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Three-dimensional Camera Imaging in Postoperative Evaluation of Distraction Osteogenesis

Hirota, Yuka MD, PhD; Ueda, Koichi MD, PhD; Otsuki, Yuki MD, PhD; Fuse, Asuka MD; Mitsuno, Daisuke MD

Plastic and Reconstructive Surgery – Global Open: June 2019 - Volume 7 - Issue 6 - p e2200
doi: 10.1097/GOX.0000000000002200
Ideas and Innovations
Open
SDC
Japan

Summary: Distraction osteogenesis needs to be regularly assessed in some way to monitor the degree of advancement. X-ray is used for the general evaluation of osteotomy. However, radiation exposure should be avoided. The purpose of this study is to evaluate 3-dimensional (3D) camera imaging for postoperative evaluation. Three patients who underwent Le Fort I or III advancement osteotomy using rigid external distraction and internal distraction were observed in this study. The degrees of the distractions were evaluated using VECTRA H1 3D imaging in addition to computed tomographic (CT) scans. In the VECTRA 3D imaging, the tilt and size of the faces were corrected using the dedicated software for imaging. The preoperative and postoperative images were superimposed, and the distances of motion between the landmarks were measured. In CT scans, the bone distances between osteotomy points of the pterygomaxillary junction were analyzed. As the VECTRA 3D imaging can be compared by overlaying previous photographs, it served as a good tool to evaluate the distractions. However, both the soft-tissue movement measured by VECTRA and CT bony measurements did not match the total amount of movement for the internal distraction devices. The bony advancements were less than the amount of distraction. The soft tissues shrank after the distraction was completed in all cases. Three-dimensional camera imaging is considered to be a useful tool for the evaluation of distraction osteogenesis.

From the Department of Plastic and Reconstructive Surgery, Osaka Medical College, Takatsuki, Japan.

Published online 25 June 2019.

Received for publication November 7, 2018; accepted February 1, 2019.

Presented in part at the 10th World Cleft Lip, Palate & Craniofacial Congress International Cleft Lip and Palate Foundation, 2016, Chennai, India.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Koichi Ueda, MD, PhD, Department of Plastic and Reconstructive Surgery, Osaka Medical College, Takatsuki, Osaka 569–8686, Japan, E-mail: pla007@osaka-med.ac.jp

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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INTRODUCTION

Distraction osteogenesis in surgical treatments such as Le Fort advancement osteotomy requires assessment by x-ray or computed tomographic (CT) scan to monitor the degree of advancement.1,2 However, radiation exposure should be avoided in children.3,4

Daily evaluation of the progress of maxillary distraction can be evaluated visually because the soft-tissue profile changes occur after maxillary distraction, but objective evaluation of the soft-tissue profile is necessary. The purpose of this study is to evaluate 3-dimensional (3D) camera imaging as a method following maxillary distraction.

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PATIENTS AND METHODS

We assessed 3 patients who underwent Le Fort I or III advancement osteotomy using both rigid external distraction and internal distraction.5 The facial advancement by distraction was evaluated using VECTRA H1 3D imaging in addition to CT scans. Case 1 is an 8-year-old girl with Crouzon syndrome who underwent Le Fort III mid-face advancement osteotomy. The internal distraction device was fixed on the zygomatic arch. Case 2 is a 19-year-old man with bilateral cleft lip and palate who underwent Le Fort I maxillary advancement osteotomy. Case 3 is an 18-year-old man with bilateral cleft lip and palate who underwent Le Fort I maxillary advancement osteotomy. The internal distraction device was fixed on the maxilla in both cases 2 and 3. In all 3 cases, the external distraction device was detached 1 week after distraction; however, the internal devices were kept and used as fixation materials and removed 6 months after distraction.

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Three-Dimensional Camera Imaging

Handy VECTRA H1 3D imaging was taken regularly. Before evaluation, the 4 fixed points in the distraction process were decided (Fig. 1) (See Fig., Supplemental Digital Content 1, which displays the 4 fixed points were also marked on the postoperative image, http://links.lww.com/PRSGO/B85). And then, the tilt and size of the face were corrected using VECTRA dedicated software. For evaluation, the landmarks subnasal (SN) and both sides of wire-penetrated site (WP) were selected (Fig. 2).

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

The preoperative and postoperative images were superimposed against each other, and the preoperative to postoperative distances relative to landmarks SN and both sides of WP were measured (Fig. 3).

Fig. 3.

Fig. 3.

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CT Scans

CT scans were taken preoperatively and postoperatively (case 1: postoperative day 40; case 2 and case 3: postoperative day 100). For evaluation, the bone distances between osteotomy points of pterygomaxillary junction were analyzed (Fig. 4).

Fig. 4.

Fig. 4.

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RESULTS

Three-Dimensional Camera Imaging

We could see the actual facial changes by distraction and view the progress of the distraction from VECTRA images. VECTRA 3D images could be compared easily by overlaying previous photographs on top of each other to allow measurements of the distance from preoperative to postoperative points against landmarks such as SN and both sides of WP.

From the results, it was found that both the amount of soft-tissue movement measured by VECTRA and that of bone movement by CT scan did not match the total amount of movement for the internal distraction devices (Table 1). The total amount of the external distraction devices was much larger than ones of the internal distraction device. It was thought that SN points showed the average soft-tissue profile change between both WP points after distraction. In all of the cases, the soft tissue shrank after the distraction was completed (Table 1).

Table 1.

Table 1.

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CT Scans

CT scans are suitable for examining data in detail. The bone distances between osteotomy points were analyzed. The measurements showed that bone advancement in CT scans were lower than the advancement scores of the internal distractions (Table 1).

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DISCUSSION

X-rays are used for the evaluation of distraction.1,2,6 However, frequent x-ray exposures should be minimized or avoided, especially in children.3,4

Cephalometric radiography is necessary to evaluate accurate bone advancement, but it is difficult in children because the external distraction device may bump against the cephalometric device. Using ordinary lateral x-rays, detailed analysis becomes more difficult because the inclinations and rates of magnification of the face change each time.

Also, CT scans cannot be used for daily assessment because of radiation exposure. In our study, the amount of movement measured by CT scan did not match the total extension amount of the external and internal distraction devices. The differences of the external device and internal device are caused by elongation of the extension wire and bending of the bones. Such a phenomenon may be stressful for the surgeons. Visual evaluations have no risk of radiation exposure, but it is only subjective findings. However, 3D camera imaging can be taken any number of times because there is no risk of radiation exposure.7 Especially with the handy type, images can be taken easily even when the patient is restless. In addition, distraction results may be monitored easily using the VECTRA 3D imaging device because the images can be changed to various sizes and evaluated from all angles, and therefore they can be easily compared by overlaying previous photographs on top of each other.7

There have been reports of various studies on soft-tissue changes by movement of the bony structures in facial distraction and various ratios of soft-tissue changes have been reported.8–10

However, those ratios are not consistent, as we found in this study. And soft tissue is dynamic and varies in thickness depending on the muscle movement and emotions.8

In distraction, it is important to confirm that daily advancement and the relationship between soft- and hard-tissue advancement ratios may not always be necessary. Most surgeons determine endpoints for distraction, visually. We believe that 3D camera imaging can become an ideal objective tool of the soft-tissue profile changes in evaluating distraction. We must improve the method further to make it more accurate.

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CONCLUSION

Three-dimensional camera imaging is considered to be a useful tool of soft-tissue profile evaluation of distraction osteogenesis.

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PATIENT CONSENT

The patient provided written consent for the use of her image.

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REFERENCES

1. Polley JW, Figueroa AA. Management of severe maxillary deficiency in childhood and adolescence through distraction osteogenesis with an external, adjustable, rigid distraction device. J Craniofac Surg. 1997;8:181–185; discussion 186.
2. Figueroa AA, Polley JW, Ko EW. Maxillary distraction for the management of cleft maxillary hypoplasia with a rigid external distraction system. Semin Orthod. 1999;5:46–51.
3. Hall EJ. Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol. 2002;32:700–706.
4. Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet. 2004; 363:345–351.
5. Wall SA, Butler L, Byren J, et al. Combined internal and external Le Fort III distraction osteogenesis–the “elusive vector.” J Craniofac Surg. 2009;20(suppl 2):1806–1808.
6. McCarthy JG, Schreiber J, Karp N, et al. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg. 1992;89:1–8; discussion 9.
7. Gibelli D, Pucciarelli V, Cappella A, et al. Are portable stereophotogrammetric devices reliable in facial imaging? A Validation Study of VECTRA H1 Device. J Oral Maxillofac Surg. 2018;76:1772–1784.
8. Wen-Ching Ko E, Figueroa AA, Polley JW. Soft tissue profile changes after maxillary advancement with distraction osteogenesis by use of a rigid external distraction device: a 1-year follow-up. J Oral Maxillofac Surg. 2000;58:959–969; discussion 969.
9. Dann JJ 3rd, Fonseca RJ, Bell WH. Soft tissue changes associated with total maxillary advancement: a preliminary study. J Oral Surg. 1976;34:19–23.
10. Lines PA, Steinhauser EW. Soft tissue changes in relationship to movement of hard structures in orthognathic surgery: a preliminary report. J Oral Surg. 1974;32:891–896.

Supplemental Digital Content

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Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.