Bone healing in rabbit calvarial critical-sized defects filled with stem cells and growth factors combined with granular or solid scaffolds.

PURPOSE: In pediatric neurosurgery, decompressive craniectomy and correction of congenital cranial anomalies can result in major cranial defects. Corrective cranioplasty for the repair of these critical-sized defects is not only a cosmetic issue. The limited availability of suitable autogenous bone and the morbidity of donor site harvesting have driven the search for new approaches with biodegradable and bioactive materials. This study aimed to assess the healing of rabbit calvarial critical-sized defects filled with osteogenic material, either with bioactive glass scaffolds or tricalcium phosphate granules in various combinations with adipose stem cells or bone marrow stem cells, BMP-2, BMP-7, or VEGF to enhance osteogenesis. METHODS: Eighty-two bicortical full thickness critical-sized calvarial defects were operated. Five defects were left empty as negative control defects. The remaining 77 defects were filled with solid bioactive glass scaffolds or tricalcium phosphate granules seeded with adipose or bone marrow derived stem cells in combination with BMP-2, BMP-7, or VEGF. The defects were allowed to heal for 6 weeks before histologic and micro-CT analyses. RESULTS: Micro-CT examination at the 6-week post-operative time point revealed that defects filled with stem cell-seeded tricalcium phosphate granules resulted in new bone formation of 6.0 %, whereas defects with bioactive glass scaffolds with stem cells showed new bone formation of 0.5 to 1.7 %, depending on the growth factor used. CONCLUSIONS: This study suggests that tricalcium phosphate granules combined with stem cells have osteogenic potential superior to solid bioactive glass scaffolds with stem cells and growth factors.

Comparison of Oral Health-Related Quality of Life Among Schoolchildren With and Without Cleft Lip and/or Palate.

OBJECTIVE: The aim was to compare the oral health-related quality of life among 11- to 14-year-old patients with cleft lip and/or palate (CLP) and schoolchildren without CLP. The validity and reliability of the Finnish Child Perception Questionnaire designed for 11- to 14-year-olds (CPQ11-14) was also assessed. DESIGN AND SUBJECTS: Participants in this cross-sectional questionnaire survey study were children aged 11 to 14 years from two groups. The CLP sample included all children of this age who had had CLP selected from the regional treatment register (N = 51). The school sample included children from four school classes (N = 82). Informed consent from parents was obtained. Ethical clearance and parental informed consent were obtained. MAIN OUTCOME MEASURES: Oral health-related quality of life was measured with the CPQ11-14. RESULTS: The CPQ11-14 total and oral symptoms, functional limitations, emotional well-being, and social well-being subscores were poorer among patients with CLP than among schoolchildren without CLP (mean scores: 55.5 versus 15.0; 11.9 versus 5.1; 14.0 versus 2.8; 12.6 versus 4.2; and 17.1 versus 2.9, respectively; all P < .001 for Mann-Whitney tests). Cronbach alpha value was 0.97 for total scale and between 0.81 and 0.94 for subscales. Among all children in the school sample, intraclass correlation coefficient was 0.79 for total scale and varied between 0.65 and 0.74 for subscales. CONCLUSION: The oral health-related quality of life of Finnish children with CLP was considerably poorer than that of their peers in overall and all dimensions, especially social well-being. The CPQ11-14 showed appropriate reliability and validity.

Dental treatment need and dental general anesthetics among preschool-age children with cleft lip and palate in northern Finland.

Cleft lip and palate incidence is high in northern Finland. This study aimed to investigate the proportion of children in need of restorative dental treatment among cleft lip and palate patients in northern Finland, as well as their need for dental treatment under general anesthesia. The records of 183 cleft lip and palate patients, treated in Oulu University Hospital from 1997 to 2013, were reviewed. Data on dental caries were analyzed in association with cleft type, considering also the presence of syndromes. The frequency of dental general anesthetic (DGA) use, and of treatments, were also analyzed. Dental treatment need was most frequently observed, in this rather limited study population, in patients with the most severe deformities, namely bilateral cleft lip and palate, of whom 60% had caries. Among the study population, 11.5% (n = 21) had a syndrome. Of those, 57.1% had dental caries at the age of 3 or 6 yr, and only four could be treated without a DGA. Dental treatment under general anesthesia was performed in 14.8% of cleft patients without a syndrome, but in 38.1% of those with a syndrome. General anaesthesia is required for the provision of dental care more often in cleft (17.5%) than in non-cleft (0.2%) patients, and especially for those with a syndrome.

Healing of rabbit calvarial critical-sized defects using autogenous bone grafts and fibrin glue.

PURPOSE: This study aimed to evaluate ossification of cranial bone defects comparing the healing of a single piece of autogenous calvarial bone representing a bone flap as in cranioplasty compared to particulated bone slurry with and without fibrin glue to represent bone collected during cranioplasty. These defect-filling materials were then compared to empty control cranial defects. METHODS: Ten White New Zealand adult male rabbits had bilateral critical-sized calvarial defects which were left either unfilled as control defects or filled with a single full-thickness piece of autogenous bone, particulated bone, or particulated bone combined with fibrin glue. The defects were left to heal for 6 weeks postoperatively before termination. CT scans of the calvarial specimens were performed. Histomorphometric assessment of hematoxylin-eosin- and Masson trichrome-stained specimens was used to analyze the proportion of new bone and fibrous tissue in the calvarial defects. RESULTS: There was a statistically significant difference in both bone and soft tissue present in all the autogenous bone-grafted defect sites compared to the empty negative control defects. These findings were supported by CT scan findings. While fibrin glue combined with the particulated bone seemed to delay ossification, the healing was more complete compared to empty control non-grafted defects. CONCLUSIONS: Autogenous bone grafts in various forms such as solid bone flaps or particulated bone treated with fibrin glue were associated with bone healing which was superior to the empty control defects.

A descriptive epidemiology study of cleft lip and palate in Northern Finland.

OBJECTIVE: The aim of this study was to determine the incidence of cleft lip and/or cleft palate in a population uniquely from Northern Finland. MATERIALS AND METHODS: The records of a total of 214 cleft patients treated between 1998-2011 at the Oulu Cleft Lip and Palate Center at the University of Oulu were assessed on a retrospective basis. Data regarding cleft type, sex and side of cleft was collected and analyzed. Family history of clefting was investigated. RESULTS: Cleft palate (68.7%) was most frequently found, followed by cleft lip and palate (18.7%) and cleft lip with or without alveolus (12.6%). Cleft palate occurred more frequently in females (63.3%) and cleft lip and palate was more frequently found in males (62.5%). The left side was more frequently affected in both male and female patients. Left-sided clefts were observed in 82% of patients compared to right-sided clefts in 18%. A family history of clefting was detected in 20.1% of patients. CONCLUSION: The incidence of clefts in Northern Finland is higher than the corresponding incidence in other European countries. Cleft palate was the most frequent cleft type and it was more frequent in females. In males, cleft lip and palate was more frequent. The left side was more frequently affected in both genders. One fifth of the patients had a family history of clefts.

Navigation-assisted Le Fort I osteotomy with midpalatal split to treat compressive pathologies of the craniovertebral junction.

This report describes the management of the case of an 11-year-old girl with serious compressive pathology of the craniocervical junction using a navigation-guided Le Fort I level maxillotomy and midline split. In this pediatric case, image guidance significantly enhanced intraoperative orientation and helped to determine the correct location of the horizontal osteotomy lines at the Le Fort I level.

Maxillary arch dimensions in cleft infants in Northern Finland.

OBJECTIVE: The aim of this study was to examine the maxillary arch dimensions in cleft lip and/or palate infants in Northern Finland before surgery. MATERIALS AND METHODS: The subjects consisted of 70 Finnish cleft patients born between 1997-2004 in Northern Ostrobothnia Hospital District in Finland. The study casts were obtained before surgery at the mean age of 5.6 months (SD = 2.2). There were 42 children with cleft palate (CP) (26 girls/16 boys), 13 with unilateral cleft lip and palate (UCLP) (eight girls/five boys), eight children with cleft lip (CL)(two girls/six boys) and seven with bilateral cleft lip and palate (BCLP) (two girls/five boys). Conventionally-used landmarks were marked on study casts and cleft width, arch circumference, anterior and posterior arch width and arch length were measured with a digital sliding calliper. The statistical method was ANOVA. RESULTS: The prevalence of CP in this study, 60% of all clefts, is higher than the average standards. There were statistically significant differences in cleft width, posterior and anterior arch width, arch length and arch circumference, when different cleft groups were compared. When differences between girls and boys were compared, boys had larger cleft size and arch dimensions generally, but the results were not statistically significant. CONCLUSIONS: The results show the large variation in the severity of cleft lip and/or palate deformity at birth and in maxillary arch dimensions between different cleft types. It also demonstrates the effect of phenotypic variability within the groups of cleft lip and/or palate.

Posterior cranial vault distraction osteogenesis in craniosynostosis: estimated increases in intracranial volume.

PURPOSE: To study distraction osteogenesis of the posterior cranial vault in children requiring increased intracranial volume. MATERIALS AND METHODS: Ten patients were treated with cranial distractors. Five children had previously been operated for scaphocephaly and one child for Saether-Chotzen syndrome. Two patients had bilateral coronal suture synostosis with Muenke syndrome and two patients had Apert syndrome. At surgery, the cranial bones were mobilized, the head was widened during surgery, and the segments fixed to each other with distractors. Further expansion at a rate of 1 mm/day was performed over 2-4 weeks. The cranium was distracted posteriorly from 20 to 30 mm. RESULTS: The patients all tolerated surgery and distraction well. In all cases, the parents were able to perform the distraction at home. There were no technical problems with the distraction devices. Two cases had minor cutaneous problems, where the distractor penetrated the skin. These cases responded to gentle local wound care measures. At the time of distractor removal, ossification had occurred sufficiently in one of these two cases. In the other case, the device was removed and replaced with a resorbable plate, without any harmful effect on the result. In all cases, sufficient expansion was achieved without causing more cosmetic deformity. Ossification occurred in all cases. This method seems effective, as the calculated increase in intracranial volume was a mean of 20.2% (range 10.2-28.5%). CONCLUSIONS: This preliminary series shows that cranial bone distraction is a useful method for cranial expansion with low morbidity in children with craniosynostosis.

Oral health-related quality of life among young adults with cleft in northern Finland.

OBJECTIVES: This study aimed to examine Oral Health-related Quality of Life (OHRQoL) among patients with cleft lip with or without palate (CLP) at their final scheduled follow-up visit at the age of 18 years. Another aim was to investigate the motivation to attend multiple follow-up appointments and the satisfaction with care given by the cleft team using inductive qualitative analysis. METHODS: This cross-sectional study was conducted among the cohort of children born with CLP who had undergone treatment at the Oulu University Hospital Cleft Lip and Palate Centre, in northern Finland since 1995. OHRQoL was assessed using the validated Finnish version of the short form of the Oral Health Impact Profile (OHIP-14). In addition to the OHIP-14, two open-ended questions were also included. These questions investigated the experience of each participant concerning their motivation to attend the Oulu University Hospital Cleft Lip and Palate Centre to receive complex treatments, and their satisfaction with care provided by the cleft team. Results were presented as proportions, means, and SD. Inductive content analysis method was performed for analysis of the open-ended questions. RESULTS: A total of 63 patients with CLP participated in this study. More than half of the participants had cleft palate. More than half of the participants reported an impact on OHRQoL (OHIP-14 score ≥ 3). All the participants with bilateral cleft lip and palate, three fourths of the participants with unilateral cleft lip and palate, and half of the participants with cleft palate reported impact on OHRQoL. Inductive content analysis showed that one fourth of the participants reported a good outcome as a motivation to attend cleft center despite of complex procedures. All the participants reported their appreciation of the cleft team. CONCLUSIONS: Despite the comprehensive treatment received by the patients born with a CLP, they still experienced lower OHRQoL, especially physical pain and psychological discomfort were more pronounced. However, good outcome, support, and oral health care being a normal routine were the motivating factors to attend a long and demanding oral health care regimen.

Management of facial asymmetry.

Asymmetries of the craniofacial region encompass a multitude of diverse and potentially complex abnormalities that may be the result of numerous causes. The expression and degree of asymmetry for a given condition, although a highly variable process, is the ultimate determinant of the nature of its treatment. This article highlights some of the key features and treatment strategies for various common facial asymmetries.

Increases in Cranial Volume with Posterior Cranial Vault Distraction in 31 Consecutive Cases.

BACKGROUND: Posterior cranial vault distraction (PCVD) is a technique widely used in surgical treatment of craniosynostosis when cranial expansion is required. It has proven to be safe and to allow a significant increase of intracranial volume. OBJECTIVE: To evaluate increases in intracranial volume as a result of PCVD performed in Oulu Craniofacial center using 2 different methods based on 3-dimensional (3-D) photogrammetric imaging or plain skull radiographs. METHODS: All children less than 16 yr of age who were treated by PCVD (n = 31) from 2009 to 2015 at the Oulu Craniofacial Center were included. All patients were followed at outpatient clinics with plain radiographs performed for follow-up. In 5 patients, additional 3-D photogrammetric imaging was done pre- and postoperatively. RESULTS: The mean intracranial volume increase was 25.0%, ranging from 16.9% to 39.4%. In 5 patients, the increase in volume was calculated from the photogrammetric 3-D images comprising a mean of 17.4%. Volume calculations from cephalograms in the same patients gave a mean of 20.8%. Whether the distraction was a primary operation or patient had undergone previous cranioplasty did not influence the achieved volumetric results. There were no statistically significant differences in the distraction results between different diagnostic groups. CONCLUSION: PCVD is an effective surgical method to increase intracranial volume in a variety of clinical entities. Volumetric results of this procedure could be easily evaluated using 3-D photogrammetric imaging or plane radiographs that expose the patients to only low ionizing radiation doses.

Autotransplantation donor tooth site harvesting using piezosurgery.

BACKGROUND: The harvesting of a tooth as a candidate for tooth autotransplantation requires that the delicate dental tissues around the tooth be minimally traumatized. This is especially so for the periradicular tissues of the tooth root and the follicular tissues surrounding the crown. The aim of this report is to describe the use of piezosurgery as an attempt at morbidity reduction in the harvesting of teeth for autotransplantation. METHODS: A piezosurgical handpiece and its selection of tips were easily adapted to allow the harvesting and delivery of teeth for autotransplantation purposes. RESULTS: Twenty premolar teeth were harvested using a piezosurgical device. The harvested teeth were subsequently successfully autotransplanted. All twenty teeth healed in a satisfactory manner without excessive mobility or ankyloses. CONCLUSIONS: Piezosurgery avoids some of the traumatic aspects of harvesting teeth and removing bone which are associated with thermal damage from the use of conventional rotary instruments or saws. Piezosurgery can be adapted to facilitate the predictable harvesting of teeth for autotransplantation purposes.

Piezo harvesting of bone grafts from the anterior iliac crest: A technical note.

BACKGROUND: Autogenous bone graft harvesting from the iliac crest is associated with donor site morbidity. The aim of this report is to describe the use of piezosurgery as an attempt at morbidity reduction. MATERIALS AND METHODS: A piezosurgical handpiece and its selection of tips can easily be accommodated in an iliac crest wound to osteotomize and allow the harvest and delivery of autogenous bone grafts. RESULTS: Corticocancellous blocks or cancellous strips of autogenous bone can be readily harvested using a piezosurgical technique at the anterior iliac crest. CONCLUSION: Piezosurgery avoids some of the traumatic aspects of harvesting bone associated with the use of conventional rotary instruments or saws.

Middle ear findings and need for ventilation tubes among pediatric cleft lip and palate patients in northern Finland.

PURPOSE: Middle ear problems are common in cleft patients. This study aimed to determine the need for ventilation tubes (VTs) and complications such as tympanic perforation and cholesteatoma. MATERIAL AND METHODS: Data of 156 children with clefts managed in northern Finland spanning 15 years from 1997 to 2011 were collected from 6 hospitals. The following were recorded: birth date, gender, cleft type, surgery timing, surgery type, number of tube insertions, tube material, middle ear findings, and tube placement timing. Clefts were divided into 4 groups: cleft palate (CP), cleft lip and palate (CLP), cleft lip (CL), and submucous cleft palate. The prevalence of middle ear findings was reported. RESULTS: Mucous secretion was noted in 96.8% of CLP patients, 69.2% of CP patients, and 13.0% of CL patients. In all, 82.7% of study group had 1 or more VTs placed during follow-up. All CLP patients required more than 1 VT placement. A total of 94.5% of CP patients required VTs compared to 13.0% of CL patients. In the presence of residual oral nasal fistula, the mean number of tube insertions was 5.3. The prevalence of tympanic perforations in clefts was 35.9% and cholesteatoma in 2.6% of patients. CONCLUSIONS: CLP and isolated CP patients have frequent middle ear infections requiring multiple VT placements.

Distraction osteogenesis of the midface.

Distraction osteogenesis has become an important part of pediatric oral and maxillofacial surgery. It is especially useful in the midface to overcome the perturbations of growth caused by congenital malformations, benign and malignant tumors, and traumatic injuries. Midfacial distraction osteogenesis can take various forms, depending on the exact anatomic site where it is applied in the midfacial skeleton. This article reviews the various locations in the midface in which distraction techniques might be used and highlights the important differences in application at these sites.

Perpendicular serial maxillary distraction osteogenesis in cleft lip and palate patients.

BACKGROUND: Cleft lip and palate patients often have a retruded maxilla with a severely narrowed deficient maxillary arch. This report aims to describe the management of severe maxillary retrusion and constriction in cleft lip and palate patients using distraction osteogenesis applied in serial sequence in two directions perpendicular to each other. MATERIALS AND METHODS: Two adult male cleft lip and palate patients were treated with maxillary distraction osteogenesis in two stages. In the first stage, surgically assisted rapid palatal expansion with a tooth-borne device was performed to significantly expand the maxillary arch in the transverse dimension. After the teeth were orthodontically aligned, the horizontal distraction of the maxilla was made by two internal maxillary distraction devices. RESULTS: In the first patient, the maxilla was initially widened by 11 mm and then distracted forward by 20 mm. Despite the breakage of the shaft of one of the two distractors at the end of distraction, a satisfactory occlusion was found at the time of distractor device removal. The maxillary position has remained stable through 8 years of follow-up. In the second patient, the palate was widened by 14 mm and the maxilla was distracted forward by 22 mm. The maxillary position has remained stable through 3 years of follow-up. CONCLUSION: Sequential serial distraction of maxilla in two planes perpendicular to each other is a safe and stable approach for the treatment of cleft lip and palate patients with severe transverse and anteroposterior discrepancies.

The association of cleft severity and cleft palate repair technique on hearing outcomes in children in northern Finland.

BACKGROUND: The consequences of cleft lip and palate include scaring, dental malformations, tooth misalignment, speech problems, and hearing loss. Otitis media with effusion causing hearing loss is a problem for many cleft palate patients. METHODS: This study examines the association among cleft severity, palate repair technique, and hearing outcomes in children from northern Finland with clefts, aged 3-9 years. The study included 90 cleft patients who were treated at the Oulu University Hospital Cleft Lip and Palate Center between 1998 and 2011. The severity of the cleft, the surgical technique used to repair the palate, audiogram configuration data, and the need for ventilation tube placement were determined retrospectively from patient records. RESULTS: Only 3.3% of cleft patients had an abnormal pure tone average hearing threshold representing abnormal hearing. Neither the surgical technique used to repair the cleft palate nor the severity of the cleft was a significant factor related to hearing loss or to the number of ventilation tubes required. Hearing improved significantly with increasing age over a span of 6 years. CONCLUSIONS: Continuous follow-up with proactive placement of ventilation tubes before or at the time of palatoplasty results in hearing outcomes in cleft children that are similar to those reported in non-cleft children.

Frequency of pharyngoplasty after primary repair of cleft palate in northern Finland.

OBJECTIVE: One measure of primary cleft palate repair success is the subsequent need for secondary pharyngoplasty due to velopharyngeal insufficiency. This study aimed to assess primary palatoplasty outcomes and frequency of secondary pharyngoplasty. STUDY DESIGN: A total of 138 patients underwent palatoplasty between 1998 and 2011. All patients were treated with 1-stage palatoplasty closing the hard and soft palate concurrently. RESULTS: Overall frequency of pharyngoplasty after palatoplasty was 21% of patients. The rate of secondary surgery was significantly higher for girls (27%) than for boys (13%). Patients with cleft lip and palate were more likely to require secondary pharyngoplasty (24%) than the patients with soft and hard cleft palate (20%). Surgical technique and cleft severity were significant factors for secondary surgery. Pharyngoplasty was least common in patients whose palatal clefts were treated at 9 to 12 months of age. CONCLUSIONS: The majority of patients undergoing primary palatal repair do not need secondary pharyngoplasty.

Incidence of palatal fistula formation after primary palatoplasty in northern Finland.

OBJECTIVE: The purpose of this retrospective study was to determine the incidence of palatal fistulas after primary cleft palate repair. STUDY DESIGN: The study included 136 patients who were treated at the Oulu University Hospital cleft lip and palate center between 1998 and 2011. All patients were treated by the same surgeons with 1-stage palatoplasty closing the hard and soft palate concurrently. RESULTS: The overall frequency of postoperative fistula was 9.6% of patients. Patients with cleft lip and palate (20.0%) were more likely to develop postoperative palatal fistulas than patients with cleft palate (6.6%). Surgical technique and cleft severity were not significant factors for the development of palatal fistulas. CONCLUSIONS: The majority of patients undergoing primary palatal repair do not develop palatal fistulas.

Experience with craniosynostosis treatment using posterior cranial vault distraction osteogenesis.

BACKGROUND: Craniosynostosis compromises the cranial vault volume, severely impede growth, and may lead to increased intracranial pressure (ICP). Posterior cranial vault (PCV) distraction osteogenesis (DO) offers an excellent treatment opportunity for this condition. This article intends to describe the outcomes of PCV DO. MATERIALS AND METHODS: Nine males and seven female children indicated for PCV DO were included in the study. The single vector distraction devices with quick-disconnect distraction rods, a type of miniaturized hardware, was used in all cases. RESULT: Seven of the 16 patients had a history of one or more prior cranioplasty. All reoperations in this series were performed for the indication of raised ICP including five of the scaphocephaly patients and the syndromic patients. Clinical signs of raised ICP were present in all patients with either measured raised intracranial pressure or those with clinical signs of raised ICP preoperatively. There was substantial decrease in the ICP postoperatively. DISCUSSION: The outcomes of this study were encouraging. Placing the distractor stems as flat as possible against the outer layer of the cranial bone seems to be a very important maneuver. This keeps the distractor stem less proud and less likely to sustain future trauma. Removal of the distractor stems keeps the devices further away from the risk of later traumatic dislodgement. Moreover, miniaturized distractors allow precise control of the rate and the amount of distraction.