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M. J. Recker et al.
Contemporary Treatment
The dilemmas posed by the challenging morphology of HFM and TCS patients
have motivated surgeons and engineers to develop creative solutions that are no
more invasive than the aforementioned treatment options. Currently, ramus distraction can be simulated digitally as discussed in the previous section (Fig.1.6). In the
a
Fig. 1.6 Patient with Nager syndrome presenting with decient rami and microretrognathia. (a, b)
Preoperative prole view and skeletal anatomy. (c) Simulated movement using curvilinear distractor. (d) Ramus cutting guide with predictive holes. (e, f) Intraoperative t of cutting guide and
distractor with (g) stereolithographic model for verication. (h, i) Clinical result following the
completion of mandibular distraction. (j, k) Second-stage maxillary surgery and genioplasty
planned at the time of distractor removal to correct occlusion and further improve chin projection.
(l, m) Final pre- and postoperative results showing improved midface and chin projection
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c
d
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Fig. 1.6 (continued)
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f
g
h
i
Fig. 1.6 (continued)
j
k
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l
m
Fig. 1.6 (continued)
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M. J. Recker et al.
1950s, Trauner and Obwegeser described the inverted L osteotomy; however, a transcervical approach was traditionally required to achieve the necessary exposure
[39]. With computer-aided design and patient-specic cutting guides, bone graft
templates, and xation hardware, it is now possible to perform the inverted L osteotomy via a completely transoral approach [40]. This is a useful options for patients
with enough soft tissue stretch to accommodate large counterclockwise advancements. The inverted L technique also permits surgeons to perform these large movements with less fear of lengthening the pterygomasseteric sling which is generally
considered an unstable movement and prone to relapse in the context of the sagittal
split osteotomy.
Another relatively recent development that began in the early 2000s was the
commercially available custom temporomandibular joint (TMJ) replacement. The
custom TMJ prosthesis has several advantages over the stock replacement and is
almost mandatory for patients with extremely atypical anatomy as the stock prosthesis may not reliably t the available bone even with surface contouring. For
Kaban–Pruzansky type 3 patients with agenesis of both the RCU and glenoid
fossa, extended custom TMJ replacements can be designed to independently recreate the missing anatomy without the need for preceding bony reconstruction.
Large, broad footplates can be adapted to the skull base and shaped to simultaneously recreate the both the zygomatic arch and glenoid fossa [41]. Long distal
extensions off condylar component can be used to reach suitable bone in the parasymphyseal region. These unconventional custom joint replacements have been
shown to have excellent mechanical stability and to drastically improve maximal
incisal opening [41]. The extended custom joint is a welcomed solution for cases
where the RCU anatomy is underdeveloped and inadequate for distraction or conventional orthognathic osteotomies.
Custom facial implants have emerged as an alternative to onlay bone grafts for
midfacial augmentation. Although bone grafts are able to add reasonable bulk, it is
hard to precisely contour them into the quadrangular shape needed to replace large
zygomatic segments. For cases of HFM, mirroring technology allows engineers to
create an immediate symmetric outcome that would be hard to manually reproduce.
In our experience, the most frequently used materials for alloplastic implants
include silicone, polyetheretherketone (PEEK), titanium, and high-density porous
polyethylene (MedPor) (Fig.1.7). PEEK implants are thermally resistant and biomechanically similar to cortical bone, and unsurprisingly, they are the preferred
material for cranial reconstruction. Although PEEK implants are considered the
gold standard of patient-specic implants, their high cost may be prohibitive for
some. MedPor is an affordable alternative that is also remarkably stable. Unlike
PEEK, MedPor implants are porous in nature and conducive to rapid bovascular
ingrowth, which is thought to improve long-term stability but also complicate subsequent removal [42, 43].
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a
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Fig. 1.7 Orthognathic surgery combined with custom silicone implant malar augmentation. Preand postoperative (a) facial and (b) intraoral photos. (c) Orthognathic surgical plan. (d, e) Frontal
view showing implant height, lateral view showing implant projection. (f, g) Patient-specic
implants are xated after LeFort I osteotomy with care taken to avoid impinging on the infraorbital
nerve. (Implantech Associates, Inc.; Ventura, CA). Pre- and postoperative side prole views of
patient (h)
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Postoperative
c
Fig. 1.7 (continued)
d
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e
f
Fig. 1.7 (continued)
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M. J. Recker et al.
g
h
Fig. 1.7 (continued)
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Summary andOutlook
In conclusion, the benets of modern technology have extended into the eld of
craniofacial surgery. The original osteotomies described by Tessier and Obwegeser
are still used today; however, we are now able to execute them with an unprecedented level of precision and condence. The acceptable margin of deviation from
the surgical plan has narrowed thanks in large part to patient-specic guides and
implants. Computer-aided surgical technology is becoming more commonplace,
and medical centers are beginning to realize the associated healthcare value that it
brings as the cost of doing business decreases. Consequently, we anticipate that
there will be a drive to decentralize manufacturing. High-volume centers will likely
reduce their reliance on outsourcing and seek to develop on-site point of care planning and printing. This in-house service is already in place at many centers and has
been shown to be cheaper with a shorter lead-time [44].
Although we are able to manipulate and predict the location of the bony skeleton,
the quality of our soft tissue simulations still does not reach a level of usefulness.
Likewise, one of the primary challenges of craniofacial surgery is being able to
operate in the fourth dimension. We need to understand and predict the effects of
surgery on growth and the effects of growth on surgery. In the future, computational
frameworks may provide insight into these problems. Overall, it is important to
recognize that continued progress in this eld relies on the cooperative multidisciplinary efforts of all professionals caring for patients with craniofacial differences.
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