Assessing Performance in Simulated Cleft Palate Repair Using a Novel Video Recording Setup.

OBJECTIVE: To test the feasibility of implementing a high-fidelity cleft palate simulator during a workshop in Santiago, Chile, using a novel video endoscope to assess technical performance. DESIGN: Sixteen cleft surgeons from South America participated in a 2-day cleft training workshop. All 16 participants performed a simulated repair, and 13 of them performed a second simulated repair. The repairs were recorded using a low-cost video camera and a newly designed camera mouth retractor attachment. Twenty-nine videos were assessed by 3 cleft surgeons using a previously developed cleft palate objective structured assessment of technical skill (CLOSATS with embedded overall score assessment) and global rating scale. The reliability of the ratings and technical performance in relation to minimum acceptable scores and previous experience was assessed. RESULTS: The video setup provided acceptable recording quality for the purpose of assessment. Average intraclass correlation coefficient for the CLOSATS, global, and overall performance score was 0.69, 0.75, and 0.82, respectively. None of the novice surgeons passed the CLOSATS and global score for both sessions. One participant in the intermediate group, and 2 participants in the advanced group passed the CLOSATS and global score for both sessions. There were highly experienced participants who failed to pass the CLOSATS and global score for both sessions. CONCLUSIONS: The cleft palate simulator can be practically implemented with video-recording capability to assess performance in cleft palate repair. This technology may be of assistance in assessing surgical competence in cleft palate repair.

Economy of Hand Motion During Cleft Palate Surgery Using a High-Fidelity Cleft Palate Simulator.

OBJECTIVE: The objectives of this study were to assess economy of hand motion of residents, fellows, and staff surgeons using a high-fidelity cleft palate simulator to (1) stratify performance for the purpose of simulator validation and (2) to estimate the learning curve. DESIGN: Two residents, 2 fellows, and 2 staff surgeons performed cleft palate surgery on a high-fidelity cleft palate simulator while their hand motion was tracked using an electromagnetic hand sensor. The time, number of hand movements, and path length of their hands were determined for 10 steps of the procedure. The magnitude of these metrics was compared among the 3 groups of participants and utilized to estimate the learning curve using curve-fitting analysis. RESULTS: The residents required the most time, number of hand movements, and path length to complete the procedure. Although the number of hand movements was closely matched between the fellows and staff, the overall total path length was shorter for the staff. Inverse curves were fit to the data to represent the learning curve and 25 and 113 simulation sessions are required to reach within 5% and 1% of the expert level, respectively. CONCLUSION: The simulator successfully stratified performance using economy of hand motion. Path length is better matched to previous level of experience compared to time or number of hand movements.

Psychometric findings and normative values for the CLEFT-Q based on 2434 children and young adult patients with cleft lip and/or palate from 12 countries.

BACKGROUND: Patients with cleft lip and/or palate can undergo numerous procedures to improve appearance, speech, dentition and hearing. We developed a cleft-specific patient-reported outcome instrument to facilitate rigorous international measurement and benchmarking. METHODS: Data were collected from patients aged 8-29 years with cleft lip and/or palate at 30 hospitals in 12 countries between October 2014 and November 2016. Rasch measurement theory analysis was used to refine the scales and to examine reliability and validity. Normative CLEFT-Q values were computed for age, sex and cleft type. RESULTS: Analysis led to the refinement of an eating and drinking checklist and 12 scales measuring appearance (of the face, nose, nostrils, teeth, lips, jaws and cleft lip scar), health-related quality of life (psychological, social, school, speech distress) and speech function. All scales met the requirements of the Rasch model. Analysis to explore differential item functioning by age, sex and country provided evidence to support the use of a common scoring algorithm for each scale for international use. Lower (worse) scores on CLEFT-Q scales were associated with having a speech problem, being unhappy with facial appearance, and needing future cleft-related treatments, providing evidence of construct validity. Normative values for age, sex and cleft type showed poorer outcomes associated with older age, female sex and having a visible cleft. INTERPRETATION: The CLEFT-Q represents a rigorously developed instrument that can be used internationally to collect and compare evidence-based outcomes data from patients aged 8-29 years of age with cleft lip and/or palate.

What Matters to Patients With Cleft Lip and/or Palate: An International Qualitative Study Informing the Development of the CLEFT-Q.

OBJECTIVE: The goal of treatment for individuals with cleft lip and/or palate (CL/P) is to improve physical, psychological, and social health. Outcomes of treatment are rarely measured from the patient's perspective. The aim of the study was to develop a conceptual framework for a patient-reported outcome (PRO) instrument for individuals with clefts (CLEFT-Q) by developing an in-depth understanding of issues that individuals consider to be important. DESIGN: The qualitative methodology of interpretive description was used. Setting, Participants, and Intervention: We performed 136 individual in-depth interviews with participants with clefts of any age, presenting for cleft care, across 6 countries. Parents were involved if the child was more comfortable. Interviews were audio-recorded, transcribed verbatim, and coded using constant comparison. The data were used to develop a refined conceptual framework. RESULTS: Participants described concepts of interest in 3 top-level domains, each of which included subdomains: appearance (face, nose, nostrils, teeth, lips, jaw, cleft lip scar), health-related quality of life (psychological, social, school, speech-related distress), and facial function (speech, eating/drinking). Participants were able to describe changes over time with regard to the 3 domains. CONCLUSIONS: A conceptual framework of concepts of interest to individuals with CL/P formed the basis of the scales in the CLEFT-Q. Each subdomain represents an independently functioning scale. Understanding what matters to patients is essential in guiding PRO measurement.

Bilateral Malar Reconstruction Using Patient-Specific Polyether Ether Ketone Implants in Treacher-Collins Syndrome Patients With Absent Zygomas.

The authors performed bilateral malar reconstruction using polyether ether ketone implants in 3 patients with Treacher-Collins syndrome with absent, as opposed to hypoplastic, zygomata. These patient-specific implants were fabricated using computed-aided design software reformatted from three-dimensional bony preoperative computed tomography images. The first time the authors performed this procedure the implant compressed the globe resulting in temporary anisocoria that was quickly recognized intraoperatively. The implant was immediately removed and the patient made a full-recovery with no ocular disturbance. The computer-aided design and manufacturing process was adjusted to include periorbital soft-tissue boundaries to aid in contouring the new implants. The same patient, and 2 further patients, subsequently underwent malar reconstruction using this soft tissue periorbital boundary fabrication process with an additional 2 mm relief removed from the implant's orbital surface. These subsequent procedures were performed without complication and with pleasing aesthetic results. The authors describe their experience and the salutary lessons learnt.

Is Linear Advancement Related to Relapse in Unilateral Cleft Lip and Palate Orthognathic Surgery?

OBJECTIVE: To investigate the stability of major versus minor Le Fort I maxillary advancements in unilateral cleft lip and palate (UCLP) patients. DESIGN: A retrospective longitudinal study was undertaken on 30 nonsyndromic UCLP patients treated with the same protocol at The Hospital for Sick Children, Toronto, Canada. Patients were grouped into major and minor movement groups based on planned surgical advancement. Standard lateral cephalometric radiographs were taken preoperatively (T1), immediately postoperatively (T2), and at least 1 year postoperatively (T3). Skeletal and dental variables were measured using cephalometric analysis. Stability was compared between groups using repeated-measures analysis of variance. Linear regression analysis was used to assess the relationship between advancement and relapse for the entire study population. RESULTS: A mean maxillary advancement of 9.8 mm and 4.9 mm was seen for the major (n = 10) and minor (n = 20) movement groups, respectively. The mean skeletal horizontal relapse was 1.8 mm (18%) for the major advancement group and 1.5 mm (31%) for the minor advancement group. There was no significant difference in skeletal horizontal relapse between the groups (P > .05). The correlation coefficient (r) between linear horizontal advancement and relapse was calculated to be .31 (P > .05). Dental horizontal relapse was not significant for either the major or minor groups, and no significant difference was found between the groups (P > .05). CONCLUSION: Skeletal and dental relapse was found to be unrelated to the amount of maxillary linear advancement using conventional Le Fort I osteotomies in UCLP.

Single versus segmental maxillary osteotomies and long-term stability in unilateral cleft lip and palate related malocclusion.

PURPOSE: To investigate the stability of single-piece versus segmental (2-piece) maxillary advancement in patients with unilateral cleft lip and palate (UCLP) treated using conventional Le Fort I orthognathic surgery. PATIENTS AND METHODS: A retrospective study was undertaken in 30 patients with nonsyndromic UCLP treated with the same surgical and orthodontic protocol from 2002 through 2011. Standard lateral cephalometric radiographs were taken preoperatively, immediately postoperatively, and at least 1 year postoperatively. Patients were divided into single-piece and segmental Le Fort I groups based on planned surgical movement. Postoperative movements were compared between groups using repeated measures analysis of variance. RESULTS: The mean skeletal horizontal advancement was 7.3 and 7.5 mm in the single-piece and segmental groups, respectively. The skeletal horizontal relapse was 1.3 mm (18%) for the single-piece group and 1.9 mm (25%) for the segmental group. The skeletal surgical extrusion was 2.7 mm for the 2 groups. The skeletal vertical relapse was 0.6 mm (22%) and 1.5 mm (56%) for the single-piece and segmental groups, respectively. The mean dental horizontal postoperative movement was an advancement of 0.4 mm for the single-piece group and a relapse of 0.2 mm (3%) for the segmental group. The mean dental vertical relapse was 0.1 mm (4%) for the single-piece group and 0.3 mm (11%) for the segmental group. There was no statistically significant difference in relapse between the single-piece and segmental groups for all movements (P>.05). CONCLUSION: Skeletal and dental relapse was similar between single-piece and segmental maxillary advancements using conventional Le Fort I orthognathic surgery in patients with UCLP.

Cephalometric outcomes of orthognathic surgery in hemifacial microsomia.

Hemifacial microsomia is a hypoplastic disorder of the first and second branchial arches that significantly impacts on the development of the jaws, leading to malocclusion and facial asymmetry. There is little in the literature regarding the application of orthodontic/orthognathic approaches to the correction of these deformities and the stability of the surgical results. To address this, a retrospective chart review of 10 patients with complete orthodontic records and greater than 1 year of follow-up was performed. Posteroanterior cephalograms were assessed by modified Grummons analysis to determine mandibular offset (deviation of the chin point from the skeletal midline) and occlusal cant. These measurements were performed at 3 time points (T1: preoperative, T2: immediate postoperative, T3: follow-up) to elucidate the surgical movement (T2-T1), the postoperative relapse (T3-T2), and the net gain movement (T3-T1). Maxillary movements were quantified, and the occlusal cant was expressed as a ratio between vertical heights of the maxilla at the first molar on each side. One sample t test demonstrated statistically significant surgical movement and net gain. Relapse was statistically insignificant. Repeated-measures analysis of variance demonstrated similar results for chin point position relative to the putative midline. Our results suggest that a combined orthodontic/orthognathic approach at skeletal maturity delivers improved occlusal outcomes in the long term as assessed by chin point deviation and occlusal cant, but secondary surgery rates are higher than those for orthognathic surgery in other patient groups. We advocate limiting surgery to skeletal maturity whenever possible to achieve stable long-term results while limiting morbidity and number of procedures.

Upper and Lower Limb Anomalies in Craniofacial Microsomia and Its Relation to the OMENS+ Classification: A Multicenter Study of 688 Patients.

BACKGROUND: Craniofacial microsomia (CFM) is characterized by several malformations related to the first and second pharyngeal arch. Patients typically present with facial asymmetry, but extracraniofacial organ systems might be involved, including limb anomalies. The purpose of this study was to analyze the occurrence of upper and lower limb anomalies in CFM patients. Furthermore, the relation between limb anomalies and the OMENS+ (orbital distortion; mandibular hypoplasia; ear anomaly; nerve involvement; soft-tissue deficiency; and associated extracraniofacial anomalies) classification was examined. METHODS: A retrospective study was conducted including patients with CFM from craniofacial units in three different countries. Patients were included when clinical and/or radiographic images were available. Demographic, radiographic, and clinical information was obtained. RESULTS: A cohort of 688 patients was available and selected for analysis. In total, 18.2% of the patients were diagnosed with at least one upper and/or lower limb anomaly. Upper and lower limb anomalies were seen in, respectively, 13.4% and 7.8% of patients. Patients with other extracraniofacial anomalies had a significantly higher risk for limb anomalies (OR, 27.98; P = 0.005). Laterality of CFM and a higher OMENS score were not associated with limb anomalies. CONCLUSIONS: More than one in six patients with craniofacial microsomia have limb anomalies. Therefore, clinical awareness for these anomalies is warranted. Examination and, if present, follow-up on limb abnormalities in patients with CFM should be implemented in the standard assessment of CFM patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Dynamic Reconstruction of Facial Paralysis in Craniofacial Microsomia.

BACKGROUND: Craniofacial microsomia is associated with maxillomandibular hypoplasia, microtia, soft-tissue deficiency, and variable severity of cranial nerve dysfunction, most often of the facial nerve. This study evaluated the incidence of facial paralysis in patients with craniofacial microsomia and outcomes after free functioning muscle transfer for dynamic smile reconstruction. METHODS: A single-center, retrospective, cross-sectional study was performed from 1985 to 2018 to identify pediatric patients with craniofacial microsomia and severe facial nerve dysfunction who underwent dynamic smile reconstruction with free functioning muscle transfer. Preoperative and postoperative facial symmetry and oral commissure excursion during maximal smile were measured using photogrammetric facial analysis software. RESULTS: This study included 186 patients with craniofacial microsomia; 41 patients (21 male patients, 20 female patients) had documented facial nerve dysfunction (22 percent) affecting all branches (51 percent) or the mandibular branch only (24 percent). Patients with severe facial paralysis (n = 8) underwent smile reconstruction with a free functioning muscle transfer neurotized either with a cross-face nerve graft (n = 7) or with the ipsilateral motor nerve to masseter (n =1). All patients achieved volitional muscle contraction with improvement in lip symmetry and oral commissure excursion (median, 8 mm; interquartile range, 3 to 10 mm). The timing of orthognathic surgery and facial paralysis reconstruction was an important consideration in optimizing patient outcomes. CONCLUSIONS: The authors' institution's incidence of facial nerve dysfunction in children with craniofacial microsomia is 22 percent. Free functioning muscle transfer is a reliable option for smile reconstruction in children with craniofacial microsomia. To optimize outcomes, a novel treatment algorithm is proposed for craniofacial microsomia patients likely to require both orthognathic surgery and facial paralysis reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Le Fort III in Syndromic Craniosynostosis: Cost Comparison of Distraction Osteogenesis Versus Single-Stage Internal Fixation Techniques.

PURPOSE: In syndromic craniosynostosis, the Le Fort III osteotomy is used to correct dental/skeletal imbalance, improve exorbitism, and increase the airway. The purpose of this study is to perform a cost comparison between the standard technique of single-stage rigid internal fixation and distraction osteogenesis (DO) in the Le Fort III osteotomy in this patient population. METHOD: Hospital cost accounting databases were queried for patients undergoing single-stage advancement (SS) or DO from 2007 to 2016. Nominal cost data were adjusted using the Bank of Canada Consumer Price Index. Reported costs represented the full length of stay for all utilization per patient. Demographic information and cost data for single-stage osteotomy and DO were compared. RESULTS: Total costs for single-stage (n = 8) were higher than distraction (n = 6; mean $CAD57 825 vs $38 268, P < .05). Intensive care unit (ICU) costs for single-stage were significantly higher than distraction (mean, $17 746 vs $5585, P < .005). Distraction cases had higher operating room (OR) costs than single stage, but the difference was not significant (mean, $12 540 vs $9696). Length of stay was significantly longer for SS patients (mean, 11 days vs 7 days, P < .05). CONCLUSIONS: This single-institution retrospective cost analysis indicates standard SS rigid internal fixation Le Fort III is more costly than DO. Despite higher OR costs, prolonged ICU and hospital stay was the primary reason behind this difference. This information may be of benefit when advocating for new technology perceived as high cost.

OBJECTIFS: En cas de craniosynostose syndromique, l'ostéotomie de Le Fort III permet de corriger un déséquilibre dentaire et squelettique, d'améliorer l'exophtalmie et de mieux ouvrir les voies respiratoires. La présente étude vise à comparer les coûts de la technique standard de fixation interne rigide en une étape à la distraction osseuse (DO) au sein de la population de patients en cas d'ostéotomie de Le Fort III. MÉTHODOLOGIE: Les chercheurs ont fouillé les bases de données comptables des coûts hospitaliers pour les patients qui avaient subi un avancement en une étape (AUÉ) ou une DO entre 2007 et 2016. Ils ont rajusté les données sur les coûts nominaux à l'aide de l'indice des prix à la consommation de la Banque du Canada. Les coûts déclarés représentaient la durée totale de tous les séjours hospitaliers par patient. Ils ont comparé l'information démographique et les données sur les coûts de l'ostéotomie en une étape à la DO. RÉSULTATS: Les coûts totaux de l'AUÉ (n = 8) étaient plus élevés que ceux de la DO (n = 6) (moyenne de 57 825 $ CA par rapport à 38 268 $, P < 0,05). Les coûts de l'unité de soins intensifs (USI) pour les AUÉ étaient considérablement plus élevés que la ceux de la DO (moyenne de 17 746 $ par rapport à 5 585 $, P < 0,005). Les cas de DO s'associent à un rapport de cotes des coûts plus élevé que l'AUÉ, mais la différence n'était pas significative (moyenne de 12 540 $ par rapport à 9 696 $). Le séjour hospitalier était considérablement plus long pour les patients subissant un AUÉ (moyenne de 11 jours par rapport à sept jours, P < 0,05). CONCLUSIONS: D'après la présente analyse rétrospective des coûts dans un seul établissement, la fixation interne rigide de l'AUÉ standard de Le Fort III est plus coûteuse que la DO. Malgré des coûts plus élevés en salle opératoire, un séjour prolongé à l'USI et à l'hôpital est la principale raison de cette différence. Cette information peut être utile pour défendre les nouvelles technologies qui sont perçues comme coûteuses.

CLEFT-Q: Detecting Differences in Outcomes among 2434 Patients with Varying Cleft Types.

BACKGROUND: Measuring the patient perspective is important in evaluating outcomes of cleft care. Understanding how treatment outcomes vary depending on cleft type may allow for better planning of treatments, setting of expectations, and more accurate benchmarking efforts. The CLEFT-Q is a patient-reported outcome measure for patients with cleft lip and/or palate. METHODS: The 12 CLEFT-Q scales measuring appearance (i.e., face, nose, nostrils, lips, cleft lip scar, teeth, and jaws), function (i.e., speech), and health-related quality of life (i.e., psychological, school, social, and speech-related distress) were field tested in a cross-sectional study in 30 centers in 12 countries. Patients with cleft lip and/or cleft palate aged 8 to 29 years were recruited from clinical settings. Differences in CLEFT-Q scores by cleft subtypes were evaluated using one-way analysis of variance or Kruskal-Wallis H tests, with Tukey or Dunn procedure with Bonferroni corrections post hoc analyses, respectively. Scores are presented using radar charts to visualize all outcomes simultaneously. RESULTS: The field test included 2434 patients. Scores on all CLEFT-Q scales varied significantly with cleft subtype. Patients with unilateral or bilateral cleft lip and/or palate scored lower on all appearance scales compared with patients with cleft palate or unilateral incomplete cleft lip. Scores on the speech function and speech-related distress scales decreased with each progressive group in the Veau classification. Patients with complete bilateral cleft lip and palate scored lowest on the social, school, and psychological scales. CONCLUSIONS: Patient-reported outcomes measured with the CLEFT-Q vary significantly with cleft type. Visualizing multiple outcomes simultaneously with radar charts allows for an understanding of a patient's overall status in a single graph.

Utilization of a robotic mount to determine the force required to cut palatal tissue.

Determination of the material properties of soft tissue is a growing area of interest that aids in the development of new surgical tools and surgical simulators. This study first aims to develop a robot-operated tissue testing system for determination of tissue cutting forces. Second, this system was used to ascertain the cutting properties of the hard and soft palate mucosa and soft palate musculature for the purpose of developing a robotic instrument for cleft palate surgery and a cleft-specific surgical simulator. The palate tissue was cut with a 15 blade mounted to the robot with varying angles (30°, 60°, 90°) and speeds (1.5, 2.5, 3.5 cm/s) of cutting to imitate typical operative tasks. The cutting force range for hard palate mucosa, soft palate mucosa and soft palate muscle were 0.98-3.30, 0.34-1.74 and 0.71-2.71 N, respectively. The break-in force of the cut (i.e. force required for the blade to penetrate the tissue) is significantly impacted by the angle of the blade relative to the tissue rather than the cutting speed. Furthermore, the total surface area of the tissue in contact with the blade during the cut has a significant impact on the total force expended on the tissue.

Teaching Palatoplasty Using a High-Fidelity Cleft Palate Simulator.

BACKGROUND: Cleft palate repair is a challenging procedure for cleft surgeons to teach. A novel high-fidelity cleft palate simulator has been described for surgeon training. This study evaluates the simulator's effect on surgeon procedural confidence and palatoplasty knowledge among learners. METHODS: Plastic surgery trainees attended a palatoplasty workshop consisting of a didactic session on cleft palate anatomy and repair followed by a simulation session. Participants completed a procedural confidence questionnaire and palatoplasty knowledge test immediately before and after the workshop. RESULTS: All participants reported significantly higher procedural confidence following the workshop (p < 0.05). Those with cleft palate surgery experience had higher procedural confidence before (p < 0.001) and after (p < 0.001) the session. Palatoplasty knowledge test scores increased in 90 percent of participants. The mean baseline test score was 28 ± 10.89 percent and 43 ± 18.86 percent following the workshop. Those with prior cleft palate experience did not have higher mean baseline test scores than those with no experience (30 percent versus 28 percent; p > 0.05), but did have significantly higher scores after the workshop (61 percent versus 35 percent; p < 0.05). All trainees strongly agreed or agreed that the simulator should be integrated into training and they would use it again. CONCLUSIONS: This study demonstrates the effective use of a novel cleft palate simulator as a training tool to teach palatoplasty. Improved procedural confidence and knowledge were observed after a single session, with benefits seen among trainees both with and without previous cleft experience.

A cephalometric analysis of maxillary and mandibular parameters in Treacher Collins syndrome.

BACKGROUND: Treacher Collins syndrome is an autosomal dominant condition of varying severity, affecting the tissues of the first and second branchial arches. The aim of this article is to present a cephalometric analysis of the craniofacial skeleton in Treacher Collins syndrome and provide an age- and sex-matched comparison as a standard control sample. METHODS: Twenty-four Treacher Collins syndrome patients (11 male patients and 13 female patients; mean age, 17.99 +/- 1.96 years) underwent cephalometric studies, including orthopantomography and lateral and anteroposterior cephalography, as part of their preparation for bimaxillary surgery. Cephalometric parameters assessing the relationships of the skull base, maxilla, and mandible were analyzed and compared with age- and sex-matched control data (mean age, 17.75 +/- 1.95 years). RESULTS: Cephalometric analysis before orthognathic surgery documented that the Treacher Collins syndrome mandible and midface are expectedly short in the anteroposterior plane; however, the ratio of maxillomandibular deficiency is particularly significant in the female patient. The mandibular plane angle is obtuse, affecting female patients in particular, in whom there is also a posteriorly placed chin point. Affected individuals have a high antegonial notch height. Although the parameters of anterior lower facial height proportion in control and syndrome individuals are similar, posterior face height in Treacher Collins syndrome is reduced. CONCLUSIONS: This study quantifies the cephalometric dysmorphology of patients with Treacher Collins syndrome and compares it to that of age-matched controls. These cephalometric characteristics have clinical significance in Treacher Collins syndrome and in the planning of bimaxillary advancement and genioplasty in syndrome patients.

Dentigerous cyst after distraction osteogenesis of the mandible.

Damage to the dentition or tooth follicle is often cited as a potential complication of Distraction Osteogenesis (DO). The authors describe a case of a dentigerous cyst that developed following DO of the mandible. The possible histogenic mechanisms and the management are outlined. Understanding the causes of dentigerous cysts as well as the anatomy of the neonatal mandible may help avoid such a complication in the future.

Orthognathic surgery in juvenile rheumatoid arthritis patients.

BACKGROUND: Mandible advancement osteotomy in juvenile rheumatoid arthritis patients for class II anterior open-bite malocclusion is controversial; however, there is no literature discussing outcomes of surgery in this group of patients. An evaluation of such outcomes was undertaken at The Hospital for Sick Children. METHODS: A retrospective chart review revealed that eight patients with juvenile arthritis underwent orthognathic surgery during a period of 5 years. All of the patients had a bilateral sagittal split osteotomy of the mandible, six had a simultaneous Le Fort I osteotomy, and four had an additional advancement genioplasty. The age of the patients at the time of surgery ranged between 17 and 22 years (mean, 18 years), with three male patients and five female patients. The patients were under follow-up for a minimum of 8 months after surgery, and measurements were performed studying preoperative and postoperative lateral cephalometric radiographs. RESULTS: All patients have an improved occlusion and improved facial aesthetics. One patient continued to suffer from temporomandibular joint pain. The mean mandible advancement was 9.6 mm (range, 3.9 to 18.3 mm). The mean mandible relapse after surgery was 2.1 mm (range, 1 to 3.1 mm). No exacerbation of the juvenile rheumatoid arthritis was encountered as a result of the surgical procedure. CONCLUSIONS: Orthognathic surgery in juvenile rheumatoid arthritis patients improves the patient's occlusion, facial aesthetics, and therefore quality of life. The relapse rate postoperatively did not significantly affect the clinical outcome, and the authors recommend orthognathic surgery for this patient population. Future presurgical plans in this patient population will include a small posterior open bite and positioning the incisors edge to edge to allow for some postoperative relapse.

Radiation-induced craniofacial bone growth inhibition: efficacy of cytoprotection following a fractionated dose regimen.

BACKGROUND: Severe craniofacial growth disturbances are noted in 66 to 100 percent of children with head and neck cancers who received radiotherapy during their growing years. The authors have previously demonstrated the prevention of radiation-induced craniofacial bone growth inhibition following single-dose orthovoltage radiation to the orbitozygomatic complex in an infant rabbit model through the administration of the cytoprotective agent amifostine (WR-2721) before radiation treatment. The purpose of this study was to investigate the efficacy of cytoprotection using a fractionated dose regimen that better approximates the clinical application of radiation therapy. METHODS: Thirty 7-week-old male New Zealand rabbits were randomized into three groups (n = 10), each receiving six fractions of orthovoltage radiation to the right orbitozygomatic complex: group C, sham irradiation control; group F35, total dose of 35 Gy; and group F35A, total dose of 35 Gy with administration of amifostine 200 mg/kg intravenously 20 minutes before each fraction. Bone growth was evaluated up to skeletal maturity (age 21 weeks) with serial radiographs and computed tomography scans for cephalometric analysis, bone volume, and bone density measurements. RESULTS: Fractionated radiation resulted in significant (p < 0.05) bone growth inhibition compared with sham radiation in 16 of 21 cephalometric parameters measured and significantly (p < 0.05) reduced bone volume of the rabbit orbitozygomatic complex. Pretreatment with amifostine before each radiation fraction prevented growth deformities in four cephalometric parameters and significantly (p < 0.05) attenuated these effects in another seven parameters compared with radiated animals. Bone volumes were also significantly (p < 0.05) improved in F35A animals compared with F35 animals. CONCLUSIONS: This study establishes that fractionation of orthovoltage radiation does not prevent the development of growth disturbances of the rabbit craniofacial skeleton and also demonstrates that preirradiation administration of amifostine is highly effective in the prevention and attenuation of radiation-induced craniofacial bone growth inhibition.

International anthropometric study of facial morphology in various ethnic groups/races.

When anthropometric methods were introduced into clinical practice to quantify changes in the craniofacial framework, features distinguishing various races/ethnic groups were discovered. To treat congenital or post-traumatic facial disfigurements in members of these groups successfully, surgeons require access to craniofacial databases based on accurate anthropometric measurements. Normative data of facial measurements are indispensable to precise determination of the degree of deviations from the normal. The set of anthropometric measurements of the face in the population studied was gathered by an international team of scientists. Investigators in the country of the given ethnic group, experienced and/or specially trained in anthropometric methods, carried out the measurements. The normal range in each resultant database was then established, providing valuable information about major facial characteristics. Comparison of the ethnic groups' databases with the established norms of the North America whites (NAW) offered the most suitable way to select a method for successful treatment. The study group consisted of 1470 healthy subjects (18 to 30 years), 750 males and 720 females. The largest group (780 subjects, 53.1%) came from Europe, all of them Caucasians. Three were drawn from the Middle-East (180 subjects, 12.2%), five from Asia (300 subjects, 20.4%) and four from peoples of African origin (210 subjects, 14.3%). Their morphological characteristics were determined by 14 anthropometric measurements, 10 of them used already by classic facial artists, Leonardo da Vinci and Albrecht Dürer, complemented by four measurements from the nasal, labio-oral and ear regions. In the regions with single measurements, identical values to NAW in forehead height, mouth width, and ear height were found in 99.7% in both sexes, while in those with multiple measurements, vertical measurements revealed a higher frequency of identical values than horizontal ones. The orbital regions exhibited the greatest variations in identical and contrasting measurements in comparison to NAW. Nose heights and widths contrasted sharply: in relation to NAW the nose was very or extremely significantly wide in both sexes of Asian and Black ethnic groups. Among Caucasians, nose height significantly differed from NAW in three ethnic groups, with one shorter and two greater. In the Middle Eastern groups nose width was identical to those of NAW but the height was significantly greater. The present study, conducted by investigators working separately across the world and with small samples of the population, is clearly preliminary in nature and extent. Yet it may fulfill its mission if medical and anthropological investigators continue the work of establishing normative data of the face. These data are urgently needed by medical professionals but have been lacking up till now in western and northern Europe, Asia, and Africa.