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A New Classification Based On The Kaban's Modification For Surgical Management of Craniofacial Microsomia
A New Classification Based On The Kaban's Modification For Surgical Management of Craniofacial Microsomia
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A New Classification Based on the Kabans
Modification for Surgical Management
of Craniofacial Microsomia
Jose Rolando Prada Madrid, M.D.,1 Giovanni Montealegre, M.D.,1
and Viviana Gomez, M.D.1
ABSTRACT
In 1963, Longacre et al 1
proposed a descriptive Edgerton and Marsh4 described four clinical
classification based on the unilateral or bilateral involve- groups based on the dominant pattern of dysplasia: I,
ment of the external ear alteration and the presence or mandibular; II: craniofacial soft tissue; III, auricular; and
absence of facial deformity. Two years later, Grabb2 IV, composite deformity.
proposed an anatomic classification in which he estab- The first phenotypic classification, described by
lished six groups based on the combination of external Tanconi and Hall,5 introduced and incorporated ocular
ear, middle ear, mandible, maxilla, zygoma, temporal and extracranial findings such as ocular dermoides,
bone, and oral involvement. Converse3 recognized a microphthalmos, limb deficiencies, and vertebral, heart,
wide spectrum of anatomic alterations that he catego- or renal abnormalities.
rized into four groups. The first three groups were based The most recent descriptive classification was
on ear and mandible findings, whereas the fourth in- devised by Vento et al6 in 1991, using an alphanumeric
cluded facial soft tissue and bone involvement. coding system to classify the patients based on the
1
Department of Plastic and Reconstructive Surgery, Hospital Infantil Craniomaxillofac Trauma Reconstruction 2010;3:17. Copyright #
Universitario San Jose, Bogota, Colombia. 2010 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New
Address for correspondence and reprint requests: Jose Rolando York, NY 10001, USA. Tel: +1(212) 584-4662.
Prada Madrid, M.D., Department of Plastic and Reconstructive Received: May 10, 2009. Accepted: September 28, 2009. Published
Surgery, Hospital Infantil Universitario San Jose, Asociacion Medica online: March 11, 2010.
de los Andes, Av. 9 # 116 - 20 of. 715, Bogota, Colombia (e-mail: DOI: http://dx.doi.org/10.1055/s-0030-1249368.
rpradam@gmail.com). ISSN 1943-3875.
1
2 CRANIOMAXILLOFACIAL TRAUMA & RECONSTRUCTION/VOLUME 3, NUMBER 1 2010
Figure 1 Preoperative pictures of the patient: (A) anterior view; (B) and (C) lateral view. Late postoperative pictures of the
patient; (D) anterior view; (E) and (F) lateral view.
of type IV, according to our classification, who was mandible were missing, and there was no functional
managed with fibular free flap. temporomandibular joint but the mandibular body did
not show hypoplasia. Therefore, mandibular defect on
that side was classified as type III according to our
Case No. 1 classification, and reconstruction was planned to replace
An infant patient with craniofacial microsomia Golden- the missing bony segment of mandible (Fig. 1). A
har type, presented with left microtia, left mandibular panoramic was obtained before the surgical treatment
hypoplasia, deviation of mandible and mandibular in- as baseline and after the surgical treatment to compare
cisive teeth to the left, and restricted mouth opening. postoperative results (Fig. 2). Iliac bone graft was chosen
The left condilar head and ascending ramus of the as the method of reconstruction (Fig. 3).
Figure 2 Panoramic view of the patient: (A) preoperative view and (B) postoperative view.
4 CRANIOMAXILLOFACIAL TRAUMA & RECONSTRUCTION/VOLUME 3, NUMBER 1 2010
RESULTS
Plain radiographic evaluation with panoramic and 3-D
CT showed that mandibular symmetry increased, and
normooclusive closure of incisive teeth was achieved
after surgery and retained in the postoperative period
with both surgical techniques (Figs. 1 and 4). Our
classification guided us in the management of both
patients in obtaining adequate functional results.
Figure 3 Intraoperative picture of the patient: rigid fixation
of bone graft with hypoplastic mandible.
DISCUSSION
Case No. 2 The modification made by Kaban added a subdivision
Another infant patient with craniofacial microsomia, based on whether the temporomandibular joint is func-
presented with right microtia, right mandibular hypo- tional (type IIa) or dysfunctional (type IIb). Although an
plasia, and deviation of mandible and mandibular in- important finding from a descriptive point of view, there
cisive teeth to the right. The right condilar head and is no difference in management between the groups. Our
ascending ramus of the mandible were missing, and proposal differentiates the two groups based on an
there was no functional temporomandibular joint important anatomic finding that gives rise to different
and the mandibular body was hypoplastic. Therefore, surgical management.
mandibular defect on that side was classified as type IV The importance of establishing this new classi-
according to our classification, and reconstruction was fication with differentiation between the patients with
Figure 4 Preoperative pictures of the patient: (A) anterior view; (B) and (C) lateral view. Late postoperative pictures of the
patient; (D) anterior view; (E) and (F) lateral view.
KABANS MODIFICATION FOR SURGICAL MANAGEMENT OF CRANIOFACIAL MICROSOMIA/MADRID ET AL 5
Figure 5 Three-dimensional computed tomographic views of the patient. Preoperative view: (A) anterior view and (B) lateral
view. Postoperative view: (C) anterior view and (D) lateral view.
and without mandibular body hypoplasia is that the later if needed distraction osteogenesis, without the
osseous requirements are not the same. A patient with further morbidity of a free flap. On the other hand, a
mandibular body hypoplasia can achieve excellent func- patient with mandibular body hypoplasia has a larger
tional results with iliac or costochondral bone grafts and osseous deficiency that has to be managed with refined
Figure 6 Intraoperative pictures of the patient: (A) dissection of the vascularized free fibular flap; (B) elevated free fibular flap;
and (C) rigid fixation of free fibular flap with hypoplastic mandible.
6 CRANIOMAXILLOFACIAL TRAUMA & RECONSTRUCTION/VOLUME 3, NUMBER 1 2010
microvascular techniques. If a persisting structural deficit advantage of using the free flap is the reliability of
is observed after this treatment, distraction osteogenesis distraction osteogenesis thereafter, with its associated
is a secure and safe option. benefits.
In patients classified in group IV, the results of Some might argue that the epiphyseal portion of
using nonvascularized bone grafts have been disappoint- the fibula can be included18 to form a neotemporoman-
ing because of variable resorption rates ranging from 30 dibular joint because it contains a cartilaginous growth
to 80%13 and unpredictable growth rates. Graft failure center. Because there is no glenoid fossa, the addition of
has been attributed to poor vascularity of the recipient a cartilaginous fibular head would still fall short of
bed. Those grafts that survive have been poor candidates creating a neotemporomandibular joint. Furthermore,
for distraction osteogenesis, with complication rates far including the proximal epiphysis would compromise
higher than those in patients who were not grafted. knee stability and alteration of growth in a pediatric
According to Stelnicki et al,14 distraction of patient, a risk we are not willing to take.
costochondral grafts is prone to fail when the distraction
advancement to bone width ratio is more than 1.5:1, as it
is in patients classified in group IV. According to Li et REFERENCES
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