall fractures.

Medial Femoral Condyle Free Flap for Premaxillary Reconstruction in Median Facial Dysplasia.

Objective: Median facial dysplasia is a distinct development anomaly of the craniofacial region that is characterized by deficient mid facial structures. Medial femoral condyle free flap could be used as a bony flap, and the unique characteristics of this flap provide the surgeons with the periosteal component as well. In this work, the authors present our experience with a patient of median facial dysplasia with unilateral cleft lip, cleft palate, and premaxillary deficiency. Methods: The patient was diagnosed with median facial dysplasia accompanied by unilateral cleft lip, cleft palate, and premaxillary. She had presented with severe midface hypoplasia with missing premaxillary bone. Premaxillary reconstruction was performed with the use of medial femoral condyle free flap. Results: Medial femoral condyle free flap was successfully used for premaxillary reconstruction. The flap fitted well to the alveolar bony gap. Since the flap is a periosteal bone flap, the gingival mucosa was reconstructed very well. The lip harmony was considerably restored compared with the preoperative status. Conclusions: Although several other options are available, the medial femoral condyle free flap is particularly suited for the reconstruction of median facial dysplasia.

The Efficacy of Cyclic Injection of Bone Morphogenetic Protein-2 in Large-Scale Calvarial Bone Defects

Abstract Bone morphogenetic protein-2 (BMP-2) appears to be one of the most potent growth factors thus far studied. However, recent publications on the clinical application of BMP-2 revealed that its correct control is the paramount issue in clinical practice. For improving BMP-2 delivery, the cyclic administration might be an alternative. Accordingly, the authors cyclically injected BMP-2 in a cyclic injection model of large cranial defects to maintain the proper dosage during the bone healing process. A 10-mm diameter calvarial bone defect was produced using a round drill in 8-week-old Sprague-Dawley rats. Silk-hydroxyapatite scaffolds soaked in the appropriate concentration of BMP-2 were implanted into the defect. The animals were split into 4 single-injection groups and 3 multiple-injection groups; the latter groups received weekly subcutaneous injections of BMP-2 solution (1, 5, and 10 &mgr;g/mL) for 4 weeks, whereas the former groups received a single injection of BMP-2 at these concentrations. Each rat underwent computed tomography at 8 weeks. In terms of total volumes of the new bone, the 5 &mgr;g/mL multiple-injection BMP-2 group had significantly greater increases in bone volume than the single-injection groups. In terms of bone thickness, the multiple-injection groups had better outcomes than the single-injection groups. Thus, the cyclic injection protocol restored the original thickness without overgrowth. Cyclic injection of BMP-2 permits more accurate dosage control than single injection and improves thickness and dense bone regeneration. Therefore, it may represent a promising approach for future clinical trials. Further investigation using a greater number of animals is required.