Cephalometric Analysis of the Facial Skeletal Morphology of Female Patients Exhibiting Skeletal Class II Deformity with and without Temporomandibular Joint Osteoarthrosis

Purpose

This study evaluated the differences in the facial morphological characteristics of female patients exhibiting skeletal class II deformity with and without temporomandibular joint osteoarthrosis.

Methods

Eighty-three female patients with skeletal class II deformity were included in this study; these patients were classified into three groups on the basis of the condylar features shown in cone-beam computed tomography scans: normal group, indeterminate for osteoarthrosis group, and osteoarthrosis group. The cephalometric differences among the three groups were evaluated through one-way ANOVA.

Results

Of the 83 patients, 52.4% were diagnosed with osteoarthrosis, as indicated by the changes in the condylar osseous component. The cephalometric measurements that represented skeletal characteristics, including mandibular position relative to the cranial base, mandibular plane angle (MP-SN), posterior facial height (S-Go), and facial height ratio, were significantly different among the three groups (p < 0.05). The patients in the osteoarthrosis group yielded the smallest S-Go, the highest MP-SN, and the most retruded mandible.

Conclusions

Temporomandibular joint osteoarthrosis is commonly observed in female patients with skeletal class II deformity. The morphological characteristics of the facial skeleton in patients with bilateral condylar osteoarthrosis may be altered.     

Aesthetic refinements in genioplasty: the role of the labiomental fold

The vast majority of patients requesting aesthetic enlargement of their chins have a class II skeletal deformity secondary to a small mandible. Class II skeletal patterns are frequently associated with abnormalities of lower face height, which, in turn, affect labiomental fold morphology. Of 68 patients who were to undergo sagittal advancement of their chins, 88 percent were considered to have abnormal labiomental fold morphology that was closely related to abnormalities of the facial height. Patients with decreased lower face height (40 percent) had exaggerated, deepened folds with acutely closed angles between the lower lip and chin pad, whereas those with increased lower face height (25 percent) had shallow, effaced folds. Patients with normal lower face height had variable fold morphology. Isolated sagittal advancement and/or simultaneous advancement and vertical shortening deepened the labiomental fold and closed the angle between the chin pad and lower lip. Simultaneous advancement and lengthening tended to deemphasize the fold, making it appear less deep in 20 of 34 patients, or at least mitigated further accentuation of the fold in 14 of 34 patients. Altered labiomental morphology and its relationship to the class II skeletal deformity is discussed. Treatment planning decisions are suggested, taking into account labiomental aesthetics and how they are influenced by advancement genioplasty.     

Combined use of ultrasonic liposuction with the pull-through technique for the treatment of gynecomastia

The authors present a method of treatment for gynecomastia that combines the use of two techniques of soft-tissue contouring. This method uses ultrasonic liposuction in conjunction with the pull-through technique of direct excision to effectively remove the fibrofatty tissue of the male breast and the fibrous breast bud through a single 1-cm incision. Fifteen patients were treated in this fashion, and each patient demonstrated a smooth, masculine breast contour with a well-concealed scar, which eliminates the stigma of breast surgery. The procedure is technically straightforward and provides consistent results. It is offered as an additional option for the treatment of gynecomastia.     

Facial skeletal expansion: treatment strategies and rationale.

Forty-three nonconsecutive patients presenting with dentofacial deformity underwent surgical procedures designed intentionally to create skeletal disproportion in the sagittal and/or vertical dimensions. This was accomplished through expansion (enlargement) of the facial skeleton beyond normative standards. At the time of follow-up, which ranged from 14 to 36 months (mean 18.4 months), soft-tissue cephalometric analyses documented facial disproportion to exist in 37 of the 43 patients treated. Thirty-two patients had excessive anterior divergence (facial protrusion) at pogonion, and 17 patients had excessive lower face height as measured from subnasale to menton. All patients were judged to have had a favorable aesthetic outcome. This philosophy of facial skeletal expansion is predicated on two concepts: The first of these is that facial proportions and dimensions beyond those which are considered normal may be extremely attractive in a given individual. Second, the soft-tissue response to skeletal expansion is more favorable and predictable than it is to skeletal contraction in providing for well-supported soft tissues. This treatment planning approach is based on the dynamic interrelationship between the skeletal foundation and the soft-tissue facial mask. It relies on physical examination as the major determinant of aesthetic surgical options.     

The Oropharyngeal Airway in Young Adults with Skeletal Class II and Class III Deformities: A 3-D Morphometric Analysis

Objectives

1) To determine the accuracy and reliability of an automated anthropometric measurement software for the oropharyngeal airway and 2) To compare the anthropometric dimensions of the oropharyngeal airway in skeletal class II and III deformity patients.

Methods

Cone-beam CT (CBCT) scans of 62 patients with skeletal class II or III deformities were used for this study. Volumetric, linear and surface area measurements retroglossal (RG) and retropalatal (RP) compartments of the oropharyngeal airway was measured with the 3dMDVultus software. Accuracy of automated anthropometric pharyngeal airway measurements was assessed using an airway phantom.

Results

The software was found to be reasonably accurate for measuring dimensions of air passages. The total oropharyngeal volume was significantly greater in the skeletal class III deformity group (16.7 ± 9.04 mm³) compared with class II subjects (11.87 ± 4.01 mm³). The average surface area of both the RG and RP compartments were significantly larger in the class III deformity group. The most constricted area in the RG and RP airway was significantly larger in individuals with skeletal class III deformity. The anterior-posterior (AP) length of this constriction was significantly greater in skeletal class III individuals in both compartments, whereas the width of the constriction was not significantly different between the two groups in both compartments. The RP compartment was larger but less uniform than the RG compartment in both skeletal deformities.

Conclusion

Significant differences were observed in morphological characteristics of the oropharyngeal airway in individuals with skeletal class II and III deformities. This information may be valuable for surgeons in orthognathic treatment planning, especially for mandibular setback surgery that might compromise the oropharyngeal patency.     

Correcting the saddlebag deformity in the massive weight loss patient

Skin redundancy of the trunk and thigh is treated by a circumferential abdominoplasty and a lower body lift. Despite preservation and tight approximation of the subcutaneous facial system, the authors have failed to adequately correct severe saddlebag deformity and midthigh laxity in the massive weight loss patient. The technique used in the last nine of the senior author's 43 lower body lifts was modified by fully abducting each operated thigh on a side utility table, before closure in the prone position. This maneuver permits an increase in width of skin excision and causes the lateral thigh skin to be taut upon leg adduction. This is a retrospective review of the senior surgeon's experience over a 3-year period. Postoperative follow-up of the nine-patient cohort ranged from 8 to 12 months. A standardized set of six-view preoperative and postoperative photographs was available for each patient. A regional grading system was developed to assign points for deformity seen in preoperative and postoperative photographs. To compare the effect of the new technique on the correction of hip/lateral thigh deformities, the authors used this same grading system to analyze 10 other lower body lift patients treated by the same surgeon without full thigh abduction who had six sets of standardized photographs. A deformity severity score was determined for each anatomic region by four trained observers blinded to the surgical technique. The nonparametric Mann-Whitney U test using exact p values was used to compare preoperative and percentage change in deformity severity score from preoperative to postoperative scores relative to preoperative scores for each anatomical region among subjects in each treatment group. The nonparametric Wilcoxon signed rank test using exact p values was used to evaluate the change in deformity severity score from preoperative to postoperative values. The change in technique resulted in an observable symmetrical correction of the severe saddlebag deformity and better contour to the distal lateral thighs. All evaluated patients were satisfied with the lateral thigh skin contour. The grading system revealed that patients treated with or without intraoperative thigh abduction had similar preoperative deformity severity scores for each anatomic region (p > 0.05). Postoperatively, all subjects showed improvement in scores for all treated regions. However, patients closed during full thigh abduction had significantly lower deformity severity scores for the hip/thigh complex when compared with patients treated without full thigh abduction (p < 0.05). Complications in these 19 patients consisted of one 6-cm superficial skin layer dehiscence due to a broken polyester suture that healed spontaneously. There were three seromas that responded to a short series of aspirations or catheter drainage. There were no infections. Distal abdominal flap tip skin necrosis in four patients responded to outpatient débridement and healed secondarily. A new grading system for body contour deformities was successfully utilized to judge differences in the quality of trunk and thigh deformity and outcome in 19 patients with adequate photographic records. Tight suture closure in full thigh abduction in the prone position results in improved treatment of significant saddlebag deformity and midthigh skin laxity in the massive weight loss patient. The essential principles are meticulous planning, careful isolation, tight closure of the lateral trunk and thigh subcutaneous fascial system, and artistic contouring of remaining tissues. Dehiscence, undesirable scarring, and seromas were minor issues in the entire group of 43 patients.     

Two cases of joint disease in post-medieval church cemetery of St. Ilija

Evidence of disease was analyzed from the skeletal remains of 11 individuals dating to the post-Medieval period from church cemetery of St. Ilija in Serbia. Two individuals showed pathological condition affecting joints. It was supposed that first individual had been suffering from Legg-Calvé-Perthes disease. It seems that this condition remained untreated, with extensive bone remodeling, and that the deformity of femoral head and acetabulum caused secondary degenerative joint disease at a relatively early age of this individual. Second case was related to the bony akylosis of the hand finger, probably caused by Dupuytren's disease. In addition, we discussed development of differential diagnosis in both pathological conditions.     

Aesthetic surgery of the supraorbital ridge and forehead structures

A physical anthropologic basis for aesthetic evaluation of the supraorbital ridges and forehead is described. The structures included for evaluation and possible treatment are the supraorbital ridges, relation of the orbital walls to the eyes, the temporal ridges, and slope of the forehead. All can be altered by reduction contouring or augmentation using methods described. Twenty-one patients are presented having procedures for purely aesthetic reasons. If more than 5 to 6 mm of augmentation or reduction is desired, the deformity is more than aesthetic and should be treated by a craniofacial team. The aesthetic restructuring procedures described are done using tissue localized to the cranium and have proven to be safe and free of complications in the patients treated. Physical anthropology helps to put the aesthetics of these procedures on a firmer basis and to determine which patients may require more than an extracranial aesthetic procedure.     

Hemifacial microsomia: a multisystem classification

Variability of deformities in hemifacial microsomia has precluded the general acceptance of any classification based on one reference organ. We present a review of hemifacial microsomia classifications and propose a TNM-style multisystem classification. This alphanumeric coding system, SAT, provides cohesion to existing hemifacial microsomia classifications. The acronym SAT is derived as follows: S = skeletal, A = auricle, and T = soft tissue. There are five levels of skeletal deformity (S1 through S5), four levels of auricular deformity (A0 through A3), and three levels of soft-tissue deformity (T1 through T3). Hence a patient with minimal deformity would be classified S1A0T1, whereas a patient with the most severe deformity would be S5A3T3.     

A congenital orbital defect with periorbital-dural tissue adhesion

This case demonstrates a previously unreported congenital orbital deformity. The patient was born with a unilateral exophthalmos. The etiology of the defect was demonstrated by CT scan as a convex bowing of the right superomedial orbital wall behind the axis of the eye. At surgery, this convexity was revealed to be a small bony defect through which the periorbital tissue and dura mater adhered. This sort of orbital deformity, although subtle, must be considered in the differential diagnosis of congenital unilateral exophthalmos.     

Surgical reconstruction of the contracted orbit

Anophthalmic patients and patients afflicted with retinoblastoma incur severe deformity of the orbit. Treatment of the severely contracted orbit is very difficult, and patient satisfaction is often poor. Since 1988, we have performed temporalis muscle transfer and surgical expansion of the contracted bony orbit in 26 patients. Satisfactory results were obtained. Gradual expansion of the orbit was performed in case of congenital anophthalmic patients. The treatment should be established in multiplicity, among many methods available for contracted eye sockets, according to the degree of orbital deformity and the amount of residual conjunctiva. In case of severe deformity, volume expansion surgery and temporalis muscle transfer are necessary. If augmentation is required in the periorbital region, rib bone onlay graft must be performed. We were able to shorten the operative time by modifying the three-wall orbital expansion technique of Tessier and Wolfe to a more simplified method. Our observations show that our procedures achieved symmetry in both eyes in all patients, and there have been no remarkable complications.     

Untersuchungen über die Verteilung der ABO-Blutgruppen bei verschiedenen Erkrankungen im Säuglingsalter

Summary In the last ten years the ABO blood groups of our infants have been constantly ascertained and their distribution among some of the more prevalent diseases have been investigated. Other infants and healthy new-borns were used for comparison. The following results have been found:The blood group O is slightly more frequent in sick babies than in healthy new-borns. Among patients, who were under the age of 2 months at the time of admission, there were more with blood group O than among the older children. The blood group A tends to increase among the infants with anemia and with acute respiratory diseases, the blood group O tends to increase among those with staphylococcal infections and rachitis. With the latter the blood group B seems also to be found a little more frequently.Statistics show the increase of the blood group A in anemia in the 3. and 4. months of life and in acute respiratory diseases between the 3. and 12. month of life. The increase of the blood group O in staphylococcal infections is sure only among the youngest patients during their 1. month of life, it is obvious among the older patients, and there mainly among those of masculine sex. The increase of the blood groups O and B among infants with rachitis at the age of 3 to 12 months is almost certain. Premature babies show a sure decrease of the blood group O among both sexes, an increase of the blood group A among feminine, and of the blood group B among masculine patients.     

Effect of saddleback syndrome and vertebral deformity on the body shape and size in hatchery-reared juvenile red spotted grouper, Epinephelus akaara (Perciformes: Serranidae): a geometric morphometric approach

This study examined how saddleback syndrome (SBS) and vertebral deformity affect the body shape and size of juvenile stage red spotted grouper, Epinephelus akaara, using the landmark‐based geometric morphometrics method. According to the criterion of skeletal conditions, three groups, i.e. vertebral deformity, SBS, and normal groups, were identified. The results revealed significant differences in body shape among the three groups, in which the vertebral‐deformed group had the deepest mid‐body, the broadest anterior part, and a shortened caudal peduncle, while the SBS group showed the shallowest mid‐body and the narrowest anterior part. The normal group had a body shape intermediate between the vertebral and SBS groups. A comparison of body size among the three groups revealed significant differences in centroid size, with the vertebral‐deformed and SBS groups showing smallest and largest centroid size, respectively. This study illuminates that not all skeletal deformities lead to smaller body size. We suggest that rearing conditions might have caused the deformities reported herein.     

Classification for congenital anomalies of the hand: the IFSSH classification and the JSSH modification

The purpose of a classification for clinical problems which, except for a few specialized centers, occur only sporadically is to provide a system where these cases can be stored. This should allow all involved investigators to speak the same language; so-doing syndromes can be delinated, frequencies of occurence established and results of--different--treatments compared. A classification system should be simple to use, reliable and uniformly accepted. It should allow space for adaptations and/or extensions. The IFSSH proposed a 7 categories classification based on the proposed classification of Swanson et al. in 1976. This classification, was based on, which was thought in the seventies, etiopathogenic pathways. These 7 groups are: I. Failure of formation; transverse (A), or longitudinal (B) II. Failure of differentiation III. Polydactyly IV. Overgrowth V. Undergrowth VI. Amniotic band syndrome VII. Generalized skeletal syndromes. The extended classification proposed by IFSSH was used to classify 1013 hand differences in 925 hands of 650 patients. We found associated anomalies in 26.7%. The classification was straightforward in 86%, difficult in 6.6% and not possible in 7.8%. Group II was the most numerous group including 513 anomalies. We propose to include in this group the Madelung deformity, the Kirner deformity and congenital trigger fingers and trigger thumbs. In group I the radial and ulnar deficiencies, limited to the hand without forearm deficlencies should be Included. Triphalangeal thumbs are a problem, we suggest it to be listed in group III and consider it as a duplication in length. It is not always possible to evaluate the (transverse) absence of the fingers or hand. Longitudinal deficiencies (group IIB), symbrachydactyly (group V), and amniotic bands (group IV) occasionally develop a phenotype similar to the genuine transverse deficiency (group IA). Recently, the Japanese Society for Surgery of the Hand (JSSH) (16) proposed an extension/modification of the IFSSH classification. Based on newer knowledge on teratology, symbrachydactyly in all stages were transfered to group I. Two new groups were introduced. A group "failure of finger ray induction" including typical cleft hand (IC), central polydactyly (III) and (bony) syndactyly (II)--was included. Also a group of "unclassifiable" cases was added. This Japanese proposed classification is a real improvement and most clinicians and surgeons tend to use it in the future.     

An algorithmic approach to upper arm contouring

There has been a renewed interest in upper arm contouring given the recent advances and subsequent patient interest in weight loss. Patients undergoing bariatric surgery are often left with a significant amount of redundant skin and laxity of their upper extremity. Some patients within this group have excess fat in their upper arms with relatively good skin tone, while others have a paucity of excess fat with a significant amount of redundant skin. The optimal treatment for each patient can vary. A clinical algorithm is presented that is designed to select the best method for upper arm contouring based on the aesthetic analysis of the upper arm. Case examples are provided demonstrating results that were obtained by following this algorithm.     

Facial skeletal reconstruction using porous polyethylene implants

A retrospective review of clinical outcomes was performed to determine the clinical utility and morbidity associated with the use of porous polyethylene facial implants. Three hundred seventy implants were placed in 162 consecutive patients, in 178 operations performed in 11 years. The number of patients, the number of implants used, and the average follow-up period were categorized according to the cause of the deformity. The resultant distribution was as follows: acquired (tumor-related), 17 patients, 39 implants, and 30 months; congenital, eight patients, 31 implants, and 92 months; aesthetic, 39 patients, 97 implants, and 24 months; secondary posttraumatic, 48 patients, 139 implants, and 37 months; and acute trauma (internal orbit reconstruction), 50 patients, 64 implants, and 9 months. The distribution of implants according to location was as follows: frontal, 21; temporal, 30; internal orbit, 145; infraorbital rim, 28; malar, 58; paranasal, 29; nasal, 13; mandible, 24; and chin, 22. The combined average follow-up period per patient was 27 months (range, immediate postoperative period to 11 years). All implants were placed in the subperiosteal plane, and the majority were fixed with titanium screws. Antibiotics were administered perioperatively. No implants were extruded or migrated, formed clinically apparent capsules, or caused symptoms attributable to bioincompatibility. The overall reoperation rate was 10 percent (n = 16), which included operations to remove implants because of acute infections (2 percent, n = 3) or a late infection (1 percent, n = 1), to remove implants causing displeasing contours (2 percent, n = 3), and to improve contours (6 percent, n = 9). Porous polyethylene implants have biomaterial properties favorable for facial skeletal augmentation. Screw application of the implants to the skeleton allows precise predictable contouring, thus limiting the need for revisional surgical procedures.     

蜥脚类骨质尾锤之发现

自贡大山铺恐龙化石坑中出土的李氏蜀龙(Shunosaurus lii)和天府峨眉龙(Omeisaurustianfuensis)均发现由尾端脊椎愈合膨大而成之纺锤形骨质尾锤。这一特征在蜥脚类中尚属首次记述。骨质尾锤是一种适应陆地生活之特殊构造。它作为一种防御武器,主要起防卫身体的作用。它的存在说明R.T.Bakker提出的蜥脚类是一类营陆地生活的恐龙的观点是正确的。     

Correlation between MRI evidence of degenerative condylar surface changes, induction of articular disc displacement and pathological joint sounds in the temporomandibular joint

Objectives: The relationship of bony changes in the condylar surfaces in articular disc displacement without reduction in temporomandibular joint (TMJ) was investigated using diagnostic imaging. The study also evaluated whether the bony changes in the condylar surfaces limit disc and condyle motion, and produce pathological joint sounds. Materials and methods: Thirty‐seven joints in 28 patients diagnosed with degenerative bony changes in the condylar surfaces radiographically and anterior disc displacement without reduction using magnetic resonance imaging (MRI) were studied. The bony changes were assessed by radiographic examination and classified into two types: pathological bone changes (PBCs) including erosion, osteophyte formation and deformity, and adaptive bone changes (ABCs) including flattening and concavity. MRI was performed on the TMJ to examine the configuration and position of the discs. Joint sounds in the TMJ were determined using electrovibratograghy with a joint vibration analysis. Results: The articular disc motion to the condyle in the PBC group was smaller than in the ABC group irrespective of the configuration of the disc, even though there were no significant differences between the two types of bony changes in the disc position during jaw closing. The joint vibration analysis of the TMJ showed that joint sounds with a higher frequency were observed in the PBC group than in the ABC group. High energy levels needed to produce the higher frequencies (over 300 Hz) were observed only in the PBC group.     

Progression of facial asymmetry in hemifacial microsomia

Hemifacial microsomia is a common craniofacial anomaly, variably affecting structures derived from the first and second pharyngeal arches. Correction of the skeletal deformity in children has been advocated to improve growth potential and reduce secondary deformity. However, contrary reports have suggested that facial asymmetry in hemifacial microsomia does not increase with growth; therefore, skeletal correction can be postponed, even until adolescence. The purpose of this study was to test the hypothesis that facial asymmetry in hemifacial microsomia is progressive. This is a retrospective evaluation of 67 patients with untreated hemifacial microsomia. The patients were categorized as: group I (mandible type I, IIa), n = 38, and group II (mandible type IIb, III), n = 29. Pretreatment posterior-anterior cephalometric radiographs were used to analyze asymmetry by measuring the angle between the true horizontal and the following planes: piriform rim, maxillary occlusal plane, and intergonial angle. Angular measurements were averaged for patients in the deciduous (<6 years), mixed (> or =6<13 years), and permanent dentition (> or =13 years). In group I, angle piriform rim, maxillary occlusal plane, and intergonial angle increased from 7.0, 4.3, and 4.4 to 8.4, 6.6, and 6.1 degrees, respectively [mean age, 4.1 (deciduous) to 8.6 (mixed) to 21.0 (permanent) years]. In group II, angle piriform rim, maxillary occlusal plane, and intergonial angle increased from 9.5, 6.2, and 5.3 to 11.7, 7.6, and 8.0 degrees, respectively [mean age, 3.4 (deciduous) to 8.0 (mixed) years]. These data demonstrate that hemifacial microsomia is progressive and underscores the importance of early surgical correction of mandibular asymmetry in this disorder.     

Bending but not breaking the supraorbital bar

Surgical bending or contouring of the supraorbital bar may cause inadvertent fractures during craniofacial surgery. Wires may be placed in the bony segments themselves to facilitate reshaping with the Tessier rib bender. The wires are especially helpful in stabilizing the more acute curve at the lateral orbital rim.