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Introduction: Hemifacial microsomia is a deformity of variable expressivity with unilateral hypoplasia of the
mandible and the ear. In this study, we evaluated skeletal soft tissue changes after bimaxillary unilateral vertical
distraction. Methods: Eight patients (4 preadolescents 4 adolescents) each with a grade II mandibular deformity
underwent a LeFort I osteotomy and an ipsilateral horizontal mandibular ramus osteotomy. A semiburied distraction device was placed over the ramus, and intermaxillary xation was applied. Anteroposterior cephalometric
and frontal photographic analyses were conducted before and after distraction. Statistics were used to analyze
the preoperative and postoperative changes. Results: Cephalometrically, the nasal oor and the occlusal and
gonial plane angles decreased. The ratios of affected-unaffected ramus and gonial angle heights improved by
15% and 20%, respectively. The position of menton moved toward the midline. The photographic analysis
showed a decrease of the nasal and commissure plane angles, and the chin moved to the unaffected side.
The parallelism between the horizontal skeletal and soft tissue planes improved, with an increase in the
affected side ramus height and correction of the chin point toward the midline. Conclusions: Simultaneous
maxillary and mandibular distraction improved facial balance and symmetry. Patients in the permanent dentition
with xed orthodontic appliances and well-aligned dental arches responded well to this intervention. (Am J
Orthod Dentofacial Orthop 2015;147:566-77)
a
Associate professor, Department of Pedodontics and Orthodontics, School of
Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; formerly,
postdoctoral fellow, Department of Anatomy and Rush Craniofacial Center,
Rush University Medical Center, Chicago, Ill.
b
PhD student, Department of Pedodontics and Orthodontics, School of Dentistry,
Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; formerly, postdoctoral
fellow, Department of Anatomy and Rush Craniofacial Center, Rush University
Medical Center, Chicago, Ill.
c
Postdoctoral fellow, Department of Pedodontics and Orthodontics, School of
Dentistry, Federal University of Rio de Janeiro; Brazilian Army dentist, Santa
Maria, Rio de Janeiro, Brazil.
d
Codirector, Craniofacial Center, Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Ill.
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported.
Eduardo Franzotti Sant0 Anna and Georgia W.T. Lau are recipients of scholarships
from Coordenac~ao de Aperfeicoamento de Pessoal de Nvel Superior (CAPES),
and Eduardo Franzotti Sant0 Anna is recipient of grants n. E-26/171.246/2006
and n. E-26/111.647/2010 from Fundac~ao de Amparo a Pesquisa do Estado
do Rio de Janeiro (FAPERJ), Brazil.
Address correspondence to: Alvaro A. Figueroa, Craniofacial Center, Rush University Medical Center, 1725 W Harrison St, Suite 425, Professional Bldg I, Chicago,
IL 60612; e-mail, Alvaro_Figueroa@rush.edu.
Submitted, April 2014; revised and accepted, December 2014.
0889-5406/$36.00
Copyright 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.12.027
566
Sant'Anna et al
Eight patients with HFM grade II mandibular deformity and maxillary asymmetry with a mean age of
13 years 2 months underwent combined maxillary and
mandibular distractions.3
The surgical procedures were done under general
anesthesia with nasotracheal intubation. A complete
horizontal LeFort I osteotomy was performed. In
contrast to the original method of Ortiz Monasterio
et al,19 the pterygomaxillary junction was freed with a
curved chisel on both sides, not only on the affected
side. The unaffected maxillary side LeFort I osteotomy
was loosely secured with 1 surgical wire placed above
567
Sant'Anna et al
568
Fig 1. Schematic representation of bimaxillary unilateral vertical distraction surgical plan. A, Complete
maxillary LeFort I (dashed line), unilateral horizontal ramus osteotomy; mandibular buried single-vector
distractor; intermaxillary wire xation (dotted line); single wire acting as a hinge (circle, contralateral
side); vertical and curved arrows indicate the expected direction of the maxillary and mandibular movements after distraction. B, Expected vertical bone formation between osteotomies, downward and
medial rotation of the maxilla and mandible to the contralateral side with leveling of the occlusal plane
and restoration of symmetry. (Reproduced with permission from Figueroa and Polley.21)
placement is such that true vertical elongation is not obtained. The placement of the device has mainly a vertical
component with a forward and medial vector because of
the shape of the hypoplastic ramus and the contralateral
ramus that needs to be emulated to correct as much as
possible not only the size but also the form of the ramus.
The placement of the distractor in this manner results in
an effective loss of vertical length. Semiburied distractors are rigid and true to their length, but as explained
above, the skeletal change is less than the true expression of the distractor; therefore, the activation to skeletal
change ratio is not 1:1.
The goal of bimaxillary distraction is mainly to obtain
a level occlusal plane and not perfect symmetry of the
gonial angles. The reason is that the vertical discrepancy
is usually greater at the gonial angles, and if they are leveled, the occlusal plane will be canted downward on the
affected side. The gonial angle asymmetry can be addressed secondarily with bone grafting combined with
other required procedureseg, genioplasty or soft tissue
augmentationto further improve appearance.
Activation of the mandibular distractor resulted in vertical elongation of the affected ramus and medial
displacement of both the maxillary and mandibular dentitions toward the unaffected side. This was possible
because the patients had a complete affected side horizontal ramus osteotomy and a complete LeFort I
Sant'Anna et al
569
Table I. Description of the cephalometric AP analysis for the vertical and horizontal measurements
Measurement
Denition
Vertical angle measurements
HL-Co0 Co
Angle between the HL and the bicondylar plane
HL-NF0 NF
HL-J0 J
HL-OCP
HL-Go0 Go
Landmark
Condylion (Co), external lateral marginal portion of the
condylar head
Nasal oor (NF), most inferior point on inside surface of the
bony nasal cavity
Jugal process (J), bilateral points on the jugal process of the
maxilla at a crossing with the tuberosity of the maxilla
Occlusal plane (OCP), horizontal plane passing through the
molar and the incisors
Gonion (Go), most lateral and inferior point of the
mandibular angle
Tns-ANS
Fig 2. Cephalometric analysis of vertical and horizontal changes. A, Horizontal planes relative to the HL
and VL references used for analysis: 1, HL-Co0 Co bicondylar plane; 2, HL HL-NF0 NF nasal oor plane; 3,
J0 J maxillary jugal plane; 4, HL-occlusal plane; 5, HL-Go0 Go gonial plane. B, Vertical planes used for
analysis: 1, VL-isf superior midline; 2, VL-Me mental line; 3, Tns-ANS nasal septum deviation to the VL.
Sant'Anna et al
570
The results of the AP cephalometric analysis demonstrated vertical improvement in all patients as seen by statistically signicant decreases relative to the HL of the
nasal oor angle (P 5 0.004), the maxillary jugal plane
Fig 4. Planes used in the photographic analysis to evaluate vertical and horizontal facial changes relative to the
HL and VL reference lines: 1, HL-sbal0 sbal nasal base
plane; 2, HL-ch0 ch labial commissure plane; 3, VL-Pog
vertical line chin point.
Sant'Anna et al
571
Table II. Description of photographic facial analysis for the vertical and horizontal measurements
Measurement
Vertical angle measurements
HL-sbal0 sbal (nasal base angle plane)
HL-ch0 ch (labial commissure angle plane)
Horizontal angle measurement
VL-Pog (chin point)
Denition
Landmark
Table III. Vertical and horizontal angular measurements and ratios from anteroposterior cephalometric radiographs
Measurement
Bicondylar plane (HL-Co0 -Co) ( )
Nasal oor plane (HL-NF0 NF) ( )
Maxillary jugal plane (HL-J0 J) ( )
Occlusal plane (HL-OCP) ( )
Gonial plane (HL-Go0 Go) ( )
Superior midline (VL-isf) ( )
Mental line (VL-Me) ( )
Nasal septum deviation (Tns-ANS) ( )
Gonial height (HL-Go0 /HL-Go) (%)
Ramus height (Co0 -Go0 /Co-Go) (%)
T1 mean 6 SD
3.42 6 2.07
14.28 6 6.36
11.85 6 6.76
12.71 6 5.85
12.42 6 7.18
5.71 6 4.95
7.00 6 7.58
14.71 6 6.36
78.12 6 14.45
65.85 6 16.01
T2 mean 6 SD
2.14 6 1.46
8.00 6 6.55
3.00 6 4.12
4.42 6 4.07
4.00 6 5.13
3.85 6 5.08
3.4 6 7.05
11.14 6 6.36
93.06 6 9.32
86.61 6 12.35
Difference
T1 T2
mean 6 SD
1.28 6 1.70
6.28 6 3.72
8.85 6 6.03
8.28 6 4.46
8.42 6 8.24
1.85 6 3.18
3.6 6 2.50
3.57 6 4.03
14.93 6 13.59
20.76 6 21.37
Lower
0.29
2.83
2.28
4.15
0.80
1.08
0.48
0.16
2.36
0.99
Upper
2.86
9.73
3.27
12.41
16.05
4.80
6.71
7.30
27.50
40.53
Power of
paired t
test (%)
41.2
97.7
94.2
98.8
69.3
25.0
93.5
55.5
76.0
64.4
0
Affected side.
*P \ 0.05; yP \ 0.01.
Table IV. Vertical and horizontal angular measurements from frontal photographs
Difference
T1T2
Measurement
T1 mean 6 SD T2 mean 6 SD mean 6 SD P value
Nasal base angle plane (HL-sbal0 sbal) ( )
7.50 6 5.91
4.25 6 5.25 3.00 6 2.00 0.014*
Labial commissure angle plane (HL-ch0 ch) ( ) 9.75 6 4.99
6.75 6 6.89 2.33 6 3.14 0.128
8.75 6 6.23
3.75 6 6.23 4.83 6 0.98 0.000y
Vertical line-chin point angle (VL-pog) ( )
Upper
5.09
5.62
5.86
Power of
paired t
test (%)
94.9
40.0
100.0
Affected side.
*P \ 0.05; yP \ 0.01.
DISCUSSION
Reconstruction of an asymmetric mandible associated with a soft tissue deciency is one of the most challenging problems in patients with HFM. Numerous
surgical procedures have been advocated to correct
facial asymmetry in these patients, including costochondral grafts, mandibular osteotomies combined with bone
grafts, and maxillary osteotomies, done at an early age
or in late adolescence.6,9,18 The results can be
unpredictable because of undesirable resorption of the
graft, leading to decreases in volume and strength of
the reconstructed area. Furthermore, these procedures
can cause signicant morbidity at the donor site.
Conventional orthognathic surgery, such as maxillary
impaction on the unaffected side, is usually performed
Sant'Anna et al
572
Fig 5. A and D, Presurgical photographs of a 6-year-old boy with left HFM; B and E, after distraction;
and C and F, follow-up treatment frontal facial and occlusion photographs at age 16 years. Note the
transitional dentition stage (D and E) and no orthodontic appliances during distraction. A year after
distraction the asymmetry was improved and the inferior midline was overcorrected, but at the 10year follow-up the cant of the occlusal plane and the chin point had moved back toward to the affected
side.
protects the newly created bone and allows the soft tissues to adjust to the new length. Although consolidation
of the regenerate is usually advanced after 6 to 8 weeks,
it continues with additional remodeling.26 In this sample, the devices were left longer (6 months) to accommodate the patients0 school schedules.
The simultaneous distractions of the maxilla and the
mandible are designed to correct the vertical and horizontal occlusal and chin asymmetries. However, these
fail to correct, if present, an orbitozygomatic deformity.14,27 In our patients, all horizontal planes
improved, but of the midline structures only the mental
deviation from the vertical was statistically signicant.
This is explained by the fact that the structures closer
to the osteotomynasal septum and maxillary
incisorsdid not change as much because they were
closer to the center of rotation of the maxillomandibular complex. The maxilla pivoted around the
surgical wire hinge, located on the unaffected side of
the LeFort I osteotomy, thus limiting the lateral
displacement of the hinge wire side of the maxilla
toward the unaffected side. However, vertical
lengthening of the maxilla and the mandible on the
affected side resulted in a signicant rotation of the
chin toward the facial midline or the unaffected side.
Sant'Anna et al
573
Fig 7. A, Presurgical frontal facial photographs of a 14-year-old boy with left HFM; B, during distraction;
and C, posttreatment frontal facial photographs at age 18 years 6 months. Note the improvement of
facial symmetry.
Combined unilateral vertical maxillary and mandibular distractions corrected the cant of the occlusal plane
and the chin deviation. The desired complete correction
of the facial asymmetry, especially in the gonial region,
was not fully accomplished, even though the changes
were statistically signicant (P 5 0.035). This was not
surprising, since it is geometrically impossible to produce
mandibular symmetry with a unilateral mandibular
Sant'Anna et al
574
Fig 8. Occlusion photographs of the patient shown in Figure 7: A-C, presurgical; D-F, during distraction; and G-I, after treatment. Note the orthodontic appliances during distraction after initial alignment,
intermaxillary xation using the orthodontic appliances, and excellent facial symmetry and occlusion
after distraction and orthodontic treatment.
Sant'Anna et al
575
Fig 10. Occlusal photographs of a 16-year-old boy with HFM: A and C, before orthodontic alignment; B
and D, after orthodontic alignment. Note the asymmetry of the mandibular arch before orthodontic treatment with the decreased distance of the affected side to the midline (arrows). The arch was well aligned
after treatment (D), with improved symmetry. Congruent and symmetrical arches allow for better outcomes with bimaxillary unilateral vertical distraction.
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