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Occlusal & Dental Outcomes Following Facial Allotransplantation
Demetrius M. Coombs, M.D.1, Fatma B. Tuncer, M.D.1, Bahar B. Gharb, M.D., Ph.D.1, Risal Djohan, M.D.1, Brian Gastman, M.D.1, Steven Bernard, M.D.1, Mark F. Hendrickson, M.D.1, Graham Schwarz, M.D.1, Raffi Gurunian, M.D., Ph.D.1, Maria Siemionow, M.D., Ph.D.2, Francis Papay, M.D.1, Antonio Rampazzo, M.D., Ph.D.1.
1The Cleveland Clinic, Cleveland, OH, USA, 2University of Illinois College of Medicine, Chicago, IL, USA.

PURPOSE: Most of the literature surrounding face transplantation focuses on immunology, function, and psychology. Dental and orthognathic outcomes remain persistently underreported. This study sought to review the worldwide face transplant experience, and for the first time, evaluate dental, orthognathic, and skeletal outcomes.
METHODS: All composite allografts containing maxilla and/or mandible with alveolus were examined, and dental and orthognathic complications recorded. Clinical photographs, radiographs, and/or CT scans from the literature were analyzed using Angle’s Classification, cephalometrics, and facial profile angles. The most recent orthognathic outcomes of our three facial transplant patients are also presented.
RESULTS: The worldwide experience consists of 45 face transplantations; 25 patients received allografts containing maxilla or mandible, and 16 (64%) involved double-jaw. All documented patients had at least one dental/occlusal complication: TMJ ankylosis (9/25, 36%), dental caries and extractions (32%), palatal fistula (28%), Angle class II malocclusion (24%), class III (12%), open bite (20%), maxillary rotation (8%), skeletal non-union (8%), hardware infection (4%); 28% of patients underwent revision surgeries involving Lefort I, III, or mandibular osteotomies. Imaging conducive to Angle, cephalometric, or facial profile angle analysis was available in 100% (7) of reported maxilla, and 63% (10) of double jaw transplants. The majority of maxilla-only transplants had insufficient teeth, while soft tissue profile was most commonly class II. Double jaws were equally Angle class I, II, or III, but mostly class I or class III with regard to facial angle profile. All of our patients have received maxilla and/or mandible, and all have required dental extractions. Angle classification, cephalometrics, and facial profile angles vary across our patients, while class III soft tissue facial profile appears to predominate.
CONCLUSION: Dental and orthognathic complications remain extremely common but underreported after facial allotransplantation involving either single or double jaw composites. In fact, every documented face transplant has at least one occlusal or skeletal defect. The risk of malocclusion increases with simultaneous transplantation of maxilla and mandible, and often necessitates revision surgery in this unique population. Craniofacial principles and advanced surgical planning should be utilized to achieve facial balance. Additionally, we must standardize the way in which face transplant patients are presented in the literature.


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