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Facial asymmetry is common in humans. Significant facial asymmetry causes both functional as well as esthetic problems. When patients complain of facial asymmetry, the underlying cause should be investigated. The etiology includes congenital disorders, acquired diseases, and traumatic and developmental deformities. The causes of many cases of developmental facial asymmetry are indistinct. Assessment of facial asymmetry consists of a patient history, physical examination, and medical imaging. Medical imaging is helpful for objective diagnosis and measurement of the asymmetry, as well as for treatment planning. Components of soft tissue, dental and skeletal differences contributing to facial asymmetry are evaluated. Frequently dental malocclusion, canting of the occlusal level and midline shift are found. Management of facial asymmetry first aims at correcting the underlying disorder. Orthognathic surgery is performed for the treatment of facial asymmetry combined with dental occlusal problems. A symmetrical facial midline, harmonious facial profile and dental occlusion are obtained from treatment. Additional surgical procedures may be required to increase or reduce the volume of skeletal and soft tissue components on both sides to achieve better symmetry.

Dental anomalies associated with different severities of cleft lip and palate have been rarely reported. This retrospective study investigates the characteristics of dental anomalies associated with different types of cleft, and compares the dental anomaly traits based on sex and severity of cleft.Cleft patients born in 1995 with qualified diagnostic records from 7 to 11 years were included for evaluation. Records were retrieved from database of Chang Gung Craniofacial Center, including panoramic radiographs and intraoral photographs. In total, 196 patients with complete records were included in the evaluation. This study compares the dental anomalies associated with each type of cleft.The frequency of dental anomalies in the maxillary incisor area in the cleft palate (CP) group (20%) was significantly lower than that in other groups. The frequency of missing maxillary lateral incisors (MLIs) increased as the cleft severity increased. Supernumerary teeth and missing lower incisors exhibited the opposite trend. No sexual dimorphism appeared in terms of the frequencies of peg laterals and missing MLIs. The distribution patterns of missing MLIs and peg laterals in males, but not in females, were consistent for the three types of unilateral clefts.Regarding the characteristics of dental anomalies among the three unilateral clefts, missing MLIs, supernumerary teeth, and missing lower incisors were found to be related to cleft severity. The maxillary lateral incisor was the most affected tooth in the cleft area. The frequency of missing MLIs and peg laterals was not sexual dimorphic, but the distribution pattern was different between the sexes.

Lengthening the maxillary dental arch as a treatment approach for patients with maxillary deficiency and dental crowding is seldom reported. The purpose of this study was to assess dental and skeletal changes in the maxilla in the correction of maxillary deficiency associated with a retruded maxillary arch using a surgically assisted rapid maxillary anterior-posterior expansion appliance.Predistraction and postraction lateral cephalometric and periapical radiographs and maxillary dental casts of six young adolescents (four boys, two girls, mean age 11 years, 2 months) were examined. These patients received a maxillary anterior segmental osteotomy and distraction osteogenesis with an anteroposteriorly oriented Hyrax expansion appliance based on the biological principles of bone distraction.The retruded dental arch and dental crowding were successfully corrected. Significant forward movement of the point anterior nasal spine, point A, central incisors and first premolars was noted. The maxillary dental arch depth increased an average of 4.2 mm while the arch width remained unchanged. In total, 11.5 mm of dental space was created in the maxillary arch which was sufficient to resolve dental crowding. New bone formation along the distraction site was observed three months after distraction.The use of maxillary anterior segmental osteotomy combined with a Hyrax expansion distraction appliance was effective in arch lengthening and creation of dental space. An overcorrection in this interdental distraction osteogenesis could be a good treatment option for children with maxillary deficiency combined with crowded maxillary dentition.

Treatment of cleft palate has evolved over a long period of time. Various techniques of cleft palate repair that are practiced today are the results of principles learned through many years of modifications. The challenge in the art of modern palatoplasty is no longer successful closure of the cleft palate but an optimal speech outcome without compromising maxillofacial growth. Throughout these periods of evolution in the treatment of cleft palate, the effectiveness of various treatment protocols has been challenged by controversies concerning speech and maxillofacial growth. This article reviews the history of cleft palate surgery from its humble beginnings to modern-day palatoplasty, and describes various palatoplasty techniques and commonly used modifications. Current controversial issues on the timing of cleft palate repair, and the effects on speech and maxillofacial growth are also discussed.

Oronasal fistulas (ONF) following cleft palate repair are commonly encountered and remain a challenging problem. With reported recurrence rates between 33% and 37%, this urges us to critically evaluate the current treatment and propose a surgical management protocol.A retrospective study of patients treated for ONF by a single surgeon between 1995 and 2005 was performed. Data regarding cleft type, age at palate repair, complications, location and size of fistula, tissue condition, surgical technique employed, and success rate were gathered.There were 64 patients (33 male and 31 female), and 44% of them had bilateral cleft lip and palate. Hypernasality and regurgitation were the major presenting symptoms of these patients with ONF. Fistulas mostly occurred in the hard palate area (53.1%). Severe scarring surrounding the ONF was reported in 31.2% of patients. Local flap and two-flap palatoplasty were the most common techniques (62.5%) used for closure of the ONF. Twenty-five percent of patients needed more than one repair to close the fistula. However, the overall success rate of closure was high (90.5%). Velopharyngeal (VP) function was significantly improved: only 26.8% of patients had adequate VP function before ONF closure and 64.3% patients had adequate VP function after ONF closure. However, the VP function of twenty patients remained inadequate or marginal.A high success rate was achieved for closure of cleft ONF, although a certain percentage of patients required re-operation. Multiple fistulas and severely scarred palates made closure difficult. Successful closure of a fistula improved VP function but VP surgery was still indicated in certain patients. Based on the findings, an algorithm for management of cleft ONF was proposed.

Pharyngeal flaps have been widely used for the correction of velopharyngeal incompetence. The aim of this study was to compare the outcomes of velopharyngeal surgery between those who received the superiorly and inferiorly based pharyngeal flaps.A retrospective review of medical records of patients with cleft palates who received pharyngeal flap surgery for the correction of velopharyngeal incompetence at one craniofacial center was performed. The superiorly based flaps were elevated and inset using the fish-mouth method. The inferiorly based flaps were sutured to the soft palate where a distally based mucosa flap was turned over to cover the raw surface of the flap pedicle. The velopharyngeal functions were categorized as adequate, marginal, or inadequate. Complications associated with the operation were documented. Statistical comparisons between the two groups were made.There were 65 patients in each group. No statistically significant differences were found for sex distribution and age at operation. The outcomes of the velopharyngeal surgery were better in the group of patients who received the inferiorly based pharyngeal flaps (p = 0.030). The complications were not significantly different between the two groups, and were all relatively mild.The inferiorly based pharyngeal flap was more effective than the superiorly based pharyngeal flap for the correction of velopharyngeal incompetence. A probable explanation may be the fibrotic changes and scar contracture occurring in the pedicle of the superiorly based pharyngeal flap that may have impaired the velopharyngeal closure.

Unilateral cleft lip nasal deformity is characterized by prominent asymmetry resulting from distorted and displaced structures. Primary correction of the nasal deformity at the same time of lip repair has gained popularity, aiming at early restoration of the symmetry by lifting the alar cartilage and lengthening the columella on the cleft side. Postoperative relapse is a frequent finding due to the elasticity of the deformed alar cartilage. A variety of strategies have been proposed to treat this type of condition, including preoperative nasoalveolar molding, overcorrection of the nostril and alar cartilage, Tajima method of rhinoplasty, and postoperative nasal splinting. The results have been promising. Long-term assessments need to be performed to determine the final outcomes.

Airway obstruction and feeding difficulty can occur in patients born with Pierre Robin sequence. In select patients with pronounced micrognathia, surgical intervention to relieve the airway obstruction is necessary. The surgical indications and appropriate surgical procedure continue to have a great deal of controversy. The purpose of this study was to evaluate our experience of tongue-lip adhesion in the management of upper airway obstruction associated with Pierre Robin sequence.From March 1995 through May 2002, a total of 14 patients with Pierre Robin sequence, who were admitted to the pediatric neonatal intensive care unit either with prolong intubation, poor body weight gain, or repeated airway infection, underwent tongue-lip adhesion (TLA). The operation was performed by raising mucosa flaps and approximated the muscles between tongue and lower lip. Retention sutures were used. The patients were evaluated for clinical responses.Our successful rate with tongue-lip adhesion was 70%. Ten of the 14 patients showed clinical improvements including extubation of the endotraccheal tube, body weight gain, return for home care, reduced episodes of respiratory infection, and improvement in O2 saturation and blood gas. The surgical procedure was simple to perform without major complications.This retrospective review showed that with a thorough preoperative airway evaluation, TLA could be successfully used to treat select patients with Pierre Robin sequence suffering from severe upper airway obstruction. Thus, TLA should be first considered when surgical relief of airway obstruction is indicated and when obstruction is limited to the classic tongue base obstruction type.

Velocardiofacial syndrome (VCFS) is a disorder commonly associated with a characteristic facial appearance, congenital heart disease, and velopharyngeal insufficiency. An association with vascular anomalies in the cervical area and skull base has been reported. In this study, we evaluated 7 consecutive patients who received vascular imaging for preoperative planning of velopharyngeal surgery.From January 1996 to September 1997, 7 patients with VCFS were found in 1 of the senior author's service. All had documented velopharyngeal insufficiency and visible pulsations over the posterior pharyngeal wall by nasoendoscopy. Two patients had magnetic resonance angiography (MRA), 2 patients had computed tomographic angiography (CTA), and 3 patients had both.The angiographic study revealed abnormalities of the carotid and vertebral arteries in 5 patients (71%). Kinking and tortuosity of the internal carotid artery and its medial displacement were common. The observed pulsations did not correlate well with the angiographic findings. For surgical correction of the velopharyngeal sufficiency, a regular pharyngeal flap was used in 4 patients, a modified pharyngeal flap was used in 2 patients, and the surgery was abandoned in the remaining 1 patient.Expression of cervical vascular anomalies in VCFS was varied and did not correlate well with the observed pulsations from the nasopharyngoscopic examination. Preoperative vascular imaging study is essential for the purpose of planning and safety of surgical interventions in this area.

A mandibular arteriovenous malformation (AVM) is rare, and unawareness of this condition can lead to catastrophic complications. Embolization is an effective means to treat these lesions. The osseous changes and long-term outcomes among the pediatric patients after embolization treatment remain unclear. We present a 6-year-old patient with mandibular arteriovenous malformation who had sustained hemorrhagic shock after a tooth extraction. She was referred to us after stabilization of the hemodynamic condition. The patient received transarterial and direct intralesional embolization. Local infection occurred 3 months after embolization, but was well controlled. Serial computed tomography and panoramic radiographs were performed during follow-up examinations. The imaging studies showed gradual obliteration of the vascular space followed by normal bone regeneration and remodeling. The processes were complete during a period of 2 years. There was no recurrence of the vascular malformation and no abnormal growth of the right side of the mandible after 4 years and 4 months of observation.

The archival tools used for digital images in advertising are not to fulfill the clinic requisition and are just beginning to develop. The storage of a large amount of conventional photographic slides needs a lot of space and special conditions. In spite of special precautions, degradation of the slides still occurs. The most common degradation is the appearance of fungus flecks. With the recent advances in digital technology, it is now possible to store voluminous numbers of photographs on a computer hard drive and keep them for a long time.A self-programmed interface has been developed to integrate database and image browser system that can build and locate needed files archive in a matter of seconds with the click of a button. This system requires hardware and software were market provided.There are 25,200 patients recorded in the database that involve 24,331 procedures. In the image files, there are 6,384 patients with 88,366 digital pictures files. From 1999 through 2002, NT400,000 dollars have been saved using the new system.Photographs can be managed with the integrating Database and Browse software for database archiving. This allows labeling of the individual photographs with demographic information and browsing. Digitized images are not only more efficient and economical than the conventional slide images, but they also facilitate clinical studies.

A database is a system for the management of information. Databases of different forms are widely used in everyday life from telephone books to online library catalogs. The Craniofacial Center at Chang Gung Memorial Hospital has seen over 20,000 patients during the past 20 years. All of the patient records need to digitally input into a computer database.A database was custom designed using Paradox 8. The ACDSee Photo browser and DOS linked them to the original program. The Paradox 8 was programmed to a standard mode for the diagnosis and treatment data input to prevent typographical errors.We collected the records of 25,200 patients from 1987 to 2002, of which 24,331 underwent operations. The data for 14,828 patients were registered as complete and/or incomplete cleft and the proportions of unilateral to bilateral and female to male are presented in Table 1.This new database system was designed to ensure the accuracy of data input using a standard model that is capable of correct data programming using the custom designed coding system for the Craniofacial Center. The system also provides easy and reliable data retrieval when using the powerful search tools.

Three-dimensional carniofacial CT imaging has been developed and progressed during the past two decades. The advancement of the hardware and software has made the imaging study more convenient, user friendly, and affordable. Processing and analysis of the imaging data are readily performed on personal computers. Accuracy of the 3-dimensional measurement has been validated. Collaborative study can be achieved with other departments or disciplines, such as orthopedic, otolaryngologic, and dental departments, as well as mechanical engineering department. All the data should be adequately archived as medical imaging data bank for later use. The data can be transferred for production of rapid prototyping models to enhance clinical application. Inter-center sharing of imaging data can be done through common image format. Comprehensive morphological study and clinical information may help to improve or refine treatment planning, which in turn yield better treatment outcome.

Facial gunshot injuries are unusual and complicated clinical entities. Because of the mechanism of injury, early aggressive primary reconstruction might not be ideal. Initial conservative management followed by staged secondary reconstruction could be performed to obtain satisfactory functional and aesthetic results. Reconstruction of the cranio-maxillo-facial deformities requires a multi-disciplinary approach, the same way as for patients with cleft lip/palate deformities. We present a male patient with severe facial gunshot injuries. A team approach revealed maxilla recession, dental malocclusion, a large oronasal fistula over his hard palate, velopharyngeal insufficiency, and a stable psychosocial status. His main concern was facial appearance, which included the nose, lip, and scars. Staged reconstructions were performed, consisting of orthognathic surgery, rhinoplasty, lip-switch flap, and revisions of scars. A satisfactory outcome was obtained. The results indicated the importance of preoperative evaluation and treatment planning for this uncommon problem.

Conventional studies of the cleft lip/palate (CLP) dysmorphology have mainly focused on deformities of the lip, nose, and maxilla, while ignoring the mandible. Reasons for that were the lack of well-defined mandibular deformity and restriction from the research methodology.This study used 3-dimensional computed tomography (CT) imaging data from 35 patients with unilateral CLP. The 3-dimensional images were rotated into a neutral position. Eight cephalometric landmarks were recorded: the pogonion (PG) and the infradentale (ID) from the frontal view; and the condylion (CO), the tip of coronoid process (CP), and the gonion (GO) from both sides of lateral views. The nasion was used as a reference point for the facial midline. Nine linear distances and four angular measurements were calculated from these landmarks. Each mandible was segmented into two hemi-mandibles for volume measurements. The image manipulation and measurements were performed using a personal computer running Analyze' program. Landmark deviation from the facial midline was computed, and comparisons were made between the cleft and non-cleft sides.The results showed that the precision and accuracy of landmark localization was high with an average error of 0.4%. Deviation from the midline of the ID and PG points, and spatial distances between bilateral CP, CO, and GO points varied without a specific pattern. The average differences were within 2 mm. The volume of the cleft side hemi-mandible was consistently larger than that of the non-cleft side (p0.0001). Among linear and angular measurements, CP-GO-PG, CO-ID, CP-ID, and CP-GO showed significant difference between the two sides.This study demonstrated that mandibular asymmetry and deformity existed and was measurable in patients with unilateral CLP. The influence of CLP to the mandibular development was expressed by the significant differences of hemi-mandible volume and some of the linear and angular measurements between the cleft and non-cleft sides.

Congenital infiltrating lipomatosis of the face comprises a subgroup of lipomatous tumors. While rare, it remains a definite clinical entity. Its etiology is unknown. The tumor is congenital in origin and occurs in infancy or early childhood. It is poorly enveloped and characterized by diffuse infiltration of mature adipose tissue over normal muscle fibers, rapid growth, associated osseous hyperplasia, and a high recurrence rate after surgical intervention. Due to its diffuse infiltration and involvement of important facial structures, complete surgical excision is often impossible. A total of 14 cases of congenital infiltrating lipomatosis of the face was found in a literature review. Herein we present an additional case who had both diffuse infiltrating lipomatosis and a well-encapsulated lipoma on her left cheek.

Fibrous dysplasia is a benign fibro-osseous tumor of bones commonly involving the craniofacial region. Computed tomography (CT) imaging study of the disease is useful for evaluation and treatment planning. However, few studies have evaluated such large patient series.A total of 46 patients with complete medical records and CT images was included in this study. All of these patients were non-syndromic, had fibrous dysplasia involving only the craniofacial region, and had no skin pigmentation or other evidence of endocrine problems. Data analyses were performed on the clinical manifestations, time of onset, signs and symptoms, involvement of cranial and facial bones, and CT appearance of the tumors in this patient group.Painless swelling was the chief clinical problem in 78% of patients, followes by dental malocclusion in 22%. Onset of the disease was reported to have occurred before 6 years of age in 34%, between 6 and 10 years in 27%, and older than 10 years in 39% of patients. Extreme timings such as onset at infancy or older than 20 years of age were also noted. The average number of bones involved was 3.2 bones per patient. Involvement of more than one craniofacial bone occurred in 70% of patients. The maxilla, orbital, and frontal bones were most commonly involved. CT images appeared sclerotic or homogenous in 34%, mixed white and dark or heterogenous in 55%, and cystic in 11%. A correlation between the age of onset of the disease and the number of bones involved was not observed.Findings of this study demonstrate that craniofacial fibrous dysplasia displays a wide spectrum of clinical behaviors. CT imaging generally revealed extensive involvement of the tumor in the craniofacial region.