A 2-stage procedure combining maxillary advancement by distraction technique with mandibular setback surgery in patients with cleft lip and palate

A 2-stage procedure combining maxillary advancement by distraction technique with mandibular setback surgery was used to correct jaw deformities in 5 patients with severe maxillary retrusion secondary to cleft lip and palate. First, a Le Fort I maxillary osteotomy was performed. Immediately after maxillary distraction, the distraction device was removed. The advanced maxilla was fixed with miniplates after adjusting the length and direction of advancement, and mandibular setback surgery was performed simultaneously to obtain a normal occlusal relationship. This 2-stage procedure resulted in stable occlusion and a markedly improved facial profile.

Cleidocranial dysplasia: 2 generations of management

Patients with cleidocranial dysplasia (CCD) commonly present with significant dental problems, such as retention of multiple deciduous teeth, impaction or delay in eruption of permanent teeth and, often, the presence of supernumerary teeth. Several approaches have been described for the management of such patients. We report 2 cases illustrating the shift in the management paradigm from edentulation and prosthetic replacement to orthodontically assisted forced eruption and fixed appliance orthodontic treatment combined with orthognathic surgery.

[Growth of the skull and bony kinetics interfering with facial morphogenesis. Conceptual bases of success in orthopedic treatments before the age of 6]

In order to perform an orthopedic treatment without relapse, one needs to identify properly the cranial patterns responsible for the malocclusion and act on them before the age of 6.

Orthodontic treatment protocol of Ehlers-Danlos syndrome type VI

Ehlers-Danlos syndrome (EDS) type VI is an autosomal recessive disorder of the connective tissue characterized by joint hypermobility, muscle hypotonia, scoliosis, and ocular fragility. In this case report, an EDS type VI patient with a skeletal and dental Class III malocclusion is presented and the clinical approach to his orthodontic problem is emphasized. A 17-year-old male patient presenting some major and minor symptoms of the syndrome was referred to our orthodontic department for diagnosis and treatment. The typical clinical signs confirmed the diagnosis of EDS type VI. He was a skeletal and dental Class III malocclusion patient (both mandibular protrusion and maxillary retrusion) with a noncontributory family history. He had severe crowding in the lower and upper dental arches with retruded incisors. His first treatment plan included orthognathic surgery, but because of the risks of bleeding and poor healing, we elected to treat the patient without surgery.

Cephalometric evaluation of maxillomandibular relationships in patients wearing complete dentures: a pilot study

The purpose of this study was to evaluate the changes in vertical and sagittal maxillomandibular relationship of the patients who had been wearing dentures for an extensive period. Fifteen edentulous patients (seven men and eight women; mean age 63.5 years) who had worn dentures for six to 16 years (mean 10 years) were selected for this study. New prostheses were fabricated by conventional methods, and the patients were evaluated cephalometrically before and after the new prosthesis. The results were compared by Wilcoxon signed rank test (P < .05). Results indicated that a prognathic mandible and a pseudo Class III relationship with a reduced occlusal vertical dimension became a normal Class I maxillomandibular relation when the new prosthesis was inserted. A better facial profile was achieved.

An enlarged sella turcica on cephalometric radiograph

A 28-year-old male presented to the Orthodontic clinic for correction of his anterior crossbite due to mandibular prognathism as a result of pituitary adenoma with acromegaly. A radiographic cephalometric analysis and clinical orthodontic examination were made. This article describes in detail the methods of correcting the magnification of cephalometric linear measurements in sellar dimensions (length, depth and width) from lateral and posteroanterior cephalograms. Cephalometric findings revealed that the sella enlarged in all its dimensions with a deepening of the floor in this acromegalic case. We discuss the radiographic diagnosis of an enlarged sella turcica in intrasellar tumours and also emphasise the dentist's important role in the initial diagnosis of pituitary adenoma cases.

Class-III malocclusion: genetics or environment? A twins study

Etiology of class-III malocclusion is generally believed to be genetic. A wide range of environmental factors have been suggested as contributing factors for the development of class-III malocclusion. Twin study is one of the most effective methods available for investigating genetically determined variables of malocclusion. Discordancy for class-III malocclusion is a frequent finding in dizygotic twins. However, class-III malocclusion discordancy in monozygotic twins is a rare finding. The purpose of this study of monozygotic twins is to assess the genetic and environmental components of variation within the cranio-dento-facial complex.

Maxillofacial intraoral distraction osteogenesis followed by elastic traction in cleft maxillary deformity

We present a case of severe maxillary hypoplasia in a 16 years old cleft patient treated by distraction osteogenesis maxillary advancement. Initial evaluation showed vertical and antero-posterior maxillary deficiencies, and a Class III malocclusion. Two intraoral distractors (Zurich Pediatric Maxillary Distractor, KLS Martin, Tuttlingen, Germany) were placed in a high Le Fort I osteotomy. An initial advancement of 11 mm was obtained, but the resulting occlusion was unsatisfactory (end-to-end occlusion). The consolidation period was reduced to 3 weeks to allow the mechanical manipulation of the newly formed bone with Class III elastics. An additional advancement of 3 mm, caused by elastic orthodontic traction produced both normal skeletal relationship and satisfactory occlusion. This observation shows that it is possible to carry on a skeletal maxillary displacement by interdental elastics before the complete fusion of the callus. After 12 months of postoperative follow-up no osseous relapse could be detected and the occlusal result was stable.

An orthopaedic approach to the treatment of Class III malocclusions in the early mixed dentition

The aim of this investigation was to study cephalometrically the skeletal, dental and soft tissue modifications induced by a Delaire facemask and Bionator III appliance in a sample of 30 patients (17 boys and 13 girls), aged 4.1-9 years [mean 5.85 years, confidence interval (CI) 5.41-6.29], in the early mixed dentition with a skeletal Class III malocclusion caused by maxillary retrognathism (group 1) and compared with a control sample of 24 subjects (14 boys and 10 girls), aged 4-9 years (mean 5.97 years, CI 5.35-6.58) with untreated Class III malocclusions (group 2). For each patient a lateral cephalogram was taken before treatment (T0), after facemask removal (T1), and at the end of the retention period with a Bionator III (T2). Cephalometric analysis was carried out. The post-treatment cephalometric values in the treated group showed a forward displacement of the maxilla resulting in a statistically significant increase (P < 0.001) in the SNA angle, A-NPg (mm) and PNS-A (mm) linear values. There was a clockwise rotation of the mandible, with a decrease in the SNB angle and a satisfactory correction of the Class III relationship. The beneficial effects on the facial profile were confirmed by an increase in UL-EL distance and in NB--HL and NsPgs--HL angles, and by a decrease in the facial convexity angle. These findings indicate that the Delaire facemask and Bionator III treatment is effective for correcting skeletal Class III malocclusions caused by maxillary retrognathism in the early mixed dentition.

[Seip Berardinelli: the effect of the partial tongue resection]

The Seip Berardinelli or undiagnosed endocrine metabolic syndrome is a rare autosomal recessive pathology mainly described in families of Portuguese origins. This syndrome presents various metabolic disturbances responsible of various dysmorphies. We report the case of two brothers seen during their childhood for respiratory, speaking and feeding problems related to a class 3 of Angle and macroglossia. The object was to study the interaction between the size of the tongue, the prognathism and the disturbances presented in order to organize early surgery (partial glossectomy).

Hajdu-Cheney syndrome (acro-osteolysis): a case report of dental interest

Hajdu-Cheney syndrome (acro-osteolysis) is a rare disorder of bone metabolism characterized by progressive lytic lesions in a number of bones. Constant features of this condition include an osteoporotic skeleton, acro-osteolysis, and a shortened lower third of face. The purpose of this report was to focus on the craniofacial and oral manifestations of the disorder in a 9-year-old boy.

The Orthoworld Specialist Practitioner Prize Cases 2000

This paper describes the orthodontic management of three diverse malocclusions that were awarded the Orthoworld Specialist Practitioner Prize (2000) and presented at the British Orthodontic Conference in Harrogate 2001.

The pattern of malocclusion among orthodontic patients seen in Dental Centre, University College Hospital, Ibadan, Nigeria

The aim of this study was to analyse the malocclusion pattern among patients who presented for treatment in the Orthodontic Unit of the Dental Centre, University College Hospital, Ibadan, as baseline data for proper treatment planning, teaching and further research. A total of 289 subjects aged 5-34 years with mean age of 10.6 +/- 1.5 (S.D.) years were seen. Angle's classification of molar relationships among those seen is as follows: class I - 76.5%, Class II - 15.5% and Class III - 8.0%. There was increased overjet in 16.2% of the patients, reduced overjet in 0.7% while 2.1% had reversed overjet. Other occlusal abnormalities included: increased overbite (3.8%), reduced overbite (1.4%); anterior open bite (5.2%; crossbite (8.4%) and scissorsbite (0.6%). Crowding, spacing and retained primary incisors constituted 29.7%, 1.4% and 40.1%, respectively. Delayed eruption of canine (1.0%), Bimaxillary protrusion (0.7%), incompetent lips (0.7%), supernumerary teeth (0.7%) malformed tooth (0.3%), mandibular deviation on closure (1.0%) and oral habits (4.5%) were other forms of malocclusion diagnosed. Males were found to have significantly more of classes II and III molar relationships than females (P < 0.05). Occurrence of retained primary teeth as well as overjet deviations from normal were significantly higher in females (P < 0.05). No significant sex differences were found in the other occlusal disorders (P > 0.05): The findings were comparable with previous epidemiological surveys in other parts of the country.

Temporomandibular joint and masticatory muscle involvement in myotonic dystrophy: a study by magnetic resonance imaging

OBJECTIVE

The purpose of this study was to evaluate the masticatory muscles and the temporomandibular joint (TMJ) by magnetic resonance imaging (MRI) in myotonic dystrophy (MD) patients.

STUDY DESIGN

MRI of the masticatory muscles and TMJ was performed in 15 MD patients, 11 male and 4 female, aged 16 to 53 years (mean, 31 years). Many of them had dental malocclusion, especially Angle class III and anterior open bite, and 3 complained of recurrent TMJ dislocation. TMJ and masticatory muscle pain was not observed, and joint sounds were noted in only 1 patient.

RESULTS

The analysis of MRI scans showed masticatory muscle involvement in 13 patients (86.6%). In 11, the involvement was moderate to intense. The main abnormalities observed were increased intramuscular tissue signal on T1 (fatty infiltration) and volumetric reduction of muscles. Regarding the TMJ, articular disk displacement was seen in only 1 patient, but abnormalities of disk shape were common. Mild bone abnormalities were frequently observed, including changes of shape and contour of bone surface, and sclerosis of bone marrow. In 4 patients the condyle moved anterior to the eminence with the mouth opened fully (condylar hyperexcursion).

CONCLUSIONS

This study shows that masticatory muscles are frequently and intensively affected in MD patients. Bone changes are the most consistent abnormalities observed in the TMJ. It is possible that remodeling is caused by biomechanical changes in the jaw as a result of masticatory muscle involvement.

Analysis of facial growth in subjects with syndromic ectodermal dysplasia: a longitudinal analysis

OBJECTIVE

To examine the craniofacial growth pattern of patients diagnosed with syndromic ectodermal dysplasia.

DESIGN

Mixed longitudinal analysis of lateral cephalograms.

SETTING

The data were analysed using a multilevel modelling technique with the MLwiN application software and the results presented numerically and graphically.

SAMPLE POPULATION

All 61 subjects had severe hypodontia with the number of absent teeth (excluding third molars) ranging from 6 to 28 (mean = 15.4). At presentation the subjects had a mean age of 133 months and were followed longitudinally for between one and five subsequent occasions (mean 2.66 occasions; mean age at completion of observation 207 months).

OUTCOME MEASURES

Lateral cephalograms taken at each visit.

EXPERIMENTAL VARIABLES

Analysis of four angular measurements and four linear measurements, together with one calculated ratio.

RESULTS

Growth curves are presented showing the trends of craniofacial growth.

CONCLUSIONS

The most significant findings were for a universal tendency for the individuals to undergo a change in sagittal relationship of the jaws, becoming markedly more Class III with time. We have also demonstrated a significant difference in growth between the anterior and posterior face heights indicating that the subjects have a tendency to an anterior growth rotation.

Traumatic chronic TMJ dislocation: report of an unusual case and discussion of management

Dislocation of the temporomandibular joint (TMJ) is most often spontaneous, but it can be associated with direct or indirect head and neck trauma. The disorder may be treated in general by simple closed techniques, if managed acutely. If the dislocation becomes chronic, however, open reduction is usually required. The article discusses various methods for an open surgical approach described in the literature. A case of a prolonged TMJ dislocation is presented, involving a severe bilateral mandibular dislocation with the condyles displaced into the infratemporal fossa and the lateral poles of the condyles articulating on the inner aspect of the zygomatic arch. An open approach, involving masseter, temporalis, and the medial pterygoid muscles, was utilized, followed by the use of scissors mouth props, Erich arch bars, and postoperative elastic traction.

Modifying the two-stage cleft palate surgical correction

OBJECTIVE

This paper reports the experience with a two-stage approach to surgical correction of the complete cleft palate, wherein timing of the second stage is dependent on the judgment of the speech pathologist and the orthodontist together with the surgeon.

PATIENTS

Of a total of 35 patients having complete unilateral clefts a sample of 22 were available for postsurgical assessment. The first-stage repair of the palate was carried out at an average age of 10.7 months (range 6 to 17 months), and the second-stage repair of the residual cleft was completed at an average age of 32.7 months (range 26 to 34 months).

INTERVENTIONS

The first-stage repair of the soft palate defect involved mobilizing two short posteriorly based flaps, which extend onto the posterior quarter of the hard palate thus including up to 1 cm of mucoperiosteum. Careful freeing of the muscle is followed by an intravelar veloplasty. The later closure of the residual cleft involved turnover hinge flaps and small mucoperiosteal flaps.

RESULTS

Eighty-seven percent of the sample had good to excellent speech as assessed by the Great Ormond Street screening method. Only two patients showed evidence of recessive maxillae with Class III malocclusions.

CONCLUSIONS

A two-stage surgical closure of the palate using this procedure would appear to confer several valuable advantages to the patient. These include favorable outcomes for speech in the large majority of cases and minimal adverse effects on the growth of the midface region.

Efficacy of high condylectomy for management of condylar hyperplasia

The purpose of this study was to compare the treatment outcome and long-term stability of 2 groups of young adult patients diagnosed with active condylar hyperplasia and treated with 2 different surgical methods. Thirty-seven patients (19 females and 18 males) met the criteria for inclusion in the study. Group 1 (n = 12; average age at surgery, 17.5 years) was treated with orthognathic surgery only, while group 2 (n = 25; average age at surgery, 16.7 years) had high condylectomy, articular disc repositioning, and orthognathic surgery. All patients underwent standardized clinical and radiographic examination at initial consultation, immediately before surgery, immediately after surgery, and at longest follow-up. Objective evaluation of temporomandibular joint (TMJ) function included maximum incisal opening and lateral excursions. Subjective evaluations were performed in group 2 for TMJ pain, jaw function, and diet. Lateral cephalometric radiographs were evaluated for presurgical and postsurgical mandibular growth. There were no statistically significant differences (P >.05) between the 2 groups for maximal incisal opening, lateral excursions, or subjective jaw function before surgery. Presurgical growth differed significantly (P <.05), with group 2 showing more active growth. At the long-term follow-up, no differences were found in lateral excursions or subjective jaw function. There was a statistically significant difference in maximum incisal opening (P <.01), with a greater increase in group 2, as well as a statistically significant difference (P <.05) in cephalometric stability, with group 2 being much more stable at long-term follow-up. All patients in group 1 grew back into skeletal and occlusal Class III relationships and required secondary intervention. Only 1 patient in group 2 required secondary surgery, involving maxillary surgery to correct postsurgical transverse maxillary relapse; the mandible was stable at long-term follow-up. The results of this study showed that patients with active condylar hyperplasia treated with high condylectomy, articular disc repositioning, and orthognathic surgery have stable, predictable outcomes compared with those treated with orthognathic surgery alone.

A less-invasive approach with orthodontic treatment in Beckwith-Wiedemann patients

The Beckwith-Wiedemann syndrome (BWS) is a rare genetic disorder, linked to an alteration on the short arm of chromosome 11 that comprises multiple congenital anomalies. Macroglossia is the predominant finding, with subsequent protrusion of dentoalveolar structures, which results in a protruding mandible, anterior open bite, abnormally obtuse gonial angle and increased mandibular length. A less-invasive treatment with orthopaedic appliances in a patient with early tongue reduction is presented. This work summarizes the oral signs linked to macroglossia, and highlights the influence of macroglossia on mandibular growth structures. In our opinion, glossotomy could be carried out in the paediatric patient as a preventive measure in that it curbs the tongue's influence on skeletal growth and dramatically reduces the duration and extensiveness of subsequent treatment.

A classification and characterization of skeletal class III malocclusion on etio-pathogenic basis

Skeletal Class III malocclusion has been classified by the position of the maxilla, the mandible, the maxillary alveolus, the mandibular alveolus and vertical development. This morphologic approach is simple and useful for clinical use, but it is insufficient to permit understanding of the pathophysiology of dysmorphoses. The authors hypothesized that there were different patterns of mutual relation of the skeletal components contributed to pathologic equilibrium of skeletal Class III malocclusion. The purpose of this study is 3-fold; (1) to classify skeletal Class III malocclusion in subgroups that can show the architectural characteristics of the deformity, (2) to analyze the craniofacial architecture of each subgroup on etio-pathogenic basis, and (3) to characterize and visualize the pattern as a prototype. Materials used in this study were lateral cephalograms of 106 untreated skeletal Class III malocclusion adults, which were analyzed with modified Delaire's analysis. Linear and angular measurements of each subject were obtained and cluster analysis was used for grouping. In the results, seven groups were identified and presented as prototypes, which could show the etio-pathology of the skeletal architecture. The classification and description presented in this study is thought to be biologic and helpful in the understanding of skeletal Class III malocclusion and treatment planning.

Bending of the distraction site during mandibular distraction osteogenesis in the rabbit: a model for studying segment control and side effects

PURPOSE

The purpose of this investigation was to develop an animal model for studying and correcting mandibular distraction side effects.

MATERIALS AND METHODS

Twenty-nine rabbits underwent bilateral mandibular distraction. Bending of the mandible was accomplished by offsetting a linear distraction by 35 degrees from the occlusal plane (4 screws per distractor), rotating the anterior segment inferiorly (2 screws per distractor), and removing a 3- or 6-mm wedge of the distraction site. The amount of bite opening varied according to the surgical design. Direct measurements, radiographs, and histology samples were compared.

RESULTS

Linear distraction produced a 4-mm anterior open bite and a Class III malocclusion after 2 weeks of distraction. Segmental rotation produced an 8-mm anterior open bite without complications. Removal of a wedge initiated rotation of the anterior segment. A large wedge (6 mm) produced fibrous union in the distraction site. The amount of bite opening or closure depended on the number of surgical screws and position of the distractor. Serial histologic sections showed bone formation at the rotated, triangular distraction site.

CONCLUSION

Bite opening or closure can occur from loss of segment control or by altering surgical design. This information is needed to counter unwanted side effects or to plan segment rotations.