Long-term orthognathic surgical outcomes in Treacher Collins patients.

INTRODUCTION: Treacher Collins syndrome is a rare disorder characterized by several orofacial findings including malar deficiency and hypoplastic mandibles. These patients often require a combined orthodontic-orthognathic approach to correct their malocclusion. This is most often characterized by a short posterior vertical height and an anterior open bite. Orthognathic correction often requires Le Fort I and bilateral sagittal split osteotomies. No long-term stability results have been reported after bimaxillary surgery in Treacher Collins patients. METHODS: A retrospective review of all Treacher Collins patients evaluated for orthognathic surgery by a single surgeon from 1993 to 2007 was performed. Patients were divided into groups who required surgery and those who did not. Part I analyzed the cephalometric differences between the surgical (S) and nonsurgical (NS) groups. Part II of the study assessed the preorthodontic treatment (T1), preoperative (T2), immediate postoperative (T3), and 1-year postoperative (T4) cephalometric measurement variables to determine the net surgical movement (T3 - T2) and relapse (T4 - T3). RESULTS: Twenty-two patients met the inclusion criteria, of which 11 had occlusal relationships requiring orthognathic surgery. Nine out of 11 chose to have surgery. At baseline, surgical patients exhibited a statistically significant retruded maxilla as measured by SNA and midface length compared to the NS group. In addition, the S group also had an increased gonial angle. There were significant movements in all maxillary and mandibular measurements. There was a significant relapse in the palatal plane angle when the maxilla was anteriorly impacted, with a 2.8-mm average relapse of the advancement. Relapse of the counterrotation movement of the mandible was identified, but this was not significant. Relapse did not affect the final occlusal result, which may have been compensated with postsurgical orthodontic treatment. CONCLUSION: Bimaxillary orthognathic surgery in the Treacher Collins patients may be performed safely with long-term dental and skeletal stability.

Oral health-related quality of life in non-syndromic cleft lip and/or palate patients: a systematic review.

THE OBJECTIVE: To evaluate oral health-related quality of life (OHRQoL) in non-syndromic patients with cleft lip and/or palate (CLP), in comparison to a general non-cleft population. BASIC RESEARCH DESIGN: Systematic review. A literature search was conducted to identify papers reporting on OHRQoL in cleft samples. Only studies with suitable control groups were included. From each included paper were extracted the study and sample characteristics and results. MAIN OUTCOME MEASURES: OHRQoL score. RESULTS: Three papers were chosen according to the preset inclusion and exclusion criteria. All used an OHRQoL generic patient-reported questionnaire with evidence of a development and validation process, with responses recorded on a five-point scale. The results could not be combined for the purposes of meta-analysis due to lack of standardisation. In 2 of the 3 studies, the OHRQoL was found to be significantly lower in the cleft than in the non-cleft samples (in patients 8-18 or 18-65 years of age). The third study, based on a relatively small sample size, could not detect significant differences between cleft and non-cleft individuals. CONCLUSIONS: Based on the results of the few studies included in the present systematic review, non-syndromic patients with CLP tend to have a lower OHRQoL than a general non-cleft population. This seems to hold true both for children and adults.

Correlation between facial morphology and esthetics in patients with repaired complete unilateral cleft lip and palate.

OBJECTIVE: The purpose of this study was to determine if there were correlations between anthropometric nasolabial measurements and subjective assessments of nasal esthetics in individuals with repaired complete unilateral cleft lip and palate (CUCLP). PARTICIPANTS: The sample consisted of 28 individuals with repaired CUCLP and 20 age- and gender-matched individuals without clefts. OUTCOME MEASURES: Nasolabial morphology was assessed using 2D and 3D measurements made on frontal photographs, lateral cephalometric radiographs, and plaster nose casts. A panel of orthodontists rated nasal esthetics from frontal, lateral, three-quarter, and basal view photographs and plaster nose casts using visual analog scales, and they also order ranked the nose casts. Based on the nasal esthetics ratings and rankings, two groups that had the best and the worst esthetics representing the extremes of nasolabial esthetics were statistically identified. Measurements were compared between the cleft and noncleft and the best and worst groups using t tests and analysis of variance. RESULTS: Differences in anthropometric measurements between the groups were identified. The columellar width and nose base and nasolabial angles significantly differed between the best and worst groups (p < .05). Differences in panel ratings of nasolabial esthetics between the best and worst groups were statistically detected using lateral and three-quarter view photographs (p < .05). CONCLUSIONS: Although morphologic differences between the cleft and noncleft and between the best and worst groups were identified, the slight morphologic differences noted were not sufficient to explain the subjective esthetic evaluation by the panel.

Questionnaire for measuring oral health-related quality of life in eight- to ten-year-old children.

PURPOSE: This study measured oral health-related quality of life for children, which involved the construction of child perceptions questionnaires (CPQs) for ages 6 to 7, 8 to 10, and 11 to 14. The purpose of this study was to present the development and evaluation of the CPQ for 8- to 10-year-olds (CPQ8-10). METHODS: Questions (N=25) were selected from the CPQ for 11- to 14-year-olds based on the child development literature and input from parents, child psychologist, and teacher of grades 3 and 4. Validity and reliability were evaluated on 68 and 33 children, respectively. RESULTS: There was a positive moderate correlation between the CPQ8-10 score and overall well-being rating (R=.45). The level of impact was slightly higher in the orofacial than in the pediatric dentistry group (mean score=19.1 vs 18.4, respectively). Hypotheses concerning the relationship between the CPQ8-10 score and number of decayed surfaces were confirmed with R=.29, and the mean score higher in caries-afflicted than caries-free children (21.1 vs 14.7). The Cronbach's alpha and intraclass correlation coefficients were 0.89 and 0.75, respectively. CONCLUSIONS: Results suggest good construct validity, internal consistency, reliability and test-retest reliability, but do not demonstrate discriminative validity. This is consistent, however, with theoretical models of oral disease and its consequences. Further research is required, as these are preliminary findings based on convenience sampling.

Validity and reliability of a questionnaire for measuring child oral-health-related quality of life.

Oral-health-related quality of life measures that exist are designed for adults. This study aimed to develop and evaluate the CPQ(11-14), a self-report measure of the impact of oral and oro-facial conditions on 11- to 14-year-old children. An item pool was generated with the use of a literature review and interviews with health professionals, parents, and child patients. The 36 items rated the most frequent and bothersome by 83 children were selected for the CPQ(11-14). Validity testing involved a new sample of 123 children. Test-retest reliability was assessed in a subgroup of these children (n = 65). Mean CPQ(11-14) scores were highest for oro-facial (31.4), lower for orthodontic (24.3), and lowest for pedodontic (23.3) patients. There were significant associations between the CPQ(11-14) score and global ratings of oral health (p < 0.05) and overall well-being (p < 0.01). The Cronbach's alpha and intraclass correlation coefficient for the CPQ(11-14) were 0.91 and 0.90, respectively. These results suggest that the CPQ(11-14) is valid and reliable.

The mandibular catch-up growth controversy in Pierre Robin sequence.

The purpose of this retrospective longitudinal cephalometric study was to investigate differences in craniofacial and especially mandibular morphology between patients with Pierre Robin sequence and isolated cleft palates. The experimental group comprised 96 patients (54 males and 42 females) with a history of Pierre Robin sequence. This group was compared cephalometrically with a control group of 50 patients (25 males and 25 females) with a history of isolated clefting of the palate. All 96 patients in the PR group had a lateral cephalogram at a mean age of 5.5 years. Thirty-eight of those patients had additional cephalograms at the mean ages of 10.3 years and 16.8 years. All patients in the cleft palate group had 3 corresponding cephalograms at the following mean ages: 5.7 years, 10.6 years, and 17.0 years. Twenty-nine cephalometric measurements were performed on each cephalogram with the use of computerized cephalometric software. Significant differences were identified between the 2 groups, particularly in the size and sagittal position of the mandible, which was consistently shorter in the Pierre Robin group at all 3 ages. Less severe differences were noted in the inclination of the palatal plane, the facial height proportions, and the midface depth. We conclude that patients with Pierre Robin sequence have a significantly smaller mandible as compared with patients with isolated cleft palate, and the difference does not change after the age of 5 years.

Nasal morphology and shape parameters as predictors of nasal esthetics in individuals with complete unilateral cleft lip and palate.

OBJECTIVE: The purpose of this study was to assess the ability of shape parameters of nasal morphology to predict esthetics in individuals with complete unilateral cleft lip and palate (CUCLP). METHODS: This retrospective study involved 28 patients with repaired CUCLP. Nostril morphology was analyzed using nose casts and a video-imaging technique. Calculated shape parameters included area, perimeter, centroid, angle of the principal axis, major and minor moments of area, anisometry, bulkiness, lateral offset, and three-dimensional internostril angles. Esthetics was assessed using a panel of six orthodontists who rated nasal esthetics from frontal, lateral, basal, and three-quarters view slides and from nose casts. Correlations between esthetics and the shape parameters were completed using the entire group as well as using two statistically determined subsets: those with the best and those with the worst esthetics. RESULTS: Nasal esthetics was related to only the perimeter and bulkiness parameter ratios. Symmetry of the perimeters between the right and left nostrils positively correlated with better esthetics using the entire sample group while symmetry of bulkiness between the right and left nostrils positively correlated with better esthetics using both the entire sample group and the best and worst subsets. CONCLUSIONS: Only perimeter and bulkiness showed positive correlations with nasal esthetics. The group of parameters used to assess nostril morphology had neither significant correlation with-nor predictive power for-esthetics. Thus, an assessment of the entire nasal surface topography in three dimensions needs to be completed and assessed with respect to predictability of nasal esthetics.

Comparison of anthropometric and cephalometric measurements of the adult face.

To tabulate and assess quantitative differences between anthropometric and corresponding radiographic cephalometric measurements obtained from the same persons, 19 projective linear measurements were taken from the surface of the heads and faces of 41 patients with cleft lip, cleft palate, or both, all of whom were white North Americans aged 14 to 29 years. They underwent radiographic examination shortly afterward, and corresponding cephalometric measurements were obtained. Differences between the methods were assessed by the numeric differences between the mean values of concurrent measurements. Statistical difference was assessed by paired t test, Pearson product-moment correlations, and intraclass index for degree of agreement between findings. By numeric difference, 6 of 19 anthropometric measurements were similar to (within 2% of) those taken from radiographs. Paired t tests disclosed significant differences between 16 of 19 measurements. Half of the six surface measurements similar to their skeletal counterparts showed no statistical difference; the other half showed only moderately significant differences. Differences between the 13 "dissimilar" measurement pairs (differences > 2%) were highly significant. Good correlations were found in five of the six similar measurements, which may have an important prognostic value in understanding changes in the craniofacial measurements of the face. Knowledge of the correlations between all major measurements of the head and face on the surface and skeleton is essential for anticipating changes in the morphologic characteristics of the growing face.

Outcomes of the surgical exposure, bonding and eruption of 82 impacted maxillary canines.

BACKGROUND: Advances in bonding techniques and materials allow for reliable bracket placement on ectopically positioned teeth. This prospective study evaluates the outcome of forced orthodontic eruption of impacted canine teeth in both palatal and labial positions. METHODS: Eighty-two impacted maxillary canines in 54 patients were included in the study and were observed for 18 to 30 months after exposure. Following exposure by means of a palatal flap or an apically repositioned buccal flap, an orthodontic traction hook, with a ligation chain attached, was bonded to each impacted tooth using a light cured orthodontic resin cement. A periodontal dressing was placed over the surgical site for a period of time. RESULTS: All teeth were successfully erupted. Complications consisted of: failure of initial bond, at the time of surgery, which required rebonding; premature debonding at the time of pack removal and; debonding of brackets during orthodontic eruption. There was no infection, eruption failure, ankylosis, resorption or periodontal defect (pocket greater than 3 mm) associated with any of the exposed teeth. Attached gingiva of less than 3 mm was seen in only two of the buccally positioned canines (9%). CONCLUSION: Forced orthodontic eruption of impacted maxillary canines with a well bonded orthodontic traction hook and ligation chain, used in conjunction with a palatal flap or an apically repositioned labial flap, results in predictable orthodontic eruption with few complications.

Binder syndrome: staging of reconstruction and skeletal stability and relapse patterns after LeFort I osteotomy using miniplate fixation.

The present study prospectively assesses the skeletal stability in a consecutive series of Binder syndrome patients (n = 7), aged 16 to 20 years, who underwent LeFort I osteotomy fixed with miniplates and the associated morbidity. All patients underwent a one-piece LeFort I osteotomy fixed with four miniplates in conjunction with orthodontic treatment during the period of 1986-1992. Five of seven patients underwent iliac grafting to their deficient premaxilla and interpositionally at their osteotomy sites. Six of seven patients underwent bone graft augmentation of their deficient nose (four costochondral, one cranial, and one iliac). Serial cephalometric radiographs were taken at standard intervals after surgery (1 week, 6-8 weeks, 1 year). Horizontal, anterior vertical, and posterior vertical directional changes were then measured at each interval. With the radiographs superimposed, the amount of change was measured by the method of anatomic best fit. The 1-year postoperative cephalograms also were assessed for overjet and overbite. The medical records were reviewed for morbidity. Each patient had a complete set of longitudinal records. Follow-up ranged from 1.5 to 5.5 years at the close of the study. Perioperative morbidity was unremarkable, other than one patient whose cranial bone graft dehiscence through the nasal skin required regrafting. The mean (effective) maxillary advancement for the group was 6.0 mm, with 5.9 mm maintained 1 year later. The mean anterior vertical change of the maxilla was 4.2 mm, with 3.1 mm maintained; whereas the mean posterior vertical change was 2.8 mm, with 2.2 mm maintained. All patients maintained a positive overjet and overbite at 1 year. In our series, a staged reconstructive approach for Binder syndrome was carried out in the teenage years and included orthodontic treatment, orthognathic surgery, and nasal augmentation. The extent of skeletal relapse of the LeFort I osteotomy fell within a range that could be managed effectively to maintain a long-term positive overjet and overbite.

Cleft-orthognathic surgery: complications and long-term results.

We reviewed the complications and long-term results of a consecutive series of adolescents (67 males, 49 females; age range 15 to 25 years; mean 18 years) born with a cleft who underwent primary repair in childhood and later developed a jaw deformity and malocclusion that required orthognathic surgery. Between 1986 and 1992, 116 adolescents with either unilateral cleft lip and palate (n = 66), bilateral cleft lip and palate (n = 33), or isolated cleft palate (n = 17) underwent an orthognathic procedure that included a Le Fort I osteotomy; 32 also underwent simultaneous sagittal split osteotomies of the mandible; and 87 underwent osteoplastic genioplasty. Clinical follow-up ranged from 1 to 7 years (mean 40 months) at the close of the study. The preoperative clinical examination varied according to cleft type and individual variation, but all patients had maxillary hypoplasia. Additional cleft-related deformities included residual oronasal fistula and bony defects, clefted alveolar ridges that retained dental gaps, and mobile premaxilla that lacked union to the lateral segments. Overall, 89 percent of residual fistulas underwent successful closure as part of the orthognathic procedure. Surgical cleft dental gap closure was achieved and maintained to the extent planned at 92 percent of the cleft sites. A fixed (prosthetic) bridge was used successfully for dental rehabilitation to close the gap in all other patients at each cleft site (n = 9). All patients with alveolar clefts (n = 99) maintained keratinized mucosa along the labial surface of the cleft-adjacent teeth (n = 264 teeth). Complications were few and generally not serious. There was no segmental bone loss of teeth because of aseptic necrosis or infection. Only 5 percent of cleft adjacent teeth underwent a degree of gingival recession and root exposure as a result of the maxillary osteotomy procedure; all were retained long term. The long-term maintenance of overjet and overbite measured directly from the late (> 1 year) postoperative lateral cephalometric radiograph indicated that 97 percent of patients maintained a positive overjet and 89 percent maintained a positive overbite; 5 percent shifted to a neutral overbite. The methods used to manage jaw deformity, malocclusion, residual oronasal fistula, and bony defects in adolescents born with a cleft are safe and reliable and offer the patient an enhanced quality of life. They also provide a stable foundation in which final soft-tissue lip and nose revisions may be carried out.

Perceptual characteristics of consonant errors associated with malocclusion.

The characteristics of articulation errors made by subjects having a class II, class II with open-bite, class III, or class III with open-bite malocclusion were compared. Regardless of the type of occlusal defect, errors occurred primarily on the sibilants /s, z/ and "sh, ch, j, dz," which were characterized mostly by combined visual and auditory distortions. Errors on the stop consonants /p, b, m, t, d, n/ occurred less frequently and, in all cases, consisted of isolated visual distortions. The type of malocclusion had a specific influence on the nature of the sound error. Subjects having a class II malocclusion, with or without an open bite, were able to assume a variety of tongue and mandibular postures that allowed them to approximate an /s/ or /z/. These compensations did not occur in subjects with a class III malocclusion. In these cases, the tongue remained distal to the mandibular incisors, causing the air stream to scatter. This study suggests that certain groups of sounds were more susceptible to specific types of misproductions and to particular types of occlusal defects.

Modification of the maxillary Le Fort I osteotomy in cleft-orthognathic surgery: the bilateral cleft lip and palate deformity.

The adolescent with bilateral cleft lip and palate (BCLP) undergoing orthognathic surgery may have multiple residual clefting problems, including a mobile, dysplastic premaxilla and hypoplastic lateral maxillary segments, with each segment misaligned in three dimensions. These problems are commonly compounded by residual oronasal fistulas, bony defects, soft-tissue scarring from previous surgery, and the congenital absence of the maxillary lateral incisor teeth with resulting cleft-dental gaps. This article describes modifications of the Le Fort I osteotomy that allow for the simultaneous routine and safe management of these deformities. Results of this operation on 22 consecutive patients are reported, with findings of follow-up ranging from 1 to 5 years. The long-term parameters reviewed include closure of residual oronasal fistulas, stabilization of the premaxilla, cleft-dental gap closure, maintenance of attached gingiva at the cleft site, maintenance of a positive overjet and overbite, the need for prosthetics to complete dental rehabilitation, and surgical morbidity.

Modification of the maxillary Le Fort I osteotomy in cleft-orthognathic surgery: the unilateral cleft lip and palate deformity.

Modifications of the Le Fort I osteotomy are described that allow for the simultaneous routine and safe management of maxillary hypoplasia, residual oronasal fistula, bony defects, soft-tissue scarring, and cleft-dental gap in adolescents with unilateral cleft lip and palate (UCLP). The results of this operation with 40 consecutive patients are presented, together with follow-up findings ranging from 15 months to 4 years 5 months. Parameters reviewed include cleft-dental gap closure, maintenance of attached gingiva at the cleft site, maintenance of a positive overjet and overbite, closure of residual oronasal fistula, the need for prosthetics to complete dental rehabilitation, and surgical morbidity. Thirteen of the patients also underwent simultaneous sagittal split osteotomies of the mandible, and 29 had a genioplasty performed. In 32 of the patients surgical cleft-dental gap closure was planned, and was successfully executed in all but one. Thirty-seven patients underwent successful simultaneous oronasal fistula closure, but in three cases, small residual fistulas remained. In all cases, attached gingiva was maintained in the region of the cleft site and along the tooth-bearing surfaces. Almost all of the patients maintained a positive overjet (39 of 40) and 85% maintained a positive (34 of 40) or at least neutral (4 of 10) overbite. Complications were few and generally not serious.

Orthodontics.

The authors of this article offer an introduction to the field of orthodontics. They present the latest advances in orthodontic appliances and some of the possible consequences of orthodontic treatment. They discuss a number of cases and offer examples of some of the more common problems that the orthodontist is asked to treat. Such cases include severe Class II, division 1 malocclusion, surgical orthodontics, "long-face" syndrome, adult orthodontics-TMJ-periodontics, late adult growth, and post-retention changes. Practical information useful to the physician who encounters patient with these disorders is balanced with good research data to support the various claims.