case_images: PMC4979330_01
case_images: Clinical examination of the patient revealed: (a) facial disharmony; (b) exorbitism; (c) hypoplasia of midface; (d) Class III occlusion; (e) narrowed upper dental arch; (f) impaired lower dental arch
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case_images: PMC4979330_01_AMS-6-135-g001.jpg
case_images: F1
case_images: Intraoral investigation revealed Class III malocclusion, maxillary hypoplasia, dome-like deformity of the palate, abnormal anatomy of teeth, narrowing of the upper and lower dental arches [Figure 1].
case_images: Ophthalmological investigation of the patient revealed: (a) strabismus; (b) proptosis; (c) and (d) exophthalmos
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case_images: PMC4979330_01_AMS-6-135-g002.jpg
case_images: F2
case_images: Ophthalmological investigation detected strabismus, exophthalmos, proptosis [Figure 2].
case_images: Radiological investigation of the patient detected: (a) no coronal and sagittal sutures; (b) increased distance between C5-C6; (c) increased volume of ephippium; (d) tower-like deformity of cranium; (e) increased cranial index; (f) midfacial hypoplasia; (g) digital impressions on inner surface of the cranial vault; (h) normal intercanthal distance; (i) decreased length of the orbits; (j) diameter of the eyeballs are normal; (k) the length of the optic nerves are normal; (l) SNA is compromised
case_images: AMS-6-135-g003.jpg
case_images: PMC4979330_01_AMS-6-135-g003.jpg
case_images: F3
case_images: The computed tomography (CT) scan showed no coronal and sagittal sutures on cranial vault, increase in the distance of C5-C6, increase in the volume of ephippium, tower-shaped deformity of the cranial vault as well as increased diameter of the head and cephalometric index up to 82.35 (the normal range is 78.3), hypoplasia of the midface, digital impressions on the inner surface of the cranial vault, normal intercanthal distance, decreased depth of both orbits (29.77 mm on the right side and 27.64 mm on the left side) and normal anatomy of both eyeballs [Figure 3].
case_images: Preoperative virtual planning: (a) anterior craniotomy; (b) facial bones osteotomy; (c) and (d) circular osteotomy; (e) vomer osteotomy; (f) pterygo-maxillary disjunction
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case_images: F4
case_images: Three-dimensional cephalometric investigation revealed impaired SNA and SNB [Figure 4]. As a result complete segmentation of virtual monobloc was achieved and its virtual advancement was visualized [Figure 4].
case_images: Preoperative virtual planning: (a) monobloc advancement; (b) distractors positioning
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case_images: PMC4979330_01_AMS-6-135-g005.jpg
case_images: F5
case_images: Because of primary idea to perform monobloc advancement by the means of internal distractors, the virtual analogues were used to determine their best position and distraction direction [Figure 5].
case_images: Surgical procedure: (a) Exposure of cranial skeleton; (b) access to anterior cranial fossa; (c) orbital roof osteotomy; (d) lateral orbit osteotomy
case_images: AMS-6-135-g006.jpg
case_images: PMC4979330_01_AMS-6-135-g006.jpg
case_images: F6
case_images: Then circular orbitotomy was performed on both sides starting from lateral and medial orbital walls and finalized on inferior wall, which has been done blunt by the means of chisel [Figure 6].
case_images: Surgical procedure: (a and b) internal distractors placement; (c and d) cranioplasty
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case_images: PMC4979330_01_AMS-6-135-g007.jpg
case_images: F7
case_images: All segments of monbloc were fixed together and final suturing was done [Figure 7].
case_images: Postoperative clinical view of the patient: (a) facial harmony restored; (b) no exorbitism occurs; (c) maxillary hypoplasia eliminated; (d) Class I oclussion achieved
case_images: AMS-6-135-g008.jpg
case_images: PMC4979330_01_AMS-6-135-g008.jpg
case_images: F8
case_images: On 15 months of follow-up clinical reduction of chief symptoms was noted, including restoring of facial harmony, achieving normal Class I occlusion, treating hypertelorism and bite correction making eating and chewing easier [Figure 8].
case_images: Postoperative computed tomography scan: Comparative computed tomography scan proves proper monobloc advancement
case_images: AMS-6-135-g009.jpg
case_images: PMC4979330_01_AMS-6-135-g009.jpg
case_images: F9
case_images: Postoperative CT scan showed midface and forehead advancement done properly [Figure 9].