Skeletal Deformities Involving the Maxillofacial Skeletal Complex
This month’s case report demonstrates the team approach we use to treat more complicated skeletal deformities involving the maxillofacial skeletal complex. These types of skeletal problems commonly include deformities of the nose and the bones surrounding the orbits. They are still growth deformities however and should not be confused with congenital deformities of the maxillofacial complex such as Pierre-Robin Syndrome and Treacher Collins Syndrome.
Acquired skeletal deformities that are hypoplastic/hyperplastic in nature are commonly treated in private practice but the treatment of these acquired skeletal problems with orbital reconstruction and nasal reconstruction is not. Very few orthognathic surgeons outside of academic settings can offer this valuable service to their patients. A team approach is a must. Having the right combination of a facial plastic surgeon and an oral and maxillofacial surgeon is not enough, however. The magic ingredient? A well trained operating room and anesthesia staff.
Performing nasal surgery and jaw surgery is a great benefit for the patient. It saves the patient a separate surgery, anesthetic and hospital bill, not to mention the second period of recovery. But doing them together requires a hospital-based anesthesiology department and operating room staff skilled at converting nasally intubated patients to orally intubated patients in the middle of a long, complex reconstructive surgical procedure involving the entire airway.
The case presented this month is commonly performed at Mercy Hospital- Anderson and is not possible without the skill and expertise of the operating room staff and anesthesiologists.
The patient in figure 1 is typical of individuals who present with skeletal deformities of the nose, midface and mandible. From a frontal and lateral view, the sunken in look to the orbital bones and upper jaw are easily recognizable. The nose appears large because it is long and narrow but also because it is projecting from a hypoplastic midface. The mandible appears narrow and prognathic, but in reality is not significantly enlarged, at least not horizontally. It is more so vertically. The most common mistake made in cases such as these is for the surgical team to focus on the strong looking mandible and treatment plan the patient for an extensive mandibular setback procedure. This is a disaster on many fronts – both aesthetically and more importantly from an airway standpoint. Sleep-disordered breathing is certainly to follow!
There is always overwhelming dental compensation in these cases and the orthodontist must pay special attention to positioning the upper and lower incisors to obtain perfect incisor inclination before surgery. Without proper placement of the incisors, overbite and overjet will be compromised and uncoupling of incisors can occur post-operatively. Figure 2 shows the presurgical setup of a similar case where improper incisor set up limited overjet and overbite.
Compare this to the presurgical setup in our case, figure 3 and side by side models of the two cases, figure 4.
From figure 1, the hypoplastic look to the upper jaw, orbital bones and zygomatic arches is easily recognizable. These areas will look even more sunken in if the maxilla alone is advanced. Infraorbital rim/zygomatic bone augmentation is needed to obtain good aesthetics. This graft is very simple to do once the infraorbital rim and the lateral aspect of the arch is dissected out of the overlying soft tissue and a pocket is developed next to the bone to accept the graft. The graft is a combination of nonresorbable hydroxyapatite, collagen and water. They can be molded into soft wafers the size of miniature Hershey chocolate bars and placed under a heat lamp. (Figure 5)
After several hours of drying they can be slipped into place and positioned to obtain symmetry and projection of the infraorbital rim region. (Figure 6)
Maxillary hypoplasia accentuates the complexity of any nasal deformity. In our case, the nose appears elongated with a slightly downturned nasal tip. It overwhelms the face. Softening the dorsum of the nose and advancing the maxilla greatly improved the patient’s aesthetics. (Figure 7)
The patient’s mandibular prognathism, is accentuated by his midfacial hypoplasia. A common mistake made by the inexperienced surgeon is to focus on the prognathic mandible and aggressively set it back when, in reality, an extensive maxillary advancement is in order. This can be facilitated by advancing the maxilla to its optimum aesthetic position using glabella vertical as a reference. (Figure 8)
Figure 9 compares the preoperative and postoperative facial result. His preoperative and postoperative occlusion is seen in Figure 10.
This case demonstrates the nuances of combined orthognathic surgery and nasal reconstruction. We thank Dr. David Quast for his referral of this most complicated case and for his orthodontic expertise in preparing him for surgery. Additionally, we thank Kevin Shumrick MD for his expertise in nasal reconstruction.