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Early Distraction for Mild to Moderate Unilateral Craniofacial Microsomia: Long-term Follow up and Outcomes
Katie Weichman, MD1, Jordan Jacobs, MD2, Parit Patel, MD1, Parit Patel, MD1, Barry Grayson, DMD1, Pradip Shetye, DMD1, Joseph G. McCarthy, MD1.
1New York University, New York, NY, USA, 2New York Medical College, Valhalla, NY, USA.
There is little controversy regarding mandibular distraction in the young patient with bilateral or unilateral craniofacial microsomia and associated airway compromise or severe dysmorphism. However, there is a relative indication in the young patient with unilateral craniofacial microsomia (UCFM) and moderate dysmoprhism or malocclusion. The relative indication for mandibular distraction poses several questions: Is it deleterious? Is it worth it? Is it successful in the context of craniofacial growth and appearance? This study was designed to answer these questions in a group of mild to moderate UCFM patients who underwent mandibular distraction and were followed longitudinally with clinical, photographic, and radiographic studies.
A retrospective review of all patients undergoing mandibular distraction by a single surgeon between 1989 and 2010 was conducted. Patients with UCFM, long term follow up, and Pruzansky I or IIa mandibles were included for analysis. Those with Pruzansky IIB or III mandibles and skeletal immaturity at the time of analysis were excluded. The patients were then divided into two cohorts: those with superior results and those with average results based on photographic aesthetic evaluation at initial presentation and at skeletal maturity by a panel of three independent observers. Clinical variables included the following: soft tissue deficiency (subjective), age at initial distraction, device vector angle, length of activation and consolidation, use of postoperative orthodontic therapy, need for secondary surgery and complications. Additionally, cephalometric measurments included length of overcorrection from craniofacial midline and ratio of condylion:gonion (Co-Go) at three distinct time points: preoperative, after consolidation, and at skeletal maturity.
Twenty patients, eight females and twelve males, met inclusion criteria for analysis. Their average age at distraction was 68.2 months (22-137 months) and average age at long-term follow up was 19.55 years (15-29 years). Seven (35%) patients had Pruzansky I mandibles while thirteen (65%) had Pruzansky IIA. Thirteen (65%) patients had superior outcomes based on the above measures, while seven (35%) had average outcomes. Comparing the two cohorts, patients with superior outcomes had distraction at an earlier age (56.4 months versus 87.4 months (p =0.056)), a greater overcorrection from craniofacial midline (3mm (range 1-8mm) versus 0mm (range -6-4mm)(p<0.005)), and male sex (84.6% versus 28.4% (p=0.04)).
This study demonstrates that mandibular distraction is indicated in the UCFM patients with mild to moderate dysmorphism provided that there is a comprehensive program emphasizing: adequate mandibular bone stock, overcorrection from craniofacial midline, comprehensive orthodontic involvement (bite block, cross-tongue elastics, and maxillary expansion if necessary), and longitudinal clinical, photographic, and radiographic follow-up.
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