Does functional appliance treatment truly improve stability of mandibular vertical distraction osteogenesis in hemifacial microsomia?

doi:10.1016/j.jcms.2008.03.002

Journal of Cranio-Maxillofacial Surgery

Volume 36, Issue 7, October 2008, Pages 384-389

https://doi.org/10.1016/j.jcms.2008.03.002 Get rights and content

Summary

Aim

After mandibular unilateral distraction osteogenesis (DO) a gradual reappearance of the vertical asymmetry during growth is observed. A pre- and post-surgical functional-orthodontic treatment was added to our distraction protocol in the attempt to increase long-term stability. In order to evaluate the actual efficacy of such a combined treatment, two samples of children affected by hemifacial microsomia were compared long-term.

Material

Ten children were treated by a combined orthodontic–distraction treatment, seven by distraction only.

Method

Only the vertical changes in the mandible and maxilla in the panoramic and postero-anterior cephalometric X-rays were measured.

Results

All of the patients showed a gradual return of the asymmetry with growth. Occlusal plane correction and, to a much lesser extent, mandibular vertical ramus height correction were better maintained over 5 years post-DO in the orthopaedic group.

Conclusion

Although orthopaedic treatment allows for a more stable occlusal plane and for a slower return of the mandibular vertical asymmetry, it has mainly a dento-alveolar effect. Therefore, the decision of applying an orthopaedic treatment associated with distraction, should be taken by surgeon and orthodontist together, considering both the advantages and the disadvantages of this treatment.

Introduction

Although some authors suggest that distraction osteogenesis (DO) applied to growing patients affected by hemifacial microsomia (HFM) is a relatively stable procedure (Molina and Ortiz Monasterio,, Shetye et al., 2006), a commonly reported problem during subsequent growth, is a gradual recurrence of the asymmetry, particularly of the vertical asymmetry (Hollier et al., 1999, Mommaerts and Nagy, 2002, Meazzini et al., 2005).

Many authors suggest that the addition of an orthodontic treatment or an orthopaedic plate will significantly improve the stability of the results (Tehranchi and Behnia, 2000, Takashima et al., 2003, Shetye et al., 2006), but no case–control studies are available in the literature to prove this suggestion.

The purpose of this study was to verify the long-term advantage of the addition of orthopaedic treatment to DO.

Section snippets

Materials and methods

Two samples were compared. One sample comprised 10 patients affected by unilateral HFM consecutively treated with unilateral distraction and orthopaedic preparation, the other sample comprised seven patients who underwent distraction only. The age of the patients in the orthopaedic sample at the time of distraction was 5.4 ± 0.8 years, the age of the non-orthopaedic sample was 5.9 ± 1.1 years. Only patients with a condyle and ramus (type I and II Pruzansky) were included in the study, given that

Maxillary asymmetry

Differences in the angular inclination of the occlusal plane to the reference plane from the initial records to the post-distraction records and to the 5-year post-operative records for the orthopaedic and non-orthopaedic groups are summarized in Table 1. While the non-orthopaedic group at 5 years post-DO shows an inclination which has returned to the same value as the pre-DO records, the orthopaedic group still shows an average preservation of the correction of over 50% of angular improvement (

Discussion

Although the samples are not large, this is the only case–control study attempting to verify the actual effect of orthodontic functional treatment on the long-term stability of DO in growing HFM patients. The application of DO to growing HFM patients started in the early 1990s and it was “speculated that gradual expansion of the mandible performed at an early age, could result in expansion of the muscles”, “and motor nerves”, “and an improvement in neuromuscular function”, “and attendant growth

Conclusion

Orthopaedic treatment associated with DO allows for a delay in the recurrence of the occlusal cant and, to a much lesser extent, of the mandibular vertical asymmetry in HFM patients after DO. On the other hand, it has two drawbacks. First, it only delays the return to the original disproportion, but does not interrupt this natural process. Second, functional treatment decreases the relative height of the mandibular body on the affected side, making final surgical planning slightly more complex.

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Cited by (24)

Dental and maxillofacial features of condylo-mandibular dysplasia: A case series of 21 patients
2020, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
There have been very few reports to date of condylo-mandibular dysplasia in the literature. As highlighted by Meazzini et al. (Meazzini et al., 2008a, b), a casual example of condylo-mandibular dysplasia was published in the form of ‘misdiagnosed’ hemifacial microsomia, characterized by successful orthodontic treatment despite substantial condyle deformities (Figueroa et al., 1984; Kaplan et al., 1989; Melsen et al., 1986; Sidiropoulou et al., 2003; Silvestri et al., 1996; Kahl-Nieke and Fischbach, 1998). The main differences between condylo-mandibular dysplasia and craniofacial microsomia are the permanent absence of soft-tissue involvement and a normal appearance of the ears (Meazzini et al., 2011).
Camel-hump condylo-mandibular dysplasia is a specific form of condyle dysostosis, first described by Delaire. The aim of this study was to describe the clinical and radiographic phenotype of the disease, and to discuss therapeutic options.
Twenty-one patients were analyzed retrospectively. They exhibited the same unilateral facial asymmetry, which was of mandibular origin, with an elevated commissural line and occlusal cant, and a deviated chin on the side of the deformity. The soft tissues and the ears were always normal in terms of their physical appearance. Radiographic analysis generally revealed a short, curved, and anteriorly displaced condyle, with a high and sharp coronoid process. CT scans revealed that the glenoid fossa was empty. Twelve patients exhibited dental abnormalities, consisting mainly of dental inclusions affecting the lower first and/or second molars (10 patients). A good response to functional orthodontic treatment was achieved in eight patients, while 13 patients required a surgical mandibular lengthening procedure.
Condylo-mandibular dysplasia is a congenital condyle deformity that needs to be recognized and differentiated from craniofacial microsomia in order to be able to provide patient-specific treatments.
Structural comparison of hemifacial microsomia mandible in different age groups by three-dimensional skeletal unit analysis
2018, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
However, supporters of delayed treatment prefer to take advantage of the growth potential of HFM and to avoid growth impairment due to early intervention (Polley et al., 1997; Nagy et al., 2009). Long-term studies after distraction osteogenesis reported limited vertical bone growth, reduced growth ratio of the affected side, or relapse (Marquez et al., 2000; Huisinga-Fischer et al., 2003; Meazzini et al., 2005, 2008). The main treatment goal for HFM needs to focus on the restoration of normal function and structure as well as the induction of normal growth.
The goal of this study was to understand the three-dimensional (3D) structural characteristics of hemifacial microsomia (HFM) mandible in terms of skeletal units, especially to locate the underdeveloped skeletal regions for treatment. Another goal was to compare the HFM structure of different age groups to understand growth potential relevant to treatment scheduling.
We reconstructed 3D mandibles from computed tomographic images of French and Korean patients with HFM (N = 28; group II) and normal subjects (N = 27; group I). Each mandible was classified by Pruzansky's HFM types I, II and III, and by age group (child, adolescent, and adult). The mandible was divided into skeletal units, and geometrical representation by skeletal unit line was performed, including the condylar, body, coronoid, and angular units. Their length and angulations were measured and statistically analyzed.
The results showed that the affected condylar unit in type II HFM and the condylar/coronoid unit in type III were smaller in young age groups than were other units. The angulation between the skeletal units in type II, though not type III, tended toward normalcy with age, but not to the normal degree of angulations in group I.
Our study shows the major involvement of condylar unit and minor involvement of body unit for HFM, improving with age in type II. The mandibular skeletal unit analysis seems to be a useful tool for individualized diagnosis, allowing identification of the major etiopathogenic area and treatment planning, including a simulation to set up a regimen for successful reconstruction of HFM.
Comprehensive consideration and design with the virtual surgical planning-assisted treatment for hemifacial microsomia in adult patients
2018, Journal of Cranio-Maxillofacial Surgery
Hemifacial microsomia (HFM) is a frequently encountered congenital malformation syndrome involving both hard and soft tissue. Various surgical methods have been described to correct the deformities of HFM in the literature. This study aims to evaluate the therapeutic efficacy for HFM with the assistance of virtual surgical planning (VSP) and 3-dimensionally printed surgical templates.
From January 2010 to January 2016, a total of 46 patients were referred to the study. Different surgical procedures under the guidance of VSP and 3-dimensionally printed surgical templates combined with orthodontic treatment were used to correct the deformities. Clinical outcomes were evaluated by comparing the differences of affected-side ramus height, occlusal cant degrees and chin point deviation between the preoperative VSP and postoperative surgical results.
Satisfactory facial contour and occlusion were achieved with the combination of orthognathic and orthodontic treatment. Postoperative examination results showed that VSP was accurately transferred into actual surgery. The difference between the preoperative design and the postoperative outcome was not statistically significant.
VSP and 3-dimensionally printed surgical templates serve as a reliable method and show great value in improving the accuracy and efficacy of surgical treatment of HFM.
Surgical Correction of Maxillofacial Skeletal Deformities
2017, Journal of Oral and Maxillofacial Surgery
Three-dimensional virtual-surgery simulation-assisted asymmetric bilateral mandibular distraction osteogenesis for a patient with bilateral condylar fractures
2017, American Journal of Orthodontics and Dentofacial Orthopedics
Citation Excerpt :
The vertical growth of the maxilla on the affected side would be coupled with the correction of the transverse cant of occlusal plane (Figs 14 and 15).16 Although the transverse cant correction of the occlusal plane was reported to be more stable than that of other planes such as the biantegonial plane and bijugal plane, some postdistraction osteogenesis relapse was reported in hemifacial microsomia patients.17 However, our patient's corrected occlusal plane was well maintained and even slightly improved during the retention period (Table II).
Our objective was to report a patient treated with 3-dimensional virtual-surgery simulation-assisted asymmetric bilateral mandibular distraction osteogenesis.
A boy (age, 9.5 years) had mandibular hypoplasia and facial asymmetry, induced by bilateral condylar fractures at 4 years of age. The asymmetric bilateral mandibular distraction osteogenesis was planned to correct facial asymmetry and mandibular hypoplasia. The 3-dimensional virtual-surgery simulation results were 11 mm of horizontal distraction on the right side and 4.5 mm of horizontal and 18 mm of vertical distraction on the left side of the mandible. Bilateral ramus osteotomies were performed, and intraoral unidirectional distraction devices were inserted. After a 6-day latency period, distraction was performed at 1 mm per day, followed by a 5-month consolidation period. Transarch and interarch elastics and an acrylic plate were used during distraction and consolidation. Total treatment time was 30 months.
Satisfactory outcomes were obtained (achievement ratios between postconsolidation results and simulated results: gonial angle, 106% and 103.9%; mandibular body length, 94.2% and 89.9%; ramus height, 104.1% and 94.5% [values of the right and left sides, respectively]). The chin-point deviation and the transverse cant of the maxillary occlusal plane were significantly improved (10.1 mm to 3.3 mm; −6.8° to −4.4°). At 53 months of follow-up, the Class I molar relationship was well maintained. The transverse cant of the maxillary occlusal plane was slightly improved to −3.7° during pubertal growth.
Three-dimensional virtual-surgery simulation can help clinicians to determine the optimal vector and amount of distraction with high accuracy in complex cases requiring simultaneous correction of a hypoplastic mandible and facial asymmetry.
Craniofacial Microsomia
2016, Facial Plastic Surgery Clinics of North America

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Does functional appliance treatment truly improve stability of mandibular vertical distraction osteogenesis in hemifacial microsomia?

Summary

Aim

Material

Method

Results

Conclusion

Introduction

Section snippets

Materials and methods

Maxillary asymmetry

Discussion

Conclusion

Am J Orthod Dentofacial Orthop

Am J Orthod Dentofacial Orthop

Am J Orthod Dentofacial Orthop

J Craniomaxillofac Surg

J Craniomaxillofac Surg

Am J Orthod

Serial observation of asymmetry in the growing face

Br J Orthod

New treatment principles for mandibular malformations

Mandibular growth after distraction in patients under 48 months of age

Plast Reconstr Surg

Surgical correction of hemifacial microsomia in the growing child

Plast Reconstr Surg