Craniofacial Surgery Research Articles

Ergonomics in Craniofacial Surgery: Can We Do Better? A Quality Improvement Study.

Many plastic surgeons experience musculoskeletal strain and injury from poor ergonomics during surgery. This is associated with reduced performance, shortened careers, and decreased quality of life. This study compared the ergonomics of the conventional operating table headrest and the Mayfield headrest in craniofacial surgery. A prospective cohort study of patients undergoing craniofacial operations between November 20, 2022 and April 26, 2023, within a single craniofacial surgeon's practice. The authors obtained data on the total duration of the operation and Rapid Entire Body Assessment (REBA) scores for the primary surgeon and assistant. Four operations (mean: 147 ± 60.9 min) were included in the regular headrest group, and 8 in the Mayfield headrest group (mean: 61±53.4 min). Four hundred fifty-five regular headrest time points and 851 Mayfield time points were recorded. Eight hundred thirty-five regular headrest time points and 538 Mayfield time points were recorded. The mean REBA score for the regular headrest was 5.79 ± 1.9, which was higher than the Mayfield (5.01 ± 2.0; P < 0.0001). Subgroup analysis showed the mean REBA score for the primary surgeon (5.89 ± 2.0) was higher than the assist (5.48 ± 1.6) in the regular headrest group (P < 0.0001), whereas the converse was true for the Mayfield headrest (primary surgeon: 4.67 ± 1.8, assist: 5.65 ± 2.15, P < 0.0001). Ergonomic scores were better using the Mayfield headrest than the regular headrest. The primary surgeon scored better with the Mayfield headrest, whereas the assists had better scores with the regular headrest.

Developmental Risk for Infants with Cleft Lip with or Without Cleft Palate Based on Caregiver-Proxy Reports.

(1) Assess caregiver-reported development in infants born with cleft lip ± alveolus (CL ± A) and cleft lip and palate (CLP); (2) determine factors associated with increased developmental risk; and (3) determine consistency of developmental risk before and after surgery for cleft lip. Prospective, longitudinal assessment of development. Time (T) 1, prior to lip closure; T2, 2 months post lip closure. Three US craniofacial teams and online parent support groups. 123 total caregivers (96% mothers); 100 at T1, 92 at T2, and 69 at both T1 and T2. Ages and Stages Questionnaire-3 (ASQ-3): Communication, Gross Motor, Fine Motor, Problem Solving, Personal Social Domains. At T1 47%; at T2 42% passed all 5 Domains; 36% of infants pass all 5 Domains at both T1 and T2. Infants with CLP were at greatest risk on Communication [B = 1.449 (CI = .149-20.079), p = .038; Odds Ratio (OR) = 4.3 (CI = .923-19.650)] and Gross Motor Domains [B = 1.753 (CI = .316-20.605), p = .034; OR = 5.8 (CI = 1.162-28.671)]. Male infants were at greatest risk on Fine Motor [B = 1.542 (CI = .495-20.005), p = .009; OR = 4.7 (CI = 1.278-17.101)] and Problem Solving Domains [B = 1.200 (CI = .118-19.708), p = .044; OR = 3.3 (CI = .896-12.285)]. Based on caregiver report, infants with CL ± A and CLP meet referral criteria at a high rate. Infants with CLP and male infants were at greatest risk. Regular developmental screening is recommended.

Craniofacial Surgery in a Low-Resource Setting: The Successes, Challenges, and Prospects

Background:Craniofacial Trauma and Anomalies affect a substantial proportion of the global society, especially those in the low-and middle-income countries (LMICs). The literature stresses the concept of a team approach for craniofacial surgery and the need for the interaction of many specialists to provide optimal care for the patient. Craniofacial surgery is practiced mainly in the advanced countries of Europe and America. This report describes the establishment of craniofacial care in an African country. It reports on 6-year early outcomes of craniofacial surgery in a low-resourced country, counting the successes, challenges, and prospects. Methods: The establishment of an international collaboration that facilitated the training in craniofacial surgery is described. A 6-year retrospective review of craniofacial surgery cases managed by the Multidisciplinary Cleft and Craniofacial team at the Komfo Anokye Teaching Hospital (KATH) was done from January 2016 to December 2022. Results: Two Ghanaian surgeons were trained in Alabama, USA (a maxillofacial surgeon and a neurosurgeon), then returned to Kumasi to begin a Craniofacial practice with the help of the craniofacial team in Children of Alabama Birmingham Al, USA. A total of 646 procedures were performed (616 cases of orofacial cleft, 20 cases of craniofacial anomalies, and 10 cases of craniofacial trauma involving the cranial vault or base of the skull). Ninety percent of the cases were cleft lip and palate, with the remainder being a mixture of isolated and syndromic craniosynostosis, craniofacial trauma, encephalocele, and craniofacial fibrous dysplasia. Conclusion: The Commonest craniofacial procedure performed was cleft lip and palate repair. Other surgeries were for the repair of velopharyngeal incompetence (VPI) and atypical facial clefts. Complex craniosynostosis and encephaloceles are also now being repaired at KATH. The foundation for a sub-regional center of excellence in cleft and craniofacial surgery is being laid in Ghana at KATH.

Advancements in facial implantology: a review of hydroxyapatite applications and outcomes.

The search for an ideal bone substitute in reconstructive surgery has led to the exploration of various materials, with hydroxyapatite (HaP) emerging as a promising candidate due to its biocompatibility, osteoconductive properties, and structural similarity to human bone. Despite its potential, there is a paucity of data on the long-term safety and efficacy of HaP in facial skeletal reconstruction and augmentation. We conducted a systematic review following PRISMA 2020 guidelines, searching PubMed/MEDLINE, Google Scholar, CENTRAL, and Web of Science databases for studies on hydroxyapatite facial implants in reconstruction and augmentation. Our search yielded 12 studies that met our inclusion criteria, encompassing 74 patients treated with HaP implants for various indications including facial fractures/defects, aesthetic facial balancing, and after tumor resection. The studies reported on outcomes such as implant integration, complications, aesthetic results, and patient satisfaction, with a general trend indicating positive outcomes for the use of HaP in facial reconstruction. Hydroxyapatite appears to be a viable and effective material for facial skeletal reconstruction and augmentation, offering benefits in terms of biocompatibility, osteoconductivity, and patient outcomes. However, limitations such as low mechanical strength and the need for further research on long-term safety and efficacy were identified. This review underscores the potential of HaP in craniofacial surgery while highlighting areas for future investigation.

The Role of Virtual Surgical Planning in Surgery for Complex Craniosynostosis.

Virtual surgical planning (VSP) decreases reliance on intraoperative subjective assessment of aesthetic and functional outcomes in craniofacial surgery. Here, we describe our experience of using VSP for complex craniosynostosis surgery to inform preoperative decision making and optimize postoperative outcomes. Chart review was performed for children treated with craniosynostosis at our institution from 2015 to 2021. Eight VSP maneuvers were defined and assigned to each patient when applicable: (1) complex cranioplasty: combined autologous and synthetic; (2) autologous cranioplasty; (3) synthetic cranioplasty; (4) vector analysis and distractor placement; (5) complex osteotomies; (6) multilayered intraoperative plans; (7) volume analysis; and (8) communication with parents. Outcomes between VSP and non-VSP cohorts were compared. Of 166 total cases, 32 were considered complex, defined by multisutural craniosynostosis, syndromic craniosynostosis, or revision status. Of these complex cases, 20 underwent VSP and 12 did not. There was no difference in mean operative time between the VSP and non-VSP groups (541 versus 532 min, P = 0.82) or in unexpected return to operating room (10.5% versus 8.3%, P = 0.84). VSP was most often used to communicate the surgical plan with parents (90%) and plan complex osteotomies (85%). In this cohort, VSP was most often used to communicate the surgical plan with families and plan complex osteotomies. Our results indicate that VSP may improve intraoperative efficiency and safety for complex craniosynostosis surgery. This tool can be considered a useful adjunct to plan and guide intraoperative decisions in complex cases, reducing variability and guiding parental expectations.

A Review of 3D Printing and Surgical Planning

Three-Dimensional Printing (3DP), also known as rapid prototyping or additive manufacturing, has revolutionized the field of medicine, particularly in preoperative planning. By transforming intricate Two-Dimensional (2D) medical imaging data into tangible, patient-specific Three-Dimensional (3D) models, 3DP enhances surgical precision and patient care. This technology facilitates detailed preoperative visualization, enabling surgeons to interact with accurate anatomical models, plan complex procedures, and anticipate potential challenges. The evolution of 3DP, driven by advances in Fused Deposition Modeling (FDM), Selective Laser Sintering (SLS), and Stereolithography (SLA), has democratized access to affordable and sophisticated 3D printers, spurring innovation in medical applications. In this study, a comprehensive review of the literature on the integration of 3DP technology into preoperative planning is conducted. Applications across various surgical disciplines, including cardiovascular, orthopedic, craniofacial, neurosurgical, oncological, transplant, and pediatric surgeries are examined. Benefits of 3DP in providing tactile feedback, creating patient-specific surgical guides and implants, and enhancing surgical simulation and training are evaluated. Additionally, challenges associated with the high costs, time-intensive processes, and material limitations of 3DP are assessed. Findings demonstrate that 3DP significantly reduces operative times, improves surgical outcomes, and lowers complication rates. The study highlights the transformative impact of 3DP on surgical practice and underscores its potential for future advancements. With ongoing research and innovation in materials science, bioprinting, artificial intelligence, and augmented reality, 3DP is poised to further revolutionize preoperative planning, offering more personalized, precise, and patient-centered healthcare solutions.

Effects of alveolar bone grafts vs. orthognathic surgery on cleft palate speech nasalance: a meta-analysis

Patients born with cleft palate frequently struggle with speech nasalance issues, such as hypernasality and hyponasality. Hypernasality results in patients having nasal speech, whereas hyponasality results in patients having a congested voice. To improve speech function, cleft palate patients may undergo numerous surgical interventions. Two of the most common secondary cleft repair surgeries are alveolar bone grafting and orthognathic surgery. The purpose of this meta-analysis was to determine whether one surgical intervention is more effective in addressing hypo- and hypernasality in cleft palate patients. We assessed three key outcomes: change in nasalance scores post- operation, percent change of patients with excess nasal emission post-operation, and presence of hypo/ hypernasality post-operation. We hypothesized that alveolar bone grafts will be superior to orthognathic surgery for addressing speech nasalance. Results from nine studies conducted over 47 years revealed distinct outcomes for bone grafts and orthognathic surgery. Alveolar bone grafts were found to generally improve hypernasality, whereas orthognathic surgery resulted in worsened hypernasality. For each treatment type, both hypo- and hypernasality can be found in patients post-operation, with no statistical indication of immediate changes to hyponasality. Limitations to this analysis included the small sample size used in the component studies, so more research would be helpful for additional understanding. Studies used in the analysis consisted of both cohort studies and randomized controlled trials, resulting in some confounding effects. From a clinical perspective, this meta-analysis has the potential to inspire future studies comparing these surgical methods, which may ultimately enable craniofacial surgeons to enhance nasalance outcomes for individuals with cleft palates.

Application of three-dimensional printing in plastic surgery: a bibliometric analysis.

Recent years have seen the publication of numerous papers on the application of three-dimensional (3D) printing in plastic surgery. Despite this growing interest, a comprehensive bibliometric analysis of the field has yet to be conducted. To address this gap, we undertook a bibliometric study to map out the knowledge structure and identify research hotspots related to 3D printing in plastic surgery. We analyzed publications from 1995 to 2024, found in the Web of Science Core Collection (WoSCC), utilizing tools such as VOSviewer, CiteSpace, and the R package "bibliometrix". Our analysis included 1,057 documents contributed by 5,545 authors from 1,620 organizations across 71 regions, and these were published in 400 journals. We observed a steady growth in annual publications, with Europe, Asia, North America, and Oceania leading in research output. Notably, Shanghai Jiao Tong University emerged as a primary research institution in this domain. The Journal of Craniofacial Surgery and Journal of Oral and Maxillofacial Surgery have made significant contributions to the field, with Thieringer, Florian M being the most prolific and frequently cited author. Key areas of focus include medical education and surgical procedures, with "3D printing", "virtual surgical planning" and "reconstructive/orthognathic surgery" highlighted as future research hotspots. Our study provides a detailed bibliometric analysis, revealing the evolution and progress of 3D printing technologies in plastic surgery. As these technologies continue to advance, their impact on clinical practice and patient lives is expected to be profound.

Tension Pneumocephalus After Craniofacial Surgery Treated with Conservative Measures

Tension pneumocephalus (TP) is a neurological emergency characterized by air in the intracranial cavity. This can present with seizures, neurological deficits, coma, or even cardiac arrest in severe cases. Typically, TP requires urgent/emergent surgical intervention to decompress the intracranial cavity; however, this is not always the case. The aim of this case report is to highlight one such scenario where large-volume TP was treated with, full neurological recovery, using only conservative measures. Keywords: Tension, Pneumocephalus, Oxygen therapy.

Chang Gung Forum: An Exemplary Strategy for Implementing a Multidisciplinary Network of Experts in Craniofacial Anomalies.

The Chang Gung Forum has been dedicated to the care of craniofacial anomalies since 2000. This annual continuing medical education program focuses on orofacial cleft and surgery-first orthognathic surgery by providing up-to-date information and management guidelines. This study explored how the Chang Gung Forum has influenced medical perspectives, decisions, and practices in a multidisciplinary craniofacial team. Between 2000 and 2022, 20 Chang Gung Forums have been held. A questionnaire was distributed among 170 attendees who had participated in the forum more than once. The questionnaire collected information on the participants' experiences and levels of satisfaction with the educational program and whether or how it had influenced their clinical practice. Valid responses from 86 attendees (response rate, 50.6%) who had participated more than once were collected and analyzed. The overall satisfaction rate of the Chang Gung Forum based on the respondents' most recent visits was 4.28 ± 0.63 out of 5. Of the respondents, 90.9% acknowledged changes in their clinical practice, with modifications in surgery plans and decisions being the most notable (48.5%). In addition, comprehension increased throughout years of attending the annual forum (P < 0.001). The Chang Gung Forum has contributed markedly to the community of congenital craniofacial anomalies. The program will continue providing updated information and influencing the clinical decision-making of health care professionals.

Craniomaxillofacial Surgery with Computer-generated Three-dimensional Solid Models.

Restoring complex craniofacial deformities presents numerous challenges. Recent years have seen the development of new surgical techniques aimed at improving operation quality and reducing difficulty. However, designing the reduction volume for the affected region and achieving precise contouring remain difficult tasks. The use of three-dimensional (3D) solid models can provide significant assistance at all stages of the operations. This study aimed to investigate the validity of prototype 3D solid models for complex craniofacial operations. Simulated 3D models of the patients were used. Conventional surgical instruments were employed for the planning of the operations. Patients had follow-up periods ranging from 6 to 18 months. Operations have been planned and performed using three-dimensional solid models. Intraoperative steps were executed as simulated during planning. No major complications were developed. All bone and soft-tissue reconstructions healed without major infection. Stereolithographic models provide: 1) a better understanding of anatomy, 2) presurgical simulation, 3) intraoperative accuracy in lesion localization, 4) accurate fabrication of implants, and 5) improved education for trainees. An accurate method for intraoperative navigation and preoperative planning is clearly useful. This technology offers a direct representation of the patient's anatomy through computer reconstruction, allowing for the efficient and precise transfer of information in complex facial restorative procedures.

From Augmented to Virtual Reality in Plastic Surgery: Blazing the Trail to a New Frontier.

Augmented reality (AR) and virtual reality (VR)-termed mixed reality-have shown promise in the care of operative patients. Currently, AR and VR have well-known applications for craniofacial surgery, specifically in preoperative planning. However, the application of AR/VR technology to other reconstructive challenges has not been widely adopted. Thus, the purpose of this investigation is to outline the current applications of AR and VR in the operative setting. The literature pertaining to the use of AR/VR technology in the operative setting was examined. Emphasis was placed on the use of mixed reality technology in surgical subspecialities, including plastic surgery, oral and maxillofacial surgery, colorectal surgery, neurosurgery, otolaryngology, neurosurgery, and orthopaedic surgery. Presently, mixed reality is widely used in the care of patients requiring complex reconstruction of the craniomaxillofacial skeleton for pre- and intraoperative planning. For upper extremity amputees, there is evidence that VR may be efficacious in the treatment of phantom limb pain. Furthermore, VR has untapped potential as a cost-effective tool for microsurgical education and for training residents on techniques in surgical and nonsurgical aesthetic treatment. There is utility for mixed reality in breast reconstruction for preoperative planning, mapping perforators, and decreasing operative time. VR has well- documented applications in the planning of deep inferior epigastric perforator flaps by creating three-dimensional immersive simulations based on a patient's preoperative computed tomography angiogram. The benefits of AR and VR are numerous for both patients and surgeons. VR has been shown to increase surgical precision and decrease operative time. Furthermore, it is effective for patient-specific rehearsal which uses the patient's exact anatomical data to rehearse the procedure before performing it on the actual patient. Taken together, AR/VR technology can improve patient outcomes, decrease operative times, and lower the burden of care on both patients and health care institutions.

Parents’ Perception of the Benefit of Receiving a Patient Information Leaflet Prior to Attending a Craniofacial Multidisciplinary Team Appointment

Objective To investigate how a patient information leaflet describing what to expect during a craniofacial multidisciplinary team (MDT) appointment is experienced by parents of children with craniofacial anomalies (CFAs) and whether it helps with preparation for the appointment. Design Combination of qualitative and quantitative design. Setting Norwegian National Unit for Craniofacial Surgery. Participants Thirty-three parents of children with CFAs completed the questionnaire and fourteen were subsequently interviewed. Interventions A patient information leaflet, sent to all parents before their MDT appointment. Main Outcome Measures Descriptive questionnaire data and interview data. Results All parents ( N = 33, 100%) found the leaflet easy to understand, while 31 (93.9%) found it provided helpful information. However, many first-time attendees still found the MDT setting overwhelming. Conclusions A leaflet may be helpful for parents when preparing for their child's MDT appointment. However, some parents may need additional support and information related to their child's treatment pathway.

Part II: Blood Transfusion and Donor Exposure in the Surgical Management of Trigonocephaly Patients: A Protocol From Alder Hey Craniofacial Unit.

Trigonocephaly is a craniofacial malformation caused by premature fusion of the metopic suture. Surgical correction frequently results in the need for blood transfusion. Transfusion complications include transfusion-transmitted infections (TTIs), immune-mediated reactions, and volume overload. Donor exposure (DE) describes the number of blood products from unique donors with increasing DE equating to an increased risk of TTI. We evaluate data on 204 trigonocephaly patients covering 20 years of practice with respect to blood transfusions and DE. This represents the largest series from a single unit to date. A protocol based on our experiences has been devised that summarizes the key interventions we recommend to minimize blood transfusions and DE in craniofacial surgery. Patients operated on between 2000 and 2020 were included. DE and a range of values were calculated including estimated red cell loss (ERCL) and estimated red cell volume transfused (ERCVT). Groups were established by relevant interventions and compared using the Mann-Whitney U test. Mean DE fell from 1.46 at baseline to 0.85 ( P <0.05). Median allogenic transfusion volume fell from 350mL at baseline to 250mL ( P <0.05). Median ERCL fell from 15.05mL/kg at baseline to 12.39mL/kg and median ERCVT fell from 20.85 to 15.98mL/kg. Changes in ERCL and ERCVT did not reach statistical significance. DE can be minimized with the introduction of key interventions such as a restrictive transfusion policy, preoperative iron, cell saver, tranexamic acid, and use of a matchstick burr for osteotomies.

Manufacturing Process of Low‐Contamination Titanium Foam as Implant Material for Cranioplasty Based on Replica Technique

The article investigates the development of a manufacturing route for highly porous titanium foams suitable for craniofacial surgery applications, particularly in cranioplasties. The study focuses on the polyurethane replication method for foam production and emphasizes reducing residual gas content, as it significantly affects the mechanical properties and suitability for approval of the foams. Various factors such as starting materials, solvent debinding, heating schedules, and hydrogen atmosphere are analyzed for their impact on residual gas content. It is shown that significant reductions in residual gas content can only be achieved by reworking each step of the process. A combination of initial solvent debinding of the PU template with dimethyl sulphoxide, reduction of suspension additives, use of coarser Gd. 1 powders, and an integrated debinding and sintering process under partial hydrogen atmosphere achieves a significant reduction in residual gas content. This way, the potential for producing titanium foams that comply with relevant standards for craniofacial implants is demonstrated.

ASSESSMENT OF OUTCOMES OF RECONSTRUCTION FOR MAJOR SCALP DEFECTS USING LOCAL FLAPS OF VASCULAR PEDICLE

Objectives: Assess treatment outcomes of major scalp defects using local flaps of vascular pedicle. Materials and methods: Cross-sectional descriptive study on 16 patients with major scalp defects who received surgery at Center of Craniofacial and Plastic Surgery, Military Central Hospital 108 from September 2016 to April 2021. Participants were received reconstruction surgery to cover their defects using local flaps of vascular pedicle. Results: 15/16 participants were reconstructed using temporal fasciocutaneous flap based on superficial temporal artery pedicle, 1/16 participant was used skin flap based on occipital artery pedicle. Short-term results showed that 14/16 reconstruction flaps had good vitality and covered 100% of the defects. For each participant, the average surgery duration lasted 140 minutes, and the average post-operative hospitalization duration was 12 days. Long-term results showed that 16/16 flaps had good vitality and 100% coverage. Conclusions: reconstruction of major scalp defects using local flaps of vascular pedicle brought good coverage, high vitality, and was safe for patients, especially the elderly with many underlying diseases.

CLINICAL FEATURES OF MAJOR SCALP DEFECTS AT MILITARY CENTRAL HOSPITAL 108

Objectives: describe the clinical features of major scalp defects requiring surgery. Materials and methods: The above cross-sectional descriptive study included 16 patients with major scalp defects who received surgery at Center of Craniofacial and Plastic Surgery, Military Central Hospital 108 from September 2016 to April 2021. Participants were taken medical history, received clinical examination, and measured their defect sizes to record research indices. Results: Participants had an average age of 61 years old, male/female ratio = 1/1; 81.25% of them had comorbid chronic systemic diseases. The most common cause of the defects was scalp cancer, which accounted for 75%. The defects had an average area of 84.4cm2 and mainly located in the occipital region which occurred in 87.5% of patients, alone or combined with other regions, 100% of patients had to been removed the periosteum. Conclusions: Major scalp defects were mainly seen in elderly people with an average age of 61 years old, the ratio of male to female was equal. Chronic diseases accounted for 81.25%, the main cause was scalp cancer and accounted for 75%, common clinical symptoms were vegetations, ulcers, periosteal loss and defects mainly occurred in compression regions.

Bone Regeneration Capacity through Microvesicles and Exosomes

Many orthopedic and dental complications involve the need for bone grafting procedures, such as repairing congenital defects and traumatic injuries. However, achieving complete and functional bone regeneration remains a significant challenge for orthopedic, craniofacial, and dental surgeons

Lefort I Osteotomy With and Without Osteogenic Distraction in Cleft Lip and Palate Patients: Experience at Hospital Universitario Infantil De San José.

Cleft lip and cleft palate (CLP) are congenital diseases that lead to several secondary craniofacial anomalies, such as hypoplasia of the middle third of the face, which can be treated with different surgical techniques to help improve functional and esthetic alterations associated with the maxilla. This article reports the results of patients managed with LeFort I osteotomy in the same craniofacial surgery center for 10 years. To determine the postoperative results regarding recurrence rates, malocclusion, and speech status after surgical treatment, in patients with retrusion of the midface with CLP, who underwent LeFort I osteotomy with or without osteogenic distraction (OD). A descriptive cohort study was performed at the Hospital Infantil Universitario de San José in Bogotá, Colombia, between 2010 and 2020, evaluating 38 patients with CLP who met the inclusion criteria, all managed by LeFort I osteotomy with and without OD. The authors reported the sociodemographic information, as well as data related to speech before and after surgery, recurrence, complications, and cephalometric characteristics. The recurrence of the patients was described at 6 and 12 months after the surgical procedure. A total of 43 patients met the inclusion criteria, of which 20 patients were managed with conventional LeFort I osteotomy, and 23 with LeFort I osteotomy with OD; 5 patients were excluded due to lack of data in the medical records, with a final sample of 38 patients. The distribution based on sex was: 57.8% men and 42.1% women. Regarding laterality, we have 7 patients with right CLP (18.42%), 11 patients with left CLP (28.9%), and 20 patients with bilateral CLP (52.63%), 100% of patients with a class III bite in Angle's classification. In group 1 (OD), 55% of the patients did not present changes in speech before surgery, 30% presented improvement in speech, and 15% worsened it. In group 2 (conventional advancement), 66% of the patients did not present changes in speech, 5.5% presented improvement, and 27.7% presented worsening of speech based on the preoperative condition, with a clinical recurrence at 6 months of 15% for group 1 and of 33% for group 2, and at 1 year of 20% for group 1 and 16% for group 2. Osteogenic distraction is a safe method that can be applied in patients with CLP depending on the clinical characteristics. According to what is described in the literature, those patients who require advancement of up to 6 mm treated without OD have obtained good results, showing esthetic improvement by increasing the projection of the middle third of the face, without worsening of velopharyngeal insufficiency and achieving an adequate occlusal class (Angle I) in the immediate postoperative period or after the postoperative orthodontic management. However, in patients who require advances ≥7 mm, it is clear that OD is the best option, given its association with a lower recurrence rate, minimal changes in the speech, achieving occlusion edge-to-edge at the end of the distraction or Angle's class I, which is corroborated by the results obtained in this study.

Potential of Three-Dimensional Portable Document Format for Article Publication in Craniofacial Surgery.

The portable document format (PDF) is a globally recognized standard file format of Word documents. The PDF supports the embedding of three-dimensional objects. This three-dimensional PDF can contribute to new ways of presenting and disseminating medical information in future medical journals.