Nasal and ethmoidal alterations in anterior synostotic plagiocephaly

Approach to Fronto-Orbital Sequelae in Anterior Synostotic Plagiocephaly: Our Flow Chart Based on Di Rocco Classification

INTRODUCTION

Anterior synostotic plagiocephaly recognizes the synostosis of one of the hemicoronal sutures as a cause and can manifest itself with varying degrees of severity. Clinically it presents a reduction of the sagittal growth of the affected side and flattening of the frontoparietal complex.

MATERIALS AND METHODS

The authors retrospectively examined our case sample dividing it into 3 groups based on the Di Rocco classification. For each category, we assessed the extent of facial alterations at the end of skeletal growth and retrospectively analyzed the surgical options aimed at correcting aesthetic and skeletal deficits.

RESULTS

The authors found that predictable results could be obtained by standardizing the surgical procedure based on Di Rocco's classification groups; in particular, the authors achieved satisfactory results by assigning a specific surgical procedure to each class.

Custom made onlay implants in peek in maxillofacial surgery: a volumetric study

PURPOSE

Facially malformed patients often present a variable degree of facial imbalance even after basal bone correction, and resolution of the residual hard- and soft-tissue deficiencies and asymmetries of the face are of great importance for achieving a satisfactory post-implant procedure result. The use of polyether ether ketone (PEEK) implants for maxillofacial reconstruction has been documented in the literature, but the number of patients who have received them is limited. The aim of this study was to evaluate the overall volumetric results in patients with facial imbalance after onlay custom implant positioning for mandible and fronto-orbital reconstructions. Analysis was performed by confronting volumes with the use of three-dimensional (3D) photogrammetry.

METHODS

Fifteen patients were eligible for PEEK implant placements, eight for mandibular angle reconstruction, and seven for fronto-orbital reconstruction. Pre- and post-surgical 3D images of each patient's face were acquired. Facial asymmetry was analyzed by comparing each face with its mirrored copy.

RESULTS

Three-dimensional analyses have shown that some degree of volume imbalance was still present in the patients with only 1.32 ± 1.02 mm residual discrepancy after treatment.

CONCLUSION

Results of the study were found to fall within clinically acceptable limits since an asymmetry rate of < 3 mm is considered to fall into the norm.

Early Surgical Treatment in Anterior Synostotic Plagiocephaly: Is This the Best Choice?

At the end of craniofacial growth, in anterior synostotic plagiocephaly, some aesthetical deficiencies may still be evident. This can depend on an inadequate initial correction or on altered postoperative growth or even on the combination of the 2 factors.Aesthetic alterations can result from various factors that could potentially affect the skeleton, the skin, subcutaneous, and muscular tissues.The pathological changes in the cutaneous and subcutaneous tissues are greater in patients who have undergone multiple surgical treatments of the frontoorbital area. The aim of this observational cohort study is to assess the residual aesthetic and functional impairment at the end of skeletal growth, in patients affected by anterior synostotic plagiocephaly who have undergone surgery at an early age. The purpose is to investigate whether early surgery can still be considered unavoidable in patients with this malformation.Between July 2012 and February 2015, patient's data were retrieved from our archives among the patients referred to our department from 2003 to 2012 for Anterior Synostotic Plagiocephaly at an early age.The authors studied this patient with CT scans and photographic documentation. On CT scans, the authors have assessed skeletal alterations, soft tissues alterations, and muscular tissue alterations. With photographic documentation, the authors have studied the perception of the malformation among external subjects.From this study it was possible to demonstrate that is many esthetical alterations are to still to be found in patients treated with an early surgical approach; for this reason in children without early complications, the authors suggest that surgical treatment should be delayed after the end of craniofacial growth.

A scanographic study of asymmetry of the frontal process of zygoma in unilateral coronal synostosis

INTRODUCTION

Unilateral coronal synostosis (UCS) is a complex craniosynostosis, combining malformations of the upper (frontal bone, orbito-naso-frontal bandeau (ONFB) ) and the middle thirds of the face. In our centre, the surgical correction consists in the repositioning of the ONFB in front of the zygomaticofrontal suture on the affected side. Defects in the corrections have been observed post-operatively for some patients with a persistent asymmetry in the side walls of the orbits. The purposes of our study were to perform an analysis of the frontal process of zygoma (FPZ) in children affected by UCS using preoperative CT-scans and to consider the modification of surgical techniques in order to achieve a better ONFB repositioning and thus, better symmetry.

MATERIAL AND METHOD

The preoperative CT-scans of 13 children with UCS who underwent corrective surgery in our department from 2005 to 2016, were analyzed. After the selection of 6 morphological points in 2 and 3 dimensions using planning software, the sutures constituting the coronal arch and the sagittal distances between the coronal plane and the zygomaticofrontal sutures were analyzed. We compared the measurements on the pathological side to the healthy side, the non-affected side being the reference side. The patients included were those for whom the lack of symmetry between the healthy side and the affected side was more than 2 mm. Statistical analyses were carried out using a Student t-test.

RESULTS

Of the 13 children, 10 (1 day to 42 months old) met the inclusion criteria. The mean sagittal distance between the coronal plane and the healthy zygomaticofrontal suture was 33.8 mm ± 5.43 mm [range: 25.9: 40.9] [median: 34.3]. On the pathological side, the distance was 28.75 mm ± 4.76 mm [range: 20.8: 36.3] [median: 29.55], (p = 0.04).

DISCUSSION

There is a significant asymmetry between the FPZ on the healthy and the pathological sides in children affected by UCS. This asymmetry is variable, therefore justifying a personalized surgical correction whichtakes into account not only the shape of the ONFB but also the degree of asymmetry of the FPZ. A prospective study with immediate preoperative CBCT image acquisition and long-term clinical and radiological follow-up, will be our next step.

Nasal Root Deviation in Unicoronal Craniosynostosis: A Craniometric Analysis of Early and Late Postoperative Outcomes

PURPOSE

Current operative techniques for correcting unicoronal craniosynostosis (UCS) leave the nasal bones untouched, resulting in an unclear long-term impact on nasal root deviation. The purpose of this study is to quantify nasal root deviation in the preoperative and late postoperative setting in patients who have undergone conventional single-staged UCS correction.

METHODS

The authors performed a retrospective, craniometric analysis of nasal root deviation comparing preoperative computed tomography scans, with those of the early, and late postoperative period. Three vectors were analyzed to measure nasal root deviation, one extending from the nasion to the rhinion (nasal bone vector), the second from the rhinion to the anterior nasal spine (nasal aperture vector), and the third from the nasion to the anterior nasal spine (nasal longitudinal vector).

RESULTS

Twenty-five subjects were included in the study. Average ages at the time of preoperative, early, and late postoperative imaging were 0.6 ± 0.3, 0.9 ± 0.6, and 9.3 ± 2.7 years, respectively. Improvement of angular deviation of both the nasal aperture vector and nasal longitudinal vector was observed. Mean angular deviation of the nasal aperture vector was 6.0 ± 1.9 degrees preoperatively, 6.0 ± 2.1 degrees early postoperatively (P = 0.952), and 2.4 ± 2.1 in the late postoperative period (P = 0.013). Mean angular deviation of the nasal longitudinal vector was 5.7+2.0 degrees preoperatively, 5.8 ± 2.3 degrees early postoperatively (P = 0.948), and 3.7 ± 1.6 degrees in the late postoperative period (P = 0.019).

CONCLUSION

Nasal root deviation decreased significantly only in the late postoperative period, lending credence to the notion that though UCS correction does not directly address nasal root deviation, this pathology improves significantly over time.

Nasal soft-tissue and vault deviation in unicoronal synostosis

BACKGROUND

Unicoronal synostosis (UCS) results in nasal root deviation toward the fused side of the face, resulting in an apparent nasal dorsal deviation to the non-fused side. The impact of the altered radix position on the osteocartilaginous vault and nasal soft tissue has not been analyzed. The purpose of this study is to morphometrically assess the nasal structure and deviation in UCS. We hypothesize the proximal etiology exerts an impact on the distal nasal form, compared to controls.

METHODS

Demographic data were tabulated and computed tomographic information recorded. Three-dimensional reconstruction was created and analyzed digitally (using Surgi Case). Morphometric landmarks were determined and used to perform measurements on the nasal soft tissue and osseous skull surface to evaluate nasal deviation within a midsaggital plane (MSP).

RESULTS

Forty three-dimensional CT scans of 20 UCS patients and 20 control subjects were analyzed. The deviation angle of the nose to the non-fused side was 6.6 ± 2.9° in the bony layer. In the soft-tissue layer, the deviation angle of the nasal dorsum line to the non-fused side was 5.4 ± 3.4°. The tip of the nose showed a significant deviation to the non-fused side (2.2 ± 1.2 mm). Paired landmarks (alares, inferior lateral nostril bases) related to the MSP showed a greater distance on the non-fused side. Paired landmarks related to an intrinsic nasal midline (Nsup-ANS; tip-columella line (TCL)) did not show any significant differences.

CONCLUSION

UCS confers osteocartilaginous and soft-tissue nasal deviation, with the distal nose toward the non-fused side. The nasal root inclination underpins this asymmetry across the midsaggital reference plane. However, the nose in isolation exhibits balanced side-side proportions.

The assessment of relationship between the skull base development and the severity of frontal plagiocephaly after bilateral fronto-orbital advancement in the early life

PURPOSE

The deformation of the skull base in patients with unilateral frontal plagiocephaly (UFP) is well known, but the mechanism is not still clear. We analyzed the skull base in the patients with UFP who underwent fronto-orbital advancement (FOA) in the early life during the last decade.

METHODS

We assessed the treatment results and outcome of FOA performed in six patients, four girls and two boys younger than 2 years, in the last decade. Also, the basal cranium's angles were measured by 3D reconstruction images on computed tomography (CT) scan.

RESULTS

The mean patients' age at FOAs was 11 months. Two cases were classified as grade 2A, two cases as grade 2B, and two cases as grade 3 (the classification of Di Rocco and Velardi). The ethmoidal axis was deviated a mean of 8.2° to the affected side. The mean angle between the petrosal pyramids and the midline (anterior-petrosal-sagittal angle, APSA) was 75.3° on the affected side and 66.2° on the normal side. The mean difference of APSA was 9.2°. On the follow-up CT images 5 years after surgery, the deviations of the ethmoidal axis clearly decreased, 5.7°, but the differences of APSA did not change, 8.8°.

CONCLUSIONS

The midline distortion of anterior skull base should be considered to be spontaneously corrected during the follow-up periods in patients with all types of UFP who underwent FOA, unlike posterior skull base in the patients with grades 2B and 3 classification.

Mandibular alterations and facial lower third asymmetries in unicoronal synostosis

PURPOSE

Maxillary and mandibular alterations in children affected by anterior synostotic plagiocephaly have, until today, received only scarce attention. The goal of this paper is to focus on the mandibular alterations, persisting after the early correction of anterior plagiocephaly during the first year of life.

METHODS

Maxillary and mandibular metric measurements were performed on high resolution, thin slices CT scans; all images were reconstructed into 3D models which were used to perform the metrical assessments.

RESULTS

Twelve patients were selected; all of them had been treated in early age with a neurosurgical intervention and had reached the end of maxillo-mandibular growth at the time of the evaluation. Significant discrepancies were documented between the two affected sides, with all measured distances being shorter on the synostotic side than the nonsynostotic one, the only exception being the vertical dimension of the mandibular ramus.

DISCUSSION

Mandibular alterations resulted to be characterized by lower jaw hypoplasia on the side of the affected suture and anterior displacement of the glenoid fossa; these two entities compensated each other uncompletely, ending in a rotation of the mandibula towards the synostotic side.

Correlations between the abnormal development of the skull base and facial skeleton growth in anterior synostotic plagiocephaly: the predictive value of a classification based on CT scan examination

BACKGROUND

Anterior cranial plagiocephaly, depending on the early hemicoronal suture fusion, is the most relevant form of plagiocephaly in terms of clinical implications. Its estimated incidence ranges between 0.4 and 1 per 1,000 live births. In the present report, we aim at validating the classification of Di Rocco and Velardi, proposing a scheme based on basicranium analysis using CT scans and its predictive value by evaluating the developmental characteristics of a population of adult subjects affected by anterior plagiocephaly who had underwent the surgical correction in the first months of life.

MATERIALS AND METHODS

The group of patients here considered was retrieved from among all patients operated upon for craniostenosis in the pediatric neurosurgery unit of Policlinico Gemelli in Rome between January 1, 1980 and December 31, 1989. The study group consisted of 13 patients, seven females and six males, affected by anterior synostotic plagiocephaly ranging in age between 20 and 32 years (mean 25.54 years). We also formed a group of unaffected patients in order to control for normal variability in the population. The subjects of the study group were evaluated using CT scan exams and cephalometric analyses were performed using three-dimensional reconstruction.

DISCUSSION AND CONCLUSION

In this study, we were able to associate a facial phenotype to confirm the predictive value of the classification proposed. It is highly probable that the different outcomes depend on the different degrees of involvement in the synostotic process by the various skull base sutures which were essentially unaffected by the surgical procedures.