Appropriateness of standard cephalometric norms for the assessment of dentofacial characteristics in patients with cleidocranial dysplasia

OBJECTIVES

Cleidocranial dysplasia (CCD) is a rare skeletal syndrome affecting craniofacial and dental development. As a consequence, conventional cephalometric landmarks may not be valid for CCD patients, and the appropriateness of norms used for the general population should be critically discussed.

METHODS

Five patients 9- to 22-year-old (three females, two males) with CCD were included. Lateral-cephalograms, orthopantomographies, and intra-oral photos were retrospectively analysed. Lateral-cephalograms of 50 normal controls (ten for each CCD patient) matched for age and sex were selected from an online database. Cephalometric measurements of each CCD patients were compared with average values of matched controls using Wilcoxon signed-rank test for paired values (α = 0.05).

RESULTS

In CCD patients, a shortening of the cranial base was present (ΔSN = -17.1 mm, p = 0.043). Thus, the mandible (ΔSNPg = +9.5°, p = 0.043) and the maxilla (ΔSNA = +11.2°, p = 0.043) showed protrusion compared to the cranial base, despite a reduced maxillary (ΔCo-A = -15.1 mm, p = 0.043) and mandibular (ΔCo-Gn = -15.2 mm, p = 0.080) length. The mandibular divergence was reduced (ΔSN/GoGn = -6.4°, p = 0.043), a reduced overbite was present (ΔOverbite = -2.9 mm, p = 0.043), and the interincisal angle was increased (ΔInterincisalAngle = +13.7°, p = 0.043), mainly due to retro-inclination of lower incisors.

CONCLUSIONS

Standard cephalometric norms for the assessment of horizontal jaw position may not be applicable to CCD patients because of a reduced anterior cranial base length compared to normal subjects. Vertical relationships may not be affected, and mandibular hypodivergency was confirmed.

Orbital volume changes during growth and development in human children assessed using cone beam computed tomography

Objectives

To measure growth-related changes in orbital volume from childhood to the late teenage years using cone-beam computed tomography (CBCT) scans.

Methods

This retrospective cohort study involved 65 (24 male, 41 female) healthy Caucasian children (ages 6–18 years) with existing serial craniofacial CBCT scans. CBCT scans were available for 292 orbits. Each orbit was transformed into a closed space with well-defined boundaries, and orbital volume was measured using manual segmentation. A novel statistical analysis was applied to extract the maximum amount of longitudinal information from the data. Intra- and inter-operator correlation coefficients were calculated from replications performed on a random subset of 10% of the sample.

Results

Orbital volume increased at a rate of 1–2% annually until the late teenage years. Intra- and inter-operator agreement between repeated measurements were >90%.

Conclusions

Orbital volume increases by 1–2% per year throughout childhood continuing until the late teenage years. This annual increase is large enough to be clinically relevant as it may lead to less-than-optimal long term surgical outcomes when reconstructive surgery for the pediatric anophthalmic socket is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13005-022-00310-9.

PRDM paralogs antagonistically balance Wnt/β-catenin activity during craniofacial chondrocyte differentiation

Cranial neural crest cell (NCC)-derived chondrocyte precursors undergo a dynamic differentiation and maturation process to establish a scaffold for subsequent bone formation, alterations in which contribute to congenital birth defects. Here, we demonstrate that transcription factor and histone methyltransferase proteins Prdm3 and Prdm16 control the differentiation switch of cranial NCCs to craniofacial cartilage. Loss of either paralog results in hypoplastic and disorganized chondrocytes due to impaired cellular orientation and polarity. We show that these proteins regulate cartilage differentiation by controlling the timing of Wnt/β-catenin activity in strikingly different ways: Prdm3 represses whereas Prdm16 activates global gene expression, although both act by regulating Wnt enhanceosome activity and chromatin accessibility. Finally, we show that manipulating Wnt/β-catenin signaling pharmacologically or generating prdm3-/-;prdm16-/- double mutants rescues craniofacial cartilage defects. Our findings reveal upstream regulatory roles for Prdm3 and Prdm16 in cranial NCCs to control Wnt/β-catenin transcriptional activity during chondrocyte differentiation to ensure proper development of the craniofacial skeleton.

Craniofacial and dentoalveolar morphology in individuals with Prader-Willi syndrome: a case-control study

BACKGROUND

Prader-Willi syndrome (PWS) is a complex multisystem genetic disorder with distinct genetic and clinical features. Among other clinical symptoms, PWS is characterized by severe infantile hypotonia with feeding problems, childhood onset hyperphagia, obesity, scoliosis, short stature combined with growth hormone deficiency and developmental delay. PWS is associated with facial dysmorphology, orofacial dysfunction, oral abnormalities, low salivary flow and subsequent severe tooth wear. Little is known about the craniofacial growth direction or dental and skeletal relationships in individuals with PWS in different ages. The purpose of this study was to assess the craniofacial and dentoalveolar characteristics and to investigate the craniofacial growth direction separately in children, young adults and adults with PWS, using a cephalometric analysis of lateral cephalograms.

RESULTS

Lateral cephalograms of 42 individuals with a confirmed genetic diagnosis of PWS were analysed and divided into three groups according to their age: Children (< 12 years), young adults (12-20 years) and adults (> 20 years). Cephalometric variables were compared between PWS patients and controls by age and sex. Significant deviations and distinct craniofacial patterns were found in children, young adults and adults with PWS compared with the control group. Children showed retrognatic mandible with a skeletal class II relationship, posterior growth direction and longer anterior face height. The young adults had smaller cranial base angle, a skeletal class II pattern and a higher anterior lower face than the control group. Adults with PWS had a prognathic mandible, skeletal class III relationship with anterior growth direction, more retroclined lower incisors and proclined upper incisors than the controls. Similar results were found when comparing the three groups with PWS; the adults had a prognathic mandible, skeletal class III pattern and anterior growth direction. Children had a retropositioned mandibula, skeletal class II relationship and posterior growth direction.

CONCLUSION

This study may contribute to a better understanding of the craniofacial growth pattern in children, young adults and adults with PWS and may have a clinical importance when planning dental treatment, such as prosthodontics and/or orthodontics.

Micro-CT-Based Bone Microarchitecture Analysis of the Murine Skull

X-ray micro-computed tomography (micro-CT) imaging has important applications in microarchitecture analysis of cortical and trabecular bone structure. While standardized protocols exist for micro-CT-based microarchitecture assessment of long bones, specific protocols need to be developed for different types of skull bones taking into account differences in embryogenesis, organization, development, and growth compared to the rest of the body. This chapter describes the general principles of bone microarchitecture analysis of murine craniofacial skeleton to accommodate for morphological variations in different regions of interest.

Histological Techniques for Sectioning Bones of the Vertebrate Craniofacial Skeleton

Histochemical analysis is an indispensable technique in the field of biology used routinely to characterize pathologies of interest throughout the system. This chapter provides the craniofacial biologist with an introduction to tissue harvesting, embedding, and sectioning as well as a toolkit of useful stains for stromal/mesenchymal tissues including bone and cartilage. Techniques are tailored to decalcified, paraffin-embedded mouse tissue; however, these methods are applicable under a broad range of conditions.

Management of Lambdoid Craniosynostosis: A Comprehensive and Systematic Review

BACKGROUND

Craniosynostosis is a condition characterized by the premature fusion of 2 or more skull bones. Craniosynostosis of the lambdoid suture is one of the rarest forms, accounting for 1-4% of all craniosynostoses. Documented cases are separated into simple (single suture), complex (bilateral), and associated with adjacent synostoses ("Mercedes Benz" Pattern) or syndromes (i.e., Crouzon, Sathre-Chotzen, Antley-Bixler). This condition can manifest phenotypic deformities and neurological sequelae that can lead to impaired cognitive function if improperly treated or left undiagnosed. Preferred surgical techniques have varied over time but all maintain the common goals of establishing proper head shape and preventing of complications that could contribute to aforementioned sequelae.

SUMMARY

This comprehensive review highlights demographic distributions, embryological development, pathogenesis, clinical presentation, neurological sequelae, radiologic findings, surgical techniques, surgical outcomes, and postoperative considerations of patients with lambdoid craniosynostosis presentation. In addition, a systematic review was conducted to explore the operative management of lambdoid craniosynostosis using PubMed, Embase, and Scopus databases, with 38 articles included after screening. Key Messages: Due to a low volume of published cases, diagnosis and treatment can vary. Large overlap in presentation can occur in patients that display lambdoid craniosynostosis and posterior plagiocephaly, furthering the need for comprehensive analysis. Possessing the knowledge and tools to properly assess patients with lambdoid craniosynostosis will allow for more precise care and improved outcomes.

Wholemount In-Situ Hybridization (WISH) in Zebrafish Embryos to Analyze Craniofacial Development

Wholemount in-situ hybridization in zebrafish is a powerful technique for visualizing spatiotemporal gene expression during development. Here we describe a technique to detect endogenous mRNA expression in zebrafish that can be adapted to use on embryos from the single-cell stage until 5 days postfertilization.

E-liquids and vanillin flavoring disrupts retinoic acid signaling and causes craniofacial defects in Xenopus embryos

Environmental teratogens such as smoking are known risk factors for developmental disorders such as cleft palate. While smoking rates have declined, a new type of smoking, called vaping is on the rise. Vaping is the use of e-cigarettes to vaporize and inhale an e-liquid containing nicotine and food-like flavors. There is the potential that, like smoking, vaping could also pose a danger to the developing human. Rather than waiting for epidemiological and mammalian studies, we have turned to an aquatic developmental model, Xenopus laevis, to more quickly assess whether e-liquids contain teratogens that could lead to craniofacial malformations. Xenopus, like zebrafish, has the benefit of being a well-established developmental model and has also been effective in predicting whether a chemical could be a teratogen. We have determined that embryonic exposure to dessert flavored e-liquids can cause craniofacial abnormalities, including an orofacial cleft in Xenopus. To better understand the underlying mechanisms contributing to these defects, transcriptomic analysis of the facial tissues of embryos exposed to a representative dessert flavored e-liquid vapor extract was performed. Analysis of differentially expressed genes in these embryos revealed several genes associated with retinoic acid metabolism or the signaling pathway. Consistently, retinoic acid receptor inhibition phenocopied the craniofacial defects as those embryos exposed to the vapor extract of the e-liquid. Such malformations also correlated with a group of common differentially expressed genes, two of which are associated with midface birth defects in humans. Further, e-liquid exposure sensitized embryos to forming craniofacial malformations when they already had depressed retinoic acid signaling. Moreover, 13-cis-retinoic acid treatment could significantly reduce the e-liquid induced malformation in the midface. Such results suggest the possibility of an interaction between retinoic acid signaling and e-liquid exposure. One of the most popular and concentrated flavoring chemicals in dessert flavored e-liquids is vanillin. Xenopus embryos exposed to this chemical closely resembled embryos exposed to dessert-like e-liquids and a retinoic acid receptor antagonist. In summary, we determined that e-liquid chemicals, in particular vanillin, can cause craniofacial defects potentially by dysregulating retinoic acid signaling. This work warrants the evaluation of vanillin and other such flavoring additives in e-liquids on mammalian development.

Ambient noise limits efficacy of smartphone-based screening for hearing loss in children at risk

OBJECTIVE

To determine if hearScreen®, a smartphone-based pure tone audiometric screen, serves as an effective hearing screen for identifying hearing loss in children at risk, such as those with chronic otitis media and/or craniofacial anomalies.

METHODS

A cross-sectional, single-center, prospective study at an urban tertiary care hospital was completed. From June to October 2019, a total of 208 pediatric ears at risk for hearing loss were evaluated by both hearScreen® and conventional pure tone audiometry. The efficacy of hearScreen® for detecting hearing loss in a pediatric population at risk was determined.

RESULTS

A total of 208 pediatric ears at risk for hearing loss were screened. HearScreen® demonstrated a sensitivity of 85%, a specificity of 41%, a positive predictive value of 36%, and a negative predictive value of 87%. Subgroup analysis stratified by hearing loss type showed that hearScreen® screens for conductive hearing loss with increased sensitivity.

CONCLUSIONS

This investigation suggests that hearScreen® may serve as a an accessible, low-cost, and sensitive pure tone audiometric screen for hearing loss in children at risk, particularly those with conductive hearing loss, with the caveat that it may generate a high proportion of false positives due to the influence of ambient noise, especially when screening at 500 Hz. Future investigations should weigh the utility of including 500 Hz in the screening protocol as well as assess methods that may mitigate the influence of ambient noise during a pure-tone audiometric screen.

Assessment of the effect of silica calcium phosphate nanocomposite on mesenchymal stromal cell differentiation and bone regeneration in critical size defect

Objective

The research was designed to assess silica calcium phosphate nanocomposite (SCPC) biocompatibility and bioactivity as an osteoinductive scaffold and cell carrier. Consequently, the ability of cell seeded SCPC implant to regenerate a critical size defect in rat calvarium.

Materials and Methods

The study was conducted in two parts. A series of in vitro experiments on bone marrow stromal cells (MSCs) seeded in the SCPC scaffold evaluated cell attachment, proliferation and osteogenic differentiation. In the second part, a cell seeded SCPC construct was implanted in rat calvarium and bone regeneration was assessed by histological examination to evaluate the newly formed bone quality and the residual graft volume.

Results

In vitro experimentation revealed that MSCs cultured on SCPC maintained viability and proliferation when seeded into the SCPC. Scanning electron microscopy demonstrated cell adhesion and calcium appetite formation, MSCs differentiated towards the osteogenic lineage as indicated by the upregulation of RUNX2, ALP, Col1a1 markers. Histological examination showed regeneration from the periphery and core of the defect with new bone formation at different stages of maturation.

Conclusion

Regenerative medicine delivers promising solutions and technologies for application in craniofacial reconstruction. SCPC scaffold has the potential to be used as a cell carrier to achieve stem cell-based bone regeneration, which provides a viable alternative for treatment of challenging critical size defect.

Fungal Necrotizing Fasciitis of Craniofacial Region: A Diagnostic Challenge

Necrotizing fasciitis is a rare rapidly progressive, devastating surgical emergency that results in necrosis of superficial fascia, and subcutaneous tissue. It most commonly affects the abdominal wall, extremities and perineum, while the involvement in the head and neck region is relatively rare. Here, we report a successfully treated case of necrotizing fasciitis of the craniofacial region caused by Mucor in an uncontrolled diabetic patient. Early diagnosis, early surgical intervention with radical excision of infected tissue, management of underlying predisposing medical condition and supportive therapy (antimicrobials, rehydration, proper rest and nutrition) can reduce the morbidity and mortality associated with this condition.

Access to oral & maxillofacial surgery in Sub-Saharan African countries

In many regions of Africa, and especially in rural areas, basic health services are scarce, access to general surgery very difficult and Oral and Maxillofacial Surgery non-existent. In these regions, patients with pathologies in the maxillofacial area, whether malformations, tumours, infections, trauma, etc., do not have the possibility of receiving any treatment, and the mortality rate from any of these pathologies is very high. Patients who survive with these maxillofacial pathologies will have to face all their lives, in addition to the limitations of their disease, the stigma of social marginalization linked to the obvious visibility of any facial deformity. Achieving universal access to surgery (including oral and craniomaxillofacial surgery) for all human beings is part of the Sustainable Development Goals set by the UN for 2030. Achieving these goals requires the cooperation of all: public and private sectors, academic institutions, professional associations, NGOs, international agencies, medical industry and the entire global Oral and Craniomaxillofacial surgery community.

Contribution of computed tomography and magnetic resonance imaging in the analysis of fetal craniofacial malformations

A wide range of craniofacial malformations can be diagnosed in utero using ultrasonography. However, even with highly experienced sonographers and diagnostic physicians and optimal conditions of examination, some anatomical structures cannot be properly analyzed by this technique. The aim of this pictorial essay is to show the additional value of fetal magnetic resonance imaging and computed tomography in this setting and to illustrate the role of these modalities in facial clefts; craniosynostosis; ear, eye and nose abnormalities; otomandibular dysplasias; and facial cephaloceles.

The need to belong: Subjective experiences of living with craniofacial conditions and undergoing appearance-altering surgery

The purpose of this study was to better understand how individuals with craniofacial conditions experience living with visible differences and make sense of appearance-altering surgery. We conducted semi-structured qualitative interviews with 11 adults with Goldenhar or Crouzon syndrome. Interviews were analysed using a hermeneutic-phenomenological approach to thematic analysis. Our analysis revealed the following overarching theme, To see myself as other people see me, which encompassed three main themes: a) Striving to fit in, b) Altering the way I look and c) Support from family and friends. The participants' sense of their own appearance seemed to be connected to how they perceived others to evaluate their appearance. All had experienced negative reactions from others. They experienced themselves as different and had a desire to belong. All participants had undergone appearance-altering surgery, hoping that by changing appearance, they would reduce negative reactions and feel more connected to and accepted by other people. The process of undergoing appearance-changing surgery was experienced as challenging, and participants wished for a dialogue with surgeons which included psychological and emotional aspects of changing appearance. A better understanding of how to strengthen positive identity processes and feelings of belongingness should be a key focus of future research.

Three-dimensional printing and craniosynostosis surgery

OVERVIEW

The goal of this study was to review the current application and status of three-dimensional printing for craniosynostosis surgery.

METHODS

A literature review was performed using the PubMed/MEDLINE databases for studies published between 2010 and 2020. All studies demonstrating the utilization of three-dimensional printing for craniosynostosis surgery were included.

RESULTS

A total of 15 studies were ultimately selected. This includes studies demonstrating novel three-dimensional simulation and printing workflows, studies utilizing three-dimensional printing for surgical simulation, as well as case reports describing prior experiences.

CONCLUSION

The incorporation of three-dimensional printing into the domain of craniosynostosis surgery has many potential benefits. This includes streamlining surgical planning, developing patient-specific template guides, enhancing residency training, as well as aiding in patient counseling. However, the current state of the literature remains in the validation stage. Further study with larger case series, direct comparisons with control groups, and prolonged follow-up times is necessary before more widespread implementation is justified.

Ossifying Fibroma of Non-odontogenic Origin: A Fibro-osseous Lesion in the Craniofacial Skeleton to be (Re-)considered

In the cranio-facial skeleton, a heterogeneous group of well characterized fibro-osseous lesions can be distinguished. Whereas fibrous dysplasia can affect any skeletal bone, ossifying fibroma and cemento-osseous dysplasia exclusively develop in the cranio-facial region, with most subtypes restricted to the tooth bearing areas of the jaws. Herein we present a series of 20 fibro-osseous lesions that developed mostly in the frontal bone and in the mandible, presenting as expansile intramedullary tumors with a unique histologic appearance and an indolent clinical course. We provide evidence that these tumors are distinct from the categories included in the WHO classification and are therefore currently unclassifiable. The definition of cemento-ossifying fibroma as an odontogenic neoplasm developing only in close proximity to teeth should be re-considered and incorporate also extragnathic lesions as shown here.

Extensive titanium mesh invasive cranial fibrous dysplasia

Background:

Craniofacial fibrous dysplasia (FD) is a benign lesion. It presents as bony swelling. Even after complete excision, it has a tendency to recur due to some residual lesion in normal bone. Recurrence at same site is common, but it recurs in bone. We are reporting a rare case of recurrent FD engulfing titanium mesh.

Case Description:

A 22-year-old girl, who underwent frontal FD excision and reconstruction using titanium mesh surgery 2 years back, came with complaint of progressive bony swelling at same site for 1 year. CT head confirmed bony lesion involving mesh, frontal air sinus. She underwent complete excision of lesion and cranioplasty using bony cement. Biopsy confirmed recurrence of FD and invasion of titanium mesh.

Conclusion:

Recurrence of FD, involving cranioplasty titanium mesh, is extremely rare. It suggests local invasiveness of lesion. Recurrence can be prevented by excision of lesion with free bony margins.

FACE-Q Craniofacial Module: Part 1 validation of CLEFT-Q scales for use in children and young adults with facial conditions

BACKGROUND

The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions.

METHODS

Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined.

RESULTS

DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria.

CONCLUSION

The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

Responses of neurons in rostral ventromedial medulla to nociceptive stimulation of craniofacial region and tail in rats

The rostral ventromedial medulla (RVM) plays a key role in the endogenous modulation of nociceptive transmission in the central nervous system (CNS). The primary aim of this study was to examine whether the activities of RVM neurons were related to craniofacial nociceptive behaviour (jaw-motor response, JMR) as well as the tail-flick response (TF). The activities of RVM neurons and TF and JMR evoked by noxious heating of the tail or perioral skin were recorded simultaneously in lightly anaesthetized rats. Tail or perioral heating evoked the TF and JMR, and the latency of the JMR was significantly shorter (P < 0.001) than that of the TF. Of 89 neurons recorded in RVM, 40 were classified as ON-cells, 27 as OFF-cells, and 22 as NEUTRAL-cells based on their responsiveness to heating of the tail. Heating at either site caused an increase in ON-cell and decrease in OFF-cell activity before the occurrence of the TF and JMR, but did not alter the activity of NEUTRAL cells. Likewise, noxious stimulation of the temporomandibular joint had similar effects on RVM neurons. These findings reveal that the JMR is a measure of the excitability of trigeminal and spinal nociceptive circuits in the CNS, and that the JMR as well as TF can be used for studying processes related to descending modulation of pain. The findings also support the view that RVM ON- and OFF-cells play an important role in the elaboration of diverse nociceptive behaviours evoked by noxious stimulation of widely separated regions of the body.

Differential developmental toxicity of crude oil in early life stages of Atlantic halibut (Hippoglossus hippoglossus)

To further understand the complexity of developmental toxicity of dispersed oil and importance of exposure timing on fish early life stages, Atlantic halibut (Hippoglossus hippoglossus) were exposed to environmentally relevant concentrations through two embryonic developmental windows: the first period occurred during the epiboly process (named as "early embryonic exposure") and the second period overlapped the ontogenesis and cardiogenesis processes (named as "late embryonic exposure"). Following 72 hour oil exposure, embryos were transferred to clean seawater and a toxicity screening was performed in the yolk-sac larvae until first-feeding stages (56 days). The current study demonstrated that the exposure timing is essential for the development of toxic effects of crude oil in Atlantic halibut. Neither embryonic exposures (early or late) showed notable acute toxicity during exposure, yet both showed global latent teratogenic effects during yolk sac stages. Fish exposed during organogenesis (late) displayed stronger and more severe toxic effects than fish exposed during epiboly process (early), including reduced condition, severe craniofacial deformities and cardiovascular disruptions. The uptake level of polycyclic aromatic hydrocarbons into larval tissue and metabolic activity were greater following the late embryonic exposure and remained high during the depuration period at the highest exposure concentration. Overall, the long yolk sac stage development timing of Atlantic halibut makes this species a good candidate for evaluation of embryonic crude oil toxicity and its mechanisms.

Symmetry and fluctuation of cell movements in neural crest-derived facial mesenchyme

In the face, symmetry is established when bilateral streams of neural crest cells leave the neural tube at the same time, follow identical migration routes and then give rise to the facial prominences. However, developmental instability exists, particularly surrounding the steps of lip fusion. The causes of instability are unknown but inability to cope with developmental fluctuations are a likely cause of congenital malformations, such as non-syndromic orofacial clefts. Here, we tracked cell movements over time in the frontonasal mass, which forms the facial midline and participates in lip fusion, using live-cell imaging of chick embryos. Our mathematical examination of cell velocity vectors uncovered temporal fluctuations in several parameters, including order/disorder, symmetry/asymmetry and divergence/convergence. We found that treatment with a Rho GTPase inhibitor completely disrupted the temporal fluctuations in all measures and blocked morphogenesis. Thus, we discovered that genetic control of symmetry extends to mesenchymal cell movements and that these movements are of the type that could be perturbed in asymmetrical malformations, such as non-syndromic cleft lip.

This article has an associated ‘The people behind the papers’ interview.

Highlighted Article: Live imaging of the chick embryo face followed by mathematical analysis of mesenchymal cell tracks captures novel fluctuations between states of order/disorder as well as symmetry/asymmetry, revealing developmental instabilities that are part of normal morphogenesis.

Growing skull fractures of the orbital roof: a multicentric experience with 28 patients

BACKGROUND

Growing skull fracture (GSF) is a rare condition that may complicate pediatric head trauma. Patients may present with delayed-onset neurological manifestations.

AIM

This study aims to highlight the different presentations, methods of evaluation, treatment modalities, and outcomes in patients with orbital roof GSF.

METHODS

This retrospective multicentric cohort study reviewed the hospital records of children with GSF who presented at the Craniomaxillofacial Plastic Surgery Department, and Neurosurgery Department with Otorhinolaryngology Department (Maxillofacial unit), from 2011 to 2020. The collected data included age, gender, delay, manifestations, findings of imaging techniques, surgical treatment, complications, and satisfaction of patients' parents.

RESULTS

Twenty-eight patients with orbital roof GSF were included in this study. Most of the patients (82.1%) were boys, and the mean (SD) age was 5 (2) years old. Head trauma was caused by falls in all cases. Clinical manifestations included eyelid swelling (75%), pulsatile proptosis (25%), headache (17.9%), and seizures (10.7%). The mean (SD) diameter of bony defects was 24.3 (8.7) mm. Duraplasty alone was performed in 57.1%, while dura-cranioplasty was done in 42.9% of patients. Dural reconstruction was done using pericranial graft in 82.1% and artificial grafts in 17.9% of patients. Most of the parents (95%) were absolutely satisfied. No mortalities or recurrence of symptoms were recorded. The median follow-up period after surgery was 3.9 years.

CONCLUSION

Orbital roof GSF should be considered among the differential diagnoses in pediatric patients with history of head trauma presenting with ocular and/or neurological manifestations. Duraplasty is mandatory in all cases, whereas cranioplasty is required mainly in cases with large bony defects more than 25 mm. Prognosis in most patients was good both subjectively and objectively.

Evaluation of the OSA treatment protocol in syndromic craniosynostosis during the first 6 years of life

INTRODUCTION

Obstructive sleep apnea (OSA) is frequently present in patients with syndromic craniosynostosis. The aim of this study is to determine the long-term effectiveness of our OSA treatment protocol in our tertiary center in a cohort of children with syndromic craniosynostosis.

METHODS

Children with syndromic craniosynostosis born between January 2005 and December 2013 were eligible for inclusion (n = 114). Data from ambulatory and inhospital polysomnographies were used. The obstructive-apnea/hypopnea index was used for OSA classification.

RESULTS

Polysomnographies were performed in 83 patients. Mild OSA was diagnosed in 19, moderate in six, and severe in seven children. Of the 32 patients with OSA, 12 patients (37.5%) initially received expectant care of which OSA resolved spontaneously in nine without recurrence. Twenty patients were surgically treated. Adenotonsillectomy (ATE) had a 90% success rate with no OSA recurrence. Monobloc surgery was performed in four patients with mild OSA, although not OSA-indicated. Monobloc was performed for moderate or severe OSA in six patients, in four patients in combination with ATE and with mandibular distraction in one. Monobloc surgery for moderate or severe OSA had a 100% success rate in treating OSA and decannulation.

CONCLUSION

Expectant care is often sufficient to resolve mild OSA in patients with syndromic craniosynostosis, and should also be considered in patients with moderate OSA with close follow-up. ATE has an important role in the OSA treatment protocol. Monobloc surgery, combined with mandibular distraction on indication, is effective in resolving moderate to severe OSA with a stable long-term result.