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A to Z Orthodontics. Volume 19: Craniofacial deformity

Chapter · January 2011

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A to Z
ORTHODONTICS
Volume: 19

CRANIOFACIAL
DEFORMITY
Dr. Mohammad Khursheed Alam
BDS, PGT, PhD (Japan)
 First Published August 2012

© Dr. Mohammad Khursheed Alam

© All rights reserved. No part of this publication may be reproduced stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without prior permission of author/s or publisher.

ISBN: 978-967-0486-08-6
Correspondance:

Dr. Mohammad Khursheed Alam

Senior Lecturer

Orthodontic Unit

School of Dental Science

Health Campus, Universiti Sains Malaysia.

Email:

dralam@gmail.com

dralam@kk.usm.my

Published by:
PPSP Publication
Jabatan Pendidikan Perubatan, Pusat Pengajian Sains Perubatan,

Universiti Sains Malaysia.

Kubang Kerian, 16150. Kota Bharu, Kelatan.

Published in Malaysia

1
 Contents

1. 5 principal stages in cranio-facial development.........3

2. Classification of CFD….………................................3-5

3. CFD in details……………………..…………………..6-12

2
There are 5 principal stages in cranio-facial development:

1. Germ layer formation & initial organization of CF structure.

2. Neural tube formation.

3. Origins, migration & interaction of self population.

4. Formation of organ system.

A. Pharyngeal arches,

B. Primary & secondary palate.

5. Final differentiation of tissues (Skeletal, muscular & nervous)

Most of the anomalies arise in the 3rd stage of development.

Facial deformities can be classified as:

1. Congenital- a. First arch syndromes, i.e. Treacher-colllins syndrome,

b. Cleft-lip and palate, auriculo-facial deformity etc.

2. Developmental – a. Deformities due to hormonal imbalance, early

trauma [TMJ],

b. contracture of early burn scar etc.

3. Acquired – Loss of osseous soft tissue due to traumatic injury, mal-

united fractures, infection, tumors etc.

3
According to site

A.Variations in facial width [FACIAL ASYMMETRY]

1. Hemifacial hyperplasia or hypoplasia

2. Hemifacial atrophy

3. Unilateral facial nerve paralysis

4. Unilateral trauma or infection.

5. First arch trauma or infection.

a. Unilateral cleft-lip and palate,

b. Unilateral auriculo-facial Hypoplasia

c. Failure of other facial components such as fronto-nasal and

lateral-nasal process.

6. Vascular tumors:

a. Haemangioma

b. Lymphangioma

7. Wryneck or torticollis-postural, structural and muscular.

8. Neurofibromatosis.

4
B. Variations in facial depth [Anterior- posterior aspect];

1. Mandibular prognathism

2. Macrogenia - over development of chin.

3. Microgenia - lack of prominence of chin.

4. Micrognethia - short mandible

C. Variations in facial height; e.g.mandibular prognathism with open bite.

Rotary displacement in which the maxilla and mandible is bodily displaced

in vertical planes, affect the face height unilaterally.

CRANIO-FACIAL DEFORMITY IN ANT POST PLANE

Variation in facial depth

1. Mandibular prognathism.

2. Macrogenia: over development of chin.

3. Microgenia: lock of prominence of chin.

4. Micrognethia : Short mandible

5
Mandibular prognathism

This is usually accompanied by a ‘true’ class III MO. Class III MO and mn

prognathism are terms often used inter changeably, but class II MO refers

to dento alveolar relationship, while mandibular prognathism describes a

particular type of facial dysharmony. It is possible to have a prognathic

appearance in the absence of class II. Consversely, not every pt who has a

class III MA develop mandibular prognathism.

Sever morphological combination have been described:

A) Maxillary dento-alveolar area relatively underdeveloped with an

adequately developed mandible.

B) Prognathic mandible with underdeveloped maxilla.

C) Mandibular dento-alveolar process prognathic with an ad3quately

developed maxilla.

D) Both maxilla and mandible i in normal range.

Macrogenia – Chin process is overdeveloped.

Microgenia: May be

i) Of structural origin, the mental process being underdeveloped or.

6
ii) May accompany certain types of dental MO that tend to impart a

microgenic appearence because of the excessive prominence of the

maxillary dento-alveolar structure.

Micrognathia

Characterised by shortness of the body of the mandible and extreme

antigonial notching and dentition is almost always class II, with flared and

protrusive upper anterior teeth, extremely procumbent lower incisors and

frequently ant open bite.

Caused by

a) Conditions that interfere mandibular growth [e.g. trauma, disease]

b) Bone standing T.M.J. ankylosis.

c) Pierre Robin syndrome, due to intra-uterine compression.

Hemifacial hyperplasia and hypoplasia: [usually congenital];

In hemifacial hyperplasia there is enlargement of one half of the face,

the maxilla, the mandible, zygomatic arch, tongue and the teeth may be

enlarged. Teeth may erupt prematurely on that site.

7
In hemifacial hypoplasia there is diminution of all tissues on one side

of the face, the teeth. localized hypoplasia of the mandible due to

infection or trauma to growing condyler head. It is also characterized by

lack of tissues on the affected side. The external ear is deformed, the

ramus of the mandible and the affected site are deficient or missing.

Hemifacial hypoplasia must not be confused with the hemifacial

atrophy in which there is not just wasting and just reduction of sizes.

Diagnostic features of mandibular hypoplasia

1. Lack of height of the vertical ramus.

2. Progonial notch of lower border of the mandible.

3. Ankylosis or limitation of movement.

4. Elevation of occlusal plane with deviation of the chin of the

Hemifacial atrophy (Romberg’s disease):

It is an acquired condition. It is characterized by

8
 1. Wasting of one half of the face involving the orbit, zygomatic arch,

maxilla & mandible.

2. Ramus and body is shortened on the affected side with displacement

of chin on the affected side.

3. Both osseous and soft tissue involve in this syndrome.

4. There is pigmentation and twisting of the face on the affected site.

5. Occlusal plane is elevated.

6. There may be reduction of tongue size and tooth roots.

Neurofibromatosis

The condition is associated with areas of pigmentation of skin known as

‘Catelulait’. Areas with sessile nodular tumors are tumors of the nerve in

that area. The cranial nerves, tongue, soft tissues of the cheek may be

affected with enlarged mandible and facial asymmetry.

Vascular tumor

1. Capillary hemangioma

2. Cavernous hemangioma

9
Capillary hemangioma is slightly elevated and port wined stain color which

do not cause any deformity. But Capillary hemangioma may cause

deformity depending on the size, position etc. Capillary hemangioma do

not shows spontaneous resolution but cavernous hemangioma shows

spontaneous resolution before the age of 6 year so it effect deciduous

dentition & will be self correcting.

 Lymphangioma

Less common then cavernous hemangioma but it is more marked and do

not show spontaneous resolution.

Wry neck or Torticollis

It is a common deformity of the neck.

1. Postural torticollis: due to postural habit

2. Structural torticollis: due to structural defect of cervical vertebra and

surrounding bone.

3. Muscular torticollis: It is the commonest type; this is due to muscular

defect. Exm: short sternocleido mastoid muscle.

10
Mandibular prognathism

This is usually accompanied by a ‘true’ class III MO. Class III MO and Mn

prognathism are terms often used inter changeably, but class II MO refers

to dento-alveolar relationship, while mandibular prognathism describes a

particular type of facial dysharmony. It is possible to have a prognathic

appearance in the absence of class II. Conversely, not every patient that

has a class III MA develops mandibular prognathism.

Sever morphological combination have been described:

A) Maxillary dento-alveolar area relatively underdeveloped with an

adequately developed mandible.

B) Prognathic mandible with underdeveloped maxilla.

C) Mandibular dento-alveolar process prognathic with an ad3quately

developed maxilla.

D) Both maxilla and mandible i in normal range.

Macrogenia – Chin process is overdeveloped.

11
Microgenia: May be

i) Of structural origin, the mental process being underdeveloped or.

ii) May accompany certain types of dental MO that tend to impart a

microgenic appearance because of the excessive prominence of the

maxillary dento-alveolar structure.

Micrognathia

Characterized by shortness of the body of the mandible and extreme

antigonial notching and dentition is almost always class II, with flared and

protrusive upper anterior teeth, extremely procumbent lower incisors and

frequently ant open bite.

Caused by:

a) Conditions that interfere mandibular growth [e.g. trauma, disease]

b) Bone standing T.M.J. ankylosis.

c) Pierre Robin syndrome, due to intra-uterine compression.

12
Bibilography:
1. Bhalajhi SI. Orthodontics – The art and science. 4th edition. 2009

2. Gurkeerat Singh. Textbook of orthodontics. 2nd edition. Jaypee, 2007

3. Houston S and Tulley, Textbook of Orthodontics. 2nd Edition. Wright, 1992.

4. Iida J. Lecture/class notes. Professor and chairman, Dept. of Orthodontics, School of dental
science, Hokkaido University, Japan.

5. Lamiya C. Lecture/class notes. Ex Associate Professor and chairman, Dept. of Orthodontics,

Sapporo Dental College.

6. Laura M. An introduction to Orthodontics. 2nd edition. Oxford University Press, 2001

7. McNamara JA, Brudon, WI. Orthodontics and Dentofacial Orthopedics. 1st edition, Needham
Press, Ann Arbor, MI, USA, 2001

8. Mitchel. L. An Introduction to Orthodontics. 3 editions. Oxford University Press. 2007

9. Mohammad EH. Essentials of Orthodontics for dental students. 3rd edition, 2002

10. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 4th edition, Mosby Inc., St.Louis,
MO, USA, 2007

11. Sarver DM, Proffit WR. In TM Graber et al., eds., Orthodontics: Current Principles and
Techniques, 4th ed., St. Louis: Elsevier Mosby, 2005

12. Samir E. Bishara. Textbook of Orthodontics. Saunders 978-0721682891, 2002

13. T. M. Graber, R.L. Vanarsdall, Orthodontics, Current Principles and Techniques, "Diagnosis and
Treatment Planning in Orthodontics", D. M. Sarver, W.R. Proffit, J. L. Ackerman, Mosby, 2000

14. Thomas M. Graber, Katherine W. L. Vig, Robert L. Vanarsdall Jr. Orthodontics: Current Principles
and Techniques. Mosby 9780323026215, 2005

15. William R. Proffit, Raymond P. White, David M. Sarver. Contemporary treatment of dentofacial
deformity. Mosby 978-0323016971, 2002

16. William R. Proffit, Henry W. Fields, and David M. Sarver. Contemporary Orthodontics. Mosby
978-0323040464, 2006

17. Yoshiaki S. Lecture/class notes. Associate Professor and chairman, Dept. of Orthodontics, School
of dental science, Hokkaido University, Japan.

18. Zakir H. Lecture/class notes. Professor and chairman, Dept. of Orthodontics, Dhaka Dental
College and hospital.

13
 Dedicated To

My Mom, Zubaida Shaheen

My Dad, Md. Islam
&
My Only Son
Mohammad Sharjil

14
 Acknowledgments
I wish to acknowledge the expertise and efforts of the various
teachers for their help and inspiration:

1. Prof. Iida Junichiro – Chairman, Dept. of Orthodontics,

Hokkaido University, Japan.
2. Asso. Prof. Sato yoshiaki –Dept. of Orthodontics, Hokkaido
University, Japan.
3. Asst. Prof. Kajii Takashi – Dept. of Orthodontics, Hokkaido
University, Japan.
4. Asst. Prof. Yamamoto – Dept. of Orthodontics, Hokkaido
University, Japan.
5. Asst. Prof. Kaneko – Dept. of Orthodontics, Hokkaido
University, Japan.
6. Asst. Prof. Kusakabe– Dept. of Orthodontics, Hokkaido
University, Japan.
7. Asst. Prof. Yamagata– Dept. of Orthodontics, Hokkaido
University, Japan.
8. Prof. Amirul Islam – Principal, Bangladesh Dental college
9. Prof. Emadul Haq – Principal City Dental college
10. Prof. Zakir Hossain – Chairman, Dept. of Orthodontics,
Dhaka Dental College.
11. Asso. Prof. Lamiya Chowdhury – Chairman, Dept. of
Orthodontics, Sapporo Dental College, Dhaka.
12. Late. Asso. Prof. Begum Rokeya – Dhaka Dental College.
13. Asso. Prof. MA Sikder– Chairman, Dept. of Orthodontics,
University Dental College, Dhaka.
14. Asso. Prof. Md. Saifuddin Chinu – Chairman, Dept. of
Orthodontics, Pioneer Dental College, Dhaka.

15
 Dr. Mohammad Khursheed Alam
has obtained his PhD degree in Orthodontics from Japan in 2008.
He worked as Asst. Professor and Head, Orthodontics
department, Bangladesh Dental College for 3 years. At the same
time he worked as consultant Orthodontist in the Dental office
named ‘‘Sapporo Dental square’’. Since then he has worked in
several international projects in the field of Orthodontics. He is
the author of more than 50 articles published in reputed journals.
He is now working as Senior lecturer in Orthodontic unit, School
of Dental Science, Universiti Sains Malaysia.

Volume of this Book has been reviewed by:

Dr. Kathiravan Purmal
BDS (Malaya), DGDP (UK), MFDSRCS (London), MOrth
(Malaya), MOrth RCS( Edin), FRACPS.
School of Dental Science, Universiti Sains Malaysia.

Dr Kathiravan Purmal graduated from University Malaya 1993.

He has been in private practice for almost 20 years.
He is the first locally trained orthodontist in Malaysia with
international qualification. He has undergone extensive
training in the field of oral and maxillofacial surgery and
general dentistry.

16

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