Craniofacial Patients Research Articles

S4B-01 SESSION 4B: ORTHOGNATHIC / TREACHER-COLLINS DENTAL CARIES IN A CRANIOFACIAL POPULATION: ‘UNDERSTANDING THE RISK: PREVENTING THE PREVENTABLE’ WEST MIDLANDS SUPRA REGIONAL CRANIOFACIAL UNIT, UK

Introduction: Abnormalities of oral and dental anatomy are noted in many craniofacial conditions. Children diagnosed with craniosynostosis may present with dental anomalies, skeletal abnormalities and cognitive defects. This puts them at a greater risk of developing dental caries. Dental caries is a largely preventable disease, however dental extractions are still a common reason for hospital admission in the UK. Having a healthy dentition will provide a more accurate base for later proposed orthognathic/ facial deformity surgery in the craniofacial patient. Aim: A prospective audit to assess craniofacial patients’ caries experience and associated risk factors at Birmingham Children’s Hospital. Objectives: 1.To assess the patients’ caries risk against UK guidelines; 2. To assess if the patients have access to a General Dental Practitioner (GDP) To assess the patients’ previous experience of dental treatment Methods: Questionnaires were disseminated prospectively over a 4-month period to patients who attended the craniofacial clinic at BCH. This comprised a series of questions to understand their risk of developing dental decay, access to dental professionals and any experience of dental treatment. Results: 40 patients completed the questionnaire, 16 had craniosynostosis related to a syndrome or multi-suture synostosis, the other 24 patients had single suture synostosis. Caries risk status: The caries risk for each patient was assessed based on their diet, availability of fluoride and dental caries experience. In the single suture cohort, 4 patients were regarded as being ‘low caries risk’ and the remaining 20 were ‘high caries risk’. In the syndromic/multi-suture craniosynostosis cohort, all children were regarded as being ‘high caries risk’ as a result of their medical condition and the other risk factors for caries. Access to routine dental care: In the syndromic/multi-suture synostosis cohort, 3 children did not have access to a dentist and 4 children did not have access in the single suture group. Patients’ previous dental experience: Of the study population, 10 had experienced dental fillings, 4 had previous extractions and 2 children had undergone a general anaesthetic for dental treatment. The 4 children who had undergone extractions were in the multi-suture craniosynostosis group. Conclusion: This patient reported questionnaire, demonstrated that the majority of our craniofacial patients sampled were at high risk of developing dental caries. To reduce this risk, there is a need for a preventative strategy and development of a robust pathway to support the young craniofacial patient population.

S12-04 SESSION 12: FACIOCRANIOSYNOSTOSIS – PART II INFLUENCE OF MONOBLOC/LEFORT III DISTRACTION ON THE DEVELOPING POSTERIOR MAXILLARY DENTITION AND ITS RESULTANT EFFECT ON ORTHOGNATHIC SURGERY.

Introduction: Patients with syndromic craniosynostosis often undergo midface advancements with distraction, such as a Lefort III or Monobloc, while posterior maxillary dental formation is ongoing which may indirectly damage developing tooth buds. The purpose of this study is to evaluate the dental development of the posterior maxilla after monobloc or lefort III and its clinical implications on orthognathic surgery. Methods: We evaluated the medical records and imaging (CT +/- Panorex) of all syndromic craniosynostosis patients treated at our institution from 1999–2018. Those patients without at least 1 year follow-up, incomplete medical records, or incomplete imaging were excluded from the study. Those patients who also underwent orthognathic surgery between 2014–2018 were also reviewed. Statistical comparisons of demographic, procedural, dental status and imaging data were performed. Results: 90 patients underwent midface advancement during the study period and 32 met the inclusion criteria. Average age of surgery was 7.2years. 65% (21/32) had radiographic evidence of posterior maxillary dental pathology. Increased age at time of surgery was significantly correlated with a decreased risk of dental injury (p=0.034, OR=0.55) (see attached graph). Damage to either second or third maxillary molar was significantly associated with a younger age at time of surgery (p=0.021 and p=0.034), and surgery at age seven and above trended towards being protective of the posterior maxillary dentition (Fischer exact p=0.074). There was no significant age relationship with time of surgery and injury to the first molar (p=0.173). 5 patients, average age of 17 years old, who had a previous monobloc/lefort III distraction underwent orthognathic surgery between 2014–2018. All needed adjunctive oral surgery procedures involving posterior maxillary teeth (extractions, dental exposure, anchorage of maxillary molars), and all have at least one quadrant with only first molar or no molar occlusion. Pre-orthognathic surgery orthodontics averaged 38.6 months. Conclusion: Monobloc and Lefort 3 distraction for syndromic craniofacial patients has obvious functional benefits. Early intervention is significantly associated with injury to the growing posterior maxillary dentition, and waiting until at least age 7 trends towards being protective. Damage to developing permanent maxillary molars may affect timing of orthodontic management and treatment planning for orthognathic surgery.

S3-13 SESSION 3: FACIOCRANIOSYNOSTOSIS – PART I SURGICAL OUTCOMES OF COMBINED LEFORT III AND LEFORT I OSTEOTOMY: IMMEDIATE POST-SURGERY AND AT ONE YEAR FOLLOW UP

Introduction: The purpose of this study was to evaluate the surgical outcomes of combined LeFort III and I osteotomies in the treatment of craniofacial patients with severe midface hypoplasia. Methods: A single-institution retrospective review of all patients who underwent combined LeFort III/I surgery from 1980 to 2018 (38 years). Inclusion criteria included 1) Le Fort III/I surgery at skeletal maturity 2) lateral cephalograms at pre-surgical and one week post-surgery and 3) computerized and traditional surgical planning records. 15 consecutive patients met the inclusion criteria (11 male and 4 female patients). Of the 15 patients, 7 patients had one year follow-up records. The mean age at the time of the surgery was 19.1± 6.1 years (range 17 to 26 years). Patient diagnosis included: Crouzon (N=9), Pfeiffer (N=2), Apert (N=1), Antley-Bixler (N=1), fronto-nasal dysplasia (N=1) and cleidocranial dysplasia (N=1). All study patients underwent a standard subcranial LeFort III with repositioning using an intermediate splint followed by interposition bone graft and rigid fixation. After fixation of LeFort III segment, a LeFort I osteotomy was performed and a final splint was used to repositioned the LeFort I segment prior to rigid fixation. Lateral cephalograms were studied at pre surgery (T1), immediate one week post surgery (T2), and one year post surgery (T3). Results: Mean blood loss during surgery was 888 ± 800 ml and mean duration of surgery was 7.3 ± 3.3 hrs. The LeFort III segment was planned for a 7.6 ±2.2mm advancement measured at orbitale. The LeFort I segment was planned to advance a total of 12.1±5.2mm at A point and 12.1± 5.5mm at upper incisor edge. One week post-LeFort III/I advancement shows that the LeFort III segment was advanced 5.8 ±4.3mm anteriorly and displaced 2.6±4.3mm inferiorly measured at Orbitale. The LeFort I segment advanced a net total of 10.1 ± 3.4mm anteriorly, 3.8 ±5.4mm inferiorly at A point and 8.9±4.1mm anteriorly, 4.2 ±5.6mm inferiorly at upper incisor edge. ANB angle increased by 6.6±4.6 degrees from T1 to T2. At one year follow-up, ANB angle decreased by 1.3±1.5 degrees compared to T2. Additionally, when compared to T2, Orbitale advanced 0.37 ± 2.9mm, A Point decreased by 3.4±3.5mm, and upper incisor edge retracted 1.9±2.5 mm at T3 post surgery. Conclusion: Combined LeFort III and I advancement surgery significantly improved midface position and occlusal relationship in patients with midface hypoplasia. At one year follow up, LeFort III/I segments shows about 20% relapse at upper incisal edge and 35% at point A. However, patients still maintained a positive overjet and overbite. Overcorrection is recommended to compensate for the post-surgical relapse.

S7A-04 SESSION 7A: SAGITTAL SYNOSTOSIS SAGITTAL SYNOSTOSIS WITHOUT SCAPHOCEPHALY – A REVIEW OF 8 CASES

Introduction: Sagittal Synostosis presenting with scaphocephaly is the most common form synostosis with a prevalence of up to one in 2000 live births. However sagittal synostosis without scaphocephaly is rarely reported in the literature, with only one case series of 8 patients reported to date1. We also identified a large cohort and reviewed our patients to expand upon the current knowledge of the clinical presentation and management of this group. Methods: A search was conducted using the hospital database in order to identify craniofacial patients with a diagnosis of sagittal synostosis. On review, 306 patients were identified, 8 (2.6%) of which had a diagnosis of sagittal synostosis without scaphocephaly (Male 6, Female 2) where scaphocephaly was taken as a cephalic index less than 73. Cases were reviewed using the hospital database and the patient’s electronic records. Results: All patients had a normal cranial index. Only one patient had symptoms of headache with a strong family history of migraine. Clinical features of the headache were not in keeping with raised pressure but due to the chronic nature, intracranial pressure (ICP) monitoring was undertaken and was normal. All patients had normal ophthalmological assessment. None of these patients required vault surgery. Conclusion: To the best of our knowledge, this is jointly the largest case-series conducted amongst this group. Results from the previous case series revealed that in 6 of the 8 cases, intracranial pressure monitoring was required. Of those six patients, 4 (67%) were said to be abnormal and later went on to have vault surgery. Our data challenges this as none of our series required intracranial monitoring. This could be more in keeping with the fact that there are presumably many patients in the community with this diagnosis who are not identified due to the absence of the classic scaphocephalic head shape. Further studies into cases of this condition would need to be identified to allow a wider and more comprehensive comparison

S4A-25 SESSION 4A: GENERALITIES IN CRANIOSYNOSTOSIS – PART I INTERNATIONAL ESTABLISHMENT OF CRANIOFACIAL PROGRAM: 15 YEARS IN THE REPUBLIC OF MOLDOVA

Introduction: The prevalence of craniosynostosis is estimated to be 1 in 2100 births in the US. The global prevalence is unknown due to a lack of recognition, limited technology for diagnosis, and limited resources for treatment. Moldova, a country of 2.8 million people. The infrastructure for surgical treatment of craniosynostosis in Moldova was non-existent in 2003. Given the clear need and lack of alternatives, we will describe a replicable pathway to develop local surgical care for craniofacial patients through education and training. Methods: A bilateral state partnership for collaboration began between North Carolina and Moldova in 1999. This facilitated the beginning of our relationship in 2003 between the surgical departments of our Universities. Stake holders were identified and jointly committed to the establishment of a program. Yearly surgical educational exchanges were conducted. A local team was established including pediatric oral maxillofacial surgeons, neurologists, pediatricians, dentists, neurosurgeons, and anesthesiologists. Data was collected from 2011 to 2018 on more than 33 patients who underwent surgical intervention from the joint team. The patients were assessed including gender, age, blood loss, blood transfusion, duration of surgery, complications, cephalic index (CI), length of stay, and cost. Additional patients treated by the Moldova team were also monitored for the same outcome parameters. Results: Surgical intervention began with minimally invasive surgery utilizing springs for treatment of sagittal synostosis. This allowed the local team to provide time sensitive surgery with limited resources. As the team built confidence and resources were added, complete cranial vault surgery was successfully performed. The joint cases included treatment of metopic (6), sagittal (13), unicoronal (9), bicoronal (4) and multi-suture (1) synostosis. There were no significant complications during the follow-up period. For the past several years the Moldova team has been independently treating a wide range of craniofacial deformities with minimal morbidity and excellent aesthetic outcomes. Conclusion: Organizations desiring to develop craniofacial programs should begin with establishing relationships at the local level. A commitment is needed to build trust among the physicians, administrators and patients. Financial resources are helpful to provide the needed educational exchange programs and equipment needed for the perioperative care of the patients. Significantly more patients can receive needed and life-saving surgical care in their own country when there is a dedicated local team trained to provide the surgery.

Comparison of Pain Perception in Patients Affected by Cleft and Cranio Facial Anomalies Treated With Traditional Fixed Appliances or Invisalign.

The objective of this prospective study was to compare the difference in pain perception between treatment with aligners (AL) and fixed appliances (FA) in patients affected by cleft and craniofacial anomalies (CFA). The sample consisted of 100 syndromic caucasian patients affected by various CFA from 2 different hospitals. Fifty patients treated with AL were matched for sex, age, and CFA with a control sample of 50 patients treated with FA. A modification of the Mc Gill Pain Questionnaire was adapted to our needs. Statistical differences were found. Aligners induced more tightness and tension than FA, while FA induced more pain descriptors and patients reported a higher intake of painkillers. The results of this study documented a higher pain perception with FA than with AL in patients affected by CFA. The higher sensitivity to pain in cleft and craniofacial patients with fixed treatment could be related to their higher prior sensitization, given the past surgeries and orthodontic treatments. Thus, this study might suggest that Invisalign treatment might be a further interesting treatment option for patients with cleft in order to reduce their burden of orthodontic pain.

Long-Term Results for a One-Stage Surgery Technique for Patients With Craniofacial Plexiform Neurofibroma.

Neurofibromatosis (NF) is an autosomal dominant genetic disorder, and NF type 1 (NF1) is one of the most common forms. Plexiform neurofibroma (PNF) is one of the characteristic expressions of NF1. The proper treatment for patients with craniofacial PNF is surgery. The evaluation methods for the surgical outcome of these patients are still controversial. As a consequence, a one-stage surgical technique and an appropriate evaluation method for patients with craniofacial PNF were discussed in this article. This research is a retrospective study. Nine patients with craniofacial PNF were included in this study. They had undergone a one-stage surgical technique of tumor debulking and nasolabial fold reconstruction. Three methods had been applied to evaluate the surgical outcome. Significant improvement was observed in 8 patients. Eight patients were assessed by the relatively objective evaluation method. Obvious symmetry improvement was calculated using Mimics software in 7 patients. The surgical technique could achieve good surgical outcomes in both functional and cosmetic terms. Additionally, the relatively objective evaluation technique based on Mimics software could be a more convincing method for evaluating the surgical outcomes of craniofacial patients with PNF.

Evaluation of parental and surgeon stressors and perceptions of distraction osteogenesis in pediatric craniofacial patients: a cross-sectional survey study.

There is a paucity of literature on how limitations of distraction osteogenesis (DO) are perceived by physicians and parents of pediatric patients. Specifically understanding which features of DO are most concerning to these two groups may better inform parent education, as well as direct improvements in distraction protocols and devices. Parents/guardians of patients (between January 2016 and October 2017) being treated with craniofacial distraction were recruited to complete a survey regarding level of stress (1 = not stressful, 9 = maximally stressful) associated with eight features of DO. Craniofacial surgeons completed a survey asking them to report (1) their personal level of stress and (2) their perceptions of parental stress regarding these same eight features of DO. Thirty-five parents and 15 craniofacial surgeons completed the survey. The risk of the device getting infected was perceived as most stressful by parents (5.5 ± 2.3) followed by the device sticking through the skin (4.9 ± 2.6) and the second operation for removal (4.7 ± 2.3). These same three features also elicited the highest level of stress among surgeons. Surgeon-perceived parental stress regarding turning of the distractor (5.8 ± 1.5) was significantly higher than parent self-reported stress (4.2 ± 2.8, p = 0.042). Both parents and surgeons perceive risk of device-associated infection, the protrusion of the device through the skin, and the requirement of a second operation for removal as the most stressful drawbacks of distraction. Infection reduction protocols, less obtrusive devices, and devices that do not require removal are potential targets for stress reduction.

Complications following intracranial pressure monitoring in children: a 6-year single-center experience.

OBJECTIVE Intracranial pressure (ICP) monitoring is an important tool in the neurosurgeon's armamentarium and is used for a wide range of indications. There are many different ICP monitors available, of which fiber-optic intraparenchymal devices are very popular. Here, the authors document their experience performing ICP monitoring from 2005 to 2015 and specifically complication rates following insertion of the Microsensor ICP monitor. METHODS A retrospective case series review of all patients who underwent ICP monitoring over a 10-year period from 2005 to 2015 was performed. RESULTS There were 385 separate operations with an overall complication rate of 8.3% (32 of 385 cases). Hardware failure occurred in 4.2% of cases, the CSF leakage rate was 3.6%, the postoperative hemorrhage rate was 0.5%, and there was 1 case of infection (0.3% of cases). Only patients with hardware problems required further surgery as a result of their complications, and no patient had any permanent morbidity or mortality from the procedure. Younger patients (p = 0.001) and patients with pathologically high ICP (13% of patients with high ICP vs 6.5% of patients with normal ICP; p = 0.04) were significantly more likely to have complications. There was no significant difference in the complication rates between general neurosurgical patients and craniofacial patients (7.6% vs 8.8%, respectively; p = 0.67). CONCLUSIONS Intraparenchymal ICP monitoring is a safe procedure associated with low complications and morbidity in the pediatric craniofacial and neurosurgical population and should be offered to appropriate patients to assess ICP with the reassurance of the safety record reported in this study.

Normal/Modern: Reconstructive Surgery in a Mexican Public Hospital

ABSTRACTA growing corpus of anthropological scholarship demonstrates how science and medicine in Mexico are imbued by national concerns with modernization. Drawing on ethnographic research in a public hospital located in the south of Mexico City, I unpack one manifestation of this dynamic, which is the conjugation of the normal and the modern in Mexican reconstructive surgery. The aspiration toward normality underlies everyday clinic practices and relationships in this field, including why parents want surgery for their children and how doctors see their patients and their responsibilities toward them. It is also central to the professional ethic of reconstructive surgeons. I argue that the realities of health care provision in Mexico coalesced with this ethic to produce reconstructive surgeons as political subjects. They aimed to modernize craniofacial surgery in Mexico and so make the bodies of craniofacial patients normal.

Orthognathic surgery in cleft and craniofacial patients

Orthognathic surgery in cleft and craniofacial patients

Etiology and treatment in craniofacial fractures

AbstractIntroduction. Facial trauma remains an important pathology in present days because of its effects. Facial deformities and functional alteration affect patient’s life quality and his society reinsertion. First evaluation has to be thorough to avoid any secondary complications .This type of pathology involves a pluridisciplinary approach: ENT, OMF, neurosurgeon,plastic surgeon,intensive care doctor. Healing implies complex biological process .A healed bone is capable to perform normal duties without titanium plates help. Osteosynthesis allows a faster and correct recovery. Doctors need to possess profound knowledge with regard to anatomy and physiology and to be acquainted with the reconstructive methods used in craniofacial surgery. Material and methods. This study evaluates craniofacial trauma patients who suffered different types of surgical interventions at the ENT Clinic and OMF Department of Constanta County Hospital since January the 1st 2013 until June the 1st 2017. Results. The group involves 133 cases, both genders and all ages. These 2 elements play an important role in this pathology because of the fact that the vast majority of patients are young active males. The sex ratio in the study is 7:1. In most of cases, craniofacial traumas appear after aggressions and car accidents. The nose and mandibular are fractured in a higher percentage in comparison to other parts of facial structures. Discussions. Important and sensitive structures located at this level increase the risk of possible important and definitive damages.

Lip line changes in Class III facial asymmetry patients after orthodontic camouflage treatment, one-jaw surgery, and two-jaw surgery: A preliminary study.

To evaluate the effects of orthodontic camouflage treatment (OCT), one-jaw surgery, and two-jaw surgery on the correction of lip line cant (LLC) and to examine factors affecting the correction of LLC in Class III craniofacial asymmetry patients. A sample of 30 Class III craniofacial asymmetry patients was divided into OCT (n = 10), one-jaw surgery (n = 10), and two-jaw surgery (n = 10) groups such that the pretreatment LLC was similar in each group. Pretreatment and posttreatment cone-beam computed tomography scans were used to measure dental and skeletal parameters and LLC. Pretreatment and posttreatment measurements were compared within groups and between groups. Pearson's correlation tests and multiple regression analyses were performed to investigate factors affecting the amount and rate of LLC correction. The average LLC correction was 1.00° in the one-jaw surgery group, and in the two-jaw surgery group, it was 1.71°. In the OCT group it was -0.04°, which differed statistically significantly from the LLC correction in the other two groups. The amount and rate of LLC correction could be explained by settling of skeletal discrepancies or LLC at pretreatment with goodness of fit percentages of approximately 82% and 41%, respectively. Orthognathic surgery resulted in significant correction of LLC in Class III craniofacial asymmetry patients, while OCT did not.

Racial disparities in health care access among pediatric patients with craniosynostosis.

OBJECTIVE Disparities in surgical access and timing to care result from a combination of complex patient, social, and institutional factors. Due to the perception of delayed presentation for overall health care services and treatment in African American patients on the part of the senior author, this study was designed to identify and quantify these differences in access and care between African American and Caucasian children with craniosynostosis. In addition, hypotheses regarding reasons for this difference are discussed. METHODS A retrospective study was conducted of 132 children between the ages of 0 and 17 years old who previously underwent operations for craniosynostosis at a tertiary pediatric care facility between 2010 and 2013. Patient and family characteristics, age at surgical consultation and time to surgery, and distance to primary care providers and the tertiary center were recorded and analyzed. RESULTS Of the 132 patients in this cohort, 88% were Caucasian and 12% were African American. The median patient age was 5 months (interquartile range [IQR] 2-8 months). African Americans had a significantly greater age at consult compared with Caucasians (median 341 days [IQR 192-584 days] vs median 137 days [IQR 62-235 days], respectively; p = 0.0012). However, after being evaluated in consultation, there was no significant difference in time to surgery between African American and Caucasian patients (median 56 days [IQR 36-98 days] vs median 64 days [IQR 43-87 days], respectively). Using regression analysis, race and type of synostoses were found to be significantly associated with a longer wait time for surgical consultation (p = 0.01 and p = 0.04, respectively, using cutoff points of ≤ 180 days vs > 180 days). Distance traveled to primary care physicians and to the tertiary care facility did not significantly differ between groups. Other factors such as parental education, insurance type, household income, and referring physician type also showed no significant difference between racial groups. CONCLUSIONS This study identified a correlation between race and age at consultation, but no association with time to surgery, distance, or family characteristics such as household income, parental education, insurance type, and referring physician type. This finding implies that delays in early health-seeking behaviors and subsequent referral to surgical specialists from primary care providers are the main reason for this delay among African American craniofacial patients. Future studies should focus on further detail in regards to these barriers, and educational efforts should be designed for the community and the health care personnel caring for them.

Versatility of Distraction Osteogenesis for the Craniofacial Skeleton.

Malformations of the craniofacial skeleton are common. Restoration of anatomic shape, size, and position has been traditionally accomplished using autologous bone grafting to fill gaps created by surgery and segmental movement. The authors present their practice using distraction in many different ages and settings over 20 years. A retrospective review was performed of all craniofacial patients treated using distraction osteogenesis for mandible, midface, and calvarium. The authors identified 205 patient. Mandible: 112 patients were treated at an average age of 3.4 years. 18.8% of patients required repeat distraction. There was no difference in the neonatal versus older group (P = 0.71). There were significantly higher reoperation rates in syndromic children (P < 0.01). Midface: 58 patients underwent Lefort III distraction at an average age of 13.6 years. One (1.7%) required repeat distraction (Miller syndrome). Five (8.6%) patients underwent subsequent Lefort I advancement for occlusal changes. Calvarium: 33 patients were treated at an average age of 4.7 years. No repeat distractions were performed. One patient required an additional advancement procedure. Distraction demonstrates successful long-term correction of defects in the craniofacial skeleton with the versatility and control needed to treat the wide spectrum of deformity.

Current Trends in Craniosynostosis

Craniofacial syndromes and defects can be complex medical problems. They affect multiple organ systems and frequently require interventions by many different specialties. It has been recognized for years that complex craniofacial patients benefit from a comprehensive team approach. Patients with Apert and Crouzon syndromes are the most commonly treated in craniofacial teams, though patients with other diagnoses benefit as well. Providers recognize the need for specialists in each discipline and, preferably, providers who work together frequently to care for these patients. As was recently presented in Tokyo, Japan at the 16th Congress of the International Society of Craniofacial Surgery, surgeons from around the globe are addressing the myriad anomalies of craniosynostosis in different ways. One group from Japan is using a multidirectional distraction system. Dr. Hopper in Seattle, Washington, United States, is using rotational distraction for the treatment of sleep apnea in these patients. In Phoenix, Arizona, United States, we use a minimally invasive approach for sagittal but not other synostoses. This field is in an exciting time of

Craniofacial orthodontics and postgraduate orthodontic training in Nigeria.

Craniofacial orthodontics has been shown to be a critical component of the care of patients with craniofacial anomalies such as cleft lip and palate. Thus, the purpose of this study was to assess the perceptions and clinical experience in cleft and craniofacial care, of orthodontic residents in Nigeria. Questionnaires were sent out to orthodontic residents in the six Postgraduate Orthodontic Training Centers in the country at that time. The questionnaires were self-administered and covered areas in beliefs in cleft care and the clinical experience and challenges faced by the residents in the provision of craniofacial orthodontic care at their various institutions. Thirty-three respondents returned completed questionnaires, with a response rate of 97%. All the respondents believed that residents should be involved in cleft and craniofacial care. Postnatal counseling was the clinical procedure in which the residents reported the highest level of clinical experience (47.4%). The least clinical experience was recorded in pre-bone graft orthodontics (7.4%) and orthodontic preparation for orthognathic surgery (5.5%). Some of the challenges highlighted by the residents were low patients turn out for orthodontic care and the absence of multidisciplinary treatment for craniofacial patients in their centers. Orthodontic residents in Nigeria believe that they should be involved in the management of patients with craniofacial anomalies and cleft lip and palate. However, majority of the residents have limited clinical experience in the management of these patients. A lot more needs to be done, to expose orthodontic residents in training, to all aspects of the orthodontic and multidisciplinary team care required for the cleft/craniofacial patient.

Pterygoid Plate Fractures: Not Limited to Le Fort Fractures.

Pterygoid plate fractures are often described in the setting of Le Fort fractures. The goal of this study was to define other craniofacial fracture patterns causing injury to the pterygoid plates. A retrospective review of computed tomography (CT) scans obtained on craniofacial trauma patients over a 5-year period revealed 209 patients with pterygoid plate fractures. Pterygoid plate fractures in 78 patients (37.3%) were unrelated to Le Fort fractures. Common causes included sphenotemporal buttress fractures in 26 patients (33.3%), temporal bone fractures in 18 patients (23.1%), zygomaticomaxillary complex fractures in 17 patients (21.8%), and displaced mandible fractures in 14 patients (17.9%). These findings indicate that approximately one third of pterygoid plate fractures do not result from Le Fort pattern injuries and that the craniofacial surgeon should have a broad differential for causes of pterygoid plate fractures when reviewing trauma imaging.

Facing up to the challenges of advancing Craniofacial Research.

Craniofacial anomalies are among the most common human birth defects and have considerable functional, aesthetic, and social consequences. The early developmental origin as well as the anatomical complexity of the head and face render these tissues prone to genetic and environmental insult. The establishment of craniofacial clinics offering comprehensive care for craniofacial patients at a single site together with international research networks focused on the origins and treatment of craniofacial disorders has led to tremendous advances in our understanding of the etiology and pathogenesis of congenital craniofacial anomalies. However, the genetic, environmental, and developmental sources of many craniofacial disorders remain unknown. To overcome this problem and further advance craniofacial research, we must recognize current challenges in the field and establish priority areas for study. We still need (i) a deeper understanding of variation during normal development and within the context of any disorder, (ii) improved genotyping and phenotyping and understanding of the impact of epigenetics, (iii) continued development of animal models and functional analyses of genes and variants, and (iv) integration of patient derived cells and tissues together with 3D printing and quantitative assessment of surgical outcomes for improved practice. Only with fundamental advances in each of these areas will we be able to meet the challenge of translating potential therapeutic and preventative approaches into clinical solutions and reduce the financial and emotional burden of craniofacial anomalies.

The evolution of a new Craniofacial Procedure: From Concept to established Intervention. The 8 year history of Posterior Calvarial Osseodistraction and its use in Craniofacial Surgery

Introduction: Posterior Calvarial Osseodistraction was first presented at the annual scientific meeting BAOMS, Aviemore, 2007 by the lead author. Its indication was to alleviate raised intracranial pressure in syndromic craniosynostotic patients. Since then the procedure has been accepted and used in many craniofacial surgery units worldwide. In addition in some patients with Chiari malformation at the craniocervical junction, there is regression of the Chiari and improvement in symptoms when this technique is used. Method: We prospectively collected data for the 38 cases who have undergone this intervention in our unit in the 8 years since the inception of the technique. Parameters measured included age, diagnosis, indication, distraction distance achieved and complications. Results: There have been modifications in the technique and distractors used in the study period.. 22 patients had a confirmed craniofacial syndrome. The majority of patients required the procedure for raised intracranial pressure (n=24); other indications were Chiari malformation (n= 2) and Chiari malformation with syrinx (n=2). This will be discussed further. Complications of the procedure are discussed and include cerebro spinal fluid leaks (n= 5) and distractor loosening (n=5). Conclusion: Posterior Calvarial Osseodistraction is an accepted intervention for increasing intracranial volume in patients who have premature sutural fusion. It is used in our unit as an adjunct in the management of complex craniofacial patients.