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Maxillary hypoplasia that necessitates surgical advancement affects approximately 25% of patients born with cleft lip and palate. Syndromic conditions such as Crouzon may also be accompanied by significant maxillary hypoplasia. Severe maxillary hypoplasia can result in airway obstruction, malocclusion, proptosis, and facial disfigurement. For optim...
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Context 1
... disruption of normal tooth eruption patterns has been noted to date in patients who have undergone distraction. All of the patients have been followed for !1 year. Obstructive apnea symp- toms and facial appearance improved in all of the patients. All of them went from concave midfacial patterns to more normal convex patterns (Fig. ...
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Objectives
The objective of this study is to analyze the hard and soft-tissue profile changes as well as the upper airway changes after distraction osteogenesis (DO) using rigid external distraction device in adult cleft lip and palate (CLP) patients. The study also evaluates the stability of the surgical result.
Materials and Methods
Three latera...
Introduction: Patients with cleft lip and palate usually present with maxillary hypoplasia. Upper jaw intraoral distraction osteogenesis (DO) is an alternative technique for patients with severe maxillary hypoplasia. An evaluation was made of the changes produced in hard and soft tissues and their stability over time. Material and methods: Six pati...
The management of the palatal cleft, dental arch, and subsequent maxillary form is a challenge for the craniomaxillofacial surgeon. The purpose of this paper is to present the experience of a senior surgeon (KES) who has treated over 2000 patients with cleft lip and palate. This paper focuses on the experience of a recent series of 103 consecutive...
Citations
... Studies have shown that the traditional consolidation phase duration of 8 weeks or longer can be shortened without compromising stability. 35,36 Though these devices have served the specialty well, there is still a need to develop an appliance system that would carry out automated and continuous distraction. It is not uncommon to find that many patients could not adhere to the distraction protocol -intentionally, due to the pain or discomfort associated with activation, or unintentionally, when they failed to comprehend or remember the distraction protocol. ...
... The bipartition monobloc advancement using vertical osteotomy in the midline to pull the central face gives effective correction in midface concavity. 36 Greater soft-tissue resistance laterally as compared to the center of the face during advancement results in a more convex shape of the sagittal facial profile. The separation of the zygoma after Le Fort III osteotomy at the zygomaticomaxillary suture also aids in differential advancement and the repositioning of the midface in the desired position relative to the corneal surface. ...
The techniques and procedures involved in craniofacial distraction are constantly evolving. The understanding of histological and biochemical response at the distraction site is now improved. The cascade of events in distraction osteogenesis (DO) differs significantly from the typical fracture healing, and a better knowledge about these events has helped us identify suitable candidates for DO, make appropriate modifications to the distraction protocols and minimize the risk of complications. Recent advances in the manufacturing techniques have also facilitated the availability of distractors of various shapes and designs, which are now changing the way different craniofacial defects are being treated. Small but rigid intraoral distractors now enable easy placement, are well tolerated by patients and allow for a long consolidation period. The introduction of newer approaches toward treatment, together with the simultaneous management of different craniofacial defects at multiple osteotomy sites and enhanced surgical accuracy with the help of digital imaging, have made treatment outcomes more predictable.
... In their description of an intraoral device, Burstein et al. again discuss two potential downsides of internal devices: the limited amount of distraction compared to external devices and the potential for traditional orthognathic surgery at skeletal maturity due to lack of vector correction (Burstein et al., 2015). The same is true for the cohort of Nakajima et al. who showed successful application of an internal device but reported the problem of frontal open bites at the end of the distraction period (Nakajima et al., 2012) (Satoh et al., 2006). ...
Introduction: Le Fort III distraction osteogenesis with a rigid external distraction device is a powerful procedure to correct both exorbitism and impaired airways in faciocraniosynostosis. The aim of this study was to investigate treatment effect, perioperative parameters and volumetric outcomes after Le Fort III distraction osteogenesis in patients with Crouzon syndrome in a retrospective study design and to explore potential strengths and weaknesses of this procedure. Materials and methods: From June 2013 to February 2015, a total of nine children with Crouzon syndrome underwent Le Fort III distraction osteogenesis with a rigid external distraction device (RED device, KLS Martin, Tuttlingen, Germany). Along with perioperative parameters, sleep study reports, traditional cephalometric analysis, three-dimensional imaging and photographs were evaluated for severity of disease and therapeutic effect and structural and functional changes of the upper airway preoperatively, after device removal and one year postoperatively. Results: Surgery for Le Fort III distraction was performed at a median age of 12.5 years (SD 2.5 months) with an average weight of 43.0 kg (SD 12.9 kg). Mean estimated blood loss was 535.7 ml (SD 128.1 ml), not requiring any red blood cell transfusions. Mean duration of surgery was 240 min (SD 30.6min), average hospital stay eight days (SD 0.5 days) with a planned median ICU stay of 1.7 days (SD 0.4 days) for all patients. There were a total of five minor complications. Exorbitism and Angle class III malocclusions were corrected in all patients. No patient showed velopharyngeal problems postoperatively. The average amount of distraction was 18.4 mm (14–26 mm). Average length of the distraction period was 18.3 days (SD 0.4 days), with a total distraction plus consolidation time of three months (SD 0.25 months). In two patients, vector correction was performed during distraction. A counterclockwise movement despite vector correction, clinically resulting in an open bite, was observed in one of these two patients. Eight of the nine patients showed a frontal overbite at the end of the distraction period. Cephalometric analysis revealed a significant increase of Sella-Nasion-Point A angle (SNA) from 76.0° (+/− 2.9; T1) to 86.0° (+/− 3.4; T2) (p = 0.006) and growth-related point A-Nasion-point B angle (ANB) from −4.8° (+/−3.7) to 5.7° (+/−4.8) (p = 0.001) from preoperatively to device removal and stable results one year postoperatively. Upper airway structure and respiratory function were improved clinically after the Le Fort III DO treatment in all cases with an average posterior airway space increase from 3199 mm³ (+/− 229.6 mm³) to 8917,7 ml (+/−415.1 mm³) (T1 to T2). Surgical outcome was judged good to excellent both by patients and families and the craniofacial team. Conclusion: Le Fort III DO with a rigid external distraction device in patients with Crouzon syndrome is a powerful and reliable surgical procedure that reliably produces a more significant change of appearance than most other single procedures routinely performed by craniofacial surgeons. It effectively treated sleep apnea in the affected patients. In our collective, the maxilla remained stable after advancement without any relapse, but there was no subsequent anterior growth on one year follow-up. Careful vector planning was able to avoid frontal open bite in eight patients. Complication rates were acceptably low and patients’ functional and esthetic outcome was high.
... The external frame device is also known to be more effective in severe cases of retrusion needing greater anterior movement of the maxilla. Finally, there is an added advantage of removing the frame without requiring a second surgery (Nout et al., 2006;Burstein et al., 2015). ...
Background::
Maxillary advancement with a rigid external distractor (RED) II is a commonly performed procedure for correcting midface hypoplasia. While there are various methods of anchoring the osteotomized maxillary segment to the halo device, the looped transpyriform wire is the simplest and most cost-effective. However, a common complication with this is the cutting through of the stainless steel traction wire across the pyriform buttress during distraction. The patient with cleft undergoing midface distraction is particularly vulnerable since the force needed for distraction is higher due to scarring from previous operations.
Innovation and design::
A single-hole titanium plate is introduced as an interface between the bone of the pyriform buttress and the looped stainless steel traction wire attached to the external frame device.
Evaluation::
Twenty-four patients with cleft who underwent midface advancement using the external frame distractor before the introduction of the innovation were compared with 26 patients who underwent the same procedure after its introduction. The former group had 12.5% complication in the form of cut through of the traction wire, while the latter group had only 3.8% complication rate.
Conclusion::
Introduction of the titanium eyelet as an interface between the traction wire and the bone is a simple technical addition for a more reliable distraction using the RED II device in patients with cleft even in the presence of extensive scarring.
... In 1997, some authors proposed the use of the rigid external distraction device I (RED I) [4][5][6] in order to overcome these shortcomings. The device was anchored to the skull and the denture in order to distract facial bones. ...
... They also allow modification and better control of the distraction vector. [6,15,16] When an extraoral device is used, further surgery is not needed to remove the distractor. [6,17] This study aimed to overcome some of these limitations by modifying the method by which facial bones are anchored to an extraoral distraction device, specifically RED II. ...
... [6,15,16] When an extraoral device is used, further surgery is not needed to remove the distractor. [6,17] This study aimed to overcome some of these limitations by modifying the method by which facial bones are anchored to an extraoral distraction device, specifically RED II. Several authors [1,5,10,11] describe one of the limitations being the need for teeth to be used as anchorage. ...
Aim: Maxillofacial surgery has always aimed to find alternative therapies to treat severe maxillary hypoplasia. Distraction osteogenesis of the midface has become the technique with the best functional and aesthetic results. Nevertheless, anchoring a distractor to the middle third of the face continues to involve complex planning. Plus, achieving the desired force vector can sometimes be cumbersome and uncomfortable. The aim of this study is to propose a novel skeletal anchorage technique for the rigid external distractor.
Methods: Non-controlled, prospective study of 9 patients with severe midface hypoplasia who were treated with distraction osteogenesis using a rigid external distractor anchored to the infraorbital rims and the bilateral pyriform apertures. The activation phase started the first postoperative day at a rate of 1 mm per day. The consolidation period lasted 6 to 8 weeks.
Results: Eight patients achieved the desired distraction objective (24.5 mm on average), with only 1 suffering a 5-mm relapse. None of the patients reported complications.
Conclusion: Distraction osteogenesis of the midface by skeletal anchorage is an alternative method when treating patients with severe maxillary hypoplasia. It has significant advantages compared to traditional anchoring because it simplifies the procedure, diminishes the costs and complications.
La corrección quirúrgica de grandes asimetrías faciales son un desafío para el equipo quirúrgico. En dichos casos, los resultados de la corrección utilizando técnicas quirúrgicas convencionales son limitados, lo que hace necesario la utilización de otras herramientas terapéuticas. La distracción ósea (DO) es una de ellas, pues permite el estiramiento controlado del callo óseo previamente creado mediante osteotomías. La DO permite realizar cambios en el posicionamiento óseo de gran envergadura, favoreciendo el crecimiento óseo como mecanismo de acción. El objetivo de este artículo es describir los resultados quirúrgicos de DO intraoral del tercio medio facial utilizado en dos pacientes con severas asimetrías faciales asociadas a malformaciones de origen genético. Se relata el diagnóstico, la planificación, las herramientas tecnológicas utilizadas, técnica quirúrgica y los resultados obtenidos.
Background:
The choice between internal versus external distraction osteogenesis for midface advancement in patients with syndromic craniosynostosis is primarily based on surgeon preference and expertise. However, differences in outcomes between the two techniques have been sparingly compared. In this work, we performed a systematic review to compare outcomes between internal versus external midface distraction.
Methods:
A systematic review was performed of studies published between 1998 and 2018 (61 studies included, n=689 patients). Operative characteristics, early reoperations, complications, and relapse rates were extracted. Bias evaluation was performed using the Newcastle-Ottawa instrument. Statistical analyses were performed with independent samples t tests and linear regression analyses (p<0.05 considered significant).
Results:
We found that external distraction was associated with more Le Fort III osteotomies and hardware adjustments (p=0.023), whereas internal distraction was associated with more monobloc osteotomies and longer consolidation times (p=0.008). No significant differences in the distance of midface advancement, reoperations, complications, or relapse rates were noted between internal versus external distraction, although external distraction trended towards a slightly higher relapse rate. Regardless of distraction protocol, consolidation time was found to be a strong negative predictor for relapse (beta=-0.792, p=0.02).
Conclusions:
Internal and external distraction for midface advancement do not demonstrate significant differences in advancement distance, reoperative rates, complication rates, or relapse rates. Regardless of distraction type, consolidation time was strongly inversely associated with relapse rates. The trend towards higher relapse in external distraction is potentially explained by the significantly lower consolidation times.
Osteotomies of the Le Fort II and Le Fort III were initially developed for the reconstruction of facial trauma [1]. Along with technical advances in anesthesia and surgical access and the development of new fixation techniques, it is possible to move the midface in almost any desired direction and fix it with long-term stability [2, 3]. Virtual planning, 3D navigation is helpful as an intraoperative guiding system. Intraoperative navigation was first used in neurosurgery and has been applied to various other specialties including trauma reconstruction, head and neck, orthopedic and vascular surgery [4]. Precise and correct placement of the osteotomies is crucial for success and minimizing collateral damage. With regard to surgery, with the exception of the optic nerve and the cone (apex) of the orbit movement of all else is possible. Moreover, the midface either in segments or en bloc can then be stabilized with bone grafts and internal fixation.
Background:
Both internal and external distraction devices have been used successfully in correcting midface hypoplasia. Although the indication for surgery and the osteotomy techniques may be similar, deciding when to use internal versus external devices has not been studied. The authors studied patient-reported outcomes with FACE-Q and functional surveys for internal and external devices for midface distraction patients.
Methods:
Patients who underwent distraction advancement after Le Fort I and Le Fort III were surveyed using the FACE-Q survey and a functional survey. Equal groups of internal and external device patients were compared (n = 64). Data recorded included: sex, age, follow-up, diagnosis, operating room time, expected blood loss, length of stay, distraction length, consolidation time, and complications.
Results:
Internal and external device groups were similar with regards to patient diagnosis, operative time, expected blood loss, distraction length but consolidation times differed (internal = 3.6 versus external = 1.1 months). For FACE-Q appearance appraisal, there were similarities in domain and scale. For the functional survey (airway/breathing, ocular/vision, occlusion/eating, speech/articulation), there was also similar scoring. However, internal device patients had superior FACE-Q scores for Quality of Life: Social Function (80.9 versus 68.9), Early Life Impact (92.9 versus 62.4), Dental Anxiety (70.2 versus 48.3), Psychological Well-being (87.8 versus 68.6); and Decision Satisfaction (81.2 versus 56.9) and Outcome Satisfaction (91.0 versus 84.7).
Conclusions:
Internal and external midface distraction patients had similar patient-reported outcomes for appearance and functional improvement; however, internal device patients were more satisfied with their quality of life and their decision to undergo the procedure.
