How to Prevent Mandibular Lower Border Notching After Bilateral Sagittal Split Osteotomies for Major Advancements: Analysis of 168 Osteotomies.

PURPOSE: Mandibular ramus bilateral sagittal split osteotomy (BSSO) has been the most commonly used technique in orthognathic surgery for mandibular advancement. However, a common complication of BSSO has been the occurrence of visible and palpable osseous defects at the inferior border of the mandible. The aim of the present study was to determine whether bone grafting of the osseous defect at surgery would reduce the defect at 1 year postoperatively compared with no bone grafting. MATERIALS AND METHODS: The present retrospective cohort study evaluated patients who had undergone mandibular ramus BSSO for 10 mm or more of advancement. The primary predictor variable was BSSO surgery with bone grafting of the defect (graft group [GG]) versus no bone graft (no graft group [NGG]). The size of the mandibular ramus inferior border defect was the outcome variable considered within the framework of a 1-year postoperative cone beam computed tomography (CBCT) analysis. Gender, age, and the amount of advancement were also considered in the multilevel regression analyses. RESULTS: From January 2012 to November 2016, 84 patients (168 osteotomies) had undergone BSSO surgery with 10 mm or more of mandibular advancement at the Facesurgery Center (Parma, Italy). Their mean age was 27.4 years (range, 17 to 44 years). Of the 84 patients, 40 had undergone BSSO with bilateral bone grafts (GG). The monocortical block of the iliac crest bone was used as the bone homograft. The final residual defect was measured at 1 year postoperatively on CBCT scans. The GG and NGG had presented with a mean final defect of 0.7 mm (range, 0 to 4.5 mm) and 3.0 mm (range, 0 to 5.5 mm), respectively. Complete absence of the defect was achieved in 72% of the osteotomies in the GG and 9% of the osteotomies in the NGG. CONCLUSIONS: The use of an iliac crest bone allograft block in the gap between 2 segments during mandibular advancement of 10 mm or more substantially reduced the size and incidence of inferior border defects.

Mandibular distraction in neonates: indications, technique, results.

BACKGROUND: The Pierre Robin Sequence features were first described by Robin in 1923 and include micrognathia, glossoptosis and respiratory distress with an incidence estimated as 1:8,500 to 1:20,000 newborns. Upper airway obstruction and feeding difficulties are the main concerns related to the pathology. Mandibular distraction should be considered a treatment option (when other treatments result inadequate). PATIANTS AND METHODS: Ten patients between the ages of 1 month and 2 years with severe micrognathia and airway obstruction were treated with Mandibular Distraction Osteogenesis (MDO).All patients underwent fibroscopic examination of the upper airway and a radiographic imaging and/or computed tomography scans to detect malformations and to confirm that the obstruction was caused by posterior tongue displacement. All patients were evaluated by a multidisciplinary team. Indications for surgery included frequent apneic episodes with severe desaturation (70%). Gavage therapy was employed in all patients since oral feeding was not possible. The two tracheotomy patients were 5 months and 2 years old respectively, and the distraction procedure was performed to remove the tracheotomy tube. All patients were treated with bilateral mandibular distraction: two cases with an external multivector distraction device, six cases with an internal non-resorbable device and two cases with an internal resorbable device. In one case, the patient with Goldenhar's Syndrome, the procedure was repeated. RESULTS: The resolution of symptoms was obtained in all patients, and, when present, tracheotomy was removed without complications. Of the two patients with pre-existing tracheotomies, in the younger patient (5 months old) the tracheotomy was removed 7 days postoperatively. In the Goldenhar's syndrome case (2 years old) a Montgomery device was necessary for 6 months due to the presence of tracheotomy-inducted tracheomalacia. Patients were discharged when the endpoint was obtained: symptoms and signs of airway obstruction were resolved, PAS and maxillomandibular relationship improved, and tracheotomy, when present, removed. During the follow-up, no injury to the inferior alveolar nerve was noted and scarring was significant in only the two cases treated with external devices. CONCLUSION: Mandibular Distraction Osteogenesis is a good solution in solving respiratory distress when other procedures are failed in paediatric patients with severe micrognatia.

Tessier 3 cleft with bilateral anophthalmia: case report and surgical treatment.

Tessier clefts type 3 and 4 are rare. In this paper the authors report on the management of a wide Tessier 3 cleft. There is no standardized protocol or timing of the surgical procedures in this rare disfiguring condition. Generally speaking, the aim is to preserve the function of important anatomical structures (e.g., a seeing eye.) and reconstruct, as best as possible, harmonic facial features. The authors present a "step by step" solution of the malformation pointing out the limitations of the surgical procedures they used and the goals they wanted to obtain. Despite of the uniqueness and the complexity of the pathology, the authors think they obtained reasonable results both in term of function and aesthetics, permitting the patient to be accepted in the social environment.

The importance of a differential diagnosis between true hemifacial microsomia and pseudo-hemifacial microsomia in the post-surgical long-term prognosis.

Long-term results after surgical treatment of the mandibular asymmetry in growing children with hemifacial microsomia (HFM), whether with osteotomies or distraction osteogenesis, have mostly shown a tendency towards the recurrence of the asymmetry. In contrast, in the literature we find sporadic case reports where the long-term post-surgical follow-up of patients diagnosed as HFM, are surprisingly stable. All these reports refer to patients who have substantially no soft tissue involvement, but only severe mandibular ramus and condyle deformities. The phenotypes of these cases are unexpectedly similar. The authors suggest, that it is possible that all of these cases might be isolated hemimandibular hypoplasias, misdiagnosed as HFM, which present a normal functional matrix and, therefore, tend to grow towards the original symmetry. Differential diagnosis between true HFM and this HFM-like isolated hemimandibular hypoplasia (pseudo-HFM) is of great importance given the very different prognosis and it is possible through the collaboration between not only surgeons and orthodontists, but also of geneticists and dysmorphologists.

Cranioplasty for repair of a large bone defect with autologous and homologous bone in children.

Cranioplasty is a well-established reconstructive procedure for restoring craniocerebral protection and improving cosmetic defects. Most allograft materials are not suitable in pediatric patients owing to skull growth; thus, autologous bone is often preferred in the reconstruction of the pediatric skull because of its capacity to osseointegrate and grow with the pediatric skeleton. A 33-month-old boy with Ewing sarcoma of the right frontal bone underwent surgical treatment with tumor excision. The resected bone was reconstructed with full-thickness calvaria harvested from the right parietal region. The residual parietal gap was filled with homologous bone taken from the iliac wing. This reconstructive technique was chosen to guarantee normal development of the frontal region and tissue integration, while considering possible radiotherapy after the primary surgery.