Risk of persistent palatal fistula in patients with cleft palate.

IMPORTANCE: Many individuals with a cleft palate also have an associated craniofacial syndrome or anomaly. OBJECTIVE: To investigate the predictive associations of persistent palatal fistulas in patients with previously repaired cleft palate. DESIGN, SETTING, AND PARTICIPANTS: We performed a case-control study of patients with cleft palate repairs from January 1, 1986, through December 31, 2000, at a major tertiary care hospital center in the Bronx, New York. The study population consisted of patients who had their primary surgery before the age of 3 years and had all their cleft-related treatment completed at the same hospital center. Palatal fistula was defined as a breakdown of the primary surgical repair of the palate, resulting in persistent patency between the oral and nasal cavities. Data collection was conducted by using the hospital centers' electronic medical records and patient tracking systems and confirmed by review of hard copies of patient records. MAIN OUTCOMES AND MEASURES: The Veau classification system was used to classify the preoperative cleft severity. RESULTS: A total of 130 patients were identified-23 patients with palatal fistula and 107 controls. A total of 12 girls and 11 boys were identified in the palatal fistula group and 56 girls and 51 boys in the control group. The mean patient age at the time of palatoplasty was 12.6 and 14.5 months in the palatal fistula and control groups, respectively. A statistically significant association was found between the outcome of fistula and severity of cleft, as defined by the Veau classification system (P = .01). Furthermore, for each Veau class increase, the odds of a palatal fistula increased by 2.64 (95% CI, 1.35-5.13; P = .004). No statistically significant associations were found between the outcome of fistula and the following independent variables: patient sex (P = .98), patient age at palatoplasty (P = .82), type of palatoplasty (P = .57), surgeon (P = .15), orthodontic treatment (P = .59), ear infection (P = .30), or clefts associated with syndromes (P = .96). CONCLUSIONS AND RELEVANCE: Palatal fistulas are reliably associated with severity of cleft, as defined by the Veau classification system. This knowledge gives the health care professional a more reliable method of preoperatively assessing the risk of postoperative palatal fistula in the cleft palate population. LEVEL OF EVIDENCE: 3.

Improvement in smile esthetics following orthodontic treatment: a retrospective study utilizing standardized smile analysis.

OBJECTIVE: To quantify smile esthetics following orthodontic treatment and determine whether these changes are correlated to the severity of the initial malocclusion. MATERIALS AND METHODS: A standardized smile mesh analysis that evaluated nine lip-tooth characteristics was applied to two groups of successfully treated patients: group 1 (initial American Board of Orthodontics Discrepancy Index [DI] score<20) and group 2 (initial DI score>20). T-tests were used to detect significant differences between the low-DI and high-DI groups for baseline pretreatment measurements, baseline posttreatment measurements, and changes from pre- to posttreatment. A Spearman correlation test compared the initial DI values with the changes in the nine smile measurements. RESULTS: Five of the smile measurements were improved in both groups following orthodontic treatment. Both groups demonstrated improved incisor exposure, an improved gingival smile line, an increase in smile width, a decreased buccal corridor space, and an improvement in smile consonance. Spearman correlation tests showed that initial DI value was not correlated to changes in any of the individual smile measurements. CONCLUSIONS: Smile esthetics is improved by orthodontic treatment regardless of the initial severity of the malocclusion. In other words, patients with more complex orthodontic issues and their counterparts with minor malocclusions benefitted equally from treatment in terms of their smile esthetics.

Clinical case report: a multidisciplinary solution to a complex restorative problem and a macro-esthetic dilemma.

The restoration of facial harmony and establishment of a functional occlusion can pose unique problems in the treatment of complex dentoskeletal malformations. The advantages offered by the conjoint treatment planning, proper treatment sequencing, and the cooperation of various dental providers can create the best solutions for complex problems in patients. This case presentation demonstrates the interdisciplinary approach used by implant and restorative dentists, oral and maxillofacial surgeons, and orthodontists in a case that required "thinking outside the box" for optimal functional and esthetic solutions.

Root and pulp response after intentional injury from miniscrew placement.

INTRODUCTION: The purpose of this study was to evaluate the effects on the pulp and supporting tissues when miniscrews severely abrade the root surface. METHODS: Sixty self-drilling and self-tapping miniscrews were placed between the premolars and molars of 3 beagles (20 miniscrews per dog). The miniscrews were placed according to the protocol suggested by the manufacturer, but with the intention of inflicting root damage. Radiographs were taken of all 60 interdental alveolar sites, 5 in each quadrant, and sites that evidenced root proximity were identified. The animals were killed at 12 weeks, and 20 of the most probable injury sites were selected for histologic analysis. Serial nondecalcified sections and microcomputed tomography scans were obtained with the implants in place. RESULTS: There was no histologic evidence of inflammatory response either at the root surface or in the pulp. Pulp necrosis, external resorption, and ankylosis were not found, but reparative cementum was seen at each injury site. The presence of woven bone along miniscrew threads lends evidence to support the osseointegration of miniscrews. CONCLUSIONS: Permanent damage to the pulp and supporting tissues is not a regular occurrence when miniscrews abrade or even enter the root surface.

Cementum, pulp, periodontal ligament, and bone response after direct injury with orthodontic anchorage screws: a histomorphologic study in an animal model.

PURPOSE: To assess the histologic response of the periodontium, cementum, and pulp after intentional root injury with titanium screws. MATERIALS AND METHODS: Three female beagle dogs were used, and a total of 60 self-drilling/self-tapping miniscrews were manually inserted into the maxilla and the mandible with the intention of placement in close proximity or in direct contact with the roots. Digital radiographs were taken to select the sites with root injuries. After a 3-month period, the animals were killed and serial nondecalcified histologic sections were obtained with the miniscrew in place. RESULTS: Sixteen sites with significant root injury were identified. Four sites presented with cementum abrasion, 7 sites had dentin penetration up to 50% of the diameter of the screw, and 5 sites had miniscrew penetration into the pulp space with root fragmentation. At all damaged sites, continuous cementum repair could be observed. There was no evidence of external resorption or pulpal necrosis and/or inflammatory infiltrate. Point ankylosis was seen only in cases of severe injury with root fragmentation. Finally, woven bone was present along the miniscrew threads. CONCLUSION: When titanium screws penetrate root cementum or dentin, pulpal necrosis and/or inflammation was not observed at 12 weeks in an animal model. Cementum regenerates at every injury site, but ankylosis can occur with root fragmentation. Woven bone is present at the screw-bone interface even with root contact suggesting osteointegration.

Treatment of obstructive sleep apnea with combined orthognathic-orthodontic approach assessed by nocturnal polysomnography.

This paper presents an evaluation of the effect of surgical mandibular advancement on obstructive sleep apnea (OSA) by sequential nocturnal polysomnography (NPSG). The case of a patient who had undergone several unsuccessful approaches is presented. The main outcome measures were assessed by the functional, occlusal, radiographic and esthetic changes achieved and also by reduction in the Apnea Hypopnea Index. After orthodontic preparation and advancement surgery, a normal over-jet and over-bite were established, the inferior pharyngeal airway space was increased, and there was a profound esthetic profile enhancement. His snoring and overall AHI significantly improved, and our patient is more rested and alert. The authors have concluded that mandibular and genioglossus advancement surgery illustrated objective improvement in the symptoms associated with severe OSA when measured by NPSG.

Craniofacial characteristics evidenced in Bartsocas-Papas syndrome from birth to five years. Case report.

Bartsocas-Papas Syndrome (BPS) is a rare congenital disorder, first described in 1972. It is usually characterized by neonatal or intrauterine death, and, as such, only 26 cases have been reported. Physical manifestations such as antecubital and popliteal pterygia (webbing), syndactyly of fingers, toes and talipes are frequently reported. However, oral, facial, cranial and dental anomalies are often overlooked. This case focuses on the latter anomalies and the effect they have on the facial growth of a 5-year-old patient.

Dento-skeletal implications of Klippel-Feil syndrome [a case report].

Klippel-Feil syndrome is a disorder characterized by failure of normal segmentation of any two of the seven cervical vertebrae. It presents with a high frequency of cleft lip and/or palate and occasional oligodontia in both the primary and permanent dentition, craniofacial asymmetry, maxillary constriction and velopharyngeal insufficiency.