Faculty Bibliography

BACKGROUND:: Three-dimensional digital animation can enable surgeons to create anatomically accurate, virtual models of normal and pathologic human anatomy. From these models, surgical procedures can be digitally performed, recorded, and distributed as a teaching tool or as a virtual surgical atlas. The idea of a virtual surgical atlas has recently become a part of contemporary surgical teaching. In the field of craniofacial surgery, no such educational tool exists. Presented is the first part of the creation of a virtual atlas of craniofacial surgical procedures: the three-dimensional digital modeling of pathologic deformities commonly treated by craniofacial surgeons. METHODS:: Three-dimensional craniofacial models were constructed using Maya 8.5. A skeletally 'normal' craniofacial skeleton was first produced from a preexisting digital skull using Bolton tracings as a reference. The remaining soft-tissue elements were then added to create an anatomically complete three-dimensional face. The 'normal' model was then deformed in Maya to produce specific craniofacial deformities using computed tomographic scans, cephalograms, and photographs as a reference. One of the craniofacial deformity models was created directly from computed tomographic data. RESULTS:: One model of the normal face and eight pathologic models of craniofacial deformities were created: microgenia, micrognathia, prognathia, temporomandibular joint ankylosis, maxillary hypoplasia, Crouzon syndrome with and without the need for cranial vault expansion, and bicoronal craniosynostosis. CONCLUSIONS:: For the first time, anatomically accurate three-dimensional digital models of craniofacial deformities have been created. The models are the first step in the creation of a virtual surgical atlas of craniofacial procedures

BACKGROUND:: Pediatric temporomandibular joint (TMJ) dysfunction, resulting from either soft tissue or skeletal disorders, may be congenital or acquired. Congenital TMJ disorders are uncommon. Here we review our experience with pediatric TMJ disorders and propose a new classification system. METHOD:: Clinical records, cephalograms, computed tomography, magnetic resonance images, and pathologic specimens of all pediatric patients (< 18 years) with trismus or restricted mandibular excursion from 1976-2008 were reviewed. Cases were stratified according to soft tissue or skeletal pathology; skeletal abnormalities were further characterized as intra- or extra-capsular. RESULTS:: 38 patients, ranging in age from 1 day to 18 years of age at diagnosis, were identified with TMJ disorders. Ten cases (26.3%) were due to soft tissue pathology. The remaining 28 cases (73.7%) were due to skeletal pathology, consisting of 14 congenital and 14 acquired cases (50% each). Acquired skeletal deformities included 12 (85.7%) intracapsular ankyloses and 2 (16.7%) extracapsular ankylosis (extra-articular bone blocks). Congenital skeletal deformities accounted for 5 (35.7%) intracapsular ankyloses and 9 (64.3%) extracapsular ankyloses. CONCLUSION:: On initial survey, the data are consistent with published reports that attribute TMJ dysfunction to acquired pathology (i.e., trauma and infection). However, we observed a significantly higher percentage (50%) of congenital TMJ skeletal disorders than previously reported. Most congenital cases involved extracapsular pathology (i.e., coronoid hypertrophy); only a minority of cases had glenocondylar fibro-osseous fusion (i.e., intracapsular ankyloses). Since the diagnosis and classification of TMJ disorders determines treatment options, we provide a new classification that characterizes the extent of capsular involvement

BACKGROUND:: The purpose of this study was to compare clinical outcomes and 1-year postsurgical stability with three different techniques of Le Fort III midface advancement. METHODS:: The records of 212 syndromic craniosynostosis patients were reviewed from the period 1973 to 2006. A total of 60 patients satisfied the inclusion criteria, and the mean age of the sample at surgery was 6.2 years. In group I (1977 to 1987), fixation was performed by interosseous wiring and intermaxillary fixation; in group II (1987 to 1996), fixation was achieved by only rigid plate fixation; and in group III (2000 to 2005), the patients underwent midface distraction with the rigid external distraction device. Cephalometric landmarks were identified and digitized at each of the time intervals (preoperatively, postoperatively, and 1 year postoperatively). RESULTS:: The mean advancement measured at point A in group I averaged 9.7 mm; in group II, it was 10.6 mm; and in group 3, it was 16.1 mm. There was no statistically significant difference in the amount of advancement between groups I and II. However, when groups I and II were compared with group III, there was a statistically significant difference (p < 0.05). No statistical significance was noted within and between all three groups at 1-year follow-up. CONCLUSIONS:: Significantly larger midface advancement was achieved with rigid external distraction (group III) compared with classic Le Fort III midface advancement with wire (group I) or plate (group III) fixation. At 1 year after surgery, the three groups showed relative stability of the advanced midface segment

BACKGROUND: Patients with Apert, Crouzon, and Pfeiffer syndromes who have severe midfacial hypoplasia are treated by Le Fort III midface advancement. The purpose of this study was to examine long-term (10-year) midface skeletal stability and growth following Le Fort III midface advancement in growing children. METHODS: A review of 192 patients with syndromic craniosynostosis treated by classic (nondistracted) Le Fort III advancement osteotomy between 1973 and 1998 was performed. Twenty-five patients met the inclusion criteria (age at surgery < 11 years and availability of cephalograms of diagnostic quality before treatment, after surgery, and at 1-, 5-, and 10-year follow-up). The mean age at the time of surgery was 5.8 years and the diagnosis was either Crouzon (n = 10), Apert (n = 9), or Pfeiffer (n = 6) syndrome. RESULTS: After surgery, point A advanced sagittally 10.72 mm and moved downward 3.77 mm. At 1 year, point A moved forward 0.10 mm and downward 0.47 mm. At 5 years, point A moved back 0.18 mm, whereas at 10 years it advanced 0.12 mm. During the same periods, however, pogonion came forward 5.72 mm and 7.32 mm, respectively. CONCLUSIONS: Le Fort III midface advancement in growing children with syndromic craniosynostosis is stable after the first year postoperatively. There is minimal horizontal growth of the midface between postoperative years 5 and 10, although the mandible continues to grow. Due to the differential growth rate of the midface and mandible, the facial profile becomes concave, thereby necessitating secondary midface surgery at the completion of skeletal growth

BACKGROUND: Precise control of the position of the midface through distraction with the rigid external distraction (RED) device has been a challenge. The present RED device with wire attachments to the intraoral dental splint and to the skeletal bone plates allows for flexibility in the vertical plane of the osteotomized Le Fort III segment. This tends to rotate the midface in a counterclockwise direction with inferior movement of the posterior nasal spine. OBJECTIVES: To report the development of a rigid distraction splint attachment to the RED device that permits precise control of the position of the midface during the latency period and through the activation and consolidation phases. METHODS: This paper describes the appliance design and the clinical application of a new device in controlling the position of the midface during distraction. Placement of the device and application of the desired force vectors are discussed. Patients treated by this modified device are illustrated to document the planned midface position after Le Fort III midface advancement. RESULTS: Examination of predistraction and postdistraction cephalograms of 2 patients treated with the new device showed advancement with minimum inferior displacement of the midface during all phases of the distraction process. CONCLUSIONS: The new device prevents undesired inferior movement of the posterior midface immediately after osteotomy and helps to stabilize the midface during the latency period. The device enables directional control of the distraction vectors, resulting in more predictable midface position at the end of treatment

Patients born with a craniofacial deformity and their families experience significant psychosocial effect as they deal with physical appearance that has been esthetically and functionally compromised. The deformity usually involves skeletal and soft-tissue elements, which often affect facial symmetry and esthetics. As the dentition is directly related to the jaw structures, a wide variety of malocclusions may result. As patients with craniofacial anomalies present with multiple dental and medical conditions, an interdisciplinary team approach is highly recommended to accurately diagnose and to properly customize a treatment plan. Craniofacial Orthodontics is the area of orthodontics that treats patients with congenital and acquired deformities of the integument and its underlying musculoskeletal system within the craniofacial area and associated structures. As part of the craniofacial and cleft teams, the craniofacial orthodontist is involved in data collection, clinical examination, diagnosis, treatment planning, and orthopedic or orthodontic treatment of the craniofacial disorder. The craniofacial orthodontist has been shown to play an intrinsic role in the care of patients with craniofacial anomalies and cleft lip and palate

Presurgical infant orthopedics has been employed since 1950 as an adjunctive neonatal therapy for the correction of cleft lip and palate. Most of these therapies did not address deformity of the nasal cartilage in unilateral and bilateral cleft lip and palate as well as the deficiency of the columella tissue in infants with bilateral cleft. The nasolaveolar molding (NAM) technique a new approach to presurgical infant orthopedics developed by Grayson reduces the severity of the initial cleft alveolar and nasal deformity. This enables the surgeon and the patient to enjoy the benefits associated with repair of a cleft deformity that is minimal in severity. This paper will discuss the appliance design, clinical management and biomechanical principles of nasolaveolar molding therapy. Long term studies on NAM therapy indicate better lip and nasal form, reduced oronasal fistula and labial deformities, 60 % reduction in the need for secondary alveolar bone grafting. No effect on growth of midface in sagittal and vertical plane has been recorded up to the age of 18 yrs. With proper training and clinical skills NAM has demonstrated tremendous benefit to the cleft patients as well as to the surgeon performing the repair

BACKGROUND: The purpose of this investigation was to determine the response of the osteotomized Le Fort III midface bony segment to variations in the location and direction, or vector, of force application on using the rigid external distraction device. METHODS: This retrospective study involved 18 consecutive syndromic craniosynostotic patients (average age, 5.7 years) who underwent Le Fort III midface advancement distraction. Various cephalometric and novel landmarks, located on the mobilized Le Fort III segment and on the components of the distraction device, were identified before activation and at mid-activation. The direction and magnitude of change for these points were recorded. RESULTS: Based on the observed change in the position of the midface during distraction, the sample was divided into the following groups. In group 1 (n = 5), the Le Fort III segment translated forward and no rotation was noted. In group 2 (n = 3), the Le Fort III segment rotated clockwise and showed downward displacement. In group 3 (n = 6), the Le Fort III segment showed forward displacement and rotated counterclockwise. In group 4 (n = 4), the Le Fort III segment translated forward and downward. CONCLUSIONS: Direction of movement and resultant change in position of the Le Fort III segment during distraction are directly related to the location and direction of force application. Translation forward, with minimal rotation, was achieved when the force was applied at a location 55 percent above the occlusal plane (between the occlusal plane and the nasion) and in a direction parallel to the maxillary occlusal plane

BACKGROUND: Le Fort III distraction osteogenesis improves midface form and dental relationships in patients with syndromic craniosynostosis, but its effect on the upper airway is not well documented. METHODS: A retrospective review was conducted of patients with syndromic craniosynostosis undergoing Le Fort III distraction osteogenesis from 2000 to 2006 (n = 20). Changes in velar angle and nasopharyngeal, velopharyngeal, oropharyngeal, and hypopharyngeal spaces were measured cephalometrically. Three-dimensional airway casts were created from computed tomographic data to ascertain circumferential airspace changes. Patients with the preoperative diagnosis of severe obstructive sleep apnea or a tracheostomy were designated as having significant airway compromise. Cephalometric differences in the preoperative superior airspace were compared between patients with and without significant airway compromise. Improvement in the symptoms of obstructive sleep apnea was studied. RESULTS: Cephalometric analysis revealed an increase in the velar angle (121 degrees to 148 degrees; p < 0.001) and an increase in the nasopharyngeal (3.9 mm to 13.0 mm; p < 0.001) and velopharyngeal airspaces (2.0 mm to 5.9 mm; p < 0.01). Three-dimensional computed tomographic analysis confirmed these findings. Comparison between preoperative cephalograms of patients with (n = 10) and without significant airway compromise (n = 10) revealed smaller nasopharyngeal (2.2 mm versus 5.7 mm; p < 0.05) and velopharyngeal airspaces (0.9 mm versus 3.0 mm; p = 0.05). Nine of 10 patients with significant airway compromise experienced improvement in their symptoms of obstructive sleep apnea or had their tracheostomy removed. CONCLUSIONS: Le Fort III distraction osteogenesis significantly increases nasopharyngeal and velopharyngeal airspaces in patients with syndromic craniosynostosis. Midface distraction improves but does not resolve all causes of obstructive sleep apnea in this patient population

BACKGROUND: Nasoalveolar molding was developed to improve dentoalveolar, septal, and lower lateral cartilage position before cleft lip repair. Previous studies have documented the long-term maintenance of columella length and nasal dome form and projection. The purpose of the present study was to determine the effect of presurgical nasoalveolar molding on long-term unilateral complete cleft nasal symmetry. METHODS: A retrospective review of 25 consecutively presenting nonsyndromic complete unilateral cleft lip-cleft palate patients was conducted. Fifteen patients were treated with presurgical nasoalveolar molding for 3 months before surgical correction, and 10 patients were treated by surgical correction alone. The average age at the time of follow-up was 9 years. Four nasal anthropometric distances and two angular relationships were measured to assess nasal symmetry. RESULTS: All six measurements demonstrated a greater degree of nasal symmetry in nasoalveolar molding patients compared with the patients treated with surgery alone. Five symmetry measurements were significantly more symmetric in the nasoalveolar molding patients and one measurement demonstrated a nonsignificant but greater degree of symmetry compared with the patients treated with surgery alone. CONCLUSIONS: The data demonstrate that the lower lateral and septal cartilages are more symmetric in the nasoalveolar molding patients compared with the surgery-alone patients. Furthermore, the improved symmetry observed in nasoalveolar molding-treated noses during the time of the primary surgery is maintained at 9 years of age