Long-term evaluation of bilateral cleft lip and palate patients after early secondary closure and premaxilla repositioning

The aim of this retrospective, mixed longitudinal study was to assess the long-term outcome of early secondary closure and premaxilla osteotomy in 40 bilateral cleft lip and palate patients who underwent early secondary osteotomy of the premaxilla and bone grafting at the age of 8-12 years. Clinical and cephalometric evaluations of profile, lip relation, nasolabial angle and position of the maxilla preoperatively, postoperatively and at adolescence were compared to normal values of non-cleft individuals and the reported data of 90 bilateral cleft lip and palate patients treated in Oslo. In 68% of patients the profile was considered acceptable, but in 26 maxillary growth appeared to be impaired by cephalometric standards. In four patients a Le Fort I osteotomy was carried out and nine patients would have benefited from such a procedure. This study reveals a trend towards maxillary growth retardation partially compensated by orthodontic and dental treatment. Since the results are comparable to those reported for the Oslo group with regard to maxillary growth, the surgical protocol followed does not require revision. Considering the benefits, i.e. closure of alveolo-palatal cleft, continuity of dental arch, eruption of canine in the graft and closure of oro-nasal communications, this mode of treatment should be continued.     

Growth and development: hereditary and mechanical modulations

Growth and development is the net result of environmental modulation of genetic inheritance. Mesenchymal cells differentiate into chondrogenic, osteogenic, and fibrogenic cells: the first 2 are chiefly responsible for endochondral ossification, and the last 2 for sutural growth. Cells are influenced by genes and environmental cues to migrate, proliferate, differentiate, and synthesize extracellular matrix in specific directions and magnitudes, ultimately resulting in macroscopic shapes such as the nose and the chin. Mechanical forces, the most studied environmental cues, readily modulate bone and cartilage growth. Recent experimental evidence demonstrates that cyclic forces evoke greater anabolic responses of not only craniofacial sutures, but also cranial base cartilage. Mechanical forces are transmitted as tissue-borne and cell-borne mechanical strain that in turn regulates gene expression, cell proliferation, differentiation, maturation, and matrix synthesis, the totality of which is growth and development. Thus, hereditary and mechanical modulations of growth and development share a common pathway via genes. Combined approaches using genetics, bioengineering, and quantitative biology are expected to bring new insight into growth and development, and might lead to innovative therapies for craniofacial skeletal dysplasia including malocclusion, dentofacial deformities, and craniofacial anomalies such as cleft palate and craniosynostosis, as well as disorders associated with the temporomandibular joint.     

Thermal analysis of commercial Gutta-percha using differential scanning calorimeter and dynamic mechanical thermal analysis.

Gutta-percha is the most widespread root canal filling material and knowledge of its chemical and thermomechanical properties is of a great interest to its use in clinical dentistry. In the present investigation, the results from differential scanning calorimeter were compared with those obtained by dynamic mechanical thermal analysis. A significant correlation was established between these results and the chemical composition of six different commercial samples of gutta-percha.     

Okklusion,Kiefergelenke und kieferorthopädische Behandlung

Zusammenfassung Für die Okklusion und den Gelenkbereich sind Zuordnungsnormen existent. Dies ist im Seitenzahnbereich die Höcker-Fossa-Relation, im Frontzahnbereich die Zuordnung der Unterkiefer-Inzisalkanten zu der Nullpunktlinie der palatinalen Konkavitäten im Oberkiefer und im Gelenkbereich die physiologische Kondylenposition. Letztere läßt sich im Pantogramm durch den Wendepunkt der von der Achse bei sagittaler Grenzführung gezeichneten Kurve präzisieren, in Übertragung aber auch im Röntgenbild ermitteln.Ziel der kieferorthopädischen Behandlung sollte die physiologische Zuordnung von Seitenzähnen, Frontzähnen und Gelenken sein. Das vorgestellte Funktionsmodell gibt Hilfestellungen bei der Behandlung auf ein funktionelles Optimum hin.Die Gelenke sind bei der Behandlung wie ein eigenes terminales Okklusionspaar zu betrachten. Ihre korrekte Einstellung läßt sich bisher nur durch Röntgenbilder und durch die pantographische Aufzeichnung darstellen.

---

Summary We are convinced that there is a relation between the occlusion and the temporomandibular joint. In the molar region the correlation is known as the cusp-fossa relationship. In the incisor region the corresponding structures are the mandibular incisor tips and the palatal concavities of the upper incisors. We have designated the correlation in the TMJ-region as the physiological condyle position, which can be identified in the sagittal pantogram by the turning point of the traced sigmoid curve. Similarly this position can be shown by our method on the TMJ-radiograph.The aim of orthodontic treatment should be a physiological positioning of molars, incisors and joints. The functional model presented above can render assistance in achieving a functional optimum in treatment.The temporomandibular joints must be regarded in treatment as additional occluding points. Up to now their correct positioning has been visible only through the use of TMJ-radiographs and pantographic tracings.

---

Résumé Il existe des normes structurelles correspondantes entre l'occlusion et l'articulation temporomandibulaire; à savoir dans les zones latérales d'arcades la relation cuspide-sillon, dans le segment antérieur l'arête des incisives inférieures glissant le long des faces palatines des incisives supérieures jusqu'à la ligne d'arrêt et au niveau de l'articulation la position physiologique du condyle. Cette corrélation s'établit dans le plan sagittal du pantogramme par l'existence d'un point tournant du tracé sigmoïde; on peut transposer cette position dans l'image radiographique.Le but d'un traitement orthodontique est de coordonner physiologiquement les segments latéraux et antérieur d'arcades et l'articulation temporo-mandibulaire. Des moulages fonctionnels préétablis nous aident à obtenir la meilleure fonction au cours du traitement.On doit considérer la double articulation temporo-mandibulaire comme une occlusion finale. Seuls la radiologie et les tracés pantographiques permettent de juger de la position correcte des condyles dans leurs fosses glénoïdes.

---

---

In memoriam Herrn Prof. Dr.G. Müller von seinen ehemaligen Schülern und Mitarbeitern.     

A clinical study of rest position using the Kinesiograph and Myomonitor.

The clinical study was designed to study the vertical dimension of rest position and mandibular closure to maximum intercuspation of the teeth before, during, and after relaxation procedures on 14 subjects with stable dentitions. The findings call attention to the potential of both the Myomonitor and the Kinesiograph for research and clinical use, to the physiologic need for flexibility of the vertical dimension of rest position, and to the importance of measuring all three dimensions when examining the rest position.     

Healing of onlay mandibular bone grafts covered with collagen membrane or bovine bone substitutes: a microscopical and immunohistochemical study in the sheep

The objective of this study was to evaluate the role of collagen membrane and Bio-Oss coverage in healing of an onlay graft to the mandible. Twelve adult sheep each received an onlay bone graft (experiment 1), bone graft+Bio-Gide (experiment 2), and bone graft+Bio-Oss/Bio-Gide (experiment 3) on the lateral surface of the mandible. The animals were euthanized at 4, 8, 12 or 16 weeks after surgery, and findings were analysed by routine microscopy and immunohistochemistry for proliferation (Ki67) and apoptotic (Caspase-3) markers. Grafts were fully incorporated in all specimens. Pronounced resorption was observed in experiment 1. Minimal loss of graft volume was seen in experiment 2 specimens without membrane displacement. A remarkable increase in the augmented region of the mandible was observed in experiment 3. A high number of osteoclasts were expressed within the grafts during the early healing period, and thereafter declined markedly. Osteoblasts within the grafts expressed a moderate level of Ki67 at 8 weeks, which thereafter declined markedly. The strongest expression of Caspase-3 on the bone surface was observed after 16 weeks. In conclusion, the effect of collagen membrane coverage on bone graft volume maintenance was dependent on membrane stability during healing. An autogenous bone graft covered with Bio-Oss particles resulted in a remarkable increase in augmented lateral surface of the mandible. The late stage of bone graft healing was associated with a high apoptotic induction pathway of osteoblasts lining the surfaces of the new bone, demonstrated by strong positive Caspase-3 immunoreactivity.     

A comparison of Shepard's osteotome versus trapdoor flap technique to harvest iliac crest bone for secondary alveolar bone grafting

OBJECTIVE: To compare the postoperative donor site morbidity and alveolar bone graft results following two different techniques for iliac crest bone graft harvest: a closed (Shepard's osteotome) and an open (trapdoor flap) technique. DESIGN: A retrospective review of two cohorts of alveolar bone grafts performed from 1998 to 2004 in Birmingham Children's Hospital by two surgeons using different harvest techniques. Medical and nursing anesthetic notes and medication charts were reviewed. Alveolar bone graft results were assessed using preoperative and postoperative radiographic studies. PATIENTS: A total of 137 patients underwent an operation. Of these, 109 patients were compatible with the inclusion criteria (data available, first operation, no multiple comorbidities). Sixty-four patients had iliac bone harvested using the open trapdoor technique, while 45 had the same procedure using the closed osteotomy technique. RESULTS: Maximum bone graft volumes harvested were similar with both techniques. The mean length of hospital stay was 50.9 hours for the osteotome and 75.5 hours for the open technique group (p < .0001). The postoperative analgesia requirement was higher and the postoperative mobilization was delayed and more difficult for the open technique patients (p < .0005). Kindelan scores performed by two independent orthodontists were similar for both techniques. CONCLUSION: The findings demonstrate that harvesting bone from the iliac crest using an osteotome technique reduces time in hospital, analgesia requirements, and postoperative donor site morbidity with no detrimental outcome.     

Surgical correction of pseudoankylosis and microgenia: report of case.

The coronoid process was fused to the zygomatic buttress and posterior aspect of the maxilla, resulting in a restricted mandibular opening. In addition to the functional limitation, the patient also had a skeletal deformity of microgenia. A coronoidectomy released the extracapsular ankylosis and restored normal mandibular function, and an augmentation genioplasty corrected a contour deficient chin.