Orthognathic surgery with iliac bone grafting for an interpositional gap in a patient with type III hemifacial microsomia: A case report.

Hemifacial microsomia (HFM) is characterized by uni- or bilateral microtia and hypoplasia of the mandible, orbits, facial nerve, and adjacent soft tissues. Patients with Pruzansky-Kaban type III HFM show the most severe facial deformities and often encounter difficulty obtaining treatment. In recent years, orthognathic surgery for HFM-related deformities has often been performed after the patient has stopped growing. However, few detailed reports have described the difficulties of orthognathic surgery for patients with type III HFM. This report describes the case of a patient with type III HFM who underwent three unilateral mandibular reconstructions while still growing, including autogenous reconstructions and secondary distraction osteogenesis, followed by orthognathic surgery with iliac bone grafting for an interpositional gap between the proximal and distal segments after she had stopped growing to improve facial asymmetry and malocclusion.

Labial Vestibular Flap Closure of the Cleft Palate Is Advantageous for Maxillary Development.

Objective: Using labial vestibular flap was performed to close the primary alveolar and hard palate cleft at the second stage of early 2-stage closure surgery for unilateral cleft lip and palate for minimizing the damage to the maxillary periosteum. We analyzed maxillary development to clarify the influence of cleft palate surgery. Design: Retrospective longitudinal study in 5 years after primary palatal closure. Setting: Institutional study Patients: Study subjects included 214 patients with nonsyndromic complete unilateral cleft lip and palate who were consecutively treated in our clinic. Main Outcome: We used a 3D dental model scanner to assess maxillary development in patients aged 3 months to 5 years after using either the conventional pushback method (PB) (51 cases) or 2-stage closure (Local palatal flap closure: LF [67 cases] and Labial vestibular flap closure: VF [96 cases]). Results: Comparing the measurement results, the major axis of maxilla, width, intercanine distance, and intermolar distance was significantly larger in the LF group compared to the PB group. After the age of 3, the cleft side of VF group had grown significantly to compare with LF group in width. It was also confirmed that the inserted labial mucosal flap itself grew. Enlargement of the labial mucosal flap was observed at all sites except the canine. Conclusion: Good maxillary growth occurred in the following order: VF groups > LF group > PB group. Poor growth was correlated with the extent of periosteal damage during surgery and the degree of postoperative bone surface exposure.

Maxillary Development and Dental Arch Relationships Following Early Two-Stage Palatoplasty: A Comparative Study.

OBJECTIVE: To examine skeletal morphology and dental arch relationships at 8 years of age following early 2-stage palatoplasty, which consists of soft palate plasty at 1 year of age and hard palate closure at 1.5 years of age, and to compare the results with those of conventional pushback palatoplasty. DESIGN: Retrospective. SETTING: Single institutional study. PATIENTS: Eighty-six patients with nonsyndromic complete unilateral cleft lip and palate (UCLP) were selected. INTERVENTION: The subjects were divided into 2 groups according to the palatoplasty protocols, as follows: 45 patients, who underwent early 2-stage palatoplasty (ETS group), and 41 patients, who underwent 1-stage pushback palatoplasty (PB group). MAIN OUTCOME MEASURES: Skeletal morphology was assessed using lateral cephalometric analysis, and dental arch relationships were examined using the GOSLON yardstick. RESULTS: Cephalometric analysis revealed that the anterior-posterior length of the maxilla, measured by PTM-A and PTM-ANS, both projected to the nasal floor (NF) plane, was longer in the ETS group than in the PB group (PTM-A/NF, p = .04; PTM-ANS/NF, p = .03, unpaired t-test), although no significant difference was observed in SNA (p = .09, unpaired t-test). Upper posterior facial height was shorter in the ETS group than in the PB group (p = .02, unpaired t). Assessments with the GOSLON yardstick showed that the ETS group presented better dental arch relationships than the PB group (p = 0.04, Mann-Whitney's U-test). CONCLUSIONS: The present results suggested that the ETS protocol reduced the negative effects of palatal surgery on facial development and dental arch relationships in patients with complete UCLP at 8 years of age.

Morphological Correlations in Nasolabial Formation After Primary Lip Repair for Unilateral Cleft Lip.

PURPOSE: We aim to reveal postoperative morphological correlations between the nasolabial components in patients with unilateral cleft lip (UCL). The hypothetical correlations are first, a correlation between the vertical height of the cleft-side alar base and the length of the cleft-side red lip, and second, a correlation between the length of the cleft-side red lip and the vertical position of the cleft-side oral commissure. We explain how these morphological balances are controlled by surgery. METHODS: Three-dimensional bilateral measurements of the length of the red lip, vertical height of the nasal alar base, and vertical height of the oral commissure were conducted retrospectively on 31 patients with UCL and palate (complete UCL: 26; incomplete UCL: 5) who underwent primary lip plasty at Osaka Women's and Children's Hospital from 2017 to 2019. RESULTS: We found a statistically significant correlation between the vertical height of the cleft-side alar base and cleft-side red lip length (P = .012, r = 0.45); thus, the longer the red lip, the lower was the nasal alar base. The correlation between the cleft-side red lip length and the vertical height of the cleft-side oral commissure also showed a statistical significance (P = .00074, r = 0.57); thus, the shorter the red lip, the higher was the oral commissure. CONCLUSIONS: The present results provided objective evidence showing basic morphological relationships between the postoperative nasolabial features of patients with UCL. The results lead to a reasonable approach to define the proposed peak of the Cupid's bow, an unsettled major controversy in cleft lip surgery.

Clinical outcomes of ex utero intrapartum treatment for fetal airway obstruction.

PURPOSE: The aim of this study was to evaluate the indications and the clinical outcomes of the fetuses managed with ex utero intrapartum treatment (EXIT) procedures. METHODS: We retrospectively reviewed the medical records of all fetuses who underwent EXIT procedures between 2003 and 2018. RESULTS: EXIT procedures were performed in nine cases. The prenatal diagnosis of the neonates was congenital high airway obstruction syndrome in four cases, the neck masse in five cases. Although the airway management under the EXIT procedure was successful in eight cases, the airway management failed in one case. During the EXIT procedures, the airway was managed by endotracheal intubation in two cases, whereas six cases underwent tracheostomy. Six cases with fetal airway obstruction survived to discharge, whereas three cases died due to airway management failure or complications of the underlying disease. A case with a cervical teratoma underwent tumor resection the day after birth due to rapid enlargement of the neck mass. Long-term survival was achieved in five cases. CONCLUSIONS: We concluded that the EXIT procedure was effective and could be performed safely in the airway management of fetuses with suspected airway obstruction. The treatment strategy for the neck masses should be planned before birth.

Improved Quality of Life for Children With Beckwith-Wiedemann Syndrome Following Tongue Reduction Surgery.

Macroglossia is observed in the majority of patients with Beckwith-Wiedemann syndrome (BWS), a congenital condition with characteristic anomalies. In addition, sleep disordered breathing (SDB) associated with macroglossia has occasionally been noted in BWS patients, for which tongue reduction surgery is generally performed. However, macroglossia is related to various health problems, such as eating and articulation disorders, attention deficit disorder, enuresis, and thorax deformation, as well as aesthetic issues. Therefore, in addition to treating airway obstruction, tongue reduction surgery can also exert favorable effects on the overall quality of life (QOL) of patients. However, surgical indications for tongue reduction have yet to be established and reports on QOL assessments after surgery are rare. The OSA-18 questionnaire is used for screening SDB and is also useful for assessing the effect of tongue reduction surgery on QOL. We report a patient whose QOL was improved by tongue reduction surgery. On the basis of our patient's results, we recommend tongue reduction surgery in early childhood not only to treat SDB but also to improve QOL.

Protein kinase A regulates the long-term potentiation of intrinsic excitability in neonatal trigeminal motoneurons.

Although much is known about neuronal plasticity in the mammalian hippocampus and other cortical neurons, the subcellular mechanisms underlying plasticity at the level of motor pools are less well characterized. Protein kinase A (PKA) activation plays an essential role in long-term potentiation of intrinsic excitability (LTP-IE) in layer V (LV) visual cortical neurons and may be involved in other systems as well. Trigeminal motoneurons (TMNs) participate in rhythmical motor behaviors, such as suckling, chewing, and swallowing. Using the whole-cell patch clamp method and various kinase inhibitors and activators, we investigated the mechanism of LTP-IE in neonatal rat TMNs. Ca(2+) depletion using ACSF with 0mM Ca(2+) or the Ca(2+) chelator bis-(o-aminophenoxy)-N,N,N',N'-tetraacetic acid (BAPTA) blocked the long-lasting increase in intrinsic excitability in TMNs, showing that intracellular Ca(2+) during the induction protocol is necessary for the induction of LTP-IE. We next used specific inhibitors of PKA, protein kinase C, and calcium/calmodulin-dependent protein kinase II during the induction protocol. Only the PKA inhibitor H-89 blocked the increase in the firing rate induced by the induction protocol. In addition, forskolin, which activates PKA, induced a long-lasting increase in excitability that resembled the excitability produced by the induction protocol. Thus, we conclude that LTP-IE in TMNs is calcium-dependent, and PKA is the primary regulator of this process.

Role of endothelin receptor signalling in squamous cell carcinoma.

Endothelin plays important roles in various physiological functions including vascular constriction. Recent studies reported that the endothelin receptors ETA and ETB are highly expressed in lung and skin tumor tissues. In contrast, there are few reports on endothelin signalling in the proliferation of head and neck cancer. We found that both ETA and ETB endothelin receptors were overexpressed in tumor cells of tongue cancer samples by immunohistochemistry. ETA and ETB were expressed in cultured lingual and esophageal squamous cell carcinoma (SCCs) cell lines. When both cultured cell lines were treated with an ETA selective antagonist (BQ123) or an ETB selective antagonist (BQ788), inhibition of cell growth was observed. Similar results were observed when SCCs were treated with specific siRNA for the suppression of ETA or ETB. Furthermore, inhibition of the mitogen-activated protein (MAP) kinase pathway by the treatments with ET receptor antagonists and siRNA was also observed. These results indicate that endothelin signalling may, in part, play important roles in cell growth in SCCs through the MAP kinase pathway.

Early two-stage double opposing Z-plasty or one-stage push-back palatoplasty?: comparisons in maxillary development and speech outcome at 4 years of age.

Determining the optimal timing and procedure of palatal surgery for children with cleft lip and palate has long raised a major controversy. An early two-stage palatoplasty protocol has been a recent trend in an attempt to obtain preferable maxillary growth without compromising adequate speech development. In this study, we aim to address whether the resulting maxillofacial growth and speech development obtained by an early 2-stage palatoplasty protocol are better than those obtained by conventional 1-stage push-back palatoplasty. Seventy-two nonsyndromic children with complete unilateral cleft lip and palate were enrolled in this study. They were divided into 2 groups: 30 children, who were treated with early 2-stage palatoplasty, in which soft palate closure was performed using a modified Furlow's procedure at 12 months of age and hard palate closure was performed at 18 months of age (Early Tow Stage [ETS] group: 22 boys, 8 girls), and 42 children, who underwent 1-stage Wardill-Kilner push-back palatoplasty at 12 months of age (Push Back [PB] group: 31 boys, 11 girls). Cephalometric analysis for maxillofacial growth and assessments of speech development were performed for each child at 4 years of age. The ETS group showed a lager maxillary length than the PB group [anterior nasal spine (ANS)-ptm': ETS, 46.7 ± 2.0 mm; PB, 43.6 ± 2.3 mm]. The ANS in the ETS group was positioned more anteriorly than that in the PB group (N'-ANS: ETS, 2.5 ± 1.8 mm; PB, 0.26 ± 2.5 mm), whereas the posterior edge of the maxilla positioned anteroposteiorly was comparable between the 2 groups. The anterior facial height was significantly greater in the ETS group than in the PB group (N-N': ETS, 43.3 ± 2.9 mm; PB, 40.1 ± 2.3 mm, S-S': ETS, 29.7 ± 3.2 mm; PB, 31.0 ± 3.2 mm). No statistically significant differences were observed in the incidence of either velopharyngeal incompetence or articulation errors between the 2 groups at 4 years of age. Our results show that the early 2-stage protocol is advantageous with regard to maxillary growth compared with 1-stage push-back palatoplasty without compromising speech development as evaluated for all children at 4 years of age.

Early two-stage palatoplasty using modified Furlow's veloplasty.

OBJECTIVE: To achieve sufficient velopharyngeal function and maxillary growth for patients with unilateral cleft lip and palate (UCLP), the authors have designed a new treatment protocol for palate closure involving early two-stage palatoplasty with modified Furlow veloplasty. Details of the surgical protocol and the outcomes of the dental occlusion of patients at 4 years of age are presented. DESIGN AND SETTING: This was an institutional retrospective study. PATIENTS: Seventy-two UCLP patients were divided into two groups based on their treatment protocols: patients treated using the early two-stage palatoplasty protocol (ETS group; n = 30) and patients treated using Wardill-Kilner pushback palatoplasty performed at 1 year of age (PB group; n = 42). INTERVENTIONS: The features of the ETS protocol are as follows: The soft palate is repaired at 12 months of age using a modified Furlow technique. The residual cleft in the hard palate is closed at 18 months of age.Lip repair is carried out at 3 months of age with a modified Millard technique for all subjects. RESULTS: The ETS group showed a significantly better occlusal condition than the PB group.The incidence of normal occlusion at the non-cleft side central incisor was 7.1% in the PB group; whereas, it was 66.7% in the ETS group. CONCLUSION: The results indicate that the early two-stage protocol is advantageous for UCLP children in attaining better dental occlusion at 4 years of age.

Effect on maxillary arch development of early 2-stage palatoplasty by modified furlow technique and conventional 1-stage palatoplasty in children with complete unilateral cleft lip and palate.

PURPOSE: The purpose of this study was to evaluate the palatal morphology of patients with complete unilateral cleft lip and palate after early 2-stage palatoplasty (ETS) consisting of soft palate closure by a modified Furlow palatoplasty at 12 months of age and hard palate closure at 18 months of age. We compared the result with the palatal morphology obtained by Wardill-Kilner push-back palatoplasty (PB) at 12 months of age with that of children with noncleft palate. In the present study we investigated whether ETS can result in better palatal development than conventional PB. MATERIALS AND METHODS: Thirty subjects were treated by ETS and 42 underwent PB. We also included cross-sectional data obtained from 66 children with noncleft palate as control. We measured the arch length, width, and cleft width using dental cast models that were consecutively taken at 3 months to 4 yrs of age and compared the results among the 3 groups. RESULTS: At 4 years of age, the anteroposterior palatal length of ETS was significantly longer than that of PB by 9.8%, and the transversal palatal width of ETS was also markedly wider than that of PB at every point measured. Furthermore, ETS showed potential catch-up growth in the anteroposterior palatal length from 12 months to 4 years of age. CONCLUSION: These results demonstrate that ETS has a considerable benefit for the palatal development of patients with complete unilateral cleft lip and palate compared with PB.

Real-time kinetic modeling of voltage-gated ion channels using dynamic clamp.

We propose what to our knowledge is a new technique for modeling the kinetics of voltage-gated ion channels in a functional context, in neurons or other excitable cells. The principle is to pharmacologically block the studied channel type, and to functionally replace it with dynamic clamp, on the basis of a computational model. Then, the parameters of the model are modified in real time (manually or automatically), with the objective of matching the dynamical behavior of the cell (e.g., action potential shape and spiking frequency), but also the transient and steady-state properties of the model (e.g., those derived from voltage-clamp recordings). Through this approach, one may find a model and parameter values that explain both the observed cellular dynamics and the biophysical properties of the channel. We extensively tested the method, focusing on Na(v) models. Complex Markov models (10-12 states or more) could be accurately integrated in real time at >50 kHz using the transition probability matrix, but not the explicit Euler method. The practicality of the technique was tested with experiments in raphe pacemaker neurons. Through automated real-time fitting, a Hodgkin-Huxley model could be found that reproduced well the action potential shape and the spiking frequency. Adding a virtual axonal compartment with a high density of Na(v) channels further improved the action potential shape. The computational procedure was implemented in the free QuB software, running under Microsoft Windows and featuring a friendly graphical user interface.

High incidence of blood exposure due to imperceptible contaminated splatters during oral surgery.

PURPOSE: To evaluate the incidence of blood exposure during outpatient oral surgery from splattering caused by use of high-speed rotary instruments at the Referral and Teaching Center, University Dental Hospital. MATERIALS AND METHODS: Twenty-five consecutive patients who had impacted mandibular third molars were selected. The attending surgeon wore an operation gown and visor mask, and carried out the tooth extraction with the regular procedure. We counted the number of bloodstains found on the operation gown and visor mask, and confirmed the presence of diluted and invisible bloodstains using a leucomalachite green presumptive test, which was able to detect dilutions up to 1:4,000. RESULTS: There were 469 separate bloodstains on the gown and visor mask of oral surgeons, which came from 19 (76%) of 25 patients during impacted mandibular third molar surgery. Presumptive tests for invisible bloodstains resulted in 1,206 positive reactions, 2.57-fold greater than the visible stains, from 88% of the cases. All of the surgeons were right-handed and the common areas of staining were the right forearm, face, and thorax regions. CONCLUSIONS: Dental procedures with high-speed instruments exposed surgeons to possible blood-borne infections by splashing in nearly 90% of the cases. Greater than 50% of the stains were invisible to the naked eye. Based on our results, strict compliance with barrier precautions, including routine use of an operation gown and visor mask, is recommended whenever oral surgery is carried out with high-speed rotary instruments.

A case of extragingival peripheral ameloblastoma in the buccal mucosa.

Peripheral ameloblastomas (PAs) of the extragingival areas are extremely rare. To the best of our knowledge, only five cases of extragingival PA have been reported. We present here a sixth case of extragingival PA of the buccal mucosa in an 80-year-old male. The tumor was surgically removed by blunt dissection and there is no evidence of recurrence for 7 months. We also discuss here the clinical characteristics, the origin, and the management of the tumor by reference to the relevant literature.

[Lockjaw caused by induction of anesthesia in a volunteer bone marrow donor].

A 43-year-old healthy female volunteer donor was scheduled for bone marrow harvesting. In the operating room her mouth opening was ascertained to be 5 cm. Anesthesia was induced with thiamylal 250 mg, fentanyl 0.1 mg and vecuronium 6 mg i.v. Her mouth opening was found reduced to 2 cm that was not improved by additional vecuronium 2 mg. A consulted oral surgeon diagnosed temporomandibular disorder. After she was awakened once with resumed mouth opening, anesthesia was reinduced with a bite block placed and with her jaw held open by the oral surgeon, which brought the same results. Laryngoscopy was performed with the jaw forcefully opened and with cricoid pressure applied and the trachea was intubated. The surgical procedure and anesthesia thereafter were uneventful. Postoperative MRI was coincident with the diagnosis of temporomandibular disorder. It was speculated that in the donor patient with preexisted type II temporomandibular disorder, muscle relaxation induced by anesthesia caused the mandibular head fall behind the articular disk and dislocated the disk forwardly ending up in closed lock of temporomandibular joint.