Papers by Alvaro Figueroa
The Angle Orthodontist, 2012
Objective: To systematically review the long-term skeletal stability after maxillary advancement ... more Objective: To systematically review the long-term skeletal stability after maxillary advancement with distraction osteogenesis (DO) in cleft lip and palate (CLP) patients. Materials and Methods: Electronic databases, grey literature, and reference list searches were conducted. The inclusion criteria were stability of maxillary advancement with distraction osteogenesis assessed at the posttreatment follow-up $ 1 year in CLP patients. Full articles were retrieved from abstracts or titles that appear to meet the inclusion criteria or lacked sufficient detail for immediate exclusion. Once full articles were collected, they were again reviewed considering more detailed inclusion criteria for a final selection decision. A methodologic quality assessment tool was utilized. Results: Thirty abstracts/titles met the initial search criteria, and 13 articles were finally selected. Overall, methodologic quality scores were high in only one randomized clinical trial. After maxillary advancement with DO in CLP patients, the long-term horizontal relapse in A-point was less than 15% in eight studies and between 20% and 25% in four studies. The study that was judged as a high-quality study reported 8.2% horizontal relapse in A-point. The relapse rate was higher in DO with external distracter device than DO with internal distracter device. Conclusions: Current evidence suggests maxillary advancement with DO has good stability in CLP patients with moderate and severe maxillary hypoplasia.
Journal of Maxillofacial and Oral Surgery, Apr 28, 2015
Introduction Distraction osteogenesis is a powerful tool in craniomaxillofacial surgery, allowing... more Introduction Distraction osteogenesis is a powerful tool in craniomaxillofacial surgery, allowing for large advancements of osteotomized segments in the setting of a restrictive soft tissue envelope. Despite its benefits, distraction can have negative functional consequences. We present a case of a patient with Crouzon syndrome who developed reduced mouth opening capability after a Le Fort III midfacial advancement with rigid external distraction. Technique Radiographic evaluation revealed that the coronoid process was restricting the normal excursion of the mandible by contacting the posterior zygoma. The patient was subsequently treated with a bilateral coronoidectomy via an intraoral approach, which improved his interincisal opening. Maximum interincisal distance was improved from 18 mm to 33 mm following bilateral cornoid resection. Conclusion We report coronoid impingement as a potential complication after Le Fort III distraction. Such a finding suggests the need for a detailed vector analysis in cases undergoing midface advancement with distraction. Post-distraction coronoidectomy is a useful surgical procedure to treat mouth opening limitation due to coronoid impingement against the zygoma after midfacial advancement.
Closure of the secondary palate in most vertebrates involves reorientation of the bilateral palat... more Closure of the secondary palate in most vertebrates involves reorientation of the bilateral palatal shelves from a vertical position on either side of the tongue to a horizontal position above the tongue (Figure 10.1). The apposing medial- edge epithelia (MEE) adhere and then degenerate, allowing the merging of mesenchymal cells to form a single continuous structure, the secondary palate. The overall process of palatogenesis can be divided into four stages: growth of the vertical palatal shelves, reorientation to a horizontal position and, finally, epithelial adhesion and subsequent programmed epithelial cell death. These events occur at midgestation after most organogenetic events have occurred in the embryo.
Journal of Maxillofacial and Oral Surgery, Jun 5, 2017
The prevention of scar contracture after surgery is an important aspect of lateral facial cleft r... more The prevention of scar contracture after surgery is an important aspect of lateral facial cleft repair. Maintaining adequate mouth opening is essential for speech, expression, chewing, oral hygiene and psychosocial wellbeing. Although there have been extensive reviews of nonsurgical microstomia management in patients with oral electrical burns, there have been no reports on the use of oral commissure splints to manage the surgical scar in patients with lateral facial clefts. The case study presented here will demonstrate the clinical use of cheek retractors to provide physical resistance to scar contracture. We recommend early rehabilitation with cheek retractors to minimize scar contracture and the negative sequelae of scarred tissues on the dentition after lateral facial cleft repair.
Springer eBooks, 1999
In 1992 McCarthy opened new horizons in craniofacial surgery with the publication of the first ap... more In 1992 McCarthy opened new horizons in craniofacial surgery with the publication of the first application of distraction osteogenesis in the human craniofacial skeleton (1). Since the introduction of this pioneering work, distraction osteogenesis has rapidly become the keystone for the reconstruction of many craniomaxillofacial anomalies. For the management of severe maxillary hypoplasia, maxillary distraction osteogenesis is becoming one of the most important aspects of treatment planning. In this chapter, we present our technique for the reconstruction of severe maxillary hypoplasia utilizing rigid external distraction (RED).
PubMed, 1985
There is increasing evidence that hemifacial microsomia (HFM), Goldenhar syndrome (GS), and oculo... more There is increasing evidence that hemifacial microsomia (HFM), Goldenhar syndrome (GS), and oculoauriculovertebral dysplasia (OAV) are part of a spectrum within a single entity. In support of this thesis are the family studies that have suggested that isolated microtia (M) may represent the mildest form of the condition [Kaye et al, 1979; Rollnick and Kaye, 1983]. Vertebral malformations are pathognomonic of OAV, but they have also been described in HFM and GS. In this investigation we studied the frequency and type of cervical spine malformations in HFM, GS, OAV, and M. Our findings show that the frequency of cervical spine malformations in HFM and M was greater than values for a normal population. This further supports the probable association between HFM, GS, OAV, and M. Fusions were the most prevalent cervical spine malformation encountered. The study also included analysis of the cranial base and craniovertebral junction.
PubMed, Nov 1, 1998
The application of distraction osteogenesis in craniomaxillofacial surgery has created new treatm... more The application of distraction osteogenesis in craniomaxillofacial surgery has created new treatment methods for patients with craniofacial skeletal dysplasias. Most of the applications in the craniofacial skeleton have been for the correction of severe congenital or acquired conditions. As more understanding is gained with these new approaches, refinements in techniques will enhance treatment planning and outcome. This will expand the application of distraction osteogenesis to more common, less severe types of skeletal dysplasias. One of the important areas in mandibular distraction osteogenesis is the management of the dental gap created when distraction is applied within the tooth-bearing segment of the mandibular body. In this study, the authors investigated the effects of orthodontic tooth movement into new bone created through the process of distraction osteogenesis. Orthodontic tooth movement through newly formed mandibular bone in the canine model was performed and, through histologic studies, was found to create compact bone along the path of the moving tooth. This compact bone replaced the more unstructured woven bone that was originally created by the process of mandibular distraction osteogenesis. These findings indicate that orthodontic tooth movement can be performed in distracted bone and can have significant influence on the stability and long-term structural preservation of the bone created by distraction osteogenesis within the tooth-bearing segment of the mandible.
Springer eBooks, May 19, 2006
Patients with severe maxillary hypoplasia secondary to congenital facial clefting present numerou... more Patients with severe maxillary hypoplasia secondary to congenital facial clefting present numerous challenging problems for the reconstructive surgeon. Traditional surgical/orthodontic approaches for these patients often fall short of expectations, especially for achieving normal facial aesthetics and proportions. The purpose of this paper is to present our clinical experience and cephalometric results with the use of rigid external distraction for the treatment of patients with severe maxillary deficiency. Eighteen consecutive orofacial cleft patients with severe maxillary hypoplasia were treated with maxillary distraction osteogenesis. Criteria for patient selection included severe maxillary hypoplasia with negative overjet of 8 mm or greater, patients with normal mandibular morphology, and patients with full primary dentition or older. There were 10 unilateral cleft lip and palate patients, 6 bilateral cleft lip and palate patients, and 2 patients with severe congenital facial clefting. A maxillary splint was prepared for each patient, and all patients underwent a high Le Fort I maxillary osteotomy. All surgery was performed on either an outpatient or a 23-hour admission basis. No patient required blood transfusions or intermaxillary fixation. Two types of mechanical distraction were utilized in this series. In group 1 (n = 14), the patients underwent rigid external distraction with an external distraction device. In group 2 (n = 4), patients underwent face mask distraction with elastics. There was no surgical morbidity in any of the patients. For the patients in the rigid external distraction group, the mean effective horizontal advancement of the maxilla was 11.7 mm. All of these patients had correction of their negative overjet. For patients in the face mask distraction group, the results were disappointing. The mean effective advancement of the maxilla in this group was only 5.2 mm. In all face mask distraction patients, the initial maxillary hypoplasia was undercorrected. Maxillary distraction osteogenesis with rigid external distraction permits full correction of the midfacial deficiency, including both the skeletal and soft-tissue deficiencies. Rigid external distraction in patients with severe maxillary hypoplasia allows full correction of the deformity through treatment of the affected region only. It offers the distinct advantage of correcting these severe deformities through a minimal procedure. Rigid external distraction has dramatically improved our treatment results for patients with severe cleft maxillary hypoplasia.
Journal of Craniofacial Surgery, Mar 8, 2023
Background: Patients with Down syndrome have severe facial deformities that can precipitate funct... more Background: Patients with Down syndrome have severe facial deformities that can precipitate functional consequences and social stigmatization. Craniofacial surgical intervention can play a role in improving these symptoms and patient quality of life. The objective of this study was to investigate the long-term outcomes of distraction osteogenesis and orthognathic surgical intervention in patients with Down syndrome. Materials and Methods: Charts of 3 patients with Down syndrome who were treated with external maxillary distraction osteogenesis were retrospectively reviewed. The patients’ caregivers were prospectively interviewed between 10 and 15 years after surgery to determine surgical stability, long-term function, and quality of life status. Results: All patients and their caregivers reported excellent results with improvements in function and quality of life. Facial skeletal changes have been stable over time. The cephalometric analysis demonstrated significant maxillary advancement in all 3 patients and mandibular changes to correct mandibular prognathism and asymmetry in the patient who underwent finishing orthognathic surgery. Conclusions: External maxillary distraction osteogenesis and orthognathic surgery may be considered in select patients with Down syndrome as part of their multidisciplinary health care. These interventions can result in long-term improvements in patient function and quality of life.
Journal of Craniofacial Surgery, Jun 18, 2020
Custom alloplastic temporomandibular joint (TMJ) reconstruction has been well established for the... more Custom alloplastic temporomandibular joint (TMJ) reconstruction has been well established for the management of end-stage TMJ disease. However, its use in congenital TMJ deformities is limited. Here, the authors present initial outcomes of skeletally mature patients who underwent custom alloplastic TMJ reconstruction and simultaneous orthognathic surgery. A retrospective case series of patients who underwent custom alloplastic TMJ reconstruction concurrent with orthognathic surgery between 2014 and 2019 was completed. Functional, aesthetic and orthodontic outcomes as well as complications were recorded. Seven TMJs in 5 skeletally mature patients (4 female, 1 male, ages 16-30) (2 bilateral, 3 unilateral) were replaced. All but 1 patient had previous attempts at reconstructive surgery with poor results. All cases were prepared using virtual surgical planning and underwent concomitant maxillomandibular orthognathic surgery. All patients demonstrated improved post-operative occlusions. Four of 5 patients achieved >30 millimeters of post-operative MIO. Complications included ear canal perforation and facial nerve dysfunction. There were no infections or other implant-related complications. Mean follow up was 2 years and 15 days. Alloplastic TMJ reconstruction at the time of skeletal maturity for patients with congenital mandibular TMJ defects is an alternative to existing management options. Further long-term prospective outcomes studies are ongoing.
The Cleft Palate-Craniofacial Journal, Mar 1, 2010
Objective: This retrospective study was conducted to analyze changes in the maxillary permanent m... more Objective: This retrospective study was conducted to analyze changes in the maxillary permanent molars after monobloc advancement with rigid external distraction (RED). Setting: University hospital-based craniofacial center. Materials and Methods: Fourteen patients, three in primary, eight in mixed, and three in permanent dentition underwent monobloc advancement with RED. After a latency period of 6 days, distraction was carried out for 18 days. Lateral cephalometric radiographs were taken before surgery (T1) and an average of 3.72 months after the removal of the distractor (T2). Panoramic radiographs were taken at T1, T2, and T3 (an average of 14.87 months after RED removal), to search for surgical tooth trauma, arrested crown/root development, impaction, tooth germ displacement, dilacerations, and other possible dental abnormalities. Vertical and horizontal displacement and angulations of the permanent maxillary molars were evaluated before and after surgery. Statistics: A paired t test was used to analyze significant changes in molar position after distraction. Results and Conclusions: Distraction created posterior arch length with significant horizontal forward movement of the first and second molars (p , .05) and minimal vertical displacement (p. .05). The procedure disrupted the development of one of the first molars, three of the second molars, and two of the third molars. Incidence of molar damage was increased in patients operated on during primary dentition. Careful surgical technique during pterygomaxillary disjunction, especially in young children, and long-term radiographic follow-up of maxillary molars is strongly recommended.
Development, Aug 1, 1981
Whole-embryo culture techniques have advanced to the point where the study of normal and abnormal... more Whole-embryo culture techniques have advanced to the point where the study of normal and abnormal primary palate development in vitro is possible. The purpose of this study was to ascertain whether localized administration of tunicamycin (TM) an inhibitor of protein glycosylation, into the region of the developing primary palate would induce cleft lip in culture. Rat embryos were explanted on late day 11 of gestation and cultured with open yolk sacs for 40 h. TM was administered by implanting a sterile eyelash soaked in TM into the nasal placode region. The contralateral placode was used as the control by implanting an eyelash lacking TM. Under these conditions, TM-treated placodes were found to develop cleft lip in 14 out of 15 embryos compared to 0 for the controls. These experiments demonstrate that localized administration of TM results in cleft lip formation in whole embryo culture. The technique of localized administration of drugs and teratogens in whole embryo culture should prove useful for similar studies on embryonic development.
Journal of Oral and Maxillofacial Surgery, Dec 1, 2008
The Cleft Palate-Craniofacial Journal, 2012
Background: A multidisciplinary meeting was held from March 4 through 6, 2010, in Atlanta, Georgi... more Background: A multidisciplinary meeting was held from March 4 through 6, 2010, in Atlanta, Georgia, to conceptualize, map out, and operationalize the variables most relevant to the care of patients with craniosynostosis. In this article, the authors highlight the development of the craniofacial and neurologic surgery parameters of care. Methods: Fifty-two conference attendees, representing a broad range of expertise in craniosynostosis care and 16 professional societies, participated in this working group. Literature and expert opinion were used to identify the variables important for the care of patients with craniosynostosis. In an iterative manner, specialty-specific data were compiled into draft recommendations and presented to all conference attendees. Cross-discipline analysis was used to assess the completeness of the data, facilitate exchange of ideas, and achieve consensus. Results: Consensus was reached among the 52 conference attendees and two post hoc reviewers in 18 areas of craniosynostosis care. Longitudinal parameters of care were developed for the diagnosis, treatment, and management of craniosynostosis in each of the specialty areas of care, from prenatal evaluation to completion of care in adulthood. Conclusions: To our knowledge, this is the first multidisciplinary effort to develop parameters of care and best practices for craniosynostosis. In conjunction with patient input, these parameters may help to heuristically develop core outcome sets that are important not only to patients and their families, but also to health care providers and health services and outcome researchers. (Plast.
Clinics in Plastic Surgery, Jul 1, 2021
Distraction osteogenesis is a viable treatment option for patients with a cleft associated with s... more Distraction osteogenesis is a viable treatment option for patients with a cleft associated with severe maxillary retrusion. A rigid external distraction device and a hybrid internal maxillary distractor have been used to advance the maxilla allowing for predictable and stable results. These techniques can be applied by itself or as an adjunct to traditional orthognathic procedures. The technical aspects are presented. These procedures tend to be simpler and demonstrate great stability compared to traditional surgical methods. The reasons for stability are discussed.
Journal of Craniofacial Surgery, Nov 9, 2021
ABSTRACT A 32-year-old female with a repaired right unilateral cleft lip and palate underwent sev... more ABSTRACT A 32-year-old female with a repaired right unilateral cleft lip and palate underwent several surgical and orthodontic procedures during the rehabilitation process of her condition. Nine years after this extensive treatment she underwent transverse relapse of her maxilla and requested a consultation for its correction as she felt her speech and chewing were negatively affected. She presented with a transverse maxillary arch collapse on the cleft side with significant palatal scarring secondary to multiple palate procedures. A course of maxillary expansion and dental alignment with fixed orthodontic appliances was carried out. In addition, she had 2 triamcinolone injections 7 months apart while undergoing orthodontic treatment and one 10 months after completion to soften the scarred palatal tissues. The maxillary arch was successfully expanded and aligned. She was retained with a removable chrome cobalt palatal frame to be used full-time and assure stability of the correction. She has been followed for 4 years with no clinical evidence of relapse. Triamcinolone injection into significant palatal scarring in cleft palate patients with a decreased transverse maxillary dimension can be considered an adjunct procedure in conjunction with orthodontic treatment.
Journal of Craniofacial Surgery, Nov 1, 2004
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Papers by Alvaro Figueroa