- Email: [email protected]
The frequency of Le Fort I osteotomy in cleft patients
ICOMS 2011—Abstracts: Oral Papers appliances. The age at the time of surgery ranged from 5 weeks to 36 months. One patient was intubated, three patients were tracheostomy dependent, two managed CPAP, thirty-three patients were naso-pharyngeal tube dependent and one positionally managed. All patients have more than 12 months of follow-up since surgery. Polysomnography studies were undertaken pre-operatively when possible and post-operatively. Results: Of the tracheostomy dependent group; one was decannulated after distraction and two were delayed. Thirtythree patients had no further obstructive symptoms following mandibular distraction. Six patients had continuing or developed further obstructive symptoms in the follow-up period, and one patient underwent further mandibular distraction at 7-year old. Feeding responses varied post-distraction from early conversion to slow progress to oral feeds and four continue to require supplemental nasogastric feeds. Conclusion: In selected neonates and infants mandibular distraction appears to be a good modality for the correction of upper airway obstruction due to micrognathia and to facilitate oral feeding. Conflict of interest: None declared. doi:10.1016/j.ijom.2011.07.219
volume, position of the infra-orbital rim and globe-position. Material and method: Pre- and postoperative CT-scans of 18 syndromic craniosynostosis patients were analyzed. In each scan, segmentation of the left and right orbit was performed and the infra-orbital rim and globe were marked. By superimposing the pre- and postoperative scan and the creation of a reference coordinate system, the movement of the infra-orbital rim and globe was evaluated. Results: Orbital volume increased significantly (p < 0.001) with 27.2% for the left and 28.4% for the right orbit. A significant anterior movement of the left infra-orbital rim of 12.0 mm (sd 4.2) and right infra-orbital rim of 12.8 mm (sd 4.9) were found. A significant medial movement of 1.7 mm (sd 2.2) of the left globe and 1.5 mm (sd 1.9) of the right globe were found (p < 0.005). There was a significant correlation (rs = 0.498, p = 0.035 (left) and 0.642, p = 0.018 (right)), between the anterior infra-orbital rim movement and the orbital volume gain. Summary: Significant orbital volume gain has been demonstrated after Le Fort III advancement. The position of the infraorbital rim was significantly transferred anterior, whereas the position of the globe remained relatively unaffected. Conflict of interest: None declared.
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during adolescence and post-puberty was recorded to identify the timing and type of intervention. Results: A range of different procedures and timing was recorded but in general, severe mid-facial deficiency was managed by an interim mid-facial advancement, followed by definitive orthodontic treatment and a final orthognathic procedure. Rhinoplasty and fronto-orbital contouring was performed in 6 patients to complete treatment. Conclusion: Due to the variability of mid-facial deficiency in this group of patients, a definitive protocol is difficult to develop. However, in severe cases post-puberty, advancement of the midface to normalize the orbital contours and minimize the gross Class III malocclusion is recommended. This can then be followed by orthodontic treatment and maxillo-mandibular surgery post-growth. Subsequently, nasal and frontal cranioplasty procedures to fine-tune aesthetics and function were required in some cases. In less severe cases, mid-facial advancement may be delayed for a one-stage correction post-growth. Cases will be presented to illustrate these pathways of treatment. Conflict of interest: None declared. doi:10.1016/j.ijom.2011.07.221
doi:10.1016/j.ijom.2011.07.220
219 Orbital changes following Le Fort III advancement in syndromic craniosynostosis: quantitative evaluation of orbital volume, infra-orbital rim and globe position M.J. Koudstaal 1,∗ , E. Nout 1 , S.J. van Bezooijen 1 , J. Veenland 2 , W. Hop 3 , E.B. Wolvius 1 , K.G. van der Wal 1 1 Maxillofacial Surgery, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands 2 Department of Medical Informatics, Radiology - Faculty of Medicine, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands 3 Department of Biostatistics, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands
Aim: Patients with syndromic craniosynostosis often suffer from shallow orbits due to midface hypoplasia. The present study aims to evaluate quantitatively the influence of Le Fort III advancement on orbital
220 Skeletal correction of the mid-face in the adolescent craniofacial patient A.A. Heggie ∗ , T. Holmes, J. Shand Plastic and Maxillofacial Surgery, Royal Children’s Hospital of Melbourne, Melbourne, VIC, Australia
Introduction: Following a fronto-orbital or monobloc advancement in infancy, further mid-facial deficiency is usually corrected by a Le Fort III advancement (now often with distraction techniques: external and internal). The approach to final skeletal correction of the adolescent patient with a syndromic craniosynostosis or a related anomaly receives less attention with respect to providing the best function and aesthetics. Objective, patient and methods: Fifteen patients with significant craniofacial anomalies who had completed growth and treatment undergone the usual treatment sequence in the Melbourne Craniofacial Unit were identified. The management of the mid-face and associated structures
221 The frequency of Le Fort I osteotomy in cleft patients M.J. Koudstaal 1,∗ , I.E. Voshol 1 , E.M. Ongkosuwito 2 , L.N. van Adrichem 3 , K.G. van der Wal 1 1 Maxillofacial Surgery, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands 2 Section Orthodontics, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands 3 Plastic Surgery, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands
Introduction: Maxillary hypoplasia is the most frequent seen skeletal malformation in repaired cleft patients, which can be translated into the number of Le Fort I osteotomies (LFI) performed. Aim of this research was to study the incidence of LFI in skeletal full-grown cleft patients treated according to protocol of the Erasmus University Medical Center, Rotterdam, the Netherlands. Possible correlated prognostic factors were assessed.
1092 ICOMS 2011—Abstracts: Oral Papers Methods: Retrospective cohort study of 508 cleft patients born between 01-011983 and 31-12-1992. 251 non-syndromic cleft patients fulfilled inclusion criteria. Results: Overall, 28 of the 251 patients (11.2%) required LFI. The incidence of LFI increased with the severity of the cleft type. The number of previous surgical interventions is significantly higher in cases with an indication for Le Fort I osteotomy (p < 0.001). The incidence of LFI is significantly higher in male cleft patients (p < 0.05). 69 of the 251 included cleft patients required pharyngoplasty (27.5%). The LFI frequency of 19% in cleft patients with pharyngeal flap surgery is significantly higher compared to the percentage of 8% LFI in patients without pharyngeal flap surgery. Conclusion: The frequency of LFI in repaired cleft patients is low compared to previous reports. Possibly, the twostaged palatal closure over several years leaves more room for maxillary growth. The significant difference between cleft lip patients and cleft lip and alveolus patients marks the importance to differentiate between these two cleft types. The significant higher incidence of LFI in patients who underwent pharyngeal flap surgery indicates a negative influence on maxillary outgrowth. Conflict of interest: None declared. doi:10.1016/j.ijom.2011.07.222
222 Hemifacial (craniofacial) microsomia – an assessment of protocol driven outcomes A.A. Heggie ∗ , J. Shand Plastic and Maxillofacial Surgery, Royal Children’s Hospital of Melbourne, Melbourne, VIC, Australia
Introduction: The spectrum of craniofacial microsomia ranges from mild unilateral mandibular hypoplasia to gross facial asymmetry involving hypoplasia of the temporo-zygomatico-orbital complex, masticatory muscles and mandibular condyle/ramus unit together with cranial nerve palsies. Various interventions have been recommended by many Units to correct these facial deformities, particularly unilateral interim distraction osteogenesis. Objective, patient and methods: It is the objective of this presentation to discuss the protocols of management in these patients with respect to the need for staged surgical intervention that will produce the best outcome for adult life. The distribution of patients with mandibular Type I,
IIA, IIB and III deformities was recorded from our Unit database and the protocols for management identified. Results: Early composite free tissue transfers were initially undertaken but resulted in unpredictable soft tissue bulk. Attempts to minimize asymmetry with distraction techniques were also abandoned as definitive skeletal correction was required in all patients in any case. Patients will be presented demonstrating the results using traditional orthognathic techniques following the reconstruction of the condyle/ramus unit where indicated in severe cases. Conclusion: As yet, there is no consensus regarding the optimum protocol for managing craniofacial microsomia and while initially promising, it is our view that unilateral distraction does not confer any significant advantage over existing skeletal correction techniques. Conflict of interest: None declared. doi:10.1016/j.ijom.2011.07.223
223 A case of application of bone transport and bone graft using Auto-tooth bone for alveolar cleft repair S. Hara 1,∗ , M. Mitsugi 1,2 , K. Okazaki 3 , A. Nomachi 1 , Y. Tatemoto 1 1 Oral and Maxillofacial Surgery, Kochi Health Sciences Center, Kochi-City, Japan 2 Takamatsu OMS Clinic, Takamatsu-City, Japan 3 Okazaki Orthodontic Dental Clinic, Kochi-City, Japan
Introduction: Secondary autogenous cancellous bone grafting is a widely used method for the treatment of alveolar clefts and oronasal fistulae. However, failure of iliac bone grafting sometimes occurs due to inadequate covering with the surrounding soft tissue and marked scar formation, or large clefts. We report a case of application of the combination for alveolar cleft repair of Maxillary bone transport surgery and Auto-tooth bone graft system using autogenous extracted teeth developed in Korea. Case: A female 9-years old patient suffering from unilateral cleft lip and palate (left-side) were treated with this method. We planned maxillary bone transport surgery using a virtual operation with SimPlant OMS to correct the maxillary midline and deviated nasal septum. After sagittal interdental right-side maxillary osteotomy between #11 and 12 is performed completely to the nasal floor, alveolar maxillary bone (#11, 21) was transported in the planned direction (left)
using a Martin’s distractor and closed the alveolar cleft. At the end of the transporter activation period, soft tissue in the cleft was removed so called “Docking surgery” using an electric knife for close bone contact at the docking site. We performed teeth extraction; 2 supernumerary teeth and small Lt. lateral incisor for Autotooth bone materials. We performed bone transporter removal and simultaneously Auto-tooth bone grafting to the docking area. Result: Maxillary bone transport allowed good distraction osteogenesis and soft tissue expansion. Auto-tooth bone grafting to the docking site allowed repair of bone defects of nasal floor and alveolar and better bone connection. Conflict of interest: None declared. doi:10.1016/j.ijom.2011.07.224
224 Coronoid hyperplasia in pediatric patients L. Castellón Zirpel 1,2,3 , C. Fuenzalida Kakarieka 1,∗ , A. Basili Esbry 1 , J.P. Alister Herdener 1 , C. Plaza Alvarez 1 1 Cirugía Oral y Maxilofacial, Universidad Mayor, Chile 2 Cirugía Máxilofacial, Hospital Dr. Luis Calvo Mackenna, Chile 3 Cirugía Máxilofacial, Hospital Exzequiel González Cortés, Santiago, Chile
Coronoid hyperplasia is a rare condition that is characterized by enlargement of the coronoid process. It causes painless progressive limitation of the mouth opening because of the impaction of the coronoid process on the posterior aspect of the zigomatic bone. It is frequently seen in males during pre-pubertal age. The etiological factors described in literature are; TMJ dysfunction, TMJ hipomobility, hormonal stimulus, genetic inheritance or idiopathic. Panoramic Films and CT Scans are used to confirm and characterize the presence and extent of coronoid hyperplasia. Generally the coronoid process exceeds the zigomatic arch. The treatment consists in surgical coronoidectomy and postoperative physical therapy. The aim of this study is to present five pediatric cases of coronoid hyperplasia; their treatment and long term follow up. The five patients described have different coronoid hyperplasia etiologies, some have coronoid hyperplasia alone and others are associated to syndromes. Coronoidectomy is the treatment for coronoid hyperplasia. Active physical therapy is cru-
volume, position of the infra-orbital rim and globe-position. Material and method: Pre- and postoperative CT-scans of 18 syndromic craniosynostosis patients were analyzed. In each scan, segmentation of the left and right orbit was performed and the infra-orbital rim and globe were marked. By superimposing the pre- and postoperative scan and the creation of a reference coordinate system, the movement of the infra-orbital rim and globe was evaluated. Results: Orbital volume increased significantly (p < 0.001) with 27.2% for the left and 28.4% for the right orbit. A significant anterior movement of the left infra-orbital rim of 12.0 mm (sd 4.2) and right infra-orbital rim of 12.8 mm (sd 4.9) were found. A significant medial movement of 1.7 mm (sd 2.2) of the left globe and 1.5 mm (sd 1.9) of the right globe were found (p < 0.005). There was a significant correlation (rs = 0.498, p = 0.035 (left) and 0.642, p = 0.018 (right)), between the anterior infra-orbital rim movement and the orbital volume gain. Summary: Significant orbital volume gain has been demonstrated after Le Fort III advancement. The position of the infraorbital rim was significantly transferred anterior, whereas the position of the globe remained relatively unaffected. Conflict of interest: None declared.
1091
during adolescence and post-puberty was recorded to identify the timing and type of intervention. Results: A range of different procedures and timing was recorded but in general, severe mid-facial deficiency was managed by an interim mid-facial advancement, followed by definitive orthodontic treatment and a final orthognathic procedure. Rhinoplasty and fronto-orbital contouring was performed in 6 patients to complete treatment. Conclusion: Due to the variability of mid-facial deficiency in this group of patients, a definitive protocol is difficult to develop. However, in severe cases post-puberty, advancement of the midface to normalize the orbital contours and minimize the gross Class III malocclusion is recommended. This can then be followed by orthodontic treatment and maxillo-mandibular surgery post-growth. Subsequently, nasal and frontal cranioplasty procedures to fine-tune aesthetics and function were required in some cases. In less severe cases, mid-facial advancement may be delayed for a one-stage correction post-growth. Cases will be presented to illustrate these pathways of treatment. Conflict of interest: None declared. doi:10.1016/j.ijom.2011.07.221
doi:10.1016/j.ijom.2011.07.220
219 Orbital changes following Le Fort III advancement in syndromic craniosynostosis: quantitative evaluation of orbital volume, infra-orbital rim and globe position M.J. Koudstaal 1,∗ , E. Nout 1 , S.J. van Bezooijen 1 , J. Veenland 2 , W. Hop 3 , E.B. Wolvius 1 , K.G. van der Wal 1 1 Maxillofacial Surgery, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands 2 Department of Medical Informatics, Radiology - Faculty of Medicine, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands 3 Department of Biostatistics, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands
Aim: Patients with syndromic craniosynostosis often suffer from shallow orbits due to midface hypoplasia. The present study aims to evaluate quantitatively the influence of Le Fort III advancement on orbital
220 Skeletal correction of the mid-face in the adolescent craniofacial patient A.A. Heggie ∗ , T. Holmes, J. Shand Plastic and Maxillofacial Surgery, Royal Children’s Hospital of Melbourne, Melbourne, VIC, Australia
Introduction: Following a fronto-orbital or monobloc advancement in infancy, further mid-facial deficiency is usually corrected by a Le Fort III advancement (now often with distraction techniques: external and internal). The approach to final skeletal correction of the adolescent patient with a syndromic craniosynostosis or a related anomaly receives less attention with respect to providing the best function and aesthetics. Objective, patient and methods: Fifteen patients with significant craniofacial anomalies who had completed growth and treatment undergone the usual treatment sequence in the Melbourne Craniofacial Unit were identified. The management of the mid-face and associated structures
221 The frequency of Le Fort I osteotomy in cleft patients M.J. Koudstaal 1,∗ , I.E. Voshol 1 , E.M. Ongkosuwito 2 , L.N. van Adrichem 3 , K.G. van der Wal 1 1 Maxillofacial Surgery, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands 2 Section Orthodontics, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands 3 Plastic Surgery, Erasmus University Medical Center, Sophia’s Children’s Hospital Rotterdam, Rotterdam, The Netherlands
Introduction: Maxillary hypoplasia is the most frequent seen skeletal malformation in repaired cleft patients, which can be translated into the number of Le Fort I osteotomies (LFI) performed. Aim of this research was to study the incidence of LFI in skeletal full-grown cleft patients treated according to protocol of the Erasmus University Medical Center, Rotterdam, the Netherlands. Possible correlated prognostic factors were assessed.
1092 ICOMS 2011—Abstracts: Oral Papers Methods: Retrospective cohort study of 508 cleft patients born between 01-011983 and 31-12-1992. 251 non-syndromic cleft patients fulfilled inclusion criteria. Results: Overall, 28 of the 251 patients (11.2%) required LFI. The incidence of LFI increased with the severity of the cleft type. The number of previous surgical interventions is significantly higher in cases with an indication for Le Fort I osteotomy (p < 0.001). The incidence of LFI is significantly higher in male cleft patients (p < 0.05). 69 of the 251 included cleft patients required pharyngoplasty (27.5%). The LFI frequency of 19% in cleft patients with pharyngeal flap surgery is significantly higher compared to the percentage of 8% LFI in patients without pharyngeal flap surgery. Conclusion: The frequency of LFI in repaired cleft patients is low compared to previous reports. Possibly, the twostaged palatal closure over several years leaves more room for maxillary growth. The significant difference between cleft lip patients and cleft lip and alveolus patients marks the importance to differentiate between these two cleft types. The significant higher incidence of LFI in patients who underwent pharyngeal flap surgery indicates a negative influence on maxillary outgrowth. Conflict of interest: None declared. doi:10.1016/j.ijom.2011.07.222
222 Hemifacial (craniofacial) microsomia – an assessment of protocol driven outcomes A.A. Heggie ∗ , J. Shand Plastic and Maxillofacial Surgery, Royal Children’s Hospital of Melbourne, Melbourne, VIC, Australia
Introduction: The spectrum of craniofacial microsomia ranges from mild unilateral mandibular hypoplasia to gross facial asymmetry involving hypoplasia of the temporo-zygomatico-orbital complex, masticatory muscles and mandibular condyle/ramus unit together with cranial nerve palsies. Various interventions have been recommended by many Units to correct these facial deformities, particularly unilateral interim distraction osteogenesis. Objective, patient and methods: It is the objective of this presentation to discuss the protocols of management in these patients with respect to the need for staged surgical intervention that will produce the best outcome for adult life. The distribution of patients with mandibular Type I,
IIA, IIB and III deformities was recorded from our Unit database and the protocols for management identified. Results: Early composite free tissue transfers were initially undertaken but resulted in unpredictable soft tissue bulk. Attempts to minimize asymmetry with distraction techniques were also abandoned as definitive skeletal correction was required in all patients in any case. Patients will be presented demonstrating the results using traditional orthognathic techniques following the reconstruction of the condyle/ramus unit where indicated in severe cases. Conclusion: As yet, there is no consensus regarding the optimum protocol for managing craniofacial microsomia and while initially promising, it is our view that unilateral distraction does not confer any significant advantage over existing skeletal correction techniques. Conflict of interest: None declared. doi:10.1016/j.ijom.2011.07.223
223 A case of application of bone transport and bone graft using Auto-tooth bone for alveolar cleft repair S. Hara 1,∗ , M. Mitsugi 1,2 , K. Okazaki 3 , A. Nomachi 1 , Y. Tatemoto 1 1 Oral and Maxillofacial Surgery, Kochi Health Sciences Center, Kochi-City, Japan 2 Takamatsu OMS Clinic, Takamatsu-City, Japan 3 Okazaki Orthodontic Dental Clinic, Kochi-City, Japan
Introduction: Secondary autogenous cancellous bone grafting is a widely used method for the treatment of alveolar clefts and oronasal fistulae. However, failure of iliac bone grafting sometimes occurs due to inadequate covering with the surrounding soft tissue and marked scar formation, or large clefts. We report a case of application of the combination for alveolar cleft repair of Maxillary bone transport surgery and Auto-tooth bone graft system using autogenous extracted teeth developed in Korea. Case: A female 9-years old patient suffering from unilateral cleft lip and palate (left-side) were treated with this method. We planned maxillary bone transport surgery using a virtual operation with SimPlant OMS to correct the maxillary midline and deviated nasal septum. After sagittal interdental right-side maxillary osteotomy between #11 and 12 is performed completely to the nasal floor, alveolar maxillary bone (#11, 21) was transported in the planned direction (left)
using a Martin’s distractor and closed the alveolar cleft. At the end of the transporter activation period, soft tissue in the cleft was removed so called “Docking surgery” using an electric knife for close bone contact at the docking site. We performed teeth extraction; 2 supernumerary teeth and small Lt. lateral incisor for Autotooth bone materials. We performed bone transporter removal and simultaneously Auto-tooth bone grafting to the docking area. Result: Maxillary bone transport allowed good distraction osteogenesis and soft tissue expansion. Auto-tooth bone grafting to the docking site allowed repair of bone defects of nasal floor and alveolar and better bone connection. Conflict of interest: None declared. doi:10.1016/j.ijom.2011.07.224
224 Coronoid hyperplasia in pediatric patients L. Castellón Zirpel 1,2,3 , C. Fuenzalida Kakarieka 1,∗ , A. Basili Esbry 1 , J.P. Alister Herdener 1 , C. Plaza Alvarez 1 1 Cirugía Oral y Maxilofacial, Universidad Mayor, Chile 2 Cirugía Máxilofacial, Hospital Dr. Luis Calvo Mackenna, Chile 3 Cirugía Máxilofacial, Hospital Exzequiel González Cortés, Santiago, Chile
Coronoid hyperplasia is a rare condition that is characterized by enlargement of the coronoid process. It causes painless progressive limitation of the mouth opening because of the impaction of the coronoid process on the posterior aspect of the zigomatic bone. It is frequently seen in males during pre-pubertal age. The etiological factors described in literature are; TMJ dysfunction, TMJ hipomobility, hormonal stimulus, genetic inheritance or idiopathic. Panoramic Films and CT Scans are used to confirm and characterize the presence and extent of coronoid hyperplasia. Generally the coronoid process exceeds the zigomatic arch. The treatment consists in surgical coronoidectomy and postoperative physical therapy. The aim of this study is to present five pediatric cases of coronoid hyperplasia; their treatment and long term follow up. The five patients described have different coronoid hyperplasia etiologies, some have coronoid hyperplasia alone and others are associated to syndromes. Coronoidectomy is the treatment for coronoid hyperplasia. Active physical therapy is cru-