# Imaging for Facial Deformity Dr Dayea Oh Oral and Maxillofacial Radiologist Dr Dayea Oh Oral and Maxillofacial Radiologist # Objectives * Understand types of facial deformity * Compare imaging modalities * Recognise key radiographic features relevant to treatment planning * Understand functional and surgical implications - Understand types of facial deformity - Compare imaging modalities - Recognise key radiographic features relevant to treatment planning - Understand functional and surgical implications - ==Facial deformities can affect both function and aesthetics.== - ==Assessment and treatment often require a multidisciplinary approach involving orthodontists, maxillofacial surgeons, and radiologists.== - ==Imaging supports diagnosis, surgical simulation, and postoperative evaluation in addition to treatment planning.== - ==Precise knowledge of craniofacial skeletal anatomy is essential for identifying deformities, interpreting imaging, and planning surgery.== - ==Modern 3D imaging and digital workflows are contributing to more predictable and personalized outcomes.== > [!note] Lecturer — Anatomy Knowledge > Precise knowledge of craniofacial skeletal anatomy is fundamental to accurate diagnosis, imaging interpretation, and surgical planning. Bones in the Skull • 11 are paired • Parietal • Temporal • Zygomatic • Maxilla • Palatine • Nasal • Lacrimal • Inferior nasal concha • Malleus • Incus • Stapes • 6 are single • Frontal • Occipital • Sphenoid • Ethmoid • Vomer • Mandible Frontal bone Glabella Supraorbital notch (foramen) Orbital surface Nasal bone Lacrimal bone Zygomatic bone Frontal process Orbital surface Temporal process Zygomaticofacial foramen Maxilla Zygomatic process Orbital surface Frontal process Alveolar process Anterior nasal spine Infraorbital foramen Coronal suture Parietal bone Sphenoid bone Lesser wing Greater wing Temporal bone Ethmoid bone Orbital plate Perpendicular plate Middle nasal concha Inferior nasal concha Vomer Mandible Ramus Body Mental foramen Mental tubercle Mental protuberance  #### Bones in the Skull **Paired bones (11):** - Parietal - Temporal - Zygomatic - Maxilla - Palatine - Nasal - Lacrimal - Inferior nasal concha - Malleus - Incus - Stapes **Single bones (6):** - Frontal - Occipital - Sphenoid - Ethmoid - Vomer - Mandible #### Anterior View — Labeled Structures - Frontal bone - Glabella - Supraorbital notch (foramen) - Orbital surface - Nasal bone - Lacrimal bone - Zygomatic bone - Frontal process - Orbital surface - Temporal process - Zygomaticofacial foramen - Maxilla - Zygomatic process - Orbital surface - Frontal process - Alveolar process - Anterior nasal spine - Infraorbital foramen - Coronal suture - Parietal bone - Sphenoid bone - Lesser wing - Greater wing - Temporal bone - Ethmoid bone - Orbital plate - Perpendicular plate - Middle nasal concha - Inferior nasal concha - Vomer - Mandible - Ramus - Body - Mental foramen - Mental tubercle - Mental protuberance A labelled anatomical illustration showing an anterior view of the human skull with individual bones color-coded to distinguish them. The figure identifies various cranial and facial bones, such as the frontal, parietal, nasal, maxilla, and mandible, along with specific surface features like the glabella, coronal suture, and mental protuberance. Sphenofrontal suture **Sphenoid bone** Greater wing **Frontal bone** Frontozygomatic suture Lacrimal bone Nasal bone Maxilla Zygomatic bone Temporozygomatic suture Coronal suture Parietal bone Squamosal suture Temporal bone Squamous part Zygomatic process Articular tubercle Groove for posterior deep temporal artery External acoustic meatus Mastoid process Lambdoid suture Occipital bone Occipitomastoid suture Mandible Sphenoparietal suture Intermaxillary suture Maxilla Palatine process Transverse palatine suture Palatine bone Horizontal plate Vomer Foramen lacerum Occipital bone Sphenoid bone **Maxilla** Palatine process **Palatine bone** Horizontal plate **Temporal bone** **Vomer** **Occipital bone** Sphenoid bone Intermaxillary suture Transverse palatine suture Sphenoid bone   #### Lateral View — Labeled Structures - Sphenofrontal suture - Sphenoid bone - Greater wing - Frontal bone - Frontozygomatic suture - Lacrimal bone - Nasal bone - Maxilla - Zygomatic bone - Temporozygomatic suture - Coronal suture - Parietal bone - Squamosal suture - Temporal bone - Squamous part - Zygomatic process - Articular tubercle - Groove for posterior deep temporal artery - External acoustic meatus - Mastoid process - Lambdoid suture - Occipital bone - Occipitomastoid suture - Mandible - Sphenoparietal suture #### Inferior View — Labeled Structures - Intermaxillary suture - Maxilla - Palatine process - Transverse palatine suture - Palatine bone - Horizontal plate - Vomer - Foramen lacerum - Occipital bone - Sphenoid bone #### Basal Structures — Labeled - Maxilla - Palatine process - Palatine bone - Horizontal plate - Temporal bone - Vomer - Occipital bone - Sphenoid bone - Intermaxillary suture - Transverse palatine suture This is a labelled anatomical diagram showing the lateral view of the human skull, with bones color-coded (e.g., frontal bone in blue, parietal in green, temporal in pink) and various sutures identified. Visible labels include Sphenofrontal suture, Greater wing, Frontal bone, Frontozygomatic suture, Lacrimal bone, Nasal bone, Maxilla, Zygomatic bone, Temporozygomatic suture, Coronal suture, Parietal bone, Squamosal suture, Temporal bone, Squamous part, Zygomatic process, Articular tubercle, Groove for posterior deep temporal artery, External acoustic meatus, Mastoid process, Lambdoid suture, Occipital bone, Occipitomastoid suture, Mandible, and Sphenoparietal suture. Anatomical illustration showing an inferior view of the skull base and hard palate, with color-coded bones. Visible labels identify the Maxilla (Palatine process), Sphenoid bone, Temporal bone, Occipital bone, Palatine bone (Horizontal plate), Vomer, Intermaxillary suture, Transverse palatine suture, and Foramen lacerum. Craniofacial Development * Migratory cranial neural crest cells * Abnormal quantity or migration of NCC cells can result in craniofacial syndromes * External facial structures develop between 4^th and 6^th week * Palate develops between 6^th and 8^th week, and completes at the 12^th week - Migratory cranial neural crest cells - Abnormal quantity or migration of NCC cells can result in craniofacial syndromes - External facial structures develop between 4th and 6th week - Palate develops between 6th and 8th week, and completes at the 12th week > [!note] Lecturer — Developmental Disruption > Craniofacial development is tightly regulated, begins early in embryogenesis, and continues throughout adolescence. > > - Neural crest cells migrate into the developing branchial or pharyngeal arches and contribute to the bones, cartilage, and connective tissues of the face and neck. > - Developmental disruption may result from genetic mutations, environmental factors, or vascular disturbances. > - Potential features include facial asymmetry, hypoplasia of facial structures, ear abnormalities, and mandibular abnormalities. > - These disturbances can produce asymmetry, skeletal discrepancies, and syndromic conditions. # Facial Deformity * *Hard tissue only, Soft tissue only or BOTH* * **Congenital** * Birth defects eg. cleft palate & various craniofacial syndromes * **Developmental** * Growth-related eg. bilateral or unilateral hypoplasia & hyperplasia (of the jaws) * **Acquired** * Trauma, cysts, tumours, bone dysplasias, post-surgery etc. *Hard tissue only, Soft tissue only or BOTH* - **Congenital** - Birth defects eg. cleft palate & various craniofacial syndromes - **Developmental** - Growth-related eg. bilateral or unilateral hypoplasia & hyperplasia (of the jaws) - **Acquired** - Trauma, cysts, tumours, bone dysplasias, post-surgery etc. Nasal chamber 7 weeks Eye Primary palate Nasal septum Oral cavity Palatine shelf Tongue Nasal septum Nasal chamber 8 weeks Primary palate Nasal septum Tongue Palatine shelf Nasal chamber 10 weeks Incisive foramen Nasal conchae Nasal septum Fused palatal shelves Tongue Oral cavity Uvula Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins failure of the medial and lateral nasal processes to fuse with the maxillary process   *Palatal development — labelled figure views:* - **7 weeks:** Nasal chamber, Eye, Primary palate, Nasal septum, Oral cavity, Palatine shelf, Tongue - **8 weeks:** Nasal septum, Nasal chamber, Primary palate, Tongue, Palatine shelf - **10 weeks:** Nasal chamber, Incisive foramen, Nasal conchae, Nasal septum, Fused palatal shelves, Tongue, Oral cavity, Uvula *Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins* Failure of the medial and lateral nasal processes to fuse with the maxillary process The image displays two anatomical illustrations of an infant's face, specifically focusing on the mouth and nose. The top illustration depicts a cleft lip, showing a separation in the upper lip structure. The bottom illustration shows a more extensive cleft involving both the lip and the nostril base. This labelled diagram illustrates the embryological development of the palate across three stages: 7, 8, and 10 weeks. It depicts the progression from separate palatine shelves to fused palatal shelves using both coronal cross-sections and inferior views, with specific anatomical structures identified including the nasal chamber, nasal septum, primary palate, tongue, incisive foramen, nasal conchae, and uvula. Craniofacial Syndromes • Many are branchial arch syndromes related to **first and second** branchial/ pharyngeal arches $\rightarrow$ • Hemifacial Microsomia (Goldenhar) • Treacher Collins • Manifest a spectrum of hypoplasia and aplasia of the structures composing the facial bones and ear • Severity depends on the alteration of gene-expression profiles | Origins | Adult Structure(s) | | :--- | :--- | | 1st pharyngeal arch<br>*Maxillary process* | Maxilla | | | Temporal bone | | | Zygoma | | | Palatine | | | Lacrimal | | | Vomer | | | Nasal | | | Inferior nasal concha | | 1st pharyngeal arch<br>*Mandibular process* | Mandible | | | Malleus | | | Incus | | 2nd pharyngeal arch | Styloid process | | | Stapes | | | Hyoid |   - Many are branchial arch syndromes related to **first and second** branchial/pharyngeal arches → - Hemifacial Microsomia (Goldenhar) - Treacher Collins - Manifest a spectrum of hypoplasia and aplasia of the structures composing the facial bones and ear - Severity depends on the alteration of gene-expression profiles #### Pharyngeal Arch Origins of Adult Structures | Origins | Adult Structure(s) | | :--- | :--- | | 1st pharyngeal arch — *Maxillary process* | Maxilla, Temporal bone, Zygoma, Palatine, Lacrimal, Vomer, Nasal, Inferior nasal concha | | 1st pharyngeal arch — *Mandibular process* | Mandible, Malleus, Incus | | 2nd pharyngeal arch | Styloid process, Stapes, Hyoid | > [!note] Lecturer — Syndrome Involvement > Craniofacial syndromes may involve multiple hard- and soft-tissue structures, and their severity and symptoms vary between conditions. > > - The spectrum of hypoplasia and aplasia may involve the facial bones, jaws, ears, zygomatic bones, and lateral orbital regions. A two-column table listing the embryological origins of craniofacial structures and their corresponding adult derivatives. The left column categorizes origins by pharyngeal arch (1st Maxillary process, 1st Mandibular process, and 2nd pharyngeal arch), while the right column lists specific bones and tissues such as the maxilla, mandible, malleus, incus, stapes, and hyoid. An anatomical illustration in profile view depicting a patient with craniofacial abnormalities, specifically showing hypoplasia of the zygomatic bone (cheekbone) and mandible (lower jaw), along with malformed external ear structures.       A black-and-white portrait photograph of a man with a beard, wearing a suit and tie. A black-and-white close-up photograph showing the upper face of a man, focusing on his deep-set eyes and prominent eyebrows. The image is cropped tightly to reveal only the forehead, brow ridge, and eyes. Radiograph: A lateral cephalometric radiograph of a human skull, showing the cranial bones, cervical vertebrae, and dentition in profile. The image includes visible soft tissue outlines of the face and neck, as well as positioning hardware near the ear and forehead. A composite image of three dental and craniofacial radiographs: (a) a lateral cephalometric radiograph showing the skull in profile, (b) a frontal cephalometric radiograph (PA view) showing the skull from the front, and (c) a panoramic radiograph displaying the full dentition and jaws. Radiograph: A frontal (PA) skull X-ray showing the cranium, orbits, nasal cavity, maxilla, mandible, and dentition. The image reveals asymmetry in the midface and jaw region. A panoramic dental radiograph (orthopantomogram) displaying the complete maxillary and mandibular arches, including erupted teeth and developing tooth buds. A B C D Continued    A B C D *Continued* "No discernible content is present." Radiograph: A panoramic dental X-ray showing the maxilla and mandible with multiple teeth, including several unerupted or supernumerary teeth visible within the jawbones. The image illustrates the complex dentition often associated with the condition described in the slide text. A composite medical figure consisting of four panels illustrating the clinical and radiographic features of cleidocranial dysplasia. Panel A is a chest radiograph showing the absence of clavicles; Panel B is a clinical photograph demonstrating excessive shoulder mobility with arms drawn anteriorly to meet at the midline; Panels C and D are lateral skull radiographs highlighting wormian bones in the occipital region (arrows) and an open fontanel. A B C D E a b c d   A B C D E a b c d Clinical photo: A frontal and lateral view of an infant's face, demonstrating characteristic features such as midface hypoplasia and proptosis. Radiograph: C-E show three views (AP, PA, and lateral) of the skull, illustrating craniosynostosis with a visible vertical metallic strip in image C. A composite clinical photo panel showing four views of a patient's craniofacial features, labelled a-d. Panel a displays frontal orbital and nasal regions with white vertical arrows pointing to the eyes and a black horizontal arrow indicating the nose; panel b shows a lateral profile view with white arrows highlighting the eye and midface area; panels c and d depict intraoral views, with c showing an occlusal view of the maxillary arch featuring a black arrow pointing to a constriction in the palate, and d showing a frontal view of the dentition held open by yellow retractors. A B C D E F G H I J K L   A B C D E F G H I J K L Clinical photograph showing the dorsal view of a pair of hands with syndactyly (webbing/fusion) between the index and middle fingers. The digits appear fused by soft tissue, creating a characteristic "mitten" appearance often associated with Apert syndrome. A composite figure containing clinical photographs of children (frontal and profile views), anatomical line drawings of the skull, and axial CT scans. The images are arranged in a grid with letter labels A through L corresponding to specific panels. B Pfieffer  B Pfieffer Clinical photo showing the facial features of an infant with a prominent forehead, wide-set eyes (hypertelorism), and midface hypoplasia. The image also includes close-up photographs of hands and feet demonstrating broad thumbs and big toes.    Radiograph: A lateral X-ray view of the cervical spine and upper thoracic region, showing the vertebral bodies and alignment. The image illustrates skeletal abnormalities consistent with the context of Proteus syndrome. Radiograph: A lateral X-ray view of the cervical spine and skull base. The image displays the vertebral column, cranial bones, and soft tissue structures of the neck. Radiograph: A lateral X-ray of the head and neck region showing the skull, cervical spine, and facial bones in profile. The image reveals the alignment of the vertebrae and the structure of the jaw and teeth.    Axial MRI scan of the head at the level of the orbits and posterior fossa. The image displays bilateral globes, ethmoid sinuses, and the cerebellum with visible folia. Axial T2-weighted MRI scan of the brain showing a hyperintense lesion in the right frontal lobe with surrounding edema and mass effect. Coronal MRI scan of the head showing a cross-section of the brain, skull, and upper neck structures. Imaging for Congenital Facial Deformity • Craniofacial syndromes involve multiple structures with varying degrees of severity and symptoms • **CT +/- MRI** are the imaging modality of choice • Detailed assessment of hard & soft tissues in 3D, especially pre-surgery • Assess for any intracranial abnormalities • OPG may be useful for overview of dental complications - Craniofacial syndromes involve multiple structures with varying degrees of severity and symptoms - **CT +/- MRI** are the imaging modality of choice - Detailed assessment of hard & soft tissues in 3D, especially pre-surgery - Assess for any intracranial abnormalities - OPG may be useful for overview of dental complications > [!note] Lecturer — Imaging Limitations > CT was described as the gold standard for imaging congenital facial deformities. > > - Traditional skull views have limitations when demonstrating complex facial deformities. > - Conventional skull views may nevertheless remain useful for initial assessment because they are quick, cost-effective, and associated with low radiation exposure. <table> <tr> <th>Resultant image</th> <th>Skull view</th> <th>Illustration of patient placement</th> <th>Diagram of patient placement</th> <th>Central beam</th> <th>Patient placement</th> <th></th> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td>Beam perpendicular to film</td> <td>Film parallel to midsagittal plane</td> <td><b>Lateral Ceph</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td>Beam perpendicular to film</td> <td>Canthomeatal line parallel to film</td> <td><b>SMV</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td>Beam perpendicular to film</td> <td>Canthomeatal line at 37° with film</td> <td><b>Waters</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td>Beam perpendicular to film</td> <td>Canthomeatal line at 10° with film</td> <td><b>PA Ceph</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td>Beam perpendicular to film</td> <td>Canthomeatal line at –30° with film</td> <td><b>Reverse Towne</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td>Beam aims at the molar- perimolar area</td> <td>Film in contact with cheek at molar area</td> <td><b>Oblique Lateral Body</b></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> <td>Beam aims at the ramus area</td> <td>Film in contact with cheek at ramus area</td> <td><b>Ramus</b></td> </tr> </table>                              | Skull view | Central beam | Patient placement | | --- | --- | --- | | **Lateral Ceph** | Beam perpendicular to film | Film parallel to midsagittal plane | | **SMV** | Beam perpendicular to film | Canthomeatal line parallel to film | | **Waters** | Beam perpendicular to film | Canthomeatal line at 37° with film | | **PA Ceph** | Beam perpendicular to film | Canthomeatal line at 10° with film | | **Reverse Towne** | Beam perpendicular to film | Canthomeatal line at –30° with film | | **Oblique Lateral Body** | Beam aims at the molar-perimolar area | Film in contact with cheek at molar area | | **Ramus** | Beam aims at the ramus area | Film in contact with cheek at ramus area | A comprehensive reference table comparing seven different skull radiographic projections (Lateral Ceph, SMV, Waters, PA Ceph, Reverse Towne, Oblique Lateral Body, and Ramus). Each row details the specific projection through columns showing resultant X-ray images, 3D skull views, photographic illustrations of patient positioning, schematic diagrams of beam alignment relative to anatomical planes, and textual descriptions of the central beam and placement. Radiograph: A lateral cephalometric radiograph showing a side profile view of the human skull, cervical spine, and mandible with teeth in occlusion. This figure shows a lateral view of a human skull, displaying the cranium, mandible with teeth, and cervical spine. It serves as an anatomical reference for the 'Skull view' column in the accompanying table. Clinical photo: A patient is positioned with their face resting against a vertical support, likely for a radiographic examination. The head is tilted such that the chin and nose are in contact with the surface. Radiograph: A posteroanterior (PA) cephalometric X-ray of a skull, displaying the frontal view of the cranial bones and dentition. A radiograph of a skull viewed from an oblique angle, showing the cranial bones and teeth. This image illustrates the resultant appearance for the Reverse Towne projection. Schematic top-down diagram of a skull and film holder, illustrating the 'Oblique Lateral Body' projection. A horizontal line indicates the central beam path, while a shaded vertical band across the right side represents the film position in contact with the cheek at the molar area. Radiograph: A skull radiograph showing the cranial vault, facial bones, and dentition. The image displays the maxillary and mandibular teeth in alignment, along with the orbits and nasal cavity structures. A black-and-white clinical photograph showing the side profile of a patient's head positioned against an imaging device. The image illustrates the physical setup for a lateral cephalometric radiograph, with the ear rod inserted into the external auditory meatus and the orbital support resting on the cheekbone. Clinical photo: A lateral view of a patient's head positioned for radiographic imaging, showing the side profile with hair and ear visible against a plain background. A black-and-white photograph shows a lateral view of a person's head positioned for radiographic imaging. The individual is facing left with their forehead and chin resting against a support structure, while a curved plastic device stabilizes the side of the head. This is a radiographic image (specifically an SMV or submentovertex view) of a human skull, showing the base and facial structures. The crop illustrates the anatomical appearance resulting from this projection, where the canthomeatal line is parallel to the film. Radiograph: An axial skull radiograph showing the base of the skull, including symmetrical foramina and the midline structures. A "RIGHT" marker is visible in the upper right corner to indicate orientation. A lateral view of a mannequin head secured in a cephalostat positioning device, illustrating the setup for a Lateral Ceph radiograph. The image shows the patient placement with the film parallel to the midsagittal plane. A radiograph of a skull viewed from the side (lateral projection), showing the profile of the cranium, facial bones, and mandible. The image displays internal structures such as the nasal cavity, maxillary sinuses, and eye sockets against a dark background. A schematic lateral view of a human skull in profile, illustrating the canthomeatal line (a diagonal line drawn from the outer eye corner to the ear canal) positioned parallel to a horizontal film receptor below the head. This setup visualizes the patient placement for a Skull-Mandible View (SMV) radiograph. Radiograph: A lateral cephalometric radiograph showing the profile of a skull. The image displays bony structures including the cervical spine, mandible, and cranial vault, used for analyzing patient placement in this projection. A schematic line drawing illustrating the lateral cephalometric positioning of a skull. The diagram shows a profile view of the cranial bones and teeth, with a vertical black line indicating the central beam's path perpendicular to the film (represented by the horizontal bar at the bottom), and a grey wavy band depicting the X-ray source or collimator. A radiograph showing a lateral projection of the skull, displaying the profile view of the cranial bones and facial structures. Schematic diagram of lateral cephalometric radiograph positioning. Shows skull in profile with central beam perpendicular to film and film parallel to midsagittal plane. A schematic diagram showing a lateral view of a human skull with the central beam (vertical arrow) perpendicular to the film (horizontal bar at top), illustrating patient placement for a Lateral Ceph radiograph. Clinical photograph showing a patient in the lateral position for a skull radiograph, with the head resting on a support surface and a vertical positioning device visible. Radiograph: A lateral skull X-ray showing the profile of a human cranium, including the mandible, maxilla, teeth, and cervical spine. The image demonstrates the anatomical structures visible in this specific projection. A lateral radiograph of a skull showing the profile view of the cranial and facial bones. The image displays the cervical spine, mandible, maxilla, and dentition in a side-on projection. A grayscale 3D reconstruction of a human skull viewed from the side, clearly showing the mandible with teeth and the maxilla. This image serves as a visual reference for the anatomical structures relevant to lateral radiographic positioning. Clinical photo showing a patient lying on an examination table with their head resting against a vertical surface, illustrating the positioning for a lateral skull radiograph. Radiograph: A lateral skull X-ray showing the side profile of the cranium, facial bones, and mandible. The image displays the bony structures in greyscale against a dark background, consistent with a cephalometric view. This is a schematic diagram illustrating patient placement for a lateral cephalometric radiograph. It depicts the side profile of a human skull positioned against a vertical film holder, with an X-ray beam entering from the left to demonstrate the projection geometry. # Cases Imaging of Facial Deformity Imaging of Facial Deformity  An axial computed tomography (CT) scan of the head, displaying a cross-section through the oral cavity and maxillofacial region. The image reveals the bony structures of the upper jaw with teeth, the dark air-filled space of the nasal cavity or oral pharynx, and surrounding soft tissues.    Coronal CT scan of the midface showing the nasal cavity with septum, maxillary sinuses, and upper dentition. Coronal CT scan of the midface and nasal cavity, showing the maxillary sinuses, nasal septum, turbinates, and upper dentition. A coronal computed tomography (CT) scan of the human skull, specifically showing the paranasal sinuses and nasal cavity. The image displays the maxillary sinuses, ethmoid air cells, frontal sinuses, and sphenoid sinus in a bone window setting. CCD CCD   Radiograph: A panoramic dental X-ray (orthopantomogram) showing the complete dentition and maxillofacial structures. The image reveals a mixed dentition stage with developing permanent tooth buds, erupted teeth, and radiopaque restorations on several molars. A lateral cephalometric radiograph showing a profile view of the human skull, cervical spine, and dentition. The image reveals significant skeletal discrepancies, including an open bite malocclusion where the upper and lower teeth do not meet, along with visible restorations on the molars.  Two coronal CT scans of the cervical spine and skull base displayed side-by-side, each marked with the label 'A' in the bottom right corner. The images show bony structures including the vertebrae, mastoid air cells, and occipital bone.   Radiograph: A lateral cephalometric X-ray of a human skull showing the profile view. The image reveals extensive metallic hardware, including a perforated reconstruction plate and screws along the mandible (lower jaw) and multiple smaller plates and screws in the midface region. A composite of two cephalometric radiographs (lateral and frontal views) showing a patient's skull with extensive metallic reconstruction hardware, including plates, screws, and mesh implants in the mandible and maxilla.  A panoramic dental radiograph (OPG) showing the maxilla and mandible with extensive reconstructive hardware. A large, lattice-structured metallic implant replaces the right mandibular ramus and body, secured by screws, while multiple reconstruction plates and fixation screws are visible across the midface and left mandible. Orthodontic brackets and an archwire are present on the lower teeth. Developmental Dentofacial Deformity • Prognathism or retrognathism (A-P) • Transverse jaw discrepancy • Increased or decreased vertical dimension of the jaws → Can affect **quality of life** eg. function (chewing, breathing & swallowing) aesthetics & speech - Prognathism or retrognathism (A-P) - Transverse jaw discrepancy - Increased or decreased vertical dimension of the jaws → Can affect **quality of life**, e.g. function (chewing, breathing & swallowing), aesthetics & speech - ==Developmental deformities occur during growth and are commonly seen in orthodontic and orthognathic patients== - ==Retrognathism may produce a skeletal Class II relationship and is associated with a retrognathic mandible== - ==Skeletal Class III deformity may involve a prognathic mandible or a deficient maxilla== - ==These are among the most common deformities encountered in dental and maxillofacial practice== Imaging for Orthognathic Surgery • OPG, Lat Ceph & PA Ceph • CBCT (orofacial scan) • CT (head)   - OPG, Lat Ceph & PA Ceph - CBCT (orofacial scan) - CT (head) > [!note] Lecturer — Surgical Planning > The imaging protocol is similar to that used for orthodontic treatment planning. > > - Three-dimensional imaging is essential for modern surgical planning. > - Current surgical planning relies on virtual surgical planning. > - Bimaxillary surgery may be selected when treatment must address both jaws to achieve functional improvement and aesthetic balance. > [!note] Lecturer — Acquired Causes > Acquired deformities develop after birth due to external or pathological causes. > - ==Paget’s disease of bone== > - ==Iatrogenic causes, including postsurgical changes== A 3D CT reconstruction of a human skull in lateral view, with the mandible highlighted in blue to distinguish it from the rest of the craniofacial skeleton. A 3D reconstructed lateral view of a human skull, likely generated from CBCT data, showing the craniofacial skeleton with specific segments color-coded in blue, yellow, and green to illustrate surgical planning or anatomical segmentation for orthognathic surgery.  A panoramic dental radiograph (OPG) displaying the maxilla, mandible, and dentition. The image shows bilateral temporomandibular joints, nasal cavity, and maxillary sinuses, with 'R' and 'L' markers indicating patient orientation.   Radiograph: A frontal (posterior-anterior) skull X-ray displaying the cranial vault, orbits, nasal cavity, and dentition. A vertical radiopaque line extends from the vertex down to a rectangular radiopaque marker positioned at the midline near the anterior cranial fossa. Radiograph: A lateral cephalometric X-ray of a human skull in profile, displaying the cranial bones, cervical spine, nasal cavity, maxilla, mandible, and dentition. The image includes vertical measurement scales on the left and right edges to assist with anatomical assessment.   Radiograph: A frontal (posteroanterior) skull radiograph showing the facial skeleton, including the orbits, nasal cavity, maxilla, mandible, and dentition. Vertical and horizontal reference lines are superimposed on the image to aid in assessing symmetry or alignment. A lateral cephalometric radiograph showing a side profile of a human skull, cervical spine, and soft tissues. The image captures the skeletal structure including the mandible, maxilla, teeth, and nasal cavity, with vertical rulers visible on the left and right edges for measurement.   Radiograph: A lateral cephalometric X-ray of a human skull in profile view. The image displays the craniofacial skeleton, cervical spine, and soft tissue outlines, with metallic orthodontic appliances (brackets) visible on the teeth. Radiograph: Lateral cephalometric radiograph of a human skull showing extensive orthognathic hardware, including plates and screws in the maxilla and mandible, likely post-surgical.     A 3D reconstructed CT scan (radiograph) showing an anterior view of a human skull, highlighting the craniofacial bones, orbits, nasal cavity, and dentition. A 3D CT scan reconstruction showing a lateral view of the human skull and cervical spine. The image highlights skeletal structures including the mandible, maxilla, teeth, and vertebrae, with orientation markers for Anterior (A) and Posterior (P). Technical data such as date, voltage, and scale are visible in the corners. A 3D reconstructed computed tomography (CT) scan of a human skull, presented in an anterior view. The image displays the craniofacial skeleton, including the orbits, nasal cavity, maxilla, and mandible with teeth, rendered from volumetric data. This is a 3D volume-rendered CT scan (VR) showing a lateral view of a human skull. The image displays the bony structures of the face, cranium, and cervical spine in profile, with technical annotations visible on the black background.   A lateral cephalometric radiograph showing the human skull, cervical spine, and soft tissue profile in side view. The image reveals dental hardware, specifically orthodontic braces on both the upper and lower teeth. A lateral cephalometric radiograph showing the craniofacial skeleton in profile, including the cervical spine and skull base. The image reveals extensive metallic hardware fixation (plates and screws) across the maxilla, mandible, and midface regions, along with orthodontic brackets on the teeth.  Radiograph: A side-by-side comparison of two frontal cephalometric X-rays (posteroanterior skull views). The images illustrate a pre-operative state on the left and a post-operative state on the right, showing the addition of extensive orthodontic hardware (brackets and wires) and surgical fixation plates along the mandibular body and chin. Acquired Facial Deformity * Trauma * Benign cysts & tumours * Infection * Malignancy * Other bony lesions * Fibro-osseous lesions * Giant cell lesions * Post-surgery (for removal of pathological lesions)   - Trauma - Benign cysts & tumours - Infection - Malignancy - Other bony lesions - Fibro-osseous lesions - Giant cell lesions - Post-surgery (for removal of pathological lesions) Clinical photo: A frontal portrait of a man displaying significant, asymmetric soft tissue swelling and deformity affecting the lower face, jaw, and neck region. Radiograph: A lateral skull X-ray demonstrating a large, multilocular radiolucent lesion in the mandible containing multiple displaced tooth-like structures. Imaging for Acquired Facial Deformity Depends on the nature of the abnormality • OPG (good overview) • CBCT • **CT** • MRI • NMI esp. bone scans CASE REPORT DOI: 10.1016/S1808-8694(15)30589-9 Open Access Marcelo Medeiros¹, Gabriela Granja Porto², Jose Rodrigues Laureano Filho³, Luís Portela⁴, Ricardo Holanda Vasconcellos⁵  Depends on the nature of the abnormality. - OPG (good overview) - CBCT - CT - MRI - NMI, especially bone scans *Marcelo Medeiros¹, Gabriela Granja Porto², Jose Rodrigues Laureano Filho³, Luís Portela⁴, Ricardo Holanda Vasconcellos⁵. CASE REPORT, DOI: 10.1016/S1808-8694(15)30589-9, Open Access.* > [!note] Lecturer — Imaging Modalities > The choice of imaging depends on the abnormality, with CT serving as the main modality for acquired facial deformity. > > - CT can assess ==both hard and soft tissues== and is useful for evaluating the morphology of affected bones and condyles. > - Orthopantomograms provide an overall view of the jaws and dentition but have inherent artifacts and limited skeletal accuracy. > - CBCT provides accurate three-dimensional visualization of bony structures, but high image noise, a low contrast-to-noise ratio, and poor soft-tissue contrast can limit its use when soft-tissue information is needed for surgical planning. > - MRI provides excellent soft-tissue detail and is particularly useful for tumors, cysts, and vascular malformations; it is generally an adjunct to CT. > - MRI is especially valuable for identifying vascular malformations associated with conditions such as Proteus syndrome. > - Nuclear medicine imaging is primarily functional rather than morphological and can determine whether a deformity or lesion is progressive or stable, helping determine the timing of surgery, particularly in unilateral condylar hyperplasia. A composite image showing three views of the mandible: a 3D CT reconstruction with a large lesion, a skull model with a reconstruction plate, and a radiograph.   A coronal fusion image combining a CT scan of the skull with a functional nuclear medicine overlay. A focal area of intense radiotracer uptake, depicted in orange and purple hues, is localized to the right temporomandibular joint region. Axial fused PET/CT image of the skull base and upper neck, displaying a focal area of intense radiotracer uptake (depicted in orange and purple) within the right temporal bone or mastoid region.  A coronal CT scan of the skull base, focusing on the temporomandibular joints (TMJ) and surrounding bony structures. The image displays the mandibular condyles seated within the glenoid fossae, along with the petrous ridges and mastoid air cells. (b) (c) Oral Diseases / Volume 23, Issue 6 / p. 697-708 Invited Medical Review | Free Access Fibrous dysplasia of bone: craniofacial and dental implications AB Burke, MT Collins, AM Boyce, First published: 05 August 2016 https://doi.org/10.1111/odi.12563 Citations: 36   (b) (c) *AB Burke, MT Collins, AM Boyce. Fibrous dysplasia of bone: craniofacial and dental implications. Oral Diseases, Volume 23, Issue 6, p. 697-708. Invited Medical Review | Free Access. First published: 05 August 2016. https://doi.org/10.1111/odi.12563. Citations: 36.* A whole-body bone scintigraphy scan (likely a Tc-99m MDP bone scan) of a pediatric patient, showing multiple areas of increased radiotracer uptake consistent with polyostotic fibrous dysplasia. The image is labeled '(a)' in the top left corner. A composite figure containing three panels labeled (a), (b), and (c). Panel (a) displays a 3D CT reconstruction of a skull with asymmetry, while panels (b) and (c) show axial CT slices with red asterisks and arrows indicating specific sites. ## Case: Treacher Collins syndrome ### Question **Scenario:** A diagram is presented to illustrate a rare bilateral facial deformity syndrome affecting the first and second branchial arches. **What's shown:** Bilateral facial hypoplasia affecting the jaws, ears, zygomatic bones, and lateral aspects of the orbits. **Consider:** Identify the syndrome and its characteristic anatomical features based on the diagram. ### Answer **Observations:** - Bilateral facial hypoplasia - Involvement of the jaws, ears, zygomatic bones, and lateral orbits **Reasoning:** The bilateral nature of the deformity and the specific involvement of first and second branchial arch derivatives (jaws, ears, zygoma, orbits) are characteristic of this rare syndrome, distinguishing it from unilateral conditions. **Outcome:** None stated. **Takeaway:** Treacher Collins syndrome is a rare first and second branchial arch syndrome characterized by bilateral facial hypoplasia affecting the jaws, ears, zygomatic bones, and lateral orbits. ## Case: Hemifacial microsomia (Abraham Lincoln example) ### Question **Scenario:** A historical example is used to illustrate a first and second branchial arch syndrome. **What's shown:** Unilateral involvement of facial structures. **Consider:** Identify the condition and its laterality based on the historical presentation. ### Answer **Observations:** - Unilateral facial involvement - First and second branchial arch syndrome **Reasoning:** Unlike bilateral syndromes, this condition presents with unilateral involvement. It is noted as the second most common congenital facial deformity after cleft lip and palate. **Outcome:** None stated. **Takeaway:** Hemifacial microsomia (craniofacial microsomia) is a first and second branchial arch syndrome characterized by unilateral facial involvement. ## Case: Cleidocranial dysplasia ### Question **Scenario:** A specific condition is highlighted using a pop culture reference to illustrate its distinct skeletal and dental features. **What's shown:** Absent or hypoplastic clavicles, persistent open cranial sutures, supernumerary teeth, prolonged retention of primary teeth, multiple impacted permanent teeth, and a hypoplastic maxilla. **Consider:** Identify the syndrome and its distinguishing dental and skeletal features. ### Answer **Observations:** - Absent or hypoplastic clavicles - Persistent open cranial sutures - Supernumerary teeth, prolonged retention of primary teeth, multiple impacted permanent teeth - Hypoplastic maxilla **Reasoning:** These specific skeletal and dental findings distinguish this condition from other facial deformity syndromes, particularly the combination of clavicular hypoplasia and multiple dental anomalies. **Outcome:** None stated. **Takeaway:** Cleidocranial dysplasia is distinguished by absent or hypoplastic clavicles, open cranial sutures, and multiple dental anomalies including supernumerary and impacted teeth. ## Case: Crouzon syndrome ### Question **Scenario:** A syndrome characterized by premature cranial suture fusion is presented. **What's shown:** Decreased anterior-posterior dimension at the cranial base, copper-beaten appearance on skull imaging, hypoplastic jaws, shallow orbits resulting in proptosis, and a class three skeletal relationship. **Consider:** Identify the syndrome and its cranial, orbital, and skeletal manifestations. ### Answer **Observations:** - Premature fusion of cranial sutures (craniosynostosis) - Decreased AP dimension and copper-beaten skull appearance - Hypoplastic jaws and shallow orbits with proptosis - Class three skeletal relationship due to maxillary hypoplasia **Reasoning:** The combination of craniosynostosis with a copper-beaten skull appearance, shallow orbits causing proptosis, and maxillary hypoplasia leading to a class three relationship points to this specific syndrome. **Outcome:** None stated. **Takeaway:** Crouzon syndrome features craniosynostosis with a copper-beaten skull appearance, shallow orbits causing proptosis, and maxillary hypoplasia resulting in a class three skeletal relationship. ## Case: Treacher Collins syndrome ### Question **Scenario:** A diagram is presented to illustrate a rare bilateral facial deformity syndrome affecting the first and second branchial arches. **What's shown:** Bilateral facial hypoplasia affecting the jaws, ears, zygomatic bones, and lateral aspects of the orbits. **Consider:** Identify the syndrome and its characteristic anatomical features based on the diagram.  ### Answer **Observations:** - Bilateral facial hypoplasia - Involvement of the jaws, ears, zygomatic bones, and lateral orbits **Reasoning:** The bilateral nature of the deformity and the specific involvement of first and second branchial arch derivatives (jaws, ears, zygoma, orbits) are characteristic of this rare syndrome, distinguishing it from unilateral conditions. **Outcome:** None stated. **Takeaway:** Treacher Collins syndrome is a rare first and second branchial arch syndrome characterized by bilateral facial hypoplasia affecting the jaws, ears, zygomatic bones, and lateral orbits. ## Case: Hemifacial microsomia (Abraham Lincoln example) ### Question **Scenario:** A historical example is used to illustrate a first and second branchial arch syndrome. **What's shown:** Unilateral involvement of facial structures. **Consider:** Identify the condition and its laterality based on the historical presentation.  ### Answer **Observations:** - Unilateral facial involvement - First and second branchial arch syndrome **Reasoning:** Unlike bilateral syndromes, this condition presents with unilateral involvement. It is noted as the second most common congenital facial deformity after cleft lip and palate. **Outcome:** None stated. **Takeaway:** Hemifacial microsomia (craniofacial microsomia) is a first and second branchial arch syndrome characterized by unilateral facial involvement. ## Case: Cleidocranial dysplasia ### Question **Scenario:** A specific condition is highlighted using a pop culture reference to illustrate its distinct skeletal and dental features. **What's shown:** Absent or hypoplastic clavicles, persistent open cranial sutures, supernumerary teeth, prolonged retention of primary teeth, multiple impacted permanent teeth, and a hypoplastic maxilla. **Consider:** Identify the syndrome and its distinguishing dental and skeletal features.   ### Answer **Observations:** - Absent or hypoplastic clavicles - Persistent open cranial sutures - Supernumerary teeth, prolonged retention of primary teeth, multiple impacted permanent teeth - Hypoplastic maxilla **Reasoning:** These specific skeletal and dental findings distinguish this condition from other facial deformity syndromes, particularly the combination of clavicular hypoplasia and multiple dental anomalies. **Outcome:** None stated. **Takeaway:** Cleidocranial dysplasia is distinguished by absent or hypoplastic clavicles, open cranial sutures, and multiple dental anomalies including supernumerary and impacted teeth. ## Case: Crouzon syndrome ### Question **Scenario:** A syndrome characterized by premature cranial suture fusion is presented. **What's shown:** Decreased anterior-posterior dimension at the cranial base, copper-beaten appearance on skull imaging, hypoplastic jaws, shallow orbits resulting in proptosis, and a class three skeletal relationship. **Consider:** Identify the syndrome and its cranial, orbital, and skeletal manifestations.  ### Answer **Observations:** - Premature fusion of cranial sutures (craniosynostosis) - Decreased AP dimension and copper-beaten skull appearance - Hypoplastic jaws and shallow orbits with proptosis - Class three skeletal relationship due to maxillary hypoplasia **Reasoning:** The combination of craniosynostosis with a copper-beaten skull appearance, shallow orbits causing proptosis, and maxillary hypoplasia leading to a class three relationship points to this specific syndrome. **Outcome:** None stated. **Takeaway:** Crouzon syndrome features craniosynostosis with a copper-beaten skull appearance, shallow orbits causing proptosis, and maxillary hypoplasia resulting in a class three skeletal relationship. Case: Treacher Collins syndrome An anatomical illustration in profile view depicting a patient with craniofacial abnormalities, specifically showing hypoplasia of the zygomatic bone (cheekbone) and mandible (lower jaw), along with malformed external ear structures. A composite image of three dental and craniofacial radiographs: (a) a lateral cephalometric radiograph showing the skull in profile, (b) a frontal cephalometric radiograph (PA view) showing the skull from the front, and (c) a panoramic radiograph displaying the full dentition and jaws. FIG. 30-6 Cleidocranial dysplasia. A, Chest radiograph; note the absence of clavicles. B, The result is excessive mobility of the shoulders. Note also the frontal bossing and underdeveloped maxilla. C, On a lateral radiograph, note the wormian (sutural) bones in the occipital region (arrows) and the open fontanel (large arrow). D, A lateral skull film showing a lack of development of the parietal bones (arrows). A composite medical figure consisting of four panels illustrating the clinical and radiographic features of cleidocranial dysplasia. Panel A is a chest radiograph showing the absence of clavicles; Panel B is a clinical photograph demonstrating excessive shoulder mobility with arms drawn anteriorly to meet at the midline; Panels C and D are lateral skull radiographs highlighting wormian bones in the occipital region (arrows) and an open fontanel. Radiograph: A panoramic dental X-ray showing the maxilla and mandible with multiple teeth, including several unerupted or supernumerary teeth visible within the jawbones. The image illustrates the complex dentition often associated with the condition described in the slide text. **Crouzon syndrome** Clinical photo: A frontal and lateral view of an infant's face, demonstrating characteristic features such as midface hypoplasia and proptosis. Radiograph: C-E show three views (AP, PA, and lateral) of the skull, illustrating craniosynostosis with a visible vertical metallic strip in image C. ## Case: Apert syndrome ### Question **Scenario:** A syndrome similar to Crouzon but with distinct limb findings is presented. **What's shown:** Early cranial suture fusion (craniosynostosis) and syndactyly (webbed or fused fingers/toes). **Consider:** Differentiate this syndrome from Crouzon syndrome based on the clinical features. ### Answer **Observations:** - Craniosynostosis (early cranial suture fusion) - Syndactyly - Increased chance of intellectual disability **Reasoning:** While similar to Crouzon syndrome in having craniosynostosis, the primary distinguishing feature is the presence of syndactyly, along with a higher risk of intellectual disability. **Outcome:** None stated. **Takeaway:** Apert syndrome is distinguished from Crouzon syndrome by the presence of syndactyly and an increased risk of intellectual disability. ## Case: Pfeiffer syndrome ### Question **Scenario:** Another syndrome associated with craniosynostosis is presented, featuring distinct digit and skull abnormalities. **What's shown:** Variable thumb and toe widening, extreme skull deformity described as a "clover leaf brain" shape. **Consider:** Identify the syndrome based on the specific digit and skull morphology. ### Answer **Observations:** - Variable thumb and toe widening - Extreme skull deformity (clover leaf brain shape) - Craniosynostosis **Reasoning:** The combination of craniosynostosis with variable thumb and toe widening and the classic "clover leaf" skull deformity is characteristic of this syndrome. **Outcome:** None stated. **Takeaway:** Pfeiffer syndrome is characterized by craniosynostosis, variable thumb and toe widening, and a classic "clover leaf" skull deformity. ## Case: Proteus syndrome ### Question **Scenario:** A rare, progressive genetic disorder causing asymmetrical overgrowth is presented. **What's shown:** Asymmetrical facial hypertrophy, various tumors, and vascular malformations visible on MRI. **Consider:** Identify the condition and the imaging modality used to assess its soft tissue and vascular components. ### Answer **Observations:** - Asymmetrical facial hypertrophy (overgrowth, not undergrowth) - Associated tumors and vascular malformations - Vascular malformations visible on MRI **Reasoning:** Unlike other congenital deformities that cause hypoplasia, this condition causes progressive asymmetrical overgrowth. The complex soft tissue and vascular components require MRI for detailed assessment. **Outcome:** None stated. **Takeaway:** Proteus syndrome causes progressive asymmetrical overgrowth and is associated with tumors and vascular malformations, which are best evaluated with MRI. ## Case: Bilateral cleft lip and palate ### Question **Scenario:** A patient with the most common congenital facial deformity is presented using a reconstructed CBCT panorama image. **What's shown:** Bony defects at the 12 and 22 sites on the axial view, with missing teeth in the cleft areas. **Consider:** Identify the type of cleft and the associated dental anomalies seen on the CBCT. ### Answer **Observations:** - Bilateral cleft lip and palate - Bony defects at the 12 and 22 sites - Missing teeth 12 and 22 **Reasoning:** The CBCT clearly shows bilateral bony defects in the maxilla corresponding to the lateral incisor regions, which are also missing the associated teeth, a common finding in clefts. **Outcome:** None stated. **Takeaway:** Bilateral cleft lip and palate often presents with bony defects in the maxilla and missing teeth in the cleft areas, clearly visualized on CBCT. ## Case: Unilateral right-sided cleft lip and palate ### Question **Scenario:** A patient with a unilateral cleft is presented. **What's shown:** A bony defect in the right maxilla at the 12 region involving the nasal cavity. **Consider:** Identify the location and extent of the bony defect in this unilateral cleft. ## Case: Apert syndrome ### Question **Scenario:** A syndrome similar to Crouzon but with distinct limb findings is presented. **What's shown:** Early cranial suture fusion (craniosynostosis) and syndactyly (webbed or fused fingers/toes). **Consider:** Differentiate this syndrome from Crouzon syndrome based on the clinical features.  ### Answer **Observations:** - Craniosynostosis (early cranial suture fusion) - Syndactyly - Increased chance of intellectual disability **Reasoning:** While similar to Crouzon syndrome in having craniosynostosis, the primary distinguishing feature is the presence of syndactyly, along with a higher risk of intellectual disability. **Outcome:** None stated. **Takeaway:** Apert syndrome is distinguished from Crouzon syndrome by the presence of syndactyly and an increased risk of intellectual disability. ## Case: Pfeiffer syndrome ### Question **Scenario:** Another syndrome associated with craniosynostosis is presented, featuring distinct digit and skull abnormalities. **What's shown:** Variable thumb and toe widening, extreme skull deformity described as a "clover leaf brain" shape. **Consider:** Identify the syndrome based on the specific digit and skull morphology.  ### Answer **Observations:** - Variable thumb and toe widening - Extreme skull deformity (clover leaf brain shape) - Craniosynostosis **Reasoning:** The combination of craniosynostosis with variable thumb and toe widening and the classic "clover leaf" skull deformity is characteristic of this syndrome. **Outcome:** None stated. **Takeaway:** Pfeiffer syndrome is characterized by craniosynostosis, variable thumb and toe widening, and a classic "clover leaf" skull deformity. ## Case: Proteus syndrome ### Question **Scenario:** A rare, progressive genetic disorder causing asymmetrical overgrowth is presented. **What's shown:** Asymmetrical facial hypertrophy, various tumors, and vascular malformations visible on MRI. **Consider:** Identify the condition and the imaging modality used to assess its soft tissue and vascular components.    ### Answer **Observations:** - Asymmetrical facial hypertrophy (overgrowth, not undergrowth) - Associated tumors and vascular malformations - Vascular malformations visible on MRI **Reasoning:** Unlike other congenital deformities that cause hypoplasia, this condition causes progressive asymmetrical overgrowth. The complex soft tissue and vascular components require MRI for detailed assessment. **Outcome:** None stated. **Takeaway:** Proteus syndrome causes progressive asymmetrical overgrowth and is associated with tumors and vascular malformations, which are best evaluated with MRI. ## Case: Bilateral cleft lip and palate ### Question **Scenario:** A patient with the most common congenital facial deformity is presented using a reconstructed CBCT panorama image. **What's shown:** Bony defects at the 12 and 22 sites on the axial view, with missing teeth in the cleft areas. **Consider:** Identify the type of cleft and the associated dental anomalies seen on the CBCT.  ### Answer **Observations:** - Bilateral cleft lip and palate - Bony defects at the 12 and 22 sites - Missing teeth 12 and 22 **Reasoning:** The CBCT clearly shows bilateral bony defects in the maxilla corresponding to the lateral incisor regions, which are also missing the associated teeth, a common finding in clefts. **Outcome:** None stated. **Takeaway:** Bilateral cleft lip and palate often presents with bony defects in the maxilla and missing teeth in the cleft areas, clearly visualized on CBCT. ## Case: Unilateral right-sided cleft lip and palate ### Question **Scenario:** A patient with a unilateral cleft is presented. **What's shown:** A bony defect in the right maxilla at the 12 region involving the nasal cavity. **Consider:** Identify the location and extent of the bony defect in this unilateral cleft.    Case: Apert syndrome Clinical photograph showing the dorsal view of a pair of hands with syndactyly (webbing/fusion) between the index and middle fingers. The digits appear fused by soft tissue, creating a characteristic "mitten" appearance often associated with Apert syndrome. B Pfieffer Clinical photo showing the facial features of an infant with a prominent forehead, wide-set eyes (hypertelorism), and midface hypoplasia. The image also includes close-up photographs of hands and feet demonstrating broad thumbs and big toes. Proteus syndrome Radiograph: A lateral X-ray view of the cervical spine and skull base. The image displays the vertebral column, cranial bones, and soft tissue structures of the neck. Coronal MRI scan of the head showing a cross-section of the brain, skull, and upper neck structures. Axial MRI scan of the head at the level of the orbits and posterior fossa. The image displays bilateral globes, ethmoid sinuses, and the cerebellum with visible folia. An axial computed tomography (CT) scan of the head, displaying a cross-section through the oral cavity and maxillofacial region. The image reveals the bony structures of the upper jaw with teeth, the dark air-filled space of the nasal cavity or oral pharynx, and surrounding soft tissues. A coronal computed tomography (CT) scan of the human skull, specifically showing the paranasal sinuses and nasal cavity. The image displays the maxillary sinuses, ethmoid air cells, frontal sinuses, and sphenoid sinus in a bone window setting. Coronal CT scan of the midface showing the nasal cavity with septum, maxillary sinuses, and upper dentition. Coronal CT scan of the midface and nasal cavity, showing the maxillary sinuses, nasal septum, turbinates, and upper dentition. ### Answer **Observations:** - Unilateral right-sided cleft lip and palate - Bony defect in the right maxilla at the 12 region - Involvement of the nasal cavity **Reasoning:** The defect is localized to the right side of the maxilla, extending into the nasal cavity, which is typical for a unilateral cleft. **Outcome:** None stated. **Takeaway:** Unilateral cleft lip and palate presents with a localized bony defect in the maxilla that can involve the nasal cavity. ## Case: Midline cleft lip and palate ### Question **Scenario:** An extremely rare midline cleft case is presented, often associated with larger syndromes. **What's shown:** Significant facial deformities including maxillary and nasal hypoplasia, leading to a severe Class 3 malocclusion, concave facial profile, and anterior open bite. **Consider:** Identify the associated facial deformities and skeletal relationships resulting from this rare midline cleft. ### Answer **Observations:** - Midline cleft lip and palate - Maxillary and nasal hypoplasia - Severe Class 3 malocclusion with a concave facial profile - Anterior open bite **Reasoning:** The midline cleft is associated with severe hypoplasia of the maxilla and nose, which directly causes the severe Class 3 skeletal relationship and anterior open bite. **Outcome:** None stated. **Takeaway:** Midline cleft lip and palate is extremely rare and often associated with severe maxillary and nasal hypoplasia, resulting in a Class 3 malocclusion and anterior open bite. ## Case: Hemifacial microsomia and Goldenhar syndrome ### Question **Scenario:** A patient with poor development of the right side of the face is presented, showing pre- and post-surgical images. **What's shown:** Severe mandibular asymmetry pre-operatively, and post-operative OPG with significant artifacts. **Consider:** Identify the condition, its broader spectrum classification, and the limitations of post-operative OPG imaging. ### Answer **Observations:** - Poor development of the right side of the face, severely affecting the mandible - Post-operative OPG shows significant artifacts, making it almost useless - Condition belongs to the ocular auricular vertebral spectrum (Goldenhar syndrome) when the spine is involved **Reasoning:** The unilateral mandibular hypoplasia is characteristic of hemifacial microsomia. When spinal involvement is present, it is classified as Goldenhar syndrome. Post-surgical hardware causes severe artifacts on OPG. **Outcome:** Surgical correction of mandibular asymmetry was performed. **Takeaway:** Hemifacial microsomia severely affects the mandible; when spinal involvement is present, it is part of Goldenhar syndrome, and post-operative OPGs are often limited by artifacts. ## Case: Right-sided mandibular hyperplasia ### Question **Scenario:** A patient with persistent growth of the right condyle leading to progressive facial asymmetry is presented. **What's shown:** Outward bowing and downward growth of the mandibular body and ramus on the right side. Growth is mainly in the vertical vector, symphysis slightly left of midline, coincidental dental midline, and a Class 3 skeletal relationship without reverse anterior overjet. **Consider:** Identify the condition and characterize the vector of growth and skeletal relationship. ### Answer **Observations:** - Persistent growth of the right condyle - Outward bowing and downward growth of the right mandibular body and ramus - Vertical vector growth, symphysis slightly left of midline - Coincidental dental midline - Class 3 skeletal relationship without reverse anterior overjet **Reasoning:** The persistent condylar growth causes characteristic outward and downward bowing. The vertical vector of growth shifts the symphysis slightly but keeps the dental midline coincidental, resulting in a Class 3 relationship. **Outcome:** None stated. **Takeaway:** Right-sided mandibular hyperplasia features persistent condylar growth causing outward and downward bowing, primarily in a vertical vector, leading to a Class 3 skeletal relationship. ### Answer **Observations:** - Unilateral right-sided cleft lip and palate - Bony defect in the right maxilla at the 12 region - Involvement of the nasal cavity **Reasoning:** The defect is localized to the right side of the maxilla, extending into the nasal cavity, which is typical for a unilateral cleft. **Outcome:** None stated. **Takeaway:** Unilateral cleft lip and palate presents with a localized bony defect in the maxilla that can involve the nasal cavity. ## Case: Midline cleft lip and palate ### Question **Scenario:** An extremely rare midline cleft case is presented, often associated with larger syndromes. **What's shown:** Significant facial deformities including maxillary and nasal hypoplasia, leading to a severe Class 3 malocclusion, concave facial profile, and anterior open bite. **Consider:** Identify the associated facial deformities and skeletal relationships resulting from this rare midline cleft. ### Answer **Observations:** - Midline cleft lip and palate - Maxillary and nasal hypoplasia - Severe Class 3 malocclusion with a concave facial profile - Anterior open bite **Reasoning:** The midline cleft is associated with severe hypoplasia of the maxilla and nose, which directly causes the severe Class 3 skeletal relationship and anterior open bite. **Outcome:** None stated. **Takeaway:** Midline cleft lip and palate is extremely rare and often associated with severe maxillary and nasal hypoplasia, resulting in a Class 3 malocclusion and anterior open bite. ## Case: Hemifacial microsomia and Goldenhar syndrome ### Question **Scenario:** A patient with poor development of the right side of the face is presented, showing pre- and post-surgical images. **What's shown:** Severe mandibular asymmetry pre-operatively, and post-operative OPG with significant artifacts. **Consider:** Identify the condition, its broader spectrum classification, and the limitations of post-operative OPG imaging.    ### Answer **Observations:** - Poor development of the right side of the face, severely affecting the mandible - Post-operative OPG shows significant artifacts, making it almost useless - Condition belongs to the ocular auricular vertebral spectrum (Goldenhar syndrome) when the spine is involved **Reasoning:** The unilateral mandibular hypoplasia is characteristic of hemifacial microsomia. When spinal involvement is present, it is classified as Goldenhar syndrome. Post-surgical hardware causes severe artifacts on OPG. **Outcome:** Surgical correction of mandibular asymmetry was performed. **Takeaway:** Hemifacial microsomia severely affects the mandible; when spinal involvement is present, it is part of Goldenhar syndrome, and post-operative OPGs are often limited by artifacts. ## Case: Right-sided mandibular hyperplasia ### Question **Scenario:** A patient with persistent growth of the right condyle leading to progressive facial asymmetry is presented. **What's shown:** Outward bowing and downward growth of the mandibular body and ramus on the right side. Growth is mainly in the vertical vector, symphysis slightly left of midline, coincidental dental midline, and a Class 3 skeletal relationship without reverse anterior overjet. **Consider:** Identify the condition and characterize the vector of growth and skeletal relationship.   ### Answer **Observations:** - Persistent growth of the right condyle - Outward bowing and downward growth of the right mandibular body and ramus - Vertical vector growth, symphysis slightly left of midline - Coincidental dental midline - Class 3 skeletal relationship without reverse anterior overjet **Reasoning:** The persistent condylar growth causes characteristic outward and downward bowing. The vertical vector of growth shifts the symphysis slightly but keeps the dental midline coincidental, resulting in a Class 3 relationship. **Outcome:** None stated. **Takeaway:** Right-sided mandibular hyperplasia features persistent condylar growth causing outward and downward bowing, primarily in a vertical vector, leading to a Class 3 skeletal relationship. Case: Unilateral right-sided cleft lip and palate > Answer A lateral cephalometric radiograph showing a profile view of the human skull, cervical spine, and dentition. The image reveals significant skeletal discrepancies, including an open bite malocclusion where the upper and lower teeth do not meet, along with visible restorations on the molars. Two coronal CT scans of the cervical spine and skull base displayed side-by-side, each marked with the label 'A' in the bottom right corner. The images show bony structures including the vertebrae, mastoid air cells, and occipital bone. A panoramic dental radiograph (OPG) showing the maxilla and mandible with extensive reconstructive hardware. A large, lattice-structured metallic implant replaces the right mandibular ramus and body, secured by screws, while multiple reconstruction plates and fixation screws are visible across the midface and left mandible. Orthodontic brackets and an archwire are present on the lower teeth. Radiograph: A frontal (posterior-anterior) skull X-ray displaying the cranial vault, orbits, nasal cavity, and dentition. A vertical radiopaque line extends from the vertex down to a rectangular radiopaque marker positioned at the midline near the anterior cranial fossa. Radiograph: A lateral cephalometric X-ray of a human skull in profile, displaying the cranial bones, cervical spine, nasal cavity, maxilla, mandible, and dentition. The image includes vertical measurement scales on the left and right edges to assist with anatomical assessment. ## Case: Severe right-sided hemimandibular hyperplasia ### Question **Scenario:** A more severe case of right-sided hyperplasia is presented. **What's shown:** Rotation of the mandible, symphysis shifted to the left of the facial skeletal midline, dental midline shift, and a Class 3 skeletal relationship without reversed anterior overjet. **Consider:** Differentiate this severe case from the previous one based on mandibular rotation and midline shifts. ### Answer **Observations:** - Rotation of the mandible - Symphysis shifted to the left of the facial skeletal midline - Dental midline shift - Class 3 skeletal relationship without reversed anterior overjet **Reasoning:** Unlike the previous case, the severe hyperplasia causes actual rotation of the mandible, leading to a shift in both the facial symphysis and the dental midline. **Outcome:** None stated. **Takeaway:** Severe hemimandibular hyperplasia causes mandibular rotation, resulting in shifts of both the facial symphysis and the dental midline. ## Case: Retrognathism (Class 2 skeletal relationship) ### Question **Scenario:** A patient with a Class 2 skeletal relationship is presented with pre- and post-surgical images. **What's shown:** Severe anterior overjet pre-operatively, and the post-operative result following a bimaxillary osteotomy. **Consider:** Identify the skeletal discrepancy and the surgical approach used to correct it. ### Answer **Observations:** - Class 2 skeletal relationship (retrognathism) - Severe anterior overjet pre-operatively - Correction achieved via bimaxillary osteotomy (maxilla and mandible) **Reasoning:** The severe anterior overjet and Class 2 relationship are corrected by operating on both jaws to achieve functional improvement and aesthetic balance. **Outcome:** Bimaxillary osteotomy performed to correct the deformity. **Takeaway:** Bimaxillary osteotomy is often used to correct severe Class 2 retrognathism and anterior overjet, achieving both functional and aesthetic balance. ## Case: Protrusive maxilla and retrognathic mandible ### Question **Scenario:** A rare case of a specific Class 2 skeletal discrepancy is presented with pre- and post-surgical views. **What's shown:** Very convex profile, severe anterior overjet, and Class 2 relationship pre-operatively. Post-operatively, the profile and overjet are corrected, but the vertical dimension of the face is unaltered. **Consider:** Identify the specific skeletal discrepancy and note the effect of the surgery on the vertical facial dimension. ### Answer **Observations:** - Protrusive maxilla and retrognathic mandible - Very convex profile and severe anterior overjet - Correction of profile and overjet post-surgery - Vertical dimension of the face remains unaltered **Reasoning:** The combination of a protrusive maxilla and retrognathic mandible creates a severe convex profile. Bimax surgery corrects the AP discrepancy without altering the vertical facial dimension. **Outcome:** Bimax surgery performed to correct the Class 2 relationship and convex profile. **Takeaway:** Bimax surgery can correct the severe convex profile and anterior overjet of a protrusive maxilla and retrognathic mandible without altering the vertical facial dimension. ## Case: Ameloblastoma ### Question **Scenario:** A patient with a specific benign tumor is presented. **What's shown:** Severe right-sided facial deformity caused by an expansile multilocular tumor involving the right hemimandible. **Consider:** Identify the tumor and its effect on the facial skeleton based on the imaging. ### Answer **Observations:** - Expansile multilocular tumor - Involvement of the right hemimandible - Severe right-sided facial deformity **Reasoning:** The expansile, multilocular nature of the tumor in the mandible causing severe facial deformity is characteristic of an ameloblastoma. **Outcome:** None stated. **Takeaway:** Ameloblastoma presents as an expansile multilocular tumor that can cause severe facial deformity when involving the mandible. ## Case: Severe right-sided hemimandibular hyperplasia ### Question **Scenario:** A more severe case of right-sided hyperplasia is presented. **What's shown:** Rotation of the mandible, symphysis shifted to the left of the facial skeletal midline, dental midline shift, and a Class 3 skeletal relationship without reversed anterior overjet. **Consider:** Differentiate this severe case from the previous one based on mandibular rotation and midline shifts.  ### Answer **Observations:** - Rotation of the mandible - Symphysis shifted to the left of the facial skeletal midline - Dental midline shift - Class 3 skeletal relationship without reversed anterior overjet **Reasoning:** Unlike the previous case, the severe hyperplasia causes actual rotation of the mandible, leading to a shift in both the facial symphysis and the dental midline. **Outcome:** None stated. **Takeaway:** Severe hemimandibular hyperplasia causes mandibular rotation, resulting in shifts of both the facial symphysis and the dental midline. ## Case: Retrognathism (Class 2 skeletal relationship) ### Question **Scenario:** A patient with a Class 2 skeletal relationship is presented with pre- and post-surgical images. **What's shown:** Severe anterior overjet pre-operatively, and the post-operative result following a bimaxillary osteotomy. **Consider:** Identify the skeletal discrepancy and the surgical approach used to correct it.  ### Answer **Observations:** - Class 2 skeletal relationship (retrognathism) - Severe anterior overjet pre-operatively - Correction achieved via bimaxillary osteotomy (maxilla and mandible) **Reasoning:** The severe anterior overjet and Class 2 relationship are corrected by operating on both jaws to achieve functional improvement and aesthetic balance. **Outcome:** Bimaxillary osteotomy performed to correct the deformity. **Takeaway:** Bimaxillary osteotomy is often used to correct severe Class 2 retrognathism and anterior overjet, achieving both functional and aesthetic balance. ## Case: Protrusive maxilla and retrognathic mandible ### Question **Scenario:** A rare case of a specific Class 2 skeletal discrepancy is presented with pre- and post-surgical views. **What's shown:** Very convex profile, severe anterior overjet, and Class 2 relationship pre-operatively. Post-operatively, the profile and overjet are corrected, but the vertical dimension of the face is unaltered. **Consider:** Identify the specific skeletal discrepancy and note the effect of the surgery on the vertical facial dimension.  ### Answer **Observations:** - Protrusive maxilla and retrognathic mandible - Very convex profile and severe anterior overjet - Correction of profile and overjet post-surgery - Vertical dimension of the face remains unaltered **Reasoning:** The combination of a protrusive maxilla and retrognathic mandible creates a severe convex profile. Bimax surgery corrects the AP discrepancy without altering the vertical facial dimension. **Outcome:** Bimax surgery performed to correct the Class 2 relationship and convex profile. **Takeaway:** Bimax surgery can correct the severe convex profile and anterior overjet of a protrusive maxilla and retrognathic mandible without altering the vertical facial dimension. ## Case: Ameloblastoma ### Question **Scenario:** A patient with a specific benign tumor is presented. **What's shown:** Severe right-sided facial deformity caused by an expansile multilocular tumor involving the right hemimandible. **Consider:** Identify the tumor and its effect on the facial skeleton based on the imaging.   ### Answer **Observations:** - Expansile multilocular tumor - Involvement of the right hemimandible - Severe right-sided facial deformity **Reasoning:** The expansile, multilocular nature of the tumor in the mandible causing severe facial deformity is characteristic of an ameloblastoma. **Outcome:** None stated. **Takeaway:** Ameloblastoma presents as an expansile multilocular tumor that can cause severe facial deformity when involving the mandible. Case: Severe right-sided hemimandibular hyperplasia A lateral cephalometric radiograph showing a side profile of a human skull, cervical spine, and soft tissues. The image captures the skeletal structure including the mandible, maxilla, teeth, and nasal cavity, with vertical rulers visible on the left and right edges for measurement. Radiograph: A lateral cephalometric X-ray of a human skull in profile view. The image displays the craniofacial skeleton, cervical spine, and soft tissue outlines, with metallic orthodontic appliances (brackets) visible on the teeth. Radiograph: A side-by-side comparison of two frontal cephalometric X-rays (posteroanterior skull views). The images illustrate a pre-operative state on the left and a post-operative state on the right, showing the addition of extensive orthodontic hardware (brackets and wires) and surgical fixation plates along the mandibular body and chin. Radiograph: A lateral skull X-ray demonstrating a large, multilocular radiolucent lesion in the mandible containing multiple displaced tooth-like structures. Clinical photo: A frontal portrait of a man displaying significant, asymmetric soft tissue swelling and deformity affecting the lower face, jaw, and neck region. ## Case: Unilateral condylar hyperplasia and osteochondroma ### Question **Scenario:** A patient with overgrowth of the right condyle is evaluated to determine if the lesion is active. **What's shown:** SPECT nuclear medicine imaging showing increased radionuclide uptake in the right condyle, and CT showing an enlarged condyle with lost original morphology and irregular trabecular bone pattern. **Consider:** Determine the activity status of the condylar lesion and differentiate it from developmental condylar hyperplasia based on imaging. ### Answer **Observations:** - Increased radionuclide uptake in the right condyle on SPECT - Enlarged right condyle with lost original morphology on CT - Irregular trabecular bone pattern **Reasoning:** The increased uptake on SPECT indicates the benign tumor (osteochondroma) is still active. Unlike developmental condylar hyperplasia which maintains normal morphology, tumorous activity causes irregular morphology and loss of normal trabecular pattern. **Outcome:** Surgery must be delayed because the tumor is still active and growing. **Takeaway:** SPECT imaging determines the activity of condylar tumors; active lesions show increased uptake and irregular morphology on CT, indicating surgery should be delayed until they burn out. ## Case: Fibrous dysplasia ### Question **Scenario:** A condition causing significant facial asymmetry is presented. **What's shown:** Lesion typically affecting the maxilla, mandible, or skull base. Bone scans are mentioned as being taken before surgery. **Consider:** Identify the condition and the purpose of the bone scan in its management. ### Answer **Observations:** - Significant facial asymmetry - Typically affects maxilla, mandible, or skull base - Bone scans taken before surgery **Reasoning:** The condition causes asymmetry by affecting major craniofacial bones. Bone scans are utilized pre-operatively to ensure the lesion is stable before proceeding with surgical management. **Outcome:** Managed with surgery after confirming stability with a bone scan. **Takeaway:** Fibrous dysplasia causes facial asymmetry and requires bone scans prior to surgery to ensure the lesion is stable. ## Case: Unilateral condylar hyperplasia and osteochondroma ### Question **Scenario:** A patient with overgrowth of the right condyle is evaluated to determine if the lesion is active. **What's shown:** SPECT nuclear medicine imaging showing increased radionuclide uptake in the right condyle, and CT showing an enlarged condyle with lost original morphology and irregular trabecular bone pattern. **Consider:** Determine the activity status of the condylar lesion and differentiate it from developmental condylar hyperplasia based on imaging.   ### Answer **Observations:** - Increased radionuclide uptake in the right condyle on SPECT - Enlarged right condyle with lost original morphology on CT - Irregular trabecular bone pattern **Reasoning:** The increased uptake on SPECT indicates the benign tumor (osteochondroma) is still active. Unlike developmental condylar hyperplasia which maintains normal morphology, tumorous activity causes irregular morphology and loss of normal trabecular pattern. **Outcome:** Surgery must be delayed because the tumor is still active and growing. **Takeaway:** SPECT imaging determines the activity of condylar tumors; active lesions show increased uptake and irregular morphology on CT, indicating surgery should be delayed until they burn out. ## Case: Fibrous dysplasia ### Question **Scenario:** A condition causing significant facial asymmetry is presented. **What's shown:** Lesion typically affecting the maxilla, mandible, or skull base. Bone scans are mentioned as being taken before surgery. **Consider:** Identify the condition and the purpose of the bone scan in its management.   ### Answer **Observations:** - Significant facial asymmetry - Typically affects maxilla, mandible, or skull base - Bone scans taken before surgery **Reasoning:** The condition causes asymmetry by affecting major craniofacial bones. Bone scans are utilized pre-operatively to ensure the lesion is stable before proceeding with surgical management. **Outcome:** Managed with surgery after confirming stability with a bone scan. **Takeaway:** Fibrous dysplasia causes facial asymmetry and requires bone scans prior to surgery to ensure the lesion is stable. Case: Unilateral condylar hyperplasia and osteochondroma A coronal fusion image combining a CT scan of the skull with a functional nuclear medicine overlay. A focal area of intense radiotracer uptake, depicted in orange and purple hues, is localized to the right temporomandibular joint region. Axial fused PET/CT image of the skull base and upper neck, displaying a focal area of intense radiotracer uptake (depicted in orange and purple) within the right temporal bone or mastoid region. (a) A whole-body bone scintigraphy scan (likely a Tc-99m MDP bone scan) of a pediatric patient, showing multiple areas of increased radiotracer uptake consistent with polyostotic fibrous dysplasia. The image is labeled '(a)' in the top left corner. A composite figure containing three panels labeled (a), (b), and (c). Panel (a) displays a 3D CT reconstruction of a skull with asymmetry, while panels (b) and (c) show axial CT slices with red asterisks and arrows indicating specific sites. [^1]: Original PDF page 1: [[L5 - Imaging for Facial Deformity.pdf#page=1|L5 - Imaging for Facial Deformity, p.1]] [^2]: Original PDF page 2: [[L5 - Imaging for Facial Deformity.pdf#page=2|L5 - Imaging for Facial Deformity, p.2]] [^3]: Original PDF page 3: [[L5 - Imaging for Facial Deformity.pdf#page=3|L5 - Imaging for Facial Deformity, p.3]] [^4]: Original PDF page 4: [[L5 - Imaging for Facial Deformity.pdf#page=4|L5 - Imaging for Facial Deformity, p.4]] [^5]: Original PDF page 5: [[L5 - Imaging for Facial Deformity.pdf#page=5|L5 - Imaging for Facial Deformity, p.5]] [^6]: Original PDF page 6: [[L5 - Imaging for Facial Deformity.pdf#page=6|L5 - Imaging for Facial Deformity, p.6]] [^7]: Original PDF page 7: [[L5 - Imaging for Facial Deformity.pdf#page=7|L5 - Imaging for Facial Deformity, p.7]] [^8]: Original PDF page 8: [[L5 - Imaging for Facial Deformity.pdf#page=8|L5 - Imaging for Facial Deformity, p.8]] [^9]: Original PDF page 9: [[L5 - Imaging for Facial Deformity.pdf#page=9|L5 - Imaging for Facial Deformity, p.9]] [^10]: Original PDF page 10: [[L5 - Imaging for Facial Deformity.pdf#page=10|L5 - Imaging for Facial Deformity, p.10]] [^11]: Original PDF page 11: [[L5 - Imaging for Facial Deformity.pdf#page=11|L5 - Imaging for Facial Deformity, p.11]] [^12]: Original PDF page 12: [[L5 - Imaging for Facial Deformity.pdf#page=12|L5 - Imaging for Facial Deformity, p.12]] [^13]: Original PDF page 13: [[L5 - Imaging for Facial Deformity.pdf#page=13|L5 - Imaging for Facial Deformity, p.13]] [^14]: Original PDF page 14: [[L5 - Imaging for Facial Deformity.pdf#page=14|L5 - Imaging for Facial Deformity, p.14]] [^15]: Original PDF page 15: [[L5 - Imaging for Facial Deformity.pdf#page=15|L5 - Imaging for Facial Deformity, p.15]] [^16]: Original PDF page 16: [[L5 - Imaging for Facial Deformity.pdf#page=16|L5 - Imaging for Facial Deformity, p.16]] [^17]: Original PDF page 17: [[L5 - Imaging for Facial Deformity.pdf#page=17|L5 - Imaging for Facial Deformity, p.17]] [^18]: Original PDF page 18: [[L5 - Imaging for Facial Deformity.pdf#page=18|L5 - Imaging for Facial Deformity, p.18]] [^19]: Original PDF page 19: [[L5 - Imaging for Facial Deformity.pdf#page=19|L5 - Imaging for Facial Deformity, p.19]] [^20]: Original PDF page 20: [[L5 - Imaging for Facial Deformity.pdf#page=20|L5 - Imaging for Facial Deformity, p.20]] [^21]: Original PDF page 21: [[L5 - Imaging for Facial Deformity.pdf#page=21|L5 - Imaging for Facial Deformity, p.21]] [^22]: Original PDF page 22: [[L5 - Imaging for Facial Deformity.pdf#page=22|L5 - Imaging for Facial Deformity, p.22]] [^23]: Original PDF page 23: [[L5 - Imaging for Facial Deformity.pdf#page=23|L5 - Imaging for Facial Deformity, p.23]] [^24]: Original PDF page 24: [[L5 - Imaging for Facial Deformity.pdf#page=24|L5 - Imaging for Facial Deformity, p.24]] [^25]: Original PDF page 25: [[L5 - Imaging for Facial Deformity.pdf#page=25|L5 - Imaging for Facial Deformity, p.25]] [^26]: Original PDF page 26: [[L5 - Imaging for Facial Deformity.pdf#page=26|L5 - Imaging for Facial Deformity, p.26]] [^27]: Original PDF page 27: [[L5 - Imaging for Facial Deformity.pdf#page=27|L5 - Imaging for Facial Deformity, p.27]] [^28]: Original PDF page 28: [[L5 - Imaging for Facial Deformity.pdf#page=28|L5 - Imaging for Facial Deformity, p.28]] [^29]: Original PDF page 29: [[L5 - Imaging for Facial Deformity.pdf#page=29|L5 - Imaging for Facial Deformity, p.29]] [^30]: Original PDF page 30: [[L5 - Imaging for Facial Deformity.pdf#page=30|L5 - Imaging for Facial Deformity, p.30]] [^31]: Original PDF page 31: [[L5 - Imaging for Facial Deformity.pdf#page=31|L5 - Imaging for Facial Deformity, p.31]] [^32]: Original PDF page 32: [[L5 - Imaging for Facial Deformity.pdf#page=32|L5 - Imaging for Facial Deformity, p.32]] [^33]: Original PDF page 33: [[L5 - Imaging for Facial Deformity.pdf#page=33|L5 - Imaging for Facial Deformity, p.33]] [^34]: Original PDF page 34: [[L5 - Imaging for Facial Deformity.pdf#page=34|L5 - Imaging for Facial Deformity, p.34]] [^35]: Original PDF page 35: [[L5 - Imaging for Facial Deformity.pdf#page=35|L5 - Imaging for Facial Deformity, p.35]] [^36]: Original PDF page 36: [[L5 - Imaging for Facial Deformity.pdf#page=36|L5 - Imaging for Facial Deformity, p.36]] [^37]: Original PDF page 37: [[L5 - 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