Macroscopic and roentgenographic anatomy of the skull of the ferret (Mustela putorius furo).

Normal macroscopic and roentgenographic features of the skull of the ferret (Mustela putorius furo) were examined and described. Data were based on a sample of 100 (50 male and 50 female) adult ferrets of known body weight and age. The skull was described macroscopically according to six standard views, i.e. dorsal, lateral, ventral, caudal, cranial and midsagittal. The mandible was described separately. The roentgenographic characteristics of the ferret skull were demonstrated only in lateral and dorsoventral projections. Furthermore, the skull length and width as well as the minimum frontal width were measured, and skull indices were derived from relevant measurements. Sexual dimorphism was examined both morphologically and craniometrically. Besides the common features of a carnivore skull, the ferret skull is relatively elongated and flat with a short facial region. The skulls of adult male ferrets are about 17% longer and 22% wider than those of the females. Significant sexual dimorphism also exists regarding certain skull indices. The general features and some dimensional parameters of the adult ferret skull support the contention that the ferret would be an interesting and workable alternative animal model in craniofacial research.

Long-term follow-up of dynamic cranioplasty for brachycephaly--non-syndromal bicoronal synostosis.

We followed up 10 patients whose non-syndromal bicoronal synostosis had been operated on with a dynamic cranioplasty technique developed by this craniofacial unit in 1992. With this technique, the growth of the brain is redirected in an anteroposterior direction as wire-mediated compression and restraint are exerted on the transverse and vertical dimensions of the skull. The mean operating time was 160 minutes (range 120-275) and mean stay in the intensive care unit was 36 hours (range 23-58). There was no operative mortality and few complications. The surgical results were assessed objectively by analysis of cephalometric tracings. The mean (SD) cephalic index was 87.6 (4.9) preoperatively and 77.7 (1.8) postoperatively (p = 0.001). The modified Whitaker scale was used as a subjective outcome measurement, and nine patients were classified as Whitaker grade 1 (no additional surgery). One patient required additional intracranial surgery. A questionnaire was sent to all families to obtain an additional subjective measurement of outcome. Parents' satisfaction was high. We conclude that dynamic cranioplasty is a safe and efficient operation for treatment of brachycephaly.

Long-term evidence for favorable midfacial growth after delayed hard palate repair in UCLP patients.

OBJECTIVE: To investigate whether delayed hard palate repair resulted in better midfacial growth in the long term than previously achieved with "conventional" surgical methods of palatal closure. DESIGN AND SETTING: Long-term cephalometric data from patients with unilateral cleft lip and palate were available from two Scandinavian cleft centers. The patients had been treated by different regimens, particularly regarding the method and timing of palatal surgery. Patients were analyzed retrospectively, and one investigator digitized all radiographs. PATIENTS: Thirty consecutively treated subjects from each center, with cephalograms taken at three comparable stages between 10 and 16 years of age. RESULTS AND CONCLUSIONS: Patients whose hard palates were repaired late (early soft palate closure followed by delayed hard palate repair at the stage of mixed dentition) had significantly better midfacial development than patients in whom the hard palate was operated on early with a vomer flap, and then during the second year of life, the soft palate was repaired with a push-back procedure. As the growth advantage in the delayed hard palate repair group was accomplished without impeding long-term speech development, the delayed repair regimen proved to be a good alternative in surgical treatment of patients with unilateral cleft lip and palate.

Clinical outcome of the modified pi-plasty procedure for sagittal synostosis.

The aim of the study was to evaluate the modified pi-plasty procedure for the treatment of sagittal synostosis, assessing the issues of safety, complications, morphological outcome, and degree of parental satisfaction. A retrospective evaluation of 110 patients with nonsyndromal single suture sagittal synostosis operated on with the modified pi-plasty procedure was undertaken. Cephalometric radiographs were obtained preoperatively and postoperatively at ages 3 and 5 years in three standardized projections. The Cephalic Index and the Axial Width Ratio were determined and used as objective outcome measures. An evaluation of the radiographic digital markings was carried out using a Beaten Copper Score. A parental questionnaire was used to obtain a subjective esthetical outcome assessment. The patient population consisted of 76% boys and 24% girls with a 20% incidence of a positive familial history of craniosynostosis. The mean age at surgery was 7.73 months. Morbidity from the procedure was minimal and there were no mortalities. The Cephalic Index changed from a mean preoperative value of 65% to a postoperative mean value of 72% (P = 0.00004). The mean Axial Width Ratio changed from a preoperative 80% to 72% at the 3-year evaluation (P = 0.00029). The Beaten Copper score changed from a mean preoperative value of 2.35 to 5.42 postoperatively at 3 years (P = 0.00001). The response rate to the questionnaire was 86%, and there were significant postoperative improvements in all studied aspects of the skull shape. The modified pi-plasty is a safe technique, and it induces significant objective changes in skull morphology toward normality. It also yields a high degree of parental satisfaction with regard to aesthetic outcome, as evaluated by a written questionnaire.

Dynamic cranioplasty for brachycephaly in apert syndrome: long-term follow-up study.

OBJECT: Brachycephaly is a characteristic feature of Apert syndrome. Traditional techniques of cranioplasty often fail to produce an acceptable morphological outcome in patients with this condition. In 1996 a new surgical procedure called "dynamic cranioplasty for brachycephaly" (DCB) was reported. The purpose of the present study was to analyze perioperative data and morphological long-term results in patients with the cranial vault deformity of Apert syndrome who were treated with DCB. METHODS: Twelve patients have undergone surgery performed using this technique since its introduction in 1991 (mean duration of follow-up review 60.2 months). Eleven patients had bicoronal synostosis and one had a combined bicoronal-bilambdoid synostosis. Perioperative data and long-term evolution of skull shape visualized on serial cephalometric radiographs were analyzed and compared with normative data. Changes in mean skull proportions were evaluated using a two-tailed paired-samples t-test, with differences being considered significant for probability values less than 0.01. The mean operative blood transfusion was 136% of estimated red cell mass (ERCM) and the mean postoperative transfusion was 48% of ERCM. The mean operative time was 218 minutes. The duration of stay in the intensive care unit averaged 1.7 days and the mean hospital stay was 11.8 days. There were no incidences of mortality and few complications. An improvement in skull shape was achieved in all cases, with a change in the mean cephalic index from a preoperative value of 90 to a postoperative value of 78 (p = 0.000254). CONCLUSIONS: Dynamic cranioplasty for brachycephaly is a safe procedure, yielding high-quality morphological results in the treatment of brachycephaly in patients with Apert syndrome.

Tibia as donor site for alveolar bone grafting in patients with cleft lip and palate: long-term experience.

Tibial bone grafts were studied in 137 patients with clefts of the lip and palate. Twenty-one had clefts of the lip and primary palate and 116 had complete unilateral clefts of the lip and palate. Bone grafting was performed secondarily or late secondarily. Bone was harvested from the proximal part of the tibia distal to the tuberosity through an incision about 15 mm long. The mean follow-up time after bone grafting was 5.5 years (range 2-11). There were no operative, or early or late postoperative complications reported (such as haematoma, fracture, or shortening of the limb). Harvesting time was about 15 minutes. The possibility of operating with two teams makes the total operating time shorter. Bleeding was negligible (less than 15 ml) and the amount of bone obtained was always sufficient. Patients were mobilised the next day and were back to full physical activity by one month. Indications for tibial bone grafting included facilitation of tooth eruption into the graft, giving bony support to the neighbouring teeth, making it possible to insert a titanium fixture, raising the alar base of the nose, and closing an oronasal fistula. Compared with iliac, cranial, mandibular, and costal donor sites, using the tibia took less time, gave less bleeding, made it possible for two teams to operate simultaneously, gave a smaller scar, and there were minimal complications and satisfactory quantity and quality of bone in all cases. The results suggested that the tibia is an excellent choice of graft for residual alveolar clefts in patients with cleft lip and palate.

Maxillary development and dental occlusion in patients with unilateral cleft lip and palate after combined velar closure and lip-nose repair at different ages.

Maxillary morphology and occlusal development were studied after simultaneous velar closure and lip/nose reconstruction in patients with unilateral cleft lip and palate. Fifty-two Brazilian patients were divided into three groups according to the age at which they had had the one-stage operation (mean ages: 8, 18, and 77.5 months). They were compared with 30 similar white patients who had been operated on with a corresponding method, but where surgery had been carried out in three different stages. In general, differences in outcome between the groups were attributed to racial differences in facial morphology. The combined operation did not affect the transverse development or the overall occlusion and only slightly influenced the morphology of the maxillary incisor region. The palatal cleft width reduced significantly (p < 0.001) after the combined procedure. However, the potential for this reduction seemed to be less when patients were operated on after their first year of life.

Maxillary dental arch and occlusion in repaired clefts of the secondary palate: influence of surgical closure with minimal denudation of bone.

A change in the method of surgical repair of cleft palate initiated this study of 64 patients with various degree of clefts of the secondary palate. Study casts were obtained at different ages. Certain measurements were taken and compared with those made in a previous investigation of similar patients operated on by the so-called "push-back" technique. Growth in the width of the maxillary dental arch and occlusion had improved, but there were significant differences only for the patients with velar clefts.

Craniofacial growth in unoperated craniofacial malformations.

OBJECTIVE: To review current information on craniofacial growth of unoperated patients with craniofacial malformations and stimulate the study of abnormal craniofacial growth through conventional and newer methods. This will lead to improved diagnosis and the understanding of the etiopathogenesis of craniofacial malformations. It is expected that this knowledge will also assist clinicians in planning treatment strategies to better manage these challenging conditions.

Evaluation of a surgical technique for trigonocephaly.

Clinically diagnosed trigonocephaly have been treated by a standard surgical technique developed at Göteborg University Craniofacial Unit. To evaluate the technique we designed a study to include both subjective and objective assessments. Of 30 patients operated on between 1988-1997, 15 patients with at least three years postoperative follow-up have been included. An evaluation of the surgical outcome of the bitemporal width, the forehead contour, and the intercanthal distance was made both subjectively using a visual analogue scale (VAS) and objectively with analyses of cephalograms taken preoperatively and postoperatively at 3 and 5 years of age. For the subjective evaluation a control group of 10 randomly selected children from a Child Welfare Centre were selected. For the objective evaluation the control group consisted of cephalograms from children born with cleft lip and palate who were matched regarding sex and age. Both cephalometric analysis and subjective studies of the outcome indicated improvement. When the forehead contour was investigated the number of patients who had been improved or corrected completely was higher when evaluated subjectively. When interorbital distance on cephalograms and intercanthal distance scores on VAS were evaluated, again the subjective study indicated improvement in more subjects.

Combined bone grafting and delayed closure of the hard palate in patients with unilateral cleft lip and palate: facilitation of lateral incisor eruption and evaluation of indicators for timing of the procedure.

OBJECTIVE: To compare outcomes of bone grafting performed before eruption of the lateral incisor to outcomes of grafting performed before eruption of the canine and to evaluate the long-term results of bone grafting combined with delayed closure of the hard palate during mixed dentition. DESIGN: Seventy consecutive patients (52 men and 18 women) with complete unilateral cleft lip and palate were studied. All patients underwent bone grafting with simultaneous closure of the cleft in the hard palate at the stage of mixed dentition. The velum had been repaired in infancy. Mean age for the bone grafting procedure was 8.4 years. Bone grafting was performed to facilitate eruption of the lateral incisor in 43 (61%) of the patients and to facilitate eruption of the canine in the remaining 27 (39%) patients. Intraoral radiographs were used to evaluate the morphologic characteristics of the cleft and the stage of eruption of the permanent lateral incisor and canine before bone grafting. Mean follow-up time was 4.0 years (range, 1-10.1 years). RESULTS: The mean time for the surgery, which included bone grafting and repair of the residual cleft in the hard palate, was 109 minutes, and the mean amount of bleeding was 121 ml. The rate of dehiscence in the flap covering the alveolar bone graft was 14%, and the rate of total failure of bone grafting was 3%. An oronasal fistula developed in the hard palate of 13% of patients, but the fistula was of sufficient size to serve as an indication for reoperation in only 6%. The postoperative alveolar bony height in the cleft area was more than 75% of the normal height in 94% of patients. Closure of the cleft space in the dental arch was performed or planned to be achieved orthodontically in 91% of patients. When bone grafting was performed to facilitate eruption of the lateral incisor, the cleft space was closed orthodontically in 100% of patients. The optimal indicator for timing of the bone grafting procedure from an orthodontic point of view was when the permanent lateral incisor or the canine close to the cleft was covered by a thin shell of bone (i.e., 7-9 years of age).

Vertical position, rotation, and tipping of molars without antagonists.

PURPOSE: There has been a general belief that permanent teeth without antagonists overerupt, creating, after some time, considerable clinical problems. However, very few studies in the literature support this statement. The purpose of this investigation was to examine the position of molars that had been unopposed for a long period and to test the hypothesis that overeruption does affect every tooth without an antagonist. MATERIALS AND METHODS: Fifty-three individuals were examined clinically, and dental casts were taken to evaluate the position of unopposed molars. There were 84 molars (61 in the maxilla and 23 in the mandible) with a documented period of at least 10 years without antagonists. Among these teeth, 25 molars had neither an antagonist nor a mesially adjacent tooth. A qualitative method was used to evaluate the position of the molars in the vertical direction: (1) teeth with no sign of overeruption, (2) teeth with slight overeruption (< 2 mm), and (3) teeth with moderate to severe overeruption (> or = 2 mm). RESULTS: Of the 84 molars examined, 15 teeth (18%) revealed no signs of overeruption, 49 teeth (58%) displayed overeruption of less than 2 mm, and 20 teeth (24%) showed moderate to severe overeruption. Individuals with molars that had lost their antagonists in adult age had a lower risk for overeruption than the other subjects examined. The existence of adjacent teeth was important for the position of the unopposed molar in a mesiodistal or buccolingual direction. Molar rotation was more frequent in the maxilla, whereas tipping was more common in the mandible. CONCLUSION: It is concluded that not all molars without antagonists overerupt, not even in a long-term perspective.

Mandibular setback osteotomy: facial soft tissue behavior and possibility to improve the accuracy of the soft tissue profile prediction with the use of a computerized cephalometric program: Quick Ceph Image Pro: v. 2.5.

OBJECTIVES: In part I, to derive ratios of soft to hard tissue profile changes after mandibular setback surgery and to report postoperative changes in soft tissue thickness at the lip and chin areas and, furthermore, to test the hypothesis that soft tissue thickness can act as one of the predictors of soft tissue response after surgery. In part II, to compare the predicted profile lines, using either the customized or the pre-programmed ratios, with the actual postsurgical outcomes. DESIGN: A retrospective study with the sample divided into two groups for different purposes. SETTING AND SAMPLE POPULATION: Department of Orthodontics and Department of Oral and Maxillofacial Surgery at Göteborg University, Sweden. Forty-one Caucasian subjects in need of mandibular setback surgery only. EXPERIMENTAL VARIABLE: Hard and soft tissue movements and changes in soft tissue thickness after surgery were calculated using a customized analysis. Comparisons of the predicted profile outcomes with the actual postsurgical outcomes were carried out with another customized analysis. OUTCOME MEASURE: Distance measurements of certain landmarks in relation to constructed reference lines, both in horizontal and vertical planes, were calculated. RESULTS: The upper lip thickness decreased and the lower lip thickness increased after surgery. The hypothesis that the soft tissue thickness at the lip and chin areas could act as predictors of the ratios of soft to hard tissue changes after surgery, was not supported. Ratios for the lower lip of about 83% of the horizontal and 14% of the vertical movement of the PM point on the bony chin were found in Part I. In Part II, these ratios were introduced and the predicted profile moved significantly closer to the actual postsurgical outcome than if using the pre-programmed ratios (p < 0.05). CONCLUSION: Being able to customize the ratios of soft to hard tissue changes after a particular type of orthognathic surgery will enhance the accuracy of a patient's predicted profile outcome. These ratios should be pre-programmed in future versions of the software.

Comparisons of facial growth in patients with unilateral cleft lip and palate treated by different regimens for two-stage palatal repair.

The aim of this study was to compare facial development, particularly growth of the maxilla, of two groups of patients with unilateral cleft lip and palate in whom palatal surgery had been done slightly differently, particularly the timing of the procedures. Two-stage palatal repair had been used at 8 (velar closure) and 102 months (hard palate surgery) at one cleft centre and at 20 and 62 months at another centre. Lateral roentgencephalograms were used to analyse the first sample of 20 patients, who were followed longitudinally from 7-16 years of age. The other group comprised 17 subjects in the same age range, who were investigated cross-sectionally, also by cephalometry. Generally, the outcome of the two surgical regimens was similar and equally satisfactory, with no evident difference in facial or maxillary morphology between the two samples. From the midfacial growth point of view, it might be questioned whether it is necessary to delay closure of the cleft in the hard palate until the mixed dentition stage as was done at the first cleft centre.

Current knowledge in cleft lip and palate treatment from an orthodontist's point of view.

The aim of this review was to put new clinical research findings into proper perspectives relative to previously accepted knowledge on treatment of patients with cleft lip and palate. The first part of the paper deals with various aspects of infant orthopedic treatment, such as its influence on primary surgery, maxillary arch form and dimensions, feeding, psychological situation of the parents and speech development. Following parts analyze general maxillofacial growth outcome after surgery and also maxillofacial growth in relation to particular surgical procedures (palatal repair, periosteoplasty/gingivoplasty, bone grafting). The last part of the review discuss the effects of certain orthodontic/orthopedic treatment approaches as well as the role of dental implants in treatment of cleft lip and palate patients.

Development of the residual cleft in the hard palate after velar repair in a 2-stage palatal repair regimen.

Delayed closure of the hard palate is believed to improve maxillary growth and facial appearance in cleft lip and palate patients. However, the cleft opening in the hard palate after velar closure might impair speech development. The aim of this investigation was to study the development of the residual cleft in the hard palate after 2-stage palatal repair (TSPR) in children born with complete cleft lip and palate (bilateral [BCLP]; n = 7 or unilateral [UCLP]; n = 22) or isolated cleft palate (CP; n = 9). Moreover, we aimed to investigate whether any morphologic factors before surgery might predict development of the residual cleft. Dental casts obtained prior to velar repair (mean age 7 months) and postoperatively at 1 1/2, 3, 4, 5 and 7 years were analyzed with a Reflex Microscope regarding the width, length and area of the cleft in the hard palate. The palatal cleft varied in size both pre- and postoperatively in all 3 types of cleft patients. The width of the cleft in the UCLP subgroup showed a marked reduction immediately after velar repair, but then, on average, remained stable until final surgical closure of the hard palate. In the BCLP subgroup the initially rather narrow width of the clefts remained unchanged postoperatively. Clefts in the CP subgroup, especially in those with a complete cleft, remained large after veloplasty. In 4 of the UCLP and 2 of the BCLP patients, the cleft width increased gradually. In some other subjects, both in the UCLP and BCLP subgroups, the residual cleft closed functionally with time, but this development could not be foreseen.

Use of titanium dental implants as an integrated part of a CLP protocol.

The problem of edentulousness in the cleft area of patients with cleft lip and palate was formerly resolved with a conventional fixed bridge construction, but this approach did not always prove optimal. Nowadays, in these patients the bridge can be substituted by a crown on an osseointegrated titanium implant fixture. The concept of dental rehabilitation using titanium implants has gradually merged into our routine treatment for patients with cleft lip and palate. In this report we describe our surgical technique using osseointegrated titanium implants and evaluate our result in patients with cleft lip and palate. Sixteen patients with cleft lip and palate, 11 men and five women, were divided into two groups: group 1 consisted of six patients who did not need bone grafting prior to the fixture installation, and group 2 comprised 10 patients who had additional bone grafting three months before the fixture installation. Abutments were applied six months after fixture installation. Dental crowns and fixed bridges were then constructed. All patients were seen on regular follow-up visits. Routine roentgenograms were obtained preoperatively and when the abutments were applied. Photographs were taken at these occasions and also after the prosthodontic work was completed. Of a total of 31 fixtures, all except two were osseointegrated at the time of the abutment connection, and the remaining 29 have all been functional during the observation period, giving a success rate of 93%. In group 1 all fixtures (100%) were osseointegrated. The non-integrated fixtures were found in group 2 giving a success rate of 91% in this group. The mean follow-up time after fixture installation was six years and three months, and the mean observation time with loaded fixtures was five years and six months.

[Improved treatment of cleft lip and palate is now available]. / Nu finns bättre behandling av läpp-käk-gomspalt.

When cleft lip and palate treatment was introduced at Gothenburg in 1957, the procedure used was early bone grafting (EBG). By 1965, EBG had been omitted from the regimen, bone grafting being postponed until the appearance of mixed dentition. Analysis of the results of both techniques showed maxillary retrusion of different degrees. Accordingly, this routine was abandoned in 1975, being replaced by a procedure which is characterised by delayed closure of the hard palate (DCHP). Thus, the surgical procedure comprised the following steps: 1, lip closure at 1-2 months of age; 2, soft palate repair at 6-8 months; 3, final lip-nose surgery at 12 months; and 4, closure of the left in the hard palate, and bone grafting to the alveolar process during mixed dentition at about 8-10 years of age. Follow-up has shown the majority of patients to manifest acceptable speech development during childhood, though problems may occur in some cases. Maxillary growth has been found to be improved after DCHP, and at present the need of maxillary advancement surgery has been reduced to approximately 5% of cases, as compared with the former rates of 50% of cases among those treated with EBG, and of 25% among those treated with the vomer flap procedure.

A comparison of babbling and speech at pre-speech level, 3, and 5 years of age in children with cleft lip and palate treated with delayed hard palate closure.

Babbling and speech in 21 children with cleft palate were compared at pre-speech level, 3, and 5 years of age. The aims were to study if misarticulations in pre-school speech appear to be articulatorily related to the sound productions in pre-speech, whether the feeding technique influenced the prevalence of anterior articulation, and if there was a relationship between speech and the size of the residual cleft at 3 and 5 years of age. All the children had the soft palate closed, whereas the cleft in the hard palate was left open to be closed later on. Perceptual judgement of speech revealed a high prevalence of hypernasality, nasal escape and retracted oral articulation of dental or alveolar plosives. The latter was correlated with the size of the residual cleft area. There was a tendency towards a relationship between absence of anterior sound productions in babbling and retracted oral articulation in speech. The feeding technique, however, appeared not to have had any influence on articulatory place.