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A question that remains unanswered is at what level of surgical correction does the public perceive a head shape to be "normal" or "acceptable?" For most cases of non-syndromic asymptomatic craniosynostosis, the parents desire for surgical correction is to improve the cosmetic appearance of head shape. At the time of this writing, the intraoperative surgeons' perspective of what constitutes an acceptable head shape is the target for surgical correction. In introducing an improved objectively cosmetic goal, an appropriate outcome measure would be to assess what the general public considers a normal or acceptable head shape in children with craniosynostosis. Method Twenty-two unique images were presented via an online crowdsourcing survey of a severe case of non-syndromic sagittal craniosynosis gradually corrected to an age and gender matched normalized head shape. Participants were recruited via the Sick Kids Twitter account. Participants were invited to rate the head shapes as "normal" or "abnormal." Results The 538 participants completed the online survey. Participants were able to reliably and consistently identify normal and abnormal head shapes with a Kappa Score >0.775. Furthermore, participants indicated that a correction of 70% is required in order for the cranial deformity to be regarded as "normal." This threshold closely reflects a normal Cranial Index, which is a widely used morphometric outcome in craniosynostosis. Conclusion Crowdsourcing provides an ideal method for capturing the general population's perspective on what constitutes a normal and acceptable head shape in children with sagittal craniosynostosis. Laypersons are able to reliably and consistently distinguish cranial deformities from a "normal" head shape. The public indicates a threshold correction of 70% in sagittal craniosynosis to regard it as a "normal" head shape.

Background Minor cranial sutural synostosis is currently regarded as a rare diagnosis. As clinical awareness grows, a greater number of cases are being documented. This study aims to describe the variants of unicoronal synostosis with regard to major and minor sutural involvement and secondary effects on cranial and orbital morphology. The information is aimed to improve clinical diagnosis and management. Methods A retrospective study was conducted collecting preoperative computed tomographic scans of patients diagnosed with unicoronal synostosis and listed for surgical interventions, identified from a craniofacial database. Within these patients, different synostotic variants were identified based on which suture was affected. Scans of normal pediatric skulls (trauma) were used for a control group. Computed tomographic scans were analyzed for sutural involvement, cranial base deflection, and ipsilateral and contralateral orbital height and width. One-way analysis of variance was used to detect differences between synostotic variants and controls. Results A total of 57 preoperative computed tomographic scans of patients with unicoronal synostosis were reviewed, in addition to 18 computed tomographic scans of normal skulls (control group). Four variants of unicoronal synostosis were identified: frontoparietal, frontosphenoidal, frontoparietal and frontosphenoidal, and frontosphenoidal and frontoparietal. The last two variants differ in their temporal involvement in the direction of sutural synostosis and ultimately cranial and orbital morphology. Three variants have been previously identified, but the fourth is presented for the first time. Conclusions An understanding of the variants of unicoronal synostosis and their temporal relationships is integral for accurate clinical diagnosis and surgical correction. Recommendations for treatment are based on discrete changes in orbital morphology.

Sagittal craniosynostosis is the most common form of congenital cranial deformity. Surgical interventions are performed either open or endoscopic. Advancements in minimally invasive surgery have enabled the development of the endoscopic suturectomy technique. This is contrasted to the traditional open cranial vault reconstruction. There is a paucity of data comparing the head shape changes from both techniques. This study aims to compare the morphological outcome of endoscopic suturectomy versus total cranial vault reconstruction. Methods This is a retrospective comparative study involving 55 cases of sagittal craniosynostosis, 37 of which has open total cranial vault reconstruction and 18 had endoscopic suturectomy procedure. Preoperative and postoperative 3D photographs of both groups were analyzed and compared. The change in correction between preoperative and postoperative state was measured against a crowd-driven standard for acceptable head shape. Results Total cranial vault had higher percentage change between pre and postoperative cranial index than endoscopic suturectomy (14.7% versus 7.7%, P = 0.003). However, both techniques were able to achieve the minimum standard of 70% correction (TCV 107.5%, ES 100.4%, P = 0.02). Conclusion Total cranial vault and endoscopic suturectomy are effective in correcting scaphocephaly among children with sagittal craniosynostosis. Additionally, both techniques are able to achieve a percentage correction that exceeds the 70% benchmark established by the lay public.

CAD-CAM patient-specific implants offer cerebral protection and improved facial balance without the disadvantages of autologous bone grafting such as donor site morbidity and unpredictable resorption. Several alloplastic materials are available, but titanium, polymethylmethacrylate (PMMA), and polyetheretherketone (PEEK) are the current popular choices. We reviewed our experience of applying different alloplastic CAD-CAM materials in the reconstruction of complex pediatric craniofacial deformities.A retrospective review was performed of all pediatric patients who underwent a complex inlay or onlay implant craniofacial reconstruction using CAD-CAM PEEK, PMMA, or titanium implants at a single institution. Demographics, cost, operative time, complications, and outcomes were assessed.Between 2003 and 2014, 136 patients (69 male; 67 female; mean age 11.5 years (3-22 years); mean follow-up 30 months) had custom patient-specific craniofacial reconstruction with PEEK (n = 72), PMMA (n = 42), and titanium (n = 22) implants (inlay = 93; onlay = 43). Indications included congenital anomalies (26.5%), decompressive craniectomies (25.0%), craniofacial syndromes (25.7%), tumor defects (14.0%), and post-trauma (6.6%). Implant cost varied significantly for PEEK ($7703 CAD) and PMMA ($8328 CAD) compared with that for titanium ($11,980 CAD) (p 0.0005). Six patients (4.4%) required surgery due to infection consisting of irrigation and antibiotic administration with successful implant salvage in three patients. All infections occurred in the PEEK group. Five patients (3.7%) ultimately had implants removed due to infection (n = 3), late exposure (titanium; n = 1), or late fracture (PMMA; n = 1).CAD-CAM alloplast reconstruction in the management of complex pediatric craniofacial deformities is effective although expensive. Implant infection does not always require explantation. A reconstruction algorithm is presented.

OBJECTIVEDespite increasing adoption of endoscopic techniques for repair of nonsagittal single-suture craniosynostosis, the efficacy and safety of the procedure relative to established open approaches are unknown. In this systematic review the authors aimed to directly compare open surgical and endoscope-assisted techniques for the treatment of metopic, unilateral coronal, and lambdoid craniosynostosis, with an emphasis on quantitative reported outcomes.METHODSA literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 electronic databases (MEDLINE, EMBASE, and CENTRAL [Cochrane Central Register of Controlled Trials]) from their inception to August 2017. The quality of methodology and bias risk were assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies.RESULTSOf 316 screened records, 7 studies were included in a qualitative synthesis of the evidence, of which none were eligible for meta-analysis. These reported on 111 unique patients with metopic, 65 with unilateral coronal, and 12 with lambdoid craniosynostosis. For all suture types, 100 (53%) children underwent endoscope-assisted craniosynostosis surgery and 32 (47%) patients underwent open repair. These studies all suggest that blood loss, transfusion rate, operating time, and length of hospital stay were superior for endoscopically treated children. Although potentially comparable or better cosmetic outcomes are reported, the paucity of evidence and considerable variability in outcomes preclude meaningful conclusions.CONCLUSIONSLimited data comparing open and endoscopic treatments for metopic, unilateral coronal, and lambdoid synostosis suggest a benefit for endoscopic techniques with respect to blood loss, transfusion, length of stay, and operating time. This report highlights shortcomings in evidence and gaps in knowledge regarding endoscopic repair of nonsagittal single-suture craniosynostosis, emphasizing the need for further matched-control studies.

In syndromic craniosynostosis, the Le Fort III osteotomy is used to correct dental/skeletal imbalance, improve exorbitism, and increase the airway. The purpose of this study is to perform a cost comparison between the standard technique of single-stage rigid internal fixation and distraction osteogenesis (DO) in the Le Fort III osteotomy in this patient population.Hospital cost accounting databases were queried for patients undergoing single-stage advancement (SS) or DO from 2007 to 2016. Nominal cost data were adjusted using the Bank of Canada Consumer Price Index. Reported costs represented the full length of stay for all utilization per patient. Demographic information and cost data for single-stage osteotomy and DO were compared.Total costs for single-stage (n = 8) were higher than distraction (n = 6; mean $CAD57 825 vs $38 268,This single-institution retrospective cost analysis indicates standard SS rigid internal fixation Le Fort III is more costly than DO. Despite higher OR costs, prolonged ICU and hospital stay was the primary reason behind this difference. This information may be of benefit when advocating for new technology perceived as high cost.En cas de craniosynostose syndromique, l’ostéotomie de Le Fort III permet de corriger un déséquilibre dentaire et squelettique, d’améliorer l’exophtalmie et de mieux ouvrir les voies respiratoires. La présente étude vise à comparer les coûts de la technique standard de fixation interne rigide en une étape à la distraction osseuse (DO) au sein de la population de patients en cas d’ostéotomie de Le Fort III.Les chercheurs ont fouillé les bases de données comptables des coûts hospitaliers pour les patients qui avaient subi un avancement en une étape (AUÉ) ou une DO entre 2007 et 2016. Ils ont rajusté les données sur les coûts nominaux à l’aide de l’indice des prix à la consommation de la Banque du Canada. Les coûts déclarés représentaient la durée totale de tous les séjours hospitaliers par patient. Ils ont comparé l’information démographique et les données sur les coûts de l’ostéotomie en une étape à la DO.Les coûts totaux de l'AUÉ (n = 8) étaient plus élevés que ceux de la DO (n = 6) (moyenne de 57 825 $ CA par rapport à 38 268 $,D’après la présente analyse rétrospective des coûts dans un seul établissement, la fixation interne rigide de l’AUÉ standard de Le Fort III est plus coûteuse que la DO. Malgré des coûts plus élevés en salle opératoire, un séjour prolongé à l’USI et à l’hôpital est la principale raison de cette différence. Cette information peut être utile pour défendre les nouvelles technologies qui sont perçues comme coûteuses.

Supplemental Digital Content is available in the text., Background: Cranial vault reshaping to correct craniosynostosis in infants may injure terminal branches of the trigeminal nerve, namely the supraorbital, supratrochlear, zygomaticofacial, and zygomaticotemporal nerves, especially if a fronto-orbital advancement is performed. Despite numerous studies demonstrating successful esthetic outcome after FOA, there are no long-term studies assessing facial sensation after possible damage to these nerves as the result of surgery. Methods: A cross-sectional case-control research design was used to evaluate facial sensory threshold in the trigeminal branches after cranial vault reconstruction in children with isolated, nonsyndromic metopic, and unicoronal craniosynostosis, compared with those with sagittal craniosynostosis and age-matched nonaffected controls. Study participants were recruited from the Hospital for Sick Children between the ages of 6 and 18 years. Sensory outcome was determined using the Weinstein Enhanced Sensory Test, the Ten Test, and self-reported facial sensibility function questionnaire. Results: The sensory outcomes of 28 patients and 16 controls were examined at an average age of 9.6 years and 10.3 years, respectively. No subjective or objective sensory deficit was noted in supraorbital, supratrochlear, zygomaticofacial, or zygomaticotemporal nerve distributions between groups. Qualitative reports of facial sensibility function indicated no difference in subjective sensation, protective sensation, or motor behavior between groups. Conclusions: These results suggest that while sensory nerve injury during routine FOA may occur, it does not result in a quantifiable nor clinically significant long-term sensory deficit threshold. Patients do not develop long-term neuropathic pain following surgical intervention.

The authors performed bilateral malar reconstruction using polyether ether ketone implants in 3 patients with Treacher-Collins syndrome with absent, as opposed to hypoplastic, zygomata. These patient-specific implants were fabricated using computed-aided design software reformatted from three-dimensional bony preoperative computed tomography images. The first time the authors performed this procedure the implant compressed the globe resulting in temporary anisocoria that was quickly recognized intraoperatively. The implant was immediately removed and the patient made a full-recovery with no ocular disturbance. The computer-aided design and manufacturing process was adjusted to include periorbital soft-tissue boundaries to aid in contouring the new implants. The same patient, and 2 further patients, subsequently underwent malar reconstruction using this soft tissue periorbital boundary fabrication process with an additional 2 mm relief removed from the implant's orbital surface. These subsequent procedures were performed without complication and with pleasing aesthetic results. The authors describe their experience and the salutary lessons learnt.

Introduction: Assessment of cranial dysmorphism in sagittal synostosis is often subjective but objective measures can be applied. These include cephalic index (CI) and midsagittal vector analysis (MSVA). Objective: To assess discriminant validity, construct validity, and responsiveness of CI and MSVA measured from computed tomography (CT) in patients with sagittal synostosis. Methods: Patients with nonsyndromic isolated sagittal synostosis with complete preoperative (n = 30) and postoperative (n = 13) CT data were included. Age-matched control group (n = 24) comprised of normocephalic patients who underwent CT for reasons related to trauma. Outcome Measures: Retrospective CT evaluation of CI and MSVA was conducted and correlated with a dysmorphism numeric rating scale (D-NRS) that measured surgeon-rated severity of sagittal synostosis. Responsiveness of CI and MSVA was evaluated using dysmorphism global rating of change (D-GRC). Results: Thirty patients with sagittal synostosis were demographically similar to 24 normocephalic patients. The difference in CI and MSVA was statistically significant between normocephalic and scaphocephalic patients. Cephalic index had a good correlation with D-NRS ( r = −0.665, ρ = −0.667), but not with MSVA ( r = 0.250, ρ = 0.203). Change in CI ( r = 0.738, ρ = 0.657) was well correlated with D-GRC, but not with MSVA ( r = −0.409, ρ = −0.301). Conclusion: Cephalic index appears to quantify the severity of sagittal synostosis better than MSVA. Cephalic index also has better responsiveness than MSVA to measure a reduction in severity of disease; however, MSVA is a better descriptive craniometric measurement. Midsagittal vector analysis was able to quantify the shift in morphology in sagittal synostosis following surgical treatment.

OBJECTIVEIn this systematic review and meta-analysis the authors aimed to directly compare open surgical and endoscope-assisted techniques for the treatment of sagittal craniosynostosis, focusing on the outcomes of blood loss, transfusion rate, length of stay, operating time, complication rate, cost, and cosmetic outcome.METHODSA literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 electronic databases (MEDLINE, EMBASE, and CENTRAL [Cochrane Central Register of Controlled Trials]) from their inception to August 2017. The quality of methodology and bias risk were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Effect estimates between groups were calculated as standardized mean differences with 95% CIs. Random and fixed effects models were used to estimate the overall effect.RESULTSOf 316 screened records, 10 met the inclusion criteria, of which 3 were included in the meta-analysis. These studies reported on 303 patients treated endoscopically and 385 patients treated with open surgery. Endoscopic surgery was associated with lower estimated blood loss (p < 0.001), shorter length of stay (p < 0.001), and shorter operating time (p < 0.001). From the literature review of the 10 studies, transfusion rates for endoscopic procedures were consistently lower, with significant differences in 4 of 6 studies; the cost was lower, with differences ranging from $11,603 to $31,744 in 3 of 3 studies; and the cosmetic outcomes were equivocal (p > 0.05) in 3 of 3 studies. Finally, endoscopic techniques demonstrated complication rates similar to or lower than those of open surgery in 8 of 8 studies.CONCLUSIONSEndoscopic procedures are associated with lower estimated blood loss, operating time, and days in hospital. Future long-term prospective registries may establish advantages with respect to complications and cost, with equivalent cosmetic outcomes. Larger studies evaluating patient- or parent-reported satisfaction and optimal timing of intervention as well as heterogeneity in outcomes are indicated.

Objective To investigate the stability of major versus minor Le Fort I maxillary advancements in unilateral cleft lip and palate (UCLP) patients. Design A retrospective longitudinal study was undertaken on 30 nonsyndromic UCLP patients treated with the same protocol at The Hospital for Sick Children, Toronto, Canada. Patients were grouped into major and minor movement groups based on planned surgical advancement. Standard lateral cephalometric radiographs were taken preoperatively (T1), immediately postoperatively (T2), and at least 1 year postoperatively (T3). Skeletal and dental variables were measured using cephalometric analysis. Stability was compared between groups using repeated-measures analysis of variance. Linear regression analysis was used to assess the relationship between advancement and relapse for the entire study population. Results A mean maxillary advancement of 9.8 mm and 4.9 mm was seen for the major (n = 10) and minor (n = 20) movement groups, respectively. The mean skeletal horizontal relapse was 1.8 mm (18%) for the major advancement group and 1.5 mm (31%) for the minor advancement group. There was no significant difference in skeletal horizontal relapse between the groups ( P > .05). The correlation coefficient ( r) between linear horizontal advancement and relapse was calculated to be .31 ( P > .05). Dental horizontal relapse was not significant for either the major or minor groups, and no significant difference was found between the groups ( P > .05) Conclusion Skeletal and dental relapse was found to be unrelated to the amount of maxillary linear advancement using conventional Le Fort I osteotomies in UCLP.

Purpose To investigate the stability of single-piece versus segmental (2-piece) maxillary advancement in patients with unilateral cleft lip and palate (UCLP) treated using conventional Le Fort I orthognathic surgery. Patients and Methods A retrospective study was undertaken in 30 patients with nonsyndromic UCLP treated with the same surgical and orthodontic protocol from 2002 through 2011. Standard lateral cephalometric radiographs were taken preoperatively, immediately postoperatively, and at least 1 year postoperatively. Patients were divided into single-piece and segmental Le Fort I groups based on planned surgical movement. Postoperative movements were compared between groups using repeated measures analysis of variance. Results The mean skeletal horizontal advancement was 7.3 and 7.5 mm in the single-piece and segmental groups, respectively. The skeletal horizontal relapse was 1.3 mm (18%) for the single-piece group and 1.9 mm (25%) for the segmental group. The skeletal surgical extrusion was 2.7 mm for the 2 groups. The skeletal vertical relapse was 0.6 mm (22%) and 1.5 mm (56%) for the single-piece and segmental groups, respectively. The mean dental horizontal postoperative movement was an advancement of 0.4 mm for the single-piece group and a relapse of 0.2 mm (3%) for the segmental group. The mean dental vertical relapse was 0.1 mm (4%) for the single-piece group and 0.3 mm (11%) for the segmental group. There was no statistically significant difference in relapse between the single-piece and segmental groups for all movements ( P > .05). Conclusion Skeletal and dental relapse was similar between single-piece and segmental maxillary advancements using conventional Le Fort I orthognathic surgery in patients with UCLP.

Cranio-orbital reshaping for anterior cranial-vault deformities associated with craniosynostosis traditionally relies on the surgeon's subjective estimate of the shape and appearance of a normal forehead. Computer-aided design/computer-aided manufacture (CAD/CAM) bandeau templates to guide reconstruction were introduced in our centre to eliminate this subjectivity and to effect more reproducible surgical results. The aim of this study was to compare two groups of patients (template, n = 14 vs. no template, n = 23) to measure surgical outcomes. The virtual, computational version of the template was used as an outcome assessment tool. It was used to calculate an intervening area under the curve (AUC) between the normative template and the patient's reconstructed supra-orbital bar on a representative computed tomography (CT) axial section. A comprehensive chart review was conducted of patients in both groups to examine the preoperative and postoperative variables. Based on the analysis performed on the immediate postoperative CT scans, in the template group - as compared to the control, no-template group - the use of the bandeau template led to a greater reduction in AUC (74% vs. 56%, p = 0.016), indicating a better conformity between the reconstructed supra-orbital bar and the ideal, normal bandeau shape. The duration of operation was significantly reduced with the use of the template (212 vs. 258 min, p0.001). The application of prefabricated templates in cranio-orbital reshaping is highly useful for accurate preoperative planning; reproducible and efficient intra-operative correction of dysmorphology; and objective surgical outcomes assessment.

Predicting outcomes based on a variety of fixation techniques remains problematic in the treatment of mandible fractures. There is inherent difficulty in comparing the hundreds of published articles on the subject because of the large number of variables, including injury patterns, assessment techniques, treatment approach, device selection and application, and definition of outcome.The authors review the behavior of the human mandible. Behavior of the intact mandible, multiple fracture scenarios, and small and large (single and multiple) plating applications are reviewed.Several misconceptions in the literature are clarified. Factors that will resolve the dichotomy between clinical results and current biomechanical theories are presented such that a more logical biomechanical model may be used to approach fixation of the mandibular fracture being treated.Current mandibular biomechanics theory must be expanded to reflect the complex nature of the system and to more accurately describe conditions that exist in the physical world. Otherwise, further analysis in advancements in outcome and treatment will be relegated to chance.

Cranio-orbital remodeling aims to correct the dysmorphic skull associated with craniosynostosis. Traditionally, the skull is reconstructed into a shape that is subjectively normal according to the surgeon's perception. We present a novel technique using a mathematical algorithm to define the optimal location for bony osteotomies and to objectively reshape the fronto-orbital bar into an ideal normal skull contour. Using pre-operative computed tomography images, the abnormal skull contour at the frontal-orbital region was obtained for infants planned to undergo cranio-orbital remodeling. The ideal skull shape was derived from an age- and sex-matched normative skull library. For each patient, the mathematical technique of dynamic programming (DP) was applied to compare the abnormal and ideal skull shapes. The DP algorithm identifies the optimal location of osteotomy sites and calculates the objective difference in surface area remaining between the normative and dysmorphic skull shape for each solution applied. By selecting the optimal solution with minimal objective difference, the surgeon is guided to reproducibly recreate the normal skull contour with defined osteotomies. The DP algorithm was applied in 13 cases of cranio-orbital remodeling. Five female and 8 male infants with a mean age of 11 months were treated for craniosynostosis classified as metopic (n = 7), unicoronal (n = 4), or bicoronal (n = 2). The mean OR time was 190.2 min (SD 33.6), mean estimated blood loss 244 cc (SD 147.6), and 10 infants required blood transfusions. Compared with a historical crania-orbital remodeling group treated without application of the algorithm, there was no significant difference in OR time, estimated blood loss, or transfusion rate. This novel technique enables the craniofacial surgeon to objectively reshape the fronto-orbital bar and reproducibly reconstruct a skull shape resembling that of normal infants.

Summary Introduction Treacher Collins syndrome is a rare disorder characterized by several orofacial findings including malar deficiency and hypoplastic mandibles. These patients often require a combined orthodontic–orthognathic approach to correct their malocclusion. This is most often characterized by a short posterior vertical height and an anterior open bite. Orthognathic correction often requires Le Fort I and bilateral sagittal split osteotomies. No long-term stability results have been reported after bimaxillary surgery in Treacher Collins patients. Methods A retrospective review of all Treacher Collins patients evaluated for orthognathic surgery by a single surgeon from 1993 to 2007 was performed. Patients were divided into groups who required surgery and those who did not. Part I analyzed the cephalometric differences between the surgical (S) and nonsurgical (NS) groups. Part II of the study assessed the preorthodontic treatment ( T 1 ), preoperative ( T 2 ), immediate postoperative ( T 3 ), and 1-year postoperative ( T 4 ) cephalometric measurement variables to determine the net surgical movement ( T 3 − T 2 ) and relapse ( T 4 − T 3 ). Results Twenty-two patients met the inclusion criteria, of which 11 had occlusal relationships requiring orthognathic surgery. Nine out of 11 chose to have surgery. At baseline, surgical patients exhibited a statistically significant retruded maxilla as measured by SNA and midface length compared to the NS group. In addition, the S group also had an increased gonial angle. There were significant movements in all maxillary and mandibular measurements. There was a significant relapse in the palatal plane angle when the maxilla was anteriorly impacted, with a 2.8-mm average relapse of the advancement. Relapse of the counterrotation movement of the mandible was identified, but this was not significant. Relapse did not affect the final occlusal result, which may have been compensated with postsurgical orthodontic treatment. Conclusion Bimaxillary orthognathic surgery in the Treacher Collins patients may be performed safely with long-term dental and skeletal stability.

Background: Mandible advancement osteotomy in juvenile rheumatoid arthritis patients for class II anterior open-bite malocclusion is controversial; however, there is no literature discussing outcomes of surgery in this group of patients. An evaluation of such outcomes was undertaken at The Hospital for Sick Children. Methods: A retrospective chart review revealed that eight patients with juvenile arthritis underwent orthognathic surgery during a period of 5 years. All of the patients had a bilateral sagittal split osteotomy of the mandible, six had a simultaneous Le Fort I osteotomy, and four had an additional advancement genioplasty. The age of the patients at the time of surgery ranged between 17 and 22 years (mean, 18 years), with three male patients and five female patients. The patients were under follow-up for a minimum of 8 months after surgery, and measurements were performed studying preoperative and postoperative lateral cephalometric radiographs. Results: All patients have an improved occlusion and improved facial aesthetics. One patient continued to suffer from temporomandibular joint pain. The mean mandible advancement was 9.6 mm (range, 3.9 to 18.3 mm). The mean mandible relapse after surgery was 2.1 mm (range, 1 to 3.1 mm). No exacerbation of the juvenile rheumatoid arthritis was encountered as a result of the surgical procedure. Conclusions: Orthognathic surgery in juvenile rheumatoid arthritis patients improves the patient’s occlusion, facial aesthetics, and therefore quality of life. The relapse rate postoperatively did not significantly affect the clinical outcome, and the authors recommend orthognathic surgery for this patient population. Future presurgical plans in this patient population will include a small posterior open bite and positioning the incisors edge to edge to allow for some postoperative relapse.

Lateral canthopexy is a commonly performed procedure in craniofacial and cosmetic surgery. In craniofacial surgery, lateral canthal fixation is performed in conjunction with a wide range of transcranial or subcranial procedures during the process of soft tissue re-suspension. A number of fixation materials have gained popular use. A case of craniofrontonasal dysplasia is reported in which a wire loop canthopexy fixation has become disengaged 3 months after a history of trauma and rotated to present a sharp surface against the sclera. Urgent surgical exploration prevented the apparently imminent complication of globe penetration with associated threat to vision.

Background: Mandible reconstruction in the growing facial skeleton is challenging, especially with reconstructions necessitating free vascularized bone grafts. The need for further combined orthodontic-orthognathic intervention at skeletal maturity must be anticipated. The growth potential of these grafts and potential new problems associated with performing a sagittal split osteotomy at skeletal maturity are poorly understood. Methods: A retrospective chart review revealed 11 patients who underwent reconstruction with a free fibula at The Hospital for Sick Children from 1990 to 2000. Radiographic and photographic studies were assessed for long-term growth of the reconstructed mandible, with follow-up ranging from 2 to 12 years. Results: Of the 11 patients who underwent reconstruction with a free fibula, two had surgery at skeletal maturity, two moved out of the country, one died as a result of her malignancy, and one was lost to follow-up. The remaining five patients are being followed by the craniofacial and orthodontic services and have not reached skeletal maturity. Of the two patients who have had orthognathic surgery, the one patient whose reconstruction involved the temporomandibular joint exhibited no growth on the reconstructed side and required a 57-mm advancement on the reconstructed side. The other patient, who had preservation of the temporomandibular joint at the time of reconstruction, required only a 5-mm advancement on the reconstructed side. Both patients had significant surgical complications as a result of the initial reconstructive techniques. Technical modifications necessary at the initial reconstruction became apparent when the authors performed a sagittal split osteotomy on the reconstructed side. Conclusions: Certain technical modifications to the original free fibula reconstructed pediatric mandible should be considered in anticipation of the need for a subsequent bilateral sagittal split at skeletal maturity.

The purpose of this study was to appraise the value of preoperative speech assessments, nasopharyngoscopy, and surgical models as predictors of velopharyngeal deterioration after a Le Fort I maxillary advancement in cleft patients. This retrospective study involved a series of 26 cleft patients (16 unilateral complete and nine bilateral complete cleft lips and palates, and one isolated complete cleft palate) who had Le Fort I maxillary advancements between March 1, 1993, and February 7, 1996. The 13 male patients and 13 female patients ranged in age from 15.3 to 46 years (mean age, 19.5 years). Four of these patients had previously undergone pharyngeal flap surgery. Eleven patients had palatal fistulas and one had a bifid uvula that was repaired at the time of orthognathic surgery. Patients with perceived hypernasal speech preoperatively all had hypernasality after advancement (nine of nine). Velopharyngeal insufficiency was observed in two of the 16 whose resonance preoperatively was within normal limits. Speech assessment, therefore, predicted accurately the postoperative status in 23 of 26 patients. Twelve patients had preoperative nasopharyngoscopy that indicated a high risk for velopharyngeal insufficiency (borderline or inadequate closure). Nine of these patients had postoperative velopharyngeal insufficiency. Two of the 14 patients not judged at risk by nasopharyngoscopy developed velopharyngeal insufficiency. Therefore, 21 of the 26 patients were accurately predicted by nasopharyngoscopy. Scoping detected borderline velopharyngeal insufficiency in one patient who was not detected by speech alone. The combined predictive value of speech and scope identified all but one patient who would develop postoperative velopharyngeal insufficiency. The degree of anteroposterior movement determined from surgical models was not predictive of the outcome. Patients with hypernasal speech preoperatively continue to have hypernasal speech after Le Fort I advancement. Preoperative perceptual speech assessment by specially trained speech-language pathologists is an excellent test for predicting postoperative velopharyngeal insufficiency status. Nasopharyngoscopy is an invasive and resource-dependent test that should be assessed with respect to cost effectiveness. In this series, only one patient's risk was more accurately predicted using nasopharyngoscopy than by speech assessment alone.

Due to the rarity of arteriovenous malformations (AVMs), there is a paucity of information on the outcomes of various treatments. Presently, the mainstays of treatment of an AVM are embolization, surgical excision or a combination of both. A retrospective study of 26 patients with AVMs treated at The Hospital for Sick Children, Toronto, Ontario between 1985 and 1995 was performed. The treatment strategies and patient outcomes were compared in terms of efficacy, complications and the response of patients and their families to their overall treatment. The overall findings showed that embolization alone was effective in controlling symptoms, but may be associated with an increased AVM size. A partial excision of an AVM does not appear to exacerbate recurrence, as has been previously reported. In fact, even after what appears to be a complete excision of the AVM, recurrence may still occur. Complications from a surgical excision of the AVM are more frequent but less devastating than complications from embolization of the lesion. The overall patient or parent satisfaction with treatment was high with respect to improvement in outcome. It is expected that with an increasing understanding of vascular malformations, and the evolution of interventional radiological techniques, complications will decrease and results as a whole will improve.Compte tenu de leur rareté, on dispose de peu d’informations sur le résultat des divers traitements appliqués aux malformations artérioveineuses (MAV). À l’heure actuelle, le traitement d’une MAV repose sur l’embolisation, l’excision chirurgicale ou sur les deux approches combinées.Les auteurs ont procédé à une étude rétrospective de 26 cas de MAV traités au

The lack of tip projection on the affected side of a unilateral cleft lip nasal deformity can be difficult to correct due to lack of adequate structural support. A new technique for the correction of the unilateral cleft lip nasal deformity is described. The key components of the technique involve the use of a dorsally angulated unilateral spreader graft on the cleft side and the use of an L-shaped septal graft to provide support to the cleft nasal tip.

Purpose To determine whether 3-dimensional ultrasonography (3D US) provides information about anatomy and position of extraocular muscles to better guide surgeons approaching strabismus in patients with craniosynostosis who often have anomalous or absent eye muscles. Methods The 4 rectus eye muscles were imaged using 3D US for 7 children with craniosynostosis before or after strabismus surgery. Reconstructed 3D images were interpreted as having normal or abnormal anatomy and position, based on comparison with images acquired from 6 normal eyes. Interpretation was validated against the intraoperative findings from strabismus surgery. Results A total of 34 scans from the study group were used for comparison and validation purposes. Accuracy of anatomical assessments was 85% ± 12% (percentage ± confidence interval) and of positional assessments was 62% ± 16%. Sensitivity and specificity of anatomical assessments was 80% ± 14% and 88% ± 10%, respectively. Anatomic anomalies detected by 3D US included excessively thick, thin, scarred and fibrotic, and absent muscles. Sensitivity and specificity of positional assessments was 48% ± 17% and 85% ± 12%, respectively. Positional anomalies such as muscle displacement off the normal clock hour axis or posteriorly displaced insertion were also detected. Conclusions The 3D US may have an adjunctive role in determining anatomy and position of rectus muscles in patients with craniosynostosis, although it was more accurate in assessing anatomic features rather than positional features of rectus muscles.

Hemifacial microsomia is a hypoplastic disorder of the first and second branchial arches that significantly impacts on the development of the jaws, leading to malocclusion and facial asymmetry. There is little in the literature regarding the application of orthodontic/orthognathic approaches to the correction of these deformities and the stability of the surgical results. To address this, a retrospective chart review of 10 patients with complete orthodontic records and greater than 1 year of follow-up was performed. Posteroanterior cephalograms were assessed by modified Grummons analysis to determine mandibular offset (deviation of the chin point from the skeletal midline) and occlusal cant. These measurements were performed at 3 time points (T1: preoperative, T2: immediate postoperative, T3: follow-up) to elucidate the surgical movement (T2-T1), the postoperative relapse (T3-T2), and the net gain movement (T3-T1). Maxillary movements were quantified, and the occlusal cant was expressed as a ratio between vertical heights of the maxilla at the first molar on each side. One sample t test demonstrated statistically significant surgical movement and net gain. Relapse was statistically insignificant. Repeated-measures analysis of variance demonstrated similar results for chin point position relative to the putative midline. Our results suggest that a combined orthodontic/orthognathic approach at skeletal maturity delivers improved occlusal outcomes in the long term as assessed by chin point deviation and occlusal cant, but secondary surgery rates are higher than those for orthognathic surgery in other patient groups. We advocate limiting surgery to skeletal maturity whenever possible to achieve stable long-term results while limiting morbidity and number of procedures.

Morphological characteristics of the "cleft face" were analyzed by calculating proportion indices in young adults who had undergone surgery in childhood for cleft lip and/or palate: 592 in 37 subjects with unilateral clefts and 432 in 27 with bilateral clefts. Three areas of the face with 16 indices based on 12 projective linear measurements were analyzed in each subject: 5 indices in the general face, 6 in the upper face, and 5 in the lower. Although a balanced relationship was found in two thirds of the indices assessed, severe disproportions, which greatly influence appearance, were noted in about one quarter. In the general face, the most frequent abnormal anthropometric findings contributing to severe disproportions were small upper-face height and a severely high or moderately narrow mandible. In the soft tissues, disproportions included wide nose, small nasal tip protrusion, and short or long columella. Deviations from normality were rarely noted in the nose and upper-lip height, mouth width, total facial height, and width of the upper face. In the upper face, severe disproportions occurred much more frequently in bilateral cleft subjects (67.6%) than in unilateral clefts (30.3%). In the lower face, however, severe disproportions were twice as frequent among unilateral clefts (39.4%) than bilateral (14.7%). The results, although interesting, require complementary preoperative data for reliable analysis of the adult "cleft face."

In this study, the authors review their experience with vascularized fibula transfers for mandibular reconstruction in children. They outline the indications for such reconstruction, their method of contouring the fibula to accurately resemble the resected mandible, reconstruction of the temporomandibular joint, and the use of vascularized muscle for the management of associated soft-tissue deficiencies. Ten consecutive patients, 5 to 17 years of age and undergoing this procedure, were assessed from a medical, dental, radiographic, and photographic standpoint. The fibulae were elevated via a lateral approach, osteotomized, as required, and fixation was achieved with titanium miniplates and screws. All transfers survived, with viability confirmed by early postoperative bone scanning. Five patients had temporomandibular joint reconstruction, and five patients required simultaneous reconstruction of soft-tissue defects with associated vascularized muscle. The postoperative follow-up ranged from 3 to 30 months The occlusion of the remaining dentition, mandibular symmetry and projection, adequacy of lining and skin cover, and maximal mouth opening were reassessed. Occlusion was class 1 in all patients, and free-flap stability and function were in the normal range. However, soft-tissue contour was a problem. All wounds healed primarily without donor-site complications and with minimal recipient-site complications.

We have suggested that rigid fixation of membranous bone grafts in the presence of infection may improve graft-recipient bone union by facilitating graft revascularization. To test this hypothesis, we grafted autogenous membranous bone grafts to the mandibles of 94 New Zealand White rabbits. Lag screw fixation was applied in half the animals. The wounds were inoculated with a range of Staphylococcus aureus doses. Infected and noninfected rabbits were injected weekly over a 5-week course with fluorescein bone markers and with a marker of vascular endothelium (procion red) just prior to sacrifice. Revascularization and new bone deposition in the grafts were then quantified histologically for the 75 rabbits available for data collection. Infection decreased the amount of graft revascularized and the amount of new bone deposited for both rigidly fixated and nonfixated grafts. Grafts fixated with a lag screw showed a greater amount of revascularization and new bone deposition in the presence and absence of infection when compared with nonfixated grafts, supporting the hypothesis that rigid fixation of membranous bone grafts in the presence of infection may promote graft survival and union by improving revascularization and osteogenesis within the graft.

Guided tissue regeneration has been shown to permit osteoconduction in otherwise nonhealing cranial defects. The relative importance of preventing the prolapse of soft tissue versus the infiltration of individual connective tissue cells has not been determined. A fibrillar form of polylactic acid (PLA) was tested in 13-mm-diameter defects in the parietal bones of 12 sheep. The polymer was hypothesized to prevent the prolapse of dura and periosteum but allow entrance of individual cells. Control defects in the same sheep were either filled with autogenous bone shavings or left unfilled. The animals were killed at times ranging from 6 to 25 weeks and the defects examined grossly, radiologically, and histologically. The autogenous bone-filled defects were spanned by trabeculated bone by 6 weeks. The unfilled defects demonstrated prolapse of soft tissues into the defect; however, progressive centripetal bone growth was evident. The fibrillar PLA-filled defects were occupied by a full-thickness mixture of fibrous tissue interspersed with PLA. After 19 weeks, small "fingers" of bone were seen to minimally infiltrate the fibrous tissue. Although separation of the dura and periosteum was maintained by the fibrillar PLA, invasion of fibrous tissue restricted osteoconduction.

Craniofacial fibrous dysplasia is a benign developmental anomaly in which normal bone is replaced by fibro-osseous tissue. The aim of this study was to audit the patient population at a tertiary paediatric centre and report our treatment protocols. A retrospective chart review of all patients with craniofacial fibrous dysplasia treated at the Hospital for Sick Children between 1999 and 2010 was performed. The treatment algorithm used by our centre is presented. A total of 55 patient records were reviewed; 37 patients had sufficient documentation for study; 27 (16 male, 11 female) patients underwent surgery at our institution, of these patients, 26 had post-operative follow up of greater than one year (mean 41 months; median 24 months). Mean age at presentation was 9.9 years (median 10 years) and mean age of surgery was 13 years. Ten patients underwent surgery on the fronto-orbital region, 7 of the calvarium, 2 the skull base and 8 upon tooth-bearing bones. Fourteen cases underwent debulking surgery as their primary therapy whereas 13 patients had complete resection. Nine patients experienced recurrence and all but one case of these occurred in patients that underwent debulking therapy. When age of surgery is considered, total resection and reconstruction or debulking surgery after skeletal maturity has a lower recurrence rate (1/7 cases) than earlier surgery (8/16). Complete resection at any age and debulking surgery once skeletal maturity has been reached may be associated with lower recurrence rates than incomplete resections at an earlier age. Patients with McCune-Albright syndrome may benefit from repeated debulking procedures rather than complex resections and reconstructions.

After studying this article, the participant should be able to: 1. Identify the skeletal changes in the cleft patient that necessitate surgery. 2. Describe the orthodontic principles that precede surgical treatment. 3. Demonstrate the surgical principles involved in cleft orthognathic surgery and how to avoid common pitfalls particular to cleft orthognathic surgery. 4. Anticipate when dentoalveolar distraction can help in the treatment of problems not easily treated with conventional orthognathic techniques.This CME article covers the basic multidisciplinary approach to the treatment of patients requiring a combined orthodontic orthognathic approach to their skeletally based malocclusion. The dentoskeletal abnormalities are described for these patients, as are the fundamental orthodontic principles in the presurgical treatment of these patients. The basic surgical principles are discussed in general, and the reader is provided with advice on avoiding common pitfalls. Specific attention is given to the more recent advances in dentoalveolar distraction in cases of large defects that would have been difficult to treat using conventional orthognathic surgery. Videos are provided to illustrate the general principles in treating the cleft orthognathic patient and to illustrate the treatment of large defects using dentoalveolar distraction.

Summary Introduction Trauma to the pediatric orbit may produce a unique fracture in which entrapment of the periorbital tissue and/or inferior rectus muscle may occur due to a "trap-door" effect of the compliant orbital floor. This study was designed to assess the outcome following the surgical management of orbital trapdoor fractures in children and to examine alterations in the morphology of the inferior rectus (IR) muscle. Methodology Outcome assessment on patients undergoing surgery at the Hospital For Sick Children, Toronto with symptomatic orbital floor trapdoor fractures over a 10-year period and a CT-based morphometric analysis of the inferior rectus muscle were performed. Results 18 patients (5F, 13M) mean age 12.6 years (range 8.3–16.6 years) underwent surgical exploration (average time to surgery 9.7 ± 3.5 days (range 1–45 days). Follow-up was 15.4 months (range 6–36 months). All patients noted improvement in extra-ocular muscle (EOM) range of motion post-operatively: 7 patients had normal EOM with no diplopia; 9 patients had minimal diplopia on extreme secondary (upwards) gaze and 2 patients had residual significant diplopia with upward gaze. CT morphologic assessment (8 patients) demonstrated: a) zone of bony injury was posterior to the equator of the globe; b) minimal to no extra-conal fat exists to protect the IR muscle; c) a trend toward increased length in the injured IR muscle. Conclusions With surgical intervention, improvement of diplopia (complete or near-complete resolution) occurred in 16/18 (89%) of patients presenting with symptomatic trapdoor orbital floor fractures. CT-based assessment demonstrated the vulnerability of the inferior rectus muscle with close proximity to the orbital floor and lack of periorbital fat for protection. Alteration of the length of the IR muscle may impact the force-length relationship and play a role in the outcomes. Early surgical intervention for symptomatic trapdoor fractures is recommended.

While the goal of craniofacial reconstruction surgery is to restore the cranial head shape as much towards normal as possible, for the individual patient, there is, in fact, no normal three-dimensional (3D) model to act as a guide. In this project, we generated a library of normative pediatric skulls from which a guiding template could be fabricated for a more standardized, objective and precise correction of craniosynostosis.Computed tomography data from 103 normal subjects aged 8-12 months were compiled and a 3D computational model of the skull was generated for each subject. The models were mathematically registered to a baseline model for each month of age within this range and then averaged, resulting in a single 3D point cloud. An external cranial surface was subsequently passed through the point cloud and its shape and size customized to fit the head circumference of individual patients.The resultant fabricated skull models provide a novel and applicable tool for a detailed, quantitative comparison between the normative and patient skulls for preoperative planning and practice for a variety of craniofacial procedures including vault remodeling. Additionally, it was possible to extract the suprafrontal orbit anatomy from the normative model and fabricate a bandeau template to guide intraoperative reshaping.Normative head shapes for pediatric patients have wide application for craniofacial surgery including planning, practice, standarized operative repair, and standardized measurement and reporting of outcomes.

A stereotactic system has been designed to address the problem of achieving symmetry in complex and extensive craniofacial defects. Preliminary testing suggests that such a system, which allows for the intraoperative application of preoperative CT planning, will be useful in guiding the reconstruction of congenital or acquired bony time, is being used to investigate the correlation of intraoperative globe position following enophthalmos correction with long-term outcome, particularly as it relates to the size and location of the orbital defect, and the timing of the procedure.

In choosing the ideal donor site for bone replacement, attention must be given to the recipient site’s revascularization potential and mechanical needs. The most appropriate graft type may be harvested based on histologic differences in architecture as related to these two factors. This article also reviews strain effects, area grafted, distraction osteogenesis, and craniofacial implications.

On the modern battlefield, the majority of injuries currently seen are to the extremities, often involving a large number of metallic fragments. Although they are typically left in place, the effects of these retained metal fragments on nerve healing have not been studied.In a rat model, the right peroneal nerve was surgically sectioned and reanastomosed (control group). In the study group, metal fragments from an artillery casing were placed around the reanastomosed peroneal nerve. Functional recovery in both groups was evaluated over a 4-week period by measuring maximum ankle dorsiflexion captured on video as the animals walked through a tunnel. Morphologic analyses included distal and proximal axon counts, measurement of nerve fiber and axon diameter ratios, and myelin thickness.A significant decrease (p0.05) in return toward baseline for the rats' ankle angle in the nerves exposed to metal fragments was noted at weeks 2 through 4. Distal axon counts were significantly less (p0.05) in the metal fragment group for weeks 1 through 4. Proximal axon counts were increased in both groups, with a greater (p0.05) increase in the metal fragment group.Functional recovery after rat peroneal nerve transection and repair is decreased when metal fragments are placed in and around the injury site. Select histologic indicators of nerve regeneration showed decreased healing when exposed to metal fragments. Further studies of functional recovery in patients sustaining penetrating injuries from bullets or explosive devices are indicated.

Following craniofacial procedures that involve stripping of the periosteum and soft tissue over the zygomatic maxillary complex, descent of soft tissue with a decrease in anterior projection over the malar area and increase in fullness in the nasolabial fold have been seen to be a problem by these authors. Simple repositioning of the soft tissues to their normal anatomic position may be used to alleviate this problem.

Treacher Collins syndrome is an autosomal dominant condition of varying severity, affecting the tissues of the first and second branchial arches. The aim of this article is to present a cephalometric analysis of the craniofacial skeleton in Treacher Collins syndrome and provide an age- and sex-matched comparison as a standard control sample.Twenty-four Treacher Collins syndrome patients (11 male patients and 13 female patients; mean age, 17.99 +/- 1.96 years) underwent cephalometric studies, including orthopantomography and lateral and anteroposterior cephalography, as part of their preparation for bimaxillary surgery. Cephalometric parameters assessing the relationships of the skull base, maxilla, and mandible were analyzed and compared with age- and sex-matched control data (mean age, 17.75 +/- 1.95 years).Cephalometric analysis before orthognathic surgery documented that the Treacher Collins syndrome mandible and midface are expectedly short in the anteroposterior plane; however, the ratio of maxillomandibular deficiency is particularly significant in the female patient. The mandibular plane angle is obtuse, affecting female patients in particular, in whom there is also a posteriorly placed chin point. Affected individuals have a high antegonial notch height. Although the parameters of anterior lower facial height proportion in control and syndrome individuals are similar, posterior face height in Treacher Collins syndrome is reduced.This study quantifies the cephalometric dysmorphology of patients with Treacher Collins syndrome and compares it to that of age-matched controls. These cephalometric characteristics have clinical significance in Treacher Collins syndrome and in the planning of bimaxillary advancement and genioplasty in syndrome patients.

The ratio of morphological (bialar diameter [al-al]):anatomical (alar base width [ac-ac]) nose width defines the quality of the soft nose contours. Quantitative data on ac-ac and its relationship to al-al, and the relationship of both nose widths to face width (bizygomatic diameter) have not been available in the literature. To correct this, the anatomical and morphological widths of the nose were measured anthropometrically in an ethnically mixed group of 120 healthy, young adult, Caucasian Canadians, and the ratios of nose widths:face width (which greatly influences nasofacial harmony in the frontal view) calculated. In 80% of subjects, the morphological (classical) nose width was larger than the anatomical nose width, which has close contact with the underlying skeleton. Mean nose width was 24.9% (ac-ac) and 26.1% (al-al) of the face width. This study may help in the corrective surgery of disproportions between the two nose-width measurements in patients with cleft lip nose, and in the restoration of harmony between the nose and face widths.

Background: Traditional Le Fort III osteotomies have been described by several authors; however, few have reported the distances advanced and stability over time. Methods: The authors assessed their last 30 Le Fort III osteotomies with respect to the immediate incisor advancement achieved at surgery and long-term advancement as measured at the A-point from preoperative and postoperative cephalometric tracings. The authors then compared their results with those in the literature for Le Fort III distraction techniques. Comparisons were made with respect to distraction distance maintained, the need for bone grafting, airway results, morbidity, and cost. Results: The mean incisor advancement at the time of surgery as recorded in 14 patients was 21.6 mm (range, 12 to 28 mm). The long-term cephalometric A-point measurements in 14 patients demonstrated a mean of 14.14 mm (range, 8 to 25 mm). Conclusion: The authors conclude that, at the present time, no significant improvement in the results using Le Fort III distraction osteogenesis when compared with traditional methods has been shown.

The authors report on their experience with a particular hydroxyapatite cement in the pediatric population and review cases that elucidate potential limitations of its use in this population. In all patients, the implant was used for recontouring and augmenting the cranial vault. Seven of 15 patients had a direct communication between sinus mucosa and the implant at the time of surgery. Three of the seven patients developed late postoperative inflammatory reactions of the surgical site with delamination of the implant. Each patient required an aggressive irrigation and debridement with removal of the delaminated hydroxyapatite. Pathologic findings showed evidence of a foreign body inflammatory reaction in the tissue, and mixed bacterial flora were identified in all specimens. No late problems with the cement were seen in patients without a communication to the sinuses. Our findings suggest that the use of BoneSource, an essentially nonviable, nonvascularized implant, in areas exposed to bacterial contamination is contraindicated in the pediatric population. BoneSource and other similar hydroxyapatite biomaterials do have a role as implants in the craniofacial skeleton. The indications and contraindications of these substances will need to be further defined for wide acceptance to occur.