Changes in maxillofacial morphology and velopharyngeal function with two-stage maxillary distraction-mandibular setback surgery in patients with cleft lip and palate.

Maxillary distraction is increasingly used for the correction of severe maxillary retrusion in patients with cleft lip and palate. However, control of the maxillary movement is difficult, and the need to wear visible distractors for a long period of time causes psychosocial problems. A two-stage surgical approach consisting of maxillary distraction and mandibular setback was developed to overcome these problems. In this study, changes in maxillofacial morphology and velopharyngeal function were examined in 22 patients with cleft lip and palate who underwent this two-stage approach. Lateral cephalograms taken just before the first surgery, immediately after the second surgery, and at completion of the active post-surgical orthodontic treatment were used to examine maxillofacial morphology. Velopharyngeal function was evaluated by speech therapists using a 4-point scale for hypernasality. The average forward movement of the maxilla with surgery at point A was 7.5mm, and the average mandibular setback at pogonion was 8.6mm. The average relapse rate during post-surgical orthodontic treatment was 25.2% for the maxilla and 11.2% for the mandible. After treatment, all patients had positive overjet, and skeletal relapse was covered by tooth movement during postoperative orthodontics. Velopharyngeal function was not changed by surgery. This method can shorten the period during which the distractors have to be worn and reduce the patient burden.

Complications after intraoral vertical ramus osteotomy: relationship to the shape of the osteotomy line.

Intraoral vertical ramus osteotomy (IVRO) is used widely to correct mandibular prognathism. However, several disadvantages of this procedure have been reported, such as condylar luxation and bony interference at the osteotomy site. The aim of this study was to survey the incidence of complications (condylar luxation and bony interference) based on the shape of the osteotomy line. One hundred and eighty-five rami in 118 patients with jaw deformities, which were treated with IVRO, were examined retrospectively. The shape of the osteotomy line and the postoperative complications were examined on panoramic radiographs. Osteotomy lines were classified into three types: vertical, C-shaped, and oblique. Of the 185 osteotomy sites, 98 were vertical, 37 C-shaped, and 50 oblique. Condylar luxation was found in six rami (3.2%); four had undergone vertical osteotomy and two had undergone C-shaped osteotomy. Bony interference occurred in seven rami (3.8%), all with vertical type osteotomy lines. Most complications occurred in the vertical type cases and no complications were found in oblique type cases. Condylar luxation was found mainly in unilateral IVRO cases and bony interference was found in bilateral IVRO cases. These results suggest that the oblique type of osteotomy line has the advantage of avoiding complications.

Unilateral expansion of a narrow mandibular dental arch combined with bimaxillary osteotomies in a patient with hypoglossia.

A 23-year-old female with hypoglossia, who had a narrow mandibular dental arch, was treated using the gradual expansion technique. Three lower incisors were missing and the right molar occlusion showed a scissor bite. Her speech was acceptable. Gradual unilateral expansion of the mandibular alveolar bone was performed. Orthodontic tooth alignment was performed prior to surgical treatment. A tooth-borne expander was devised using a hyrax-type screw to move the inclined right alveolar bone into an upright position. Alveolar bone osteotomies were performed under general anesthesia and the expander was placed in the mandibular dental arch. After a 5-day latency period, the screw was activated for 21 days. After expansion, the width of the mandibular dental arch increased by 10mm at the first molar region and the right molars were moved to an upright position. After a consolidation period of 7 days, simultaneous two-jaw surgery that combined Le Fort I osteotomy and intraoral vertical ramus osteotomies was performed to obtain a stable occlusion. After post-surgical orthodontic and prosthodontic treatment, her occlusion improved without deterioration of her speech. The results indicate that this technique is useful for unilateral expansion of distorted mandibular alveolar process.

Cyclooxygenase-2 activity is essential for the osseointegration of dental implants.

The aim of this study was to examine the effect of cyclooxygenase (COX)-2 on bone response after the placement of implants in the femurs of mice. titanium implants 1.0mm in diameter were placed into the middle of the femurs of 9-week-old male COX-2 wild-type (COX-2(+/+)) and knockout (COX-2(-/-)) mice. For RNA analysis, the mice were killed 0, 1, 2, 4, 7 and 56 days after implantation. RNA was extracted from the bone surrounding the implants. For histological analysis, the mice were killed 4 and 8 weeks after treatment, and undecalcified sections were prepared. Contact microradiography was performed, and the sections were stained with 1% toluidine blue for histological examination. Histomorphometric measurements were obtained with a computer-based image analyser to quantify bone newly formed around the implant and the rate of implant-bone contact. Expression of COX-2 and osteocalcin mRNA was induced in bone surrounding implants in COX-2(+/+) mice, but not in COX-2(-/-) mice. In cortical bone, the implant surface was in direct contact with newly formed bone lamellae in COX-2(+/+) mice; new bone formation was minimal in COX-2(-/-) mice. These results suggest that COX-2 plays an essential role in osseointegration and provide evidence that COX-2-selective non-steroidal anti-inflammatory drugs may interfere with osseointegration clinically.

A 2-stage procedure combining maxillary advancement by distraction technique with mandibular setback surgery in patients with cleft lip and palate.

A 2-stage procedure combining maxillary advancement by distraction technique with mandibular setback surgery was used to correct jaw deformities in 5 patients with severe maxillary retrusion secondary to cleft lip and palate. First, a Le Fort I maxillary osteotomy was performed. Immediately after maxillary distraction, the distraction device was removed. The advanced maxilla was fixed with miniplates after adjusting the length and direction of advancement, and mandibular setback surgery was performed simultaneously to obtain a normal occlusal relationship. This 2-stage procedure resulted in stable occlusion and a markedly improved facial profile.

Sequence analysis of fibroblast growth factor receptor 2 ( FGFR2 ) in Japanese patients with craniosynostosis.

Recently, mutations of the fibroblast growth factor receptor ( FGFR ) genes have been detected in syndromic craniosynostosis. We examined nucleotide sequences of FGFR2 in Japanese craniosynostosis patients (Crouzon syndrome: 9 cases; Apert syndrome: 6 cases; scaphocephaly: 3 cases as non-syndromic patients) by polymerase chain reaction (PCR) followed by direct sequencing methods. The results demonstrated FGFR2 heterozygous mutations at codons 252, 290 of exon 7, and at codon 342, 354 of exon 9 in Crouzon syndromes. In Apert syndrome patients, Ser252Trp and Pro253Arg were detected in five and one patients, respectively. No mutation was detected in one case of Crouzon, all cases of scaphocephaly and healthy individuals. Thus far sequence analysis of FGFR2 in syndromic craniosynostosis has been reported in many white patients, whereas in Japanese only several cases have been studied. The current study with 18 patients confirmed that a similar series of mutations occur in Japanese patients as in white patients regardless of ethnicity and environment. The frequency of the mutation was 82% (9/11 cases) in Japanese Crouzon patients. The ratio of S252W:P253R was 5 : 1 in Japanese Apert patients. Moreover, in Japanese Apert patients, complication rate of cleft palate was 60% for mutation of Ser252Trp and 0 of 2 patients for Pro253Arg, with their syndactyly score being 4.90 and 5.50, respectively.

Peroxynitrite production by TNF-alpha and IL-1beta: implication for suppression of osteoblastic differentiation.

To determine the roles of nitric oxide (NO) and its metabolite, peroxynitrite (ONOO(-)), on osteoblastic activation, we investigated the effects of a NO donor [ethanamine, 2, 2'-(hydroxynitrosohydrazono)bis- (dNO)], an O(-2) donor (pyrogallol), and an ONOO(-) scavenger (urate) on alkaline phosphatase (ALPase) activity and osteocalcin gene expression, which are indexes of osteoblastic differentiation. dNO elevated ALPase activity in the osteogenic MC3T3-E1 cell line. The combination of dNO and pyrogallol reduced both ALPase activity and osteocalcin gene expression. Because both indexes were recovered by urate, ONOO(-), unlike NO itself, inhibited the osteoblastic differentiation. Furthermore, treatment with a combination of the proinflammatory cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) was found to yield ONOO(-) as well as NO and O(-2). The reductions in ALPase activity and osteocalcin gene expression were also restored by urate. We conclude that ONOO(-) produced by TNF-alpha and IL-1beta, but not NO per se, would overcome the stimulatory effect of NO on osteoblastic activity and inhibit osteoblastic differentiation.

Large myxofibroma of the mandible treated with segmental mandibular resection and vascularized fibular graft.

This report summarizes a case of large myxofibroma of the mandible. On the basis of the clinical appearance, radiographic findings, and biopsy specimen, the lesion was diagnosed as a myxofibroma. Segmental mandibular resection and immediate reconstruction by vascularized fibular graft were performed. At the 18-month follow-up there was no evidence of recurrence of the tumor, and good functional and aesthetic results were maintained.

Ellis-van Creveld syndrome: craniofacial morphology and multidisciplinary treatment.

OBJECTIVE: The craniofacial morphology and multidisciplinary treatment of a patient with Ellis-van Creveld Syndrome are presented. PATIENT: The patient presented is female. Her treatment began at the age of 10 years 6 months. She exhibited small stature with acromelic shortening of the extremities, postaxial syndactyly, and dysplastic nails. In the oral region, hyperplastic frena, absent anterior teeth, and small barrel-shaped teeth were noted. SETTING AND INTERVENTION: The patient was treated at the University Hospital, Faculty of Dentistry, of the Tokyo Medical and Dental University. The treatment was divided into three stages: growth observation during which the patient wore acrylic plates with artificial anterior teeth; surgical-orthodontic treatment with sagittal split ramus osteotomy; and prosthodontic treatment with removable partial dentures. MAIN OUTCOME MEASURES: Cephalometric analyses were performed to evaluate the changes in craniofacial morphology with growth during treatment. RESULTS: Characteristic craniofacial morphology included a small posterior cranial base, small maxilla, and a large mandible with an increased gonial angle. Maxillo-mandibular relation was skeletal class III, and skeletal open bite was found. The skeletal class III relationship was progressive with growth. The patient was satisfied by the results of the multidisciplinary treatment. CONCLUSION: The craniofacial morphology of the patient demonstrated disturbed growth of the cartilage bones. An acceptable result was obtained through combined surgical-orthodontic-prosthodontic treatment.

Multi-bracket appliance in management of mandibular reconstruction with vascularized bone graft.

BACKGROUND: The most commonly used tool for maxillo-mandibular fixation to the patient who underwent reconstruction using a vascularized bone graft after mandibular resection is a dental arch-bar. However, the occlusal relationship achieved by this method is not ideal. Different from the dental arch-bar, the multi-bracket appliance which is frequently used in orthodontic treatment can control the position of each individual tooth three dimensionally. Thus, this appliance was applied for maxillo-mandibular fixation to patients who underwent mandibular reconstruction using a vascularized bone graft. METHODS: A multi-bracket appliance was applied to three patients. Prior to the surgery, standard edgewise brackets were bonded to the teeth in the maxilla and in the remaining mandible. After mandibular resection, wires for maxillo-mandibular fixation were applied. The harvested bone was then carefully fixed with miniplates to maintain the occlusion. The multi-bracket appliance was worn for 3 months when the wound contraction became mild. RESULTS: All three cases demonstrated stable and good occlusion. They also demonstrated satisfactory post-surgical facial appearance. CONCLUSIONS: Compared to conventional dental arch-bars, a multi-bracket appliance offers improved management of mandibular reconstruction. Firstly, its properties are helpful in maintaining occlusion of the remaining dentition accurately in bone grafting procedure as well as protecting against postsurgical wound contraction. Secondly, the multi-bracket appliance keeps the oral cavity clean without periodontal injury. As a result, stable occlusion of the residual teeth and good facial appearance were obtained.

Secondary lengthening of the reconstructed mandible using a gradual distraction technique--two case reports.

We have performed mandibular lengthening to restore oral function in 2 cases after tumour resection. Both cases had already undergone a vascularised fibular graft for mandibular reconstruction and had severe contracture and absence of an alveolar ridge for dentures. Gradual distraction was applied after corticotomy of the fibular bone at 0.9 mm per day. After completion of bone lengthening of 20-30 mm, both patients underwent a split thickness skin graft to obtain a good alveolar ridge for dentures and implants. Osteointegrated implants have since been applied in one of these cases, and the other patient has been able to eat a normal diet using dentures. Gradual distraction is applicable for vascularised bone grafts and useful for restoration of the alveolar ridge to accommodate dentures in cases with severe contracture of the oral space after tumour ablation.

Modification of the Abbé flap for reconstruction of the vermilion tubercle and Cupid's bow in cleft lip patients.

PURPOSE: This article reports on the modification of the Abbé flap for correction of mild tightness of the corrected cleft lip deformity. PATIENTS AND METHODS: Twelve patients with a moderately tight lip deformity, from 16 to 35 years old, underwent this procedure. Nine had a unilateral deformity and 3 a bilateral deformity. The flap, which was taken from the central portion of the lower lip vermilion, was designed to repair the vermilion tubercle and the Cupid's bow. A tiny portion of skin was included to facilitate closure of the donor site. It was inserted into the center of the upper lip and the pedicle was divided 1 week after operation. RESULTS: Each patient showed a more natural contour of the vermilion tubercle and the Cupid's bow. The scarring of the donor site was inconspicuous. CONCLUSIONS: Use of modified Abbé flap to reconstruct the contour of the vermilion tubercle and the Cupid's bow makes the upper lip look more natural.

Use of cantilever iliac bone grafts for reconstruction of cleft lip-associated nasal deformities.

PURPOSE: The purpose of this study was to describe the clinical and radiographic observations on cantilever iliac bone grafts for reconstruction of cleft lip-associated nasal deformities. MATERIALS AND METHODS: Cantilever iliac bone grafts were performed on 14 patients with a severely deformed cleft lip-associated nose using the open rhinoplasty technique. An approximately 6-cm length of iliac bone was tightly inserted into a subperiosteal pocket over the nasal bones, and the nasal tip was elevated by the distal end of the graft. The clinical follow-up ranged from 7 months to 3 years. RESULTS: All patients were judged to have satisfactory results. The grafted bone decreased slightly in size during the first 2 to 3 months, and irregularities in contour became rounded. During the same period, bony union with the underlying nasal bones was observed in all cases. After about 6 months, further changes did not occur in the grafts. CONCLUSION: This type of bone graft can be used for additional structural support and to achieve the desired nasal projection and profile. Augmenting the nasal bridge creates the illusion of a narrower nose. The key to success of the operation seems to be the proper fixation of the grafted bone to the underlying nasal bones.

Columella lengthening using a cartilage graft in the bilateral cleft lip-associated nose: choice of cartilage according to age.

PURPOSE: This article describes the technique of columellar lengthening using a cartilaginous strut in patients with a severely deformed bilateral cleft lip-associated nose. MATERIALS AND METHODS: When the upper lip is not deficient, and especially when resection of lip scar tissue is indicated, the Millard forked flap technique is recommended. Advancement of the prolabium into the columella for lengthening, combined with an Abbé flap for upper lip reconstruction, is indicated when a deficient upper lip is unable to provide adequate donor tissue. A cartilaginous strut is inserted behind the forked flap or the advanced prolabium. According to the age of the patient, septal cartilage, costal cartilage, or ear cartilage is selected. Ten patients with a severely deformed bilateral cleft lip-associated nose underwent these procedures. RESULTS: In each case, the columella was lengthened satisfactorily. In four patients, the scar became hypertrophic at the base of the columella and scar revision was performed secondarily. CONCLUSIONS: A cartilaginous strut is the key to avoiding the tendency toward retraction or thickening of the lengthened columella. It gives a slight lift to the tip, provides more definition, and improves the columellar contour.

Early correction of the nose in unilateral cleft lip patients using an open method: a 10-year review.

PURPOSE: To review a 10-year follow-up of cases with rhinoplasty for a cleft lip-associated nose deformity done during the preschool years. MATERIALS AND METHODS: Sixteen patients from 16 to 19 years of age were evaluated with two indices: the nasal index and the lobule portion of the columella index. RESULTS: Several years after surgery the results appeared to be reasonably satisfactory. However, as the patients approached their adolescent growth spurt at 15 years of age, undesirable features became obvious. Each patient showed a strikingly bulbous nose. The nasal index of male patients ranged from 68.8% to 82.7% (mean, 75.4%) and that of female patients ranged from 72.7% to 85.0% (mean, 79.2%). The mean value of the nasal index in the Japanese male and female is 58.5% +/- 1.5% and 59.0% +/- 1.0%, respectively. The lobule portion index of male patients ranged from 57.1% to 72.0% (mean, 65.1%) and that of female patients ranged from 62.5% to 82.0% (mean, 74.2%). The lobule portion of the columella constitutes 33% of the total columellar length on average. CONCLUSIONS: A possible cause of the undesirable deformities is use of an open surgical method. A second possible cause is mobilization and suspension of the alar cartilages. These undesirable features may occur only in Oriental noses.

Correction of the cleft nasal deformity with an L-shaped iliac bone graft.

We describe our technique for correcting a cleft lip nasal deformity using L-shaped iliac bone grafts to achieve additional structural support and the desired nasal projection and profile. Augmenting the nasal bridge creates the illusion of a narrower nose. Further, the columellar portion of the L-shaped graft provides stabilization, eliminating the "see-saw" effect of the bridge graft on the fulcrum of the bony bridge, which can lead to a depressed tip and loss of the root indentation. Clinical and radiographic observation has revealed that this method of correction has consistently produced satisfactory results.

Mandibular lengthening by gradual distraction: analysis using accurate skull replicas.

Bone lengthening in the upper and lower extremities by gradual distraction has become an accepted procedure. We have used an extraoral device to lengthen the mandible in four patients with unilateral mandibular hypoplasia. Using an accurate skull replica, the proposed corticotomy line, intended direction of lengthening, and appropriate position for the screws were determined. Following distraction, a significant increase in the dimensions of the affected mandible was obtained in each case. In this series, accurate skull replicas proved very useful for defining the anatomy, for surgical simulation and for pre- and postoperative evaluation.

Characterization of a system of mineralized-tissue formation by rat dental pulp cells in culture.

Pulp tissue was obtained from maxillary incisors of young adult male Wistar rats, minced and digested with 0.5% trypsin and 0.02% EGTA at 37 degrees C for 30 min. Dissociated cells were cultured with or without 10 nM dexamethasone using Eagle's minimal essential medium supplemented with 10% fetal bovine serum and 50 micrograms/ml ascorbic acid. Confluent cells were subcultured at 7 days and the medium further supplemented with beta-glycerophosphate (beta-GP). Dexamethasone in primary culture and/or secondary culture enhanced the formation of mineralized tissue while > 5 mM beta-GP was necessary for mineralization to occur. Biochemical analysis of the radiolabelled medium revealed that these cells produced type I, type I trimer and type III collagens. Analysis of [32PO4]-labelled medium, using DEAE-Sephacel ion-exchange chromatography and sodium dodecylsulphate-polyacrylamide gel electrophoresis, showed that these cells produced phosphophoryn-like protein. These results indicate that some of the rat dental pulp cells in culture express an odontoblast-like phenotype.