Associations between mandibular symphysis form and craniofacial structures

Objectives

This study aimed to (1) analyze the relationships between mandibular symphysis characteristics (height, prominence, inclination, concavity, and convexity) and facial pattern, skeletal class, lower incisor position, and sex, and (2) determine the associations between the symphysis soft tissue dimensions and the underlying osseous structures.

Methods

Cone-beam computed tomography (CBCT) images were selected for 385 patients (206 women and 179 men). The patients were classified according to their skeletal class and vertical pattern. The lower incisor inclination (IMPA) was recorded. Twelve measurements were taken for each mandibular symphysis using Invivo5 software (Anatomage, San Jose, CA, USA).

Results

Symphyseal measurements were larger in males than in females. Skeletal Class II and III hyperdivergent patients showed the highest symphysis height values. Hypodivergent individuals showed lower symphysis convexity angles. Concavity of the symphysis was greater for Class II hyperdivergent patients. Lower incisor inclination showed a positive correlation with symphysis concavity and inclination. Moderate and weak correlations were found between hard tissue and soft tissue parameters.

Conclusions

Only a few characteristics of symphysis morphology depend on sex, incisor position, skeletal class, and vertical pattern. More significant relationships are found when the vertical pattern and skeletal class are analyzed in combination. The shape of the symphysis soft tissue is not directly correlated with the underlying skeletal structures.

     

Psychosocial acceptance of cleft patients: has something changed?

Objective

The main purpose of this study was to analyse the reactions of a panel (non-cleft adults) when observing cleft lip morphology. Although rehabilitation of cleft lip and palate is improving, there are still indications of social rejection of cleft patients by the people around them. Polarity profiles have been used since 1973 to measure social distance with regard to cleft patients. Because rehabilitation results and education of the society have improved in recent decades, we investigated whether social distance has been affected.

Setting

The setting of this study is the Department of Oral, Craniomaxillofacial, and Facial Plastic Surgery, University Hospital of Leipzig, Germany

Patients and participants

Using a cross-sectional study design, we enrolled a sample of adult laypersons (n = 273). For the survey, we followed the concept of photograph presentation and questionnaire investigation reported by Sergl and Schmid (1973). We presented anonymised frontal and profile pictures of the faces of 50 cleft patients and asked the laypersons to specify social distance. Three predictor variables (layperson gender, profession and year of evaluation) were grouped.

Results

Although social distance has reduced during the last 40 years, life situations which require emotional proximity still cause some concern. Professional background and gender affect laypersons’ attitudes.

Conclusion

Although rehabilitation of cleft lip and palate is much better than 40 years ago, social distance remains a problem in society. It is necessary to improve both results of rehabilitation of cleft patients and social acceptance by the people around them.

     

Long-Term Effect of Maxillary Distraction Osteogenesis (DO) on Nasal Index in Adult Patients with Cleft Lip and Palate Deformities

Purpose

To test the hypothesis that there is no immediate and long-term effects of maxillary distraction osteogenesis (DO) on nasal index among adult subjects with cleft lip and palate deformities.

Materials and Methods

Twelve adult subjects in the age range of 17–20 years with complete unilateral cleft lip and palate underwent advancement of maxilla by DO. The immediate and long-term effects of maxillary DO on nasal index were evaluated from extra-oral full face frontal photographs recorded prior to DO (T₀), at the end of active DO (T₁) and at least 2-years after the DO (T₂). The ANOVA, Post Hoc test (Bonferroni) and Pearson correlation coefficients were used. The probability value (P value) 0.05 was considered as statistically significant.

Results

SNM angle and Ptm-M distance increased significantly by DO (P < 0.001). The nasal index increased significantly (P < 0.01) by 13.85 % from T₀ value of 85.15 ± 4.49 to 99.02 ± 11.16 % at the end of active distraction (T₁) and by 12.69 to 97.84 ± 9.14 % at the end of long-term follow-up (T₂). The correlation between sagittal maxillary advancement and nasal index was statistically significant (P < 0.001). For each millimeter of maxillary advancement, the nasal index increased by 1.38 % and 1.8 % at the end of active distraction and long-term follow-up respectively.

Conclusion

The advancement of maxilla by distraction osteogenesis among subjects with cleft lip and palate deformities increased nasal index significantly.

     

The role of the tensor veli palatini muscle in the development of cleft palate-associated middle ear problems

Objective

Otitis media with effusion is common in infants with an unrepaired cleft palate. Although its prevalence is reduced after cleft surgery, many children continue to suffer from middle ear problems during childhood. While the tensor veli palatini muscle is thought to be involved in middle ear ventilation, evidence about its exact anatomy, function, and role in cleft palate surgery is limited.This study aimed to perform a thorough review of the literature on (1) the role of the tensor veli palatini muscle in the Eustachian tube opening and middle ear ventilation, (2) anatomical anomalies in cleft palate infants related to middle ear disease, and (3) their implications for surgical techniques used in cleft palate repair.

Materials and methods

A literature search on the MEDLINE database was performed using a combination of the keywords “tensor veli palatini muscle,” “Eustachian tube,” “otitis media with effusion,” and “cleft palate.”

Results

Several studies confirm the important role of the tensor veli palatini muscle in the Eustachian tube opening mechanism. Maintaining the integrity of the tensor veli palatini muscle during cleft palate surgery seems to improve long-term otological outcome. However, anatomical variations in cleft palate children may alter the effect of the tensor veli palatini muscle on the Eustachian tube’s dilatation mechanism.

Conclusion

More research is warranted to clarify the role of the tensor veli palatini muscle in cleft palate-associated Eustachian tube dysfunction and development of middle ear problems.

Clinical relevance

Optimized surgical management of cleft palate could potentially reduce associated middle ear problems.

     

Nasal Profile Changes Following Anterior Maxillary Segmental Osteotomy: A Lateral Cephalometric Study

Purpose

Orthognathic surgery in reference to the maxilla attempts to correct underlying skeletal deformities and improve function. Consequently it has the potential to significantly alter the central esthetic unit of the face, the nasolabial region. In order to evaluate the nasal morphological changes which would result following anterior maxillary segmental osteotomy (superior and posterior repositioning); four angles namely, nasolabial, nasal tip projection, columellar labial and supra tip break angle were evaluated.

Method and materials

In ten selected subjects who have undergone anterior maxillary segmental osteotomy with superior and posterior repositioning, pre (T1) and post operative (T2) lateral cephalometric parameters pertaining to the four angles were analysed using Wilcoxon signed rank test.

Results

A significant increase in nasolabial angle and mild changes in nasal tip projection, columellar labial angle and supra tip break angle were observed.

Conclusion

The results of this study emphasize the need for the pre surgical evaluation of nasal morphology in every individual planned for anterior maxillary segmental osteotomy.

     

Comparison of Outcome of Modified Millard’s Incision and Delaire’s Functional Method in Primary Repair of Unilateral Cleft Lip: A Prospective Study

Background

Certain preoperative anatomical features may lead the surgeon to choose one particular incision pattern in preference to another. No one technique of cleft lip repair consistently produces ideal aesthetic and functional results.

Objectives

This study was conducted to compare the outcomes attained using two different designs of skin incision used for surgical correction of unilateral cleft lip.

Materials and Methods

Modified Millard’s incision and Delaire’s functional method techniques were performed and evaluated on 18 patients who received primary unilateral cleft lip repair. Soft-tissue measurements of the lip and nose were recorded preoperatively. Analysis was based on postoperative assessment of the white roll, vermilion border, scar, Cupid’s bow, lip length, and nostril symmetry and appearance of the alar dome and base. Chi-square and Fisher exact test, Student t test (two tailed, independent) and Student t test (two tailed, dependent) were used for statistical analysis of study parameters at 5 % level of significance.

Results

Preconceptions that one particular technique was better suited to certain preoperative cleft anatomical forms were not proven statistically. The outcome of our surgical methods was good and suggested quantitative changes with progressive diminution of asymmetry of the cleft and non cleft sides.

Conclusion

Lip length improvement was better in case of modified Millard’s incision. The Delaire’s functional method of cleft lip repair results in improved nasal symmetry due to correction of the abnormal insertions of the underlying musculature.

     

Erratum to: Nasal Profile Changes Following Anterior Maxillary Segmental Osteotomy: A Lateral Cephalometric Study

Purpose

Orthognathic surgery in reference to the maxilla attempts to correct underlying skeletal deformities and improve function. Consequently, it has the potential to significantly alter the central esthetic unit of the face, the nasolabial region. In order to evaluate the nasal morphological changes which would result following anterior maxillary segmental osteotomy (superior and posterior repositioning), four angles, namely nasolabial, nasal tip projection, columellar labial and supra tip break angle, were evaluated.

Method and Materials

In ten selected subjects who have undergone anterior maxillary segmental osteotomy with superior and posterior repositioning, preoperative (T1) and postoperative (T2) lateral cephalometric parameters pertaining to the four angles were analyzed using Wilcoxon’s signed-rank test.

Results

A significant increase in nasolabial angle and mild changes in nasal tip projection, columellar labial angle and supratip break angle were observed.

Conclusion

The results of this study emphasize the need for the presurgical evaluation of nasal morphology in every individual planned for anterior maxillary segmental osteotomy.

     

Anatomical relation between nasal septum deviation and oropharynx volume in different facial patterns evaluated through cone beam computed tomography

Introduction

The objective of this study was to establish the anatomical relation between nasal septum deviation (NSD) and oropharynx volume in different facial patterns using cone beam computed tomography (CBCT).

Methods

Ninety CBCT examinations were analyzed. InVivoDental software was used to evaluate cephalometric image reconstructions in terms of facial type, determined from cephalometric measurements indicative of growth direction; the presence of NSD was also evaluated. ITK-SNAP software was employed for delimitation of the oropharynx. Intra-examiner error methods were recorded. The results were subjected to parametric and non-parametric tests using Bioestat 5.0.

Results

A comparison of facial types revealed a significantly lower prevalence of NSD in the dolichofacial group compared with the brachyfacial and mesofacial groups (P = 0.0101 and 0.0149, respectively). In the total sample, there was a very strong positive relation between the presence of NSD and oropharynx space volume (P = 0.0162). The oropharynx volume was larger in all facial patterns in the presence of NSD.

Conclusion

The presence of NSD was not associated with facial type, although the oropharynx volume in patients with NSD increased. Therefore, deviation of the septum influences oropharynx volume.

     

The innervation of the soft palate muscles involved in cleft palate: a review of the literature

Objective

Surgical techniques to obtain adequate soft palate repair in cleft palate patients elaborate on the muscle repair; however, there is little available information regarding the innervation of muscles. Improved insights into the innervation of the musculature will likely allow improvements in the repair of the cleft palate and subsequently decrease the incidence of velopharyngeal insufficiency. We performed a literature review focusing on recent advances in the understanding of soft palate muscle innervation.

Material and methods

The Medline and Embase databases were searched for anatomical studies concerning the innervation of the soft palate.

Results

Our literature review highlights the lack of accurate information about the innervation of the levator veli palatini and palatopharyngeus muscles. It is probable that the lesser palatine nerve and the pharyngeal plexus dually innervate the levator veli palatini and palatopharyngeus muscles. Nerves of the superior-extravelar part of the levator veli palatini and palatopharyngeus muscles enter the muscle form the lateral side. Subsequently, the lesser palatine nerve enters from the lateral side of the inferior-velar part of the levator veli palatini muscle. This knowledge could aid surgeons during reconstruction of the cleft musculature. The innervation of the tensor veli palatini muscle by a small branch of the mandibular nerve was confirmed in all studies.

Conclusion

Both the levator veli palatini and palatopharyngeus muscles receive motor fibres from the accessory nerve (through the vagus nerve and the glossopharyngeal nerve) and also the lesser palatine nerve. A small branch of the mandibular nerve innervates the tensor veli palatini muscle.

Clinical relevance

Knowledge about these nerves could aid the cleft surgeon to perform a more careful dissection of the lateral side of the musculature.

     

Pierre-Robin-Sequenz — postoperative Komplikationen nach Gaumenspaltverschluss

Background

In a 25-year retrospective review of 1976–2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied.

Patients and methods

The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life.

Results

A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.

     

Evaluation of the oropharynx in class I and II skeletal patterns by CBCT

Purpose

This study aimed to evaluate the dimensions of the oropharynx and its shape in the minimum cross-sectional area, in individuals with Class I and Class II skeletal patterns, using three-dimensional CBCT images.

Methods

Forty-two cone-beam computed tomography images of grown individuals were evaluated. The images were divided according to the patient’s skeletal patterns. The dimensions of the oropharyngeal airway space were determined using the Dolphin Imaging software.

Results

The volume and the minimum cross-sectional area were greater in patients with a Class I skeletal pattern, with a median difference of 5379 mm³ and 86.8 mm², respectively. The anteroposterior and lateral diameters in the minimum cross-sectional area were also higher in Class I individuals (2.3 and 6.0 mm, respectively), but the ratio between them was not different.

Conclusions

The volume and the minimum cross-sectional area of the oropharynx, as well as the anteroposterior and lateral diameters, are lower in individuals with a class II skeletal pattern than in individuals with a class I skeletal pattern. There was no difference in the shape of the oropharynx in healthy individuals with different skeletal patterns.

     

Hard and Soft Tissue Changes Following Maxillary Distraction Osteogenesis and Mandibular Setback with Bilateral Sagittal Split Osteotomy

Aims of this Study

(1) To highlight the role of intraoral submerged device in distraction osteogenesis (DO) of patients requiring two jaw surgeries for the correction of severe developmental maxillary hypoplasia (MH) and mandibular prognathism (MP) (2) To analyse the hard and soft tissue changes following maxillary DO and mandibular setback with bilateral sagittal split osteotomy (BSSO) in patients with severe MH and MP requiring two jaw surgeries.

Materials and Methods

During the period Jan 2004 to Dec 2006, five patients with severe developmental MH along with MP were treated. In 1st stage maxillary distraction was done. Distraction started on 6th postoperative day, 1 mm distraction was carried out for 10–15 days on either side. Serial radiographs were taken immediate postoperative period for baseline comparison, post-distraction and at the end of distraction. After a period of 3–4 months of distraction 2nd stage was done. In 2nd stage, mandibular setback was done with BSSO and distractors were removed under general anesthesia. Radiographs were taken immediately and at 4 months post-operatively. Cephalometric tracings were carried out preoperatively, post DO and finally after mandibular setback with BSSO.

Results

The mean horizontal movement of maxilla was 11.4 mm at ANS and 9.6 mm at A point. Upper incisor edge was advanced by 8.8 mms. SNA increased by 8.4° and SNB decreased by 4.6°. Nasal projection advanced by 4°. Nasolabial angle normalized in all patients, mean change achieved was 10.8°. Upper lip moved forward by 5.4 mm. Lower lip moved backward by 5.4 mm. Mandible positioned backward by 4 mm at B point. No vertical change occurred in the position of A, ANS and upper incisor edges. Mean increase in skeletal angle of convexity was 26.4°. Concave profile was significantly changed to convex in all patients.

Conclusion

Maxillary DO and mandibular setback with BSSO was associated with improved facial balance and esthetics.

     

A Self-Retaining Lingual Flap Guarding Device During Surgical Removal of Impacted Mandibular Third Molar

Introduction

Lingual nerve damage is one of the common complications following mandibular third molar surgery. On considering the impact of lingual nerve damage on the patient’s quality of life, it is necessary to exercise caution to minimize its occurrence.

Material and methods

Although many lingual retractors are available, in this article we describe an indigenously designed lingual retractor for use in mandibular third molar surgery.

Conclusion

The indigenous lingual retractor described in this article provides advantages like clear access and excellent retention unlike conventional retractors.

     

Prevalence of isolated maxillary lateral incisor agenesis in Syrian adolescents

Purpose

This research is designed to obtain a better understanding and provide more insight of this phenomenon through evaluating the prevalence of congenital absence of maxillary lateral incisors in a Syrian population.

Methods

The method involved clinical examination of 8000 school children with an equal number of males and females (age range 12–15 years) to identify students only affected by bilateral or unilateral congenital absence of maxillary lateral incisors. Agenesis was determined based on radiological evidence.

Results

The results of this study showed that the prevalence of isolated maxillary lateral incisors agenesis was 1.15%. In the sample studied, 66.3% of the patients were female and 33.7% were male (p < 0.05). Absence was bilateral in 47.8% of patients and unilateral in 52.2%. Of the unilateral cases, 48% occurred on the right side and 52% on the left side, and the contralateral maxillary incisor was found to be microdont in 43.75%, right lateral in 47.6%, and left lateral in 52.4%.

Conclusion

The results of this study allow the conclusion that the prevalence of isolated maxillary lateral incisors agenesis in a Syrian population is within the average range with regard to other populations. A significant familial component to the etiology of maxillary lateral incisors agenesis was found.

     

Three-dimensional analysis of tooth dimensions in the <Emphasis Type="Italic">MSX1</Emphasis>-missense mutation

Objectives

A novel, 3D technique to measure the differences in tooth crown morphology between the MSX1 cases and non-affected controls was designed to get a better understanding of dental phenotype-genotype associations.

Materials and methods

Eight Dutch subjects from a single family with tooth agenesis, all with an established nonsense mutation c.332 C > A, p. Ser 111 Stop in exon 1 of MSX1, were compared with unaffected controls regarding several aspects of tooth crown morphology of incisor and molar teeth. A novel method of quantitative three-dimensional analysis was used to detect differences.

Results

Statistically significant shape differences were observed for the maxillary incisor in the MSX1 family compared with the controls on the following parameters: surface area, buccolingual dimension, squareness, and crown volume (P?≤?0.002). Molar crown shape was unaffected.

Conclusions

A better understanding of dental phenotype-genotype associations may contribute to earlier diagnosis of some multiple-anomaly congenital syndromes involving dental anomalies.

Clinical relevance

A “shape database” that includes associated gene mutations resulting from developmental syndromes may facilitate the genetic identification of hypodontia cases.

     

Internal derangement in the temporomandibular joint of juveniles with clinical signs of TMD

Aim

The aim of this study was to investigate possible correlation of specific skeletal or dental class in children and adolescents with clinical signs of temporomandibular dysfunction (TMD) with the severity of internal derangement (ID) of the temporomandibular joint.

Materials and methods

Based on MRI images, the ID of 232 juvenile temporomandibular joints in 116 patients were retrospectively recorded. The distribution of the ID stages within the skeletal and dental classes was compared by means of the χ ² test.

Results

Excluding the comparison between skeletal Class I (S I) and skeletal Class II (S II; p < 0.05), no statistically significant differences in the distribution of the ID stages were found between the skeletal classes (p > 0.05). No statistically significant differences were found when comparing the distribution of the ID stages between the dental classes (p > 0.05).

Conclusion

According to these findings, there is no skeletal or dental class that is related to higher degrees of internal derangement in the TMJs of children and adolescents presenting clinical signs of TMD. Therefore, it is not possible to draw conclusions about the severity of the ID in relation to the dental and skeletal class in symptomatic juvenile TMJs.

     

Techniques to Improve Reliability and Predictability of the Dorsal Pedicled Tongue Flap in Closure of Palatal Defects and Oronasal Fistulae

Introduction

Despite the improvement in surgical techniques in cleft palate surgery, oronasal fistulas continue to remain a challenge, usually the result of residual palatal and alveolar clefts and post-palatoplasty defects. The tongue flap is an extremely versatile, sturdy, reliable and efficient means of closure of anterior as well as posterior, unilateral and bilateral palatal defects, effectively functionally obliterating the oronasal communication, owing much of its success to its highly vascular structure, good mobility, texture match, central location and low donor site morbidity. However, it has a few drawbacks. Flap dehiscence and detachment during the early postoperative period is a troublesome complication owing to tongue movements during normal activities such as speaking, swallowing, yawning and coughing.

Aim

This article describes some of the methods which can be used to effectively alleviate these shortcomings.

Methods

A protocol of immobilizing the tongue by tethering it to the maxillary teeth for the 3-week postoperative period, and also maintaining the patient on nasogastric feeding, until the patient is taken up for surgical separation the pedicle, was employed in all patients in this case series.

Results

There was a successful and predictable take of the tongue flap at the donor site, namely the palatal/oronasal fistula with its successful closure, in all the patients.

Conclusion

Treatment of the oronasal fistula using a two-layer closure using the nasal mucoperiosteum together with an anteriorly based dorsal tongue flap is an easy and efficient method, whose reliability can be further increased by avoiding a common complication, namely tongue flap detachment in the postoperative period brought on by movements of the tongue, by immobilizing the tongue by tethering it to the maxillary teeth and also maintaining the patient on nasogastric feeding for the 3-week postoperative period.

     

Management of the premaxilla in the treatment of bilateral cleft of lip and palate: what can the literature tell us?

Objective

In the treatment of bilateral cleft lip and palate (BCLP) patients, there is discussion about the management of the position of the premaxilla. This literature analysis summarises the literature on managing this condition.

Materials and methods

A PubMed, Embase and Cochrane Library search was conducted resulting in 4465 articles which were screened on title and abstract.

Results

Seventy-one articles were available in full text, 16 of which were included in this literature analysis. We searched on keywords timing and technique, complications, growth of the maxilla and results after bone grafting the alveolar process. This literature analysis has shown that there are various ways to correct the position of the premaxilla. These can be divided into primary, early, late secondary and tertiary intervention before the age of 8 years, between the ages of 8 and 12 years and older than 12 years. Correction is done with surgery, orthodontics or a combination, with or without bone grafting.

Conclusions

An osteotomy of the premaxilla in combination with secondary alveolar bone grafting appears to be the most successful technique. Combining early secondary alveolar bone grafting with osteotomy creates more room to ensure a watertight closure of the nasal mucosa resulting in fewer postoperative complications. Before surgery, the orthodontist should try to optimise the position of the premaxilla for its surgical correction prior to bone grafting.

Clinical relevance

The treatment of BCLP patients is still based on experience and expert opinions. This literature analysis tries to give a summery on how to handle the protruded and displaced premaxilla.

     

Sub-Periosteal Dissection with Denture-Guided Epithelial Regeneration: A Novel Method for Peri-Implant Soft Tissue Management in Reconstructed Mandibles

Background

In patients with reconstructed mandibles using free fibula flaps, management of soft tissues around implants supporting dental rehabilitation, is often a clinical problem.

Aim

The aim of this paper is to describe a new technique, namely "Sub-periosteal dissection and denture-guided epithelial regeneration (SD-DGER)", as a method of peri-implant soft tissue management in these patients.

Materials and methods

The technique consists of performing a subperiosteal dissection with creation of buccal and lingual flaps. These flaps form the buccal and lingual vestibule. Implants are placed and an interim denture is immediately loaded onto the implants to guide the regenerated epithelium. A keratinized mucosal layer is formed on the bare fibula bone in six months time.

Results

This technique was successful in producing fixed keratinized epithelial tissue around implants in patients with mandibles reconstructed using the free fibula flap in patients who did not undergo radiotherapy.

Conclusion

The sub-periosteal dissection with denture guided epithelial regeneration is a predictable form of peri-implant soft tissue management in selected patients with reconstructed jaws.