Treatment of hemifacial microsomia in a growing child: the importance of co-operation between the orthodontist and the maxillofacial surgeon

Growth Evaluation After Costochondral Graft Combined With Functional Appliance in Children With Temporomandibular Joint Ankylosis

The treatment of temporomandibular joint (TMJ) ankylosis in children is a great challenge for surgeons. Costochondral graft (CCG) is a common method of reconstructing the TMJ in children. However, the growth pattern of CCG is unpredictable. In this study, we introduced a surgical-orthodontic approach and evaluated the growth results of the mandible and maxilla in children with TMJ ankylosis through 3-dimensional computed tomography measurements. A prospective cohort study was conducted on child patients diagnosed as having TMJ ankylosis between September 1, 2018 and June 1, 2020. Computer-aided virtual mandibular position guided the CCG, and removable functional appliance was used after surgery. The maximal incisal opening (MIO), the maxilla height, and the length of mandibular ramus were determined. Paired t test was performed to analyze the differences among various stages. Six patients (3 females, 3 males; aged 6-9 y) were included in this study. MIO was 12.4 mm before surgery and improved to 36.8 mm after 42.8 months' follow-up. Mandible length increased by 5.1 mm in the affected side and by 5.3 mm in the unaffected side, without significant difference. The affected maxilla height increased by 6.7 mm, which was more than 5.0 mm in the unaffected side. In conclusion, continued growth of mandible and maxilla can be achieved through CCG combined with functional appliance treatment for children TMJ ankylosis.

Mechanical stress can regulate temporomandibular joint cavitation via signalling pathways

The temporomandibular joint (TMJ), composed of temporal fossa, mandibular condyle and a fibrocartilage disc with upper and lower cavities, is the biggest synovial joint and biomechanical hinge of the craniomaxillofacial musculoskeletal system. The initial events that give rise to TMJ cavities across diverse species are not fully understood. Most studies focus on the pivotal role of molecules such as Indian hedgehog (Ihh) and hyaluronic acid (HA) in TMJ cavitation. Although biologists have observed that mechanical stress plays an irreplaceable role in the development of biological tissues and organs, few studies have been concerned with how mechanical stress regulates TMJ cavitation. Based on the evidence from human or other animal embryos today, it is implicated that mechanical stress plays an essential role in TMJ cavitation. In this review, we discuss the relationship between mechanical stress and TMJ cavitation from evo-devo perspectives and review the clinical features and potential pathogenesis of TMJ dysplasia.

Three-dimensional surgical management of a patient with Pruzansky I hemifacial microsomia and severe facial asymmetry: A 4-year follow-up

Treatment of hemifacial microsomia is challenging and often requires multiple interventions to restore function and facial esthetics. In this article, the combined orthodontic-surgical treatment of a young patient exhibiting Pruzansky I hemifacial microsomia is reported. The patient was aged 15 years, but his bone age was determined to be 18 years. His facial asymmetry was severe, with the nose and a retrusive chin deviated to the left side and a canted smile. The presurgical phase was aimed at centering the mandibular midline to the center of the chin through the distal movement of the mandibular left buccal dentition. The surgery was planned with 3-dimensional computer-aided surgical simulation and included a LeFort I and unilateral sagittal split osteotomies combined with a genioplasty. This report illustrates the therapeutic stages and a 4-year follow-up of a unique and complex orthognathic surgical approach, chosen among other alternatives and leading to improved function and appearance and stable results.

Pseudo Hemifacial Microsomia With Condylar-Coronoid Collapse: New Therapeutic Approach in Growing Patients

The purpose of this study is to describe the management of 2 dimorphic patients affected by Hemimandibular Hypoplasia with Condylar-Coronoid Collapse (HH-CCC), also called Pseudo Hemifacial Microsomia, where the orthopedic treatment gave an excellent long-term follow-up. The patients were a 7-year-old female and a 6-year-old male with a HH-CCC on the left side, an asymmetrical face with chin deviation, class II dental malocclusion and canting of the occlusal plane. An X-ray evaluation and clinical observation confirmed the unilateral mandibular deficiency and the collapse of the condyle on the coronoid process on the affected side. The treatment plan consisted of the use of an asymmetrical functional appliance with a vertical screw. The appliance was gradually activated on the vertical plane on one side by a screw incorporated on an acrylic plate. It was used for 22 hours/day, including sleep time but not during meals. This treatment improved the patient' s facial appearance. HH-CCC showed a positive response to functional therapy.

One-Year Relapse of Mandibular Distraction for Hemifacial Microsomia Using Masseteric Botulinum Toxin Type A Injections

BACKGROUND

The relapse of hemifacial microsomia was thought to be highly related to the soft tissue envelope around the mandible angle mainly composed by masseter and medial pterygoid. According to the reason, we tried to apply masseter injection of type A botulinum toxin to weaken the soft envelope tension on the early stage post mandible distraction in adult HFM patients.

METHODS

Eight patients diagnosed with HFM were studied and randomly assigned to an experimental or control group. Patients in the experimental group were treated with DO, orthognathic surgeries, autologous fat grafting, and bilateral masseter muscle injection with type A botulinum toxin. The patients in control group were treated with the same procedures as the patients in experimental group except for masseter muscle injection with type A botulinum toxin. The recurrence rates of both groups were evaluated and analyzed after nearly 1 year of follow-up.

RESULTS

The mean recurrence rate was 26.30% ± 11.84% (range 7.62%-37.27%) in the 8 patients after 1-year follow-up. The relapse rate was 16.32% ± 7.78% (7.62%-26.22%) in the experimental group and 36.28% ± 1.03% (34.84%-37.27%) in the control group. There was a significant difference (P = 0.002) between the experimental group and the control group.

CONCLUSIONS

The combination of DO, orthognathic surgeries, autologous fat particle transplantation, and masseter muscle type A botulinum toxin injection technique could be a comprehensive treatment plan for adult patients of HFM. Furthermore, masseter injection of type A botulinum toxin might be an alternative method to reduce the early recurrence rate of postoperative adult patients of HFM.

Goldenhar syndrome: current perspectives

BACKGROUND

Progress in medical branches that has taken place since the first child with Goldenhare syndrome (GS) had been described in 1952 by Maurice Goldenhar, facilitated better understanding of this congenital defect. It also gave new perspectives and the opportunity to achieve satisfactory treatment results, mainly due to development of surgical techniques.

DATA SOURCES

Based on the literature and own experience, we discussed the phenotype of presentation of GS, ethiopathogenesis, genetic counselling and treatment with particular emphasis on surgery correction of hemifacial microsomia.

RESULTS

The spectrum of GS abnormalities ranges from mild to severe ones and include patients with barely noticeable facial asymmetry to very pronounced facial defect with more or less severe abnormalities of internal organs and/or skeleton. It is characterized most commonly by impaired development of eyes, ears, lips, tongue, palate, mandible, maxilla, zygomatic and orbital structures and deformations of the teeth structures. Ethiopathogenesis is multifactorial and dependent on genetic and environmental factors but there are still many unknowns about the syndrome which should be revealed.

CONCLUSIONS

Patients with GS due to a large variety of abnormalities and different severity of symptoms pose a challenge for clinicians. All of this necessitate an individual approach to each single patient and involvement a team of specialists in treatment planning. It is a complex, long-lasting, multidisciplinary process and should be divided into stages, according to patient's age, as well as the extent and severity of observed abnormalities. Neonatologists and pediatricians are involved in care of these patients from the onset.

Hemifacial Microsomia : Clinicoradiological Insight and Report of a Case

Background

Hemifacial microsomia is a congenital malformation characterized by deficiency in the amount of hard and soft tissue on one side of the face. It is primarily a syndrome of the first branchial arch, involving underdevelopment of the temporomandibular joint, masticatory muscles, mandibular ramus, ear and, occasionally, defects in facial nerve and muscles.

Case Details

The clinical and radiological manifestations of a 14-year-old male patient having hemifacial microsomia is highlighted in this article to enhance our knowledge and diagnostic skill of this rare entity.

Conclusion

This case illustrates that early diagnosis and intervention in a patient with hemifacial microsomia is quintessential for proper functioning and esthetics of the orofacial structures, which will lead to a better prognosis.

Surgical Classification of the Mandibular Deformity in Craniofacial Microsomia Using 3-Dimensional Computed Tomography

Background:

Grading systems of the mandibular deformity in craniofacial microsomia (CFM) based on conventional radiographs have shown low interrater reproducibility among craniofacial surgeons. We sought to design and validate a classification based on 3-dimensional CT (3dCT) that correlates features of the deformity with surgical treatment.

Methods:

CFM mandibular deformities were classified as normal (T0), mild (hypoplastic, likely treated with orthodontics or orthognathic surgery; T1), moderate (vertically deficient ramus, likely treated with distraction osteogenesis; T2), or severe (ramus rudimentary or absent, with either adequate or inadequate mandibular body bone stock; T3 and T4, likely treated with costochondral graft or free fibular flap, respectively). The 3dCT face scans of CFM patients were randomized and then classified by craniofacial surgeons. Pairwise agreement and Fleiss' κ were used to assess interrater reliability.

Results:

The 3dCT images of 43 patients with CFM (aged 0.1–15.8 years) were reviewed by 15 craniofacial surgeons, representing an average 15.2 years of experience. Reviewers demonstrated fair interrater reliability with average pairwise agreement of 50.4 ± 9.9% (Fleiss' κ = 0.34). This represents significant improvement over the Pruzansky–Kaban classification (pairwise agreement, 39.2%; P = 0.0033.) Reviewers demonstrated substantial interrater reliability with average pairwise agreement of 83.0 ± 7.6% (κ = 0.64) distinguishing deformities requiring graft or flap reconstruction (T3 and T4) from others.

Conclusion:

The proposed classification, designed for the era of 3dCT, shows improved consensus with respect to stratifying the severity of mandibular deformity and type of operative management.

Nonsurgical Treatment of Hemifacial Microsomia: A Case Report

Introduction:

Hemifacial microsomia (HFM) is a birth defect involving craniofacial structures derived from the first and second branchial arches. Although it is a relatively uncommon malformation, it is the second most common craniofacial birth defect after cleft lip and palate (CL/P).

Case Presentation:

This is a case report about the successful orthodontic treatment of a patient with mild hemifacial microsomia (HFM), using a non-surgical orthopedic and orthodontic treatment approach. The aim of this approach was to make the best noninvasive modality to treat HFM. A 7-year-old boy with a mild HFM presented with a convex profile and slight chin deviation. Orthopedic treatment performed using a hybrid functional and high pulls headgear. Treatment continued by fixed orthodontic straight wire appliance to achieve perfect occlusion.

Conclusions:

Excellent esthetic and functional results achieved; total treatment duration was about 72 months.

Costochondral grafting in craniofacial microsomia

BACKGROUND

Craniofacial microsomia encompasses a spectrum of diagnoses associated with variable degrees of mandibular hypoplasia, facial asymmetry, chin deviation, occlusal abnormalities, and potential airway compromise. This study presents one surgeon's experience with costochondral rib grafting for mandibular reconstruction in children with Pruzansky/Kaban type 2B and type 3 mandibular hypoplasia.

METHODS

An institutional review board-approved retrospective chart review was performed of all patients with craniofacial microsomia who underwent costochondral rib grafting for mandibular reconstruction performed by the senior author (S.P.B.) at The Children's Hospital of Philadelphia from January of 1998 to September of 2013. Demographic information, surgical history, operative details, postoperative complications, and outcomes were recorded. Plain radiographs and preoperative and postoperative three-dimensional computed tomographic scans were reviewed.

RESULTS

Two hundred fifty-five patients were diagnosed with craniofacial microsomia, and 22 patients met inclusion criteria. Twelve boys and 10 girls underwent grafting at an average age of 7.2 years. Thirty-three costochondral rib grafts were performed, 11 unilateral reconstructions and 11 bilateral reconstructions. Twelve hemimandibles were type 2B and 21 were type 3. No intraoperative complications were reported, and no incidence of graft resorption was noted. No additional procedures were required in 27 reconstructed hemimandibles (81.8 percent), whereas six (18.2 percent) required secondary distraction osteogenesis. Only one patient developed postoperative ankylosis. No malunion or nonunion was noted.

CONCLUSION

The approach described in this article allowed the authors to obtain reliably good results with costochondral rib grafting for type 2B and type 3 mandibular hypoplasia associated with craniofacial microsomia.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Hemifacial microsomia: a series of three case reports

Hemifacial Microsomia (HFM) is an asymmetric craniofacial malformation which results in hypoplasia of the components of the first and second branchial arches. There can be various anomalies, which include conductive hearing loss which is caused by external and middle ear deformities. HFM is the second most common congenital facial anomaly which is seen after cleft lip/palate. For the pre-surgical evaluation of this anomaly, diagnostic imaging and classification of the facial structures, based on OMENS classification, is of prime importance. The management of this developmental malformation is multidisciplinary. We are presenting a series of three cases with diverse clinical and radiographic features which ranged from mild facial asymmetry and ear malformation to facial paralysis.

New therapeutics in promoting and modulating mandibular growth in cases with mandibular hypoplasia

Children with mandibular growth deficiency may develop airway obstruction. The standard treatment of severe airway obstruction involves invasive procedures such as tracheostomy. Mandibular distraction osteogenesis has been proposed in neonates with mandibular deficiency as a treatment option to avoid tracheostomy procedure later in life. Both tracheostomy and distraction osteogenesis procedures suffer from substantial shortcomings including scarring, unpredictability, and surgical complications. Forward jaw positioning appliances have been also used to enhance mandible growth. However, the effectiveness of these appliances is limited and lacks predictability. Current and future approaches to enhance mandibular growth, both experimental and clinical trials, and their effectiveness are presented and discussed.

Effects of growth hormone and ultrasound on mandibular growth in rats: MicroCT and toxicity analyses

It has been shown by previous studies that mandibular growth can be enhanced by the systemic administration of recombinant growth hormone (rGH) and/or local application of therapeutic low intensity pulsed ultrasound (LIPUS). The purpose of this study was to determine if local injection of rGH and application of LIPUS to the temporomandibular joint (TMJ) would synergistically enhance mandibular growth. In an animal study, the effect of rGH, LIPUS, and combination of rGH and LIPUS on male Sprague-Dawley rats was observed. Mandibular growth was evaluated by measuring total hemimandibular and condylar bone volume and bone surface area as well as condylar bone mineral density (BMD) after 21 days on dissected rats' mandibles using micro-computed tomography (MicroCT). The expression of c-jun mRNA extracted from the liver of each of these rats was also quantified by real-time polymerase chain reaction to evaluate possible systemic effect of local rGH administration. Significant growth stimulation was observed in the mandibular and condylar bone of the animals treated with rGH, LIPUS, and rGH/LIPUS combined when compared with the control group. Bone volume, surface area, condylar bone mineral density, and c-jun expression were also compared between the treatment groups and the control in the liver. The results suggest that mandibular growth may be enhanced by injection of rGH or LIPUS application. The current study although showed synergetic effect of rGH and LIPUS application in increasing mandibular condylar head length, there was no significant changes in mandibular bone volume using both treatments together when compared to the two individual treatments. Moreover, combined rGH and LIPUS decreased condylar bone mineral density than each treatment separately. Future research could be directed to investigate the effects of different rGH doses and/or different LIPUS exposures parameters on lower jaw growth.

Hemifacial microsomia: a clinicoradiological report of three cases

Hemifacial microsomia is a congenital malformation in which there is deficiency in the amount of hard and soft tissues on one side of the face. It is primarily a syndrome of first and second branchial arches involving underdevelopment of the temporomandibular joint, mandibular ramus, masticatory muscles, ears and occasionally defects in facial nerve and muscles. Here, we report three cases of hemifacial microsomia diagnosed based on clinical and radiographic findings. All three cases had variable presentations ranging from the mildest form that included facial asymmetry and ear deformity to the most severe and unusual form with facial nerve paralysis and spine deformity.

Hemifacial microsomia

Hemifacial microsomia (HFM) is a craniofacial disorder characterized by a wide spectrum of anomalies, including conductive hearing loss due to external and middle ear deformities [1]. Hemifacial microsomia is the second most common developmental craniofacial anomaly after cleft lip and palate. Diagnostic imaging is important for presurgical evaluation of patients with this anomaly; however the broad spectrum of abnormalies encountered in patients with hemifacial microsomia can be confusing [2]. We present a case of a hemifacial microsomia in 12 year old male.

Congenital deformities and developmental abnormalities of the mandibular condyle in the temporomandibular joint

The temporomandibular joint (TMJ) consists of the mandibular condyle and the articular eminence of the temporal bone. The morphological development of the TMJ during prenatal life lags behind other joints in terms of both the timing of its appearance and its progress. At birth, the joint is still largely underdeveloped. There are many causes of the various growth disturbances and abnormalities of the mandibular condyle and related structures. Growth disturbances in the development of the mandibular condyle may occur in utero late in the first trimester and may result in disorders such as aplasia or hypoplasia of the mandibular condyle. Meanwhile, hyperplasia of the mandibular condyle is not visible at birth and seems to be gradually acquired during growth. In the present review article, the congenital abnormalities of the mandibular condyle are classified morphologically into three major groups and two subgroups from a clinical standpoint: (1) hypoplasia or aplasia of the mandibular condyle, including (i) primary condylar aplasia and hypoplasia, (ii) secondary condylar hypoplasia; (2) hyperplasia; and (3) bifidity. In addition, the molecular-based etiology of anomalies of the mandibular condyle is also discussed.