Common craniofacial anomalies: the facial dysostoses

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the etiology and pathogenesis of facial dysostosis syndromes. 2. Recognize and classify common facial dysostoses. 3. Understand the different management plans for the reconstruction of facial dysostoses. The wide spectrum of craniofacial malformations makes classification difficult. A simple classification system allows an overview of the current understanding of the etiology, assessment, and treatment of the most frequently encountered craniofacial anomalies. Facial dysostoses are reviewed on the basis of their diverse etiology, pathogenesis, anatomy, and treatment. Conditions discussed include craniofacial microsomia, Goldenhar syndrome, Treacher Collins syndrome, Nager syndrome, Binder syndrome, and Pierre Robin sequence. Approaches to the surgical management of these conditions are reviewed.     

Distraction osteogenesis for obstructive apneas in patients with congenital craniofacial malformations

Infants with congenital craniofacial malformations often have associated severe mandibular hypoplasia causing obstruction of the hypopharynx by retroposition of the base of the tongue into the posterior pharyngeal airway. Management depends on the severity of the airway obstruction. Most cases can be managed by prone positioning until the infant outgrows the problem at 3 to 6 months of age. In more critical cases, monitoring of oxygen saturation, temporary placement of a nasopharyngeal tube, and placement of an endotracheal tube will be useful procedures. Tracheotomy is an effective method for more severe cases, but longstanding tracheotomies result in high morbidity and occasional mortality. Mandibular distraction was performed in seven patients, ranging in age from 1 to 18 months, with critical obstructive apnea secondary to mandibular hypoplasia characterized by an apnea/hypopnea index greater than 20 apneas per hour and oxygen saturation below 80 percent. Two patients were tracheotomized previously. Mandibular lengthening, from 16 to 25 mm on the left side and from 10 to 22 mm on the right, was achieved in 21 to 25 days. Improvement of airway obstruction parameters was measured on polysomnograms and lateral cephalograms. Mandibular lengthening by gradual distraction is a successful method for young patients with severe mandibular hypoplasia causing critical obstructive apneas. Avoidance of tracheotomy or early decannulation in previously tracheotomized patients is a great advantage for patients with congenital craniofacial malformation.     

Common craniofacial anomalies: facial clefts and encephaloceles

The wide variety of craniofacial malformations makes classification difficult. A simple classification system allows an overview of the current understanding of the causes, assessments, and treatments of the most frequently encountered craniofacial anomalies. Facial clefts and encephaloceles are reviewed with respect to their diverse causes, pathogenesis, anatomical features, and treatments. Approaches to the surgical treatment of these conditions are reviewed.     

Mouse resources for craniofacial research

The mouse, as a genetically defined and easily manipulated model organism, has played a critical role in unraveling the mechanisms of craniofacial development and dysmorphology. While numerous gene knockout strains that display craniofacial abnormalities and essential recombinase tool strains with craniofacial-specific expression have been generated, many are absent from public repositories. Large-scale, international resource-generating initiatives promise to address this concern, providing a comprehensive set of targeted mutations and a suite of new Cre driver strains. In addition, panels of genetically defined strains provide tools to dissect the multigenic, complex nature of craniofacial development, adding to the foundation of information gained from single gene studies. Continued progress will require awareness and access to these essential mouse resources. In this review, current mouse resources, large-scale efforts, and potential future directions will be outlined and discussed.     

The potential of adipose‐derived stem cells in craniofacial repair and regeneration

The recent identification of a mesenchymal stem cell population in adipose tissue has led to an abundance of research focused on the regenerative properties of these cells. As such, adipose‐derived stem cells (ASCs) and potential therapies in craniofacial regeneration have been widely studied. This review will discuss the identification and potential of ASCs, and specifically, preclinical and clinical studies using ASCs in craniofacial repair. Studies involving ASCs in the repair of defects caused by craniosynostosis and Treacher Collins syndrome will be discussed. A comprehensive review of the literature will be presented, focusing on fat grafting and biomaterials‐based approaches that include ASCs for craniofacial regeneration. (Part C) 96:95–97, 2012. © 2012 Wiley Periodicals, Inc.     

An additional manifestation in acrocallosal syndrome: temporal lobe hypoplasia

Acrocallosal Syndrome is a rare genetic disorder which is characterized by moderate to severe mental retardation, agenesis or hypoplasia of the corpus callosum and polydactyly of fingers and toes. The spectrum of this syndrome is very variable. Prominent forehead, broad nasal bridge, short nose and mandible, hypertelorism, epicanthic folds, large anterior fontanelle and tapered fingers, omphalocele and inguinal hernia are some other common findings in this syndrome. Twenty percent of the patients have associated brain abnormalities such as cerebral atrophy, hypothalamic dysfunction, small cerebrum, micropolygyria, hypoplasia of pons, hypoplasia of cerebellar hemispheres, hypoplasia of medulla oblongata, agenesis or hypoplasia of cerebellar vermis and corpus callosum abnormalities. Here we present a 10-month-old female infant with clinical and radiological findings indicative of acrocallosal syndrome. She was noted to have craniofacial abnormalities suggestive of acrocallosal syndrome, optic atrophy and polydactyly. MRI revealed cerebral atrophy, corpus callosum agenesis, dilated lateral ventricules and unilateral right temporal lobe hypoplasia, the latter not previously reported in the spectrum of this syndrome. Based on this observation we conclude the importance of screening brain abnormalities and present temporal lobe hypoplasia as a new additional anomaly in this syndrome.     

Distraction osteogenesis of the craniofacial skeleton

In summary, distraction osteogenesis is a safe and effective means of achieving bone lengthening. These techniques were originally applied to the long bones of the extremities; over the past 10 years they have been effectively applied to the bones of the craniofacial skeleton. The new bone regenerate that is observed after distraction osteogenesis is stable, and relapse rates after skeletal advancement are believed to be lower than with conventional osteotomy and bone graft techniques. There is considerable variability in distraction protocols employed in clinical practice, including differences in the types of devices used and in the rate, rhythm, latency, and period of consolidation for distraction osteogenesis. The greatest application for distraction osteogenesis in the craniofacial skeleton has been with mandible lengthening, for which there is presently a 10-year clinical experience. Midfacial advancement is a newer application of distraction osteogenesis, for which clinical experience has been accrued over the past 5 years. This latter experience indicates that distraction osteogenesis is a viable treatment option for lengthening of the hypoplastic mandible and midface. These techniques have advantages over conventional means of bone graft and rigid fixation because of the quality of the bone regenerate, the decrease in the long-term relapse rate of the advanced bone segments in both the mandible and the midface, and the simultaneous soft-tissue elongation that accompanies the distraction process. Distraction osteogenesis is particularly applicable to the correction of severe deformities of the mandible and midface in children with developmental hypoplasia and syndromic craniosynostosis. However, growth is an added variable in this patient population. The amount of overcorrection in lengthening of the hypoplastic bone required to compensate for continued growth discrepancy of the adjacent facial bones is difficult to predict. Therefore, the families of these patients should be informed that many children will require repeated operations at a later age as they reach skeletal maturity.     

Pharyngeal endoderm expression of nanos1 is dispensable for craniofacial development

Nanos proteins are essential for developing primordial germ cells (PGCs) in both invertebrates and vertebrates. In invertebrates, also contribute to the patterning of the anterior-posterior axis of the embryo and the neural development. In vertebrates, however, besides the role of Nanos proteins in PGC development, the biological functions of the proteins in normal development have not yet been identified. Here, we analyzed the expression and function of nanos1 during craniofacial development in zebrafish. nanos1 was expressed in the pharyngeal endoderm and endodermal pouches essential for the development of facial skeletons and endocrine glands in the vertebrate head. However, no craniofacial defects, such as abnormal pouches, hypoplasia of the thymus, malformed facial skeletons, have been found in nanos1 knockout animals. The normal craniofacial development of nanos1 knockout animals is unlikely a consequence of the genetic redundancy of Nanos1 with Nanos2 or Nanos3 or a result of the genetic compensation for the loss of Nanos1 by Nanos2 or Nanos3 because the expression of nanos2 and nanos3 was rarely seen in the pharyngeal endoderm and endodermal pouches in wild-type and nanos1 mutant animals during craniofacial development. Our findings suggest that nanos1 expression in the pharyngeal endoderm might be dispensable for craniofacial development in zebrafish.     

Tissue expansion in the reconstruction of Tessier craniofacial clefts: a series of 17 patients

Tessier craniofacial clefts are among the most surgically challenging examples of craniofacial dysmorphology. These clefts are characterized by hypoplasia of soft-tissue and skeletal elements throughout the three-dimensional extent of the cleft. Whereas bone grafting and craniofacial osteotomies have been successful toward correcting the underlying skeletal abnormalities, the ultimate success of these reconstructions has been limited by the deficiency of skin and soft tissue. This deficiency demands reconstruction ideally with tissue of like texture, consistency, and, especially in the face, color. Craniofacial tissue expansion was used toward reconstructing these facial clefts with like-quality tissue, allowing for tension-free reconstruction after osteotomy and bone grafting. Seventeen patients with Tessier craniofacial clefts underwent preoperative craniofacial soft-tissue expansion in the surgical management of their clefts. Tissue expansion was used in the primary correction of facial clefts in eight patients, with nine patients undergoing expansion before secondary surgery. In this series, tissue expansion has evolved as an important element in overcoming the skin and soft-tissue deficiency associated with these clefts, allowing for tension-free closure and improved aesthetic results in these surgically challenging patients.     

Reconstruction of late craniofacial deformities after irradiation of the head and face during childhood

Little is known about the results of surgical management of late craniofacial abnormalities arising after irradiation of the head and face for treatment of childhood cancers. The clinical records of 10 children (4 males and 6 females) who received 4500 to 6500 rads (mean 5160 rads) of craniofacial radiation between birth and 8 years of age (mean 5 years) and who subsequently had reconstructive surgery were reviewed. Six of the 10 patients received orbital radiation, 3 received maxillary-midfacial radiation, and 1 patient underwent radiation to the frontal bone. Histologic tumor types included retinoblastoma (4), rhabdomyosarcoma (3), Ewing's sarcoma (2), and neurofibrosarcoma (1). In addition to radiation, 7 of the 10 patients underwent surgical resection or debulking of their tumors and 6 received adjuvant chemotherapy. All patients presented from 4 to 20 years after treatment (mean 10 years) with varying, but severe degrees of soft-tissue and bony hypoplasia of the irradiated territories. Onlay bone grafting with soft-tissue reconstruction by a combination of local pedicle flaps and dermal-fat grafts was initially performed in 9 patients, and an occipitoparietal bone-flap switch procedure was done in 1 patient. Late follow-up ranged from 11 months to 7.5 years (mean 34 months). A total of 8 secondary procedures were necessary in 4 of the 10 patients (40 percent). Of these 4 patients, major revisions were performed in 3 and minor adjustments in 1. In addition, 2 patients in whom secondary procedures had not been done would benefit from further reconstruction. Therapy for cancer of the head and face during childhood has profound and ongoing effects on the growth of soft tissue and bone.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of fast-setting hydroxyapatite cement for secondary craniofacial contouring

Patients who have previously had surgical correction of major craniofacial deformities will often have residual contour deformities they wish to have improved at a later date. The development of hydroxyapatite cement has simplified these procedures. The setting time is reduced to 5 to 8 minutes by mixing the cement with a phosphate-based solution, increasing the tensile strength, and maintaining the same biocompatibility and osseoconductivity. This study includes 48 patients who presented with a variety of residual contour irregularities secondary to a craniofacial congenital anomaly or a posttraumatic defect. All but one of the patients with congenital craniofacial conditions had their initial surgical correction performed by the senior author (Magee) and had regular follow-up visits. Variable amounts of hydroxyapatite cement were used according to the size of the defect to be corrected. Five patients had a postoperative complication: two infections, one seroma, one persistent swelling, and one drain retention. Patients were followed from 6 months to 3 years (mean, 1 year 5 months). Good results were achieved in 38 patients, acceptable results with minor asymmetries were seen in seven patients, and three other patients required a second intervention to obtain a better contour. Cranioplasty with fast-setting hydroxyapatite cement is a simple and reliable procedure, with a low complication rate. Attention to simple technical and operative principles can provide excellent results.     

Evolving maps in craniofacial development

The shaping of the vertebrate head results from highly dynamic integrated processes involving the growth and exchange of signals between the ectoderm, the endoderm, the mesoderm and Cephalic Neural Crest Cells (CNCCs). During embryonic development, these tissues change their shape and relative position rapidly and come transiently in contact with each other. Molecular signals exchanged in restricted regions of tissue interaction are crucial in providing positional identity to the mesenchymes which will form the different skeletal and muscular components of the head. Slight spatio-temporal modifications of these signalling maps can result in profound changes in craniofacial development and might have contributed to the evolution of facial diversity. Abnormal signalling patterns could also be at the origin of congenital craniofacial malformations. This review brings into perspective recent work on spatial and temporal aspects of facial morphogenesis with particular focus on the molecular mechanisms of jaw specification.     

Head posture and craniofacial morphology

The associations between craniofacial morphology and the posture of the head and the cervical column were examined in a sample of 120 Danish male students aged 22–30 years. Two head positions were recorded on lateral cephalometric radiographs, one determined by the subject's own feeling of a natural head balance (self balance position), and the other by the subject looking straight into a mirror (mirror position). Craniofacial morphology was described by 42 linear and angular variables, and postural relationships by 18 angular variables. A comprehensive set of correlations was found between craniofacial morphology and head posture. The correlations were similar for both head positions investigated. Of the postural variables, the position of the head in relation to the cervical column showed the largest set of correlations with craniofacial morphology. Extension of the head in relation to the cervical column was found in connection with large anterior and small posterior facial heights, small antero-posterior craniofacial dimensions, large inclination of the mandible to the anterior cranial base and to the nasal plane, facial retrognathism, a large cranial base angle, and a small nasopharyngeal space. The possible role of functional factors in mediating the relationship between morphology and posture was discussed.     

Analysis and visualization of growth-related and treatment-induced craniofacial changes

An analysis and visualization of craniofacial shape changes due to growth or orthodontic treatment is presented. The suggested method is based on an adapted Karhunen-Loève decomposition of time-discrete data based on landmarks in lateral X-rays of the skull. It allows for a reduction of the high-dimensional dynamic problem to a few spatial modes representing synchronous components of growth patterns with time-dependent mode coefficients. The growth-related shape changes as well as the orthodontic treatment effects are visualized by overdrawing the underlying shape changes. The results based on this technique give insight into the still controversially discussed question to which degree the craniofacial skeletal structures can be influenced by orthodontic appliances.     

The FaceBase Consortium: a comprehensive program to facilitate craniofacial research

The FaceBase Consortium consists of ten interlinked research and technology projects whose goal is to generate craniofacial research data and technology for use by the research community through a central data management and integrated bioinformatics hub. Funded by the National Institute of Dental and Craniofacial Research (NIDCR) and currently focused on studying the development of the middle region of the face, the Consortium will produce comprehensive datasets of global gene expression patterns, regulatory elements and sequencing; will generate anatomical and molecular atlases; will provide human normative facial data and other phenotypes; conduct follow up studies of a completed genome-wide association study; generate independent data on the genetics of craniofacial development, build repositories of animal models and of human samples and data for community access and analysis; and will develop software tools and animal models for analyzing and functionally testing and integrating these data. The FaceBase website (http://www.facebase.org) will serve as a web home for these efforts, providing interactive tools for exploring these datasets, together with discussion forums and other services to support and foster collaboration within the craniofacial research community.     

Thymus,kidney and craniofacial abnormalities in Six 1 deficient mice

Six genes are widely expressed during vertebrate embryogenesis, suggesting that they are implicated in diverse differentiation processes. To determine the functions of the Six1 gene, we constructed Six1-deficient mice by replacing its first exon by the beta-galactosidase gene. We have previously shown that mice lacking Six1 die at birth due to thoracic skeletal defects and severe muscle hypoplasia affecting most of the body muscles. Here, we report that Six1(-/-) neonates also lack a kidney and thymus, as well as displaying a strong disorganisation of craniofacial structures, namely the inner ear, the nasal cavity, the craniofacial skeleton, and the lacrimal and parotid glands. These organ defects can be correlated with Six1 expression in the embryonic primordium structures as revealed by X-Gal staining at different stages of embryogenesis. Thus, the fetal abnormalities of Six1(-/-) mice appear to result from the absence of the Six 1 homeoprotein during early stages of organogenesis. Interestingly, these Six1 defects are very similar to phenotypes caused by mutations of Eya 1, which are responsible for the BOR syndrome in humans. Close comparison of Six1 and Eya 1 deficient mice strongly suggests a functional link between these two factors. Pax gene mutations also lead to comparable phenotypes, suggesting that a regulatory network including the Pax, Six and Eya genes is required for several types of organogenesis in mammals.     

Deep inferior epigastric perforator dermal-fat or adiposal flap for correction of craniofacial contour deformities

Craniofacial contour deformities are difficult to reconstruct. This article summarizes the authors' use of deep inferior epigastric perforator dermal-fat or adiposal flaps in eight patients with such deformities. Of these patients, three had traumatic craniofacial or facial deformities, one had congenital craniofacial deformity, two had hemifacial atrophy (one because of radiation), one had hemifacial microsomia, and one had localized frontonasal lipodystrophy. Stable restoration of the facial contour was achieved in all eight patients. The advantages of this flap are numerous. It has minimal donor-site morbidity, because the rectus abdominis muscle is preserved as a whole, and it accommodates pregnancy in female patients. Simultaneous elevation of this flap during preparation of the recipient site makes it possible to complete surgery in a shorter time than with the scapular flap. Furthermore, a considerable amount of the superficial or deep fatty layer can be removed primarily, making a bulky flap into a thinner one. This flap also allows the use of a large transverse abdominal ellipse of skin, fat, and Scarpa's fascia with abdominoplasty closure. Conversely, it requires a technically difficult dissection of the muscle perforator and skin grafting of donor defects in patients with a large dermal-fat flap. Also, additional minor operations may be necessary to reduce fat volume around the perforator. Ultimately, the deep inferior epigastric perforator adiposal flap seems to be suitable for craniofacial contouring surgery. It is especially indicated for use in children and female patients who are expecting to have children.