Simultaneous Maxillomandibular Distraction Research Articles

Simultaneous Maxillomandibular Distraction in Hemifacial Microsomia: A Comprehensive Review and Report of Case

Abstract Hemifacial microsomia (HFM) is a deformity of variable expressivity with unilateral hypoplasia of the mandible and the ear. Treatment of such poses a challenge as both soft and hard tissue deficiencies are to be addressed. The goal is to improve facial symmetry, allow functional jaw movement, obtain stable occlusion, and achieve patient satisfaction. This article discusses about the management of a patient with HFM using simultaneous maxillomandibular distraction also popularly known as the Oritz-Monasterio Molina technique.

A systematic review on the outcome of distraction osteogenesis in TMJ ankylosis

IntroductionTMJ ankylosis (TMJa) management by arthroplasty alone fails to address the deformity and the compromised airway. Distraction osteogenesis (DO) can offer a pragmatic solution to TMJa. The aim of the study was to generate evidence towards the role of DO in TMJa, evaluate its efficiency and develop an algorithm for use of DO in TMJa. Material and methodsThe research question was formulated using the PICOS statement for reporting guidelines in systematic reviews, where the efficiency of DO was evaluated in terms of mouth opening, correction of facial deformity and asymmetry, airway correction, and its long term effects. Results1130 articles reported DO as a treatment modality for TMJ ankylosis, of which 32 prospective studies, 16 retrospective and 2 RCTs were included in the study. DO was used for mandibular distraction in 45 studies and for simultaneous maxillamandibular distraction in only five studies. An algorithm for use of DO in TMJa was developed. ConclusionAlthough DO has proven its application in TMJ ankylosis cases, its best use is for correction of obstructive sleep apnoea. Relapse causing loss of posterior ramal height is a concern after transport DO. Prearthroplastic DO appears to best correct mandibular deformity. A maxillomandibular deformity requires simultaneous maxillomandibular distraction. However, a metanalysis is still awaited for effectiveness of DO in TMJ ankylosis.

Simultaneous maxillomandibular distraction in unilateral mandibular hypoplasia.

In craniomaxillofacial surgery we often deal with hypoplastic mandibles and mandibular asymmetries, the correction of which is critical to obtaining acceptable aesthetic results. In all of them we find common skeletal problems once growth has finished, such as an inclined occlusal plane and facial asymmetry with a stable dental occlusion. Simultaneous maxillomandibular distraction, which involves a Le Fort I osteotomy and a mandibular osteotomy with intermaxillary fixation during the period of active distraction, is an excellent technique to solve these problems. Virtual surgical planning, stereolithographic models, and surgical guides are supportive tools for obtaining excellent results. In this paper we present our experience with five cases of hypoplastic mandibles and mandibular asymmetries of different aetiologies. In all patients we achieved a considerable improvement in their physical appearance in the distance between the lateral canthus and oral commissure, the height of the mandibular ramus, the inclination of the occlusal plane, and the medial position of the chin. The benefits of virtual surgical planning in terms of choosing the optimal vector and the amount of distraction make it a promising technological tool to achieve excellent outcomes.

Versatility of uniplanar prearthoplastic distraction osteogenesis in the correction of post-ankylosis facial deformities—a report of five different cases

Unilateral or bilateral ankylosis can lead to severe micrognathia and facial deformity that requires multiple, often, staged surgical corrections. To date, there is no ideal treatment modality that satisfactorily corrects the complex anatomy, restores the ramal height, and corrects the micrognathia and microgenia. Distraction osteogenesis has been acclaimed as a successful modality for the treatment of such deformities. It is a cost-effective approach with low morbidity and less relapse thus providing better functional and esthetic outcomes. It allows the surgeon to correct the deformity in various planes by using various devices by changing osteotomy designs and vectors, with simultaneous hard tissue and soft tissue reconstruction. Here, we present a series of five cases where different types of distraction osteogenesis were combined with various other procedures to correct post-ankylotic facial asymmetry. In one case, simultaneous maxillo-mandibular distraction [Molina's technique] was used. All patients showed significant improvement in function and esthetics. Outcome assessment was made using clinical photographs and radiographs. Pre-arthroplastic distraction osteogenesis is a versatile cost effective approach that can be customized for every patient based on their needs.

Simultaneous maxillomandibular distraction osteogenesis in hemifacial microsomia: Report of 7 cases

IntroductionThe goal in treating Hemifacial microsomia (HFM) is to improve facial symmetry, allow functional jaw movement, obtain stable occlusion, and achieve patient satisfaction. This study was planned with an aim to assess the outcome of simultaneous maxillomandibular distraction osteogenesis in hemifacial microsomia. Material & methodsSeven patients with hemifacial microsomia were included in this study and demographic data was obtained. Simultaneous maxillo-mandibular distraction was planned for correction of maxillary cant, vertical ramal lengthening and midline, by performing unilateral mandibular osteotomy in ramus and distractor fixation, a Le Fort I osteotomy, with fixation at contralateral zygomatic buttress and intermaxillary elastics. Derriford Appearance Scale was used to measure individual responses to address problems of appearance. Results6 males and 1 female, with age range 18–26 years, mean 22.14 were included in the study. Maxillary occlusal cant varied from 4–16°, mean 9.85° and distraction achieved ranged from 12–19mm, mean 15.57. Preoperatively DAS score ranged from 42–61, mean 51.7 and improved to 10–27, mean 18.4. 100% success was achieved in 5 cases, while other two showed 96% and 99% success. ConclusionSimultaneous maxillomandibular distraction osteogenesis improves facial esthetics and obviates the need for postoperative orthodontics, minimizing the treatment period.

Simultaneous maxillomandibular unit distraction osteogenesis in treatment of hemifacial microsomia patients with facial using multiple internal distraction devices

Simultaneous maxillomandibular unit distraction osteogenesis in treatment of hemifacial microsomia patients with facial using multiple internal distraction devices

Simultaneous maxillo-mandibular distraction in early adolescence as a single treatment modality for durable correction of type II unilateral hemifacial microsomia: Follow-up till completion of growth.

Timing of surgical intervention in hemifacial microsomia (HFM) is controversial. Although mandibular osteodistraction in childhood for HFM is popular, recent data for single-stage distraction in growing HFM patients demonstrated long-term relapse. Literature suggests that adolescents in the late mixed dentition age or permanent dentition age (11-16-year-old) had more stable outcomes post-distraction than younger children. We present favorable experience using single-treatment simultaneous maxillo-mandibular distraction in early adolescent Pruzansky-Kaban type II HFM patients. This was a retrospective longitudinal study of seven consecutive type IIa/b HFM growing patients (12-16-year-old) treated with simultaneous maxillo-mandibular distraction. Oral commissure cant was photographically measured preoperatively and at 6 months and annually ranging 3-7 years post-distraction. Ramus height and chin deviation were measured from radiographs done preoperatively and at distractor-removal, 1 year, 2 years, and 4 years post-distraction. Average age at osteodistraction and at latest follow-up was 13.7 and 18.6 years, respectively. Improvement was significant (p<0.05) and sustained for mean oral commissure cant (5.1°-0.41°), mean ramus height ratio (0.59-0.86), and average chin deviation (15.9mm-1.2mm). Two subjects had mandibular branch palsy and one had mild pin-tract infection - all resolved. All were satisfied with their facial appearance. We have demonstrated good lasting outcomes at completion of growth with single-stage simultaneous maxillo-mandibular distraction for type II HFM adolescents in the late mixed-dentition or older age, and advocate this as an alternative to osteodistraction or orthognathic surgery upon skeletal maturity.

Pre-arthroplasty simultaneous maxillomandibular distraction osteogenesis for the correction of post-ankylotic dentofacial deformities

The aim of this study was to evaluate the hard and soft tissue changes after pre-arthroplasty simultaneous maxillomandibular distraction osteogenesis for the correction of post-ankylotic dentofacial deformities. This prospective study included 10 patients with unilateral temporomandibular joint (TMJ) ankylosis who presented with a facial deformity and a maxillary cant. Informed patient consent was obtained for participation. Simultaneous maxillomandibular distraction was planned based on clinical and radiographic examinations. A horizontal mandibular osteotomy was performed in the ramus and the distractor device was fixed. A bilateral Le Fort I osteotomy was then performed and a four-hole straight plate was fixed on the contralateral zygomatic buttress to act as a fulcrum. After a latency period of 5 days, the distractor was activated twice daily by 0.5mm until the required vertical lengthening was achieved. Intermaxillary fixation was maintained during the entire distraction period. After a consolidation period of 8–12 weeks, the distractor was removed. The TMJ ankylosis was released and a temporal fascia interpositional arthroplasty was performed as second surgery, along with a genioplasty if needed. All patients were followed up for a period of 12–24 months. A marked improvement in the facial asymmetry was noted in all cases. The occlusal cant and mandibular retrusion improved satisfactorily, and the average postoperative inter-incisal opening was 35.6mm. Pre-arthroplasty simultaneous maxillomandibular distraction offers a good treatment outcome, as it allows improvements in facial aesthetics as well as function.

Comparison of soft-tissue changes in simultaneous maxillomandibular distraction with mandibular distraction with second-stage maxillary osteotomy.

The purpose of this study was to compare the frontal lip cant changes in common facial asymmetry (FA) cases after simultaneous maxillomandibular distraction osteogenesis (DO) and mandibular DO with maxillary orthognathic surgery. Retrospective analysis of FA cases at tertiary craniofacial referral was performed. Patients of either gender with all medical imaging records and pre- and post-operative (1 year) facial photographs in natural head position were included in the study. The lip cant change was assessed by the ratio of the linear dimension between affected and unaffected side labial commissures and the bi-pupillary reference line. Difference between the pre- and post-operative ratio was analyzed. Statistical analysis was performed for the outcome. P ≤0.05 was taken as significant. The mean preoperative measured value of the affected side was 0.845 ± 0.036 while the postoperative value was 0.95 ± 0.032. The effective change was 0.11 ± 0.044. The postoperative ratio compared with simultaneous DO case was 0.98 ± 0.06 while that of mandibular distraction with orthognathic surgery was 0.92 ± 0.08 (P = 0.048). The mean change of the simultaneous DO case was measured as 0.114 ± 0.041 while the same for the mandibular distraction with orthognathic surgery was 0.069 ± 0.035 (P = 0.013). The results indicate that the simultaneous DO yields more better frontal lip cant change between both halves than the mono-DO with orthognathic surgery. The mean change is much higher in the simultaneous DO cases indicating a more effective correction and desired result. The biological reason and lip musculature mechanism behind the response in both conditions are discussed.

上下顎同時骨延長術を施行した著しい垂直的上顎劣成長を伴う下顎前突症の1例

When maxillary downgraft is performed for patients with severe maxillary deficiency, postoperative stability is sometimes insufficient. We report a case of mandibular protrusion with excessive vertical maxillary deficiency treated with simultaneous maxillo-mandibular distraction osteogenesis using alveolar distractors.A 25-year-old male patient visited our orthodontic clinic for treatment of his chief complaint that his upper incisors were invisible upon smiling. Upon examination, he was diagnosed as mandibular overgrowth with excessive vertical maxillary deficiency. Simultaneous maxillo-mandibular distraction osteogenesis was performed for considerable downward movement of the maxilla. Le Fort I osteotomy and bilateral inverted L osteotomy of the mandible were performed under general anesthesia. Bilateral alveolar distractors were set to the maxilla. After maxillo-mandibular fixation, distraction osteogenesis was performed downward by 10.5mm. Although slight relapse occurred 1 year after surgery and the final total amount of distraction was 9.0mm, the facial height and profile were improved and adequate exposure of the upper incisors was obtained.

Maxillomandibular Tandem Osteotomy With Distraction Osteogenesis for Hemifacial Microsomia

Currently, simultaneous maxillomandibular distraction osteogenesis is a standard procedure for the correction of hemifacial microsomia. Many variations of the procedure have been reported. However, a common problem has been the extended duration of the procedure. In particular, the lengthy intermaxillary fixation period includes a prolonged distraction series that requires the restriction of oral food intake and creates significant stress for the patient, which has a profound effect on patient satisfaction. To avoid this stress, we have developed tandem osteotomy with distraction osteogenesis, termed the TODO procedure. The TODO procedure not only shortens the intermaxillary fixation period and the duration of therapy but also creates the ideal skeletal proportions, with horizontalization of the occlusal plane. The TODO procedure has the added benefit of producing a marked aesthetic improvement. The patient was extremely satisfied by the result and endured minimal stress.

Maxillary-driven simultaneous maxillo-mandibular distraction for hemifacial microsomia

We treat hemifacial microsomia with a combination of surgery and orthodontic treatment during the growth period, resulting in early improvement in facial asymmetry and the induction of normal growth. We previously used gradual distraction of the mandibular ramus for Pruzansky’s type II classification ( Pruzansky, 1969). In type II cases, the maxilla should also be treated actively as, using this technique, improvement of the occlusal plane is difficult to achieve, resulting in a cross bite and difficulties in post-operative orthodontic treatment—especially in older patients. Morphologically, the mandibular angle region of the operative side is flat, and the angle of the mouth remains elevated. We performed mandibular-driven simultaneous maxillo-mandibular distraction while the occlusion was maintained using intermaxillary anchorage. However, mandibular-driven distraction tended to elongate the face because the mandible only elongated downwards and the mandibular ramus did not reach the glenoid. Furthermore, external distraction devices produce significant distress for patients until removal of the device and cause scars on the face. We developed a new internal distraction device with a variable angle and performed maxillary-driven simultaneous maxillo-mandibular distraction using this device. The result was morphologically satisfactory and solved the above problems. Because the patient was in the growth period, careful follow-up and induction to normal growth were important while the inferior growth of the affected side was monitored.

Simultaneous maxillomandibular distraction osteogenesis in severe progressive hemifacial atrophy with two distractors

Progressive hemifacial atrophy is a rare disorder characterized by an acquired, idiopathic, self-limited, unilateral facial atrophy involving skin, subcutaneous tissue, fat, muscle, and bone. Symmetry and contour restoration are the main treatment challenges. Among many techniques, microvascular reconstruction has been introduced as the gold standard to correct the atrophic deformity. For some patients with severe manifestations, soft tissue reconstruction alone does not obtain the desired outcome. In this series, we used an effective method to restore the severe progressive hemifacial atrophy by simultaneous maxillomandibular distraction osteogenesis with 2 distractors. The results demonstrate an improvement in both the profile and the occlusion plane of the patients with corresponding satisfactory esthetic and functional outcomes. We conclude that the simultaneous maxillomandibular distraction osteogenesis with 2 distractors is an effective method for hemifacial atrophy and bone frame reconstruction, especially ones involved in the discrepancy of the occlusal plane.

Simultaneous Maxillomandibular Distraction Osteogenesis Using a Subcutaneous Device for a Bilateral Cleft Lip and Palate Patient

This report describes a 26-year-old man with repaired bilateral cleft lip and palate treated by simultaneous maxillomandibular distraction osteogenesis using submucosal intraoral distraction devices for skeletal and soft tissue restoration.

Simultaneous Maxillo-Mandibular Distraction Osteogenesis in Hemifacial Microsomia: A New Technique Using Two Distractors

The goal of this study was to prospectively evaluate the use of two distractors for a simultaneous maxillo-mandibular distraction osteogenesis without the use of intermaxillary fixation in the restorative treatment of hemifacial microsomia. The authors analyzed the clinical and radiological data of five patients with type I hemifacial microsomia (one patient), type IIa hemifacial microsomia (two patients), and Goldenhar syndrome (two patients). Follow-up examinations were performed at 1, 3, 6, and 12 months. All the patients had satisfactory correction of the facial asymmetry without complications. Complete horizontalization of the occlusal plane was achieved in three patients, whereas a cant of 2 degrees persisted in two patients. None of the children in this study were noncompliant with the prescribed duration of the active distraction period, nor did they experience technical problems with the two devices. Simultaneous maxillo-mandibular distraction osteogenesis resulted in a high rate of success in correcting facial asymmetry as well as occlusal plane cant. It offered good aesthetic satisfaction.