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Despite anatomical abnormalities, there is noneed to treat a craniofacial anomaly unless it is,or will become, a real problem for the patient.

There must be either an interference with function oran effect on facial esthetics that interferes with psy-chosocial development. Many craniofacial anomaliesdo not cause a functional problem. Indeed, in a societyless obsessed with facial esthetics, there would be noproblem associated with “different” faces.

The severe expression of hemifacial microsomiamay unilaterally have a condyle and ramus that areseverely dysplastic or even absent, no temporal fossa,and severely hypoplastic or virtually absent muscles ofmastication. Yet such patients have no associated pain ordiscomfort, can chew and swallow comfortably, canspeak with normal articulation and nasal resonance, andcan breathe adequately. Apart from the loss of hearing,there may be no dysfunction except in the narrowest ofdefinitions: the mandible and temporomandibular jointdo not function in a “normal” way. Therefore, the pri-mary purpose of treatment is to establish optimumfacial esthetics, in the course of which there is usuallyvery favorable jaw(s) repositioning that permits theorthodontist to achieve excellent occlusal function.Thus, planning treatment begins with the identificationof (1) the desired facial esthestics, (2) the skeletal andsoft tissue alterations necessary to make the desiredchanges, and (3) the dental changes required.

THE TEAM APPROACH

Complex craniofacial anomalies generally requiretreatment by many different specialists. This seems towork best when a dedicated team is organized andtreatment is coordinated. The orthodontist is an essen-tial member of any craniofacial team. The role of theorthodontist on the team is to:

• Help determine which craniofacial structures areabnormal in the affected patient.

• Determine the facial growth pattern and predictthe future morphology.

• Estimate the effect that various treatment modali-ties, particularly surgery, would have on subse-quent growth and advise on the appropriate natureand timing of treatment.

• Plan with the surgeon the desired skeletal and softtissue alterations.

• Prepare for the orthognathic component of thesurgery by manipulating the teeth and alveolarprocess, and complete orthodontic correctionsafter the surgery.

• Become involved in clinical research on facialmorphology, growth, and response to treatment.

HOW WILL THE FACE GROW IF LEFTUNTREATED?

When development goes awry, there will be, overtime, 1 of 3 outcomes: the situation will improve,worsen, or remain constant. However, few craniofacialanomalies improve. Infants with Robin sequence mayappear to make a remarkable recovery in the firstmonths of life, but they remain decidedly retrognathicinto adulthood. On rare occasions a child with hemifa-cial microsomia will appear to recover.

Conditions that become worse with growth includethose with direct inhibition of growth areas, such as max-illary and mandibular ankylosis. Developmental bonyankylosis of the mandible is very rare; neonatal or infanttrauma or infection is usually the cause of bony ankylo-sis in young children. Decreased mobility of themandible is caused by the soft tissue elements of the jointand does not restrict growth. Maxillary ankylosis occursin Apert and Crouzon syndromes. The posterior displace-ment and tethering of the condyle in mandibulofacialdysostosis (Treacher Collin syndrome) may be responsi-ble for both the limited mobility and the unusual shape ofthe lower border that worsens over time. But stability isthe rule in the vast majority of cases. Even the facial andbony asymmetries in hemifacial microsomia or unoper-ated cleft lip and palate are invariably stable duringgrowth of the child; a few worsen slightly and a fewimprove slightly without treatment. Growth of theaffected side parallels that of the nonaffected, regardlessof the degree of the initial deformity.

Reprint requests to: Bruce Ross, Department of Dentistry, Division of Ortho-dontics, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario,M5G 1X8, Canada.Am J Orthod Dentofacial Orthop 2001;119:92-4Copyright © 2001 by the American Association of Orthodontists0889-5406/2001/$35.00 + 0 8/1/110518doi:10.1067/mod.2001.110518

COMMENTARY

The orthodontist and complex craniofacial anomaliesBruce Ross, DDS, MSc, FRCD(C)Toronto, Ontario

American Journal of Orthodontics and Dentofacial Orthopedics Ross 93Volume 119, Number 2

do little more than tip the teeth and alveolar process.Yet some clinicians mistakenly believe in the “worsen-ing” theory, and conclude, for example, that growth ofthe dysmorphic condyle in hemifacial microsomiawhile a functional appliance is being worn proves theeffectiveness of the appliance. In fact, the same profusegrowth would occur without appliance intervention. Intreating patients with cleft lip and palate, orthodontistsplace appliances at birth and needlessly keep the childunder treatment almost continuously until young adult-hood. Presurgical infant orthopedics, for example, havebeen in use for more than 50 years without a singleconfirmed benefit. For any protocol or procedure, theonus is on the advocates to prove it is worthwhile andsafe, not on the opponents to prove it is not.

There are times to intervene and times to simplyobserve as the child participates in other therapeuticactivities or is permitted to have a rest and just grow.

CAN ORTHODONTIC OR ORTHOPEDIC TREATMENTINFLUENCE CRANIOFACIAL GROWTH?

Alas, it would seem that orthodontists have very lit-tle effect on the growth of the basal bones of the face,including the mandible and maxilla. The permanentresponse to treatment can be measured in millimetersor fractions thereof. This is a small accomplishment ina face that is severely deficient or deformed.

THE EFFECTS OF SURGERY ON FACIAL GROWTH

Most anomalies have functional or esthetic prob-lems that require reconstructive surgery to the hard andsoft tissues. There are usually compelling reasons toattempt treatment of these conditions as early as possi-ble, and surgery to the growing child is often proposed.Surgery to an area generally affects the subsequentgrowth of that area, usually in a detrimental way.Surgery to the mandible or maxilla can attenuate orarrest subsequent growth. In most cases, electivesurgery should be delayed until facial growth is closeto completion unless one has reasonable certainty thatsurgical treatment will not inhibit further growth.

CONGENITAL OR ACQUIRED?

It is useful and often essential to determine whethera facial malformation is developmental or acquired.There are many indicators:

• Pain indicates an acquired anomaly. There is nopain or discomfort with developmental anomalies,and no history of pain.

• A change over time in the condition, either theappearance of new symptoms or a change in mor-phology, indicates an acquired anomaly.

When one is confronted with an infant or child witha developmental anomaly, and the parent, pediatrician,and surgeon are asking for the prognosis, a useful ruleof thumb is that the face continues to grow in the wayit has been growing. It will invariably remain in thesame configuration, with the affected areas growingproportionately to the unaffected areas. This does notapply, of course, to an acquired anomaly.

WHEN SHOULD TREATMENT BEGIN?

Most craniofacial anomalies are recognized at birth,and the various specialists involved in their manage-ment plan the best and safest time to begin treatment,particularly with regard to surgical intervention. Theparents would like treatment completed in the neonatalperiod. The speech pathologist would like the speechmechanism corrected in the first year. The psychologistwould like the facial appearance treated at least beforethe child reaches school age. The orthodontist wouldlike a corrected jaw relationship stabilized in the pri-mary dentition. The surgeon might like to wait as longas possible to avoid interfering with facial growth.

If a condition threatens the life or health of thepatient, treatment must be instituted at once. If an anom-aly poses no serious problem and is stable, as it is in thevast majority of cases, we have the luxury of treatingwhen it is most convenient for all concerned: the patient,the parents, and the health care professionals.

One advantage of an early approach is that the childhas a more attractive face throughout childhood. Surgeryfor a preschooler will alleviate the impact of a severefacial deformity on the child during the early school yearswhen self-esteem is fragile and patterns of social interac-tions are developing. In moderate cases with someesthetic problems, the timing of treatment depends on theattitude of the patient and parents. If the facial differenceis not of great concern to the patient and parents, if it doesnot appear to be causing a psychosocial problem, and ifno significant functional advantage is to be gained byearly correction, then it is probably preferable to waituntil facial growth has neared completion. Treatment canbegin as the patient enters adolescence and social activi-ties begin to cause more concern about facial differences.

OVERTREATMENT

With a serious anomaly, there is an urgent desire todo something. Many orthodontists and surgeons micro-manage their cases in an attempt to control the condi-tion and please the parents. Early orthodontic treatmentis often wasted, and early and frequent surgery mayproduce a poor result. Almost every craniofacial anom-aly requires some form of surgical treatment to achievea safisfactory result; orthodontic treatment alone can

94 Ross American Journal of Orthodontics and Dentofacial OrthopedicsFebruary 2001

• A temporary change in symptoms associated withfunction (eg, heavy chewing) indicates an acquiredanomaly. Developmental anomalies are not affectedby function.

• The presence of developmental anomalies of contigu-ous structures (eg, ear, eye, palate, macrostomia, mus-cle deficiency) suggests a developmental etiology.

• Crepitis or clicking in the joint suggests an acquiredanomaly.

• Ankylosis is almost always acquired. Limitationof mandibular forward translation may be devel-opmental, but rotation is not usually limited to anygreat extent.

• Marked dental compensations for an asymmetricalmandible indicate that there was very early devel-

opment of the asymmetry, possibly congenital orin infancy. The corollary is that if there are severecrossbites, then the condition was probablyacquired at a later time.

• The condyle in a developmental condition may bedeficient or excessive, but it is round and smooth.If the condylar head is flat or an irregular shape, itis an acquired anomaly.

Orthodontists tend to have an admirably idealisticapproach to the occlusion, but in dealing with cranio-facial anomalies, we must always be prepared toaccept some functional and esthetic compromises.Modern techniques have made these compromisesmuch more tolerable.

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