Facial growth and development in unilateral cleft lip and palate: comparison between secondary alveolar bone grafting and primary periosteoplasty.

OBJECTIVE: To describe the effect of secondary alveolar bone grafting in patients with unilateral cleft lip and palate by comparison with a sample of patients who have undergone primary periosteoplasty. DESIGN: Cephalometric analysis of lateral x-ray films in a retrospective semilongitudinal study. PATIENTS: Lateral x-ray films of 18 secondary alveolar bone grafting patients and 48 primary periosteoplasty patients at 10 years of age and again at 15 years of age. SETTINGS: The treatment of secondary alveolar bone grafting patients included lip repair according to Tennison, palatoplasty including retropositioning, pharyngeal flap surgery, and secondary alveolar bone grafting. The lips of primary periosteoplasty patient were repaired using the methods of Tennison and Veau, followed by primary periosteoplasty, palatoplasty including retropositioning, and pharyngeal flap surgery. METHODS: Lateral radiographs were assessed using classical morphometry. RESULTS: There were few significant differences at 10 years of age between the secondary alveolar bone grafting and primary periosteoplasty patients. At 15 years of age, there were several significant differences. Compared with primary periosteoplasty patients, subsequent development in patients who had undergone secondary alveolar bone grafting was characterized by a significantly better position of the upper and lower dentoalveolar components in relation to the facial plane, a higher increase in the global convexity of the soft profile, a significantly better maxillary inclination, and a more favorable development of vertical intermaxillary relationships. CONCLUSION: Craniofacial development in secondary alveolar bone grafting patients was better than that in primary periosteoplasty patients due to the more marked facial convexity, the increased prominence of the nose, and better vertical intermaxillary relationships.

Three-dimensional morphology of the palate in patients with bilateral complete cleft lip and palate at the stage of permanent dentition.

OBJECTIVE: Three-dimensional analysis of palate size and shape in 30 patients with complete bilateral cleft lip and palate (BCLPc) at the stage of permanent dentition. DESIGN: Cross-sectional study based on laser scanning. SUBJECTS: Thirty dental casts of boys approximately 15 years old with BCLPc and 28 dental casts of healthy boys of the same age. INTERVENTIONS: Arched-lip suture with periosteoplasty and push-back of the palate with pharyngeal-flap surgery. MAIN OUTCOME MEASURES: Data on palate height in the 210 defined locations and on palate widths and profile area in 10 transverse sections. RESULTS: The palate in patients with BCLPc was conical and narrower than in control study subjects, much more anteriorly than posteriorly. From the canines posteriorly, the palate was of almost constant height of 10 mm in the midline, being higher than in control study subjects at this location and lower more posteriorly (by 24% to 29% between molars). The area of transverse sections was reduced as compared with control study subjects from the first premolars posteriorly and reached more than 40% between molars. The length of the palate up to the first molars was not changed. CONCLUSION: BCLPc subjects exhibited narrow, low, and flat palate. Palate size and shape differences indicate a substantial reduction of the space for the tongue.

Scar flap for extension of the nasal and lip soft tissue shell in secondary cleft deformities: final aesthetic touches in clefts-part iii.

A scar flap is formed with the pedicle at the lateral part of the columella base at the cleft side, that is, in the center of the affected region. It enables flap placement according to individual need. A prospective evaluation was performed in a group of 76 patients with cleft lip and palate, all operated on by the same plastic surgeon. The flap was used to improve the height of the columella and the extent of nasal mucosa on the frontal septum and on the nostril base in the vestibule. In the lip, the flap raised its height and improved proportionality. The average area of flap used in a unilateral deformity was 42 mm. Both flaps in a bilateral deformity were 77 mm. The average follow-up was 22.4 months. Neither local nor general complications were noted apart from a recurrence of the deformity of the nasal septum in 7.9% of patients. The nasal passage was improved in 59.9% of patients and normalized in 19.6% upon follow-up rhinomanometry, but nevertheless, only one third of patients overcame their dynamic stereotype of breathing by the mouth. Anthropometric measurements showed an absence of statistically significant differences between patients after surgery and healthy individuals in crucial parameters (nasal tip projection, length of columella, nasolabial angle, nasal angle, and lip angle). The loss of the stigmatizing deformity is based on rotation of the nasolabial angle in relation to the aesthetic axis of the face. Direct examination proved aesthetic and functional improvement as statistically significant in 92.1% of patients.

The anthropometric verification of corrective surgery outcome in cleft secondary deformities.

An anthropometric measurement serves as both an objective assessment and a description of shape and size. Gypsum casts were used for the measurement, along with a statistical evaluation of results, to compare the appearance of patients with a complete unilateral or bilateral cleft lip and palate prior to corrective surgery of their secondary deformity and following this intervention. The evaluated approach was our own modification of rhinoplasty and lip correction, using the remodeling and extension of soft tissues envelope by a skin flap. That is formed from a lip scar after primary reconstruction. Both data of the studied group (n = 49), pre- and postoperative, were compared to a control group of healthy individuals (k = 19), thereby allowing the original severity of the deformity and the morphologic change after surgery to be objectively assessed. Upon correlation to healthy volunteers, we proved that the effect of surgery shifted the monitored parameters into a range found in the normal population. An anthropometric measurement on gypsum casts appeared to be simple, easy to perform, precise, easy to repeat, inexpensive, and yet of a three-dimensional nature with no burden for the patient. It is suitable for verifying the effects of new therapeutic procedures.

Three-dimensional morphology of the palate in subjects with unilateral complete cleft lip and palate at the stage of permanent dentition.

OBJECTIVE: Three-dimensional analysis of palate size and shape in patients with complete unilateral cleft lip and palate (UCLP) at the stage of permanent dentition. SUBJECTS: Thirty randomly selected dental casts of boys approximately 15 years old with complete UCLP and 28 dental casts of normal boys of the same age. INTERVENTIONS: All patients underwent lip repair according to Tennison with primary periosteoplasty (mean age 8.5 months) and palate repair by pushback and pharyngeal flap surgery (mean age 4.9 years). MAIN OUTCOME MEASURES: Data on the palate height in 210 defined locations. RESULTS: The palate in patients with UCLP was narrower throughout its whole extent, more anteriorly than posteriorly. From the canines posteriorly, it was also lower, and the difference as compared with controls increased in a posterior direction up to the level of second premolars (up to 30%) and then slightly diminished (to 21% between the first molars). The reduction of area of transverse sections reached 45% between premolars and 39% between first molars. The palate in the anterior portion was highest on the cleft side and in a posterior direction the maximum height of the palate shifted toward the midline and even beyond that line toward the noncleft side. Palatal height did not depend on dentoalveolar arch width. CONCLUSION: The smaller width and height of the palate confirm the substantially reduced space for the tongue in patients with UCLP. The reduction is only slightly larger than in previously examined patients with isolated cleft palate. Palatal vault is asymmetrical, highest anteriorly on the cleft side and posteriorly on the noncleft side.

Three-dimensional analysis of maxillary dental casts using Fourier transform profilometry: precision and reliability of the measurement.

OBJECTIVE: Fourier transform profilometry was used for the three-dimensional measurement of maxillary dental casts to analyze the size and shape of the palate. The objective of this study was to test the accuracy of the measuring system and determine the precision and reliability of the measurement METHODS: Images of dental casts were analyzed using newly developed measuring software. Based on five landmarks located on the alveolar ridge, the measuring software constructed 10 transversal sections of the palate. In each section profile, the width, area, and 23 height variables were assessed. SUBJECTS: Maxillary dental stone casts of 25 healthy girls, 14.1 to 15.3 years of age, were studied. RESULTS: The technical error of measurement exceeded 5% of the size of the measurement only in variables with means less than approximately 3 mm. In fact, such small absolute dimensions were exhibited only by the palate height in anterior profile 2 and the palate height at the margins of other profiles. Reliability of the measurements was found to be very high for the width and area of the profiles. For height measurements, the coefficient of reliability was slightly lower at the profile margins than near the midline. Nevertheless, only three height variables showed a coefficient of reliability lower than 0.90. The coefficients of reliability of other height measurements of profiles 3 through 10 were only sporadically lower than 0.97. CONCLUSION: With regard to the accuracy of the measuring system as well as the precision and reliability of the measurement, this method proved to be a suitable tool for studying palatal morphology.

Three-dimensional morphology of the palate in subjects with isolated cleft palate at the stage of permanent dentition.

OBJECTIVE: Three-dimensional analysis of palate size and shape in patients with isolated cleft palate at the stage of permanent dentition. DESIGN: Cross-sectional study using Fourier transform profilometry. SUBJECTS: Twenty-nine randomly selected dental casts of approximately 15-year-old boys with isolated cleft palate and 28 dental casts of normal boys of the same age. INTERVENTIONS: All patients were operated on by the same method (pushback and pharyngeal flap surgery) at a mean age of 4.5 years. MAIN OUTCOME MEASURES: Data on the palate height in 210 defined locations (pixels). RESULTS: The palate in isolated clefts is narrower throughout its whole extent and lower from the level of the first premolars. The difference, as compared with controls, increases in a posterior direction. At the level of the first molars, palatal height is reduced by one-quarter, the area of the transversal section by more than one-third. The shaping of the palate vault is, on average, symmetrical with a marked interindividual variability. Palatal height does not depend on the width of the dentoalveolar arch, and the height of the primary palate is not reduced. CONCLUSION: The smaller width and reduced height from the level of the first premolars posteriorly confirm the substantially reduced space available for the tongue in patients with isolated cleft palate. Deviations are on the average symmetrical, and the anterior part of the palate is not shallower.

Cephalometric assessment of cranial abnormalities in patients with acromegaly.

OBJECTIVE AND PATIENTS: Patients with acromegaly (12 women, 26 men) and a control group (36 women, 50 men) were chosen for cephalometry to assess the size, shape and positional characteristics of the craniofacial bones and the upper airways. RESULTS: When compared with the controls, patients of both sexes with acromegaly were found to have significant anomalies in the orofacial skeleton: increased facial height, elongated ascending ramus mandibulae and greater basion-supramentale distance, a negative difference between maxillary and mandibular protrusions, enlarged lower part of the gonion angle and of the angle of inclination of the maxilla, as well as alterations in the neurocranium: enlargement of sella turcica and of sinus frontalis and protrusion of the supraorbital ridges. As for the soft tissues, patients with acromegaly exhibited an elongated soft palate and a diminished angle between the uvular axis and the palatal plane. A comparison between the cephalometric parameters of patients with active acromegaly and those without active disease revealed no significant differences in either sex. CONCLUSION: Patients with acromegaly exhibited an enlargement of all parts of the neurocranium and orofacial bones except the maxilla. The greatest anomaly was seen in the mandible, with greater enlargement of the ascending ramus than of the body of the mandible. The shape of this bone was also altered.

Bioactive glass-ceramics in facial skeleton contouring.

The removal of certain facial-bone defects is a prerequisite to restoration of function, stability, and appearance. Synthetic bone substitutes are beneficial in cases where other operative techniques would be an unacceptable burden for a patient. Satisfactory results can be achieved in one surgical intervention with low costs and low demand on technical equipment. Osteoconductive, biocompatible, non-resorbable glass-ceramic implants based on oxyfluoroapatite and wollastonite permit osteointegration--a direct physical and chemical bond between live bone tissue and the implant without formation of a fibrous capsule. They display better stress durability in simulated body fluid than hydroxyapatite implants do. This material was used for facial skeletal framework, contour restoration in 44 cases under conditions where other solutions were doubtful. Patients were observed for 24.8 months. Immediate healing occurred without any adverse reaction. The main problem was extrusion, observed in 20.45% cases over a 2-3 month period after the implantation. All cases, with one exception, were solved with a satisfactory final result by reoperation, implant size reduction, and increased soft tissue cover. This approach was found to be a suitable technique, especially for patients exhausted by prior incompetent treatment but still dissatisfied with their appearance. Successful reconstruction with a bone substitute may remarkably increase quality of life for affected persons and, at the same time, reduce surgery-related time and costs.

Increased risk of traffic accidents in subjects with latent toxoplasmosis: a retrospective case-control study.

BACKGROUND: The parasite Toxoplasma gondii infects 30-60% of humans worldwide. Latent toxoplasmosis, i.e., the life-long presence of Toxoplasma cysts in neural and muscular tissues, leads to prolongation of reaction times in infected subjects. It is not know, however, whether the changes observed in laboratory influence the performance of subjects in real-life situations. METHODS: The seroprevalence of latent toxoplasmosis in subjects involved in traffic accidents (N=146) and in the general population living in the same area (N=446) was compared by a Mantel-Haenszel test for age-stratified data. Correlation between relative risk of traffic accident and a level of anti-Toxoplasma antibody titre was evaluated with the Cochran-Armitage test for trend. RESULTS: A higher seroprevalence was found in the traffic accident set than in the general population (Chi2MH=21.45, p<0.0001). The value of the odds ratio (OR) suggests that subjects with latent toxoplasmosis had a 2.65 (C.I.95= 1.764.01) times higher risk of an accident than the toxoplasmosis-negative subjects. The OR significantly increased with level of anti-Toxoplasma antibody titre (p<0.0001), being low (OR=1.86, C.I.95=1.14-3.03) for the 99 subjects with low antibody titres (8 and 16), higher (OR=4.78, C.I.95=2.39-9.59) for the 37 subjects with moderate titres (32 and 64), and very high (OR=16.03, C.I.95=1.89-135.66) for the 6 subjects with titres higher than 64. CONCLUSION: The subjects with latent toxoplasmosis have significantly increased risk of traffic accidents than the noninfected subjects. Relative risk of traffic accidents decreases with the duration of infection. These results suggest that 'asymptomatic' acquired toxoplasmosis might in fact represent a serious and highly underestimated public health as well as economic problem.