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New treatment for midfacial hypoplasia shows promise

Beijing — Compared with other techniques in patients with severe midfacial hypoplasia, sutural distraction osteogenesis (SDO) may be performed at a younger age and without invasive surgery. A bone-borne traction system is used to draw the bone forward at the plane of maximum resistance — about 5 mm above the nasal floor, according to Chunming Liu, M.D., D.D.S., chief of plastic surgery at 301 Hospital and Postgraduate Medical College of the People's Liberation Army.


Dr. Liu
Midfacial hypoplasia is a common developmental deformity. Especially in patients born with complete unilateral cleft of the lip and palate, the incidence of subsequent midfacial hypoplasia has been estimated to be between 25 percent and 60 percent. The resulting appearance is a boat-shaped face when viewed laterally.

"There has definitely been some progress in the treatment of the disease," Dr. Liu tells Cosmetic Surgery Times. "My technique makes it possible to treat patients 10 years earlier."

Dr. Liu suggests installing traction hooks through the nostrils into bone holes drilled at the lateral-inferior pyriform aperture to draw the midfacial skeleton forward. While older procedures require skeletal maturity, the new technique of sutural distraction can be done in younger patients, produces no visible scarring and prevents dental injury.

"The most conspicuous advantages are its micro-trauma and safety," Dr. Liu says.

The study

Dr. Liu, , and his colleagues published the results of their distraction study in the Journal of Craniofacial Surgery in July 2005.

Three adult patients and four children (ages 6 to 12 years) took part in the study. While the distraction method is the same in both the adult and child populations, each adult patient received a Le Fort III osteotomy prior to distraction due to their more mature age.

Following the installation of the traction hooks, a transverse bar, face bow and orthodontic elastics were attached to initiate distraction. The period of active distraction ranged from 16 days to 48 days, while retention lasted three to six months.

All of the patients in the study achieved a harmonious facial profile and normal occlusion at the conclusion of treatment. The retrograde nose, suborbit, zygoma, maxilla and cross-bite were ideally corrected with an average advancement of 10 mm in the adults and 8 mm in the children. After six months, no relapse had occurred.

New vs. traditional technique

According to Dr. Liu, the new technique solves various problems associated with traditional corrective methods, especially in young patients.

While orthodontists have been using intraoral appliances to advance the upper dental arch in pediatric patients for more than 100 years, the technique has had little influence on the retrograde maxillary bone due to the lower position of the distraction force.

Not only does this traditional procedure require an intact dental arch, the force exerted on the maxilla is too inferior and may cause rotation during advancement.

Furthermore, plastic and maxillofacial surgeons must wait until the patient achieves skeletal maturity before advancing the retrogressed maxillary skeleton. These surgical procedures require many incisions, major bony cuts and subsequent distraction.

Not only are they more invasive; they also prolong the aesthetic and physical complications that accompany the patient into adulthood, explains Scott Bartlett, M.D., director of the craniofacial program at the University of Pennsylvania

"Malocclusion has a negative effect on speech, breathing and eating," Dr. Bartlett says. "It goes way beyond self-esteem issues."

Lasting impact

Dr. Bartlett believes Dr. Liu's procedure will have a lasting impact on the future of craniofacial surgery.

"He's got some promising early results," he says. "While it'll be important to see what happens over time, he's certainly on the right track to make a huge contribution. I can safely say that it may lessen the need for major surgery or secondary surgery in the future."

For more information:
Journal of Craniofacial Surgery 2005, 16: 537-548.

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