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Monozygotic Twin Sister as a Template for Facial Trauma Reconstruction

Aizenbud, Dror, D.M.D., M.Sc.; Morrill, Larry R., D.D.S.; Schendel, Stephen A., M.D., D.D.S.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 443e-445e
doi: 10.1097/PRS.0b013e3181bcf535
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Orthodontic and Craniofacial Center, Rambam Health Care Campus and Technion–Bruce Rappaport Faculty of Medicine, Haifa, Israel (Aizenbud)

Craniofacial Anomalies Center, Packard Children's Hospital, Stanford University School of Medicine, Stanford, Calif. (Morrill, Schendel)

Correspondence to Dr. Aizenbud, Orthodontic and Craniofacial Center, Rambam Health Care Campus, P.O. Box 9602, Haifa 31096, Israel, aizenbud@ortho.co.il

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Sir:

Traumatic deformity of the cartilaginous septum is related to later underdevelopment of the cartilaginous middle third of the nose and disturbed maxillary growth.1,2 Many studies retrospectively relate traumatic events to skeletal class III relations. However, these do not provide clear relationships between the environment and genetics.

Twin studies have proven beneficial in separating genetic and environmental influences on facial growth and malocclusion. A review of the literature has revealed only one study of identical twins in which one sustained a traumatic injury to the midfacial region at a young age.3,4

The aim of this study was to compare longitudinally the growth of the face in a pair of identical twins after severe midfacial trauma (twin A) in early childhood and to present a method of facial reconstruction by the use of the normal twin sister's facial growth pattern as a template for the reconstruction.

One pair of female identical twins (twin A) was presented for consultation in relation to facial deformity because of midfacial trauma at age 2 that included Le Fort II and III fractures. Until age 19, the facial profile difference between the twins gradually became more pronounced and included, in twin A, severe retrusion, midfacial class III malocclusion, and a negative overbite relation of 9 mm with enlarged facial height.

Radiographic studies, including lateral and posteroanterior cephalometric and panographic radiographs, where obtained at intervals during growth and development. The preoperative cephalometric radiograph was taken at the age of 19 after a presurgical orthodontic preparation phase (Fig. 1, above) revealed a negative overjet of 12 mm. Cephalometric radiographs were at this time also obtained on the unaffected twin (Fig. 1, below). Cephalometric radiographs were analyzed and compared between twin A and twin B. Superimpositions of the cephalograms of both twins were performed for comparison and surgical planning (Fig. 2).

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

At the age of 20 years, twin A underwent surgical correction of the traumatic deformity according to the facial template phenotype of the unaffected twin sister. The orthognathic surgery procedure included a high Le Fort I osteotomy with maxillary advancement and impaction and with bilateral mandibular sagittal split osteotomy with setback associated genioplasty.

The present case demonstrates long-term follow-up of the influence of the facial trauma consisting of Le Fort II and III fractures. The comparison of the facial growth and development between twin A and twin B suggested that the cartilaginous septum and facial sutures plays an important role in the development of the nasomaxillary complex. Superimposition of the cephalometric radiographs before orthognathic surgery of the twin sisters (Fig. 2) revealed severely forward mandibular growth inhibition that resulted in significant posterior rotation of the nasal and maxillary bones and a vertical pattern of jaw growth. Because we compared two genetically identical twins, the disturbed nose and facial growth must be linked to the traumatized cartilaginous septum and facial sutures.

According to our observations in the patient presented here, it is suggested that trauma is most likely the cause of the developmental deformity of twin A. The unaffected twin sister (twin B) may serve as the genetic facial phenotype for the surgical orthognathic reconstruction intervention in twin A.

Dror Aizenbud, D.M.D., M.Sc.

Orthodontic and Craniofacial Center

Rambam Health Care Campus and Technion–Bruce Rappaport Faculty of Medicine

Haifa, Israel

Larry R. Morrill, D.D.S.

Stephen A. Schendel, M.D., D.D.S.

Craniofacial Anomalies Center

Packard Children's Hospital

Stanford University School of Medicine

Stanford, Calif.

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REFERENCES

1. Meeuwis J, Verwoerd-Verhoef HL, Verwoerd CD. Normal and abnormal nasal growth after partial submucous resection of the cartilaginous septum. Acta Otolaryngol. 1993;113:379–382.
2. Verwoerd-Verhoef HL, Verwoerd CD. Surgery of the lateral nasal wall and ethmoid: Effects on sinonasal growth. An experimental study in rabbits. Int J Pediatr Otorhinolaryngol. 2003;67:263–269.
3. Grymer LF, Pallisgaard C, Melsen B. The nasal septum in relation to the development of the nasomaxillary complex: A study in identical twins. Laryngoscope 1991;101:863–868.
4. Grymer LF, Bosch C. The nasal septum and the development of the midface: A longitudinal study of a pair of monozygotic twins. Rhinology 1997;35:6–10.

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