Cloverleaf Skull Syndrome: A Rare Case Report

Cloverleaf deformity is an extremely rare skull deformity that happens when mutiple joints (sutures) between a baby's skull bones begin to fuse too premature. Also known as Kleeblattschädel syndrome, the cloverleaf deformity causes bossing at the front and sides of the skull, resembling a cloverleaf shape. Cloverleaf skull syndrome is an abnormal configuration of the calvaria classified as Craniosynostosis, consisting of premature ossification of cranial bones. It is a deformity characterized by a remarkable enlargement of the head, with a trilobed configuration of the frontal view, resembling a three leaved clover .The first report about such a syndrome in the literature occurred in 1973 and, over the years only some tens of cases have been documented worldwide. The present report describes a case of a severe craniofacial condition that is known as "cloverleaf skull syndrome". On Physical examination multiple malformations were observed, with altered craniofacial configuration, low set ear, hypertelorism, exopthalmos, syndactyly, closed anterior fontanelle, high arched palate, bilateral CTEV. The vast majority of patients with kleeblattschädel have mentalretardation and hydrocephalus. It is usually seen in thanatophoric dysplasia: classically type II only, severe Apert syndrome, severe Crouzon syndrome, Boston-type craniosynostosis & Carpenter syndrome. Craniosynostosis has an overall incidence of 1 in 2100 to 1 in 2500 live births with multi-suture craniosynostosis constituting about 5% of all the cases

Alendronato de sódio tópico associado ao osso bovino liofilizado no reparo ósseo / Topical alendronate associated with lyophilized bovine bone in bone repair

Introdução: O osso bovino inorgânico é o enxerto mais utilizado na Odontologia, tendo como desvantagem longo tempo de integração ao leito receptor. Os bifosfonatos têm sido utilizados para modular a quantidade e a qualidade do osso regenerado e diminuir o tempo de integração do enxerto. Objetivo: Avaliar o efeito do bifosfonato alendronato de sódio (ALN) 0,5%, associado ou não ao osso bovino inorgânico, na reparação de defeitos ósseos. Material e método: Dois defeitos ósseos foram confeccionados na calvária de 12 coelhos, sendo a cavidade esquerda/experimental preenchida com: GI = osso bovino inorgânico (Bio-Oss®); GII = Bio-Oss® + ALN 0,5%; GIII = ALN 0,5%; e a cavidade direita por coágulo sanguíneo (controle). Os animais foram mortos aos 60 dias pós-operatórios. Por meio de análise histomorfométrica calculou-se o percentual de osso neoformado e remanescente do biomaterial em relação à área total do defeito. Resultado: Osso neoformado: GI = 38,16 ± 15,44%; GII = 55,77 ± 16,75%; GII I = 60,28 ± 11,45%. Controle = 45,11 ± 11,09%. Remanescente do enxerto: GI = 7,02 ± 5,36% e GII = 16,59 ± 9,56%. Não houve diferença quanto ao percentual de osso neoformado entre os grupos (ANOVA p = 0,15512; teste de Tukey F = 2,089). O percentual de remanescente do enxerto também foi estatisticamente semelhante entre os grupos GI e GII (teste de Tukey F = 5,019). Conclusão: O uso tópico da solução de ALN 0,5% isoladamente ou associado ao osso bovino liofilizado não alterou o percentual de neoformação óssea nem a degradação dos grânulos do enxerto.

Introduction: Inorganic bovine bone is the most used graft in dentistry, with the disadvantage of long integration time into the receptor bed. Bisphosphonates have been used to modulate the quantity and quality of regenerated bone and decrease graft integration time. Objective: To evaluate the effect of alendronate sodium bisphosphonate (ALN) 0.5%, associated or not with Inorganic bovine bone, in the repair of bone defects. Material and method Two bone defects were made in the calvaria of 12 rabbits, and the left/experimental cavity was filled with: GI = Inorganic bovine bone (Bio-Oss®); GII = Bio-Oss® + 0.5% ALN; GIII = 0.5% ALN; and the right cavity/blood clot control. The animals were killed at 60 days after surgery. Through histomorphometric analysis, the percentage of newly formed bone and remnant biomaterial relative to the total area of the defect was calculated. Result: Neoformed bone: GI = 38.16 ± 15.44%, GII = 55.77 ± 16.75%; GIII= 60.28 ± 11.45%; Control=45,11 ± 11,09%. Graft remnant: GI = 7.02 ± 5.36% and GII = 16.59 ± 9.56%. There was no difference in the percentage of newly formed bone between the groups (ANOVA p = 0.15512; Tukey's test F = 2.089). The percentage of graft remnant was also statistically similar between groups GI and GII (Tukey's test F = 5019). Conclusion: Topical use of 0.5% ALN solution alone or associated with lyophilized bovine bone did not change the percentage of bone neoformation, nor the degradation of graft granules.

Development of an experimental model for radiation-induced inhibition of cranial bone regeneration / 대한악안면성형재건외과학회지

BACKGROUND: Radiation therapy is widely employed in the treatment of head and neck cancer. Adverse effects of therapeutic irradiation include delayed bone healing after dental extraction or impaired bone regeneration at the irradiated bony defect. Development of a reliable experimental model may be beneficial to study tissue regeneration in the irradiated field. The current study aimed to develop a relevant animal model of post-radiation cranial bone defect. METHODS: A lead shielding block was designed for selective external irradiation of the mouse calvaria. Critical-size calvarial defect was created 2 weeks after the irradiation. The defect was filled with a collagen scaffold, with or without incorporation of bone morphogenetic protein 2 (BMP-2) (1 μg/ml). The non-irradiated mice treated with or without BMP-2-included scaffold served as control. Four weeks after the surgery, the specimens were harvested and the degree of bone formation was evaluated by histological and radiographical examinations. RESULTS: BMP-2-treated scaffold yielded significant bone regeneration in the mice calvarial defects. However, a single fraction of external irradiation was observed to eliminate the bone regeneration capacity of the BMP-2-incorporated scaffold without influencing the survival of the animals. CONCLUSION: The current study established an efficient model for post-radiation cranial bone regeneration and can be applied for evaluating the robust bone formation system using various chemokines or agents in unfavorable, demanding radiation-related bone defect models.

Effect of herbal extracts on bone regeneration in a rat calvaria defect model and screening system

OBJECTIVES: The aim of this study was to evaluate the effects of herbal extracts on bone regeneration. Two known samples were screened. MATERIALS AND METHODS: We previously established a rat calvaria defect model using a combination of collagen scaffold and herbal extracts. An 8 mm diameter trephine bur with a low-speed dental hand piece was used to create a circular calvaria defect. The experimental group was divided into 4 classifications: control, collagen matrix, Danshen with collagen, and Ge Gan with collagen. Animals in each group were sacrificed at 4, 6, 8, and 10 weeks after surgery, and bone regeneration ability was evaluated by histological examination. RESULTS: Results revealed that both Danshen and Ge Gan extracts increased bone formation activity when used with collagen matrix. All groups showed almost the same histological findings until 6 weeks. However, after 6 weeks, bone formation activity proceeded differently in each group. In the experimental groups, new bone formation activity was found continuously up to 10 weeks. In the Danshen and Ge Gan groups, grafted materials were still present until 10 weeks after treatment, as evidenced by foreign body reactions showing multinucleated giant cells in chronic inflammatory vascular connective tissue. CONCLUSION: Histological analyses showed that Danshen and Ge Gan extractions increased bone formation activity when used in conjunction with collagen matrix.

Physico-chemical and Histomorphometric Evaluation of Zinc-containing Hydroxyapatite in Rabbits Calvaria

Abstract The aim of this study was to characterize the physico-chemical properties and bone repair after implantation of zinc-containing nanostructured porous hydroxyapatite scaffold (nZnHA) in rabbits' calvaria. nZnHA powder containing 2% wt/wt zinc and stoichiometric nanostructured porous hydroxyapatite (nHA - control group) were shaped into disc (8 mm) and calcined at 550 °C. Two surgical defects were created in the calvaria of six rabbits (nZnHA and nHA). After 12 weeks, the animals were euthanized and the grafted area was removed, fixed in 10% formalin with 0.1 M phosphate buffered saline and embedded in paraffin (n=10) for histomorphometric evaluation. In addition, one sample from each group (n=2) was embedded in methylmethacrylate for the SEM and EDS analyses. The thermal treatment transformed the nZnHA disc into a biphasic implant composed of Zn-containing HA and Zn-containing β-tricalcium phosphate (ZnHA/βZnTCP). The XRD patterns for the nHA disc were highly crystalline compared to the ZnHA disc. Histological analysis revealed that both materials were biologically compatible and promoted osteoconduction. X-ray fluorescence and MEV-EDS of nZnHA confirmed zinc in the samples. Histomorphometric evaluation revealed the presence of new bone formation in both frameworks but without statistically significant differences (p>0.05), based on the Wilcoxon test. The current study confirmed that both biomaterials improve bone repair, are biocompatible and osteoconductive, and that zinc (2wt%) did not increase the bone repair. Additional in vivo studies are required to investigate the effect of doping hydroxyapatite with a higher Zn concentration.

Resumo O objetivo deste estudo foi caracterizar físico-químicamente e avaliar o reparo ósseo de discos de hidroxiapatita porosa contendo zinco após a implantação em calvária de coelhos (nZnHA). O pó de nZnHA e o pó hidroxiapatita porosa estequiométrica nanoestruturada (controle - nHA) foram confeccionados em discos (8 mm) e calcinados a 550˚C. Dois defeitos cirúrgicos foram criados na calvária de seis coelhos para a implantação dos discos. Após 12 semanas, os animais foram eutanasiados e as áreas enxertadas foram removidas, fixadas em formol a 10% e embebidas em parafina (n=10) para avaliação histomorfométrica. Além disso, uma amostra de cada grupo (n=2) foi embebida em metilmetacrilato para análise de MEV e EDS. O tratamento térmico dos discos de nZnHA transformou-os em implantes bifásicos compostos por HA contendo Zinco e β fosfato tricálcico com Zinco (ZnHA/βZnTCP). Os discos de nHA, apresentaram-se altamente cristalinos e com baixa solubilidade quando comparados aos discos de ZnHA. A análise histológica revelou que ambos os materiais foram biologicamente compatíveis e promoveram a osteocondução. As análises de FRX e MEV-EDS confirmaram a presença do zinco nas amostras de nZnHA. A avaliação histomorfométrica revelou a presença de neoformação óssea em ambos os grupos, porém sem diferenças estatísticas entre eles, com base no teste de Wilcoxon (p>0,05). O presente estudo confirmou que ambos os biomateriais otimizaram o reparo ósseo, foram biocompatíveis e osseocondutivos e a presença do zinco não favoreceu o reparo ósseo. Estudos adicionais in vivo devem ser conduzidos a fim de investigar o efeito de maiores concentrações de zinco.

Immunoexpression of BMP-2 protein on bone repair of critical size defects treated with autogenous macerated adipose tissue

Introduction: The adipose tissue is an important reservoir of adult stem cells which have capacity of differentiating in osteoblasts with potential implication in reaching bone regeneration. The evaluation of the osteoblastic differentiation can be verified through immunohistochemical markers such as bone morphogenetic protein- 2 (BMP-2). Objective: To evaluate the immunoexpression of BMP-2 protein on the bone repairing of critical size defects (CSD) surgically created in rat calvaria and treated by autogenous macerated adipose tissue. Material and methods: Forty male rats had a CSD measuring 5 mm created on their calvaria. The animals were randomly divided into two groups: group C (control) and group AT (macerated adipose tissue grafting). In group C, the defect was filled with only blood clot. In group AT, the defect was filled with autogenous macerated adipose tissue. The groups were subdivided into two subgroups (n = 10) for euthanasia at 7 and 90 post-operative days. Histological and immunohistochemical analyses were carried out. Data were submitted to descriptive statistics (mode). Results: In group AT, both at 7 and 90 post-operative days, the main healing type was the presence of dense conjunctive tissue exhibiting bundles of collagen fibers disposed in beams permeating the remaining adipose tissue with rare heterotopic bone formation associated to fibrosis and different types of tissue necrosis. In group C, the repair was achieved by the formation of bundles of collagen fibers oriented parallelly to the surface of the wound at the two post-surgical periods. The immune-staining of BMP-2 was present only in group C (7 and 90 post-operative days). Conclusion: Within the limits of this present study, it can be concluded that the adipose tissue grafting did not favor bone neoformation in critical size defects and BMP-2 signaling was not observed.

Electrospun Silk Nano-Fiber Combined with Nano-Hydoxyapatite Graft for the Rabbit Calvarial Model

Efeito local do paratormônio sintético na reconstrução óssea em calvária de coelhas / Local effect of synthetic parathyroid hormone in bone reconstruction of calvaria rabbit model

Objetivo: avaliar a ação local do paratormônio sintético (PTH) na regeneração óssea em calvária de coelhas. Método: foram utilizadas 20 coelhas, adultas, que receberam um cilindro de titânio fixado na calvária. Os animais foram divididos em dois grupos: GC (controle) e GE (experimental). Em cada animal foi realizado, com auxílio de micromotor, descorticalização do osso no local onde foi implantado um cilindro de titânio com volume interno útil de 112 mm3. Cada cilindro, após fixação na calvária, foi preenchido por coágulo sanguíneo obtido do próprio animal. Ao coágulo do grupo experimental foi adicionado 20 µg de PTH sintético derivado de DNA recombinante humano. Após oito e 12 semanas, cinco animais de cada grupo foram anestesiadas, sendo o volume do cilindro avaliado e o tecido presente no interior do cilindro retirado e fixado em formol a 10%. Após fixação o material foi descalcificado e processado para inclusão em parafina. Foram feitos cortes de 5 µm que foram corados pela hematoxilina-eosina e tricrômico de Mallory. Foi feita avaliação histomorfométrica do tecido e os dados submetidos á análise estatística (P < 0,05). Resultados: notamos no interior dos cilindros a presença de tecido conjuntivo frouxo, trabéculas ósseas e regiões de medula óssea, sendo mais desenvolvido no grupo experimental, tanto na 8ª quanto na 12ª semana. A morfometria mostrou maior quantidade de tecido ósseo neoformado no interior dos cilindros, nos grupos experimentais, em relação aos controles. Conclusões: o uso do PTH estimula a formação de tecido ósseo no interior de cilindros implantados em calvária de coelhas.

Objective: to evaluate the local action of synthetic parathyroid hormone (PTH) in bone regeneration of calvaria rabbit model. Methods: twenty animals were divided into two groups: GC (control) and GE (experimental). In each animal, bone removal (decorticalization) was performed with a micromotor and a titanium cylinder (internal useful volume of 112 mm3) was implanted. Afterwards, all cylinders were filled by autogenous blood clots; in the experimental groups, 20ìg of synthetic PTH derived from recombinant human DNA was incorporated into the cylinders. After 8 and 12 weeks, five animals from each group were anesthetized, the cylinder volume measured and the tissue inside the cylinder removed and fixed in 10% formalin. After fixation, the material was decalcified, processed, and 5ìm-thick slices stained with hematoxylin-eosin and Mallory's trichrome. Histomorphometric analysis was made and data submitted to statistical analysis (p<.05). Results: The presence of loose connective tissue, bone trabeculae and bone marrow regions were observed in the cylinders, being more developed in the experimental group, both at 8th and 12th weeks. Also, a higher amount of newly formed bone tissue within the cylinders in the experimental groups compared to controls was seen. Conclusions: the use of PTH stimulated the formation of bone tissue within the cylinders implanted in the calvaria rabbit model.

Bone healing capacity of the new fluoridated hydroxyapatite in the rabbit cranium defect

The bone graft materials are grossly divided into autogenous bone, allogenic bone, xenogenic bone, and alloplastic material. Among the various allogenic graft materials, hydroxyapatite(Ca10(PO4)6(OH)2, HA), the main inorganic phase of human hard tissue, is widely used as a repair material for bones. When HA applied to bony defect, however, it may be encapsulated with fibrous tissue and floated in the implanted area by the lack of consolidation. Fluoridated hydroxyapatite(Ca10(PO4)6(OH)2, FHA), where F- partially replaces the OH- in the hydroxyapatite, is considered as an alternative material for bone repair due to its solubility and biocompatibility. This study was designed to find out the bone healing capacity of FHA newly produced as a nanoscale fiber in the laboratory. We implanted HA and FHA in the rabbit cranium defect and histologically analysed the specimen. The results were as follows. 1. In the 4 weeks, fibrous connective tissue and little bone formation around materials of the experimental group I implanted HA were observed. In the experimental group II implanted FHA, newly formed bone around materials were observed. 2. In the 8 weeks, the amount of newly formed and matured bone of the experimental group II was more than the experimental group I and control group. From the results obtained, we suggest that FHA, newly synthesized, is relatively favorable bone substitute with bioconpatibility and has better bone healing capacity than pure HA.

The Effects of Recombinant Human BMP-7, Prepared from a COS-7 Expression System, on the Proliferation and Differentiation of Rat Newborn Calvarial Osteoblasts

A family of proteins, the bone morphogenetic proteins (BMPs), which promote osteoblast differentiation and bone mineralization, have recently been identified. One, BMP-7, has shown the ability to induce cartilage and bone formation processes. In this report, the possibility that other cell lines, to CHO cells, may also be available as host cells for the expression of hBMP-7 was validated. Recombinant human BMP (rhBMP) -7 was produced in COS-7 cells, as a processed mature disulfide-linked homodimer, with an apparent molecular weight of 36, 000. Examination of the expressions of the markers characteristic of osteoblast phenotypes showed that the rhBMP-7 specifically stimulated the inductions of alkaline phosphatase (ALP) (5-fold increase at 100 ng of rhBMP-7/ml), parathyroid hormone (PTH) -mediated intracellular cAMP production (4-fold increase at 100 ng of rhBMP-7/ml) and osteocalcin synthesis (5-fold increase at 100 ng of rhBMP-7/ml). In summary, the in vitro mineralization assay results provide evidence that the rhBMP-7 peptide, produced by COS-7 expression system, possesses intact biological activity. A similar pattern of biological activity was observed for the BMP-7 in COS-7 cells compared to the corresponding CHO cell expression system. Thus, these findings can be experimentally utilized for the production of rhBMPs for in vitro or in vivo studies.

The Effect Of Hyaluronic Acid On Xenograft In Rat Calvarial Defect

The purpose of this study was to evaluate the tissue response in various bone grafting materials, especially xenogenous bone materials in vivo, compare of bone formation capacity of various bone grafting materials on rat skull defects and evaluate the effect of Hyaluronic acid on healing of human Demineralized Freezed Dried Bone allogenous graft (DFDBA) materials in rat calvarial defects. 30 Sprague-Dawly rats were divided into 4 groups. 7 X 7 mmsize bony defect were artificially prepared in the calvaria (both parietal bone) of all 30 rats and follwed group grafting of autogenous bone graft on right side and allogenic DFDBA on left side bone graft (rat DFDB) in 15 control group, but in 15 experimental group, xenograft (human DFDB) on left side, hyaluronic acid treated with xenograft on right side. Sequential sacrifices was performed at 1, 2, 4, 6, 8 weeks of experiment. These specimens were stained with HandE and MT stain, and then histologic analysis under light microscope was carried out. There were inflammatory reaction in all graft material during early stage. Autogenous and Allogenous DFDBA graft group observed inflammatory reaction at 1 week. Xenograft group persistant inflammatory reaction until 4 weeks, but in HA treated xenograft group inflammatory reaction was decreased at 2 weeks. Osteoblastic activity in control group was begun at 2 week, xenograft group was delayed at 6 weeks, however HA treated xenograft group was begun at 4 weeks. At 2 week, mild osteoclastic activity were observed in all xenograft group not in concerned to HA, but there was no difference each group after 4 weeks. There are most activated angiogenesis around graft mateirals in xenograft group at 2 weeks, but in HA treated xenograft group, decreased angiogenesis was observed at same time. Bone formation and bone maturation of xenograft group, there was no difference in HA treatment, was less than control group. Fibrosis around xenograft materials were observed until 6 weeks, there was no difference between xenograft and HA treated groups.

Guided Bone Regeneration Of Calvarial Bone Defects Using Bioabsorbable Membrane And Demineralized Freeze Dried Bone In Rats

The purpose of this study was to evaluate new bone formation and healing process in rat calvarial bone defects using BioMesh(R) membrane and DFDB. Forty eight rats divided equally into 4 groups of 1 control group and 3 experimental groups. Standardized transosseous circular calvarial defects (8 mm in diameter) were made midparietally. In the control group, the defect was only covered with the soft tissue flap. In the experimental group 1, it was filled with DFDB only, in the experimental group 2, it was covered BioMesh(R) membrane only, and in the experimental group 3, it was filled DFDB and covered with membrane. At the postoperative 1, 2, 4, 8 weeks, rats were sacrificed and histologic and histomorphometric analysis were performed. These results were as follows. In histomorphometric analysis, It showed the greatest amount of new bone formation through experimental in the experimental group 3 (P < 0.001). The amount of new bone formation at the central portion of the defect was greater in the experimental group 3 than experimental group 2. BioMesh(R) membrane began to resorb at 1 week and resorbed almost completely at 8 weeks after operation. The collapse of membrane into the defect was observed through the experimental periods in the experimental group 2. In the area of collapsed membrane, new bone formation was restricted. These results suggest that maintenance of some space for new bone to grow is required in the use of BioMesh(R) membrane alone in the defect. It is also thought that use of the membrane may promote new bone growth in DFDB graft.

Differences in the Metric Dimensions of Craniofacial Structures with Aging in Korean Males and Females / 체질인류학회지

In order to identify the sexual difference and the aging changes on the cranial metric dimensions and to clarify the anthropological characteristics of Korean skulls, authors took the radiographs of lateral skull projections and made out perspective drawings and measured 33 cranial metric dimensions using 32 standard points of normal Korean 373 heads. The results were as follows. 1. 4 items of metric dimensions on the calvarial thickness were greater in the male than the female and all the calvarial thicknesses of younger adults were thicker than the older adults. 2. As a result of measuring 11 items of skull size including the maximum cranial length (glabella to opisthocranion diameter) and the cranial height (basion to vertex diameter), all average metric dimensions of the skull were shown the sexual difference. 3. Among the metric dimensions of skull size, the maximum cranial length (glabella to opisthocranion diameter) was not different between the younger and older adults, but the cranial height (basion to bregma diameter) was greater in the younger than the older adults. 4. In according to the metric dimensions of the cranial base, the length and the angle of the cranial base were shown the sexual difference, that is, all dimensions on the cranial basewere greater in the males. 5. The breadth and height of pituitary fossa were greater in the older female than the younger females. 6. Metric dimensions on the sella position related to other cranial landmarks were shown the sexual difference, but there were no differences between the younger and older adults. 7. Metric dimensions on the frontal sinus were shown the greatest sexual difference and there were the differences between the younger and older males, not in the females. Taken all together, all the basic anthropological data of Korean crania in this study will be helpful to the sexual discrimination, and will be applied to other basic medical and dental sciences.