Timing of facial osteotomies

Timing of facial osteotomies A consensus conference Hans Peter M. Freihofer, MD, DMD, PhD,” Gunnar Bjiirk, DDSb Erik Jiinsson, DDSC and Anne-Marie Kuijpers-Jagtman, DMD, PhD,d Nijmegen, The Netherlands and Jdnkoping, Sweden UNIVERSITY HOSPITAL NIJMEGEN, INSTITUTE FOR POSTGRADUATE EDUCATION, UNIVERSITY OF J~NK~PING AND DENTAL SCHOOL, UNIVERSITY OF NIJMEGEN NIJMEGEN A concensus conference on the timing of facial osteotomies was held in Jdnkiiping, Sweden. Seven teams consisting of a maxiilofacial surgeon and an orthodontist representing five countries discussed treatment planning for young patients with maxillomandibular deformities with special emphasis on timing. Patients with severe syndromic facial deformities were not considered. Consensus was reached that for most deformities it is best advised to wait until growth has ceased, as determined by longitudinal cephalometric data. This rule is less tight for Angle Class II than for Class Ill cases. For asymmetries often there is still not enough scientific evidence to obtain well-founded uniform agreement. (ORAL SURC ORAL MED ORAL PATHOL 1994;78:432-6)

Timing of facial osteotomieshas been a matter of debate for decades.During the last 10 to 20 years, however, knowledge based on evaluation of series of patientsl and on individual or group experience has markedly increased.2Enthusiasm to advancethe limit to younger ages has decreased to some extent. Still there are nearly as many different philosophies of timing as there are teams of specialists, A conference was called to try to reach at least a regional consensus about this question to facilitate interaction between oral and maxillofacial surgeons and orthodontists. The results are presented in this article. METHOD

In October 1992 a team from Denmark (S. SindetPedersen, H.P. Harbo; University of Aarhus), Finland (K. Forsell, J. Peltola, H. Vinkka-Puhakka, T. Peltomaki; University of Abe), The Netherlands (H.P.M. Freihofer, A.M. Kuijpers-Jagtman; University of Nijmegen), Norway (K. Tornes, P.J. Wisth; University of Bergen), and two teams from Sweden (S. fsaksson, L. Lagerstrom; Halmstad; H. Bystedt,

aProfessorfor Oral and Maxillofacial Surgery, Dental School and Head, Department of Oral and Maxillofacial Surgery, University Hospital Nijmegen. bSenior Consultant, Department of Orthodontics, Institute for Postgraduate Education, University of Jonkiiping. CSenior Consultant, Department of Oral Surgery, Institute for Postgraduate Education, University of Jonkoping. dProfessorand Head Center of Craniofacia! Anomalies, Dental School, University of Nijmegen. Copyright @ 1994 by Mosby-Year Book, Inc. 0030-4220/94/$3.00+0

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B. Enqvist; University of Stockholm) were invited by E. Jijnsson and G. Bjork, University of Jonkoping, for a 3-day conference at Jijnkiiping, Sweden. The teams consistedof a maxillofacial surgeon and an orthodontist, both with extended experience in the combined treatment of oral and maxillofacial deformities, usually in a university setting. The forum may therefore be considered representative for Scandinavia completed by an important team from The Netherlands. The topic was divided into six subjects: (1) Class II short face with or without deep bite; (2) Class II long face with or without open bite; (3) Class III mandibular prognathism including vertical and transverse deformities; (4) Class III maxillary retrognathia including vertical and transversal deformities; (5) mandibular asymmetry; and (6) osteotomies in cleft palate patients. Problems involving severe facial deformities in syndromes of the head and neck were excluded becauseit was thought that timing in these casesfollows different rules from other skeletal jaw deformities and depends on many variables. Each type of jaw deformity was assignedto a team. Each team presented its conclusions about their assigned topic on the basis of their experience, their own studies, and representative international literature. In plenary sessionsthese proposals were thoroughly discussedin an attempt to reach a consensus after debate of differing points of view. On the basis of these discussions each team was asked to draw a prelimenary consensusdocument. In a secondplenary session the draft was extensively reviewed. A final near total agreement was reached with a few exceptions. The extended versions of the papers can be

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found in the consensusbooklet3 of the University of Jiinkoping. An abridged version of each chapter will ble presented here. For each subject the basic concept is given and then some comments are reported. TREATMENT OF ANGLE CLASS II WITH NORMAL AND DEEP OVERBITE INCLUDING SHORT FACE Basic concept

The treatment of choice was felt to be facial orthopedic treatment with functional appliances or extraoral traction during the growth period. Late orthodontics still can be tried before cessation of growth. Surgery is an alternative when growth has ceased, when cooperation is lacking, or when the discrepancy between the jaws is large. Although residual growth does not compromise the end result the preference of most teams was to postpone surgery until the face is mature.4 Postoperative orthodontics should be quickly instituted to perfect the result. Remarks

Although basic morphologic patterns in this group are often estalblished by the age of 5 years5>6and treatment effects are mainly restricted to dentoalveolar compensations, orthodontic or orthopedic treatment is the first choice. However, the possibility of flattening of the face as a result of maxillary extractions should be carefully considered. There is no absolute contraindication for early operation except that the maxillary canines and second molars must have erupted if maxillary surgery is planned. Lesions of these teeth by osteotomies have to be avoided. However, it is felt that it is more difficult to foresee final facial proportions when planning an osteotomy in a child’s face. Transversal corrections are better performed surgically. Whether the curve of Speewill be leveled before or after surgery may be left to the preference of the treating team and depends also on individual patient circumstances. TREATMENT OF ANGLE CLASS II LONG FACE WITH OR WITHOUT OPEN BITE AND TRANSVERSAL DEFORMITIES Basic concept

A general agreement was obtained that management of this problem should usually consist of preoperative orthodontics, bimaxillary osteotomies after growth has ceased,and orthodontics for refinements as quickly after surgery as possible. Successful treatment by orthodontics alone is unusual. Changesof the face with this treatment approach will often be dramatic. In the adult patient, especially over the age of

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30, this consideration is particularly important with respect to the preoperative psychological preparation of the patient.7 Remarks

An understanding of the different components of this deformity is important* when formulating the treatment goals. It usually results in bimaxillary surgery. Segmentation of the maxilla is often indicated. In most casesthe sole purpose of orthodontic treatment is decompensation and alignment of dental arches.9 When maxillary expansion is indicated, it should be remembered that orthodontic expansion is prone to relapse, particularly if it results in buccal tipping of the premolars and molars. In this situation surgical expansion is a better choice.1°-12No agreement could be obtained about the value of a cervical collar worn after the operation to support the new position of the mandible. TREATMENT OF ANGLE CLASS Ill MANDIBULAR PROCNATHISM INCLUDING VERTICAL AND TRANSVERSAL DEFORMITIES. Basic concept

The prevalence of mandibular prognathism with negative overjet is less than 1%in Scandinavia.t3 The morphology and functional situation vary greatly.i4 The ability to predict growth in this category is particularly difficult. I5 Forced bite into reversed overjet can be handled early in the mixed dentition by orthodontics,i6 but an orthodontic approach must not compromise a later surgical solution. So if desired results are not achieved within 12 months, treatment is discontinued and restarted as presurgical orthodontics after age 17 for creation of morphologically correct dental arches. Surgery is performed after growth is completed and may consist of vertical ramus17 or sagittal split osteotomies, maxillary osteotomy, and their combination. In special cases, additional segmental movements and a genioplasty may be indicated. Postoperative orthodontics should be completed within 4 months.18 Remarks

Casesfor early orthodontics should be selectedwith utmost care excluding cases with an open bite tendency. Timing of surgery was accepted as presented. The choice of techniques for shortening of the mandible and the indications for maxillary advancement triggered discussion; a general consensus was not reached. However, becausethese questions were not the focus of interest, the individual opinions were accepted.

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TREATMENT OF ANGLE CLASS 111MAXILLARY RETROCNATHIA Basic concept

The basic guidelines for timing did not deviate from those for the Angle Class III mandibular prognathism. If there is a tendency towards maxillary hypoplasia it should be corrected early in the deciduous dentition with orthopedic protraction of the maxilla.i9 The final result of orthopedic protraction of the midface is difficult to predict.*O A mild maxillary hypoplasia with a normal morphology of the mandible and no excessin facial height provides a more favorable prognosis. The combined orthodontic-surgical approach is the accepted treatment modality after cessation of growth.21 Remarks

The application of a wafer for a postoperative period of some months was strongly advised by the focus team.22Its usefulness was not opposed, and the rationale accepted.The useof a cervical collar, on the other hand, was questioned. There was disagreement about the need for overcorrection in maxillary surgery, but no consensuswas reached. Almost unanimous agreement was reached to apply this basic concept also to cleft palate patients23 and not to treat them during adolescenceas advised.22 TREATMENT OF ASYMMETRIC DEFORMITIES

This topic is very broad and does not lend itself to a uniform approach. A number of the more common deformities were discussedseparately to try to reach some agreement. Timing was not the only issue; treatment modalities were also discussedbecausethey can have an influence on timing. (For an extensive bibliography, please see reference 24.) Mandibular

displacement

The prevalence of unilateral crossbite as a result of a lateral forced bite is increasing.25 It should be treated orthodontically in the deciduous or early mixed dentition. If not treated then adaptive changes will lead to structural changes,26and surgery may be necessaryafter active facial growth has ceased.The timing for treatment of asymmetric prognathism follows the lines of the symmetric counterpart as indicated earlier. Condylar hyperplasia

The onset of condylar hyperplasia varies27as does its appearance.28Early facial orthopedic treatment to prevent secondary deformities is indicated. Surgical approaches are open to discussion. The side of the growing condyle should be resectedas soon as the deviation is recognized. This approach will limit the de-

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velopment of the anomaly and may lead to normal function. Others believe this approach should be reserved to extreme cases,correcting lessimportant deviations by extra-articular procedures. None of those present could give advice on the basis of sufficient personal experience. In any case, the usual aspectsof growth are only one of several factors such as the function of the joint and esthetic aspects to be considered with respect to surgery. Hemifacial microsomia

The only agreement that could be obtained was that final corrections for hemifacial microsomia should take place when growth has stopped.The optimal way to conduct the patient to that point remained open to discussion. Early treatment with functional appliances may minimize later surgery in mild cases.29 Reconstruction of the missing condyle with a costochondral graft in childhood30 can have a beneficial effect, but it is not predictable.31 Rotation and tilting of the lower facial half in the horizontal and frontal planes32as well as soft tissue procedures must often follow to correct asymmetries when the patient is grown. TMJ ankylosis

Agreement was reached that ankylosis and restrictions of opening movement with an extra-articular cause should undergo surgery early.33,34The use of costochondral grafts was not undisputed. Chronic juvenile rheumatoid

arthritis

Most teams agreed to waiting until juvenile rheumatoid arthritis is extinguished to treat the patient with an Angle Class II (open bite) protocol. Distraction splints to reduce the load of the condyles may have a prophylactic effect on damage of the condyle. (Harbo HP, Sindet-Pedersen S, personal communication, Jijnkiiping 1992.) General remarks

For this topic, clinical experience was not equally distributed over the different teams and diseases. Therefore this part was handled asan open discussion, which did not try to reach consensus.Nevertheless it was agreed that, depending on the disease,early interventions, which means a deviation from the basic approach of waiting until the end of growth, can be defended. These early interventions have the purpose to be prophylactic or to limit the damage. In ankylosis casesthe cooperation of the young patient after the operation is always a problem and may lead to unsatisfactory results on long term.34 As stated earlier the predictability of growth of costochondral grafts is very weak. Animal experi-

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ments have shown that these grafts have their own dynamics.35*36They depend possibly on the amount of cartilage in the graft, 37 which might explain the unpredictability.. Continuous passive motion38 was another issue of discussion. It should be used especially after intracapsular operations and is expected to have a greater positive effect in children than in adults.39 A rudimentary but functioning condyle is better than any of the currently used replacements.“4 CLEFT LIP AND PALATE

Only bone surgery involving cleft lip and palate was dealt with in this conference.23Considering that the discussants present represented only a small albeit important part of their cleft team, the presentation was seenmore as a stimulus for exchanging ideas than a base for definitive consensus. Bone grafting of the alveolar cleft just before eruption of the canine showsby far the best results.40The sameis true for realignment of the premaxilla.41 This is an osteotomy that, in contrast to all others, should be done during growth. 4oSome teams prefer preoperative expansion before grafting23 whereas others prefer the smaller cleft without expansion. Some interrupt orthodontic treatment between grafting and eventual osteotomies,23and other teams prefer to continue. The sosteotomiesof the jaws should follow the timing of Angle Class III cases1in females, but for males it is advisable to wait considerably longer (Kuijpers-Jagtman AM, personal communication, Nijmegen 1991.). DISCUSSION AND CONCLUSIONS

Major agreement occurred for more common problems. The usual approach is preoperative orthodontic treatment to decompensate and align the dental arches, surgery after growth has ceased,and a short postoperative phase of orthodontics to optimize the result. Of course there are exceptions. Legitimate surgery in the first decadeis reserved to caseswith serious restrictions of mouth opening33s34and patients with facial clefts.2,4oGrafting of hemifacial microsomia and resection plus reconstruction in casesof condylar hyperplasia may also be considered in the first decade.24 But, with the exception of the repositioning of the premaxilla, none of these operations is an osteotomy in the sensethat was addressedat this meeting. Osteotomies of the jaws for correction of Angle Class II deep bite may be done in the ffirst half of the second decade of life. However, this approach has certain disadvantages.4 Most other osteotomies should wait until growth

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has ceased.re3This moment can be defined by chronologic age as a general indication. It helps to give the patient and team an idea when treatment may take place. The final decision should be based on individual longitudinal cephalometric data of craniofacial growth. The headplates should be taken with an interval of at least 6 months, 12 months, or more; longer periods are preferable. Chronologic age and hand-wrist radiographs do not provide adequate information. There are exceptions to these rules. All teams agreed that psychosocial aspectscould be a reason for expedite operations. Fear was expressedthat misuse is made of this argument. In these casesreevaluation has to take place after growth has ceasedto consider additional definitive corrections.2 Also it should be mentioned that although contraindications are limited, for somepatients a relative contraindication to surgery is present when the patient, doesnot wish to undergo preoperative orthodontic treatment or should not undergo surgery for other reasons.42 In conclusion, the Jiinkoping consensusdid not result in completely new guidelines. It served to clarify someissuesand to generalize someapproaches,but it also pointed to areas of further research and discussion becausethe evidenceavailable was insufficient to reach well-founded agreements. REFERENCES

1. Freihofer HPM. Results of osteotomiesof the facial skeleton in adolescence.J Maxillofac Surg 1977;5:267-97. 2. Freihofer HPM. The timing of facial osteotomiesin children and adolescents.Clin PlastSurg 1982;8:445-56. 3. BiSrk - G. Freihofer HPM. JiinssonE. eds. Consensus:the timing of facial osteotomiesin children and adolescents.The state of art in Scandinavia and the Netherlands. JBnkBping,Sweden: Invest-odont, 1993. 4. Bystedt H, Enqvist B. Orthodontic surgical treatment of Class II normal and deep overbite, short face. In: Bjijrk G, eds. Consensus:the timing of facial osteotomiesin children and adolescents. Jonkoping, Sweden: Invest-odont, 1993:9-13. 5. Brodie A. On the growth pattern of the human head: from the third month to eight years of life. Am J Anat 1941;68:209-62. 6. Bjijrk A. Variations in the growth of the human mandible: longitudinal radiographic study by the implant method. J Dent Res 1963;42:400-11. 7. Freihofer HPM. Soft tissue contours after osteotomies: predictability and imponderabilities. In: Ousterhout DK, ed. Aesthetic contouring of the face. Boston: Little, Brown, 1991,11734. 8. Solow B. The pattern of craniofacial associations:a morphological and methodological correlation and factor analysis study on young male adults. Acta Odont Stand 1966;24Suppl 46. 9. Isaksson S, Lagerstrom L. Class II long face with or without open bite and transversal deformities. In: Bjiirk G, eds. Consensus:the timing of facial osteotomiesin children and adolescents. Jiinkiiping, Sweden: Invest-odont, 1993:14-8. 10. Haas AJ. Long-term posttreatment evaluation of rapid palatal expansion. Angle Orthod 1980;50:189-217.

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11. Krebs A. Midpalatal suture expansion studied by the implant method over a seven-year period. Proc Europ Orthod Sot 1964;40:131-42. 12. Carlotti AE, Schendel SA. An analysis of factors influencing stability of surgical advancement of the maxilla by the Le Fort I osteotomy. J Oral Maxillofac Surg 1987;45:924-30. 13. Helm S. Malocclusion in Danish children with adolescent dentition: an epidemiological study. Am J Orthod 1968;54:35266. 14. Wisth PJ. The sagittal head morphology of individuals with skeletal angle class III malocclusion and changes subsequent to surgical treatment [Thesis, University of Bergen]. 1973. 15. Ari-Viro A, Wisth PJ. An evaluation of the method of structural growth prediction. Eur J Orthod 1983;5:199-207. 16. Wisth PJ, Tritrapunt A, Rygh P, BgieOE, Norderval K. The effect of maxillary protraction on front occlusion and facial morphology. Acta Odont Stand 1987;45:227-37. 17. Tornes K, Wisth PJ. Stability after vertical subcondylar ramus osteotomy for correction of mandibular prognathism. Int J Oral Maxillofac Surg 1988;17:242-8. 18. Tornes K, Wisth PJ. Surgical-orthodontic treatment of Class III mandibular prognathism including vertical and transversal deformities. In: Bjdrk G, Freihofer HPM, Jonsson E, eds. Consensus:the timing of facial osteotomies in children and adolescents.Jonkoping, Sweden: Invest-odont, 1993:19-27. 19. Rygh P, Tindlund RS. Orthopaedic expansion and protraction of the maxilla: a new treatment rationale. Cleft Palate J 1982;19:104-12. 20. Tindlund RS. Orthopaedic protraction of the midface in the deciduous dentition. J Cranio maxfac Surg 1989;17:17-9. 21. Sinclair PM, Profitt WR. Class III problems: mandibular excess/maxillarv deficiencv. In: Profitt WR. White RP. eds. Surgical-orthodontic treatment. St. Louis: Mosby-Year Book, 1991:428-60. 22. Sindet-PedersenS, Harbo HP. Class III: horizontal, transversal and vertical maxillary deficiency including open and deep bite, In: Bjiirk G, Freihofer HPM, JiinssonE, eds. Consensus: the timing of facial osteotomies in children and adolescents. Jiinkiiping, Sweden: Invest-odont, 1993:28-37. 23. Freihofer HPM, Kuijpers-Jagtman AM. Timing of surgicalorthodontic treatment in cleft lip and palate patients. In: Bj6rk G, eds. Consensus:the timing of facial osteotomiesin children and adolescents. Jonkoping, Sweden: Invest-odont, 1993:6877. 24. Vinkka-Puhakka H, PeltomLki T, Forssell K, Peltola J. Asymmetrical mandibular deformities. In: Bjiirk G, eds. Consensus:the timing of facial osteotomiesin children and adolescents. Jiinkijping, Sweden: Invest-odont, 1993:40-67. 25. Kurol J, Berglund L. Longitudinal study and cost-benefit analysis of the effect of early treatment of posterior cross-bites in the primary dentition. Eur J Orthod 1992;14:173-9. 26. Pirttiniemi P. Associations of mandibulofacial asymmetries, with special reference to glenoid fossa remodelling [Thesis, University of Oulu] 1992.

ORAL SURGERY ORAL MEDICINE ORAL PATWOLOGY October 1994 27. Sloofweg PJ, Miiller H. Condylar hyperplasia: a clinicopathological analysis of 22 cases.J Maxillofac Surg 1986;14:209-14. 28. Obwegeser HL, Makek MS. Hemimandibular hyperplasia: hemimandibular elongation. J Maxillofac Surg 1986;14:183208. 29. Melsen B, Bjerregaard J, Bundgaard M. The effect of treatment with functional appliance on a pathologic growth pattern of the condvle. Am J Orthod Dentofac Or&on 1986:90:503-l2. 30. Vargervik -K, Kaban LB. Hemifacial microsomia: diagnosis and management. In: Bell WH, ed. Modern practice in orthognathic and reconstructive surgery. Philadelphia: Saunders, 1992:1532-60. 31. Vargervik K, Ousterhout DK, Farias M. Factors affecting long-term results in hemifacial microsomia. Cleft Palate J 1986;23 Suppl:53-68. 32. Obwegeser HL. Correction of the skeletal anomalies of otomandibular dysostosis.J Maxillofac Surg 1974;2:73-92. 33. Steinhauser EW. The treatment of ankylosis in children. Int J Oral Surg 1973;1:129-36. 34. Freihofer HPM. Restricted opening of the mouth with an extra-articular cause in children. J Cranio maxillofac Surg 1991;19:289-98. 35. Peltomaki T, Ronning 0. Interrelationship between size and tissue-separating potential of costochondral transplants. Eur J Orthod 1991;13:450-65. 36. Peltomdki T, Rijnning 0. Growth of costochondral fragments transplanted from mature to young isogeneic rats. Cleft Palate Craniofac J 1993;30:159-63. 31. Peltomaki T. Growth of the costochondraljunction and its potential applicability for the reconstruction of the mandibular condyle [Thesis, University of Turku]. 1993. 38. Sebastian MH, Moffett MC. The effects of continuous passive motion on the temporomandibular joint after surgery. ORAL SURG ORAL MED URAL PATHOL 1?89;67:644-53.

39. Kantomaa T. Ronning 0. Growth of the mandible. In: Dixon AD, Sarnat BG, HGyte DA, eds. Fundamentals in bone growth. Boca Raton: CRC Press 1991;579-85. 40. Freihofer HPM, Borstlap WA, Kuijpers-Jagtman AM, et al. Timing and transplant materials for closure of alveolar clefts. J Cranio Maxillofac Surg 1993;21:143-8. 41. Freihofer HPM, Damme van PhA, Kuijpers-Jagtman AM. Early secondary osteotomy-stabilization of the premaxilla in bilateral clefts. J Cranio Maxillofac Surg 1991;19:2-6. 42. Hakman ECJ. Een nieuw gezicht? Bohn: Stafleu, Houten-Zaventem, 1993. Reprint requests.

Prof.dr. H.P.M. Freihofer Dept. of Oral and Maxillo-Facial Surgery University Hospital Nijmegen P.O. Box 9101 6500 HB Nijmegen The Netherlands