Craniofacial growth in subjects with unilateral complete cleft lip and palate, and unilateral incomplete cleft lip, from 2 to 22 months of age

This paper reports a longitudinal quantitative cephalometric analysis of the craniofacial growth in subjects with unilateral complete cleft lip and palate (UCCLP), and unilateral incomplete cleft lip (UICL), from 2 to 22 months of age. The purpose of the study was to determine the amount and direction of growth in UCCLP compared to UICL (control group) from 2 months of age (just prior to lip repair) to 22 months of age, 20 months later. The sample comprised of 49 subjects with UCCLP (37 males and 11 females) and 45 with UICL (29 males and 16 females). The cephalometric analysis of the craniofacial morphology included lateral, frontal, and axial projections. The data were presented as mean plots of the craniofacial region including the calvaria, cranial base, orbits, nasal bone, maxilla, mandible, cervical column, pharynx, and soft-tissue profile. A valid common coordinate system (registration according to the n-s line in the lateral projection, latero-orbitale line in the frontal projection, and meatus acusticus externus line in the axial projection for the landmark positions at examination 1 and 2) was ascertained. The growth at a specific anatomical location in a patient was defined as the displacement vector from the coordinate of the corresponding landmark in the X-ray at examination 1 to its coordinate at examination 2, corrected for X-ray magnification. The growth of an anatomical region in a patient was assessed by investigating the growth pattern formed by a collection of individual growth vectors in that region. The amount of growth in the UCCLP and UICL group was very similar. The general craniofacial growth pattern, in terms of the direction of growth, was also fairly similar in the UCCLP group and the control group. However, the maxilla and mandible showed a more vertical growth pattern than that observed in the control group. This study confirms that UCCLP is a localized deviation, and not a craniofacial anomaly, due to the fact that a normal growth potential has been observed in all craniofacial regions, except where the growth had been directly influenced by surgical intervention. Furthermore, the vertical growth pattern of the maxilla and mandible supports the hypothesis of a special facial type in cleft lip and palate individuals, and the facial type as a liability factor increasing the probability of cleft lip and palate.     

Head posture and craniofacial morphology

The associations between craniofacial morphology and the posture of the head and the cervical column were examined in a sample of 120 Danish male students aged 22–30 years. Two head positions were recorded on lateral cephalometric radiographs, one determined by the subject's own feeling of a natural head balance (self balance position), and the other by the subject looking straight into a mirror (mirror position). Craniofacial morphology was described by 42 linear and angular variables, and postural relationships by 18 angular variables. A comprehensive set of correlations was found between craniofacial morphology and head posture. The correlations were similar for both head positions investigated. Of the postural variables, the position of the head in relation to the cervical column showed the largest set of correlations with craniofacial morphology. Extension of the head in relation to the cervical column was found in connection with large anterior and small posterior facial heights, small antero-posterior craniofacial dimensions, large inclination of the mandible to the anterior cranial base and to the nasal plane, facial retrognathism, a large cranial base angle, and a small nasopharyngeal space. The possible role of functional factors in mediating the relationship between morphology and posture was discussed.     

Three-dimensional lip morphometry in adults operated on for cleft lip and palate

Measurements were taken from 18 patients operated on for cleft lip and palate, aged 19 to 27 years, and 162 control subjects matched for sex, age, and ethnic group. Nine soft-tissue landmarks on the lips were digitized by a three-dimensional electromagnetic instrument. From the landmarks, several linear distances (mouth width, philtrum width, vermilion height of upper and lower lip, total vermilion height, total lip height), the interlabial angle, and some areas (vermilion of upper lip, vermilion of lower lip, total vermilion) and volumes (upper lip volume, lower lip volume, total lip volume) were calculated. Patient and reference data were compared by t tests and Watson-Williams tests. In the men, significant differences (p < 0.05) were found in width of the philtrum, height and area of the vermilion part of the upper lip, and total vermilion height and area (all larger in male patients than in controls). In the women, significant differences were found in the height and area of the vermilion part of the upper lip (larger in female patients than in controls), and in the height and area of the vermilion part of the lower lip (smaller in patients than in controls). In both sexes, the interlabial angle was smaller than in the reference population. In conclusion, the upper lip of adult patients operated on for cleft lip and palate differed from that of healthy controls of the same age, sex, and ethnic group. Surgical correction of cleft lip and palate failed to provide a completely normal appearance. The analysis pointed out those parts of the lips and mouth (in particular, the vermilion part of the upper lip) that differed the most from the norm. The method may be used to indicate to the surgeon and patient where additional procedures might be performed to approximate the morphologic characteristics of a reference population.     

Soft tissue facial profile of normal dental and skeletal subjects in Croatian population aged 12 to 15 years

This study was carried out on 40 lateral cephalograms of Croatian subjects aged 12 to 15 years with dental and skeletal class I. The purpose of this investigation was to determine the means and standard deviations of the soft tissue parameters in the sample of Croatian population exhibiting dental and skeletal class I and to find the correlations between investigated parameters. The investigation included a total of 11 variables of which 4 were angular and 7 linear. Linear and angular measurements were made to the nearest 0.5 mm or 0.5 degree with dial calipers and a standard protractor with 0.5 degree increments. Data from this investigation could serve to determine the norms of 11 soft tissue variables for Croatian population with dental and skeletal class I, and to define craniofacial morphology of the soft tissue profile in patients with normal occlusion. Significant correlations were found between thickness of upper and lower lip, and between the distance of upper and lower lip to the Ricketts esthetic line, and Holdaway angle.     

Health-related quality of life in children with craniofacial anomalies

The purpose of this study was to examine parents' perceptions of the health and health-related quality of life in a series of children and adolescents with cleft and other craniofacial anomalies. The subjects for this prospective study were a consecutive series of 54 children and adolescents presenting to an outpatient craniofacial anomalies surgery clinic, ages 5 to 18 years (mean, 8.9 +/- 4.2 years), 50 percent with cleft lip and/or palate, 9 percent synostotic (two coronal, two bicoronal, and one sagittal), 17 percent syndromic (two Apert, one Crouzon, one Noonan, two Goldenhar, two Smith-Lemli-Opitz, and one brachio-oto-renal), and 24 percent with other diagnoses. Subjects were divided into two groups, those with primary cleft lip and/or palate and those with other craniofacial anomalies. Health and health-related quality of life were assessed with the Child Health Questionnaire version PF28, a reliable and valid 28-Likert-item questionnaire completed by parents and yielding physical and psychosocial status scale scores. Physical and psychosocial scale scores largely fell within normal limits for the subset of children with cleft lip and/or palate. There were significant group differences in parents' ratings of global health status, with greater health concerns noted in the non-cleft lip and/or palate group. There were no significant associations between either age or sex and physical or psychosocial health. Physical health, behavior, and psychological status were highly correlated. Using a health status and quality-of-life assessment instrument, findings indicate perceived health differences between groups with and without primary cleft lip and/or palate. In contrast to normative data with the Child Health Questionnaire, findings suggest that there is a significant association between perceived physical health and psychosocial adjustment in the population of children with craniofacial anomalies. The significant perceived health needs of the non-cleft lip and/or palate group and the association between physical health and psychological adjustment highlight the importance of the interdisciplinary nature of craniofacial teams.     

Simultaneous cleft lip and palate repair: an experimental study in beagles

This study was designed to test the hypothesis that simultaneous lip and palate repair results in more severe craniofacial growth aberrations than lip repair or palate repair performed separately. Seventy-six purebred beagles were divided into five groups. Two of these groups were controls (unoperated and unrepaired animals); the three remaining groups were experimental (in one group only the lip was repaired, in another only the palate was repaired, and in the last the lip and palate were repaired simultaneously). Cephalometric measurements were analyzed using univariate and multivariate statistical techniques. In multivariate analysis, stepwise multiple regression and discrimination were applied to precisely assess the effects of the various surgical procedures. The results of this study indicate that simultaneous lip and palate repair results in more severe craniofacial growth aberrations than lip repair or palate repair performed separately.     

Lower lip suspension using bilateral temporalis muscle flaps and fascia lata grafts

Oral incompetence following composite reconstruction of total and subtotal lower lip defects without any functioning lower lip muscle is a difficult problem for reconstructive surgeons. The authors retrospectively reviewed the use of a novel bilateral temporalis suspension technique for oral incompetence following lower lip reconstruction over a 10-year period. The timing of the reconstruction, cause of the defect, period of follow-up, and any complications were noted. Three cases of lower lip resuspension using bilateral temporalis flaps and fascia lata grafts were performed from 2000 to 2010. Two cases were secondary to burn trauma and one was from ballistic trauma. All patients underwent traditional means of reconstruction using free microvascular composite tissue transfer with and without fascial slings. All three patients presented with persistent lower lip incompetence. The average interval between the initial reconstructive operations and the resuspension operations was 1.6 years. All patients achieved dynamic oral competence at the first postoperative visit. At a mean follow-up of 3.6 years, all patients had maintained lower lip function. Dynamic lower lip resuspension with bilateral temporalis flaps and fascia lata grafts is an option for refractory lower lip drooping following total and subtotal loss, especially after conventional static reconstruction and without any functional orbicularis muscle. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.     

The influence of the respiration disturbances on the growth and development of the orofacial complex

The disturbances of orofacial functions lead to abnormal growth and development of the orofacial complex. The aim of the study was to determine the prevalence of incompetent lip seal and respiration disturbance, and to improve the understanding of correlation between incompetent lip seal and morphological malocclusions. In the sample of 84 children (45 girls and 39 boys, aged 8.96 +/- 0.66 years) a very high prevalence of the incompetent lip seal was found (35.72%). The study cast analysis was performed. The prevalence of the morphological malocclusion was significantly higher in the incompetent lip seal group (p < 0.001). There were also differences in types of malocclusions. The most frequent malocclusion found in incompetent lip seal was Class II / 1 malocclusion (53.3%). In the competent lip seal group this malocclusion was determined in only 15.57% (p < 0.001). Narrower upper dental arches, higher palate (p < 0.05) and larger overjet (p < 0.001) were found in incompetent lip seal group.     

The role of the yolk sac in craniofacial development of cultured rat embryos

To study the role of the yolk sac and amnion in craniofacial development, the effects of opening the yolk sac and amnion on facial formation of rat embryos were examined in vitro. Rat embryos were cultured for 72 hr from day 11.5 of gestation using an improved rotation apparatus. In experiments, the yolk sac and amnion were opened at the time of explantation (day 11.5) in one group (D11 open) and were opened 24 hr after the beginning of the culture (day 12.5) in another group (D12 open). Cleft lip developed in 100% of cultured embryos when the yolk sac and amnion were opened at day 11.5 (D11 open). In the D12 open group, however, cleft lip occurrence decreased to 3.0%. Protein content, wet weight, and somite number of cultured embryos were not significantly different in the two groups. The results of this study demonstrate that it is beneficial to open the yolk sac and amnion after 24 hr in culture for normal facial formation of rat embryo cultured from day 11.5 of gestation.     

Craniocervical morphology and posture in Australian aboriginals

The length of the spinal column as a percentage of stature is smaller in the Australian aboriginal than in most other ethnic groups (Abbie, 1957). It is conceivable that relative lengths of the cervical column might influence population differences in craniocervical posture and craniofacial morphology. The present study aimed to elucidate this relationship by comparing head posture and craniofacial morphology in Australian aboriginals to the same features in a previously studied sample of 120 Danish students (Solow and Tallgren, 1976). The aboriginal sample consisted of 42 young male adults from the Yuendumu settlement, Northern Territory, Australia. Cephalometric films of the natural head position were taken during a field trip to the settlement. The comparison comprised 18 postural and 61 morphological variables. In the aboriginals, the cervical column was shorter and had a less pronounced lordosis. The head was held about 3° lower, and the upper cervical column was 81/2° more forward inclined. As a consequence, the craniocervical angle was about 6° larger. Comparison of the craniofacial morphology in the two groups showed in the aboriginals a shorter upper facial height, a larger anterior lower facial height, and a larger vertical jaw relationship (NL/ML). The length of the posterior cranial base, s-ba, was 4 mm shorter (P <0.001) in the aboriginals, possibly developmentally related to the generally shorter spinal column in Australian aboriginals.     

Growth changes in internal and craniofacial flexion measurements.

Growth changes in both internal and craniofacial flexion angles are presented for Pan troglodytes, Gorilla gorilla, and modern humans. The internal flexion angle (IFA) was measured from lateral radiographs, and the craniofacial flexion angle (CFA) was calculated from coordinate data. Stage of dental development is used as a baseline for examination of growth changes and nonparametric correlations between flexion angles and dental development stage are tested for significance. In Gorilla, the IFA increases during growth. The IFA is relatively stable in Pan and modern humans. Pan and Gorilla display an increase in the CFA. However, this angle decreases during growth in modern humans. Flexion angles were derived from coordinate data collected for several early hominid crania. Measurements for two robust australopithecine crania indicate strong internal flexion. It has been suggested that cerebellar expansion in this group may relate to derived features of the posterior cranial base. In general, australopithecine crania exhibit craniofacial flexion intermediate between great apes and modern humans. The "archaic" Homo sapiens specimen from Kabwe is most similar to modern humans.     

FGF signalling and SUMO modification: new players in the aetiology of cleft lip and/or palate

Owing to the complex aetiology and the variable penetrance of cleft lip and/or palate (CL/P), understanding the molecular basis has been challenging. Recent reports have identified two independent biochemical pathways that will help to elucidate the underlying pathology. Fibroblast growth factor signalling, previously known for its involvement in craniofacial development, is now implicated in the genetic basis of both syndromic and non-syndromic CL/P. At the same time, an important role in lip and palate development is beginning to emerge for small ubiquitin-like modifier modification, a widely used posttranslational regulatory mechanism. Both of these pathways might interact with environmental risk factors for CL/P. Here we review their contribution to normal and abnormal orofacial development.     

The influence of lip repair with and without soft-tissue undermining on facial growth in beagles

The present study was designed to test the hypothesis that undermining of the soft tissues on the surface of the maxilla at the time of lip repair in unilateral cleft lip, alveolus, and palate results in more severe craniofacial growth aberrations than lip repair alone. Sixty-seven purebred beagles were used in this experiment. The animals were divided into four groups: two control groups (unoperated and unrepaired) and two experimental groups (lip repair without undermining and lip repair with undermining). Lip pressures were monitored in all groups. Significantly higher lip pressures were observed in animals with soft-tissue undermining. Cephalometric measurements were analyzed using univariate and multivariate techniques. The results of this study indicate that lip repair performed with soft-tissue undermining results in more severe craniofacial growth aberrations than lip repair performed alone.     

Cranial base angulation and prognathism related to cranial and general skeletal maturation in human fetuses.

The purpose of the present study was to describe normal midsagittal craniofacial morphology in second trimester human fetuses. Measurements of the cranial base angle and the prognathism of the maxilla and the mandible were performed on radiographs of cranial midsagittal tissue blocks of 52 fetuses with a gestational age from 13 to 27 weeks. Special procedures were developed for the definitions of the nasion and sella reference points on the radiographs in the early stages of fetal development. Mean data were reported for stages of crown rump length (CRL) and maturation of the fetal cranial base (MSS), usable as reference in assessment of pathological fetal crania in reports and autopsy procedures. Regression equations were determined for the regression of the angular values on CRL, MSS, and general skeletal maturation (TNO). The cranial base angle was found to decrease significantly, and the angles of prognathism to increase significantly with increasing CRL, TNO, and MSS values. It was suggested that these simultaneous and similar changes in the three angles could be accounted for by the upwards movement of the sella point produced by a cranial displacement of the pituitary fossa caused by local cartilagenous growth and bony remodelling during the period of study. The study thus reflects the influence of cranial skeletal maturation on the early development in shape of the craniofacial complex.     

Pelvis morphology, trunk posture and standing imbalance and their relations to the Cobb angle in moderate and severe untreated AIS

Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis and usually affects young girls. Studies mostly describe the differences between scoliotic and non-scoliotic girls and focus primarily on a single set of parameters derived from spinal and pelvis morphology, posture or standing imbalance. No study addressed all these three biomechanical aspects simultaneously in pre-braced AIS girls of different scoliosis severity but with similar curve type and their interaction with scoliosis progression. The first objective of this study was to test if there are differences in these parameters between pre-braced AIS girls with a right thoracic scoliosis of moderate (less than 27°) and severe (more than 27°) deformity. The second objective was to identify which of these parameters are related to the Cobb angle progression either individually or in combination of thereof. Forty-five scoliotic girls, randomly selected by an orthopedic surgeon from the hospital scoliosis clinic, participated in this study. Parameters related to pelvis morphology, pelvis orientation, trunk posture and quiet standing balance were measured. Generally moderate pre-brace idiopathic scoliosis patients displayed lower values than the severe group characterized by a Cobb angle greater than 27°. Only pelvis morphology and trunk posture were statistically different between the groups while pelvis orientation and standing imbalance were similar in both groups. Statistically significant Pearson coefficients of correlation between individual parameters and Cobb angle ranged between 0.32 and 0.53. Collectively trunk posture, pelvis morphology and standing balance parameters are correlated with Cobb angle at 0.82. The results suggest that spinal deformity progression is not only a question of trunk morphology distortion by itself but is also related to pelvis asymmetrical bone growth and standing neuromuscular imbalance.     

A comparison of the craniofacial morphology in 2-month-old unoperated infants with unilateral complete cleft lip and palate, and unilateral incomplete cleft lip.

This paper reports a cephalometric analysis of the craniofacial morphology in infants with unoperated unilateral complete cleft lip and palate (UCCLP) and unoperated unilateral incomplete cleft lip (UICL). The purpose of the study was to determine the nature and extent of the craniofacial deviations in UCCLP as compared to the morphology in UICL, which has previously been shown to be close to normal. The samples comprised 82 infants with UCCLP (58 males and 24 females) and 75 with UICL (48 males and 27 females). The mean age was about 2 months in both groups. The cephalometric analysis of craniofacial morphology included the lateral, frontal, and axial projections. The data were presented as mean plots of the craniofacial region including the calvaria, cranial base, orbits, nasal bone, maxilla, mandible, cervical column, pharynx, and soft-tissue profile. The most pronounced deviations in the UCCLP group were observed in the maxillary complex and the mandible. The most striking findings were: markedly increased width of the maxilla, a short mandible, and bimaxillary retrognathia except for the premaxillary area, which was relatively protruding and asymmetric. The study did not support the hypothesis previously suggested in the literature that cleft lip and palate is a craniofacial anomaly as size and shape of the calvaria and cranial base were found to be normal. The etiology of cleft lip and palate is still incompletely understood. Based on the present study, we suggest that facial type may be a liability factor that could represent a developmental threshold increasing the probability of cleft lip and palate.     

Partial lip resection with orbicularis oris transposition for lower lip correction in unilateral facial paralysis.

Malfunction of the marginal mandibular nerve, either in combination with a generalized facial palsy or in isolation, can cause an unpleasant and disturbing appearance around the mouth. In total palsy, a cross-facial nerve graft combined with a free vascularized muscle transplant will usually deal with this problem successfully; however, all older procedures used in this situation are unpredictable. For the isolated palsy, procedures such as digastric muscle transfer or sling suspension are not uniformly successful. A method using the contralateral, nonaffected lower lip orbicularis muscle is described. A wedge is removed from the paralyzed lower lip and the orbicularis is advanced to the modiolus to provide a functional orbicularis all the way across the lower lip up to the angle of the mouth. This is a simple outpatient procedure that has produced satisfactory results in most cases.     

Cephalometric analysis of the craniofacial region of the northern Foxe Basin Eskimo

Past investigations of the Eskimo have indicated that there are marked morphological differences in the craniofacial skeleton of this relatively isolated ethnic group compared to other ethnic and racial groups. This study, using cephalometric radiography, attempted to characterize the craniofacial phenotype of the Eskimo living in the northern Foxe Basin, Northwest Territories, Canada. Age changes were examined on a cross-sectional basis with comparisons being made with a Winnipeg Caucasian group. This investigation indicates that the Igloolik Eskimo has a phenotype, established early in life, and is distinct from the Winnipeg group. The overall size of the Eskimo craniofacial complex was significantly larger at three years of age and remained larger through the ages studied. Development of the craniofacial region, however, was fairly similar in rate and direction for both populations. The greatest differences between the Eskimo and Caucasian groups were found in the linear measurements assessing cranial width, facial width, mandibular length, facial height, protrusion of the incisors, chin point development, and nasal morphology. Differences between the two groups in the morphological relationships of the component structures include the angular relationships of the maxilla and nasal bones to the anterior cranial base, the gonial angle of the mandible, and the angle of facial convexity.     

Intentional cranial vault deformation and induced changes of the cranial base and face

Three morphologically distinct populations of Peruvian crania (n = 130) were metrically analysed to quantify changes resulting from intentional artificial vault deformation. Two of these samples are artificially deformed (anteroposterior [AP] and circumferential [C] types). Measurements taken from lateral radiographs demonstrated that alternative forms of the cranial base angle (N-S-Ba, planum angle, planum sphenoidale to plane of the clivus and PANG angle, planum sphenoidale to basion-sella plane) and the orbital and OANG angles (orbital roof to plane of the clivus and basion-sella plane, respectively) of both deformed groups increased while the angle S-Ba-O decreased significantly with respect to the undeformed (N) sample. Changes in the AP group are largely due to anteroinferior displacement of the basion-sella plane. Similar changes in group C are amplified by this group's posterosuperior frontal migration. This migration results in a relatively shallow orbit at the orbital plate/frontal squama interface. Unlike the deformation experienced by the external vault plates, the basion-sella plane orientation remains stable with respect to the Frankfort Horizontal. Additionally, nasal region measurements such as maximum nasal aperture breadth and nasal height were largely stable between each deformed group and the undeformed group. However, facial (bimaxillary and bizygomatic), basicranial, cranial, and frontal breadths decreased significantly from group AP to group N to group C. Thus, gross morphological facial changes between each undeformed group and the control group are largely accounted for by dimensional changes in peripheral structures. These results stress the importance of the dynamic interrelationship between the cranial vault and base in the development of the craniofacial complex.     

下颌第三磨牙拔除中预防下唇麻木和舌麻木的方法探讨

目的:探讨下颌第三磨牙拔除导致下唇和舌麻木的有关因素。方法:按照三种分类标准进行分组。第一种分组:以不同年龄段分成两组。第二种分组:以下颌第三磨牙根尖与下颌神经管的关系分成三组。第三种分组:以不同拔牙方法分为三组。结果:1.下颌第三磨牙拔除后引起下唇麻木和舌麻木与年龄无明显关系。2.460例下颌第三磨牙拔除术后出现下唇麻木31例(占6.74%),其中第二组和第三组占26例(占5.65%),第一组和第二组分别与第三组相比具有统计学意义(P0.05);出现舌神经损伤17例(占3.70%),其中第二组和第三组占14例(占3.04%),第一组和第二组分别与第三组相比具有统计学意义(P0.05)。3.口腔全景片显示的66例下颌第三磨牙根尖与下颌神经管重叠中,CBCT显示根尖多位于下颌神经管舌侧,而跨于下颌神经管最少见。4.拔牙方法越复杂,引起下唇和舌麻木的几率就越大。结论:本组病例的方法评估对拟定合适的治疗方案和安全指导拔牙以降低下唇和舌麻木具有重要的临床意义。