Displacement of the mandible in a child with congenital unilateral temporomandibular joint ankylosis treated with two-stage condylar replacement: a long-term study with the aid of roentgen stereometric analysis.

OBJECTIVE: To monitor mandibular displacement in three dimensions with a high degree of accuracy before, during, and after treatment. DESIGN: Prospective roentgen stereometric analysis from age 3 years 7 months to age 13 years 8 months. SETTING: Center for Craniofacial Anomalies and Department of Maxillofacial Surgery, Malmö University Hospital, Malmö, Sweden. PATIENT: Girl with unilateral congenital temporomandibular joint (TMJ) ankylosis and marked facial asymmetry. INTERVENTIONS: Epipharyngeal inspection at age 2 years 6 months and insertion of implants under general anesthesia. Resection of the affected right condyle at age 5 years 4 months, replacement of the ramus-condyle complex with a custom made titanium prosthesis at age 5 years 5 months, and replacement of the artificial condyle by a costochondral graft at age 9 years 7 months. Roentgen examinations were performed at intervals from age 3 years 7 months to age 13 years 8 months. Body length was measured annually. MAIN OUTCOME MEASURES: Stereo roentgenograms were digitized by the Department of Orthopedic Surgery, Malmö University Hospital. RESULTS: Unexpected lowering of the mandible occurred before treatment. Each procedure had a distinct effect on the direction of mandibular displacement. There was little or no pathological involvement of the functional matrix. Growth of the costochondral graft exceeded growth of the unaffected TMJ. Anterior displacement as well as rotation and tilting of the mandible to the unaffected side accelerated after the age of body peak height velocity. CONCLUSIONS: Accurate monitoring of mandibular displacement may contribute to a rationale for clinicians' decision on treatment protocol and reveal compensatory differential growth.

Adult skeletal profile in isolated cleft palate: a comparison of the von Langenbeck and Wardill procedures for primary repair of the palate.

Sixty-four adult patients operated on for isolated cleft palate were evaluated with regard to facial skeletal morphology using conventional radio-cephalometry. Dental occlusion was assessed clinically. Forty-two had had a von Langenbeck repair at the age of 7 months and 22 a Wardill repair at 18 months. The mean error of the method was 0.7 degree for angular, and 0.9 mm for linear, measurements. The group with clefts had less maxillary prognathism (s-n-ss), more maxillary inclination (NSL/NL), more retroclined lower incisors (ILI/ML), and shorter total and upper facial heights (n-gn, n-sp) compared with the reference group. Multiple regression analysis was used to evaluate differences between the two treatment regimens. Explanatory variables in addition to surgical technique were sex, severity of cleft, and presence of a velopharyngeal flap. Only one variable, lower incisor inclination (ILI/ML), was different for the two regimens. Ten (24%) in the von Langenbeck group had a lateral cross-bite compared with one (5%) in the Wardill group. Other variables in a multivariate regression analysis were affected by sex and severity of cleft to various degrees. This study showed no obvious differences in facial skeletal morphology that could be attributed to surgical technique. Factors other than technique, including sex, age, and severity of cleft merit attention.

Von Langenbeck or Wardill procedures for primary palatal repair in patients with isolated cleft palate--speech results.

Sixty-six patients operated on for isolated cleft palate were evaluated as adults, and their speech was assessed clinically. Forty-four had undergone a von Langenbeck repair at the age of 7 months and 22 a Wardill repair at the age of 18 months. Speech was judged subjectively by the patients themselves, and perceptual assessment was made by three speech pathologists. The remaining speech problems, mainly hypernasality, were moderate or severe in 7 (16%) of the patients in the von Langenbeck group, and in 7 (32%) in the Wardill group. On the other hand, the patients in the Wardill group had fewer fistulas closed, and fewer velopharyngoplasties. There were no significant differences between the two methods regarding speech in adulthood. The Wardill method produced significantly more scar tissue clinically, which carries the potential risk of inhibition of facial growth. The present speech results will therefore be weighed against the outcome of maxillofacial growth for these patients.

Facial growth in a cleft palate patient treated with the Herbst appliance: a long-term profile roentgenographic and roentgen stereometric analysis of profile changes and displacement of the jaws.

OBJECTIVE: To monitor facial development in a patient with cleft palate who was treated with the Herbst appliance. Monitoring was in terms of changes in the skeletal profile and growth in the circummaxillary sutures and temporomandibular joints (TMJs). DESIGN: Prospective profile roentgenography (between the ages of 6 and 20 years) and roentgen stereometric analysis (between the ages of 8 and 19 years). SETTING: Center for Craniofacial Anomalies and Department of Plastic and Reconstructive Surgery, Malmö University Hospital, Malmö, Sweden. PATIENT: Boy with cleft of the soft and posterior part of the hard palate and marked facial convexity. INTERVENTIONS: Surgical repair of the soft palate at age 9 months, velopharyngeal flap at age 8 years, and insertion of implants under general anesthesia and treatment with the Herbst appliance at age 11 years. Roentgen examinations were performed in connection with continued clinical evaluations and treatment. MAIN OUTCOME MEASURES: Profile roentgenograms were traced and measured by one of the authors using conventional point-based analysis. Stereo roentgenograms were digitized by the Department of Orthopedic Surgery, Malmö University Hospital. RESULTS: The direction of profile changes was partly discordant with the direction of articular growth in the circummaxillary sutures and TMJs. The successful treatment result was accomplished by a temporary influence on sagittal growth direction in the circummaxillary sutures and on rotational growth direction in the TMJs, combined with a favorable natural remodeling and articular growth pattern. CONCLUSIONS: The mode of growth by which treatment aims were reached was partly unexpected, i.e., discordant with the generally accepted principal concept that treatment with the Herbst appliance positions the mandible forward.

Computing data about patients with cleft lip and palate.

For clinical research and quality control in the treatment of patients with cleft lip and palate (CLP) we created a register based on commercially available computer components. In this report we present the logical organisation of the system and give some representative examples of its applicability. There is great potential for easy access to data, and presentation.

Mandibulofacial dysostosis--variability in facial morphology and growth: a long-term profile roentgenographic and roentgen stereometric analysis of three patients.

OBJECTIVE: To monitor and compare facial morphology and growth in three individuals with variable expression of mandibulofacial dysostosis (MFD) in terms of changes in the skeletal profile and in terms of growth in the circummaxillary sutures and temporomandibular joints (TMJs). DESIGN: Retrospective conventional profile roentgenography (mean age 9 to 18 years) and prospective roentgen stereometric analysis (RSA) (mean age 7 to 17 years). SETTING: Center for Craniofacial Anomalies and Department of Plastic and Reconstructive Surgery, Malmö University Hospital, Sweden. PATIENTS: The first three MFD patients seen by one of the authors (B.R.). INTERVENTIONS: Surgery was performed at the Department of Plastic and Reconstructive Surgery. Implants were inserted at surgery under general anesthesia. Roentgen examinations were performed in connection with continued clinical evaluations and treatment. MAIN OUTCOME MEASURES: All profile roentgenograms were traced and measured by one of the authors (K.-V.S.) using a conventional point-based analysis. RESULTS: The more afflicted patient showed a greater total difference in profile morphology and growth from the norm and more pronounced effects of articular growth restriction. Little change in the skeletal profile was associated with considerable displacement of the jaws. CONCLUSIONS: The variability in MFD expression and surgical procedures in our patients is reflected less in the skeletal profile morphology and growth and more in the displacement of the jaws.

Millard repair of unilateral isolated cleft lip: a 25-year follow-up.

Twenty-five patients with isolated unilateral cleft lip took part in a follow-up study at a mean age of 28.6 years. All had had a primary, Millard lip repair, at a mean age of 4.6 months. In 20 patients, at least one secondary correction had been undertaken during adolescence. The overall long-term outcome was thought to be good, leaving a fairly inconspicuous fine lip scar and acceptable nose configuration. In half the patients, however, the lip was slightly elongated and the nostrils were still asymmetrical. These findings concurred with the patients' subjective assessments, which showed that appearance of the lip and nose were rated good by 20 (80%) and 16 (64%), respectively. The findings of this study provide a baseline for future evaluation of the results achieved with lip closure by Johanson's technique.

Intramatrix rotation--the frontal bone.

Intramatrix rotation during growth and development was studied by 2-D cephalometric technique with the use of metallic implants in the frontal bone in five patients at the Centre for Craniofacial Anomalies, Malmö General Hospital. The analysis of the frontal bone in the five patients showed rotations of the corpus inside the periosteal matrix from 1 to 9.5 degrees in the mid-sagittal plane. The essential conclusion of these observations is that an intramatrix rotation takes place during the development of the frontal bone. This observation will stimulate further studies of its nature, amount, and direction.

Long-term effect of rapid maxillary expansion studied in one patient with the aid of metallic implants and roentgen stereometry.

The articulatory displacement of maxillary bones during and after rapid maxillary expansion (RME) was studied with metallic implants and roentgen stereometry (RSA) for 3653 days in a girl aged 12 at start of treatment. She had a narrow upper dental arch with anterior crowding and a normal incisor relationship, and a normal sagittal molar relationship with bilateral cross-bite. Three implants were inserted in each maxillary bone and they remained stable in the bones during the 10-year observation period. In the 3-D analysis of the articulatory displacement, the left maxillary bone was studied in relation to the right bone in three periods: RME (23 days), retention (108 days) and follow-up (3522 days). Extensive relapse of rotations as well as translations was found and the long-term effect of RME was limited. In our opinion the relapse was caused mainly by the resistance to deformation from circum-maxillary sutures and surrounding soft tissue matrix, and inadequate bone formation in the involved sutures. As is generally known in clinical oral orthopaedics, changes obtained by short-term simple mechanical interference with a complex biological system tend to reverse spontaneously. Thus, the rationale for RME treatment may be seriously questioned.

[The effect of passive plates on the arrangement of the alveolar arch segments in unilateral total cheilognathopalatoschisis]. / Die Wirkung passiver Platten auf die Einordnung der Alveolarbogensegmente bei einseitig totalen Lippen-Kiefer-Gaumen-Spalten.

Maxillary alveolar arch morphology was studied from birth to palate repair at the age of 19 months in 24 children with complete unilateral cleft lip and palate (UCLP) treated with passive orthopaedic plates (treated children). 18 children with the same defect, who received no orthopaedic treatment, served as controls. The surgical procedures and the age at lip and palate repair were similar. Maxillary alveolar arch morphology was described by 15 linear and five angular measurements. No significant difference was found in total alveolar crest length neither between the cleft and the non-cleft maxillae nor between the treated children and the controls. Anterior alveolar arch width was significantly larger in the treated children at lip repair and at palate repair. Posterior alveolar arch width was significantly larger in the treated children at lip repair only. There was no significant difference in alveolar cleft width between the treated children and the controls at lip or at palate repair. Palatal cleft width decreased significantly in the treated children only. Medial rotation of both the cleft and the non-cleft maxillae was observed in both groups. The main difference was the absence of arch collapse in the treated children. At palate repair the relationship between the two maxillae was more favourable in the treated children for the development of the occlusion. The occlusion of the mixed dentition will be subject of a subsequent follow-up.

Extraoral traction to the maxilla with face mask: a follow-up of 17 consecutively treated patients with and without cleft lip and palate.

Lateral cephalometric films of seven cleft palate (CP) or unilateral cleft lip and palate (UCLP) and ten nonCLP patients were obtained immediately before extraoral traction with face mask, immediately after, and at 6 months follow-up. The mean age at start of treatment was 7 years for the CLP patients and 11 years for the nonCLP patients. The average duration of traction was 8 months in both groups. The traction force was gradually increased from 300 to 800 g on each side. Five angular measurements were defined and recorded. The mean net effect in anterior displacement of the maxilla in the CLP group was +0.2 degrees (range +2.5 degrees to -2.5 degrees) and in the nonCLP group +1.0 degree (range +2.5 degrees to -1.0 degree). The orthopaedic effect of extraoral traction to the maxilla was found to be independent of skeletal morphology, age, peak height velocity (PHV), and duration of traction, and thus to be unpredictable. Normal overjet was obtained in most patients, because of a combination of anterior displacement of the maxilla, posterior displacement of the mandible, tipping of the incisors, and a possible anterior sliding of the maxillary dental arch on its base.

Roentgen stereometry in the study of craniofacial anomalies--the state of the art in Sweden.

The paper is a review of ten years' experience with the method for Roentgen Stereophotogrammetric Analysis (RSA) which was presented by Selvik in 1974. The RSA was developed for the study of bone displacement in three dimensions and intended for clinical use. The accuracy of the recordings is about 0.1 degrees for rotations about and 0.05 mm for translations along any one of the three cardinal axes of the head. The method, based on the use of metallic implants, is essentially individual. Some results from our stereometric studies of patients with cleft lip and palate, hemifacial microsomia, craniofacial dysostosis (Crouzon syndrome) and dysgnathia are presented. The recordings concern the direction, the rate, and the amount of articular growth in the craniofacial sutures and the temporomandibular joints (TMJs). The information obtained is thus highly relevant to treatment planning and follow-up in craniofacial anomalies.

Roentgen stereometry with the aid of metallic implants in hemifacial microsomia.

Displacement of the mandible and the maxilla with growth in relationship to the frontal bone was recorded in eleven children with hemifacial microsomia, aged 3 to 14 years at the initial examination. The goals were to assess the efficiency of the method for accurate recording of articular growth and to obtain information on facial development in each of these children. Correction of the skeletal asymmetry was not attempted during observation periods of from 707 to 1,484 days. In continued observations three of the children were treated with functional appliances. Roentgen stereometry with the aid of metallic implants proved to be an efficient method for highly accurate recordings of articular facial growth in relationship to the frontal bone. Displacement of the jaws was asymmetrical in all of the examined children as determined in the frontal and transverse planes of the head. In about 50 percent of the children the degree of asymmetry increased in one plane while it decreased in the other plane. No correlation was found between the extent of the mandibular deformity, as seen on orthopantomograms, and the displacements of the mandible. Generally, the displacement of the maxillary bones corresponded with the displacement of the mandible. Articular growth of the jaws was redirected toward a more favorable pattern in two of the children during the time they used a functional appliance. In the third child the use of a functional appliance had no such effect.

Hemifacial microsomia treated with the Herbst appliance. Report of a case analyzed by means of roentgen stereometry and metallic implants.

The effect of Herbst appliance treatment on facial growth of one patient was recorded in terms of displacement of the mandible and the maxillary bones in relation to the frontal bone. The recordings were made with an accuracy of 0.1 degree and 0.05 mm. (S.D.). Before treatment the jaws were displaced posteriorly and to the affected side with growth, increasing the degree of retrognathia and facial asymmetry. During treatment facial growth was redirected and the jaws were displaced anteriorly and to the unaffected side, decreasing th degree of retrognathia and asymmetry. At the same time, however, the tilt of the mandible to the affected side was increased, possibly because of the morphologic and functional conditions of the jaws in hemifacial microsomia. The dental malocclusion was corrected partly through displacement of the jaws and partly through dentoalveolar adaptation.