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342
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V. Kerkfeld and U. Meyer
– Can the planned shift be made possible within
the biological limits?
– Which procedure (DO vs. augmentation)
should be performed for the skeletal part in
question?
– How many osteotomies/segmentations are to
be performed to be able to produce the desired
normal anatomy?
– Which osteotomy line is feasible and goal-
oriented in the respective segment?
In frontal view, the jaws should be aligned so
that the interocclusal plane, the mandibular angle
plane, and the chin plane are parallel to the bipupillary plane. In complex cases, it is helpful to
rst position the maxilla optimally. In particular,
the maxillary incisors should be aligned in the
optimal vertical and anteroposterior orientation
to the lower lip and face. The maxilla should be
positioned so that it is at a normal height to the
base of the skull. The mandible is then placed in
class I relation to the maxilla.
Planning
After careful consideration of the patient’s anatomy (Fig.25.2), virtual surgery is performed. For
this purpose, the maxillary osteotomy (here:
LeFort I osteotomy) is performed rst. Particular
attention should be paid to the anterior paranasal
osteotomy height, as this has a signicant effect
on the subsequent appearance. Technically, an
unobstructed displacement of the maxillary complex must be possible. However, this is signicantly limited in reality due to various biological
limiting factors. Therefore, an experienced practitioner with a lot of experience in the eld of
orthognathic surgery is necessary to assess the
displacement possibilities during the DO planning phase. For the positioning of the maxilla, the
superimposition of the norm skull (and in cases
of asymmetries, an additional mirroring) determines the placement of the maxilla in the 3D
space (Fig. 25.3). The vector should be placed
parallel to the Frankfurt horizontal and parallel to
the mandibular occlusal plane (as determined
after the virtual surgery). Subsequently, the mandibular osteotomy is planned to be performed
during the second-stage operation (removal of
distractor and bone xation by osteosynthesis
plates, combined with a mandibular sagittal split
osteotomy so that the jaws can be brought
together in harmonious class I occlusion). The
mandible thus follows the position of the
maxilla.
After the virtual maxilla distraction in the nal
position, the now virtually altered skull anatomy
is the basis for the second superimposition and
mirroring strategy to determine the remaining
soft tissue deciency. Augmentation of bone is
done to support and expand the soft tissues so
that a symmetrical and harmonious soft tissue
appearance is achieved (Fig.25.3). The augmentation is carried out using individual PEEK
implants.
Completion
After careful nal assessment, which also simulates soft tissue deformation, approval is
given. Finally, patient-specic implants are
fabricated on the basis of the planning in the
form of individual cutting and drilling guides
for the distractor as well as PEEK implants,
which are used simultaneously intraoperatively. The reconstruction surgery was performed through a bi-coronal and intraoral
incision (Fig.25.4). In the presented case, the
distraction devices was removed after 6weeks
(2weeks of distraction and 4weeks of consolidation), and osteosynthesis plates are placed to
stabilize the maxilla, combined with the anticlockwise rotation of the mandible to achieve a
class I occlusion.
Matching of the planning data and the postoperative operation is shown in Fig.25.5. The color-
coded view demonstrates the high precision of
this surgical strategy.
25 Planning Principles in Distraction Osteogenesis Including Simultaneous CAD/CAM-Based Facial…
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343
Fig. 25.3 Intraoperative
view on (a) PEEK
implant placement in the
skull area through a
bi-coronal incision, (b)
left: placement of
distractor and paranasal
PEEK implants, middle:
during the distraction
phase, and (c) at the
time of distractor
removal with xing the
maxilla by
osteosynthesis plates.
Note the direct contact
between the maxilla and
the PEEK implants
a
b
c
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V. Kerkfeld and U. Meyer
c
Fig. 25.4 Postoperative situation of a patient with apert syndrome. (a) Facial appearance, (b) occlusal view, (c) lateral
cephalogram
PEEK
Fig. 25.5 Matching of planned position towards postop-
erative position
PEEK resembles bony structures in its constitution.
It can be easily manufactured in CAD/CAM processes and may even replace titanium or ceramic
implants in the long run. The material is widely
used in various medical elds such as orthopedics,
spinal cord surgery, neurosurgery, and maxillofacial
surgery. In these areas, an exact match is required.
PEEK achieves ideal material properties as it is
hard, lightweight, stiff, and robust at the same time.
It also offers a high level of wearer comfort, which
facilitates long-term care [30].
Characteristics
PEEK is a brown-beige polyaromatic semicrystalline thermoplastic polymer (Fig.25.6) that is
sterilizable, biocompatible, radiolucent, and MRI
25 Planning Principles in Distraction Osteogenesis Including Simultaneous CAD/CAM-Based Facial…
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Furthermore, care must be taken, especially
when using PEEK augmentations, to avoid
exposing the PEEK implants. Furthermore, attention must be paid to the development of
infections.
Future Perspective
Fig. 25.6 Structure formula of polyetheretherketone.
According to Fan and Tsui [40]
compatible [31, 38]. Numerous modications are
possible to inuence the elasticity, surface properties, and other factors to optimize it for the
intended purpose [39].
Complications
Every reconstructive procedure involves the risk
of complications, and PEEK augmentation is no
exception. The most frequent complication is
unsatisfactory appearance (10%) followed by
infections (7%). Therefore, more attention should
be paid to patient communication with precise
explanation of what can be achieved, as well as
careful preoperative planning. Furthermore, a
consensus on antibiotic prophylaxis is advisable.
In view of the great benet of complex facial
reconstructions, PEEK augmentation seems to
have very few complications [41].
Follow-Up
In the postoperative follow-up, it must be determined whether the virtual planning could actually be transferred to the patient and whether the
desired harmonious and symmetrical image is
obtained. For this purpose, postoperative ndings (CBCT scans) can easily be superimposed
on the preoperative planning to determine the
deviations [42]. However, this procedure
includes any deviation of individual points in
the error calculation, regardless of whether this
has a major or null inuence on the subjective
symmetry in reality [43].
Modern surgery benets greatly from advances
in material properties and the use of CAD/CAM
techniques. This allows near-perfect positioning
of the distractor, which generates correspondingly good outcomes. In the future, distractors
can be further reduced in size to allow minimally
invasive procedures. Furthermore, in addition to
the patient-specic osteosynthesis plates and
implants already available, patient-specic distractors are also conceivable. For example,
curved distractors could nd their way into therapy, allowing dynamic vector control. Motordriven distractors are also possible, which would
mean an enormous comfort for patients and practitioners. With a priori simulations, craniofacial
surgery has reached a new milestone in diagnostics and therapy, once again making OGS more
precise and predictable.
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Aspects ofDysgnathic
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(Distraction) Intervention
inChildhood
W.Kater, M.Trommlitz, andD.Karnaus
26
Medical History
We report on a 6-year-old patient whose primary
clinical symptoms were bilateral hearing impairment as a result of constantly recurrent seromucous tympana on both sides, recurrent adenoids,
persistent rhinorrhea and otorrhea, hypertrophy
of the conchae, chronic tonsillitis, rhonchopathy,
and chronic otitis media on both sides. Therefore,
a partial C-tonsillectomy, paracentesis, and adenotomy had already been performed in November
2013 in another place. In September 2015,
another paracentesis with adenotomy was performed, but now with a tympanic drainage on the
right.
In May 2016, the young patient underwent
another operation due to the persistence and
recurrence of symptoms, this time radiofrequency ablation of the inferior nasal turbinates
(both sides), another paracentesis with T-tube
insertion on both sides, and tube dilatation with a
balloon catheter. Despite antibiotic therapy using
cephalosporins in laboratory-proven ß-hemolytic
streptococci, no improvement in the symptoms
could be recorded.
W. Kater (*) · M. Trommlitz · D. Karnaus
Clinic for Oral and Maxillofacial Surgery,
Zeppelinstr, Bad Homburg, Germany
e-mail: info@hno-trommlitz.de; info@dysgnathie.de
The patient suffered from a dysplastic pulmonary valve with severe stenosis, which is why he
received a pulmonary valve replacement (RV-PAConduit/Contegra 20mm) in June 2017.
The constant recurrence and chronication of
the seromucous tympanum, otitis media, adenoids, rhinorrhea, and otorrhea were now problematic, since the risk of endocarditis due to the
pulmonary valve replacement was signicantly
increased due to the permanent bacterial load. As
a result, almost permanent antibiotic therapy
using aminopenicillins and cephalosporins was
carried out, which led to increasing antibiotic
resistance.
In March 2018, the patient presented for the
rst time in our dysgnathia consultation. At rst
sight, a maxillary retrognathia and the resultant
mesial bite position of a premolar width (PB)
could be diagnosed.
Diagnosis
A performed digital volume tomography conrmed the diagnosis of maxillary retrognathia as
the cause of the disruptive tube ventilation. The
tooth buds of the second dentition were developed and created according to age. Resistance to
penicillin, amoxicillin, and piperacillin has
already been demonstrated in the antibiogram.
© Springer Nature Switzerland AG 2023
U. Meyer (ed.), Fundamentals of Craniofacial Malformations,
https://doi.org/10.1007/978-3-031-28069-6_26
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W. Kater et al.
Treatment
With the participation of the departments of
orthodontics, radiology, and ENT medicine, an
interdisciplinary therapy concept was developed
with a modied osteotomy to shift the midface in
the Le Fort I plane in the sense of an upper jaw
advancement. A purely orthodontic treatment
without surgical intervention appeared to be less
promising. In addition, there was a risk of endocarditis with multiresistant pathogens.
A combined orthodontic and maxillofacial
surgical approach thus represented the last resort,
since the patient’s history of the dysplastic pulmonary valve and pulmonary valve replacement,
as well as an acutely impending endocarditis,
meant that a timely solution had to be found in
order to treat the vitally endangered patient with
a causal therapeutic approach.
With an interdisciplinary assessment of risks
and side effects, early surgical treatment in the
sense of maxillary advancement with rehabilitation of the airways and maxillary sinuses was
therefore advocated.
Preoperatively, the model operation and simulation followed on April 26th, 2018, taking
into account the age-appropriate tooth systems
of the permanent teeth that were still relatively
far cranial. These were calculated and released
using the Simplant® software (Dentsply Sirona;
www.dentsplysirona.com/de- de/simplant.html).
The ideal osteotomy line could now be determined in a modied, more cranially planned Le
Fort I osteotomy in order not to damage the permanent teeth. The cranial boundary was the
infraorbital foramen with the infraorbital nerve
on both sides, taking into account the anatomically difcult initial situation. The caudal
boundary was dened by the dentition of the
permanent teeth.
Another challenge was the xation using titanium microplates. To protect the threedimensionally identied and localized tooth
systems, we used self-tapping osteosynthesis
microscrews.
The patient and his parents were informed in
detail that a possible follow-up operation could
be necessary.
The osteotomy to relocate the midface in the
modied Le Fort I level as an upper jaw advancement with rehabilitation of the airways and maxillary sinuses took place on May 4th, 2018.
The operation was performed under arterial
hypotension and vasoconstriction (Xylonest 1%
with added epinephrine (1:200,000)) in the entire
surgical area. A modied Le Fort I osteotomy
was performed with an oscillating saw under
controlled arterial hypotension (RR <80 mm
Hg). Then the upper jaw was separated from the
sphenoid bone in the pterygopalatine ssures on
both sides with the curved Obwegeser chisel, and
the osteotomy of the nasal septum with the septum chisel. This was followed by the “down fracture” and mobilization of the upper jaw, which
was typically performed very delicately and with
extreme caution to avoid bleeding.
According to the planned dorsal impaction of
the upper jaw, the dorsal, lateral, and facial maxillary sinus walls as well as the lateral nasal wall
were reduced, partly with the oscillating saw and
partly with delicate bone punches. A particular
difculty here was the permanent tooth germs.
In particular, the preparation and relocation of
the neurovascular bundle palatally on both sides
proved to be extremely time-consuming, since
the bone here proved to be very strong. The nasal
septum was now shortened and straightened, the
spina nasalis was reduced, and the nasal oor,
which was severely constricted in the sense of a
choanal stenosis, was widened with large round
burs and placed deeper to compensate for the
planned impaction. The bilateral inferior nasal
conchae, which were hyperplastic, were resected
caudally, and the mucosa located above them was
reconstructed in layers with Vicryl 4/0 sutures
and closed.
Due to the suspicion of bilateral maxillary
sinusitis, both maxillary sinuses were freed from
sinusitis-changed mucosa. The surgical splint
was xed intermaxillary in the upper and lower
jaw using transgingival titanium screws (TADs).
Subsequent adjustment and xation of the titanium microplates were done. The paranasal
plates were xed twice for better stability. Six
titanium microplates were required in the maxilla
to ensure sufcient stability. The previously
26 Aspects ofDysgnathic (Distraction) Intervention inChildhood
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349
straightened nasal septum was then xed to the
shortened spine via a drill hole caudal to the anterior nasal spine. The alae were then attached to
the nasal spine with Vicryl 2/0 sutures to narrow
the alae spacing. In order to bridge the large bony
gap and to avoid an ascending infection, Sulmycin
implants were placed and tted on both sides.
Swabs were taken from the right maxillary
sinus, the left nostril, and the right auditory canal,
from which copious amounts of pus were
emptied.
Finally, because of the extreme tongue habit,
an 11mm mini screw was inserted into the palate
as a myofunctional stimulus.
Postoperative
The postoperative course with 2-day administration of 1×2g ceftriaxone i.v., single administration of Solu-Decortin 50 mg as a decongestant
measure, and Hilotherm cooling device was
uncomplicated. Furthermore, the surgical splint
was not inserted postoperatively. The patient
could already be discharged on the second postoperative day. The further clinical oral surgery
and orthodontic and ENT follow-up checks
showed an immediate improvement of the symptoms of the seromucous tympanum, otitis media,
and tube ventilation disorder. Our patient was
also able to conrm this subjectively, as he suddenly stated after the operation that he was nally
able to hear much better, that he was now more
efcient in sports and at school, and that he was
sleeping undisturbed. Thus, the permanent antibiotic therapy could also be discontinued. The
anterior teeth 11 and 21 erupted in January 2019
and the lateral anterior teeth 12 and 22in October
2019 in an age-appropriate manner and have
properly settled in.
Discussion
There is much controversy regarding the timing
of surgical correction of malocclusions. Many
colleagues are reluctant to surgically correct
developmental anomalies in the jaws before
facial growth is complete. Waiting until skeletal
growth is complete is justied for two reasons:
1. The surgical procedures required to correct
the dysgnathia may adversely affect subsequent growth [1].
2. Facial skeletal growth continues postoperatively, which could signicantly affect the
outcome of any surgery performed [2–5].
Conicting results continue to be published,
both advocating and discouraging an early surgical approach [6–12]. However, treating these
patients with jaw abnormalities during their
growth poses a challenging problem for both
orthodontists and oral surgeons. One of the issues
that make it difcult to choose a treatment method
for such a problem is the young age and thus the
uncertain postoperative result. The patient shows
growth tendency, as there is no concrete consensus regarding the age limits for orthodontic or
maxillofacial therapies [13]. The preeminent
rationale behind effecting early surgical intervention prior to the culmination of facial growth frequently rests upon the salient psychosocial
component inherent to the maturing patient.
Many children with severe jaw anomalies have
problems accepting their peers because facial
appearance is an important factor in determining
social relationships and affects the psychosocial
perception of the child or adolescent [14, 15].
Therefore, early surgery during growth may be
warranted and should be seriously considered to
avoid negative psychological and/or psychosocial effects [14, 16, 17]. The potential benets of
early surgical correction of severe malocclusions
also include a shorter treatment time, since no
orthodontic phase treatment [18] is performed,
and an increased healing potential [19].
Determining the growth rate and growth vector
can be challenging in parts but is necessary
because degrowth of the jaws occurs in one or
more dimensions. In general, women will have
completed about 98% of facial growth by the age
of 15 and men by about the age of 17 [20, 21]. An
understanding of facial growth tendencies and
the specic anatomical face types (e.g., brachycephalic, normocephalic, dolichocephalic) pro-
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vides important information about subsequent
growth. Evaluation of the patient’s medical and
family history, as well as clinical and radiological
examinations, is helpful in identifying growth
disorders in the jaws [22]. Factors that can signicantly affect the direction and rate of maxillary growth include genetics, developmental
conditions, hormonal stimulants, and obstruction
of the nasal or oropharyngeal airways [22–29].
The surgical management of the growing patient
with maxillary anomalies continues to be the
subject of much controversy.
The most common surgical procedure in the
upper jaw to correct malocclusions is the Le Fort
1 osteotomy [22].
During this surgical procedure, the maxilla is
separated from its bony cranial pillars (apertura
piriformis, crista zygomaticoalveolaris, pterygomaxillary ssure) and the nasal septum.
This surgical separation (referred to as a
“down fracture” of the maxilla) effectively arrests
further anteroposterior growth of the maxilla [30,
31].
Thus, if surgery is performed during the growing years, postoperative recurrence resulting in
skeletal class III could occur if the mandible continues to grow normally.
If an early operation is nevertheless indicated
for functional, aesthetic, and psychosocial reasons, a certain amount of overcorrection must be
taken into account in the Le Fort I osteotomy of
the maxilla so that the mandible, which is still
growing, can develop and adjust properly in a
natural way.
If this operation is performed during growth,
the patient and parents must be fully informed
that further operation is likely to be necessary at
a later date [32]. Alternatively, the so-called
horseshoe osteotomy (complete dentoalveolar
osteotomy) of the upper jaw is under discussion.
This osteotomy technique maintains the septal
and vomerine connection in the maxilla because
only the dentoalveolar mobilization is performed [22].
It is important to keep in mind that in patients
who require maxillary advancement, there is
insufcient maxillary growth preoperatively and
there is no further anteroposterior growth; verti-
cal maxillary growth, after the Le Fort I osteotomy however, continues at the same preoperative
rate postoperatively [31, 33, 34] and the mandible
also continues to grow at the preoperative growth
rate, which could again result in a class III occlusal relationship [22].
However, severe functional or psychosocial
factors may indicate earlier treatment. Both osteotomy procedures can technically be carried out
in the rst decade of life if there is sufcient
space above the root tips of the developing permanent teeth or tooth germs to carry out the osteotomy and to carry out a sufcient osteosynthesis.
Although vertical growth of the maxilla is
unlikely to be affected by this procedure, damage
to the developing tooth germs and roots can result
in dento-osseous ankylosis and localized impairment of dentoalveolar growth [22].
ENT Aspects
The Eustachian tube protects against secretion,
germ ascension, and sound pressure from the
nasopharynx; acts as a drain; and serves to equalize pressure in both directions so that the eardrum
and the sound conduction apparatus can vibrate
optimally. Tubal dysfunction has an incidence of
about 1% in adults and almost 40% in children.
Symptoms are often nonspecic. In children,
adenoid vegetations are often the cause of
obstructive tubal dysfunction. In the case of the
obstructive form, nasal sprays containing cortisone and regular implementation of the Valsalva
maneuver as well as tube dilatation with the
Bielefeld balloon catheter are used therapeutically [35]. The typical symptoms of chronic
obstructive tubal dysfunction are a feeling of
pressure in the ears, aggravated by atmospheric
pressure uctuations, and difculty in performing the Valsalva maneuver. Symptoms are often
persistent, and affected patients have long medical histories, which may begin in childhood.
Long-lasting obstruction of the tube can lead to
tympanic effusion and tympanic membrane
retraction, often associated with a hearing loss
(usually conductive hearing loss), and plays a
crucial role in the pathogenesis of cholesteatoma
26 Aspects ofDysgnathic (Distraction) Intervention inChildhood
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[36]. Since patients with obstructive tube ventilation disorders tend to develop middle-ear infections, they often suffer from the typical (late)
consequences of recurrent or chronic inammation of the middle ear [35]. Obstructive tube ventilation disorders are a common phenomenon in
childhood. The predominant part is caused by
adenoid vegetations. These constrict the torus
tubarius and often sustain a local inammatory
reaction with mucosal swelling. In addition, the
structure and the angle of inclination of the
Eustachian tube are still different from those in
adults up to about the age of 7: the cartilaginous
part is larger, and the angle of ascent is atter.
The most important consequences of this tube
dysfunction are serous to mucous tympanic effusions and recurrent otitis media. Favoring of the
development of cholesteatomas and adhesive
processes is also discussed [35, 37]. The standard
therapy consists of adenotomy and paracentesis,
if there is necessary tympanic drainage. In the
case of recurrent tympanic effusions and middleear infections without recurrent adenoids or if the
symptoms recur after tympanic drainage, balloon
dilatation of the Eustachian tube can be considered as a second-line therapy [35, 37].
Conclusion
Treating growing patients with dentofacial abnormalities that require surgical correction presents
orthodontists and surgeons with a unique and challenging problem. Children and adolescent patients
with malocclusions may sometimes require surgical treatment during active growth due to functional, aesthetic, and psychosocial factors, as well
as vital treatment indications in this case. A sound
understanding of facial growth, available treatment options, and impact of surgery on postoperative growth patterns when treating these patients is
essential for good and desirable outcomes.
Clinical, orthodontic model and X-ray analysis are
important in predicting individual patient growth
rates and patterns. The type of dysgnathia present
and the patient’s specic growth vectors affect the
surgical outcome and must be carefully evaluated
prior to surgery. The patient and their family must
understand the expected outcomes, potential risks,
and potential complications that may arise from
early surgical interventions. Factors such as the
presence of mandibular disproportionate growth
and coexisting temporomandibular joint disease
can signicantly affect postoperative growth and
patient outcomes and must be identied and
appropriately managed. In addition, facial growth
can continue postoperatively and negate the outcome of any surgery that has been performed,
leading to subsequent surgeries. This case report is
in no way intended to be transferrable across the
board, but rather to focus on alternative treatment
methods in the case of such a diffuse medical history. It is particularly important to create a specic
treatment plan for each young patient with regard
to the appropriate type and timing of the corrective
surgical intervention.
In summary, this case is a rarity due to the
patient’s age and the multifactorial interaction of
antibiotic resistance, pulmonary valve replacement, and tube ventilation disorders, which
resulted in a life-threatening course.
However, since all known causal and surgical
therapy options were carried out without lasting
success and the general condition of the patient
was increasingly deteriorating, also due to progressive antibiotic resistance, a rapid causal and
vital therapy was required.
As a rule, it is not advisable to treat patients
before the age of 12, more precisely before the
eruption and placement of the permanent teeth in
occlusion, with surgical treatment of dysgnathia,
since the risk of a recurrence is particularly high.
In this case, however, the osteotomy and displacement of the upper jaw to stretch and tighten
the auditory tube and thus therapy of the seromucous tympanum were the last resort as the only
remaining vital treatment option.
Furthermore, our patient has no postoperative
complaints or symptoms with regard to the tube
ventilation disorder and the seromucous tympanum. To date, no dental or skeletal recurrence has
been identied.
The osteosynthesis plates were removed on
October 18th, 2019, in order not to hinder the
eruption of the tooth germs of the second
dentition.
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